# Gastroesophageal Reflux Disease — GCMD Library living collection

Everything in the library about GERD — built automatically from dossiers that name it.

Updated: n/a · 13 episodes · 308 cited statements

## Episodes
### Fundamentals
- [GERD - (GastroEsophageal) REFLUX (Disease) in Esophageal Atresia Patients: An ERNICA animation](https://team.globalcastmd.com/watch/gerd-reflux-in-esophageal-atresia-patients-an-ernica-animation-7603) — video · 4:14 · [machine version](https://team.globalcastmd.com/watch/gerd-reflux-in-esophageal-atresia-patients-an-ernica-animation-7603.md)

### Surgical Management
- [Esophageal Disconnect for Severe GERD in Neurologically-Impaired Children:...](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409) — video · 34:38 · [machine version](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409.md)
- [Gastroesophageal Reflux Disease](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751) — podcast · 33:57 · [machine version](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751.md)

### Evidence & Research
- [Esophagogastric Dissociation for GERD in Severe Neurodisability](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563) — video · 2:49 · [machine version](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563.md)
- [Gastoesophageal Reflux: Update Course 2015](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670) — video · 30:06 · [machine version](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670.md)
- [Esophagogastric Dissociation for GERD in Severe Neurodisability](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962) — video · 2:49 · [machine version](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962.md)
- [BOB in Ped Surg 2023 - PAPSA Winner - Mohamad Mahmoud Qinawy, MD](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328) — video · 16:32 · [machine version](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328.md)
- [BOB Ped Surg 2023 - Mohamad Qinawy, PAPSA  - Presentation](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342) — video · 8:09 · [machine version](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342.md)

### Case-Based Learning
- [Case-Based Journal Review: G-Tube & Fundoplication for GERD 2023](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122) — podcast · 18:19 · [machine version](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122.md)

### In-Depth Reviews
- [Pediatric Gastroesophageal Reflux Disease](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359) — podcast · 1:21:04 · [machine version](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359.md)
- [Gastroesophageal Reflux: Contemporary Management Pediatric Surgery Update...](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428) — video · 32:14 · [machine version](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428.md)
- [Gastroesophageal Reflux Disease](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289) — podcast · 1:21:04 · [machine version](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289.md)
- [Gastroesopheal Reflux Disease](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444) — podcast · 33:57 · [machine version](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444.md)

## Chapters
- [0:00](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=0) Introduction and Guest Introductions (Ep 7)
- [2:49](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=169) Initial Workup of Infant with Vomiting and Respiratory Symptoms (Ep 7)
- [8:20](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=500) Eosinophilic Esophagitis as a Masquerader (Ep 7)
- [13:20](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=800) Role of Proton Pump Inhibitors in Infants (Ep 7)
- [20:00](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1200) Medical Management Strategies (Ep 7)
- [28:00](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1680) NICU Premature Infant Management (Ep 7)
- [35:00](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2100) Diagnostic Testing: Upper GI and pH Impedance (Ep 7)
- [41:40](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2500) Rome IV Classification and Reflux Hypersensitivity (Ep 7)
- [50:00](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3000) Surgical Technique: Minimal Mobilization Nissen (Ep 7)
- [60:00](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3600) Post-Fundoplication Retching Management (Ep 7)
- [70:00](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=4200) Failed Fundoplication and Redo Surgery (Ep 7)
- [75:00](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=4500) Rumination Syndrome and Esophageal Dissociation (Ep 7)
- [0:00](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=0) Introduction and case presentation: 6-month-old with vomiting and respiratory symptoms (Ep 1)
- [2:49](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=169) Initial workup: ruling out oropharyngeal dysphagia and food allergy (Ep 1)
- [8:20](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=500) Proton pump inhibitors in infants: ineffective and harmful (Ep 1)
- [12:30](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=750) Endoscopy to rule out eosinophilic esophagitis; use of macrolides (Ep 1)
- [17:11](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=1031) Role of upper GI and when to suspect anatomic problems (Ep 1)
- [24:25](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=1465) NICU preemie with feeding intolerance: NG vs. G-tube timing (Ep 1)
- [34:57](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=2097) Diagnostic value of NJ trial and moving away from pH-impedance (Ep 1)
- [40:10](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=2410) When pH-impedance is useful: Rome IV categories in older children (Ep 1)
- [44:50](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=2690) Duration of PPI therapy and monitoring (Ep 1)
- [50:00](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3000) The 'perfect Nissen': minimal mobilization to prevent wrap migration (Ep 1)
- [56:40](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3400) Post-fundoplication retching: workup and management (Ep 1)
- [61:40](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3700) Neurologically impaired patients and indications for fundoplication (Ep 1)
- [70:00](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=4200) Failed fundoplication: when to redo and alternative procedures (Ep 1)
- [75:20](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=4520) Rumination syndrome: a critical masquerader (Ep 1)
- [0:01](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1) Case 1: 4-year-old with recurrent reflux after fundoplication (Ep 2)
- [6:20](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=380) Case 2: 9-year-old with bloody hematemesis and erosive esophagitis (Ep 2)
- [10:45](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=645) Background and surgical technique overview (Ep 2)
- [17:37](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1057) Detailed surgical technique and video demonstration (Ep 2)
- [26:45](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1605) Series results and outcomes (Ep 2)
- [30:37](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1837) Panel discussion on indications and complications (Ep 2)
- [0:00](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=0) Diagnostic Testing for Gastroesophageal Reflux: Impedance Probes, pH Studies, and Upper GI Series (Ep 3)
- [5:57](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=357) Clinical Case: Three-Year-Old with Hiatal Hernia and Growth Failure (Ep 3)
- [10:51](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=651) Paraesophageal Hernia in a Ten-Month-Old: Type 2 Hiatal Hernia Management (Ep 3)
- [13:55](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=835) Gastroschisis Patient with Reflux: Laparoscopic Approach After Prior Abdominal Surgery (Ep 3)
- [18:56](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1136) Redo Fundoplication: Laparoscopic Versus Open Approach (Ep 3)
- [21:31](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1291) Comparative Outcomes: Laparoscopic Versus Open Fundoplication (Ep 3)
- [26:47](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1607) Gastric Emptying and Pyloroplasty: Indications and Alternatives (Ep 3)
- [0:04](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=4) Introduction and Historical Context of Esophagogastric Dissociation (Ep 4)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- The vast majority of kids who have vomiting, respiratory symptoms, and wheezing are more likely to have oropharyngeal dysphagia and aspiration during swallowing than gastroesophageal reflux. — Rachel Rosen (clinical) [Ep 1 · 3:23](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=203)
- In infants fed every 2 to 3 hours, milk remains in the stomach for up to 2–3 hours; acid production only begins after 3 hours, so infants reflux non-acidic gastric content. — Rachel Rosen (clinical) [Ep 1 · 5:39](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=339)
- Proton pump inhibitors are not beneficial in children under the age of 1 because they reflux non-acidic milk, not acid. — Rachel Rosen (clinical) [Ep 1 · 5:26](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=326)
- Studies have shown that both H2 blockers and PPIs increase the risk of sepsis, UTIs, necrotizing enterocolitis, pneumonia, pharyngitis, upper respiratory infections, GI bugs, and C. diff in infants. — Rachel Rosen (epidemiological) [Ep 1 · 7:21](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=441)
- Eosinophilic esophagitis is found in about 10% of kids under age 5 who are scoped for respiratory symptoms. — Rachel Rosen (epidemiological) [Ep 1 · 9:53](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=593)
- In children under 5, the most common presentation of eosinophilic esophagitis is chronic cough; the second most common is vomiting or failure to thrive. — Rachel Rosen (clinical) [Ep 1 · 9:41](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=581)
- In older kids, eosinophilic esophagitis presents with chest pain, food impactions, and dysphagia. — Rachel Rosen (clinical) [Ep 1 · 10:08](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=608)
- You really need to scope every kid before they would get a Nissen because you don't want to wrap a kid who has eosinophilic esophagitis. — Rachel Rosen (guideline) [Ep 1 · 10:54](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=654)
- About 60 to 70% of kids with eosinophilic esophagitis are allergic to dairy. — Rachel Rosen (epidemiological) [Ep 1 · 12:02](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=722)
- Macrolides (erythromycin) are motilin agonists that make the antrum of the stomach contract and can help with vomiting; they also have an anti-inflammatory effect on the airway and lungs. — Rachel Rosen (clinical) [Ep 1 · 16:28](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=988)
- There are no great normal values for the number of reflux episodes in pediatric patients, so the best use of a probe is to correlate symptoms with reflux episodes. — Rachel Rosen (clinical) [Ep 1 · 17:48](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=1068)
- The majority of kids will outgrow their oropharyngeal dysphagia by 3 to 4 months of age. — Rachel Rosen (clinical) [Ep 1 · 28:21](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=1701)
- In kids with oropharyngeal dysphagia in the NICU, about 75% will get the NG tube out and not need to go on to gastrostomy. — Rachel Rosen (epidemiological) [Ep 1 · 28:42](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=1722)
- When we looked at our own data at Boston Children's, once a gastrostomy goes in in children that aspirate from oropharyngeal dysphagia, their rates of hospitalization are about 15 times higher than if you just fed them by mouth, even in kids who aspirate all textures. — Rachel Rosen (epidemiological) [Ep 1 · 29:37](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=1777)
- An upper GI is really not a good study for reflux; it doesn't document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux. — Whit Holcomb (clinical) [Ep 1 · 22:32](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=1352)
- In a study of patients who had upper GI and pH studies, the upper GI did not help with diagnosing reflux, but it did help identify an anatomical problem in about 4% of patients. — Whit Holcomb (epidemiological) [Ep 1 · 23:19](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=1399)
- New GERD guidelines (joint North America and Europe) recommend treating with PPI for 2 months, then attempting to wean; if unable to wean, restart the drug, but the goal should be to try to wean ideally 2 times a year. — Rachel Rosen (guideline) [Ep 1 · 43:42](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=2622)
- If you have reflux beyond the age of 3 or 4, you're likely to continue to have it long term. — Rachel Rosen (clinical) [Ep 1 · 45:31](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=2731)
- In Kansas City's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap; the primary reason for redo historically was transmigration of the wrap into the chest. — Whit Holcomb (epidemiological) [Ep 1 · 46:40](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=2800)
- By doing minimal mobilization and not disrupting the phrenoesophageal membrane, we were able to drop our transmigration rate from 12% to 5%, and in our final study there was zero recurrence and zero redo fundoplication rate in both groups. — Whit Holcomb (epidemiological) [Ep 1 · 57:32](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3452)
