Preoperative Considerations

Pectus excavatum is the most common defect of the chest wall in infants. The incidence is estimated to be up to 38 per 10,000 births in white infants. The incidence appears to be less in other races, estimated at 7 per 10,000 black infants. The precise etiology of the defect is unknown, and there appears to be genetic transmission of the condition. This defect also is associated with Marfan disease and other connective tissue disorders. The appearance and severity of pectus vary among individuals. There may be a localized defect in the lowermost portion of the sternum, or a longer trench. These defects may be symmetrical, localized to one side of the chest wall, or mixed excavatum and carinatum defects.

Children with this defect often are self-conscious about their body image. This is not an inconsequential problem, and studies have demonstrated improvement in self-image after repair. These children also can complain of exercise intolerance. Although there has been controversy about the physiologic effects of repair of the defect, some studies support an improvement in postoperative pulmonary performance when preoperative cardiac compression exists. Many patients report an improved perception of their tolerance for exercise.

Because of the lack of consistent, reproducible, postoperative improvements in pulmonary function, and the perception by some that this defect is only a cosmetic one, there have been efforts to define which patients will benefit from operative correction. Preoperative evaluation should include a chest radiograph, computed tomography (CT) of the chest, pulmonary function studies, and echocardiography. The CT scan can demonstrate the defect, including morphology of the cartilaginous component, and cardiac or pulmonary compression. It also allows for accurate measurement of the Haller index, a ratio between the anteroposterior and transverse dimensions of the chest (Fig. 39-1A). An index of greater than 3.25 is considered severe. Echocardiography can demonstrate mitral valve prolapse or other pathology that results from cardiac compression.

FIGURE 39-1 Pectus excavatum. A, Computed tomography scan demonstrating calculation of the Haller index. B, Positioning of the patient in the operating room. C, External image of tunneler placement. D, Thoracoscopic view of bar placement.

Not all children who have a pectus excavatum defect need repair. The decision to offer surgical repair should be based on objective criteria from the preoperative evaluation as well as the patient’s desire to undergo the operation. As for every operation, a detailed discussion of the risks, benefits, and potential complications of the procedure should take place in the preoperative period.

Operative Technique

Minimally invasive pectus repair has gained popularity since its introduction and probably is the most frequently done corrective procedure for pectus excavatum at this time. This approach is best suited for the more symmetrical defects, although it has been applied to different chest morphologies. There have been many reported modifications to the original procedure, including asymmetrical bar bending, a subxiphoid incision, sternocostal relaxing incisions, and use of multiple bars. The open or Ravitch repair still is used but has become less common than the minimally invasive approach and is not discussed here.

The patient is positioned supine on the operating room table, with the shoulders abducted, elbows flexed, and arm slightly rotated externally (Fig. 39-1B). Great care should be taken to properly pad the arms and avoid a stretch injury to the brachial plexus. Antibiotics are administered and continued for 24 hours after the procedure. After a sterile preparation and draping, appropriate sites are chosen for skin incisions, as well as for the entry and exit sites of the thoracic cavity. The thoracoscope is introduced through a port placed two interspaces below the lowermost skin incision on the right side in the midaxillary line. We use an insufflation pressure of 4 to 6 mm Hg. This provides good visualization when the pectus tunneler is passed across the mediastinum, anterior to the pericardium, exiting on the opposite side in a predetermined location (Fig. 39-1C).

We make a subxiphoid incision to remove the xiphoid, and then use blunt finger dissection to help create the plane between the sternum and pericardium, as well as to guide the tunneler across the mediastinum. At completion of placement of the bar or bars (Fig. 39-1D), a stabilizer is placed on the left side, while on the right side, the thoracoscope is used to guide placement of a 0-0 PDS suture around the bar to secure it to two separate ribs. The pneumothorax then is evacuated out the insufflation tubing, which is held under water as the anesthesiologist gives positive-pressure breaths. A small postoperative pneumothorax is to be expected but rarely requires placement of a chest tube.

Postoperative Considerations

Although done as a minimally invasive procedure, there is still a significant amount of postoperative pain associated with this procedure, so effective pain relief is essential. This is achieved with various modalities, including thoracic epidurals, patient-controlled analgesia (PCA) of narcotics, nonsteroidal anti-inflammatory drugs (NSAIDs), oral muscle relaxants, and oral narcotics. Patients are kept supine for the first 24 hours. On postoperative day 1, they are encouraged to be up in a chair most of the day, with precautions to avoid any twisting or rotation of the trunk. The Foley catheter is removed on postoperative day 1.

