Antireflux Surgery Benefit Not Lasting in Many Children

May 27, 2013

By David Douglas

NEW YORK (Reuters Health) May 27 - Although laparoscopic Thal fundoplication initially works well in children with severe gastroesophageal reflux disease (GERD), the benefits may wear off over time, according to Dutch researchers.

Dr. Femke A. Mauritz told Reuters Health by email that because "in over 40% of children GERD persists or recurs 10- to 15-years after laparoscopic Thal fundoplication, it is crucial to implement routine long-term follow-up, preferably using objective measurements."

In a May 7 online paper in the Annals of Surgery, Dr. Mauritz of University Medical Center Utrecht and colleagues note that the approach is an established treatment option in patients with GERD resistant to medical treatment.

Short-term results are good to excellent, with 90% of pediatric GERD patient being completely free of reflux symptoms at three to four months after the procedure, according to a previous study by the Dutch group.

But long-term, prospectively gathered information is lacking. So in the current study, the researchers prospectively examined outcome over 10 to 15 years.

They followed 57 children (aged one month to 18 years) who underwent laparoscopic anterior partial fundoplication between 1993 and 1998. Reflux-specific questionnaires were filled out, and 24-hour pH monitoring was performed repeatedly after the procedure.

At three to four months, 81% were completely free of reflux symptoms. At one to five years, this number was 80% and at 10 to 15 years, it had dropped to 73%.

However, in total, 15 patients were lost to follow-up. Thirteen, all of whom were neurologically impaired, died of causes unrelated to the surgery. Taking into account patients lost-to-follow-up and patients with reflux symptoms in earlier follow-up, using disease-free survival analysis, only 57% of patients were symptom-free at 15 years.

In addition, pH monitoring showed that although total acid exposure time significantly decreased from 13% before surgery to 0.7% at three to four months afterwards, 18% of patients still showed pathological reflux. After 10 to 15 years, this had increased significantly to 43%.

Overall, there were no significant differences between neurologically impaired and normally developed patients.

"Remarkably," say the researchers, this high recurrence rate is in contrast to that in most studies. The only published study on follow-up 10 years after surgery showed long-term reflux control in up to 87% of patients. A possible factor in the discrepancy, they suggest, is selection bias by including only patients available for follow-up. Another is the use of endpoints less strict than the "completely free of symptoms" criterion used in the current study.

Given these findings, and the risk of developing Barrett's esophagus and ultimately adenocarcinoma due to untreated GERD, the researchers stress that "it is crucial to implement routine long-term follow-up after antireflux surgery in pediatric patients with gastroesophageal reflux disease."

"Furthermore," concluded Dr. Mauritz, "future studies should focus on identifying those patients at risk of surgical failure."


Ann Surg 2013.


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