» Gastroenterology

Keyhole surgery answer to reflux

 

Dr Paul Losty.

More than 50 CdLS families and 300 people in all went to Carden Park Hotel, Cheshire, for the Foundation’s conference. Led by the Foundation’s medical advisor, Dr Laird Jackson, leading professionals shared their views and ideas

Developing techniques in ‘keyhole surgery’ now being practiced in the UK could benefit people with CdLS and put an end to reflux – a condition that affects many CdLS individuals, according to Dr Paul Losty from Liverpool’s famous Alder Hey hospital, a keynote speaker at the Foundation’s conference.

One of the most unpleasant and painful aspects of CdLS is the recurring problem of reflux and which many believe to be the cause of some of the many behavioural challenges associated with the syndrome.

Dr Losty struck an immediate chord with his audience at the conference when he began by stating that in many circumstances, the difficulties of oral feeding were immense. He also suggested that parents should be ‘pushy’ with their specialists and consultants, a point that elicited a spontaneous round of applause!

He explained that when CdLS children suffer from feeding problems (and statistics show that more than three quarters do) the problems can be immense. They can be exacerbated by poor lip closure, excessive lip retraction, a thrusting tongue which can easily be bitten and excessive drooling and uncoordinated swallowing. And these difficulties can be accentuated by breathing difficulties which may provoke choking and coughing.

He explained that gastro-oesophageal reflux (GOR) is something of a nightmare for CdLS parents. If tubes aren’t the answer – and they seldom are in the long term – then it’s worth looking at posture, thickened foods, re-scheduled meal times, antacids (such as Gaviscon), prokinetic agents like Cisapride, H antagonists such as Ranitidine or proton pump blockers like Omeprazole. But in the final analysis, Nissen fundoplication – which has a relatively high success rate - may be the only answer.

He said: “The major causes of GOR are dysmotility, neuro-muscular incoordination, delayed gastric emptying, medications, spasticity and posture. These can all cause vomiting, apnoea, recurrent chest infections, ‘failure to thrive’ and anaemia. GOR can also cause reactive airway disease which is sometimes confused with asthma.”

If none of the conventional treatments work, then Dr Losty suggests that it’s worth thinking about Nissen fundoplication which involves invasive surgery to create a new ‘valve’ by wrapping part of the stomach around the lower end of the oesophagus. This prevents stomach acids from reaching the oesophagus, reducing the likelihood of GOR.

Since 1992 it’s possible to have the operation done by laparoscopy – or key-hole surgery - although relatively few centres in the UK perform the operation. Dr Losty says that so far, results appear to indicate that the success rate is equivalent to the conventional open surgery procedure although the long-term outcomes are still awaited.

“Overall though,” he says, “we should all be aware of the fact that the failure rate of the conventional operation in all ‘special needs children’ is around 10% to 15% worse than in the population as a whole, which stands at between 80% and 90%.”

He also explained that there can be complications including excessive retching, gas bloat, dumping (where the stomach empties too quickly) and dysphagia. There can also be problems associated with the ‘wrap’ failing or causing ‘adhesions’ at the operation site.

However, he concluded, in many cases, Nissen Fundoplication is the only sensible solution and I would suggest that parents should make sure that they’re aware of the various options so that they can discuss the matter in an informed way with their consultants and specialists.
 
Reaching Out newsletter
October 2000