- The surgical message is that we need to do less rather than more dissection around the GE junction to prevent wrap transmigration. — Whit Holcomb (clinical) [Ep 1 · 59:22](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3562)
- You've got to know where the left gastric artery is, and you've got to be sure that you are cephalad to that to ensure the wrap is at the level of the lower esophagus, not the stomach. — Whit Holcomb (clinical) [Ep 1 · 60:49](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3649)
- When you're looking at the post-fundoplication patient, if they have a G tube, you have to image them both ways: putting barium through the G tube and also giving them barium from above via a nasoesophageal tube to see if the esophagus is emptying. — Rachel Rosen (clinical) [Ep 1 · 62:02](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3722)
- A study out of Cincinnati showed that blenderized feeds are a really effective therapy for treatment of post-fundoplication retching. — Rachel Rosen (clinical) [Ep 1 · 63:07](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3787)
- We use a lot of erythromycin in babies who have respiratory symptoms; macrolides are motilin agonists and also have an anti-inflammatory effect for the airway and lungs. — Rachel Rosen (clinical) [Ep 1 · 16:28](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=988)
- Pyloric Botox works not only for delays in emptying but also with the sensory component that triggers retching. — Rachel Rosen (clinical) [Ep 1 · 54:19](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3259)
- Cyproheptadine (periactin) helps with gastric accommodation and can control retching in kids. — Rachel Rosen (clinical) [Ep 1 · 54:26](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3266)
- When you look at kids that tend to do the worst after Nissen, it's the kid who had a Nissen for pulmonary reasons; if they're aspirating during swallowing, their saliva pools in the esophagus over the Nissen and they continue to aspirate, so they gag, retch, and cough all the time. — Rachel Rosen (clinical) [Ep 1 · 49:02](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=2942)
- The kids who are the most miserable post-Nissen are the kids that were retching pre-op, because they retch a lot post-op too. — Rachel Rosen (clinical) [Ep 1 · 35:28](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=2128)
- Using an esophageal bougie at the time of fundoplication has resulted in very little need for postoperative dilation; in all our prospective studies, we've dilated one or two patients. — Whit Holcomb (epidemiological) [Ep 1 · 63:46](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3826)
- Patients who ruminate describe vomiting 50 to 100 times a day, typically within minutes of starting a meal or for the hour after a meal; esophageal motility study shows simultaneous contraction of the stomach with bolus movement up into the esophagus. — Rachel Rosen (clinical) [Ep 1 · 78:58](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=4738)
- If you wrap patients who ruminate, they continue to do this even with a wrap in place, so fundoplication does not help. — Rachel Rosen (clinical) [Ep 1 · 79:31](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=4771)
- When you look at rates of reflux post-Nissen, it's somewhere between 10 and 20 reflux episodes per 24-hour period on impedance probe, and if I see that, I'm pretty happy that the Nissen is still doing its job. — Rachel Rosen (clinical) [Ep 1 · 71:39](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=4299)
- Being able to use blenderized food instead of formula has really changed our rates of needing to think about fundoplication, because everything we're putting through the gastrostomy tube is so heavy and migrates to the antrum away from the LES and cardia. — Rachel Rosen (clinical) [Ep 1 · 52:39](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3159)
- There are three Rome IV diagnostic categories for older children with chest pain or heartburn: non-erosive reflux disease (NERD, abnormal acid burden with normal scope), reflux hypersensitivity (normal acid burden but symptom correlation with reflux), and functional heartburn (normal scope, normal acid, no symptom correlation). — Rachel Rosen (guideline) [Ep 1 · 40:54](https://team.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=2454)
- A multi-center study will likely be needed to fully understand the comparative effectiveness of esophagogastric dissociation versus Nissen fundoplication. — Todd Ponsky (opinion) [Ep 4 · 2:12](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=132)
- Leaks and strictures are the primary concerns that prevent most surgeons from performing esophagogastric dissociation. — Todd Ponsky (opinion) [Ep 4 · 2:15](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=135)
- The vast majority of kids who have vomiting, respiratory symptoms, wheezing are more likely to have oropharyngeal dysphagia and aspiration during swallowing than gastroesophageal reflux. — Rachel Rosen (clinical) [Ep 7 · 3:23](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=203)
- The peak age of reflux is between 4 and 6 months of age. — Rachel Rosen (epidemiological) [Ep 7 · 4:18](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=258)
- In children under the age of 1, proton pump inhibitors are not beneficial because these kids reflux non-acidic gastric content (milk). — Rachel Rosen (clinical) [Ep 7 · 5:26](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=326)
- Normal gastric emptying of infants takes 2 to 3 hours; acid production only starts after the 3 hour mark when the stomach is empty. — Rachel Rosen (clinical) [Ep 7 · 5:45](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=345)
- Studies have shown both with H2 blockers and PPIs you can get sepsis, UTIs, necrotizing enterocolitis, pneumonias, pharyngitis, upper respiratory infections, and C. diff in young children. — Rachel Rosen (clinical) [Ep 7 · 7:21](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=441)
- In kids under the age of 5, the most common presentation of eosinophilic esophagitis is chronic cough. — Rachel Rosen (clinical) [Ep 7 · 9:27](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=567)
- When you scope all kids under the age of 5 who are presenting with respiratory symptoms, you'll find eosinophilic esophagitis in about 10% of kids. — Rachel Rosen (epidemiological) [Ep 7 · 9:53](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=593)
- You really need to scope every kid before they would get a Nissen because you don't want to wrap a kid who has eosinophilic esophagitis. — Rachel Rosen (guideline) [Ep 7 · 10:54](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=654)
- In about 60 to 70% of kids with eosinophilic esophagitis, the most likely allergen is dairy. — Rachel Rosen (epidemiological) [Ep 7 · 11:57](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=717)
- Macrolides like erythromycin are motilin agonists that make the antrum of the stomach contract and help with vomiting, plus they have anti-inflammatory effects for the airway and lungs. — Rachel Rosen (clinical) [Ep 7 · 16:28](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=988)
- There are no great normal values for the number of reflux episodes in pediatric patients, making pH impedance interpretation difficult. — Rachel Rosen (clinical) [Ep 7 · 17:48](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1068)
- Reflux in Dr. Rosen's opinion is rarely a cause of failure to thrive and respiratory symptoms in infants. — Rachel Rosen (opinion) [Ep 7 · 19:18](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1158)
- The majority of kids with oropharyngeal dysphagia will outgrow it by 3 to 4 months of age according to a study in JPGN. — Rachel Rosen (clinical) [Ep 7 · 28:21](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1701)
- In kids who aspirate from oropharyngeal dysphagia, rates of hospitalization after gastrostomy placement are about 15 times higher than if you just fed them by mouth, even in kids who aspirate all textures. — Rachel Rosen (epidemiological) [Ep 7 · 29:37](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1777)
- In Boston Children's data, about 75% of NICU babies with severe dysphagia managed with NG tubes will not need to go on to gastrostomy. — Rachel Rosen (epidemiological) [Ep 7 · 28:42](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1722)
- An upper GI study does not document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux. — Whit Holcomb (clinical) [Ep 7 · 22:38](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1358)
- In a large study at Children's Mercy, upper GI identified anatomical problems in about 4% of patients. — Whit Holcomb (epidemiological) [Ep 7 · 23:17](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1397)
- The new GERD guidelines (joint North America and Europe) recommend treating with PPI for 2 months then attempting to wean, with goal of weaning twice yearly. — Rachel Rosen (guideline) [Ep 7 · 43:42](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2622)
- If you have reflux beyond the age of 3 or 4, you're likely to continue to have it long term. — Rachel Rosen (clinical) [Ep 7 · 45:31](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2731)
- In Dr. Holcomb's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap using minimal mobilization technique. — Whit Holcomb (clinical) [Ep 7 · 46:40](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2800)
- The primary reason for redo fundoplication is transmigration of the wrap into the chest. — Whit Holcomb (clinical) [Ep 7 · 46:43](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2803)
- Before adopting minimal mobilization technique, Children's Mercy had a 12% transmigration rate which dropped to 5% after the technique change. — Whit Holcomb (epidemiological) [Ep 7 · 57:23](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3443)
- The key technical point is that the fundoplication wrap must be cephalad to the left gastric artery to ensure it's at the level of the lower esophagus rather than the stomach. — Whit Holcomb (clinical) [Ep 7 · 60:49](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3649)
- Kids who present with aspiration during swallowing and then get a Nissen tend to do worse because their saliva pools in their esophagus over the Nissen or they continue to aspirate their saliva. — Rachel Rosen (clinical) [Ep 7 · 49:02](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2942)
- Blenderized feeds through gastrostomy tubes have really changed management of reflux because the food is heavier and migrates to the antrum away from the LES and cardia. — Rachel Rosen (clinical) [Ep 7 · 52:39](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3159)
- A study from Cincinnati showed that blenderized feeds are a really effective therapy for treatment of post-fundoplication retching. — Rachel Rosen (clinical) [Ep 7 · 63:11](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3791)
- Pyloric Botox works not only for delays in emptying but also with the sensory component that triggers retching. — Rachel Rosen (clinical) [Ep 7 · 54:19](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3259)
- Cyproheptadine (Periactin) helps with gastric accommodation and can control retching in children. — Rachel Rosen (clinical) [Ep 7 · 54:26](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3266)
- Kids who wretch preoperatively will likely wretch postoperatively, and families should be counseled about this. — Rachel Rosen (clinical) [Ep 7 · 35:28](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2128)
- Using an esophageal bougie at the time of fundoplication prevents the wrap from being too tight and reduces need for postoperative dilation. — Whit Holcomb (clinical) [Ep 7 · 63:42](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3822)
- Post-fundoplication patients should have 10-20 reflux episodes per 24 hours on impedance probe, which is acceptable and indicates the Nissen is still functioning. — Rachel Rosen (clinical) [Ep 7 · 71:44](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=4304)
- Rome IV defines three categories: non-erosive reflux disease (NERD - abnormal acid burden, normal scope), reflux hypersensitivity (normal acid burden but symptoms correlate with reflux), and functional heartburn (no correlation between symptoms and reflux). — Rachel Rosen (guideline) [Ep 7 · 40:54](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2454)
- Patients with rumination syndrome describe vomiting 50-100 times a day, typically within minutes of starting a meal or for the hour after a meal. — Rachel Rosen (clinical) [Ep 7 · 78:40](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=4720)
- On esophageal motility study, rumination shows simultaneous contraction of the stomach with bolus movement up into the esophagus. — Rachel Rosen (clinical) [Ep 7 · 79:13](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=4753)
- If you wrap patients with rumination syndrome, they continue to ruminate even with a wrap in place. — Rachel Rosen (clinical) [Ep 7 · 79:31](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=4771)
- Gastric stimulation may work through a sensory effect rather than purely a motility effect, as some patients improve without improvements in motility. — Rachel Rosen (opinion) [Ep 7 · 68:04](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=4084)
- Botox doesn't reliably improve gastric emptying but helps significantly with retching, suggesting a sensory mechanism. — Rachel Rosen (clinical) [Ep 7 · 68:18](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=4098)
