The introduction of omeprazole, a potent proton pump blocker, for the treatment of gastroesophageal reflux (GER), the growing experience of pediatricians in the diagnostic management and pharmacotherapy of GER (1, 5, 6, 10), and the experience of surgeons acquired while treating recurrent GER or its postoperative complications have results in the authors reviewing their material and revising their views on gastroesophageal reflux. The term „secondary reflux ” is deeply rooted in the surgeon´s mind, denoting the necessity of searching for causes of this severe symptom. Recognizing the cause often allows prescription of the ultimate symptomatic treatment, and for avoiding sometimes long-term, „on and off ” type pharmacotherapy. Generally supporting the views of our colleague-pediatricians, we still believe a surgeon should become a partner in diagnosing the causes of GER in children at a very early stage.

Our material included 56 children, the management of whose cases changed parallel to the development of new medical concepts and our increasing experience. Ten children were treated in the years 1984-91. At that time, their management was strongly affected by their medical history, clinical assessment, X-ray results, failure to improve following dietary or positioning treatment and prokinetic agent administration. Primary reflux or oesophageal hiatus hernia were diagnosed, and the patients were operated on using the Dor-Nissen method (anterior fundoplication and oesophagohiatoplasty) COLOR="#ff0000">.

Forty-six children were managed in the years 1992--99, including 30 patients with Robin sequence and various forms of „neurological mask ”.

At that time the diagnostic management was gradually extended to include endoscopic studies with histological assessment, 24-hour pH-metry, scintigraphy, which is of special importance in children with neurological diseases and the so called Barret oesophagus, as well as oesophageal electromanometry.

Of 46 patients operated on between 1992 and 1999, 16 had anti-reflux procedures. In 30 children who were found to have a defect and oesophageal stenosis at the level of the palatopharyngeal ring, comprehensive diagnostic management revealed GER and the patients were treated surgically by excising the defect that triggered gastroesophageal reflux.

In the years 1992-93, the anti-reflux surgery consisted of Nissen fundoplication. Starting in 1993, subtotal Nissen fundoplication was employed. The change in surgical technique was dictated by contacts between the authors and surgeons from foreign centres, combined with reports on complications following the Nissen procedure. Recently, a laparoscopic procedure has become recognized as the method of choice, which combines a subtotal fundoplication with elements of the Thal operation. The surgery also includes pyloric control and a pyloromyotomy, when needed.

Thirty children with Robin sequence were subjected to causal treatment, consisting of a correction of the palatopharyngeal ring defect, by operating on the cleft palate and eradicating factors causing tightness at this level. The genioglossal muscles, which result in retrorotation of the tongue in children with micrognathia and retrognathism, were elongated.

As a consequence of the accepted treatment protocol, the general condition of children promptly improved, since their pain was alleviated and clinical reflux symptoms were resolved. We were only able to perform extended diagnostic studies for GER after surgery, providing parental consent was granted, in isolated cases. Due to an excessively tight anterior fundoplication, no improvement was achieved in a child with cystic fibrosis, only after a release of the anterior esophageal wall was a satisfactory passage of food obtained and reflux symptoms were resolved.

In 30 children with Robin sequence subjected to cleft palate surgery and genioglossal muscle elongation, the clinical symptoms of GER subsided shortly after the procedure. Follow-up 24-hour reflux studies performed 2-3 months postoperatively showed no signs of GER in 20 patients. One child demostrated only a marked reduction in the number of reflux impulses, while clinical symptoms resolved in the remaining children.

The growing experience of both pediatricians and surgeons in treating gastroesophageal reflux favour reviewing opinions on diagnosing and treating GER. Experienced pediatricians accept the management algorithm proposed by the European Society of Paediatric Gastroenterology and Nutrition (ESPGAN), or present their modifications of the programme (1, 11). The protocol may be briefly characterized as a three-phase procedure, where surgical treatment is initiated after conservative treatment possibilities, often taking many years, have been exhausted. Although in principle we agree with pediatricians, we find strong collaboration with a surgeon in searching for the anatomical causes of gastroesophageal reflux is missing. In many cases, even several months´ delay while waiting for a satisfactory outcome of conservative treatment is not necessary.

