Published online December 1, 2006
PEDIATRICS Vol. 118 No. 6 December 2006, pp. 2326-2333 (doi:10.1542/peds.2006-2212)
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ARTICLE

Do Antireflux Operations Decrease the Rate of Reflux-Related Hospitalizations in Children?

Adam B. Goldin, MD, MPHa,b, Robert Sawin, MDa,b, Kristy D. Seidel, MSc and David R. Flum, MD, MPHb

a Division of Pediatric General and Thoracic Surgery
c Office of Biostatistical Services, Children’s Hospital and Regional Medical Center, Seattle, Washington
b Department of Surgery, University of Washington Medical Center, Seattle, Washington


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVE. Gastroesophageal reflux disease is extremely common in the pediatric population, and antireflux procedures are performed with increasing frequency. The objective of this study was to determine whether pediatric antireflux procedures are associated with a decreased rate of reflux-related hospitalizations.

METHODS. A study was conducted of pediatric patients who were undergoing antireflux procedures using data that were derived from the Washington State Comprehensive Hospital Abstract Reporting System and Vital Records. Patients were identified by a search of all records (1987–2001) for procedure codes that pertained to antireflux procedures in patients who were younger than 19 years. The number of hospitalizations for and rates of reflux-related events per patient-year before and after an antireflux procedure was calculated, and factors that were associated with higher antireflux procedure rates were examined.

RESULTS. A total of 1142 patients underwent antireflux procedures. The rate of reflux-related events declined sharply with age both before and after an antireflux procedure. The cohort was divided into 3 groups on the basis of age at first antireflux procedure (<1 year, 1–3 years, or 4–19 years), and the calculations of incidence rate ratios before to after an antireflux procedure were done within the same age strata. Results suggest an overall benefit of antireflux procedures in young children. For antireflux procedures that were performed in children who were older than 4 years, the benefit is less clear. Developmental delay was significantly associated with higher rates of reflux-related events among patients who underwent an antireflux procedure after age 4.

CONCLUSIONS. The rate of reflux-related events was lower after an antireflux operation for children who underwent an antireflux procedure before age 4. Older children, however, were hospitalized at equal rates before and after an antireflux procedure, and older children with developmental delay were hospitalized at greater rates after an antireflux procedure. These findings highlight the need to clarify the subjective and objective indications for antireflux procedures in infants and children.

Key Words: antireflux surgery • Nissen fundoplication • gastroesophageal reflux • aspiration pneumonia • medical error • quality

Abbreviations: GERD—gastroesophageal reflux disease • ARP—antireflux procedure • RRE—reflux-related event • CHARS—Washington State Comprehensive Hospital Abstract Reporting System • ICD-9—International Classification of Diseases, Ninth Revision • IRR—incidence rate ratio • CI—confidence interval

Childhood manifestations of gastroesophageal reflux disease (GERD) are common, and antireflux procedures (ARPs) are increasingly offered to control these symptoms. In some medical centers, ARPs now represent the third most frequently performed operation in children.1–3 Nationwide, >35000 pediatric ARPs were performed between 1990 and 1997.4

Most published reports of ARP indicate that the procedure is safe and associated with symptom abatement in a significant percentage of patients. For example, in the largest series to date, Fonkalsrud et al5 retrospectively evaluated the physician-reported outcomes of 7467 patients who underwent ARP in 7 hospitals over 20 years. They found 95% symptom abatement in neurologically normal children and 85% abatement in neurologically impaired children. Although this review and others2,5–29 suggest that a high percentage of patients benefit from these procedures, the impact of ARPs on objective measures of outcome over the course of the child’s lifetime has yet to be assessed.