- A multi-center study will probably be needed to really understand the difference between these procedures. — Todd Ponsky (opinion) [Ep 6 · 2:12](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=132)
- The study did not look at complication rates such as leaks and strictures, which are the main concern for why most surgeons don't perform esophagogastric dissociation. — Todd Ponsky (clinical) [Ep 6 · 2:16](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=136)
- Esophagogastric dissociation is a much bigger surgery than Nissen fundoplication. — Ian Glenn (clinical) [Ep 6 · 2:24](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=144)
- Continuous gastrostomy feeds may eliminate vomiting but patients can still have severe reflux with erosive esophagitis and discomfort — Todd Ponsky (clinical) [Ep 2 · 7:23](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=443)
- Redo fundoplication with hiatal hernia repair is a 30-minute operation without cutting the stomach or dissociating the esophagus, which have significant morbidity — Steve (clinical) [Ep 2 · 2:43](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=163)
- True hiatal hernias in 6-month-old infants are very unusual and not common — Steve (clinical) [Ep 2 · 4:00](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=240)
- Large hiatal hernia at first operation may complicate esophagogastric disconnect by allowing small bowel to herniate into chest — David (clinical) [Ep 2 · 4:40](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=280)
- The Kansas technique for fundoplication, which preserves esophagophrenic ligament, may leave better options for later disconnect compared to wide hiatal dissection — David (clinical) [Ep 2 · 4:50](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=290)
- After 2-3 failed fundoplications, disconnect becomes a very attractive third option — Steve (opinion) [Ep 2 · 7:49](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=469)
- Many neurologically impaired children have life expectancy of 20-40 years, and adult surgeons may not be excited to inherit patients who have had 4 redo fundoplications — Dan (opinion) [Ep 2 · 8:13](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=493)
- Primary disconnect patients seem to have a bumpier postoperative course compared to those done after multiple fundoplications, though this is anecdotal without statistical power — Steve (clinical) [Ep 2 · 8:53](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=533)
- Both vagus nerves can be preserved during disconnect and no pyloroplasty is needed, with no gastric emptying problems observed — Todd Ponsky (clinical) [Ep 2 · 16:40](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1000)
- Roux limb length should be 25-30 centimeters; shorter limbs risk bile reflux into the stomach — Dan (clinical) [Ep 2 · 18:04](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1084)
- One patient had bile refluxing into stomach post-operatively, confirmed on contrast study, due to inadequate Roux limb length — Dan (clinical) [Ep 2 · 17:37](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1057)
- Mesenteric defects, particularly Peterson's defect, must be closed to prevent internal hernias — Todd Ponsky (clinical) [Ep 2 · 18:54](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1134)
- Prophylactic antibiotics for several days post-operatively are used, treating the case like perforated appendicitis, due to theoretical contamination when crossing the esophagus near liver parenchyma — Todd Ponsky (clinical) [Ep 2 · 19:10](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1150)
- Contrast study is typically done at 3 days post-operatively, though some de novo patients have been fed without imaging if doing very well — Todd Ponsky (clinical) [Ep 2 · 19:40](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1180)
- Low threshold for re-imaging or returning to OR if concerned about leak, similar to bariatric surgery practice — Todd Ponsky (clinical) [Ep 2 · 20:01](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1201)
- Some patients can start feeds immediately post-operatively since feeds go into stomach and downstream, not past the esophagojejunostomy — Todd Ponsky (clinical) [Ep 2 · 20:29](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1229)
- Operating from patient's right side (as in bariatric surgery) rather than between legs allows better access and avoids lithotomy position — David (clinical) [Ep 2 · 21:26](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1286)
- Hand-sewn esophagojejunostomy with interrupted sutures is preferred over stapled anastomosis, especially in smaller children, for security — Todd Ponsky (clinical) [Ep 2 · 22:30](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1350)
- 4-0 Vicryl suture is used for esophagojejunostomy; PDS or silk could also be used — Todd Ponsky (clinical) [Ep 2 · 23:50](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1430)
- One complication involved colon flipping around Roux limb causing obstruction in a patient with neurologic impairment and global motility problems; resolved by pulling colon back and tacking it to Roux limb — Dan (clinical) [Ep 2 · 24:08](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1448)
- In 24-patient series, average age was 9 years (range 14 months to 17 years), average weight 8-57 kg, average operative time 474 minutes, average length of stay 12 days — Todd Ponsky (clinical) [Ep 2 · 26:45](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1605)
- Long length of stay (12 days average) is related to complex patient population with respiratory issues, need for pulmonary toilet, and mobilization challenges, not the operation itself — Todd Ponsky (clinical) [Ep 2 · 26:45](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1605)
- Results show minimal post-operative retching and vomiting in the series — Todd Ponsky (clinical) [Ep 2 · 28:20](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1700)
- No patients in the series were readmitted for aspiration-related events or respiratory problems related to reflux — Todd Ponsky (clinical) [Ep 2 · 29:10](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1750)
- Caregivers report dramatic improvement in quality of life, with some mothers in tears saying 'you've given me my child back' — Todd Ponsky (clinical) [Ep 2 · 28:40](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1720)
- Complications in the series include internal hernias (one requiring bowel resection after delayed presentation), one death from gram-negative sepsis with no leak on contrast study, and several readmissions — Todd Ponsky (clinical) [Ep 2 · 30:00](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1800)
- Patients can continue to take food by mouth for pleasure after disconnect, including ice cream and supplemental feeds, though they may not maintain weight on oral intake alone — Todd Ponsky (clinical) [Ep 2 · 30:20](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1820)
- In neurologically normal patients who want to eat by mouth after disconnect, they will be able to eat but probably cannot maintain weight without supplemental nighttime feeds — Todd Ponsky (clinical) [Ep 2 · 25:05](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1505)
- Patients who have had total gastrectomy with Roux-en-Y reconstruction can still eat by mouth but cannot maintain weight without supplementation — Todd Ponsky (clinical) [Ep 2 · 25:50](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1550)
- Redo Nissen fundoplication in neurologically impaired children is typically a 2-hour operation with discharge in 24-48 hours, significantly less morbidity than disconnect — Steve (clinical) [Ep 2 · 33:07](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1987)
- Having a Roux limb is not necessarily benign long-term and carries significant potential complications — Steve (opinion) [Ep 2 · 32:50](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=1970)
- Patients who fail fundoplication may receive GJ tubes and not return to surgeon, so true long-term fundoplication failure rates may be underestimated — Steve (opinion) [Ep 2 · 33:35](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=2015)
- Multiple-channel intraluminal impedance probes are the best test for quantifying the presence and severity of non-acid reflux over time. — Tim (clinical) [Ep 3 · 0:08](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=8)
- Impedance probes are not readily available to all practitioners, particularly outside major centers, and even within the United States not all pediatric gastroenterologists perform them. (clinical) [Ep 3 · 0:38](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=38)
- pH probes are more readily available and more commonly used than impedance probes for reflux evaluation. (clinical) [Ep 3 · 0:38](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=38)
- Gastroenterologists report they can perform impedance studies in neonates, although they are rarely requested. — Tim (clinical) [Ep 3 · 1:04](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=64)
- Surgical decisions to operate for reflux are typically based on clinical symptoms rather than objective testing. — Tim (clinical) [Ep 3 · 1:04](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=64)
- In a study from the speaker's institution examining fundoplications and correlating upper GI studies with pH studies, the upper GI influenced management in 4% of cases. — Tim (epidemiological) [Ep 3 · 4:20](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=260)
- Of the 4% of cases where upper GI influenced management, 80% were due to detection of malrotation. — Tim (epidemiological) [Ep 3 · 4:20](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=260)
- The 4% rate of upper GI studies influencing management can be interpreted two ways: either 4% is significant enough to warrant routine pre-operative upper GI, or 4% is low enough that malrotation can be evaluated intraoperatively during fundoplication. — Tim (opinion) [Ep 3 · 4:20](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=260)
- If pre-operative upper GI demonstrates malrotation in a patient being evaluated for fundoplication, management changes from fundoplication to Ladd procedure with proton pump inhibitors instead. — Tim (clinical) [Ep 3 · 5:26](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=326)
- Upper GI studies can also detect duodenal web or duodenal stenosis in addition to malrotation, though malrotation was the most common reason for management change. — Tim (clinical) [Ep 3 · 5:47](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=347)
- For a 3-year-old child who is eating orally, gastrostomy tube placement is not routinely indicated at the time of fundoplication. (clinical) [Ep 3 · 3:45](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=225)
- Collis gastroplasty is not necessary for routine fundoplication with hiatal hernia repair in pediatric patients. (clinical) [Ep 3 · 2:24](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=144)
- Pyloroplasty is not routinely performed at the time of fundoplication. (clinical) [Ep 3 · 3:00](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=180)
- For patients who tolerate nasogastric tube feeds without vomiting, gastrostomy tube alone may be sufficient without fundoplication. (clinical) [Ep 3 · 3:00](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=180)
- For patients who continue to vomit despite nasogastric tube feeds, fundoplication (Nissen) is indicated. (clinical) [Ep 3 · 3:00](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=180)
- In 2013, laparoscopic approach should be the default for fundoplication rather than open approach. — Tim (opinion) [Ep 3 · 6:43](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=403)
- For type 2 (paraesophageal) hiatal hernias in children, fundoplication and hiatal hernia repair alone is adequate without gastropexy or gastrostomy tube. (clinical) [Ep 3 · 12:45](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=765)
- Once a paraesophageal hernia is reduced and fundoplication performed, gastropexy does not appear necessary based on available data. (clinical) [Ep 3 · 12:45](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=765)
- In gastroschisis patients being re-operated at 6 months of age, there are often not many adhesions present, making laparoscopic approach feasible. (clinical) [Ep 3 · 15:00](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=900)
- For gastroschisis patients requiring fundoplication, left upper quadrant initial port placement via mini cut-down is preferred over umbilical access to avoid adhesions. (clinical) [Ep 3 · 15:00](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=900)
- In neurologically normal 6-month-old infants with reflux, there may be justification to wait longer before proceeding to fundoplication since they may still outgrow reflux. — Tim (opinion) [Ep 3 · 16:38](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=998)
- Laparoscopic approach can be successfully attempted even in patients with previous abdominal operations, as adequate visualization can usually be achieved with patience. (clinical) [Ep 3 · 16:59](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1019)
- For redo fundoplication after prior laparoscopic Nissen, laparoscopic approach is preferred as visualization is often better than with open technique, even in the upper abdomen. (clinical) [Ep 3 · 18:11](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1091)
- Laparoscopic anti-reflux operations are well-tolerated by infants with cardiac anomalies. — Tim (clinical) [Ep 3 · 22:16](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1336)
