Fundoplication: Occasionally Trading One Set of Problems for Another

ABSTRACT & COMMENTARY

Synopsis: Retarded children treated with fundoplication may develop severe feeding problems secondary to "gastric dumping." Frequent small feedings may be beneficial.

Source: Samuk I, et al. Dumping syndrome following Nissen fundoplication, diagnosis, and treatment. J Pediatr Gastroenterol Nutr 1996;23:235-240.

Fifty infants who had fundoplication for gastroesophageal reflux underwent studies to evaluate gastric emptying. Of the 50 patients, 15 (30%) were thought to have symptoms compatible with gastric dumping in the postprandial period up to six months after the surgery. These symptoms included irritability, nausea, diarrhea, pallor, diaphoresis, weakness, and lethargy. Samuk et al used a glucose tolerance test to suggest that many of the patients had abnormally fast gastric emptying, and they found that dietary treatment of small frequent feedings, avoiding glucose-continuing nutrients, or adding 5-15 g/d of pectin into the diet were effective in treating these symptoms.

COMMENT BY HAL JENSON, MD, FAAP

Children who have significant problems with psychomotor retardation often have severe gastroesophageal reflux that is not responsive to medical therapy. If symptoms such as weight loss, recurrent pneumonia, blood loss, or esophageal stricture are present, these children often require a surgical procedure to control their symptoms of gastroesophageal reflux. A Nissen fundoplication, or a variant, is often performed, and in many childrens’ hospitals, this type of surgery has become one of the more common surgical procedures. While gastroesophageal reflux is effectively treated by these procedures, there are often severe feeding problems in the months following surgery—30% may be high, but clearly one in 10 children will have difficulty. While the mechanism for the rapid gastric emptying may be difficult to understand, the authors’ suggestion to consider dumping syndrome is certainly good advice since these symptoms may be difficult to interpret in this patient population. The problem appears to be time related because the small frequent feeds that are often required in the months after surgery are often weaned to larger feeds over time. It’s also worth remembering that in this group of patients, it is also more difficult to diagnose intestinal obstruction secondary to postoperative adhesions after a fundoplication, so one must keep a high index of suspicion.