[size=20px]A five-year old neurologically impaired child has developed symptoms of recurrent gastroesophageal reflux disease including vomiting of gastrostomy feedings, failure to thrive and aspiration pneumonia. The patient has undergone a revision Nissen fundoplication one year ago for the same problem. The parents want to know about reasonable treatment options other than another Nissen fundoplication. The option that would best resolve the child recurrent reflux is

 

A surgical jejunostomy tube.

 

B esophagogastric dissociation with Roux-en-Y reconstruction.

 

C transgastric jejunostomy tube.

 

D tracheostomy.

 

E revision Thal fundoplication.​[/size]

A

B

C - use existing gastrostomy site to place post-pyloric feeding tube

B

C

B

Esophageal dissociation as described by Bianche is the best for such a patient.

C

C

c

E

C

B

B

A is possible

C if you have experience

Correct answer

B esophagogastric dissociation with Roux-en-Y reconstruction.

 

Recurrent gastroesophageal reflux disease (GERD) after antireflux operations is a difficult and controversial problem to solve. In this case a third Nissen fundoplication is technically feasible but the chance of recurrent GERD in this setting is reported to be as high as 25%. In order to stop gastric acid reflux and vomiting in this patient an esophagogastric dissociation would be most effective. The parents should understand the magnitude of the operation and high complication rate including anastomotic leak, small bowel obstruction, paraesophageal hernia and bile reflux esophagitis.

 

A transgastric jejunostomy feeding tube may be an adequate short term treatment option but this doesn’t address reflux. A permanent surgical jejunostomy tube is a reasonable option for enteral access but again does not resolve the reflux. Converting the Nissen fundoplication to a partial wrap such as a Thal fundoplication would not likely eliminate the possibility of significant recurrent GERD. A tracheostomy also would not treat GER.

B