- Wrap herniation above the diaphragm is NOT more common in the open group compared to laparoscopic (contrary to what might be expected). — Tim (clinical) [Ep 3 · 22:16](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1336)
- Postoperative bowel obstruction rates are significantly lower with laparoscopic fundoplication compared to open approach. — Tim (clinical) [Ep 3 · 22:37](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1357)
- Traditional rates of postoperative bowel obstruction after open fundoplication were quoted as 5-10%. (epidemiological) [Ep 3 · 22:37](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1357)
- Current estimated rate of postoperative bowel obstruction after laparoscopic fundoplication is approximately 1-2%. (epidemiological) [Ep 3 · 22:37](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1357)
- For laparoscopic fundoplication, ports are placed higher in the abdomen, which may contribute to even lower bowel obstruction rates than general laparoscopic surgery. — Tim (clinical) [Ep 3 · 22:52](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1372)
- Neurologically impaired children who develop adhesive bowel obstruction after fundoplication may present late and very ill because they have a closed-loop obstruction with inability to vomit. (clinical) [Ep 3 · 23:01](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1381)
- Nasogastric tube trial is a useful diagnostic test: if a vomiting patient does well with NG feeds, they may only need a gastrostomy tube; if they continue to vomit with NG feeds, they will need fundoplication. (clinical) [Ep 3 · 23:35](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1415)
- Nasojejunal tube trial is even more diagnostic than nasogastric tube, as tolerance of NJ feeds strongly predicts success with fundoplication. (clinical) [Ep 3 · 23:35](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1415)
- For infants with hypoplastic left heart status-post stage 1 repair who have documented aspiration and recurrent desaturation events that cease with NJ feeds, fundoplication is indicated. (clinical) [Ep 3 · 24:23](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1463)
- Indications for fundoplication in cardiac patients include recurrent aspirations, apnea-bradycardia-desaturation events, or failure to thrive, not simply the presence of cardiac anomaly alone. (clinical) [Ep 3 · 24:23](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1463)
- In cardiac patients who are failing to thrive and need gastrostomy tube, performing fundoplication at the same time prevents creating an aspiration risk with G-tube alone. — Tim (clinical) [Ep 3 · 24:53](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1493)
- PEG tubes that stick straight out are particularly cumbersome in cardiac patients who have sternal wires and atrial leads. — Tim (clinical) [Ep 3 · 24:53](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1493)
- PEG tubes are not very appropriate for babies in general. (opinion) [Ep 3 · 25:19](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1519)
- Cardiologists and pulmonologists are aggressive about recommending fundoplication for children with pulmonary hypertension or cardiac anomalies who are borderline feeders. — Tim (clinical) [Ep 3 · 25:50](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1550)
- For cardiac patients too sick for fundoplication, primary GJ tube placement is an alternative, allowing jejunal feeding in hospitalized patients. — Tim (clinical) [Ep 3 · 25:50](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1550)
- Fundoplication alone typically improves gastric emptying in most patients, eliminating the need for routine pyloroplasty. — Tim (clinical) [Ep 3 · 26:47](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1607)
- There is still a segment of patients with poor gastric emptying despite fundoplication who may benefit from additional interventions. — Tim (clinical) [Ep 3 · 26:47](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1607)
- Gastric electrical stimulation can effectively stop retching in neurologically impaired children with severe gastroparesis after fundoplication, with immediate cessation of retching. (clinical) [Ep 3 · 26:56](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1616)
- Retching after fundoplication in patients with severe gastroparesis can loosen or undo the fundoplication wrap. (clinical) [Ep 3 · 26:56](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1616)
- In the past when performing open fundoplications, gastric emptying studies were routinely checked and pyloroplasties were performed on neurologically impaired patients. (clinical) [Ep 3 · 26:56](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1616)
- After switching to laparoscopic fundoplication and based on data showing it helps gastric emptying, routine pyloroplasty is no longer performed. (clinical) [Ep 3 · 26:56](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1616)
- For gastric pull-up procedures (for lye stricture or esophageal atresia), pyloroplasty is performed. (clinical) [Ep 3 · 28:12](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1692)
- For reverse gastric tube procedures performed in the neonatal period for esophageal atresia, pyloroplasty has not been performed. (clinical) [Ep 3 · 28:36](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1716)
- When pyloroplasty is not performed during gastric pull-up, there is a lower rate of stricture at the esophagogastric anastomosis, possibly because bile is seen in the stomach on endoscopy indicating the pylorus is functioning. — Tim (clinical) [Ep 3 · 28:49](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1729)
- For asymptomatic type 1 (sliding) hiatal hernias, operative intervention is not indicated. (clinical) [Ep 3 · 31:21](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1881)
- For asymptomatic paraesophageal hernias (types 2-4), operative intervention is indicated. (clinical) [Ep 3 · 31:21](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1881)
- In developmentally delayed children who develop small hiatal hernias after fundoplication, if they are asymptomatic, observation is appropriate given the high operative risk. — Tim (clinical) [Ep 3 · 31:21](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1881)
- There is a 95% chance fundoplication will be done successfully without need for another operation — Whit Holcomb (clinical) [Ep 5 · 7:17](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=437)
- Fundoplication is clinically 95% successful, though literature reports much higher failure rates depending on how recurrence is assessed (clinical) [Ep 5 · 8:11](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=491)
- Immediate morbidity and mortality of laparoscopic fundoplication, even in infants, is very low and it is a safe operation — Daniel von Allmen (clinical) [Ep 5 · 10:15](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=615)
- Children who wretch preoperatively have high likelihood of wretching postoperatively after fundoplication (clinical) [Ep 5 · 6:27](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=387)
- Long-term complications of laparotomy including bowel obstruction several years after open Nissen are underreported, with morbidity and even mortality from bowel obstruction related to laparotomy (clinical) [Ep 5 · 19:11](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=1151)
- The laparoscopic fundoplication should be the same operation done openly, just performed laparoscopically, so results should be the same (opinion) [Ep 5 · 20:37](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=1237)
- Whichever fundoplication technique (complete or partial) a surgeon does best, they should perform that technique — Whit Holcomb (opinion) [Ep 5 · 22:42](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=1362)
- Transmigration was 90% of the reasons for needing to redo fundoplications in Birmingham and Kansas City practices — Mac Harmon (clinical) [Ep 5 · 24:07](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=1447)
- Trial of bolus NG tube feeding predicts whether infant needs fundoplication: if they do well with NG tube, perform G-tube alone; if they don't, perform Nissen — Daniel von Allmen (clinical) [Ep 5 · 25:40](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=1540)
- Bolus gastric feeding trial is the most helpful functional test for determining need for fundoplication, more informative than pH impedance probes — Whit Holcomb (clinical) [Ep 5 · 25:58](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=1558)
- There is probably a 10-15% incidence of patients needing fundoplication after initial G-tube placement — Whit Holcomb (clinical) [Ep 5 · 29:02](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=1742)
- PPIs do not stop vomiting; they make refluxed material less acidic — Daniel von Allmen (clinical) [Ep 5 · 16:28](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=988)
- Eosinophilic esophagitis is becoming an issue across the board as the frequency of food allergies is skyrocketing in the pediatric population — Greg (epidemiological) [Ep 5 · 14:58](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=898)
- EE is less likely in infants given how early in the feeding process they are, but has been seen in very young children — Greg (clinical) [Ep 5 · 14:15](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=855)
- Unrecognized motility disorders can be exacerbated by fundoplication, creating a functional obstruction that makes the situation more difficult — Greg (clinical) [Ep 5 · 14:15](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=855)
- PPIs reduce gastric acid secretion more effectively than H2 blockers and are more convenient as once-daily medication — Michael Rosen (clinical) [Ep 8 · 2:59](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=179)
- Mounting data shows that lifetime use of proton pump inhibitors has consequences — Michael Rosen (clinical) [Ep 8 · 3:34](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=214)
- Patients with reflux symptoms requiring chronic PPI use need endoscopy at minimum to assess esophagitis and rule out Barrett's esophagus — Michael Rosen (guideline) [Ep 8 · 4:06](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=246)
- In 2016, patients without esophagitis, hiatal hernia, or Barrett's on endoscopy require additional workup before indefinite PPI therapy, especially young patients at risk for osteoporosis — Michael Rosen (opinion) [Ep 8 · 5:00](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=300)
- Bravo pH study is preferred over nasal catheter for patient comfort, measuring 48 hours of pH data via endoscopically placed capsule 6cm above GE junction — Michael Rosen (clinical) [Ep 8 · 5:48](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=348)
- Bravo pH testing off PPIs is preferred to establish symptom correlation, which is important for setting patient expectations about surgical outcomes — Michael Rosen (opinion) [Ep 8 · 6:17](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=377)
- Manometry is required before any surgical discussion for reflux, though not necessary for initial medical management — Michael Rosen (guideline) [Ep 8 · 6:51](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=411)
- For mild reflux (pH <4 for 6-8% of time, DeMeester score 20) without esophagitis or Barrett's, lifestyle modifications and PPI trial are appropriate before considering surgery — Michael Rosen (clinical) [Ep 8 · 7:50](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=470)
- Long-term PPI use in women is associated with osteoporosis risk; calcium supplementation and periodic bone density testing may be protective — Michael Rosen (clinical) [Ep 8 · 8:59](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=539)
- PPIs should be taken within 30 minutes before a meal, not at night before bed or in the morning without breakfast, to maximize effectiveness — Michael Rosen (clinical) [Ep 8 · 10:14](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=614)
- The primary reason for manometry before fundoplication is to rule out achalasia, as wrapping a patient with achalasia destroys esophageal function — Michael Rosen (clinical) [Ep 8 · 11:19](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=679)
- Patients with achalasia can present with heartburn due to stasis and fermentation of food in the esophagus — Michael Rosen (clinical) [Ep 8 · 11:47](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=707)
- Manometry findings guide fundoplication type: total LES relaxation with low resting pressure supports full Nissen, while poor distal esophageal amplitudes may indicate need for partial wrap to avoid postoperative dysphagia — Michael Rosen (clinical) [Ep 8 · 12:26](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=746)
- Full Nissen fundoplication (360-degree wrap) is appropriate for patients with normal peristalsis (amplitude 30mmHg or higher), total LES relaxation, and DeMeester score around 28 — Michael Rosen (clinical) [Ep 8 · 13:58](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=838)
- Laparoscopic fundoplication has the disadvantage of producing less scar tissue than open surgery; full mediastinal dissection helps create scarring to reduce recurrence rates — Michael Rosen (opinion) [Ep 8 · 15:17](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=917)
- Mediastinal dissection during fundoplication provides additional esophageal length, which is critical for a tension-free repair — Michael Rosen (clinical) [Ep 8 · 15:17](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=917)
- Taking down short gastric vessels during Nissen makes it easier to avoid twisting the wrap and ensures proper orientation of posterior to anterior stomach — Michael Rosen (opinion) [Ep 8 · 15:17](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=917)
