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Laparoscopic surgery for gastro-oesophageal reflux (fundoplication) (child)

Copyright © 2016 Page 1 of 5Expires end of May 2014

What is gastro-oesophageal reflux?Gastro-oesophageal reflux (acid reflux) is a condition where acid from the stomach travels up into the oesophagus (gullet). It is normal for a small amount of acid to travel into the oesophagus. If this happens too often in children it can lead to vomiting, causing symptoms of �failing to thrive�, or repeatedly inhaling acid, causing breathing problems. Your child may also get pain in the chest (�heartburn�). The acid can cause the lining of the oesophagus to become inflamed (oesophagitis) or scarred causing breathing problems and chest infections (see figure 1).

This can be distressing for your child.Your surgeon has recommended an operation for your child that will help prevent the acid from travelling into the oesophagus.

About this documentWe understand this can be a stressful time as you deal with different emotions and sometimes you have questions after seeing the doctor. This document will give you a basic understanding about your child�s operation. We tell you about the things you can do to help make the operation a success. It is also important to remember to tell your doctor about any medicine your child are on so they can manage this, if necessary. It will also tell you about what to expect after the operation � while in hospital and in the long term. If you think your child is mature enough, it is best to discuss the operation with them so they can be involved in the decision too. Your doctor remains the best person to speak to about any questions or concerns you or your child may have about the operation.

How does gastro-oesophageal reflux happen?At the join between the stomach and oesophagus there is a weak valve that prevents acid from travelling up into the oesophagus.Sometimes this valve does not work effectively, causing gastro-oesophageal reflux.The oesophagus normally passes through a hole in the diaphragm (the muscle that separates the chest from the abdomen). Gastro-oesophageal reflux is commonly associated with a hiatus hernia, where the top of the stomach passes through the hole in the diaphragm into the chest (see figure 2).

Figure 1a A normal valveb A faulty valve

b

a

Oesophagus

Stomach

Inflammation

Figure 2An hiatus hernia

Stomach

Copyright © 2016 Page 1 of 5Expires end of December 2017


Gastro-oesophageal reflux is more common in children with neurological disorders, such as cerebral palsy, where the stomach does not empty in the normal way.

What are the benefits of surgery?Your child should get relief from symptoms of gastro-oesophageal reflux.

Are there any alternatives to a fundoplication?Simple measures, such as giving smaller feeds more often, making the feeds thicker and nursing your child in an upright position, are often all that you need to do to treat gastro-oesophageal reflux.If your child does not respond to these simple measures, they can be given medicine to control symptoms and heal the inflammation in the oesophagus. Medicine called 'proton pump inhibitors' and 'H2 antagonists' work by lowering the acid content in the stomach and are currently the most effective treatment for gastro-oesophageal reflux in children.Surgery is usually recommended only if your child�s symptoms continue while they are on the medicine or if they have a problem like a hiatus hernia.Your child may be able to have a gastrostomy or jejunostomy, where a feeding tube is inserted in their stomach or intestine.Your surgeon will tell you why they have recommended a fundoplication for your child.

What will happen if I decide that my child will not have the operation?Surgery is not essential and your child can continue on the medicine to control the symptoms. You should discuss with your child�s doctor the side effects of long-term medicine.

What does the operation involve?The healthcare team will carry out a number of checks to make sure your child has the operation they came in for. You can help by confirming to your surgeon and the healthcare team your child�s name and the operation they are having.The operation is performed under a general anaesthetic and usually takes one to two hours. Your child may also have injections of local anaesthetic to help with the pain after the operation. Your child may be given antibiotics during the operation to reduce the risk of infection.

Your surgeon will use laparoscopic (keyhole) surgery as this is associated with less pain, less scarring and a faster return to normal activities.Your surgeon will make a small cut on or near the umbilicus (belly button) so they can insert an instrument in the abdominal cavity to inflate it with gas (carbon dioxide).They will make several small cuts on the abdomen so they can insert tubes (ports) into the abdomen. Your surgeon will insert surgical instruments through the ports along with a telescope so they can see inside the abdomen and perform the operation (see figure 3).