The purpose of this study was to determine the effectiveness of ARP on objective measures of outcome over the course of the child’s lifetime and to assess these outcomes on a community level. Our hypothesis was that the post-ARP rate of reflux-related events (RREs), specifically the post-ARP rate of aspiration pneumonia, would be lower than the pre-ARP rate.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
We conducted a retrospective cohort study using a statewide hospital discharge database. Data were obtained from the Washington State Comprehensive Hospital Abstract Reporting System (CHARS) database. This data set is derived from all public and private hospitals in Washington State (Veterans Affairs and US Military hospitals excluded). The data set contains demographic variables, admission and discharge administrative details, payer status, International Classification of Diseases, Ninth Revision (ICD-9) procedure and diagnosis codes, and coded hospital identifiers. By means of a unique patient identifier, data were linked on patients across hospitalizations, allowing a longitudinal record to be created for each patient. CHARS records of interest were linked to the Washington State Department of Health Vital Statistics Database to identify patients who died during the follow-up period. Whereas the linkage of these 2 data sets was performed with coded patient identifiers, an anonymous data set was used for the analysis.

This study was exempted from human subjects review by agreement of the University of Washington Human Subject Review Committee and the Washington State Department of Health. The data set included anonymous data and is considered within the public domain.

Patients
The cohort was defined by searching all CHARS reports (1987–2001) for ICD-9 procedure codes that pertained to ARP in patients who were younger than 19 years.

Definition of Variables
RREs were defined as hospitalizations with diagnostic or procedure codes for aspiration pneumonia, pneumonia, mechanical ventilation, esophagitis, or esophageal reflux. The rates of RRE per days of life before ARP (pre-ARP rate) and after ARP (post-ARP rate) were calculated directly. The "before" period was calculated as elapsed days of life during the study period from January 1, 1987, or birth (if born during study period) until the hospitalization for the first ARP. The "after" period was elapsed time from discharge from the ARP hospitalization until death, the patient’s 19th birthday, or December 31, 2001. Developmental delay and prematurity were defined by the presence of any 1 of several ICD-9 Clinical Modification diagnostic codes during any hospitalization.

Analysis
Categorical variables were compared using Pearson and {chi}2 methods. Incident rates of hospitalizations with diagnoses of aspiration pneumonia, esophagitis, esophageal reflux, or ventilator requirement were compared after ARP with before ARP using a negative binomial regression model. This model was chosen over the commonly used Poisson model for incidence rate data because there was strong evidence of overdispersion in our data set. The Poisson model has only a single parameter for representing both the mean and the variance of the data. This restriction results in a poor fit when the variance exceeds the mean. The negative binomial model is more flexible than the Poisson and has an additional parameter that allows it to accommodate the overdispersion (large variance) that was observed in our data set. Negative binomial modeling of the pre- versus post-ARP incidence rate ratios (IRR) was performed first for the population as a whole, without adjustment for covariates, and subsequently with additional terms added to control for developmental delay, prematurity, and gender. Patient age was treated as a stratification factor in the analysis. In addition to our analysis of all RRE hospitalizations, we compared incident rates of hospitalizations after ARP with before ARP for hospitalizations with a diagnosis of aspiration pneumonia.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
A total of 1142 patients were identified as having an ARP (mean age at discharge from hospitalization for first ARP: 4.0 ± 5.6 years; 59% male). Fifty-one percent had a diagnosis of developmental delay, and 9% were born preterm. Twenty-one percent of patients had been hospitalized before their operation with the diagnosis of pneumonia (62% of pneumonias were coded as aspiration pneumonia), 16% with esophageal reflux, 16% with ventilator requirement, and 12% with esophagitis. The observation window did not extend all the way back to birth for some patients, so these figures likely underestimate the true percentages.

Of the 1142 unique patients with hospitalizations for ARP, 85 (7.4%) were inpatients at the beginning of the study window and therefore had 0 observation time before their hospitalizations for ARP. One child was still an inpatient for the hospitalization for ARP at the end of the study and therefore had 0 observation time after this hospitalization. Of the remaining 1056 records identified, 543 (47.5%) had no hospitalizations with diagnostic or procedure codes for aspiration pneumonia, pneumonia, mechanical ventilation, esophagitis, or esophageal reflux (RREs) before the ARP. Thirty-four percent (185 of 543) of these children carried the diagnosis of developmental delay and 0.4% were preterm, whereas 70% (364 of 513) of the patients who were hospitalized before ARP had developmental delay and 12.9% were preterm (P < .001 for both [Pearson and {chi}2]; Fig 1).