- Nissen fundoplication technique is highly variable among surgeons with poor standardization, making it difficult to reproduce outcomes; proper wrap geometry is critical — Michael Rosen (opinion) [Ep 8 · 15:17](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=917)
- Common technical error in Nissen is grabbing the greater curve too low on the left side, which traps fundus above the wrap and creates improper geometry — Jeff Ponsky (clinical) [Ep 8 · 15:17](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=917)
- Nissen wrap should be approximately 2cm long with 3 sutures; making the wrap too long (wrapping all available intraabdominal esophagus) is a common mistake that increases dysphagia — Michael Rosen (clinical) [Ep 8 · 16:14](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=974)
- First suture in Nissen should be stomach-to-stomach so the knot can be used to position the wrap before securing it; subsequent sutures are stomach-esophagus-stomach — Michael Rosen (clinical) [Ep 8 · 16:54](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1014)
- Posterior gastropexy (fixing posterior stomach to crura) should be done after wrap creation to ensure stomach sits without tension, not beforehand — Michael Rosen (opinion) [Ep 8 · 17:06](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1026)
- Crural closure should create a 'triangle of air' or 'V sunlight' below the esophagus; experienced surgeons can achieve this without routine bougie use — Michael Rosen (clinical) [Ep 8 · 17:39](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1059)
- With increasing experience, surgeons tend to make crural closure progressively tighter — Michael Rosen (opinion) [Ep 8 · 18:16](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1096)
- Patients with weak esophageal peristalsis (amplitude below 20mmHg) and connective tissue disease require clear discussion that full Nissen may cure reflux but create dysphagia due to inadequate esophageal pump function — Michael Rosen (clinical) [Ep 8 · 19:02](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1142)
- Toupet fundoplication (270-degree posterior wrap) is indicated for patients with weak motility to prevent pseudoachalasia — Michael Rosen (clinical) [Ep 8 · 19:42](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1182)
- Toupet wrap is made slightly longer than Nissen (2.5-3cm vs 2cm) with 3 sutures on each side, all esophagus-to-stomach, plus single posterior gastropexy — Michael Rosen (clinical) [Ep 8 · 19:44](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1184)
- Fixing Toupet wrap to lateral crura is not recommended as it angulates anatomy awkwardly and pulls the stomach — Michael Rosen (opinion) [Ep 8 · 20:33](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1233)
- Fundoplication changes how patients swallow, how the stomach works, and how acid moves through the body; setting these expectations preoperatively is critical for patient satisfaction — Michael Rosen (clinical) [Ep 8 · 21:28](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1288)
- Fundoplication is tightest immediately after surgery and loosens over time; early dysphagia is expected and desired — Michael Rosen (clinical) [Ep 8 · 21:28](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1288)
- Patients with no dysphagia at 2 weeks post-Nissen likely have a wrap that is too loose and will have long-term problems — Michael Rosen (clinical) [Ep 8 · 21:28](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1288)
- Dysphagia in the first 6 weeks post-fundoplication should not prompt intervention, even if patient maintains liquid-only diet — Michael Rosen (clinical) [Ep 8 · 21:28](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1288)
- Endoscopic intervention for persistent dysphagia should not be considered until 3 months postoperatively with no progression and inability to tolerate anything beyond liquids — Michael Rosen (clinical) [Ep 8 · 21:28](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1288)
- Workup for dysphagia at 6-8 months post-fundoplication includes upper GI to rule out hernia recurrence and identify anatomic causes, followed by endoscopy with dilation if wrap is too tight — Michael Rosen (clinical) [Ep 8 · 23:17](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1397)
- Pseudoachalasia presents as dilated esophagus with bird's beak appearance, retained fluid pool, tight GE junction, loss of peristalsis, and non-relaxing LES on manometry after fundoplication — Michael Rosen (clinical) [Ep 8 · 24:06](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1446)
- Pseudoachalasia likely results from overly tight wrap causing esophageal burnout where the esophagus loses ability to pump food through — Michael Rosen (clinical) [Ep 8 · 24:43](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1483)
- Pseudoachalasia requires nutritional optimization before reoperation; PEG tube feeding may be necessary if nutrition is compromised — Michael Rosen (clinical) [Ep 8 · 25:14](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1514)
- Treatment options for pseudoachalasia include taking down Nissen with Heller myotomy plus Dor, or converting to Toupet with long Heller on both sides — Michael Rosen (clinical) [Ep 8 · 25:14](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1514)
- Alternative approach for pseudoachalasia is to open the wrap at 180 degrees and perform large Heller myotomy between the opened sides without complete takedown — Jeff Ponsky (clinical) [Ep 8 · 26:00](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1560)
- For reoperative foregut surgery, the best approach is to plan to start over and take down the entire wrap, though this may not always be necessary or possible — Michael Rosen (opinion) [Ep 8 · 26:57](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1617)
- Gastric bypass is an excellent operation for morbidly obese patients with failed fundoplication — Michael Rosen (clinical) [Ep 8 · 27:36](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1656)
- For primary reflux surgery in patients with BMI over 35, gastric bypass should be considered instead of Nissen because fundoplication does not work well in morbidly obese patients — Michael Rosen (clinical) [Ep 8 · 27:48](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1668)
- Reoperative fundoplication patients require repeat Bravo pH study for symptom correlation, repeat manometry, and gastric emptying study, especially if nausea and vomiting are prominent symptoms — Michael Rosen (clinical) [Ep 8 · 28:17](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1697)
- Nausea and vomiting as large component of reflux symptoms are red flags to delay surgery and investigate further, as symptoms of delayed gastric emptying overlap with reflux — Michael Rosen (clinical) [Ep 8 · 28:17](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1697)
- In reoperative fundoplication, prior port placement indicates extent of original dissection: umbilical incision suggests no chest dissection, while 5 ports with lowest 5cm from umbilicus indicates thorough original operation — Michael Rosen (clinical) [Ep 8 · 29:44](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1784)
- First goal in reoperative fundoplication is to identify the right crus at its base to know where the IVC is and avoid major vascular injury — Michael Rosen (clinical) [Ep 8 · 29:44](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1784)
- Taking liver off wrap in reoperative surgery can be done sharply accepting some bleeding, which is compressed by paddle retractor, rather than risking wrap injury with harmonic scalpel — Michael Rosen (opinion) [Ep 8 · 29:44](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1784)
- Many fundoplications recur because there is insufficient scar tissue in the chest; if struggling with dissection from below, alternative approach is to enter chest wherever possible and work back down — Michael Rosen (clinical) [Ep 8 · 29:44](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1784)
- Reoperative foregut surgery requires identifying named structures and systematic dissection rather than trying to make spaces, or the surgeon gets lost quickly — Michael Rosen (clinical) [Ep 8 · 29:44](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1784)
- If anterior vagus nerve is injured during reoperative fundoplication but posterior vagus is intact, no acute intervention is needed; postoperative upper GI on day 1-2 assesses gastric emptying — Michael Rosen (clinical) [Ep 8 · 31:57](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1917)
- For vagal injury with poor gastric emptying, early Botox of pylorus is preferred over pyloroplasty unless both vagal nerves were clearly transected — Michael Rosen (opinion) [Ep 8 · 31:57](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1917)
- Nissen fundoplication is the most commonly adopted procedure for GERD all over the world — Mohammed Qinawy (clinical) [Ep 9 · 5:02](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=302)
- Post-operative dysphagia and bloating are frequently encountered after Nissen fundoplication, creating the necessity for a more facilitative design — Mohammed Qinawy (clinical) [Ep 9 · 5:50](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=350)
- Recurrent GERD has been reported to occur in up to 15% of children requiring re-operation — Mohammed Qinawy (epidemiological) [Ep 9 · 6:20](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=380)
- The study was a prospective single-blinded randomized comparative study conducted from October 2018 to February 2020 including 40 patients divided into two groups — Mohammed Qinawy (clinical) [Ep 9 · 6:40](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=400)
- The operative setup is similar between Nissen fundoplication and Hill-Snow procedure — Mohammed Qinawy (clinical) [Ep 9 · 7:10](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=430)
- In the Hill-Snow procedure, the first step after crural approximation is excision of the distal abdominal esophagus to the phrenic decision — Mohammed Qinawy (clinical) [Ep 9 · 7:30](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=450)
- The Hill-Snow procedure establishes an angle of His by suturing the fundus of the stomach to the distal third of the esophagus with running 2-0 suture — Mohammed Qinawy (clinical) [Ep 9 · 8:20](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=500)
- Study inclusion criteria included patients with GERD with failure of medical treatment, symptomatic hiatus hernia, patients presenting with obstruction, and patients with life-threatening symptoms like apnea — Mohammed Qinawy (clinical) [Ep 9 · 10:00](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=600)
- Study excluded recurrent cases and giant hiatus hernia — Mohammed Qinawy (clinical) [Ep 9 · 10:40](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=640)
- Operative time was significantly longer in the Hill-Snow group when compared to the Nissen group — Mohammed Qinawy (clinical) [Ep 9 · 11:00](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=660)
- Early postoperative bloating was found to be lower in the Hill-Snow group: 3 cases versus 15 cases in the Nissen group — Mohammed Qinawy (clinical) [Ep 9 · 11:20](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=680)
- Early postoperative dysphagia was found to be lower in the Hill-Snow group: 2 cases versus 7 cases in the Nissen group — Mohammed Qinawy (clinical) [Ep 9 · 11:40](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=700)
- Early vomiting was encountered more in the Hill-Snow group: 6 cases versus 2 cases in the Nissen group — Mohammed Qinawy (clinical) [Ep 9 · 12:00](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=720)
- The incidence of dysphagia was found to be insignificant in both groups regarding late postoperative assessment, but it was of shorter duration in the Hill-Snow group — Mohammed Qinawy (clinical) [Ep 9 · 12:20](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=740)
- No bloating was found in any Hill-Snow patient at late follow-up, while 11 cases from the Nissen group suffered from bloating — Mohammed Qinawy (clinical) [Ep 9 · 12:40](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=760)
- Recurrent vomiting and need for drugs was found in 8 cases in the Hill-Snow group versus 6 cases in the Nissen group — Mohammed Qinawy (clinical) [Ep 9 · 12:55](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=775)
- There were 3 recurrent Hill-Snow cases versus 2 recurrent Nissen cases — Mohammed Qinawy (clinical) [Ep 9 · 13:05](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=785)
- The recurrent cases of Hill-Snow were found in the first 10 cases, which was attributed to the learning curve — Mohammed Qinawy (clinical) [Ep 9 · 14:11](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=851)
- When evaluating reflux disease surgery, you need to differentiate neurologically normal versus neurologically abnormal patients because their responses to surgery are very different (opinion) [Ep 9 · 13:37](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=817)
- Recent literature shows there is no importance of fixation of the esophagus to the crus, and current practice after this study does not use sutures between the esophagus and the crus — Mohammed Qinawy (clinical) [Ep 9 · 15:39](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=939)
- Nissen fundoplication is the most commonly adopted procedure for GERD all over the world — Mohammed Qinawy (clinical) [Ep 10 · 0:10](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342?t=10)