Your surgeon will hold the liver out of the way and free up the upper stomach and lower oesophagus, along with the muscular part of the diaphragm. If the hole in the diaphragm that the oesophagus passes through is too wide, they will use stitches to make it narrower.Your surgeon will wrap and stitch the top part of the stomach around the lower oesophagus, to produce a valve effect (see figure 4).

Figure 3Laparoscopic surgery



Your surgeon can wrap the stomach all the way round the oesophagus or just part-way round. Your surgeon will tell you what the best wrap is for your child.They may also insert a gastrostomy button into your child�s stomach if they have problems swallowing. This will allow the healthcare team to give your child nutrients and fluid directly into their stomach. They will tell you if this is a possibility.Your surgeon may place a tube (nasogastric or NG tube) into your child�s nostrils and into their stomach to remove any fluid.For about 1 in 10 children it will not be possible to complete the operation using keyhole surgery. The operation will be changed (converted) to open surgery, which involves a larger cut on the upper abdomen.Your surgeon will remove the instruments and close the cuts.

What can I do to help make my child�s operation a success?Your child should try to maintain a healthy weight. They will have a higher risk of developing complications if they are overweight.Your child can reduce their risk of infection in a surgical wound.� In the week before the operation, your child should not shave or wax the area where a cut is likely to be made.� Your child should have a bath or shower either the day before or on the day of their operation.

� Your child should keep warm around the time of the operation. Let the healthcare team know if your child feels cold.

What complications can happen?The healthcare team will try to make the operation as safe as possible but complications can happen. Some of these can be serious and can even cause death. Using keyhole surgery means it is more difficult for your surgeon to notice some complications that may happen during the operation. When your child is recovering, you need to be aware of the symptoms that may show that they have a serious complication. You should ask your doctor if there is anything you do not understand. Your doctor may be able to tell you what the risk of a complication for your child is.

1 Complications of anaesthesiaYour anaesthetist will be able to discuss with you the possible complications of having an anaesthetic.

2 General complications of any operation� Pain. The healthcare team will give your child medicine to control the pain and it is important that they take it as you are told so they can move about and cough freely. After keyhole surgery, it is common to have some pain in the shoulders because a small amount of carbon dioxide gas may be left under the diaphragm. The body will usually absorb the gas naturally over the next 24 hours, which will ease the symptoms.� Bleeding during or after the operation. Your child may need a blood transfusion or another operation.� Developing a hernia in the scar, if your child has open surgery, caused by the deep muscle layers failing to heal. This appears as a bulge or rupture called an incisional hernia. If this causes problems, your child may need another operation.� Infection of the surgical site (wound). It is usually safe for your child to shower after two days but you should check with the healthcare team. Let the healthcare team know if your child gets a high temperature, you notice pus in their wound, or if their wound becomes red, sore or painful. An infection usually settles with antibiotics but your child may need another operation.

Figure 4The stomach stitched around the oesophagus

Wrap



� Unsightly scarring of the skin, particularly if the wound becomes infected.

3 Specific complications of this operationa Keyhole surgery complications� Surgical emphysema (crackling sensation in the skin caused by trapped carbon dioxide gas), which settles quickly and is not serious.� Damage to structures such as the bowel, bladder or blood vessels when inserting instruments into the abdomen (risk: less than 3 in 1 000). The risk is higher if your child has had previous surgery to their abdomen. If an injury does happen, your child may need open surgery. About one in three of these injuries is not obvious until after the operation.� Developing a hernia near one of the cuts used to insert the ports (risk: 1 in 100). Your surgeon will try to reduce this risk by using small ports (less than a centimetre in diameter) where possible or, if they need to use larger ports, using deeper stitching to close the cuts.b Fundoplication complications� Difficulty swallowing for a few months because the site where the stomach is wrapped around the oesophagus is inflamed. This is common and your child should be able to swallow most foods normally by three months.� Air in the chest cavity, where air escapes into the space around the lung. Your child may need to have a tube in their chest (chest drain).� Making a hole in the oesophagus or stomach which needs repairing. This is serious but rare.� Damage to the liver when holding it out of the way (risk: 5 in 100). If the damage is serious, the operation may need to be converted to open surgery to repair the damage.� Tear of the stitches used for the wrap if your child retches (strains to be sick) or vomits in the first few weeks. This may cause the wrap to become loose. Sometimes a tear can make a hole in the stomach, which would need to be repaired straightaway with surgery.

