Clinical pearls
The effects of laparoscopic Nissen fundoplication to
enhance pulmonary function in the treatment of a patient
with severe asthma and gastroesophageal reflux disease
Steven S. Rothenberg, MD,a and Donna Bratton, MDb,c Denver, Colo
The association between asthma and gastroesophageal reflux
disease (GERD) is well described. However, the degree to which
one affects the other and the best course of therapy are widely
debated. One thing that is clear is that medical therapy for
GERD fails in a large number of these patients, but the degree
to which this affects their asthma is uncertain. Previously physi-
cians have been reluctant to refer these patients for surgical
correction because of the perceived high morbidity and variable
results of a fundoplication in this high-risk group. However,
over the last 15 years, minimally invasive techniques have signif-
icantly decreased the morbidity associated with antireflux proce-
dures, and a great effect on the severity of asthma has been seen,
especially in patients who have been corticosteroid-dependent or
present with nocturnal asthma refractory to medical management.
We present here the case of a 16-year-old with severe asthma to
illustrate the salient points.
CASE HISTORY
The patient is a 16-year-old male who has had a diagnosis of
asthma most of his life and had been progressing to the point
where he has had multiple hospitalizations over the last year for
exacerbations and now has a nocturnal O2 requirement. His respi-
ratory symptoms started at 1 month of life with wheezing, and he
has been on inhaled bronchodilators since that time. He has also
been on inhaled and oral steroids as needed. He has had a mini-
mum of 2 to 3 hospitalizations/year since the first year of life,
many requiring intensive care unit admission. The family moved
from the east coast to Colorado at age 8 years with some improve-
ment in his overall status. However, he still required intermittent
emergency department visits and steroid use. At age 15 years, the
patient had a tonsillectomy, and after that, he was told he had an
O2 requirement and was put on 2 L/min at night. He was referred
to National Jewish Medical and Research Center at that time for
evaluation. On physical examination, he was relatively normal ex-
cept for diffuse rhonchi and wheezes bilaterally. His forced vital
From athe Department of Pediatrics, Rocky Mountain Hospital for Children, Denver;
b
the National Jewish Medical and Research Center, Denver; and cthe University
of Colorado, Denver.
Disclosure of potential conflict of interest: S. S. Rothenberg has consulting arrangements
with Storz and Covidien. D. Bratton has declared that she has no conflict of interest.
Received for publication December 10, 2007; revised February 13, 2008; accepted for
publication February 22, 2008.
Reprint requests: Steven S. Rothenberg, MD, Chief of Pediatric Surgery, Chairman, De-
partment of Pediatrics, Professor of Surgery, Columbia University, Rocky Mountain
Hospital for Children, 1601 E 19th Ave, Suite 5500, Denver, CO 80218. E-mail: Dr.
Rothenberg@pediatricsurgeon.com.
J Allergy Clin Immunol 2008;121:1069-70.
0091-6749/$34.00
Ó 2008 American Academy of Allergy, Asthma & Immunology
doi:10.1016/j.jaci.2008.02.027
capacity was 86% predicted, and his FEV1 was 62% and im-
proved to 75% with bronchodilators. Peak inspiratory flow was
77% but improved to 95% after bronchodilators. The patient
gave no overt history nor complained of significant symptoms
of GERD. His medications included albuterol as necessary
(approximately 20/wk) and flucticasone as necessary.
He was placed on flucticasone twice daily, albuterol prn,
cetirizine 10 mg daily, and lansoprazole 20 mg twice daily, and
a 3-month course of prednisone at doses of as much as 40 mg a
day. Two months after therapy was started, the patient’s condition
deteriorated with worsening asthma. This was thought to be sec-
ondary to intercurrent respiratory infections and allergies. The pa-
tient had a pH probe on lansoprazole 4 months after the initiation
of therapy and had a Johnston and DeMeester score of 66.1 (nor-
mal < 20). There was an association of 3 ‘‘asthmalike’’ episodes
with reflux events. On the basis of his worsening condition,
nocturnal oxygen requirement, and positive pH score despite
medical therapy, the patient was referred for a laparoscopic
fundoplication.
The patient was admitted to the hospital the morning of surgery
and underwent a laparoscopic Nissen fundoplication (see the
video clip in the Online Repository at www.jacionline.org). The
surgery took 40 minutes and was performed through five 5-mm
incisions (Fig 1). The patient was started on liquids immediately
after surgery and was discharged the following morning on a soft
diet and acetaminophen with codiene for pain. At the 2-week fol-
low-up, the patient was back to full diet and activity, and his reflux
symptoms were gone. He reported his asthma symptoms were
much better, and he had not needed his albuterol inhaler since sur-
gery. At the 3-month follow-up he remains asymptomatic, is off
steroids, and continues to use his inhaler sparingly. His nighttime
oxygen requirement has also resolved.
DISCUSSION
The relationship between GERD and respiratory disease in
infants and children has been shown to be present in many forms.