On postoperative day 3, all patients are ambulating with assistance in the hallways. Incentive spirometry is taught preoperatively and started in the immediate postoperative period. The major complication of this operation is injury to the pericardium or the heart during passage of the tunneler. This can be avoided with the combination of the thoracoscopic guidance of the tunneler and subxiphoid dissection and guidance. The bar or bars are removed 2 or 3 years after the procedure.

Preoperative Considerations

Cystic lesions of the mediastinum in children often are asymptomatic and usually benign. They commonly are found incidentally on chest radiograph. Because they compress adjacent structures, they can be associated with cough, chest pain, dyspnea, and dysphagia. Rarely, the cystic cavity can become infected, resulting in fever and general malaise. Regardless of the location of the lesion, excision is indicated to (1) eliminate symptoms, if present; (2) prevent progression to symptoms, if not yet present; (3) prevent infection; and (4) rule out malignancy. The operation can be scheduled on an elective basis. In the event of infection, resection should be deferred for 6 to 8 weeks to allow for resolution of the inflammatory process.

The mediastinum is divided into three parts: the anterior mediastinum between the sternum and the anterior pericardium, the middle mediastinum between the anterior pericardium and the prevertebral fascia, and the posterior mediastinum behind the prevertebral fascia. The location of the lesion in relation to these compartments can provide clues to the pathology. Thymic cysts occur exclusively in the anterior mediastinum. Esophageal duplication cysts, pericardial cysts, and bronchogenic cysts are located in the middle mediastinum. Neuroenteric cysts arise from incomplete separation of the foregut and primitive notochord. Cystic teratomas and lymphangiomas can arise in any mediastinal compartment. Magnetic resonance imaging (MRI) or CT of the chest helps delineate the anatomy of a mediastinal cyst. When there is suspicion of esophageal or airway involvement, endoscopy may be indicated. In many of these cases, however, operative exploration and resection are necessary to obtain a diagnosis.

Thoracoscopy provides excellent exposure to important normal structures, minimizes postoperative pain, and is the preferred approach to resection of many mediastinal cysts. The objective should be to remove the lesion in its entirety, with as little disruption of adjacent structures as possible.

Operative Technique

A first-generation cephalosporin is given just before the operation. As with most thoracoscopic procedures, patients are positioned in the decubitus position with the uninvolved side against the operating room table. Depending on the location of the lesion, adjustments should be made to optimize exposure. For posterior mediastinal lesions, the patient can be placed in the anterior oblique position to allow mediastinal structures to fall forward with gravity. For anterior mediastinal lesions, the posterior oblique position allows mediastinal structures to fall away from the sternum.

Many lesions can be excised with two working ports and one camera port. Sometimes, a third working port is necessary to help with retraction by an assistant. Port positioning is individualized for each operation, depending on the specific location and dimensions of the lesion. When possible, the ports should be triangulated, and the camera should be placed between the two working ports. Once the mass is identified within the mediastinum (Fig. 39-2A), the next step is to incise the mediastinal pleura that overlies it. The cyst then is mobilized off adjacent structures, using blunt dissection and cautery when necessary (Fig. 39-2B). Most benign mediastinal cysts have little collateral circulation and can be removed with little risk for blood loss.

FIGURE 39-2 Mediastinal cysts. A, Thoracoscopic appearance. B, Incision of overlying pleura and cyst dissection.

Care should be taken to preserve the phrenic nerve that runs longitudinally, deep to the pleura of the middle mediastinum. For lesions in the area of the esophagus, an appropriately sized bougie can help clarify the anatomy to avoid inadvertent esophageal perforation. The bougie also can help define an esophageal defect in the event that a foregut duplication cyst shares a common wall with the normal esophagus. In the region of the aortic arch, the recurrent laryngeal nerve should be identified and spared. Special attention should be given to maintaining the integrity of the cyst wall because, if a cyst is ruptured, the tissues planes can become obscure. Whether ruptured or not, the entire cyst wall should be removed, or the lining stripped, to minimize the chances of recurrence.

The specimen should be placed in an endoscopic retrieval bag and removed through a port site that has been enlarged by blunt spreading of the intercostal muscles. Large cysts may require decompression within the retrieval bag before they are pulled through the chest wall. A lesion with solid components (such as a teratoma) may require a larger intercostal incision to allow enough space for retrieval between the ribs. A thoracostomy tube should be inserted through the most convenient port wound, positioned adjacent to the bed of the resection, secured at the skin with sutures, and attached to the suction drainage system.