- Post-operative bloating is frequently encountered after Nissen fundoplication, raising the necessity for a more physiologic design — Mohammed Qinawy (clinical) [Ep 10 · 0:10](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342?t=10)
- Recurrent GERD has been reported to occur in up to 15% of children requiring re-operation — Mohammed Qinawy (epidemiological) [Ep 10 · 0:10](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342?t=10)
- The study was a prospective single-blinded randomized comparative study conducted from October 2018 to April 2020 including 40 patients divided into two groups — Mohammed Qinawy (clinical) [Ep 10 · 0:10](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342?t=10)
- The first step of Helio procedure is fixation of the distal abdominal esophagus to the crura with non-absorbable sutures (1 or 2 sutures) to maintain the abdominal esophagus inside the abdomen — Mohammed Qinawy (clinical) [Ep 10 · 2:00](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342?t=120)
- The angle of His is established by suturing the fundus of the stomach to the length of the esophagus with running absorbable suture (Vicryl or silk) — Mohammed Qinawy (clinical) [Ep 10 · 2:00](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342?t=120)
- The last suture in Helio procedure incorporates the stomach, the phrenic ligament, the crura, and the proximal part of the abdominal esophagus — Mohammed Qinawy (clinical) [Ep 10 · 2:00](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342?t=120)
- Inclusion criteria included patients with GERD with failure of medical treatment, symptomatic hiatus hernia, esophageal stricture, and life-threatening symptoms like apnea — Mohammed Qinawy (clinical) [Ep 10 · 5:10](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342?t=310)
- Exclusion criteria included recurrent cases, giant paraesophageal hernia, and gastroparesis — Mohammed Qinawy (clinical) [Ep 10 · 5:10](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342?t=310)
- Operative time was significantly longer in the Helio group when compared to the Nissen group — Mohammed Qinawy (clinical) [Ep 10 · 5:10](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342?t=310)
- Early post-operative bloating was found to be lower in the Helio group: 3 cases versus 15 cases in Nissen — Mohammed Qinawy (clinical) [Ep 10 · 6:10](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342?t=370)
- Early dysphagia was found to be lower in the Helio group: 2 cases versus 7 cases in Nissen — Mohammed Qinawy (clinical) [Ep 10 · 6:10](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342?t=370)
- Early vomiting was encountered more in the Nissen group: 6 cases versus 2 cases in Helio — Mohammed Qinawy (clinical) [Ep 10 · 6:10](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342?t=370)
- Time to start oral feeding was insignificant between both groups but was shorter duration in the Helio group — Mohammed Qinawy (clinical) [Ep 10 · 6:10](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342?t=370)
- Late post-operative assessment found no bloating in any Helio patient while 11 cases from Nissen group suffered from bloating — Mohammed Qinawy (clinical) [Ep 10 · 6:10](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342?t=370)
- Recurrent vomiting and need for drugs was found in 8 Nissen cases versus 6 Helio cases — Mohammed Qinawy (clinical) [Ep 10 · 6:10](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342?t=370)
- There were 3 recurrent Helio cases versus 2 Nissen cases — Mohammed Qinawy (clinical) [Ep 10 · 6:10](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342?t=370)
- The recurrent Helio cases were found in the first 10 cases, which was attributed to the learning curve — Mohammed Qinawy (opinion) [Ep 10 · 6:10](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342?t=370)
- Helio procedure offers an effective alternative to Nissen fundoplication with no bloating and much less dysphagia, and earlier return to normal eating pattern — Mohammed Qinawy (opinion) [Ep 10 · 7:20](https://team.globalcastmd.com/watch/bob-ped-surg-2023-mohamad-qinawy-papsa-presentation-6342?t=440)
- Upper GI contrast study should only be done to rule out secondary causes of reflux such as malrotation or a web, not to diagnose reflux itself — Jose Campos (clinical) [Ep 11 · 2:40](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122?t=160)
- Clinical evaluation, not laboratory or imaging tests, should determine whether a patient needs treatment for reflux — Jose Campos (guideline) [Ep 11 · 2:40](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122?t=160)
- In a 10-year follow-up study, only a tiny percentage of patients who received G-tubes alone ended up needing a subsequent fundoplication; most had a G-tube for life — Jose Campos (epidemiological) [Ep 11 · 8:09](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122?t=489)
- Patients with neurological impairment and discoordinated swallowing often get aspiration pneumonia from their saliva, not from gastric reflux — Jose Campos (clinical) [Ep 11 · 8:51](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122?t=531)
- Laparoscopic gastrostomy allows the surgeon to choose the side of the stomach better and permits placement of a primary button rather than requiring a second anesthetic to replace a PEG with a button — Jose Campos (clinical) [Ep 11 · 10:45](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122?t=645)
- Surgery for gastroesophageal reflux disease should be far down the treatment line after appropriate medical management and workup — Michael Rosen (clinical) [Ep 13 · 1:38](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=98)
- Initial trial of 20 mg daily Prilosec (omeprazole) for 6 weeks is appropriate first-line therapy for GERD symptoms — Michael Rosen (clinical) [Ep 13 · 2:27](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=147)
- There is mounting data that a lifetime of proton pump inhibitors has consequences associated with it — Michael Rosen (clinical) [Ep 13 · 3:34](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=214)
- Endoscopy is needed at minimum to assess esophagitis and in particular to rule out Barrett's esophagus in patients with persistent reflux symptoms — Michael Rosen (clinical) [Ep 13 · 4:06](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=246)
- In 2016, for a patient without esophagitis, hiatal hernia, or Barrett's, more workup is warranted before keeping them on PPIs indefinitely, especially in young active persons due to concerns about osteoporosis and other issues — Michael Rosen (opinion) [Ep 13 · 5:02](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=302)
- A pH study is needed to confirm the diagnosis of gastroesophageal reflux disease when endoscopy does not show evidence of esophagitis — Michael Rosen (clinical) [Ep 13 · 5:33](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=333)
- The Bravo test should be done off PPIs to provide symptom correlation, which is important for setting patient expectations about what surgery will improve — Michael Rosen (clinical) [Ep 13 · 6:19](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=379)
- Manometry is essential before any surgical discussion and should be part of the preoperative workup for patients potentially going down the operative road — Michael Rosen (clinical) [Ep 13 · 6:51](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=411)
- The basic reason for manometry is number one to rule out achalasia, because wrapping someone with achalasia destroys their esophageal function — Michael Rosen (clinical) [Ep 13 · 11:19](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=679)
- Manometry findings consistent with reflux include total relaxation of the lower esophageal sphincter with swallowing and low resting pressure of the LES — Michael Rosen (clinical) [Ep 13 · 12:25](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=745)
- Distal esophageal amplitudes on manometry can be used to tailor the fundoplication, with discussion about the difference between a floppy Nissen and a Toupet based on esophageal motility — Michael Rosen (clinical) [Ep 13 · 12:38](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=758)
- A patient with normal peristalsis (amplitude of 30 mmHg or higher), total LES relaxation, DeMeester score of 28, and a 2 cm hiatal hernia should receive a full Nissen fundoplication — Michael Rosen (clinical) [Ep 13 · 13:27](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=807)
- One disadvantage of laparoscopic fundoplication is that it does not create much scar tissue; full mediastinal dissection helps reduce recurrences by creating ability for the area to scar down and provides more esophageal length — Michael Rosen (clinical) [Ep 13 · 14:20](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=860)
- Taking down the short gastric vessels makes it easier to avoid twisting the wrap and to see exactly what is being brought around during fundoplication — Michael Rosen (clinical) [Ep 13 · 14:38](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=878)
- The way a Nissen is created is highly variable and one of the downsides of this operation is lack of standardization, making it hard to reproduce data — Michael Rosen (opinion) [Ep 13 · 14:55](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=895)
- The geometry of the wrap is the most important part of the operation; surgeons should take time to ensure proper geometry and not be afraid to take down and reestablish the wrap if it does not look right — Jeff Ponsky (clinical) [Ep 13 · 15:18](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=918)
- A common mistake is making the Nissen wrap too long, which adds to dysphagia; the wrap should be about 2 centimeters with typically 3 sutures — Michael Rosen (clinical) [Ep 13 · 16:19](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=979)
- The first stitch in a Nissen should be stomach to stomach so the knot can be used to move the wrap and ensure proper positioning before placing additional sutures — Michael Rosen (clinical) [Ep 13 · 16:43](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1003)
- A bougie is not routinely needed during crural closure in experienced hands; the esophagus should have a little V-shaped triangle of air below it — Michael Rosen (clinical) [Ep 13 · 17:42](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1062)
- In patients with weak peristalsis (amplitude below 20 mmHg) and weak LES, the best operation to prevent reflux is still a Nissen, but the esophageal pump does not work well enough to overcome that barrier, necessitating a Toupet to avoid creating dysphagia — Michael Rosen (clinical) [Ep 13 · 19:05](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1145)
- A Toupet fundoplication is a posterior 270-degree wrap that is about 2.5 to almost 3 centimeters long with 3 sutures on either side through esophagus to stomach — Michael Rosen (clinical) [Ep 13 · 19:44](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1184)
- The hardest transition of becoming an attending doing foregut surgery is managing patient satisfaction after fundoplication and realizing patients come back with complaints and issues — Michael Rosen (opinion) [Ep 13 · 21:33](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1293)
- Fundoplication changes the way patients swallow, the way their stomach works, and the way acid moves from their body; patients must be counseled preoperatively about these changes — Michael Rosen (clinical) [Ep 13 · 22:03](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1323)
- The fundoplication is tightest right after surgery and gets looser over time; early dysphagia is expected and the patient who has no dysphagia at 2 weeks likely has a wrap that is too loose — Michael Rosen (clinical) [Ep 13 · 22:17](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1337)
- Dysphagia should not be a concern for the first 6 weeks postoperatively, even if the patient maintains a liquid diet, and endoscopic intervention should not be considered until 3 months with no progression and inability to tolerate anything besides liquids — Michael Rosen (clinical) [Ep 13 · 22:48](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1368)
- For persistent dysphagia at 6-8 months, workup should include upper GI to rule out hernia recurrence and look for anatomic causes, followed by endoscopy with dilation if the wrap appears too tight — Michael Rosen (clinical) [Ep 13 · 23:17](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1397)
- Pseudoachalasia after fundoplication presents with dilated esophagus, retained fluid, tight GE junction on endoscopy, and manometry showing lack of peristalsis and non-relaxing LES; this likely occurs when the wrap is too tight and prolonged dysphagia causes the esophagus to burn out — Michael Rosen (clinical) [Ep 13 · 24:06](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1446)
- For pseudoachalasia, nutrition should be optimized before reoperation, with consideration of PEG tube feeding if needed — Michael Rosen (clinical) [Ep 13 · 24:57](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1497)
- For complex reoperative foregut surgery, the best approach is to plan to start over and take down the entire wrap, though sometimes dividing it and leaving half a wrap (Toupet) may be acceptable if the wrap cannot be fully taken down — Michael Rosen (clinical) [Ep 13 · 26:40](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1600)
- For morbidly obese patients with BMI over 35 and reflux, gastric bypass should be considered instead of fundoplication as the primary operation because Nissen does not work well in morbidly obese patients — Michael Rosen (clinical) [Ep 13 · 27:36](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1656)