Figure 1
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  		FIGURE 1 Study population. aA total of 34% had developmental delay, and 0.4% were preterm. bA total of 70% had developmental delay, and 12.9% were preterm.

 
Children who received ARP in the youngest age range had the highest rates of hospitalization for RRE both before and after ARP. The rate of RRE declined sharply as individuals aged regardless of the age that the ARP was performed (Table 1). For example, among children who had their ARP within the first year of life, the post-ARP hospitalization rate declined from 0.67 RRE per patient-year for the remainder of the first year to 0.34 during ages 1 to 3 and finally to 0.07 for ages 4 to 18. Similarly, the pre-ARP rate dropped from 0.36 to 0.17 to 0.15 with increasing age group among children who did not have ARP until some time after age 4. To account for these aspects of the natural history of GERD in the pre-ARP to post-ARP comparisons, we stratified the calculations of pre- to post-ARP IRRs within the same age range so that years of follow-up distant from the actual time of the ARP would not distort the comparisons. Among children who underwent ARP during their first year of life, the pre-ARP rate was 1.95 RREs per patient-year compared with a rate of 0.67 between the procedure and the child’s first birthday (IRR: 0.34; 95% confidence interval [CI]: 0.28–0.42). Among children who underwent ARP at ages 1 to 3, the RRE rate also declined significantly from 0.91 per patient-year before ARP to 0.50 per patient-year afterward (IRR: 0.55; 95% CI: 0.42–0.71). Among children who underwent ARP at ages 4 to 18, the RRE rate did not decline after the procedure. In fact, the rate increased from 0.15 RRE per year before ARP to 0.23 RRE per year after ARP (IRR: 1.52; 95% CI: 1.19–1.94). This IRR, however, was not statistically significantly different from 1.0 after adjustment for developmental delay, preterm birth, and gender (adjusted IRR: 1.27; 95% CI: 0.97–1.64). In contrast, the adjusted IRRs for the pre-ARP to post-ARP comparisons in the 2 previous age categories remained essentially the same, with strongly significant indications of declining RRE rates after ARP. Gender was not a significant factor in the multivariable models. Preterm birth was a moderately significant factor (P values ranging from .04 to .001 in the 3 age groups), and developmental delay was a strikingly influential factor (P < .0001 in all 3 age ranges).


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  		TABLE 1 Overall Reflux-Related Event Hospitalization Rates

 
The multivariable modeling suggested an interaction between developmental delay and pre- to post-ARP status. To investigate whether the overall findings apply to both patients with and without developmental delay, we estimated the RRE incidence rates and rate ratios separately for each subset (Table 2). Both the subsets with and without delay showed reduced RRE rates after ARP when the procedure was done in the youngest or middle age range. Among the patients who did not have developmental delay and had their reflux operation after age 4, the RRE rate was unchanged after ARP; however, the patients with developmental delay in this age range experienced a significantly higher RRE rate after ARP (IRR: 1.38; 95% CI: 1.03–1.85).


