Chapter 1 of 11 · Fundamentals
Introduction
Introduction and Initial Patient Presentation
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
Video
BOB in Ped Surg 2023 - PAPSA Winner - Mohamad Mahmoud Qinawy, MD
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Podcast
Pediatric Gastroesophageal Reflux Disease
81 min · Published Aug 2018
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Gastoesophageal Reflux: Update Course 2015
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Case-Based Journal Review: G-Tube & Fundoplication for GERD 2023
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SAGES/ALACE Symposium: Integrating New Technologies, Old Tricks, and Operative Approaches
Jeffrey Ponsky · 12 min · Published Mar 2012
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Inguinal Hernia: Adult
31 min · Published Jan 2017
Podcast
Gastroesophageal Reflux Disease
Jeffrey Ponsky · 33 min · Published Jun 2016
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Inguinal Hernia With M. Rosen
Jeffrey Ponsky · 31 min · Published Oct 2015
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Pediatric Surgical Oncology Research Collaborative (PSORC): Studying Rare Pediatric Tumors
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Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
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Pooling Patients to Study Rare Pediatric Tumors: An Introduction to PSORC
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The fetal frontier: A review of current and emerging fetal therapies for genetic diseases
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Tricuspid valve surgery in transposition of the great arteries with a systemic right ventricle
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What the experts said
PPIs reduce gastric acid secretion more effectively than H2 blockers and are more convenient as once-daily dosing
Mounting data shows that lifetime proton pump inhibitor use has consequences
Minimum workup for patients with reflux symptoms requiring chronic PPI therapy includes endoscopy to assess esophagitis and rule out Barrett's esophagus
Barrett's esophagus may be subtle and asymptomatic, with risk of progression through low-grade and high-grade dysplasia to gastric cancer
Long-term PPI use in women is associated with osteoporosis risk
For PPI efficacy, the medication should be taken within 30 minutes before a meal, not at night before bed or in the morning while skipping breakfast
The primary reason for obtaining manometry before anti-reflux surgery is to rule out achalasia, because wrapping a patient with achalasia destroys esophageal function
Routine manometry before reflux surgery identifies previously undiagnosed achalasia cases that would have been missed without systematic testing
Patients with achalasia can present with heartburn symptoms due to stasis and fermentation of food in the esophagus
Manometry findings guide fundoplication type: distal esophageal amplitudes help determine whether to perform a full Nissen wrap versus a partial Toupet wrap
One disadvantage of laparoscopic fundoplication compared to open surgery is reduced scar tissue formation; full mediastinal dissection helps create scarring to reduce recurrence rates
Nissen fundoplication technique is highly variable among surgeons with poor standardization, making it difficult to reproduce research data
The geometry of the Nissen wrap is the most important part of the operation; incorrect geometry (grabbing posterior greater curve too low) can trap fundus above the wrap
A common mistake in Nissen fundoplication is making the wrap too long, which increases postoperative dysphagia; optimal wrap length is approximately 2 centimeters
Experienced surgeons no longer routinely use a 56 French bougie during hiatal closure, as it becomes less necessary with experience and carries perforation risk
For patients with weak esophageal peristalsis (amplitude below 20 mmHg) or connective tissue disease, a Toupet (270-degree posterior) fundoplication is preferred over full Nissen to avoid creating pseudoachalasia
The best operation to prevent reflux is a Nissen fundoplication, but in patients with poor esophageal motility, the esophageal pump cannot overcome the barrier, necessitating a partial wrap
Toupet fundoplication is made slightly longer than Nissen (2.5 to almost 3 centimeters) with three sutures on either side, esophagus to stomach
Anti-reflux surgery changes swallowing mechanics, stomach function, and acid movement; patients must understand these changes are permanent
Fundoplication wraps are tightest immediately after surgery and loosen over time; early dysphagia is expected and normal
A patient with no dysphagia two weeks after Nissen fundoplication is concerning because it indicates the wrap was made too loose and will likely fail long-term
Endoscopic intervention for postoperative dysphagia should not be considered until three months postoperatively, even if the patient can only tolerate liquids, as long as there is no anatomic problem
Pseudoachalasia after fundoplication presents with dilated esophagus, bird's beak appearance, and manometry showing absent peristalsis with non-relaxing LES, likely due to wrap being too tight causing esophageal burnout
Treatment options for pseudoachalasia include taking down the Nissen, performing Heller myotomy with Dor fundoplication, or converting to Toupet wrap with long Heller myotomy
For reoperative foregut surgery, the best approach is to plan to completely take down the wrap and start over, though this may not always be necessary or possible
For morbidly obese patients (BMI over 35) with GERD, gastric bypass is preferred over Nissen fundoplication as the primary operation because Nissen does not work well in this population
Before reoperative anti-reflux surgery, complete re-evaluation is essential including 48-hour Bravo study for symptom correlation, repeat manometry, and gastric emptying study
Nausea and vomiting as prominent symptoms in GERD patients are red flags suggesting delayed gastric emptying; these patients require careful evaluation before proceeding with fundoplication
In reoperative foregut surgery, prior port placement reveals the extent of original dissection: umbilical incision indicates no chest dissection was performed; five ports with lowest 5 cm from umbilicus indicates extensive original dissection
The first goal in reoperative fundoplication is to identify the right crus at its base, which provides orientation and prevents drifting into the inferior vena cava
Sharp dissection is preferred over harmonic scalpel when taking liver off the wrap in reoperative surgery, accepting some bleeding that can be compressed with the retractor paddle
Most primary fundoplications fail to create adequate scar tissue in the chest; if struggling with reoperative dissection below, the second approach is to enter the chest wherever possible and work back down
Reoperative foregut surgery requires identifying named structures and systematic dissection rather than creating spaces, or the surgeon will quickly become lost
If anterior vagus nerve is injured during reoperative fundoplication but posterior vagus is intact, observation is appropriate; postoperative upper GI on day 1-2 assesses gastric emptying
For delayed gastric emptying after vagal injury, early Botox injection to the pylorus is preferred over pyloroplasty unless both vagal nerves were clearly transected
The 'triangle of air' below the esophagus after hiatal closure, described by Ron Hinder, indicates appropriate hiatal tightness
David Ratner described an approach of taking down the Nissen, doing a long Heller, and converting to Toupet to open the wrap at 180 degrees on both sides