Cardiaplication: A Novel Surgical Technique for Refractory Gastroesophageal Reflux in the Pediatric Population

Introduction

Pathologic gastroesophageal reflux disease (GERD) in the pediatric population is common. ¹ In severe cases, clinical manifestations can include failure to thrive, aspiration pneumonia, asthma, esophagitis, bradycardia, or even death. Treatment options vary, from lifestyle changes, such as thickening feeds, avoidance of certain foods, and weight loss (in obese children), to various medications, to surgical approaches. Antireflux surgery in the pediatric population is generally employed in patients with reflux that is refractory to medical therapy. Surgical technique for managing reflux includes the Nissen fundoplication, the Toupet fundoplication, and an anterior partial wrap among others. These antireflux operations represent one of the most common operations performed by pediatric surgeons. ²

Operative treatment for GERD in both infants and adults aims at increasing the lower esophageal sphincter (LES) pressure by physically wrapping the stomach around the distal esophagus, elongating the intra-abdominal esophageal, and repair of any hiatal defect. During a Nissen fundoplication, the angle of His is modified as the stomach is wrapped around the esophagus. ³ To gain enough intra-abdominal esophagus the cura are usually dissected from the esophagus and nearly always require a crural repair. This dissection can lead to wrap herniation and a paraesophageal hernia. Holcomb et al. have shown that minimizing the hiatal dissection can lead to less wrap failure due to herniation through the esophageal hiatus. ⁴ Other risk factors for recurrent GERD are patients less than 1 year of age and patients with neurologic impairment. Others speculate that risk of recurrence is more often related to preoperative presence of a hiatal hernia, postoperative retching, and postoperative esophageal dilation. ⁵ Postoperative complications and wrap failures are not uncommon, with 10%–20% requiring re-operation.^6,7

Over the past year, our practice has encountered 3 infants with medically refractory reflux and anatomic limitations that prevented fundoplication. Out of necessity, we sought out to develop an alternative surgical technique to address their reflux. The 3 patients all had heterotaxy and tubular stomachs with essentially no fundus to perform the wrap.

We theorized that imbrication of the gastric cardia would effectively tubularize the proximal stomach creating an elongated neoesophagus. The newly formed tubularized section of stomach would function as an elongated intra-abdominal portion of the esophagus. This cardiaplication would also create an internal flapper valve at the cardia. We postulated that this procedure would allow for the antireflux properties with a decrease in postoperative recurrence.

Methods

Three patients with refractory GERD were referred to our practice for surgical intervention. Each of these patients had a history of congenital cardiac disease and heterotaxy. All patients had a UGI, which confirmed the diagnosis of reflux and demonstrated malrotation. They were all noted to have abnormal gastric anatomy, with essentially an absent fundus and a large vertical vein that coursed along the gastroesophageal junction. Two of the patients had undergone a laparoscopic Ladd's procedure before referral.

Results

Cardiaplication was performed in 3 infants with heterotaxy ranging from 62 to 292 days old. Each case was started laparoscopically and in one instance it was necessary to convert to a laparotomy secondary to dense adhesions from a prior operation. All patients had a G-tube placed at the conclusion of the operation; during one case, a concomitant laparoscopic Ladd's procedure was completed. The duration of surgery ranged from 91 to 176 minutes, and estimated blood loss for each case was 5 mL. Period of stay ranged from 6 to 41 days.

Two of the patients were started on G-tube feeds on postoperative day (POD) 2 and one had feeds initiated on POD 3. Goal feeds were attained within 2 days of initiation in 2 patients and in 16 days for one.

Two of the patients had upper GI contrast studies performed in the initial postoperative period due to concern over emesis and postoperative ileus. Imaging on POD 1 showed minimal reflux in 1 patient; however, follow-up imaging 3 months postoperative showed no reflux. Upper GI was performed on POD 8 in 1 patient and it did not demonstrate reflux.

There were no intraoperative complications from the cardiaplication. A prolonged postoperative ileus was noted in the patient that had undergone an extensive lysis of adhesions whose procedure was converted to open laparotomy.

At intermediate follow-up (13, 7, and 4 months), 2 of the 3 patients remain on antireflux medications. All of the patients who underwent cardiaplication are clinically symptom free. One of the 3 patients no longer requires G-tube feeds. The other 2 continue to take thickened oral feeds with G-tube supplementation. Patient details and outcomes are further detailed in Table 1.

Discussion

While most clinicians recognize that cause of reflux in most patients is likely multi-factorial, the classic physiologic theory for GERD is that an incompetent LES permits gastric acid and bile to reflux into the esophagus, causing the associated symptoms.^8,9 The incompetent LES is likely due to a short intra-abdominal length of esophagus with or without an associated hiatal hernia. ¹⁰ An abnormal angle of His may also play a role, but may be a marker for a short intra-abdominal esophagus. Many infants outgrow their reflux, likely due to elongation of the intra-abdominal length of esophagus with maturing of the hiatus.^10–12 An enlarged hiatal hernia, which is more common in infants, has also been implicated as an underlying cause of reflux in infants. ¹³

In this small case series, we report our initial experience with a new surgical technique, cardiaplication, for the treatment of GERD. In each case, the cardiaplication was utilized secondary to anatomic limitations that prevented performing a traditional fundoplication. Recognizing the context of the small number of patients and the fact that follow-up is intermediate, few definitive conclusions about this technique can be provided at this time. Preliminary findings, however, suggest efficacy and safety. This new surgical technique appears to be a viable alternative in patients with anatomic limitations that limit the ability to perform a traditional fundoplication. After more extensive testing and long-term follow-up, we see potential to expand the indications for cardiaplication to include infants less than a year. We postulate that there may be less recurrent GERD, as the hiatus is not disrupted. We plan to further study the characteristics of cardiaplication in a porcine model, followed by a human trial. With adequate exploration and delineation of its safety and efficacy, cardiaplication may prove to be a more favorable alternative for infants with reflux.