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  		TABLE 2 RRE Hospitalization Rates by Developmental Delay

 
We also examined outcomes that were restricted to hospitalizations with a diagnosis of aspiration pneumonia. This class of events constituted 582 (24%) of the total 2470 reflux-related hospitalizations. Among patients without developmental delay, the results for aspiration pneumonia were very similar to those that were observed for the overall RRE hospitalization rates. The IRRs for the pre- to post-ARP comparisons were 0.15 (95% CI: 0.07–0.33) for ARP at <1 year, 0.42 (95% CI: 0.08–2.18 for ARP at ages 1 to 3, and 1.17 (95% CI: 0.33–4.16) for ARP at ages 4 to 18. Among patient with developmental delay, however, the pattern was less clear, with no statistically significant differences between pre- and post-ARP rates emerging in any age group (IRR: 0.85 [95% CI: 0.51–1.42] for ARP at <1 year; IRR: 0.72 [95% CI: 0.42–1.25] for ARP at ages 1–3; IRR: 0.84 [95% CI: 0.69–2.06] for ARP at ages 4-18).

Forty-four patients died during our observation window, and 11 of these deaths occurred during the hospitalization for ARP. Of these 11 patients (mean age: 2.5 years), 7 (64%) were younger than 1 year, 2 (18%) had developmental delay, and 2 were preterm. Of the remaining 33 patients (mean age: 5.4 years), 27 (82%) had developmental delay and 3 (9%) were preterm. Thirteen (39%) of these 33 patients died during the first hospitalization after the hospitalization for ARP (Fig 2).


Figure 2
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  		FIGURE 2 Number of hospitalizations until death.

 
Eighty-three (7%) children underwent at least 1 reoperation for ARP, and 5 of these children (0.4% of the entire population) underwent a second reoperation. Sixty-one (73%) of these children had developmental delay, and 8 (10%) were preterm. The majority (71%) of these patients had their reoperation within the first 2 hospitalizations after the hospitalization for ARP. Seventy-five percent of these reoperations occurred within the first 2 years after the first ARP.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
GERD is a commonly occurring disease that involves a broad spectrum of causes and manifestations in children. The natural history of GERD in infants and children is poorly understood, especially within the context of "normal" infant regurgitation.30–32 Generally, however, both regurgitation and GERD are believed to involve symptomatic improvement over time in the majority of patients (Fig 3). 33–37 The indications for intervening in this natural history by performing an ARP have been to ameliorate the symptoms and complications of GERD when, despite maximal medical management, they are of such magnitude that they are intolerable, impeding growth and development, or life-threatening. ARPs commonly are performed, but their effectiveness in infants and children has never been evaluated objectively on a population level.


Figure 3
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  		FIGURE 3 Natural history of the percentage of children with regurgitation by age.30–32

 
Our study indicates that, in general, ARP was associated with an overall decrease in the rate of hospitalizations for RREs. Our study also supports the concept that the natural history of GERD in children is one of gradual improvement over time (at least as measured by discrete hospitalizations) and furthermore that an ARP has an impact on this natural history to varying degrees on the basis of patient characteristics. Our data suggest that children who have an ARP in the first year of life have a 65% lower rate of hospitalizations after ARP, and children between the ages of 1 and 3 years have a 45% lower rate. The impact of ARP on hospitalization rates in each of these groups remained relatively unchanged after controlling for developmental delay, preterm birth, and gender. It is interesting that the oldest age group did not demonstrate a benefit in the rate of hospitalizations for RRE after an ARP. In fact, children with developmental delay were hospitalized more frequently after ARP than before.

These findings stand in striking contrast to clinical expectations of the impact of the operation on the natural history of the disease, as well as to published reports that detail excellent outcomes after these procedures (Table 3). Differences between observed and expected findings may be related to the characteristics of the patients who undergo ARP. Whereas the symptoms of GERD in younger children may be secondary to pathologic regurgitation, these same symptoms in older children may be attributable to different underlying pathology that is not well treated by an ARP. Perhaps the younger age groups benefit from ARP because the operation has a positive influence on the natural history of regurgitation; this benefit on RREs may no longer be present once a child reaches a plateau of the natural history curve. This suggests that we are performing ARP for what clinicians consider the same indication in each of the age groups (eg, aspiration, emesis) but that the underlying cause of the aspiration/emesis is different in the older population and therefore is not treated as effectively by an ARP.


