Intraoperative esophageal manometry has not been correlated with early postoperative extended esophageal pH monitoring (EEpHM) in children with gastroesophageal reflux. Twenty-seven children were studied with the following design: (1) abnormal preoperative EEpHM; (2) intraoperative measurement of lower esophageal high pressure zone (LEHPZ) pressure and length prior to and upon completion of an antireflux procedure; and (3) EEpHM seven to ten days postoperatively. Sixteen had a Nissen or modified Thal fundoplication and eleven a Boerema gastropexy. The postoperative EEpHM was normal in patients with fundoplication regardless of the increase in LEHPZ pressure (-4 to 36 mmHg) or length (0 to 2.5 cm). Four of the patients (36%) who had a gastropexy had abnormal EEpHM. The postoperative frequency of reflux was related inversely to the elevation of LEHPZ pressure (-3 to 39 mmHg), but not to the LEHPZ length (0 to 4.5 cm). Duration of reflux was independent of observed intraoperative manometric changes. In conclusion, early postoperative EEpHM in children having a gastropexy correlates with intraoperative increases in the LEHPZ pressure. There is no such correlation in children having a fundoplication procedure.

One hundred sixteen patients underwent a modified Thal fundoplication to correct gastroesophageal reflux (GER) between July 1, 1983, and January 30, 1987. Ninety-one percent of patients were relieved of GER. When patients were evaluated with respect to the presence or absence of CNS impairment there was a marked difference in the success rate of this procedure. Eight of 48 patients with CNS disorders had recurrent reflux with gastrostomy feedings after a modified Thal fundoplication (16%) while only two of 68 neurologically normal children had a failure of operation (3%; P less than .05). These data indicate that the modified Thal fundoplication is very effective in correcting GER in neurologically normal children but is less effective in children with CNS impairment.

Following antireflux surgery, children with persistent retching symptoms are presumably more likely to have delayed gastric emptying. We report 66 children between 2 weeks and 16 years of age who had an operation to control gastroesophageal reflux (GER). All patients had GER confirmed by 18- to 24-hour esophageal pH monitoring. Preoperative gastric emptying studies were performed in each patient with 99m-Tc sulfur colloid in apple juice. In addition to the percent gastric emptying (%GE), an effective gastric emptying was estimated by correcting the %GE for postcibal reflux (corrected %GE). Repeat 18- to 24-hour esophageal pH monitoring was performed postoperatively in all patients, and a repeat gastric emptying study was performed in 32 patients. After an average postoperative follow up of 6 months (range of 1 to 18 months), persistent retching was present in 12 (18%) patients. The retching was associated with dumping symptoms in six patients. Retching was seen in patients with a preoperative increase in effective gastric emptying (10/34, 29%, P less than .05) or a decrease in effective gastric emptying (2/15, 13%, NS), and not in patients with an effective gastric emptying within the control range (0/17, 0%). Postoperatively, retching with dumping symptoms was associated with an increased effective gastric emptying, and retching without dumping symptoms with a decreased effective gastric emptying. In conclusion, persistent retching followed anti-reflux surgery in children is related to extremes in effective gastric emptying. The preoperative measurement of corrected %GE identifies children at increased risk for this postoperative problem.

In children, Stamm tube gastrostomy can initiate gastroesophageal reflux (GER) or worsen preexisting GER. We identified a possible mechanism for this problem in 25 children with GER who had esophageal manometry performed in conjunction with an antireflux operation. Intraoperative lower esophageal high pressure zone (LEHPZ) pressure and length were recorded for a simulated gastrostomy in all patients prior to performing the antireflux operation. These same parameters were then recorded for a simulated (11 patients) or real gastrostomy (14 patients) following the antireflux procedure. The LEHPZ pressure decreased with simulated Stamm gastrostomy (7.8 +/- 1.1----6.6 +/- 1.1 mm Hg, NS: Normal = 11.2 +/- 0.9 mm Hg). This decrease was less significant than the decrease in LEHPZ length (1.1 +/- 0.1----0.8 +/- 0.1 cm, P less than .01: Normal = 1.3 +/- 0.1 cm). Following Boerema gastropexy, simulated gastrostomy produced a similar decrease in LEHPZ pressure (20.8 +/- 3.8----17.1 +/- 2.7 mm Hg, NS) and length (3.3 +/- 0.4----2.5 +/- 0.3 cm, P less than .025). The LEHPZ pressure and length were not decreased by real gastrostomy performed with modified Thal fundoplication or with Nissen fundoplication. Thus, a decrease in LEHPZ length may be one mechanism whereby GER is initiated or worsened by tube gastrostomy in children. Tube gastrostomy has a similar effect when performed with a Boerema gastropexy, but not when performed with a Nissen or modified Thal fundoplication.