Postoperative Considerations

After surgery, the patient is started on a regular diet with oral pain medications. Scheduled NSAIDs can be added as an adjunct. The chest tube can be removed when there is resolution of the pneumothorax on chest radiograph, no air leak, and minimal serous fluid output. In many cases, patients can be discharged as soon as 48 hours after the operation, with minimal activity restriction.

Preoperative Considerations

Congenital lung lesions that can be managed thoracoscopically include congenital cystic adenomatoid malformations (CCAMs) and pulmonary sequestrations. A CCAM arises from an abnormal overgrowth of the terminal respiratory structures, forming an intercommunicating cyst of varying size. CCAMs are categorized by cyst size: type 1 (>2 cm), type 2 (1 to 2 cm), and type 3 (microscopic). These lesions are being diagnosed more frequently by prenatal ultrasound and should be followed prenatally and postnatally because occasionally such a lesion may resolve spontaneously. The primary symptom is respiratory distress, but a significant number are asymptomatic.

If respiratory distress exists, then the infant should be prepared for operative removal. If the child lacks any symptoms, then we prefer to obtain an MRI or CT scan of the chest at 3 to 6 months of age. If the lesion still is present, then the child should be prepared for operative removal because the goal is resection before the onset of infection. If the child does not have symptoms at birth and the diagnosis was not made prenatally, the typical presentation is recurrent pulmonary infection. Operative resection should be performed 6 to 8 weeks after treatment of the infection to optimize the chance for thoracoscopic removal.

A pulmonary sequestration is composed of nonfunctioning lung that lacks normal communication with the tracheobronchial tree and has an anomalous systemic arterial supply. A sequestration can be either intralobar (75%) or extralobar (25%). Similar to CCAMs, a sequestration is diagnosed more frequently prenatally by ultrasound and also can possibly involute. The primary symptom is respiratory distress, and, if present, the infant should be prepared for the operating room. If the patient is asymptomatic, then an MRI or CT scan of the chest should be performed at 3 to 6 months of age; if the sequestration still is present, then resection is indicated. If the patient escapes perinatal diagnosis, the primary symptom usually is recurrent infection. CT or MRI often will show the underlying lesion, and resection should be planned 6 to 8 weeks after treatment of the infection.

The presence of either a CCAM or a sequestration mandates an operation because no other treatment has been shown to be effective. Even if the patient is asymptomatic, both types of lesions have been associated with recurrent infections and even malignant transformation later in life, so these lesions should be removed. If a patient experienced recurrent infections before the discovery of the lesion, then the operation can be very challenging because the anatomy likely will be obscured. In such cases, it may be safer to convert to an open thoracotomy or simply to proceed with an open thoracotomy from the start.

Operative Technique

The infant or child is placed in the lateral decubitus position with the side of the lesion facing upward. A single dose of prophylactic antibiotics is administered. The initial port placement (5 mm) is in the midaxillary line in the fifth intercostal space. The chest is insufflated to 4 mm Hg. Depending on which lobe is involved, two or three additional 5-mm ports are placed to optimize removal and visualization. The ports should be spaced as far apart as possible to prevent “sword fighting” between the cannulas.

For a sequestration, the inferior pulmonary ligament should be divided first with a clip applier to control any aberrant vessels (Fig. 39-3A). This will be the extent of dissection for an extralobar sequestration; the lesion then can be removed after placement into a 10-cm retrieval bag. If the lesion is large, then the port site may need to be extended 1 to 2 cm. For CCAMs (Fig. 39-3B) and intralobar sequestrations, a lobectomy is the preferred treatment to ensure complete removal.

FIGURE 39-3 Congenital lung lesions. A, Clipping of inferior pulmonary ligament. B, Right lower lobe congenital cystic adenomatoid malformation. C, Clipping of right lower lobe bronchus.

The pleural is incised completely around the involved lobe with cautery. Care should be taken to identify the phrenic nerve. A tissue sealing device then is used to separate the parenchyma down to the hilum. Each of the pulmonary vessels is individually dissected out and divided with the clip applier. For smaller vessels (1 to 3 mm), the tissue sealing device usually is sufficient, but we do not hesitate to put a clip on as well. With just the bronchus remaining, one of the 5-mm ports is converted to a 12-mm port for an endostapler. The port farthest from the bronchus should be used to ensure adequate room for stapler deployment, particularly in the neonate.

