ASSESSMENT OF ALKALINE REFLUX IN CHILDREN AFTER NISSEN FUNDOPLICATIONAND PYLOROPLASTY

During an eight month period, 22 children less than 15 years of age (m ean age of three years and seven months) who underwent operative treat ment of gastroesophageal reflux (GER) were selected for study. All wer e symptomatic and unresponsive to medical therapy. Preoperative evalua tion included esophageal pH probe monitoring in 18 patients, gastric i sotope emptying study in 18 patients and contrast studies of the upper part of the gastrointestinal tract in ten patients. Four children wit h severe neurologic disorders who required placement of a feeding gast rostomy tube underwent fundoplication without preoperative evaluation. All 22 patients had GER and 14 had documented delayed gastric emptyin g (greater than 60 percent residual at 90 minutes) on radionuclide sca n with appropriate meal for age. Each child underwent Nissen fundoplic ation and tube gastrostomy. Sixteen patients also had a modified pylor oplasty with a 2.5 to 4.0 centimeter vertical seromuscular incision on the antrum. When the patients achieved a full feeding schedule (posto perative day range three to 21 days, mean of 6.2 days), they were put on a fast for six hours and an aspirate was obtained from the gastrost omy tube. Analysis of pH and bile acid content served as indicators of alkaline reflux. The six children without pyloroplasty served as the control group. Intragastric pH ranged from 1.91 to 7.00 (mean of 3.71) and bile acid content ranged from 4 to 150 micrometers per liter (mea n of 62 micrometers per liter). No significant differences were seen b etween patients with fundoplication alone and those with fundoplicatio n and pyloroplasty (p=0.97 for pH; p=0.66 for bile acid content). Two patients with pyloroplasty showed slight elevation of intragastric bil e acid content at the upper limits of normal. At follow-up evaluation from nine to 23 months (mean of 18 months), all patients were asymptom atic, with only two showing rare gagging. Additionally, nine patients have had complete resolution of their pulmonary symptoms. No patients demonstrated diarrhea, gas bloat or dumping. Nissen fundoplication com bined with a modified pyloroplasty or ''antroplasty'' for delayed gast ric emptying provides excellent clinical results with minimal demonstr able bile acid reflux and no change in intragastric pH at the one and one-half year follow-up evaluation.