- For symptomatic herniated wrap, reevaluation should include 48-hour Bravo study for symptom correlation, repeat manometry, and gastric emptying study especially if nausea and vomiting are prominent symptoms — Michael Rosen (clinical) [Ep 13 · 28:17](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1697)
- Nausea and vomiting as a large component of foregut patients' complaints are red flags to put the brakes on rushing to surgery and to understand what is going on, particularly regarding gastric emptying — Michael Rosen (clinical) [Ep 13 · 29:02](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1742)
- In reoperative fundoplication, the first goal is to reach the right crus to identify where the cava is and avoid injury; the liver and wrap often obliterate the right crus and drifting off the wrap can lead to caval injury — Michael Rosen (clinical) [Ep 13 · 30:18](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1818)
- When taking the liver off the wrap in reoperative surgery, sharp dissection with hook or scissors accepting bleeding is preferred over harmonic to avoid injuring the wrap that will be used later — Michael Rosen (clinical) [Ep 13 · 30:44](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1844)
- Most surgeons do not take the dissection low enough to the base of the crus; getting the crus at the base provides a choice of going right or straight up with known anatomy to avoid the cava — Michael Rosen (clinical) [Ep 13 · 31:11](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1871)
- Many fundoplications recur because there is not enough scar tissue in the chest; if struggling with dissection below, getting up in the chest and working back down is a useful strategy — Michael Rosen (clinical) [Ep 13 · 31:33](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1893)
- In reoperative surgery, the key is identifying named structures and digging them out in a systematic fashion rather than trying to make a space without proper dissection, or the surgeon will get lost quickly — Michael Rosen (clinical) [Ep 13 · 32:01](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1921)
- If the anterior vagus nerve is injured during reoperative fundoplication but the posterior vagus is intact, no acute intervention is needed in the operating room; postoperative upper GI on day 1 or 2 should assess gastric emptying, and early Botox of the pylorus is preferred over pyloroplasty if delayed emptying is a concern — Michael Rosen (clinical) [Ep 13 · 32:36](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1956)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- Esophagogastric dissociation was historically considered a last resort operation when Nissen fundoplication fails. — Todd Ponsky summarizes what Dr. Ian Glenn said [Ep 4 · 0:14](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=14)
- Esophagogastric dissociation is being suggested as an upfront primary operation for a small subset of patients with severe neurologic impairment. — Todd Ponsky summarizes what Dr. Ian Glenn said [Ep 4 · 0:24](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=24)
- In the study, operative failure was defined as either recurrence of preoperative reflux symptoms or requirement of additional anti-reflux surgery. — Ian Glenn summarizing a resource [Ep 4 · 1:01](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=61)
- The esophagogastric dissociation group had a 4% operative failure rate. — Ian Glenn summarizing a resource [Ep 4 · 1:13](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=73)
- The Nissen fundoplication group had a 21% operative failure rate. — Ian Glenn summarizing a resource [Ep 4 · 1:13](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=73)
- The difference in operative failure rates between esophagogastric dissociation and Nissen fundoplication was not statistically significant. — Ian Glenn summarizing a resource [Ep 4 · 1:21](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=81)
- 17% of patients in the esophagogastric dissociation group continued to require anti-reflux medications after surgery. — Ian Glenn summarizing a resource [Ep 4 · 1:23](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=83)
- 54% of patients in the Nissen fundoplication group continued to require anti-reflux medications after surgery. — Ian Glenn summarizing a resource [Ep 4 · 1:23](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=83)
- The difference in continued requirement for anti-reflux medications between groups was statistically significant. — Ian Glenn summarizing a resource [Ep 4 · 1:23](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=83)
- Caregiver-evaluated quality of life and symptom scores were the same between the esophagogastric dissociation and Nissen groups. — Ian Glenn summarizing a resource [Ep 4 · 1:39](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=99)
- The lack of statistical significance in operative failure rates could represent a type 2 error where the sample size was too small to detect an actual difference. — Ian Glenn summarizing a resource [Ep 4 · 2:03](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=123)
- The study examined perioperative factors including OR time, length of hospital stay, need for ICU stay, and time to full feeds, finding statistically significant differences following expected trends. — Ian Glenn summarizing a resource [Ep 4 · 2:26](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=146)
- The study did not report on leaks, strictures, or long-term requirement for additional surgeries other than anti-reflux operations. — Ian Glenn summarizing a resource [Ep 4 · 2:39](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=159)
- Esophagogastric dissociation was historically thought of as a last resort operation when Nissen fundoplication won't work. — Todd Ponsky summarizes what Dr. Ian Glenn said [Ep 6 · 0:14](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=14)
- Esophagogastric dissociation is now being suggested as an upfront primary operation for a small subset of patients with severe neurologic impairment. — Todd Ponsky summarizes what Dr. Ian Glenn said [Ep 6 · 0:24](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=24)
- The study compared patients with severe GERD and neurologic disability, half undergoing esophagogastric dissociation and half undergoing laparoscopic Nissen. — Ian Glenn summarizing a resource [Ep 6 · 0:48](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=48)
- Primary outcome was operative failure, defined as either recurrence of preoperative reflux symptoms or requirement of additional anti-reflux surgery. — Ian Glenn summarizing a resource [Ep 6 · 1:01](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=61)
- There was a 4% failure rate in the esophagogastric dissociation group and a 21% failure rate in the Nissen group. — Ian Glenn summarizing a resource [Ep 6 · 1:13](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=73)
- The difference in failure rates between esophagogastric dissociation (4%) and Nissen (21%) was not statistically significant. — Ian Glenn summarizing a resource [Ep 6 · 1:21](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=81)
- 17% of patients in the esophagogastric dissociation group continued to require anti-reflux medications after surgery, compared to 54% in the Nissen group. — Ian Glenn summarizing a resource [Ep 6 · 1:23](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=83)
- The difference in continued requirement for anti-reflux medications (17% vs 54%) was statistically significant. — Ian Glenn summarizing a resource [Ep 6 · 1:29](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=89)
- Caregiver-evaluated quality of life and symptom scores were the same between the two groups with no statistically significant difference. — Ian Glenn summarizing a resource [Ep 6 · 1:39](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=99)
- The lack of statistical significance in failure rates could potentially be a type 2 error where there was actually a difference but the sample size was too small to detect it. — Ian Glenn summarizing a resource [Ep 6 · 2:03](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=123)
- The study examined perioperative factors including time in the OR, length of hospital stay, need for ICU stay, and time to full feeds, with statistically significant differences following expected trends. — Ian Glenn summarizing a resource [Ep 6 · 2:26](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=146)
- The study did not report on leaks, strictures, or long-term requirement for additional surgeries other than anti-reflux operations. — Ian Glenn summarizing a resource [Ep 6 · 2:39](https://team.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=159)
- Neurologically impaired children have a higher incidence of reflux disease and higher failure rate when treated with fundoplication — Todd Ponsky summarizing the discussion [Ep 2 · 10:48](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=648)
- Esophageal disconnect was introduced by Bianchi in a 1997 paper as a rescue operation for children with failed fundoplication — Todd Ponsky summarizing the discussion [Ep 2 · 11:40](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=700)
- European results from Manchester show disconnect effectively cures reflux and respiratory complications, improves nutrition, and dramatically improves quality of life for patients and caregivers — Todd Ponsky summarizing the discussion [Ep 2 · 13:20](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=800)
- Retrospective comparison shows dissociation is associated with increased OR time, increased length of stay, and increased time to full feeds, but improved reflux results and lower failure rates compared to fundoplication — Todd Ponsky summarizing the discussion [Ep 2 · 14:10](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=850)
- Danielson's Rochester series of 27 patients (mix of children and adults) showed disconnect is definitive treatment, but only 3 had prior fundoplication so 24 were de novo procedures — Todd Ponsky summarizing the discussion [Ep 2 · 15:00](https://team.globalcastmd.com/watch/esophageal-disconnect-for-severe-gerd-in-neurologically-impaired-children-409?t=900)
- Adult thoracic surgeons performing gastric pull-ups for esophageal cancer stopped doing pyloromyotomies or pyloroplasties, and if patients had emptying trouble they performed Botox injections. — Tim summarizing the discussion [Ep 3 · 28:49](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1729)
- Adult thoracic surgeons found more problems with reflux and stricture at the esophagogastric anastomosis when they performed pyloroplasty during gastric pull-up. — Tim summarizing the discussion [Ep 3 · 28:49](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1729)
- Over time, even though vagus nerves are divided during gastric pull-up, the stomach will eventually empty without pyloroplasty. — Tim summarizing the discussion [Ep 3 · 28:49](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1729)
- Some surgeons perform a mucosal-sparing pyloroplasty (essentially a pyloromyotomy closed transversely) rather than full-thickness pyloroplasty. — The host summarizing the discussion [Ep 3 · 30:04](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1804)
- Operative intervention for hiatal hernias is indicated in symptomatic patients with type 1 or other paraesophageal hernias. — Tim summarizing the discussion [Ep 3 · 30:32](https://team.globalcastmd.com/watch/gastroesophageal-reflux-contemporary-management-pediatric-surgery-update-428?t=1832)
- Gastroesophageal reflux occurs in more than two-thirds of otherwise healthy infants and is discussed at 25% of all 6-month pediatric visits — Mac Harmon summarizing the discussion [Ep 5 · 4:57](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=297)
- 2009 NASPGHAN and ESPGHAN guidelines state surgical approaches should be reserved for children with intractable symptoms unresponsive to medical therapy and those at risk for life-threatening complications of reflux disease — Mac Harmon summarizing the discussion [Ep 5 · 5:20](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=320)
- In adult literature, after about 15 years almost all fundoplications are undone — Daniel von Allmen summarizing the discussion [Ep 5 · 8:43](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=523)
- AAP guidelines note H2 antagonists or PPIs may have risk factors for pneumonia, gastroenteritis, candidemia, and NEC in preterm infants — Mac Harmon summarizing the discussion [Ep 5 · 9:43](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=583)
- Meta-analysis of 400 fundoplications versus 125 gastrojejunostomy tubes showed no difference in pneumonia rate or mortality, but 29% major complications in fundo group versus lower rate in GJ group, and 70% minor complications in GJ group — Mac Harmon summarizing the discussion [Ep 5 · 16:52](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=1012)
- RCT of 44 laparoscopic versus 43 open fundoplications showed recurrence of reflux was 37% in laparoscopic group and only 7% in open group, with 5.2% higher risk of recurrence in laparoscopic group — Mac Harmon summarizing the discussion [Ep 5 · 18:00](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=1080)
- RCT of laparoscopic versus open fundoplication in children under age 2 (21 open, 18 laparoscopic over 7 years) showed no difference in length of stay, time to full feeds, or analgesic requirements, but laparoscopic had longer operative time and higher surgical charges — Mac Harmon summarizing the discussion [Ep 5 · 18:00](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=1080)