To ensure that the bronchus is supplying only the involved lobe, the stapler is clamped down, and large sustained breaths are given to ensure that the remaining lobes are not supplied by the bronchus that is about to be divided. The stapler is fired (Fig. 39-3C), and the lobe is placed into a 10-cm retrieval bag, which then is brought out through the 12-mm port site (extended as needed). The chest is filled with saline to cover the bronchial stump, and another sustained breath (to about 30 cm H₂O pressure) is given to ensure that there is no leak. A chest tube is inserted through one of the port sites, and the remaining port sites are closed.

Postoperative Considerations

As soon as the child is awake, formula or a regular diet is resumed. The chest tube is put on 20 cm H₂O suction until any air leak is resolved and the chest radiograph shows no pneumothorax, which should take 2 to 5 days. Chest tube output should be minimal. The risk for prolonged air leak can be minimized with removal of the entire lobe. If a segmental resection is performed for a more peripheral lesion, then a persistent air leak can result. The surgeon then must decide whether to proceed with a formal lobectomy or to release the patient with a Heimlich valve. A follow-up visit with a chest radiograph should be done 2 to 4 weeks after resection. Results of CCAM or sequestration resection generally are excellent, with essentially no chance of recurrence.

Preoperative Considerations

Congenital diaphragmatic hernia results from the lack of fusion of the diaphragmatic musculature. This defect typically occurs in two distinct areas: (1) a posterolateral location, either left (85%) or right (15%); or (2) a central-anterior location. A posterior-lateral hernia commonly is referred to as a Bochdalek hernia, and the central-anterior defect is referred to as a foramen of Morgagni hernia (Fig. 39-4A).

FIGURE 39-4 Congenital diaphragmatic hernia (Bochdalek type). A, Anatomy of diaphragmatic hernia (underside view of diaphragm). B, Patient (neonate) positioning for repair of a Bochdalek hernia. C, Thoracoscopic view of hernia after intestine reduction. D, View of repair before placing the corner stitch. E, Corner stitch placement for a Bochdalek repair. F, Completed Bochdalek repair.

Bochdalek hernia often is diagnosed prenatally and can cause a variable degree of respiratory distress shortly after birth. The primary problem is pulmonary hypoplasia and resultant pulmonary hypertension. The severity of pulmonary hypoplasia ranges from mild (asymptomatic) to incompatible with life. Patients with mild pulmonary hypoplasia, however, can present after the neonatal period with extremes of symptoms, ranging from persistent cough to near death from strangulated intestine. The hernia also may be discovered incidentally with a chest radiograph.

Regardless of the intensity of symptoms, an operation is indicated. The timing of the operation for patients who are symptomatic at birth is dependent on the degree of pulmonary hypoplasia and pulmonary hypertension. Current recommendations are to repair the diaphragm after the patient has demonstrated cardiorespiratory stability.

A foramen of Morgagni hernia rarely produces respiratory symptoms because the lungs have developed normally. This hernia type usually is noted incidentally while obtaining a chest radiograph for vague complaints of substernal pressure, chest pain, or cough. If the stomach is herniating through the defect, then the patient may experience unexplained emesis or even intermittent hematemesis. Strangulation of the contents within a Morgagni hernia is rare. The existence of a foramen of Morgagni hernia also mandates repair, but this generally can be done electively.

Eventration of the diaphragm is believed to result from either a congenital or a traumatic injury to the phrenic nerve. Without the phrenic nerve, the diaphragm undergoes weakening and atrophy. Paradoxical motion occurs when the abdominal contents push up on the diaphragm and negative inspiratory pressure within the chest pulls the diaphragm upward. This situation can impair pulmonary function. It can be difficult to distinguish between an eventration and a hernia on a plain chest radiograph. Fluoroscopy or ultrasound can show the paradoxical motion of the diaphragm, but a diaphragmatic hernia with an intact sac can have a similar appearance.

Symptoms from an eventration generally are mild unless pneumonia develops from the underexpanded lung, or the contents push on the mediastinum, causing a tracheal shift that produces stridor or wheezing. If any symptoms can be attributed to the eventration, or there is considerable lung compression from a large eventration, then elective operative repair is indicated.

Operative Technique

The minimally invasive repair of a Bochdalek hernia is best approached with a thoracoscope. The neonatal patient is placed transversely across the operating table, with bumps placed beneath the patient to elevate the body another 4 to 6 inches off the table. The patient then is placed in the lateral decubitus position with the hernia side facing up (Fig. 39-4B). For an older patient who will not fit transversely across the table, the head is positioned at the top of the bed, and the bed is turned 90 degrees. The goal is to position the surgeon at the patient’s head, facing the feet.