Long-term problems� Continued difficulty swallowing where your child cannot swallow most foods normally (risk: 5 in 100). If you find that foods such as bread and meat get stuck, avoid them and ask your doctor for advice.

� Weight loss during the first two months. It is normal for your child to feel fuller than usual and they may only be able to eat small meals. Your child should sit upright when they eat and take a drink with their meal to help the food go down. Your child should eat more often than before to try to keep their weight up. If your child does lose weight, they will usually put it back on. If you have any concerns about your child�s diet, ask the dietician.� Incomplete control of reflux symptoms if the wrap is not tight enough or becomes loose or partly undone (risk: less than 5 in 100). This may settle with medicine.� Abdominal discomfort (risk: 3 to 5 in 10). Your child will probably not be able to burp as usual, which can cause gas to build up in the abdomen. Your child may pass more wind than usual.� Diarrhoea (risk: less than 3 in 100). If loose or more frequent stools are troublesome, your doctor may give you medicine to slow down your child�s bowel.� Tissues can join together in an abnormal way (adhesions) when scar tissue develops inside your child's abdomen. Adhesions do not usually cause any serious problems but can lead to bowel obstruction.If any of these problems are severe and continue for over three months, your child may need another operation (risk: less than 5 in 100). If your child has these symptoms for over three months, let your surgeon know.

How soon will my child recover?

� In hospitalAfter the operation your child will be transferred to the recovery area and then to the ward. If your child has a drip or NG tube, these will need to stay in place for one to two days.They should be able to go home within a few days. However, your doctor may recommend that your child stays a little longer. Your child will be given anti-sickness medicine. They will be able to drink from the first day and then will go on a soft diet.You need to be aware of the following symptoms as they may show that your child has a serious complication.� Pain that gets worse over time or seems severe when your child moves, breathes or coughs.� A high temperature or fever.� Dizziness, seeming faint or short of breath.



� Seeming sick or not having any appetite (and this gets worse after the first one to two days).� Not opening their bowels and not passing wind.� Swelling of the abdomen.� Difficulty passing urine.If your child does not continue to improve over the first few days, or if they have any of these symptoms, let the healthcare team know straightaway. If your child is at home, contact your surgeon or GP. In an emergency, call an ambulance or go immediately to your nearest casualty unit.

� Returning to normal activitiesYour child will need to learn to eat slowly and chew food thoroughly. Keep your child only on soft foods for a few weeks, gradually moving on to a normal diet when they can cope with it. Do not give your child fizzy drinks.Your child should be able to return to school after three to four weeks, depending on how much surgery they need.

� The futureYour child should make a full recovery, with the symptoms of gastro-oesophageal reflux gone or much improved. If your child has a neurological disorder, some problems may continue.

SummaryGastro-oesophageal reflux can lead to symptoms of �failing to thrive�, breathing problems and heartburn. The acid can cause the lining of the oesophagus to become inflamed or scarred. Surgery may be recommended if your child�s symptoms continue while they are on medicine.Surgery is usually safe and effective but complications can happen. You need to know about them to help you to make an informed decision about surgery for your child. Knowing about them will also help you to help the healthcare team to detect and treat any problems early.

Keep this information leaflet. Use it to help you if you need to talk to the healthcare team.

AcknowledgementsAuthor: Mr Shailinder Singh DM FRCS (Paed. Surg.) and Mr Simon Parsons DM FRCS (Gen. Surg.)Illustrations: Medical Illustration Copyright © Medical-Artist.com

This document is intended for information purposes only and should not replace advice that your relevant healthcare professional would give you.

You can access references online at www.aboutmyhealth.org. Use reference PS07.


ps07 laparoscopic surgery for gastro-oesophageal reflux ... · reflux. if your child does not...

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