RPM 125-1 Miolo.indd

O R IG IN A L A R T IC L E INTRODUCTION Gastroesophageal refl ux disease (GERD) in infancy presents significantly greater incidence in the population with associated neurological disease. There is a consensus that multifactorial events are involved in its etiopathogenesis, which makes it diffi cult to evaluate the results from treatment and to obtain adequate uniformity regarding the most appropriate therapeutic conduct for children with serious cerebral palsy and GERD. The conventional clinical treatment is often ineffective. Surgical treatment, based on carrying out different procedures for introducing anti-refl ux valves, is surrounded by high morbidity and mortality. Children with neurological lesions and GERD present high rates of postoperative complications such as dysphagia, delayed stomach emptying, gas retention syndrome and infections. The reoperation rate reported in the literature for these patients ranges from 20 to 47%, whereas for patients without neurological lesions these rates are between 4 and 11%. With regard to surgical therapy, a clear preference is shown in the literature for the Nissen fundoplication (NF) procedure (complete enveloping of the abdominal esophagus by the gastric fundus). However, complications are observed with this procedure, even when treating non-neuropathic children. Collis (1957) described a gastroplasty technique for lengthening the esophagus in patients with hiatal hernia and short esophagus. This concept gained wide acceptance and was much utilized at that time, before it was understood that progressive shortening of the esophagus secondary to esophagitis can occur. Modifi cations to this technique were proposed, such that vertical gastric plication (VGP) would be performed without sectioning the gastric wall, with the association of a valve mechanism. Performing the plication produces lengthening of the abdominal esophagus, and fundoplication would offer better control over refl ux. The observations have shown that fundoplication makes it diffi cult for the stomach to distend, thereby causing additional diffi culty in passage through the esophagus and accentuating the occurrence of dysphagia and respiratory diffi culties. Taylor et al. (1989) proposed that VGP should be performed via an abdominal route, with any type of associated fundoplication. They argued that this was a rapidly performed, simple and safe technique that diminished the possibility of the postoperative complications that are so frequent with the other techniques. The various types of gastric fundoplication, especially those that are constructed right round the esophagus, can be considered to be an additional obstacle to passage through the esophagus, because they impose an angle on the esophagogastric transition and cause diffi culty in the peristalsis occurring in the fi nal portion of the esophagus. This inconvenience becomes felt more strongly among individuals with esophageal dysmotility, especially those with neuropathy, in whom such dysmotility is more severe. Thus, control over gastroesophageal refl ux disease (GERD) in patients with dysmotility should be carried out through an operative procedure that alters the anatomy and physiology of the esophagogastric transition as little as possible. Alterations of this nature are promoted by NF, given the wrapping of the distal esophagus by the gastric walls. Such alterations and the consequent discomfort induced by them are well known in clinical practice. Thus, it is routine practice for the majority of surgeons treating adults with GERD by means of NF to recommend that non-neuropathic patients (i.e. those with normal esophageal motility) should follow a Antonio Paulo Durante Sergio Tomaz Schettini Djalma José Fagundes Vertical gastric plication versus Nissen fundoplication in the treatment of gastroesophageal refl ux in children with cerebral palsy Postgraduate Surgery and Experimentation Program, Universidade Federal de São Paulo – Escola Paulista de Medicina (Unifesp-EPM), and at Hospital do Servidor Público Estadual (IAMSPE) and Hospital Municipal Infantil Menino Jesus, São Paulo, Brazil CONTEXT AND OBJECTIVE: Association between neurological lesions and gastroesophageal refl ux disease (GERD) in children is very common. When surgical treatment is indicated, the consensus favors the fundoplication technique recommended by Nissen, despite its high morbidity and relapse rates. Vertical gastric plication is a procedure that may have advantages over Nissen fundoplication, since it is less aggressive and more adequately meets anatomical principles. The authors proposed to compare the results from the Nissen and vertical gastric plication techniques. DESIGN AND SETTING: Randomized prospective study within the Postgraduate Surgery and Experimentation Program of Unifesp-EPM, at Hospital do Servidor Público Estadual (IAMSPE) and Hospital Municipal Infantil Menino Jesus. METHODS: Fourteen consecutive children with cerebral palsy attended between November 2003 and July 2004 were randomized into two groups for surgical treatment of GERD: NF, Nissen fundoplication (n = 7); and VGP, vertical gastric plication (n = 7). These were clinically assessed by scoring for signs and symptoms, evaluation of esophageal pH measurements, duration of the operation, intra and postoperative complications, mortality and length of hospital stay. RESULTS: The mean follow-up was 5.2 months; symptoms were reduced by 42.8% (NF) (p = 0.001) and 57.1% (VGP) (p = 0.006). The Boix-Ochoa score was favorable for both groups: NF (p < 0.001) and VGP (p < 0.042). The overall mortality was 14.28% in both groups and was due to causes unrelated to the surgical treatment. CONCLUSION: The two operative procedures were shown to be effi cient and effi cacious for the treatment of GERD in neuropathic patients, over the study period.