Indications for laparoscopic antireflux procedures in children.

The decision for antireflux surgery is often made on an individual basis. How symptom patterns and therapeutic suggestions relate is debatable. There is a long list of differential diagnoses for vomiting not caused by disturbances of the lower esophageal sphincter. Guidelines for the clinical practice in gastroesophageal reflux have been established for children and for adult patients by the Genval Workshop Report and the Trondheim Consensus statement. Endoscopy is indicated if macroscopically visible lesions are to be expected. Routine endoscopic biopsy is not used in the diagnosis of gastroesophageal reflux disease (GERD). pH monitoring is performed in 33 to 77% of patients. If the most prominent symptoms are respiratory, radiographic studies and pH monitoring prove that the symptoms are really related to GERD. Best results with drugs are achieved by effective initial therapy. The effects of long-term treatment are little known. Failed long-term therapy, complications of esophagitis, recurrent aspiration, apnea or "near miss" sudden infant death syndrome, failure to thrive and anatomical abnormalities are indications for surgery. The superiority of laparoscopic antireflux surgery over open surgery depends on the experience of the surgeon. Some surgeons choose a "tailored approach", ie, perform a partial wrap in children with normal peristalsis, an extrashort "floppy" Nissen or a partial wrap for those with impaired peristalsis, and a slightly tighter 360-degree wrap in neurologically impaired children. Partial wraps allow vomiting, which is considered risky in neurologically impaired children.