Definition

Anti-reflux surgery is surgery to tighten the muscles at the bottom of the esophagus (the tube that carries food from the mouth to the stomach). Problems with these muscles can lead to gastroesophageal reflux disease (GERD).

This surgery can also be done during a hiatal hernia repair.

This article discusses anti-reflux surgery in children.

Alternative Names

Fundoplication - children; Nissen fundoplication - children; Belsey (Mark IV) fundoplication - children; Toupet fundoplication - children; Thal fundoplication - children; Hiatal hernia repair - children; Endoluminal fundoplication - children

Description

The most common type of anti-reflux surgery is called fundoplication. This surgery most often takes 2 to 3 hours.

Your child will be given general anesthesia before the surgery. That means the child will be asleep and unable to feel pain during the procedure.

The surgeon will use stitches to wrap the upper part of your child's stomach around the end of the esophagus. This helps prevent stomach acid and food from flowing back up.

A gastrostomy tube (g-tube) may be put in place if your child has had swallowing or feeding problems. This tube helps with feeding and releases air from your child's stomach.

Another surgery, called pyloroplasty may also be done. This surgery widens the opening between the stomach and small intestine so the stomach can empty faster.

This surgery may be done several ways, including:

• Open repair -- The surgeon will make a large cut in the child's belly area (abdomen).
• Laparoscopic repair -- The surgeon will make 3 to 5 small cuts in the belly. A thin, hollow tube with a tiny camera on the end (a laparoscope) is placed through one of these cuts. Other tools are passed through the other surgical cuts.

The surgeon may need to switch to an open procedure if there is bleeding, a lot of scar tissue from earlier surgeries, or if the child is very overweight.

Endoluminal fundoplication is similar to a laparoscopic repair, but the surgeon reaches the stomach by going through the mouth. Small clips are used to tighten the connection between the stomach and esophagus.

Why the Procedure Is Performed

Anti-reflux surgery is usually done to treat GERD in children only after medicines have not worked or complications develop. Your child's health care provider may suggest anti-reflux surgery when:

• Your child has symptoms of heartburn that get better with medicines, but you do not want your child to continue taking these medicines.
• Symptoms of heartburn are burning in their stomach, throat, or chest, burping or gas bubbles, or problems swallowing food or fluids.
• Part of your child's stomach is getting stuck in the chest or is twisting around itself.
• Your child has a narrowing of the esophagus (called stricture) or bleeding in the esophagus.
• Your child is not growing well or is failing to thrive.
• Your child has a lung infection caused by breathing contents of the stomach into the lungs (called aspiration pneumonia).
• GERD causes a chronic cough or hoarseness in your child.

Risks

Risks for any surgery include:

• Bleeding
• Infection

Risks for anesthesia include:

• Reactions to medicines
• Breathing problems, including pneumonia
• Heart problems

Anti-reflux surgery risks include:

• Damage to the stomach, esophagus, liver, or small intestine. This is very rare.
• Gas and bloating that makes it hard to burp or throw up. Most of the time, these symptoms slowly get better.
• Gagging.
• Painful, difficult swallowing, called dysphagia. For most children, this goes away in the first 3 months after surgery.
• Rarely, breathing or lung problems, such as a collapsed lung.

Before the Procedure

Always make sure your child's health care team knows about all the medicines and supplements your child is taking, including those you bought without a prescription.

A week before surgery, you may be asked to stop giving your child products that affect blood clotting. This may include aspirin, ibuprofen (Advil, Motrin), vitamin E, and warfarin (Coumadin).

You will be told when to arrive at the hospital.

• The child should not eat or drink anything after midnight before surgery.
• Your child may take a bath or shower the night before or the morning of surgery.
• On the day of surgery, the child should take any medicine that the provider said to take with a small sip of water.

After the Procedure

How long your child stays in the hospital depends on how the surgery was done.

• Children who have laparoscopic anti-reflux surgery usually stay in the hospital for 2 to 3 days.
• Children who have open surgery may spend 2 to 6 days in the hospital.

Your child can start eating again about 1 to 2 days after surgery. Liquids are usually given first.

Some children have a g-tube placed during surgery. This tube can be used for liquid feedings, or to release gas from the stomach.

If your child did not have a g-tube placed, a tube may be inserted through the nose to the stomach to help release gas. This tube is removed once your child starts eating again.

Your child will be able to go home once they are eating food, have had a bowel movement and are feeling better.

Outlook (Prognosis)

Heartburn and related symptoms should improve after anti-reflux surgery. However, your child may still need to take medicines for heartburn after surgery.

Some children may need another operation in the future to treat new reflux symptoms or swallowing problems. This may happen if the stomach was wrapped around the esophagus too tightly or it loosens.

The surgery may not be successful if the repair was too loose.

References

Chun RH, Noel RJ, Arvedson JC. Pediatric swallowing, laryngopharyngeal and gastroesophageal reflux disease, eosinophilic esophagitis, and aspiration. In: Flint PW, Francis HW, Haughey BH, et al, eds. Cummings Otolaryngology: Head and Neck Surgery. 7th ed. Philadelphia, PA: Elsevier; 2021:chap 212.

Holcomb GW. Gastroesophageal reflux. In: Holcomb GW, Murphy JP, St. Peter SD, eds. Holcomb and Ashcraft's Pediatric Surgery. 7th ed. Philadelphia, PA: Elsevier; 2020:chap 28.

Kane TD, Brown MF, Chen MK; Members of the APSA New Technology Committee. Position paper on laparoscopic antireflux operations in infants and children for gastroesophageal reflux disease. American Pediatric Surgery Association. J Pediatr Surg. 2009;44(5):1034-1040. PMID: 19433194 pubmed.ncbi.nlm.nih.gov/19433194/.

Khan S, Matta SKR. Gastroesophageal reflux disease. In: Kliegman RM, St. Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, eds. Nelson Textbook of Pediatrics. 21st ed. Philadelphia, PA: Elsevier; 2020:chap 349.