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Gastroesophageal reflux associated with large diaphragmatic hernias
D L Sigalet1, L T Nguyen, V Adolph
1Department of Surgery, University of Alberta, Edmonton, Canada.
Insights
Infants with large congenital diaphragmatic hernias (CDH) requiring ECMO support can develop severe gastroesophageal reflux. Aggressive surgical intervention, including Nissen fundoplication and pyloroplasty, is recommended when medical management fails.
Area of Science:
- Pediatric Surgery
- Neonatal Intensive Care
- Gastroenterology
Background:
- Extracorporeal membrane oxygenation (ECMO) has improved survival for infants with congenital diaphragmatic hernias (CDH).
- Survivors of severe CDH often have larger defects, pulmonary hypoplasia, and associated comorbidities.
- Gastroesophageal reflux (GER) is a known complication in CDH patients.
Observation:
- This study focuses on the experience with GER in CDH infants requiring ECMO.
- GER in this cohort was observed to be severe and intractable, unlike previous reports.
- Associated gastric dysmotility appeared to be a contributing factor to the severe reflux.
Findings:
- Medical therapy and anterior fundoplication were ineffective in managing GER in these patients.
- Nissen fundoplication combined with pyloroplasty successfully controlled reflux.
- Surgical intervention allowed for successful gastric feeding in infants with severe GER post-CDH repair.
Implications:
- Aggressive surgical management, including early Nissen fundoplication and pyloroplasty, should be considered for refractory GER in CDH survivors.
- Insertion of a gastric feeding tube during surgical repair may be beneficial.
- This approach can improve outcomes and enable enteral feeding in complex pediatric surgical cases.
Abstract:
Extracorporeal membrane oxygenation (ECMO) support has improved the outlook for some infants who have large diaphragmatic hernias (CDH). This has resulted in a subset of survivors of CDH with typically larger defects, more severe pulmonary hypoplasia, and more associated pathologies. This report describes the authors' experience with gastroesophageal reflux in patients with large diaphragmatic hernias who require ECMO. Contrary to previous reports, this reflux was severe and intractable. There appears to be a component of associated gastric dysmotility. In treating this reflux, medical therapy and anterior fundoplication were not successful, and Nissen fundoplication combined with pyloroplasty was required to control reflux and to allow gastric feeding. On the basis of the authors' experience, it is recommended that patients who have gastroesophageal reflux after CDH repair, for whom medical management has failed, be managed aggressively by surgery, with early Nissen fundoplication, and pyloroplasty and insertion of a gastric feeding tube.