Post-operative retching from fundoplication.

[ccbournejr2004]

My son (9wks) recently (@ 4wks old) underwent a nissen for severe reflux.  He is on pump feedings (2 hrs on/ 2 hrs off) and has severe retching problems (16 incidents/day).  Our surgeon suggested that it could be gas in the fundoplication and it does appear that if we give him Mylicon and he can work gas out of his feeding tube it does provide relief... although this is a rare event.  

We've tried a multitude of different things:
   contiuous feeding
   contiuous venting
   positioning during feeding
   every formula known to mankind (although he's on MCT supplement, so if this gives him gas different formulas probably wouldn't help)

Q - Is there anything else that we could try?  Should we have any test run?  (Pre-op we had an upper GI)

Addt'l Info
-----------
Condition - Down Syndrome, Congenital Heart Defect (VSD), Nissen, G-tube.
Regular Meds - Digoxin, Lasix, Aldactone, Mylicon.
Regular Supplements - MCT, Sodium, 30 cal formaula.

[Kevin Pho, MD]

Actually, I can't think of any further suggestions in this case, as I am not a pediatric gastroenterologist.  

One possibility would include a 24-hr pH probe to monitor if reflux has returned despite the fundoplication.  If so, then possible revision to the surgery, or concurrent medical therapy, can be considered.

Another consideration can be transpyloric feeding, where a feeding tube is placed fluoroscopically into the transpyloric position.  Milk is then administed by slow infusion.

These options can be discussed with your specialist.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
Medical Weblog:
kevinmd_b

[ozark]

have you tried venting it with a 60cc syringe?  sometimes that helps...what kind of formula is he on now?  do you vent before his feeding while burping him?  is he crying before his feedings?  how does he do when he is asleep?

[ccbournejr2004]

We have tried venting with a 60cc syringe when he feels discomfort and starts to retch.
We've also tried continuous vent with a 60cc syringe and the pump dripping into the syringe... sometimes this produces burping.
He doesn't cry during his retching, but he's really never cried... my wife and I are thankful that he's a very content baby.

as for feeds while sleeping, if he's really tired he feeds well.  My wife and I are coming to realize that his stomach is very sensitive and he retches at almost any disomfort (gas, lots of movement, bowl movement)  His GI surgeon has suggested keeping him on Tylenol, but at his dosage (0.4ml q 4) it seems not to be noticable if it's helping.

His surgeon says that his fundo is working if he is not producing stomach content and we've dyed his formula blue and nothing in his mouth is ever blue.  We may try to see another specialist and get a g-tube UGI done, which was suggested by the his neonate dr. in the NICU but never happened.

[ozark]

has this been going on since the surgery or is this relatively new....what kind of gt does he have?  can it migrate and cause obstruction?....something obviously isnt right....he could possibly have dumping syndrome....have they looked into that?  have they tried him on an elemental formula?  if the blue test was negative then it probably is not reflux but possilbly something other than the formula, more mechanical....

[Carly'sMom]

My daughter Carly is also suffering from retching after she had a Nissen and a g-tube inserted.  We are about three weeks post-op and it feels like it has been three months.  I just know in my mind that something is wrong, that she shouldn't be doing this.  We have also tried everything from venting to gas drops and she is even on Reglan for increased motility.  The doctors tell us she is not tolerating her feedings but we are backing her down to a rate so slow that she is not getting enough calories in a day to allow her to gain any weight.  We have now switched to boulus feedings in which we offer her the bottle, which she takes little to nothing from, and then give her the rest over one hours time.  Still the retching.  We are going out of our minds!  We got a second opinion from another Peds GI who said this is sometimes a side effect of the Nissen.  I am just feeling really frustrated and alone and wondering if my daughter is the only one who is having these issues and what anyone else is doing to help their children.  It breaks my heart to see her retch and even though she also doesn't cry very much, I know it has to be uncomfortable for her.

[JO949]

A related discussion, Fundiplication and gastrostomy was started.