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

Results

We analyzed data from 456 patients, 306 (67.1%) LNF and 150 (32.1%) ONF. The characteristics of the LNF and ONF groups are shown in Table 1 . There were 190 (42%) females and 266 males (58%). The mean age at initial operation was 11.9 ± 13.2 months (median: 6 months, range: 1–60), and did not differ significantly between LNF and ONF. The interval between operations averaged 11.2 ± 9.2 months (median: 8, range: 1–47) for LNF versus 17.2 ± 8.9 months (median: 14.5, range: 6–36) for ONF. The shorter interval to reoperation in the LNF group was statistically different (p = 0.007). There were no operation-related deaths observed during the study period.

During the first 3 yr of the study, 222 fundoplications were performed, 100 LNF and 122 ONF; conversely, between 2000 and 2002, 206 patients underwent LNF and 28 ONF (p < 0.0001). Many patients had more than one underlying diagnosis at the time of surgery; the most common comorbidities at the time of fundoplication were chronic respiratory conditions (41.66%), neurological impairment (32.45%), and prematurity (30.04%), and their distribution did not differ significantly between LNF and ONF (Fig. 1). However, among patients with diagnosis of reflux alone, 78 (83.87%) underwent LNF compared to 15 (16.13%) from the ONF group (p = 0.0001). Children with history of prematurity were operated on primarily via LNF 95 (70%). The study included 136 ex-premature patients, 87 (64%) had the initial operation before 6 months of age, and by 1 yr of age, 111 (82%) of these former premature infants had undergone fundoplication. Children with history of prematurity had the tendency to require reoperation; 19 of 136 (14%) (OR: 1.3; 95% CI: 0.7–2.3; p = 0.4), and 13 of 19 were less than 30 wk of gestational age at birth (OR: 1.6; 95% CI: 0.8–23.2; p = 0.15) compared to 36 of 320 (11%) (OR: 0.7; 95% CI: 0.81.5; p = 0.41) children who were born full term. However, these observations did not reach statistical significance.

Distribution of underlying diagnoses comparing LNF versus ONF. Bar chart depicting the distribution of underlying diagnoses between LNF and ONF, in children under 5 yr who underwent a fundoplication procedure at the Egleston Children¡¯s Hospital Campus of Children¡¯s Healthcare of Atlanta from January 1997 to December 2002. Patients can have more than one coexisting diagnosis. Results will not add up to 456. p < 0.05.

Fifty-five (12%) of 456 patients who underwent Nissen fundoplication at our institution required reoperation; 43 (14%) in the LNF group compared to 12 (8%) for ONF (OR: 1.88; 95% CI: 0.96–3.68; p = 0.06). The frequency for reoperation by initial procedure and underlying diagnoses were not statistically significant as shown in Figure 2.

Distribution and corresponding frequency of reoperation for underlying diagnoses comparing LNF versus ONF. Bar chart depicting the distribution and corresponding frequency of reoperation by initial procedure for underlying diagnoses for LNF and ONF in children under 5 yr who underwent a fundoplication procedure at the Egleston Children¡¯s Hospital Campus of Children¡¯s Healthcare of Atlanta from January 1997 to December 2002. Patients can have more than one coexisting diagnosis. Results will not add up to 55.=NS; p=0.2. LNFr= number of reoperations in the LNF group; ONFr=number of reoperations in the ONF group. %=proportion of reoperation for each comorbidity by initial approach.

Table 2 shows the frequency of acute complications following fundoplication. Overall, ONF was associated with a significantly higher frequency of acute complications; 34 (22.7%) compared to 18 (5.9%) LNF (p < 0.0001).

Table 3 shows a comparison of acute complications and long-term outcome for LNF during the two time periods (1997–1999 and 2000–2002). Overall, 4 of 310 (1.3%) laparoscopic procedures were converted to ONF. The conversion rate improved from 2% during the first 3 yr to 1% for 2000–2002 (p = 0.59). Reasons for conversion from LNF to ONF were 1 patient with hepatomegaly and difficult visualization of the surgical field, 1 patient with distended small bowel loops, and 2 patients with dense adhesions.

Table 4 depicts odds ratios for reoperation, estimated separately for each individual risk factor. Initial laparoscopic surgery, a history of prematurity, and reflux alone tended to be associated with increased risk of reoperation. However, a bivariate analysis performed showed a confounded association between primary reflux and increased risk of reoperation since this subcohort was significantly more likely to undergo LNF initially.

Table 5 shows Results of the multiple logistic regression analysis using the final model; covariates included gender and risk factors for reoperation as determined by literature review. Goodness of fit was excellent, as indicated by the Hosmer-Lemeslow test (p = 0.78), and the absence of statistically significant interaction effects. The risk for reoperation tend to be higher in patients who underwent initial LNF and children with history of prematurity; however, the independent impact of these two risk factors did not reach statistical significance. The final model was used to predict the probability of reoperation depending on the type of procedure, age at initial operation, and presence of comorbidities. Overall, reoperation rates were higher for LNF, and they increased for LNF and ONF with the presence of comorbidities, especially prematurity and chronic respiratory conditions ( Table 6 ).

Figure 3 shows the Kaplan-Meier diagram for survival time of subjects evaluated in this study. "Survival" was defined as patients who did not require reoperation. The mean follow-up time was 36.2 months (SD: 10.9); the difference in survival curves between patients who initially underwent LNF and ONF was statistically significant (p = 0.01). Table 7 shows higher reoperation rates for LNF at 12, 24, and 36 months after initial operation. The majority of reoperations for LNF and ONF occurred in the first year following the initial operation.

Kaplan-Meier curves for reoperation in subjects who underwent LNF versus ONF. Kaplan-Meier curves of the cumulative probability of reoperation in subjects who underwent LNF or ONF. Mean follow-up time was 36.1 months; SD: 10.96; range: 12.9–59.8. A significant difference in reoperation was observed between LNF and ONF, with a log-rank χ2(1 df ) = 5.44; p = 0.01.

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