Overview
GERD is very common in infants and young children, and the vast majority improve with conservative measures and medication, without needing any surgery. But a small number of children have pathological reflux that doesn’t respond to medical treatment and requires surgery — that specific situation is what this page covers.
Simple reflux is normal in infants, caused by the lower esophageal sphincter not yet being fully mature, and usually resolves by 12-18 months without treatment. Pathological GERD, on the other hand, causes: irritability and crying, especially after feeds (“silent reflux”), frequent forceful or projectile vomiting, arching of the back during or after feeding (Sandifer syndrome), poor weight gain or failure to thrive, and recurrent chest infections or wheezing from aspirating stomach contents. In older children: heartburn, chest pain, chronic cough, or hoarseness.
When Is Surgery Necessary?
Anti-reflux surgery — most commonly Nissen fundoplication — is reserved for children who:
- Have GERD causing complications despite optimal medical treatment for 3 to 6 months.
- Have recurrent aspiration pneumonia.
- Have reflux-related apnea episodes during infancy.
- Have esophageal complications such as esophagitis or stricture.
- Have neurological impairments (such as cerebral palsy) along with severe GERD and swallowing disorders.
- Depend on a feeding tube that isn’t safe to use without first repairing the reflux.
Relationship to Diaphragmatic Hernia
Not every child with reflux has a diaphragmatic hernia — reflux is very common in infants and doesn’t necessarily mean a hernia is present. The doctor runs the necessary tests to distinguish normal reflux from cases that need intervention. Surgery becomes necessary when reflux is severe and unresponsive to medication, or when a large hernia is causing respiratory or feeding complications.
When to see the doctor: reflux that isn’t controlled by medication after 4 to 6 weeks, recurrent aspiration pneumonia, failure to thrive or feeding refusal due to pain, a child with a neurological condition alongside severe GERD, or a family wanting a second opinion before deciding on surgery.
Pre-Op
Surgery is a last step after conservative treatment has been exhausted. Before surgery is considered, the child goes through the following steps:
Trying non-surgical treatment first
This includes: keeping the infant upright during and after feeds, smaller and more frequent feeds, thickened formula, acid suppressants (proton pump inhibitors or H2 blockers), and for formula-fed infants, sometimes a trial of a protein-free or amino-acid-based formula to rule out a cow's milk protein allergy.
Distinguishing it from diaphragmatic hernia
Tests to determine whether a diaphragmatic hernia is present alongside the reflux, and its size — having reflux doesn't necessarily mean a hernia is present.
Confirming the surgical criteria are met
Surgery is only decided on after confirming complications persist despite optimal treatment for 3 to 6 months, or there are recurrent aspiration infections, apnea episodes, esophageal complications, or a neurological impairment alongside severe GERD.
Full general anesthesia
The surgery is performed laparoscopically in suitable cases under full general anesthesia, taking 1.5 to 2.5 hours. A feeding (gastrostomy) tube can be placed in the same session if the child needs one.
Post-Op
Nissen fundoplication aims to permanently stop stomach contents from flowing back into the esophagus. Below is what the surgery involves and what happens afterward.
Nissen Fundoplication
The upper part of the stomach (the fundus) is wrapped 360° around the lower esophagus, forming a valve that prevents stomach contents from flowing back up. Performed laparoscopically in suitable cases; open surgery is reserved for complex cases or when the anatomy isn’t suitable for a laparoscopic approach.
Immediately After Surgery
The child is moved to the recovery room under monitoring, with some discomfort managed by doctor-prescribed painkillers.
Hospital Stay and Recovery
Hospital stay is usually two to three days, depending on the child’s response and overall health.
Signs of a Successful Surgery
- Better tolerance of feeding without recurrent vomiting or distress.
- Normal weight gain resuming.
- Respiratory symptoms related to aspiration disappearing.
- Normal wound healing.
Success Rates and Possible Complications
Success rates range from 85% to 90% at 5 years in children with normal neurological development. Children with neurological impairments have a higher rate of needing further intervention later, but surgery still dramatically improves their quality of life.
Symptoms Requiring Immediate Medical Attention
- Persistent difficulty swallowing that isn’t improving.
- Repeated dry retching.
- Signs of infection: high fever, redness or discharge from the wound.
- Return of severe reflux symptoms.
- Difficulty breathing.
Frequently Asked Questions
When does reflux in infants require surgery?
Laparoscopic surgery is recommended when: symptoms don't respond to medication and feeding adjustments, the child has clear complications like recurrent esophagitis, breathing difficulty, or weight loss, or there's a large hiatal hernia causing severe reflux of stomach contents into the esophagus.
How is reflux treated laparoscopically?
Through 3 to 5 small incisions in the abdomen for the laparoscope and surgical instruments. The doctor returns the stomach to its position below the diaphragm, closes the opening with surgical sutures, and may perform a "fundoplication" around the lower esophagus to prevent acid reflux.
What are the benefits of laparoscopic reflux surgery compared to open surgery?
Laparoscopic surgery is less painful, leaves smaller scars, requires a shorter hospital stay (two to three days in most cases), and achieves good long-term results in reducing reflux and hernia recurrence.
How long is the hospital stay after the surgery?
In most cases the infant can go home within two to three days after surgery.
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Last updated: December 5, 2024