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  		TABLE 3 Percentage of Patients With Resolution of Symptoms According to Study

 
There may be other reasons for why our findings differ from others who have addressed this issue. First, we selected a different outcome after ARP than other investigators in previous studies. Rather than address symptoms, our study compared rates of reflux-related hospitalizations for diagnoses such as aspiration pneumonia. These more objective measures of outcome were used to answer the broader question of whether ARP helps keep children out of the hospital for the manifestations of GERD. To our knowledge, only 1 other investigator evaluated hospitalizations before and after ARP.38 That study compared 77 neurologically intact and impaired children and showed a decrease in the mean number of admissions in the 6 months after ARP, although this finding was significant only for the neurologically impaired group. In that study, however, they did not evaluate the indications for subsequent hospitalization.

A second way to explain our findings compared with the work of other investigators relates to the variability in evaluation and management of children with GERD. Most studies to date in children have been case series with different indications for surgery, preoperative workup, and postoperative outcome assessment. Whereas in adults the use of preoperative objective measures of reflux severity (eg, pH monitoring, esophageal manometry) have become incorporated into standard clinical decisions,39 their use seems less common in children, and there has been little standardization in the preoperative assessment of children with severe GERD. For example, the largest retrospective case series published shows 68% having preoperative upper gastrointestinal series, only 54% having pH evaluation, 32% having a gastric emptying study, and 25% undergoing preoperative esophagoscopy.5 Given this variability in objective patient evaluation, when comparing the outcomes across an entire state, it might be expected that there would be greater heterogeneity in measured outcomes than that seen in single case series.

Third, it may be that our findings do not differ from others and we are simply choosing to focus on different aspects of the same findings. Although in clinical series symptomatic relief has been demonstrated in 70% to 100% of patients after ARP,2,5–29 this suggests that up to 30% are not improving symptomatically despite surgical intervention. Given that ~25% of postsurgical pediatric patients who are asymptomatic have been found to have "silent" reflux by upper gastrointestinal or pH testing,2,12,15,16,18,23,27 these results suggest that the manifestations of GERD in children are less than optimally controlled with surgery. Although patients’ symptoms may be controlled, our study suggests that on a population level, ARPs may not be controlling the complications of GERD in a large subset.

These findings have significant implications given the prevalence of GERD, the impact of adverse outcomes in pediatric surgery on patients and families, and the health care dollars that are involved in the care of this population. Almost half of healthy infants have emesis more than twice per day, and the prevalence of reflux is estimated to be as high as 18%.40 Amid this background, we suspect that the number of ARPs performed has increased yearly since the introduction of the laparoscopic approach, and the charges that are associated with each hospitalization has increased to approximately $20000.

