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Fundoplication may be considered in certain patients with symptomatic reflux gastritis associated with esophagitis. Esophagitis with stricture and paraesophageal hernia are other possible indications. A preliminary trial of repeated dilatations may be instituted when there is evidence of a stricture of the lower end of the esophagus. The procedure may be indicated in infants and children with gastroschisis or omphalocele repair or those with gastroesophageal reflux associated with brain injury.

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Substernal pain, especially in the recumbent position, difficulty in swallowing, and recurrent bouts of aspiration pneumonia are commonly associated with roentgenologic evidence of gastroesophageal reflux. Esophagoscopy with manometric studies and intraluminal pH measurements are indicated. The latter studies may be extended over a 24-hour period of observation. Barium studies of the entire gastrointestinal tract may demonstrate a duodenal ulcer or other disorders. A gastric analysis, as well as serum gastrin determinations, should be made. Antacid therapy, elevation of the head of the bed, and effective weight reduction in obese patients may decrease the severity of symptoms.

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Surgical procedures are designed to prevent acid peptic reflux and to restore normal sphincteric function. When reflux esophagitis is associated with duodenal ulcer, either parietal cell vagotomy or truncal vagotomy and pyloroplasty should be considered.

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Pulmonary function studies are indicated in patients with a history of aspiration pneumonia. Antacid therapy is maintained. Systemic antibiotics may be given. Nasogastric intubation should be instituted.

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General anesthesia with endotracheal intubation is employed.

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The patient is placed in a comfortable supine position on the table with the feet slightly lower than the head.

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The area from the nipples downward to the symphysis is shaved. The skin over the sternum, lower chest wall, and the entire abdomen is cleaned with the appropriate antiseptic solutions.

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A liberal incision starting over the xiphoid and extending down the midline to the umbilicus is made (Figure 1). In the obese patient, the incision should extend to the left and slightly below the umbilicus. When the xiphoid is elongated, it is removed to enhance the exposure of the esophagogastric junction. Active arterial bleeding in either xiphocostal angle is controlled with a transfixing suture of 00 silk.

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The peritoneum is opened and the abdomen explored with special attention given to the gallbladder, duodenal bulb, and the size of the esophageal hiatus. A considerable portion of the stomach may be up in the chest as a result of the enlarged hiatus opening.

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