We are presently positive that surgical treatment of GER should be considered in cases of secondary reflux, which is believed by surgeons to result from defective anti-reflux mechanisms. Such disturbances may be triggered by anatomical factors (status post-oesophageal atresia surgery, congenital short oesophagus, oesophageal hiatus hernia, and factors hindering gastrointestinal passage, such as intestinal malrotation, Ladd´s bands, pylorostenosis, annular pancreas, duodenal obstruction) or neurological factors. Our experiences indicate a role for pathological reflexes of the palatopharyngeal ring. The notion of subjecting neurological patients to surgical treatment is supported by the unclear pathophysiological mechanisms underlying the very disease where delayed oesophageal and gastric emptying is a permanent symptom. Such decision may be also affected by restricions in pharmacotherapy due to antagonistic drug activity. Thus, prompt and successful surgical treatment may be of considerable importance in the management of a child with CNS dysfunction, since fixed passage disturbances may hinder further surgical therapy (4, 9). Surgical management of GER appears helpful also in children with cystic fibrosis, in whom gastroesophageal reflux is present in approximately 85% of cases (10).

Surgical treatment may be also indicated in children with GER, who have neurological symptoms, such as dystonic body positioning in Sandifer syndrome or seizure-like convulsions. Nevertheless, our experience shows that, in such patients in the first place one should search for the possible causes of mechanisms that render GER fixed. Such a mechanism could be found in a great number of our patients with Robin sequence or another defect of the palatopharyngeal ring (2, 3). When the pathogenic factor was eradicated, gastroesophageal reflux subsided.

A failure to achieve improvement at the preliminary stage of conservative treatment, a persistent loss of body weight, recurrent respiratory tract infections in infants and persistent inflammatory lesions in the oesophageal mucosa in older children should indicate a need for comprehensive causal diagnostic management, and for o joint decision on further treatment to be reached by paediatricians and surgeons.

Successful surgical management consists of securing normal narrowing of the oesophageal hiatus, preserving the Hiss angle, oesophageal patency and peristalsis, as well as the normally long abdominal segment of the esophagus. It is our belief that at present these requirements may be met using the „abdominal approach ” and dissecting the triangular ligament of the liver. Such a procedure leads to good visualisation of the oesophageal hiatus and allows its correct narrowing. An appropriate access to the fundus of the stomach and the abdominal segment of the esophagus allows for a partial rotation of the fundus beyond the stomach and the fixation of the lateral and anterior wall of the former to the diaphragm and lateral surfaces of the oesophagus. The free anterior oesophagus wall and adequately narrowed oesophageal hiatus additionally protect against complications occurring following a Nissen fundoplication, such as gastric distension with gas, post-meal compression, epigastric distension, reflux syndrome, vomiting, ileus, oesophageal hiatus hernia and recurrent reflux (7). These warnings are fully justified, as we could find out for ourselves in a patient in whom the anterior fundoplication had been performed too tightly. An indispensable element in supplementing anti-reflux surgery may be pyloromyotomy. In children with neurological diseases, when abnormal gastric emptying is detected in scintigraphy, a supramucosal pyloromyotomy is necessary. Failure to perform this element of the procedure results in a promt recurrence of the disease, the course of which may be much more violent than before surgery.

Here the authors would like to emphasise the fact that, regardless of whether the procedure is classic or laparoscopic, its success will depend on our ability to restore the anti-reflux mechanisms and eradicate GER--facilitating factors (8, 9).

In patients with the so-called Barret oesophagus, we believe that we should primarily look for the cause of lesions in the oesophageal mucosa, initiate intensive conservative treatment, and subsequently restore the natural oesophageal and gastric functions by surgical management with an anti-reflux mechanism. As a subsequent element of therapy, one might attempt to treat the mucosal lesions, using for example a laser.

In our opinion, the diagnostic and therapeutic management of GER should be carried out jointly by various specialists interested in the problem, and on the basis of the substantial experience of both pediatricians and surgeons, who make the decision as to the further treatment. Not without importance. Not without importance should be monitoring of the psychological and economic aspects of long-term conservative management of young children, which may facilitate the development of new therapeutic standards in gastroesophageal reflux.

1. Good surgical results in GER and the growing experience of surgeons and paediatricians should facilitate a joint search for the causes of the disease and a consideration of prompt surgical intervention.

2. The detection of the so-called „secondary reflux ” followed by surgical treatment may save the child from long-term conservative treatment.

3. The single surgical complication observed in our series supports the warning postulated by numerous authors that a subtotal fundoplication may be a safer, yet equally effective method in treating GER.

4. In children with Robin sequence and tightness at the level of the palatopharyngeal ring, a cleft palate repair combined with elongation of the genioglossal muscle attachments result in GER subsidence.