- Neurologically impaired patients do worse than neurologically normal patients after fundoplication according to historical data — Daniel von Allmen summarizing the discussion [Ep 5 · 21:20](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=1280)
- Meta-analysis showed improved outcomes following complete fundoplication compared to partial wrap, though the difference was barely significant — Mac Harmon summarizing the discussion [Ep 5 · 22:00](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=1320)
- Kansas City/Birmingham prospective RCT showed aggressive esophageal mobilization had 23% to 37% incidence of transmigration over 6.5 years, while minimal mobilization increased from 3% to 12% — Whit Holcomb summarizing the discussion [Ep 5 · 23:19](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=1399)
- Time to diagnosis of hiatal hernia was significantly longer in minimal mobilization group compared to maximum mobilization group — Whit Holcomb summarizing the discussion [Ep 5 · 23:19](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=1399)
- There was no significant difference in reflux symptoms or medication use between minimal and maximal mobilization groups at 6.5 years — Whit Holcomb summarizing the discussion [Ep 5 · 23:19](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=1399)
- Study showed 4% incidence of changes on upper GI prior to G-tube placement, with 80% of that 4% due to malrotation — Mac Harmon summarizing the discussion [Ep 5 · 27:00](https://team.globalcastmd.com/watch/gastoesophageal-reflux-update-course-2015-670?t=1620)
- Barrett's esophagus may be subtle and asymptomatic, with risk of progression through low-grade and high-grade dysplasia to gastric cancer — Jeff Ponsky summarizes what Dr. Michael Rosen said [Ep 8 · 4:31](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=271)
- Manometry before routine reflux surgery now identifies achalasia cases that were previously missed when manometry was not standard practice — Jeff Ponsky summarizes what Dr. Michael Rosen said [Ep 8 · 11:47](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=707)
- There is some evidence that bilateral vagal injury may not require pyloroplasty — Jeff Ponsky summarizes what Dr. Michael Rosen said [Ep 8 · 31:57](https://team.globalcastmd.com/watch/gastroesopheal-reflux-disease-3444?t=1917)
- Data from a Kansas City study clearly shows that anterior esophagopexy is ineffective and has worse outcomes — The host summarizing the discussion [Ep 9 · 14:30](https://team.globalcastmd.com/watch/bob-in-ped-surg-2023-papsa-winner-mohamad-mahmoud-qinawy-md-6328?t=870)
- The 2018 North American and European Society for Pediatric Gastroenterology joint guideline found that no complementary study (barium imaging, ultrasonography, endoscopy, biomarkers, manometry, scintigraphy) is sufficient to diagnose gastroesophageal reflux disease requiring fundoplication — Cecilia Gigena summarizing the discussion [Ep 11 · 3:20](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122?t=200)
- Aspiration pneumonia in a patient on NG feeds indicates that feeding into the stomach in its current form will not be sufficient — Em Tombash summarizing the discussion [Ep 11 · 5:19](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122?t=319)
- After aspiration pneumonia and assuming maximum medical therapy, the next step is either post-pyloric feeding or fundoplication — Em Tombash summarizing the discussion [Ep 11 · 5:19](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122?t=319)
- In the 2013 JAMA Pediatrics study of 42 children's hospitals and over 4000 infants, those with neurological impairment who underwent fundoplication at the time of gastrostomy placement did not have a reduced rate of reflux-related hospitalization during the first year compared to those who underwent gastrostomy placement alone — Cecilia Gigena summarizing the discussion [Ep 11 · 6:08](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122?t=368)
- The 2013 JAMA Pediatrics study used propensity score matching to create two comparable groups of 1027 infants each (gastrostomy alone versus gastrostomy plus fundoplication) — Cecilia Gigena summarizing the discussion [Ep 11 · 6:08](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122?t=368)
- There is no prospective study comparing gastrostomy alone versus gastrostomy plus fundoplication; the 2013 JAMA Pediatrics retrospective study is the best available evidence — Em Tombash summarizing the discussion [Ep 11 · 7:30](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122?t=450)
- Performing fundoplication in someone who is aspirating from above (saliva) will make them worse — Em Tombash summarizing the discussion [Ep 11 · 9:26](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122?t=566)
- A nasal jejunal tube trial can be a helpful diagnostic tool: if it stops aspiration, that indicates the aspiration was from gastric reflux rather than oral secretions — Em Tombash summarizing the discussion [Ep 11 · 9:30](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122?t=570)
- Laparoscopic gastrostomy allows better visualization (grabbing the stomach and pulling it up with a camera) compared to the blind percutaneous endoscopic approach — Em Tombash summarizing the discussion [Ep 11 · 10:14](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122?t=614)
- In a 2022 systematic review of 58 publications and over 2000 patients comparing PEG versus laparoscopy, major complication rates significantly favored laparoscopy (1.2% versus 5.4%) — Cecilia Gigena summarizing the discussion [Ep 11 · 11:42](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122?t=702)
- The major complications in the 2022 systematic review did not include leaks, dislodgements, or granulomas; they were re-operation for colonic perforation or colocutaneous fistula — Cecilia Gigena summarizing the discussion [Ep 11 · 11:42](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122?t=702)
- Postoperative feeding advancement after G-tube placement has become faster over time; some centers now start feeds immediately after surgery and send patients home the same day — Em Tombash summarizing the discussion [Ep 11 · 13:43](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122?t=823)
- In a randomized prospective study comparing bolus versus continuous feeding post-gastrostomy, patients receiving bolus feeding had more leakage and more feeding modifications but achieved total feeds in the same timeframe — Cecilia Gigena summarizing the discussion [Ep 11 · 14:42](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122?t=882)
- There is no significant difference in patient outcomes between bolus and continuous feeding regimens after gastrostomy placement — Cecilia Gigena summarizing the discussion [Ep 11 · 14:42](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122?t=882)
- There is no reason to start with continuous feeds as a ramp-up to bolus feeds; clinicians can go straight to bolus feeding postoperatively — Em Tombash summarizing the discussion [Ep 11 · 15:52](https://team.globalcastmd.com/watch/case-based-journal-review-g-tube-fundoplication-for-gerd-2023-7122?t=952)
- Esophageal atresia is a rare birth defect where a part of the esophagus, the tube connecting the mouth to the stomach, is missing. — The host summarizing a resource [Ep 12 · 0:00](https://team.globalcastmd.com/watch/gerd-reflux-in-esophageal-atresia-patients-an-ernica-animation-7603?t=0)
- All patients born with esophageal atresia should be treated at a specialist center with a multidisciplinary team. — The host summarizing a resource [Ep 12 · 0:30](https://team.globalcastmd.com/watch/gerd-reflux-in-esophageal-atresia-patients-an-ernica-animation-7603?t=30)
- Patients with esophageal atresia may experience gastroesophageal reflux disease at points throughout their life after their esophagus has been surgically repaired. — The host summarizing a resource [Ep 12 · 1:00](https://team.globalcastmd.com/watch/gerd-reflux-in-esophageal-atresia-patients-an-ernica-animation-7603?t=60)
- Gastroesophageal reflux is a physiological condition common in infants where food and acid from the stomach flows back into the esophagus. — The host summarizing a resource [Ep 12 · 1:30](https://team.globalcastmd.com/watch/gerd-reflux-in-esophageal-atresia-patients-an-ernica-animation-7603?t=90)
- Gastroesophageal reflux becomes a disease when troublesome symptoms and or complications are experienced. — The host summarizing a resource [Ep 12 · 1:50](https://team.globalcastmd.com/watch/gerd-reflux-in-esophageal-atresia-patients-an-ernica-animation-7603?t=110)
- Reflux can accidentally enter the airway and the lungs, known as aspiration, and it can lead to irritation and lung infections. — The host summarizing a resource [Ep 12 · 2:05](https://team.globalcastmd.com/watch/gerd-reflux-in-esophageal-atresia-patients-an-ernica-animation-7603?t=125)
- Gastroesophageal reflux may irritate the inside wall of the esophagus, particularly the area where the esophagus was repaired during surgery. — The host summarizing a resource [Ep 12 · 2:25](https://team.globalcastmd.com/watch/gerd-reflux-in-esophageal-atresia-patients-an-ernica-animation-7603?t=145)
- In children with gastroesophageal reflux, milk or food comes back up into the mouth without effort after feeding. — The host summarizing a resource [Ep 12 · 2:45](https://team.globalcastmd.com/watch/gerd-reflux-in-esophageal-atresia-patients-an-ernica-animation-7603?t=165)
- Children with GERD may find it difficult to gain weight and have frequent lung infections. — The host summarizing a resource [Ep 12 · 3:00](https://team.globalcastmd.com/watch/gerd-reflux-in-esophageal-atresia-patients-an-ernica-animation-7603?t=180)
- For some children, the esophagus may narrow in the area where surgery was performed to repair it. — The host summarizing a resource [Ep 12 · 3:15](https://team.globalcastmd.com/watch/gerd-reflux-in-esophageal-atresia-patients-an-ernica-animation-7603?t=195)
- Some children with GERD show no external signs at all. — The host summarizing a resource [Ep 12 · 3:25](https://team.globalcastmd.com/watch/gerd-reflux-in-esophageal-atresia-patients-an-ernica-animation-7603?t=205)
- Follow up care for esophageal atresia patients should be both lifelong and structured. — The host summarizing a resource [Ep 12 · 3:30](https://team.globalcastmd.com/watch/gerd-reflux-in-esophageal-atresia-patients-an-ernica-animation-7603?t=210)
- Proton pump inhibitors work by blocking and reducing the production of stomach acid. — The host summarizing a resource [Ep 12 · 3:40](https://team.globalcastmd.com/watch/gerd-reflux-in-esophageal-atresia-patients-an-ernica-animation-7603?t=220)
- With PPI treatment, contents of the stomach still rise up to the mouth, but there is less stomach acid and therefore less irritation. — The host summarizing a resource [Ep 12 · 3:50](https://team.globalcastmd.com/watch/gerd-reflux-in-esophageal-atresia-patients-an-ernica-animation-7603?t=230)
- If PPI medication is reduced or stopped, this should be done under the guidance of the child's clinical team. — The host summarizing a resource [Ep 12 · 4:02](https://team.globalcastmd.com/watch/gerd-reflux-in-esophageal-atresia-patients-an-ernica-animation-7603?t=242)
- Fundoplication is a surgical procedure that aims to tighten the valve at the top of the stomach to stop stomach acid from rising up. — The host summarizing a resource [Ep 12 · 3:50](https://team.globalcastmd.com/watch/gerd-reflux-in-esophageal-atresia-patients-an-ernica-animation-7603?t=230)
- A 24 hour pH study measures the amount and strength of acid reflux in the esophagus over a 24 hour period using a thin tube inserted through the nostril into the esophagus. — The host summarizing a resource [Ep 12 · 4:02](https://team.globalcastmd.com/watch/gerd-reflux-in-esophageal-atresia-patients-an-ernica-animation-7603?t=242)
- An impedance study can be performed at the same time as pH study and measures non-acidic reflux in the esophagus. — The host summarizing a resource [Ep 12 · 4:02](https://team.globalcastmd.com/watch/gerd-reflux-in-esophageal-atresia-patients-an-ernica-animation-7603?t=242)
- PPIs are preferred over H2 blockers because they are more effective at reducing gastric acid secretion and require less frequent dosing — Jeff Ponsky summarizes what Dr. Michael Rosen said [Ep 13 · 2:56](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=176)
- Bravo study is preferred over traditional pH probe because it is easier for the patient (no nasal tube) and provides 48 hours of pH data — Jeff Ponsky summarizes what Dr. Michael Rosen said [Ep 13 · 5:50](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=350)
- Patients with achalasia can present with heartburn due to stasis and fermentation of food in the esophagus — Jeff Ponsky summarizes what Dr. Michael Rosen said [Ep 13 · 12:03](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=723)
- Treatment options for pseudoachalasia include taking down the Nissen, performing a Heller myotomy with Dor fundoplication, or taking down the Nissen, doing a long Heller, and converting to a Toupet — Jeff Ponsky summarizes what Dr. Michael Rosen said [Ep 13 · 25:22](https://team.globalcastmd.com/watch/gastroesophageal-reflux-disease-13751?t=1522)

## Changelog
- Sep 27: 1 item added automatically
- Sep 22: 1 item added automatically
- Sep 21: 1 item added automatically
- Sep 20: 2 items added automatically
- Sep 17: 1 item added automatically
- Sep 15: 3 items added automatically
- Sep 7: Published again automatically — condition is back above threshold
- Sep 7: 1 item no longer name gastroesophageal reflux disease
- Sep 7: 2 items added automatically
- Sep 7: Unpublished automatically — folded or below threshold
- Sep 7: 3 items added automatically

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