Infants often present with severe episodes of apnea and
bradycardia, and reflux may play a role in sudden infant death
syndrome. Reflux may also present as recurrent bouts of pneumo-
nia or sinus infections and in some children can result in signifi-
cant failure to thrive. However, the interaction between GERD
and patients with corticosteroid-dependent asthma remains some-
what unclear. A number of studies have attempted to define the
relationship, but often the findings have been conflicting. A direct
relationship was shown by Davis et al1 in a study of children with
severe asthma who had a nocturnal component. They performed
intraesophageal infusions of normal saline followed by infusion
of 0.1 meq HCl during 2 periods of the normal sleep cycle.
1069
1070 ROTHENBERG AND BRATTON
FIG 1. Completed laparoscopic fundoplication.
Although the saline infusion had no effect, the acid infusion
caused changes in breathing pattern consistent with bronchocon-
striction and in some cases caused overt wheezing.
Several studies have shown that intensive medical management
of GERD often fails to have any effect on the patients’ respiratory
status.2 Shapiro and Christie2 documented significant GERD in
47% of a group of steroid-dependent patients with asthma but
failed to show an improvement in their airway disease during a
3-week period of intensive medical therapy for their gastroesoph-
ageal reflux. There are numerous other studies that suggest a
correlation between gastroesophageal reflux and worsening respi-
ratory symptoms in a select group of patients with severe asthma,
but the benefits of antireflux therapy remain unclear. Fonkalsrud
et al3 have suggested that in this subset of patients, medical ther-
apy may be inadequate, and surgical correction may be more ef-
ficacious. They showed that although only 30% of patients with
severe asthma or recurrent pneumonia and GERD showed im-
provement on medical therapy, more than 90% of those who
failed to respond to medical therapy had symptomatic improve-
ment of their respiratory symptoms after fundoplication. This
and other similar studies suggest that in this subset of patients,
medical therapy may be inadequate in interrupting the reflex path-
way between esophageal irritation and bronchoconstriction but
that surgical correction may act as a more effective barrier.
In this case review, the patient had severe asthma and had failed
to respond to medical management of his GERD, including the
J ALLERGY CLIN IMMUNOL
APRIL 2008
use of corticosteroids. Previously this patient might not have been
considered a candidate for fundoplication because of the high
morbidity of a major upper abdominal procedure in patients with
already compromised respiratory function, and the unclear
benefits of correcting GERD as it relates to asthma. However,
in a series of more than 1000 patients, we have shown the ability
to perform the procedure safely laparoscopically in the pediatric
and young adult population even in patients with severe respira-
tory compromise.4 This has allowed us to be more aggressive in
offering surgical correction in this high-risk group. In a previous
series, we reported on 56 patients with asthma who underwent
laparoscopic fundoplication without a postoperative pulmonary
complication.5 The majority of patients noted a significant symp-
tomatic improvement in their breathing in the initial postoperative
period. This has been documented in some patients by an im-
provement in their FEV1. All patients were taken off their antire-
flux medication, and more than 90% were weaned off or had a
significant decrease in their steroid dose. There was also a marked
decrease in the need for bronchodilator treatments, as was seen in
this patient. Many of the patients also relate that minor asthma
attacks that would often progress into severe episodes requiring
hospitalization are now easily controlled with inhaler therapy.
Although it is difficult to draw definitive conclusions, there
does seem to be a decreased incidence of hospitalization in these
patients after fundoplication.
Although the exact relationship between GERD and severe
asthma is still unclear, this study suggests that in many cases,
there is a direct interaction in the pathophysiology between the
2 disease processes, and that GERD has a significant adverse
effect on the severity of asthma. It also appears clear that in these
cases, surgical fundoplication is superior to a medical antireflux
regimen in interrupting this relationship.6 In addition, laparo-
scopic techniques allow the procedures to be performed safely
even in this high-risk group of patients.
REFERENCES
1. Davis RS, Larsen GL, Grunstein MM. Respiratory response to intraesophageal acid
infusion in asthmatic children during sleep. J Allergy Clin Immunol 1983;72:393-8.
2. Shapiro GG, Christie DC. Gastroesophageal reflux in steroid dependant asthmatic
youths. Pediatrics 1979;63:207-12.
3. Fonkalsrud EW, Ashcraft KW, Coran AG, Ellis DG, Grosfeld JL, Tunell WP, et al.
Surgical treatment of gastroesophageal reflux in children: a combined hospital study
of 7467 patients. Pediatrics 1998;101:419-22.
4. Rothenberg SS. First decades experienced with laparoscopic fundoplication in in-
fants and children. J Pediatr Surg 2005;40:142-7.
5. Rothenberg SS, Bratton D, Larsen G, Deterding R, Milgrom H, Brugman S, et al.
Laparoscopic fundoplication to enhance pulmonary function in children with severe
reactive airway disease and gastroesophageal reflux disease. Surg Endosc 1997;11:
1088-90.
6. Field S. The effects of anti-reflux surgery on asthmatics with gastroesophageal
reflux disease. Chest 1999;116:766-74.