Antireflux Surgery Outcomes in Pediatric Gastroesophageal Reflux Disease

Diego M. Diaz, M.D., M.Sc.; Troy E. Gibbons, M.D.; Kurt Heiss, M.D.; Mark L. Wulkan, M.D.; Richard R. Ricketts, M.D.; Benjamin D. Gold, M.D.

Disclosures

Am J Gastroenterol. 2005;100(8):1844-1852. 

In This Article

Abstract and Introduction

Objectives: Antireflux surgery is performed frequently in children with gastroesophageal reflux disease (GERD). Few comparative studies exist which assess the indications for and short- or long-term outcome of open Nissen fundoplication (ONF) and laparoscopic Nissen fundoplication (LNF) for pediatric GERD. We investigated the frequency of reoperation and factors that might influence its occurrence.
Methods: We performed a retrospective, follow up cohort study of all children 5 years, who underwent LNF or ONF at our institution from January 1, 1997 to December 31, 2002, where five pediatric surgeons perform fundoplication. Mean follow up time was 36.2 months. The following information was obtained: surgical indications, hospital course data, and long-term surgical outcomes. Data were analyzed using univariate and multiple logistic regressions.
Results: Overall, 456 (150 [32.9%] ONF vs. 306 [67.1%] LNF) cases were analyzed. Reoperation was performed in 55 (12.06%), LNF 43 (14.05%), and ONF 12 (8%). The mean interim to reoperation for LNF was 11 months compared to 17 months for ONF (p = 0.007). The reoperation rate at 12 and 24 months were 10.5%, 13.4% and 4%, 6.7% respectively, when LNF was compared to ONF (p = 0.01). The multivariate analysis showed that initial LNF and prematurity were the main predictors for reoperation.
Conclusions: The majority of reoperations for both LNF and ONF occurred in the first year after initial operation; LNF had a significantly higher reoperation rate than ONF. The probability of reoperation for LNF and ONF increases with the presence of comorbidities, especially prematurity and chronic respiratory conditions.

Gastroesophageal reflux disease (GERD) and its sequelae are increasingly recognized in the pediatric population. Recently published, evidence-based clinical practice guidelines for pediatric GERD review a number of management alternatives for children with GERD[1] These GERD management approaches included lifestyle changes, pharmacotherapeutic agents, and surgical procedures. However, the guidelines also recommend that outcome studies be performed in children with GERD, and in particular, those undergoing antireflux surgery.

Indications for antireflux surgery include primary GERD or GERD coexisting with other comorbidities, in children considered refractory to medical management. The most frequently seen GERD coexisting conditions in children undergoing fundoplication include neurological impairment, prematurity, chronic respiratory conditions, and anatomical abnormalities.[2–5] Antireflux procedures are generally performed to control GERD-related symptoms, prevent complications, and permit adequate caloric intake to achieve growth.

The fundoplication technique used in the surgical management of GERD, originally described by Nissen,[6] has been performed for over 45 yr. The "open" or laparotomy technique is considered a "safe" surgical procedure, but has a variable rate of reoperation ranging from ≤10% to 20% in adults.[7,7] Interpretation of reported operation success is variable with many studies having poorly defined case definitions or outcome/endpoints, and a lack of optimal medical management prior to surgery.

Minimally invasive surgery for GERD, performed by the laparoscopic approach, has been available in adult patients since 1991 as an alternative to surgical laparotomy.[9] Comparative studies between the laparoscopic and open approach to fundoplication in adults suggested that short-term outcomes for laparoscopic Nissen fundoplication (LNF) may be superior to the traditional open Nissen fundoplication (ONF) in terms of cost, patient satisfaction, and acute complications.[10–12]

The original reports of LNF being used in the pediatric population appeared in the literature in 1993.[13,34] The fundoplication, in particular, LNF, has recently been postulated as being the second most commonly performed surgical procedure in children in the United States.[3]

Published comparative studies between the LNF and ONF in children have shown that LNF has a shorter time to initiation to feeds and length of hospital stay compared to ONF.[15,16] However, reports have shown a marked variability in surgical failure rates. Reported operation failures range from 2 to almost 50% of antireflux surgery procedures, particularly in certain subsets of children. The subsets of children with increased fundoplication failure rates include those with chronic respiratory conditions, neurological impairment, repaired esophageal atresia, and infants less than 1 yr of age.[17–19] Higher failure rates were reported by Taylor et al.,[20] in a study in which a 47% failure rate and 37% reoperation rate was observed in a subset of children with neurological impairment and chronic lung disease. In 1993, Wheatley et al.[21] reported a 33% reoperation rate on 22 children with repaired esophageal atresia. Although the presence of these conditions are associated with a tendency for higher reoperation rates, there is limited knowledge as to whether other preexisting conditions concurrently confer risk to and/or whether the initial surgical approach contributes to antireflux procedure failures. Indications for a second antireflux operation include recurrence of GERD symptoms, the development of postoperative symptoms related to the surgery (i.e., gas bloat), in addition to postoperative complications related to the wrap.[17,19]

There are few studies that have compared the short- and/or long-term outcome of fundoplication in the pediatric population.[15,16] In addition, a multivariate analysis of previously identified risk factors for reoperation that takes into account their potential biological significance has not been reported.

We conducted a retrospective follow-up analytical examination of 456 patients that underwent Nissen fundoplication for the management of GERD at Children's Healthcare of Atlanta, Egleston Children's Hospital. Our study aimed to specifically characterize the risk factors associated with fundoplication reoperation, and to compare the short-term outcome for LNF and ONF. Unlike previous studies, we used a statistical model to potentially predict the probabilities for reoperation occurrence for new patients. Data were analyzed using univariable statistical procedures and multivariable modeling to control for confounding and establish associations.

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