Dumping Syndrome after Fundoplication Systemic comparison of complete (Nissen) versus partial wrap (Thal/Toupet) H. Ahmed , U. Rolle, H. Till Department of Pediatric Surgery Leipzig University Hospitals/Germany Department of Pediatric surgery Benha University Hospitals/Egypt

Introduction Dumping syndrome or “rapid gastric emptying” is a group of symptoms most likely to develop after gastric surgery, as gastric resection, gastric bypass, and antireflux procedures. Dumping syndrome (DS) after fundoplication seems to be a clinical underestimated problem in the paediatric age group. The incidence of post-fundoplication dumping syndrome estimated to be up to 30% in children who undergo fundoplication.

DS occurs because of rapid transport (dumping) of large amounts of osmotically active solids and liquids into the duodenum. DS presents with non-specific symptoms with variable severity and frequency. * abdominal cramps * postprandial nausea * retching * tachycardia * paleness * lethargy * diaphoresis * watery diarrhea Early dumping: 30-60 min Late dumping: 90-240 min

The stomach Functions * Proximal stomach (fundus and body) ● reservoir (storage of food) ● secretion of acid, pepsin and intrinsic factor * Distal stomach (antrum and pylorus) ● mixing the food into fine particles (chyme) ● propulsion of food into the intestine

The stomach as a reservoir ● The fasting stomach has: *resting volume of 50 ml *intragastric pressure of 5-6 mm Hg. ● The stomach maintains a low pressure by maintaining a low wall tension by the following mechanisms; * Compliance gastric smooth muscle has a low resting tone even when it is stretched * Receptive relaxation distension of the gastric wall causes vaso-vagal feedback which reduces the tone of the stomach muscle.

The stomach as a mixer ● The stomach mixes food with digestive juices, churning it around and only allowing small amounts of fully mixed food (chyme) out of the pylorus at a time. ● The pylorus contracts and the sphincter closes as the waves arrive, allowing only small volumes (about 3 ml per minute) into the doudenum. ● The gastric emptying takes 3-4 hours, liquids come first and fats last.

Normal gastric emptying Hanimann et al., Z Kinderchir 43; 315-8, 1988

Types of Fundoplications A- complete wrap; ► Nissen(360) fundoplication (NFP) ► Nissen-Rossetti modification B- Partial wrap; ► Anterior (180) fundoplication (THAL) ► Posterior (270) fundoplication (TOUPET)

Dumping syndrome after fundoplication Hanimann et al., Z Kinderchir 43; 315-8, 1988

Material and Methods Systematic literature review Pubmed; Cochrane; Embase Key words: dumping syndrome (DS) and fundoplication Evaluation of relevant publications Technique of fundoplication Appearance and definition of DS Evaluation of gastric motility (Pre-/postoperative) Associated factors Esophageal atresia, neurological status, gastric surgery

Results 43 publications were found Pubmed: n=43 Cochrane: 0 Embase: 0 34 publications were rated as relevant 1 prospective study 14 retrospective studies 4 cohort reports 12 case reports 3 reviews

Results Nissens fundoplication (20 publications) Incidence of DS 5-30% Onset 2 weeks – 12 months postoperatively Usually moderate symptoms OGGT only in 2 studies Thal fundoplication (1 publication) No DS Toupet fundoplication (1 publication) Incidence of DS 18%

Results Performed investigations (in all studies) Motility studies Laboratory studies Contrast studies Endoscopy pH-Monitoring Motility studies No motility studies were performed Treatment Nutritional rehabilitation was achieved by dietary manipulations Others e.g Acarbose

Results Associated factors Pyloroplasty , accelerates gastric emptying after NFP. Gastrostomy, probably a predisposing factor rather than a cause Neurologically impaired children, might have DS Esophageal atresia, associated with high incidence of DS.

Discussion ● Nissen fundoplication (NFP) is the most widely used anti-reflux procedure, however an anterior and posterior partial fundoplications (Thal/Toupet) are also used. ● Fundoplication accelerates the gastric emptying time by reducing the gastric volume and disturbing the vagally mediated postprandial receptive relaxation due to the higher possibility of inadvertent damage of the vagal nerve. ● DS is the direct result of alterations in the storage function of the stomach and/or the pyloric emptying mechanism. ● The available literature suggests that complete (Nissen) fundoplication might have a higher incidence of dumping syndrome in comparison to partial (Thal/Toupet) fundoplication.

Conclusion ● Fundoplication is the most common cause of dumping syndrome (DS) in children. ● Pyloroplasty and gastrostomy should not be performed simultaneously with the NFP, but only in patients with proven delayed gastric emptying by scintigraphgy after anti-reflux surgery. ● DS seems to occur more frequently after complete (Nissen), than after partial fundoplication (Thal/Toupet). ● However, the available data do not allow to conclude, which form of fundoplication is more prone to induce DS, the point that needs further study and evaluation in the future.

Invitation to participate in a multicenter prospective study of Dumping Syndrome after Fundoplication

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