There are several limitations to this analysis. First, we used an administrative data set, and the possibility of misclassification by improper coding cannot be excluded. In addition, the observation window did not extend all the way back to birth for some patients; therefore, our estimates of various diagnoses, such as preterm birth, likely underestimate the true percentages. Second, ICD-9 Clinical Modification codes do not allow for the differentiation between laparoscopic and open procedures or distinguish between types of operations (Nissen versus Thal versus Toupet, etc). We therefore could not compare outcomes relative to the many different management approaches. Third, poorly defined diagnoses such as esophagitis or reflux may be associated with hospitalizations that were unrelated to this diagnosis, resulting in additional misclassification by associating an admission with a diagnosis that was not a primary cause of the child’s hospitalization. It is for this reason that we included mechanical ventilation as a "complication" of GERD. The populations of children who are clinically suspected of having GERD and also have chronic lung disease and/or recurrent aspiration pneumonia that requires mechanical ventilation are more likely to undergo an ARP. Because procedure codes are more accurate than diagnostic codes as markers of an event, we were hoping that this coding might help to capture real events. Fourth, given the potential inaccuracy of diagnostic codes in an administrative discharge database, we did not believe that an appropriate control population could be identified for comparison. It is for this reason that we performed a before-and-after study that compared rates. Fifth, we did not address post-ARP hospitalizations that were associated with complications of the operation but were not associated with recurrence of RREs or address recurrent reflux as a result of fundoplication failure that required revision ARPs; therefore we may be underestimating the morbidity of the procedure. Sixth, we were unable to identify individual surgeons, although 87.5% of cases were performed in hospitals that are serviced by board-certified pediatric surgeons. Finally, we could not explain why 47.5% of our population did not have any hospitalizations before ARP. Given that 90% of these patients were residents of the state of Washington, most likely this population represents patients who undergo a diagnostic evaluation and preoperative planning as outpatients and are hospitalized only for their ARP. Finally, CHARS data do not include military or VA hospitals, although we are assuming that these hospitals treat relatively few children.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
When counseling patients who are considering surgery, surgeons balance the anticipated benefits of operative procedures against their risks. Unfortunately, our ability to counsel the parents of children with severe GERD is compromised because no prospective trials have been performed to determine which children benefit from ARP. This study demonstrates that, although children indeed may have fewer symptoms subjectively, older children are being hospitalized at equal rates and older children with developmental delay are being hospitalized with even greater rates after ARPs. These findings question the effectiveness of pediatric ARPs for a proportion of patients and highlight the need to clarify the subjective and objective indications for these operations in infants and children. Pediatricians and pediatric surgeons should reassess treatment algorithms that are derived from case series and clinical experience and find a standardized approach to the diagnosis, treatment, and follow-up assessment of GERD in the pediatric population through multi-institutional studies. Once we have clarified the natural history of regurgitation and GERD in infants and children, we thereafter can assess the impact of ARP on the natural history of reflux and identify patients who will benefit best from these procedures.


   FOOTNOTES
 
Accepted Aug 21, 2006.

Address correspondence to Adam Goldin, MD, MPH, Department of Pediatric General and Thoracic Surgery, Children’s Hospital and Regional Medical Center, W-7729, PO Box 5371, Seattle, WA 98105-0371. E-mail: adam.goldin{at}seattlechildrens.org

The authors have indicated they have no financial relationships relevant to this article to disclose.