The first of three 5-mm ports is placed in the midaxillary line at the third intercostal space, and the chest is insufflated to 4 mm Hg. The remaining two ports are placed as far anterior and posterior in the third intercostal space as possible to maximize room for movement. The only visible structure for left-sided defects usually is the intestine, with the hernia being obscured. Using soft-tipped grasping instruments, the intestine is pushed gently toward the posterior lateral aspect of the diaphragm. This is continued until the intestine begins to reduce and the hernia is visualized.

The remainder of the hernia contents are pushed through the defect under direct vision, including the liver and spleen, if present. After the contents have been reduced, they should stay in the abdomen secondary to the insufflation pressure (Fig. 39-4C). If the contents are not retained in the abdomen, then a fourth port can be inserted just above the diaphragm for additional retraction. Cautery then is used to mobilize the posterior leaflet of the diaphragm from the retroperitoneum as much as possible.

Braided nonabsorbable sutures (0-0 or 2-0) are used to close the defect from a medial to lateral direction. For the most lateral suture, we have found that diaphragmatic tissue typically is lacking (Fig. 39-4D). Because this is the most likely site for recurrence, we now employ an external suture to secure this corner (Fig. 39-4E). A stab incision is made in the skin just under the rib at the corner of the diaphragm. The suture is brought through the skin and under the rib, and then grasped inside the chest using the thoracoscopic needle drivers. Next, the suture is placed through the upper rim of the diaphragm and the lower rim of the diaphragm, and then back out through the chest wall above the rib where it originally came under, in a triangular configuration. The suture is tied down with the knot just under the skin (Fig. 39-4F). For right-sided defects, care must be taken to avoid injury to the hepatic veins along the medial aspect of the defect.

The pneumothorax is evacuated through the ports, and they are removed. The port sites are closed with absorbable suture. If the defect is too large for primary closure, placement of a patch should be done with a thoracotomy.

A foramen of Morgagni hernia is repaired through a laparoscopic approach. The patient is placed supine on the operating table as close to the foot of the bed as possible. For infants and small children, the legs can be placed in a squatting position. For older children, lithotomy is the preferred position, with the surgeon standing between the legs. The first of three 5-mm ports is placed through the umbilicus, and the remaining two are placed in the right and left lower quadrants. The abdomen is insufflated to 15 mm Hg.

The contents of the hernia are reduced into the abdomen (Fig. 39-5A). The falciform ligament is mobilized with cautery all the way to the lower edge of the hernia defect so that the entire defect can be visualized. The hernia sac is grasped at the apex and inverted into the abdomen. The sac then is removed circumferentially from the edges of the diaphragm with a tissue sealing device or cautery.

FIGURE 39-5 Congenital diaphragmatic hernia (Morgagni type). A, Laparoscopic view of hernia. B and C, Placement of Morgagni hernia repair sutures (drawing and photo). D, Completed Morgagni repair.

The abdominal wall is palpated just below the xiphoid, visualizing with the laparoscope until the probing finger is centered over the defect. A 1-cm incision is made transversely in the skin. Braided, nonabsorbable 0-0 or 2-0 sutures then are placed full thickness through the abdominal wall and grasped with the laparoscopic needle drivers. We generally start on the right side of the defect and proceed sequentially to the left, placing five or six sutures to close the entire defect (Fig. 39-5B and C). Each suture is placed in a U-type fashion through the posterior aspect of the diaphragmatic defect. The needle then is directed back out through the anterior abdominal wall. All sutures are placed before tying the knots.

After the sutures have been placed, the air is released from the abdomen, and all the knots are tied while the assistant holds the untied sutures under tension. After all the knots have been tied, the abdomen is reinsufflated (but only to 10 mm Hg), and the repair is inspected (Fig. 39-5D). The ports are removed, and the sites are closed with absorbable sutures.

Diaphragmatic eventration also is approached through laparoscopy. We perform a plication instead of an imbrication; the latter commonly is used when a chest approach is used. The patient is positioned supine on the operating table. A 5-mm camera port is placed in the umbilicus, and the abdomen is insufflated to 15 mm Hg. For a right-sided eventration, a 12-mm port is placed in the left upper quadrant in the anterior axillary line just below the rib, and a 5-mm port is placed in the right lower quadrant. For left-sided eventration, the 12-mm and 5-mm port sites are reversed. The falciform ligament is mobilized with cautery up to the hepatic veins.

