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

Discussion

Although population-based studies have not been conducted, potentially preventable GERD-related complications such as erosive esophagitis appear to be rare in thriving infants who are younger than 2 yr of age. However, in children with neurological impairment or other systemic conditions, by 3 or 4 yr of age or older, reports of 20–70% describe erosive esophagitis development.[1,28,29] Therefore, our study was restricted to that of younger children below 5 yr of age. Previous investigations demonstrated a number of comorbidities that either confer more risk for development of persistent GERD or occur concurrently; neurological injury being the most predominant comorbidity.[25,30] In addition, studies indicate that surgical failures and/or complications are more common in those neurologically impaired.[30,31] We demonstrated that LNF or ONF were done more frequently in children with neurological impairment than in other conditions, except chronic respiratory conditions (Fig. 2).

In our study, significantly fewer acute respiratory problems and prolonged ileus were encountered in LNF compared with ONF. Comparative studies recently performed concluded that LNF was a valid alternative to ONF in children.[15,16,32] However, these conclusions should be interpreted with caution. Cohort sizes in these studies were small and follow-up was relatively short, ranging from 6 to 16.5 months. Bufo et al.[33] performed a larger retrospective study in which relatively smaller numbers of LNF (n = 27) versus ONF (n = 185) were used. These authors concluded that LNF was a safe and superior technique to ONF despite significant rates of immediate postoperative complications noted in LNF (37%) and an undisclosed follow-up period. Such high rates of postoperative complications for LNF are not supported by our study (5.9%). Other studies of LNF in children[10,23,30,34] and adults[35,36] have demonstrated good short-term safety and outcomes when the surgery was performed by an experienced surgeon and appropriate patient case selection was used.

Two time periods are usually evaluated in the study of relatively new surgical techniques to depict the steep "learning curve" observed early on in the experience at many large referral institutions.[37–39] The learning curve is defined in these reports as approximately 1 yr and/or first 20–25 cases performed by each individual surgeon performing laparoscopic antireflux surgery. The pediatric surgery group at our institution started to perform LNF in 1997. We determined that by the year 2000 all five members had completed approximately 20 LNF. For example, Meehan and Georgeson[38] demonstrated a rapid decrease in complication rate after a learning phase of 20–25 patients in a review of the first 160 consecutive laparoscopic fundoplication. In our study, the overall perioperative complication rate for LNF was significantly higher during 1997–1999 (11%) compared to 2000–2002 (3%), especially the immediate postoperative complications. However, the acute intraoperative complication rate was 1% for the two periods analyzed. More importantly, the reoperation rate in our study did not decline over time. The rate of conversion from LNF to ONF was 1.3% for Esposito et al.,[40] 2% for Allal et al.,[41] and up to 30% for Meehan and Georgeson; this conversion rate improved to 7.5% after the first 20 cases. The conversion rate in our study was 2% for the initial 3 yr and improved to 1% during 20002002. Thus, the higher initial conversion rate appears to be the main reflection of the learning curve in our study. The distribution of patient comorbidities did not differ significantly; therefore the type of initial surgery did not appear to be clearly influenced by patient-related disease, and was more a factor of the training of the specific surgeons and their procedure preference. Specifically, the LNF now appears to be the procedure of choice at our institution whether or not there are preexisting comorbidities in the patient. Hence, the decision for antireflux surgery is often made on an individual surgeon's choice and selection bias was not likely to affect our study Results.

One of the major benefits of LNF shown by previous studies has been the rapid postoperative recovery time compared with ONF.[42,23] These observations are supported by our study with median hospital stay being 3 days for LNF compared to 5 days for ONF (p < 0.005). Previous studies were unclear as to the length of postoperative time interval considered for follow-up and/or which complications were considered as long term.[33,34]

The indication for reoperation after Nissen fundoplication can be related to causes including recurrence of GERD symptoms, or postoperative symptoms such as gas bloat, dumping syndrome, and retching. In addition, reoperation has been associated with or due to transdiaphragmatic migration of the wrap, paraesophageal hernia, wrap dehiscence, loose wrap and slipped wrap into the fundus, or development of large hiatal hernia.[17,19] However, there have been few studies in children documenting the indications for reoperation, and reoperation rates vary significantly between studies. The published rates range from 6% to 47% for ONF,[26,27,30,45–47] compared to LNF approach from 2.3% to 25%.[19,34] This study enabled us to characterize the long-term probability for reoperation and to perform comparative analysis between ONF and LNF. Using a statistical model that included the risk factors for reoperation, therefore taking into account their potential biological significance, the predicted probabilities of reoperation were calculated. The type of analysis performed in our study has not been previously reported.

The reoperation rate reported by Kubiak et al.[18] for infants less than 4 months at initial operation was 24%. In contrast, our study showed a predicted probability of reoperation in patients who underwent surgery within the first 5 months of life and had no comorbidities for LNF of (10.7%) compared to ONF (6.7%). Based on our study, patients with one to three comorbidities had a probability of reoperation ranging from 8% to 24% for LNF compared to ONF that ranged from 6% to 16%. These predicted probabilities can be useful to clinicians and surgeons when faced with patient selection and parental questions.

Time to reoperation in our study showed differences for both surgical approaches: for LNF, time to reoperation was 11.2 months compared to 17.2 months in ONF (p = 0.007). Most reoperations for both approaches occurred within the first 12 months. A similar time interval has been described by Kimber et al.[26] for ONF. In addition, Rothenberg[34] noted early failures in his analysis of 220 cases of laparoscopic fundoplication, and Meyer et al.[48] reported a mean time to reoperation for LNF in adults of 8 months. The reoperation rate for LNF was higher than ONF at 12, 24, and 36 months after the initial operation (p = 0.01).

There are a number of limitations to this study. Information obtained by a retrospective study is not controlled, may be incomplete, and have inaccuracies. Follow-up analysis by medical record review limits the ability to ascertain specific indications for surgery, and would be optimally performed in a prospective fashion. Procedures were performed by a group of five surgeons, and personal technique and experience with either ONF or LNF are variables that are not standardized or surgical approach protocolized. To consider technique uniformity, multicenter collaborative studies are clearly needed in order to standardize the measurement of surgical outcomes for antireflux surgery, in particular a registry of a large cohort of patients, which include large pediatric surgical practices. This would facilitate conducting prospective studies that would objectively measure indications and outcomes.

In summary, LNF was the predominant fundoplication approach used in our large series. Despite a higher reoperation rate, LNF had a shorter length of stay, fewer acute respiratory complications, and was less likely to have prolonged ileus than ONF. Based on long-term outcome, our study suggests that reoperation tends to present within the first year following the procedure for both LNF and ONF. However, the children who underwent ONF had a lower reoperation rate and lesser predicted reoperation rate as well. Thus, it is important to define for future prospective and/or multicenter studies what is considered the surgical standard of care for the definitive management of refractory GERD. Long-term prospective studies are critically needed in all the major groups of children who have GERD as a primary diagnosis or GERD secondary to some underlying conditions such as prematurity, neurological impairment, and chronic lung disease to correlate these chronic conditions with the mechanism of medical and/or surgical failure.


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