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

  1. van der Zee DC, Bax NM, Ure BM. Laparoscopic refundoplication in children. Surg Endosc. 2000;14 :1103 –1104[CrossRef][ISI][Medline]
  2. Turnage RH, Oldham KT, Coran AG, Blane CE. Late results of fundoplication for gastroesophageal reflux in infants and children. Surgery. 1989;105 :457 –464[ISI][Medline]
  3. Fonkalsrud EW, Ament ME. Gastroesophageal reflux in childhood. Curr Probl Surg. 1996;33 :1 –70[Medline]
  4. Flum DR, Koepsell T, Heagerty P, Pellegrini CA. The nationwide frequency of major adverse outcomes in antireflux surgery and the role of surgeon experience, 1992–1997. J Am Coll Surg. 2002;195 :611 –618[CrossRef][ISI][Medline]
  5. Fonkalsrud EW, Ashcraft KW, Coran AG, et al. Surgical treatment of gastroesophageal reflux in children: a combined hospital study of 7467 patients. Pediatrics. 1998;101(pt 1) :419 –422
  6. Fonkalsrud EW. Gastroesophageal fundoplication for reflux following repair of esophageal atresia. Experience with nine patients. Arch Surg. 1979;114(1) :48 –51
  7. Norrashidah AW, Henry RL. Fundoplication in children with gastro-oesophageal reflux disease. J Paediatr Child Health. 2002;38 :156 –159[CrossRef][ISI][Medline]
  8. Somme S, Rodriguez JA, Kirsch DG, Liu DC. Laparoscopic versus open fundoplication in infants. Surg Endosc. 2002;16 :54 –56[CrossRef][ISI][Medline]
  9. Tashjian DB, Tirabassi MV, Moriarty KP, Salva PS. Laparoscopic Nissen fundoplication for reactive airway disease. J Pediatr Surg. 2002;37 :1021 –1023[CrossRef][ISI][Medline]
  10. Cohen Z, Fishman S, Yulevich A, Kurtzbart E, Mares AJ. Nissen fundoplication and Boix-Ochoa antireflux procedure: comparison between two surgical techniques in the treatment of gastroesophageal reflux in children. Eur J Pediatr Surg. 1999;9 :289 –293[ISI][Medline]
  11. Fonkalsrud EW, Bustorff-Silva J, Perez CA, Quintero R, Martin L, Atkinson JB. Antireflux surgery in children under 3 months of age. J Pediatr Surg. 1999;34 :527 –531[CrossRef][ISI][Medline]
  12. van der Zee DC, Arends NJ, Bax NM. The value of 24-h pH study in evaluating the results of laparoscopic antireflux surgery in children. Surg Endosc. 1999;13 :918 –921[CrossRef][ISI][Medline]
  13. Alexander F, Wyllie R, Jirousek K, Secic M, Porvasnik S. Delayed gastric emptying affects outcome of Nissen fundoplication in neurologically impaired children. Surgery. 1997;122 :690 –697; discussion 697–698[CrossRef][ISI][Medline]
  14. Bensoussan AL, Yazbeck S, Carceller-Blanchard A. Results and complications of Toupet partial posterior wrap: 10 years’ experience. J Pediatr Surg. 1994;29 :1215 –1217[CrossRef][ISI][Medline]
  15. Bliss D, Hirschl R, Oldham K, et al. Efficacy of anterior gastric fundoplication in the treatment of gastroesophageal reflux in infants and children. J Pediatr Surg. 1994;29 :1071 –1074; discussion 1074–1075[CrossRef][ISI][Medline]
  16. Kazerooni NL, VanCamp J, Hirschl RB, Drongowski RA, Coran AG. Fundoplication in 160 children under 2 years of age. J Pediatr Surg. 1994;29 :677 –681[CrossRef][ISI][Medline]
  17. Samuk I, Afriat R, Klin B, Efrati Y, Vinograd I. Nissen fundoplication for gastroesophageal reflux in children [in Hebrew]. Harefuah. 1994;126 :311 –315, 368[Medline]
  18. Smith CD, Othersen HB Jr, Gogan NJ, Walker JD. Nissen fundoplication in children with profound neurologic disability. High risks and unmet goals. Ann Surg. 1992;215 :654 –658; discussion 658–659[ISI][Medline]
  19. Ribet M, Pruvot FR, Mensier E, Ghoch K, Rousseau B. Gastro-oesophageal reflux and respiratory disorders treated by Hill’s procedure. Eur J Cardiothorac Surg. 1989;3 :414 –417; discussion 418[Abstract]
  20. Pennell RC, Lewis JE, Cradock TV, Danis RK, Kaminski DL. Management of severe gastroesophageal reflux in children. Arch Surg. 1984;119 :553 –557[Abstract]
  21. Randolph J. Experience with the Nissen fundoplication for correction of gastroesophageal reflux in infants. Ann Surg. 1983;198 :579 –584[ISI][Medline]
