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What is gastroesophageal reflux disease (GERD)?
Under normal conditions, the contents of the stomach and the acid produced do not return upwards thanks to a muscle located at the end of the esophagus. When this muscle, called the lower esophageal sphincter (EEI), does not work, the contents of the stomach rise into the esophagus. When there is a reverse flow of content, we call it ebb. When this reflux is not treated, the acid content of the stomach can injure the esophagus producing ulcers, scars or bleeding. The contents of the stomach can rise all over the esophagus and even reach the lungs. This is called “aspiration” and can cause coughing, airway irritation, bronchitis, or pneumonia. In most cases, reflux can be treated with oral medications; but in those cases in which the symptoms have not improved with the medication, surgery is recommended. In the treatment of GERD, a bow tie is performed around the esophagus. This tie makes the entrance of the esophagus to the stomach very narrow, thus making it difficult for the contents of the stomach to pass into the esophagus. This surgery is also called Nissen.
What tests are needed before surgery?
When a child has a suspicion of GERD, it is necessary to carry out a series of diagnostic tests to help us make the decision on the most appropriate treatment, and to decide whether or not he or she will need surgery.
- Esophageal-gastro-duodenal transit: these are X-rays that are taken while the child is ingesting an oral contrast so that we can see how the contrast passes from the mouth to the esophagus and then to the stomach. We can see with this test if the contrast rises from the stomach to the esophagus, demonstrating the presence of reflux.
- pH-metry: using a fine probe that is placed through the nose to the stomach we measure the presence of acid content in the esophagus. It gives us information about the reflux time, number of episodes and whether they are associated with any kind of clinic (vomiting, cough, pain, etc.).
- Esophageal biopsy: in some cases an endoscopic biopsy of the esophagus is performed. In the sample obtained we can see signs of reflux esophagitis.
There are two types of surgery for GERD: laparoscopic or open surgery. In both, the goal is the same: to create a stomach tie around the bottom of the esophagus to prevent the contents of the stomach from rising into the esophagus. The technique to be performed will be decided by the surgeon based on the specific characteristics of each patient, anatomy, number of previous interventions, etc.
Laparoscopic anti-reflux surgery / Laparoscopic Nissen
- The surgeon will use 4 or 5 incisions (cuts) in the skin to be able to insert the 5-10 mm material into the abdomen.
- A small chamber will be inserted inside the abdomen to be able to see all the structures: liver, diaphragm, stomach and the final part of the esophagus.
- The abdomen will be filled with air to facilitate a better view of all the organs and perform the surgery.
- Once the surgery is over, the abdomen is emptied of the air that has been introduced, all the material will be removed and all the wounds will be closed with stitches.
Open surgery / Nissen open
- The same surgery is performed, but with a single incision or cut in the skin along the midline of the abdomen (middle laparotomy).
- Once the surgery is over, the wound is closed with stitches. In some cases it will be necessary to place a gastrostomy in the surgery (a tube that goes from the stomach to the skin of the abdomen). The gastrostomy is a device that facilitates the feeding of children with difficulty swallowing.
Evolution after surgery
- All operated children will leave the operating room with a nasogastric tube that will be removed 24-48 hours after surgery. The probe allows the stomach to be emptied of air and gastric juices and ensures sufficient passage from the esophagus to the stomach.
- They will carry intravenous antibiotic prophylaxis for the first 48 hours to prevent infections.
- Children will start eating liquid after 24-48 hours after surgery.
In the case of patients who have a gastrostomy:
- The gastrostomy will be kept open in a bag for the first 24 hours.
- 24 hours after surgery, the nasogastric tube will be removed and feeding by gastrostomy will begin.
- The nursing staff will teach you the use and maintenance of the feed pump and gastrostomy.
- During the first month after surgery, your child will only eat food that has the consistency of a puree. This is because after surgery the passage between esophagus and stomach will be very narrow and it will not be easy for you to eat solid food.
- In the month of the surgery an esophagogastric transit will be realized where the passage of the contrast and the presence or not of residual reflux will be evaluated. If it is correct, the child will start eating solid food.
- Transit will be repeated at 6 months and one year after surgery.
- Subsequently, clinical examinations of the child will be performed, and depending on the evolution, the need to perform a diagnostic or control test will be decided.
- After surgery, the child may have difficulty rotating or vomiting. This difficulty is transient, meaning that over time it disappears. When this happens, you will need to readjust your diet to avoid carbonated beverages, and so on.
- The child may have difficulty swallowing food because the tie that has been made around the stomach is very narrow and prevents proper passage. In these cases, endoscopic dilatations of the narrow area may be considered.
A long-term complication may be that the tie is loose or that the sleeve / tie is moving / migrating to the chest. If this happens, the treatment will be carried out according to your child's symptoms.