Regurgitation and aspiration of feedings is a significant problem in children with impaired oral intake fed via gastrostomy. Using extended (18-24 hour) esophageal pH monitoring to assess gastroesophageal reflux (GER), we studied prospectively 32 children (aged 2 to 16 years) referred for feeding gastrostomy. Twenty-five patients had repeat esophageal pH monitoring after surgery. Prior to surgery, GER was documented in 23 (72%) of the 32 children. Twenty-two of the 23 children with GER before surgery had an antireflux operation performed in conjunction with the feeding gastrostomy. Gastroesophageal reflux was clinically significant in the single failed antireflux operation and in the child with GER before surgery who only had a gastrostomy performed. All nine patients without GER only had gastrostomy performed. Six of these developed GER by pH monitoring after surgery, with significant vomiting in four. Of our 11 patients remaining at risk for GER after surgery, seven (64%) had persistent vomiting with gastrostomy feedings. Thus, 91% (29 of 32) of the children were potentially at risk for GER if a gastrostomy only was performed. We believe these data support the need for a "protective" antireflux operation in children referred for feeding gastrostomy.

Persistent gastrointestinal symptoms are common postoperatively in children with intestinal malrotation. We investigated this problem in 14 children with intestinal malrotation who had a Ladd procedure (3 patients), gastroschisis repaired (6 patients), or omphalocele repaired (5 patients) between one month and 15 years prior to study. In 13 patients, gastric emptying was measured at 30 minutes (%GE30) and at 60 minutes (%GE60) following ingestion of 99m-Tc sulfur colloid in apple juice. We estimated the degree of gastric peristalsis using the %GE corrected for immediate postcibal gastroesophageal reflux (corrected %GE). Patients with vomiting exhibited slow gastric emptying compared to patients without vomiting (%GE30: 14.0 +/- 5.5 v 32.5 +/- 4.2, P less than .005). The slow gastric emptying was related to slow gastric peristalsis (corrected %GE30: 20.3 +/- 5.0 v 47.1 +/- 6.0, P less than .005). In all 5 patients with persistent bloating and diarrhea, gastric peristalsis was rapid at 30 minutes (corrected %GE30 = 56.7 +/- 4.2) and at 60 minutes (corrected %GE60 = 69.5 +/- 5.3). To assess the role of gastroesophageal reflux (GER) in persisting symptoms, all children had extended (18 to 24 hours) esophageal pH monitoring. Eleven (79%) of the 14 patients demonstrated GER by esophageal pH monitoring, including four of six patients without reflux symptoms. All ten children under two years of age demonstrated GER regardless of symptoms or congenital anatomic abnormality. In conclusion, GER is common in patients under two years of age with intestinal malrotation, but clinical symptoms seem related more to extreme variations in gastric peristalsis than to GER.

Time-activity curves of technetium-labeled diethyl-IDA were used to evaluate 31 patients in an effort to differentiate infants with cholestatic jaundice. Results can be obtained rapidly with minimal radiation exposure and no known secondary effects. The combination of diethyl-IDA time-activity curves and gamma glutamyl transferase activity was found to discriminate biliary atresia from neonatal hepatitis. The group with neonatal hepatitis was characterized by abnormal, yet lower, gamma glutamyl transferase activities and diethyl-IDA time-activity curves which peaked within 1 minute of injection, yet decayed in a manner similar to cardiac activity. The group with biliary atresia was characterized by elevated gamma glutamyl transferase activities, hepatic peaks at 8 minutes and markedly delayed decay. In that early operative intervention is associated with increased survival in biliary atresia, prompt differentiation should improve prognosis.

A quantifiable biliary function index has been developed from analysis of hepatic time--activity curves. Diethyl-IDA, a technetium-labeled iminodiacetic acid was given intravenously 27 times in 11 patients with proven biliary atresia. An estimated bile bilirubin clearance index derived from the inscribed hepatic absorption and elimination curves appears to be a reliable indicator of bile bilirubin clearance. The actual bile bilirubin clearance, previously shown to be a major determinant of survival, was clinically correlated in five patients studied before and after surgery and confirms the experimental findings. The clearance index should allow objective assessment of the efficacy of surgery for biliary atresia.