  22. Berquist WE, Fonkalsrud EW, Ament ME. Effectiveness of Nissen fundoplication for gastroesophageal reflux in children as measured by 24-hour intraesophageal pH monitoring. J Pediatr Surg. 1981;16 :872 –875[CrossRef][ISI][Medline]
  23. Carson JA, Tunell WP, Smith EI. Pediatric gastroesophageal reflux: age-specific indications for operation. Am J Surg. 1980;140 :768 –771[CrossRef][ISI][Medline]
  24. Foglia RP, Fonkalsrud EW, Ament ME, et al. Gastroesophageal fundoplication for the management of chronic pulmonary disease in children. Am J Surg. 1980;140 :72 –79[CrossRef][ISI][Medline]
  25. Euler AR, Fonkalsrud EW, Ament ME. Effect of Nissen fundoplication on the lower esophageal sphincter pressure of children with gastroesophageal reflux. Gastroenterology. 1977;72 :260 –262[ISI][Medline]
  26. Follette D, Fonkalsrud EW, Euler A, Ament M. Gastroesophageal fundoplication for reflux in infants and children. J Pediatr Surg. 1976;11 :757 –764[CrossRef][ISI][Medline]
  27. van der Zee DC, Bax NM. Laparoscopic Thal fundoplication in mentally retarded children. Surg Endosc. 1996;10 :659 –661[CrossRef][ISI][Medline]
  28. Thompson WR, Hicks BA, Guzzetta PC Jr. Laparoscopic Nissen fundoplication in the infant. J Laparoendosc Surg. 1996;6(suppl 1) :S5 –S7
  29. Parikh D, Tam PK. Results of fundoplication in a UK paediatric centre. Br J Surg. 1991;78 :346 –348[ISI][Medline]
  30. Nelson SP, Chen EH, Syniar GM, Christoffel KK. Prevalence of symptoms of gastroesophageal reflux during infancy. A pediatric practice-based survey. Pediatric Practice Research Group. Arch Pediatr Adolesc Med. 1997;151 :569 –572
  31. Miyazawa R, Tomomasa T, Kaneko H, Tachibana A, Ogawa T, Morikawa A. Prevalence of gastro-esophageal reflux-related symptoms in Japanese infants. Pediatr Int. 2002;44 :513 –516[CrossRef][ISI][Medline]
  32. Martin AJ, Pratt N, Kennedy JD, et al. Natural history and familial relationships of infant spilling to 9 years of age. Pediatrics. 2002;109 :1061 –1067[Abstract/Free Full Text]
  33. Malthaner RA, Newman KD, Parry R, Duffy LF, Randolph JG. Alkaline gastroesophageal reflux in infants and children. J Pediatr Surg. 1991;26 :986 –990; discussion 990–991[CrossRef][ISI][Medline]
  34. Treem WR, Davis PM, Hyams JS. Gastroesophageal reflux in the older child: presentation, response to treatment and long-term follow-up. Clin Pediatr (Phila). 1991;30 :435 –440[Abstract/Free Full Text]
  35. Carre IJ. The natural history of the partial thoracic stomach (hiatus hernia) in children. Arch Dis Child. 1959;34 :344 –353[ISI][Medline]
  36. Catto-Smith AG. Gastroesophageal reflux in children. Aust Fam Physician. 1998;27 :465 –469, 472–473[Medline]
  37. Herbst JJ, Meyers WF. Gastroesophageal reflux in children. Adv Pediatr. 1981;28 :159 –186[Medline]
  38. Rice H, Seashore JH, Touloukian RJ. Evaluation of Nissen fundoplication in neurologically impaired children. J Pediatr Surg. 1991;26 :697 –701[CrossRef][ISI][Medline]
  39. Horgan S, Pellegrini CA. Surgical treatment of gastroesophageal reflux disease. Surg Clin North Am. 1997;77 :1063 –1082[CrossRef][ISI][Medline]
  40. Carroll AE, Garrison MM, Christakis DA. A systematic review of nonpharmacological and nonsurgical therapies for gastroesophageal reflux in infants. Arch Pediatr Adolesc Med. 2002;156 :109 –113[Abstract/Free Full Text]
  41. Berquist WE, Rachelefsky GS, Kadden M, et al. Gastroesophageal reflux-associated recurrent pneumonia and chronic asthma in children. Pediatrics. 1981;68 :29 –35[Abstract/Free Full Text]
  42. Fonkalsrud EW, Ament ME, Byrne WJ, Rachelefsky GS. Gastroesophageal fundoplication for the management of reflux in infants and children. J Thorac Cardiovasc Surg. 1978;76 :655 –664[Abstract]
PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics



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