The apex of the eventration is visualized easily because it is nearly transparent. A 2-0 suture is advanced through the 5-mm lower quadrant port and grasped inside the abdomen. The suture is placed through the apex of the eventration and then extracted through the same 5-mm port. This is repeated with an additional 2-0 suture to help disperse the tension on the thin tissue. Tension is applied to the sutures to invert the diaphragm into the abdomen (Fig. 39-6A). An endostapler then is inserted through the 12-mm port in the upper lateral abdomen, and the redundant diaphragm is divided from medial to lateral (Fig. 39-6B). The plication typically requires three or four stapler loads to transect the atrophied muscle (Fig. 39-6C). The ports are removed, and the sites are closed with absorbable sutures.

FIGURE 39-6 Diaphragmatic eventration. A, Externalized sutures pulling eventration into the abdomen. B, Placement of endostapler to resect the eventration. C, Completed resection of eventration.

Postoperative Considerations

For the neonate who has undergone repair of a Bochdalek hernia, the postoperative recovery is dependent on the degree of pulmonary hypoplasia and any associated defects. For repairs that are performed outside of the neonatal period, the patient generally is fed that same day and discharged the following morning. Oral pain medication usually is all that is needed. All repairs are followed closely with a chest radiograph every 3 months for the first year and then yearly for the next 4 years to rule out recurrence. Recurrence is the major postoperative complication and should be less than 10%. It should be noted, however, that minimally invasive repair of this hernia does not have a long history, so the true recurrence rate is not yet known. Steps to avoid recurrence include meticulous suturing technique, gentle handling of the diaphragm, and successful placement of the corner, triangular, extracorporeal suture.

A patient who has had a repair of a foramen of Morgagni hernia is started on a regular diet, and pain is controlled with oral pain medications only. The patient is discharged the following morning. Follow-up occurs at 2 weeks with a chest radiograph. Additional follow-up with a chest radiograph is performed at 1 year to ensure that no recurrence has developed. The upper abdomen initially may appear slightly indented, but this should resolve within several months.

After repair of an eventration, the patient is started on a regular diet and then discharged the following morning. Oral pain medication is all that is needed for postoperative pain control. Initial follow-up is obtained at 2 weeks with a chest radiograph and then yearly for the next 4 years. Depending on the degree of phrenic nerve dysfunction, the remaining diaphragm may continue to atrophy during follow-up.

Preoperative Considerations

Gastrostomy and jejunostomy are invaluable interventions that can assist in both venting the gastrointestinal tract and as a conduit for enteral nutrition. With the advent of the percutaneous endoscopic gastrostomy (PEG), minimally invasive approaches to these surgical adjuncts have become a mainstay of treatment for a variety of conditions. Percutaneous approaches with or without endoscopic assistance, as well as laparoscopic approaches, have emerged as quick and safe. The intraoperative use of fluoroscopy has enabled jejunal advancement of a tube inserted into the stomach without the use of endoscopic guidance. This is particularly helpful in small infants, in whom endoscopy can be technically difficult and instrumentation may be limited by size.

Operative indications include failure to thrive for multiple reasons. Nutritional supplementation for children who do not or cannot eat enough is managed best with enteral feeding. If severe reflux is a concern, or there is concern that creating a gastrostomy will worsen mild to moderate reflux, then a gastrojejunostomy with direct jejunal feeds has become an option to an antireflux procedure in association with a gastrostomy. For most infants and children who are severely refluxing, however, a fundoplication still is the treatment of choice.

Before any operative manipulation of the upper gastrointestinal (GI) tract, an upper GI contrast study should be obtained to rule out any anatomic reason for reflux, gastric outlet obstruction, or duodenal obstruction. Although malrotation is the most common anomaly that is diagnosed on such an evaluation, the presence of gastroparesis, duodenal webs, or abnormal caliber of the proximal small bowel may lead to a surgical or medical option other than a gastrostomy or gastrojejunostomy. In addition, when reflux is a concern, we obtain an impedance study to quantitate the severity of reflux.

For children who can protect their airway, a trial of nasogastric bolus feeds can be used to predict problems associated with a gastrostomy alone. As indicated earlier, a gastrostomy can worsen existing reflux and may cause reflux in a child who previously did not have any. In patients with reflux complications (i.e., pneumonia, Barrett esophagus, esophagitis, laryngeal edema), a fundoplication always should be done with the gastrostomy, or a gastrojejunostomy should be performed as an alternative.