Failed Nissen Fundoplication in Children: Causes and Management

 

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Abstract

Introduction Nissen fundoplication (NF) is the gold standard procedure for the treatment of gastroesophageal reflux (GER) in children. However, it fails in a significant proportion of patients. The purpose of this study was to identify preoperative predictors of failure and to examine the results of reoperations.

Patients and Methods The charts of patients who underwent NF at our institution between 1992 and 2011 were retrospectively reviewed. Surgery was indicated in patients with symptomatic GER in whom medical treatment failed, particularly, in cases of esophageal atresia (EA), congenital diaphragmatic hernia (CDH), and neurologic impairment (NI). Chi-square comparisons and logistic regression were used to test comorbidities, previous abdominal surgery, surgical technique, gastrostomy, pyloromyotomy or pyloroplasty, age, weight, and surgical complications as possible predictors of NF failure.

Results A total of 360 children (217 male and 143 female) underwent NF. Comorbidities were NI (n = 100, 27.8%), EA (n = 50, 13.9%), CDH (n = 22, 6.1%), and abdominal wall defects (AWD) (n = 6, 1.7%). A total of 35 patients (9.7%) had esophageal stenosis. Age at surgery was 3.06 years (0.04–20.7 years) and weight was 12 kg (2–77 kg). NF was open in 196 patients (54.4%) and laparoscopic in 164 patients (45.6%) (with 9 conversions). Follow-up was 6.7 years (0.01–18.7 years). A total of 42 patients (11, 7%) had postoperative complications (10 wound infection, 9 dumping syndrome, 8 gastrostomy related complications, 7 intestinal obstruction, 5 evisceration, 2 chylothorax, and 1 pneumothorax). Reflux recurred in 42 patients (11.7%) and 35 patients (9.7%) underwent redo NF 1.01 years (0.02–8.4 years) after the initial surgery. A total of nine patients (2.5%) required further interventions (five another redo NF, three esophageal replacements, and one esophago-gastric disconnection). A total of 29 patients (8.1%) died during the follow-up (25 because of their baseline disease, 3 in the postoperative period, and 1 because of pulmonary aspiration 3 years after surgery). EA (31.6% failure) and CDH (46.7% failure) were the only comorbidities predictive of NF failure (p < 0.05).

Conclusions Failure of NF is particularly frequent in patients previously operated upon for EA or CDH and can be predicted preoperatively. However, the benefits of the operation may outweigh this risk. Redo NF is indicated if symptoms of GER recur, but the proportion of failure is even higher. In subsequent failures, other options like esophageal replacement or esophagogastric dissociation should also be considered.

• References

• 1 Hassall E. Decisions in diagnosing and managing chronic gastroesophageal reflux disease in children. J Pediatr 2005; 146 (3, Suppl): S3-S12
  PubMedGoogle Scholar
• 2 Tighe MP, Afzal NA, Bevan A, Beattie RM. Current pharmacological management of gastro-esophageal reflux in children: an evidence-based systematic review. Paediatr Drugs 2009; 11 (3) 185-202
  PubMedGoogle Scholar
• 3 Liu XL, Wong KK. Gastroesophageal reflux disease in children. Hong Kong Med J 2012; 18 (5) 421-428
  PubMedGoogle Scholar
• 4 Trinick R, Johnston N, Dalzell AM, McNamara PS. Reflux aspiration in children with neurodisability—a significant problem, but can we measure it?. J Pediatr Surg 2012; 47 (2) 291-298
  CrossrefPubMedGoogle Scholar
• 5 Nissen R. Eine einfache Operation zur Beeinflussung der Refluxoesophagitis. Schweiz Med Wochenschr 1956; 86 (Suppl. 20) 590-592
  PubMedGoogle Scholar
• 6 Dallemagne B, Weerts JM, Jehaes C, Markiewicz S, Lombard R. Laparoscopic Nissen fundoplication: preliminary report. Surg Laparosc Endosc 1991; 1 (3) 138-143
  PubMedGoogle Scholar
• 7 Mauritz FA, van Herwaarden-Lindeboom MY, Stomp W , et al. The effects and efficacy of antireflux surgery in children with gastroesophageal reflux disease: a systematic review. J Gastrointest Surg 2011; 15 (10) 1872-1878
  CrossrefPubMedGoogle Scholar
• 8 van Beek DB, Auyang ED, Soper NJ. A comprehensive review of laparoscopic redo fundoplication. Surg Endosc 2011; 25 (3) 706-712
  CrossrefPubMedGoogle Scholar
• 9 Islam S, Teitelbaum DH, Buntain WL, Hirschl RB. Esophagogastric separation for failed fundoplication in neurologically impaired children. J Pediatr Surg 2004; 39 (3) 287-291 , discussion 287–291
  CrossrefPubMedGoogle Scholar
• 10 Mathei J, Coosemans W, Nafteux P , et al. Laparoscopic Nissen fundoplication in infants and children: analysis of 106 consecutive patients with special emphasis in neurologically impaired vs. neurologically normal patients. Surg Endosc 2008; 22 (4) 1054-1059
  CrossrefPubMedGoogle Scholar
• 11 Kawahara H, Kubota A, Hasegawa T , et al. Lack of distal esophageal contractions is a key determinant of gastroesophageal reflux disease after repair of esophageal atresia. J Pediatr Surg 2007; 42 (12) 2017-2021
  CrossrefPubMedGoogle Scholar
• 12 Tovar JA, Fragoso AC. Current controversies in the surgical treatment of esophageal atresia. Scand J Surg 2011; 100 (4) 273-278
  CrossrefPubMedGoogle Scholar
• 13 Kawahara H, Okuyama H, Nose K , et al. Physiological and clinical characteristics of gastroesophageal reflux after congenital diaphragmatic hernia repair. J Pediatr Surg 2010; 45 (12) 2346-2350
  CrossrefPubMedGoogle Scholar
• 14 Di Pace MR, Caruso AM, Farina F, Casuccio A, Cimador M, De Grazia E. Evaluation of esophageal motility and reflux in children treated for congenital diaphragmatic hernia with the use of combined multichannel intraluminal impedance and pH monitoring. J Pediatr Surg 2011; 46 (10) 1881-1886
  CrossrefPubMedGoogle Scholar
• 15 Siddiqui MR, Abdulaal Y, Nisar A, Ali H, Hasan F. A meta-analysis of outcomes after open and laparoscopic Nissen's fundoplication for gastro-oesophageal reflux disease in children. Pediatr Surg Int 2011; 27 (4) 359-366
  CrossrefPubMedGoogle Scholar
• 16 McHoney M, Wade AM, Eaton S , et al. Clinical outcome of a randomized controlled blinded trial of open versus laparoscopic Nissen fundoplication in infants and children. Ann Surg 2011; 254 (2) 209-216
  CrossrefPubMedGoogle Scholar
• 17 Kelly JJ, Watson DI, Chin KF, Devitt PG, Game PA, Jamieson GG. Laparoscopic Nissen fundoplication: clinical outcomes at 10 years. J Am Coll Surg 2007; 205 (4) 570-575
  CrossrefPubMedGoogle Scholar
• 18 Islam S, Geiger JD, Coran AG, Teitelbaum DH. Use of radiofrequency ablation of the lower esophageal sphincter to treat recurrent gastroesophageal reflux disease. J Pediatr Surg 2004; 39 (3) 282-286 , discussion 282–286
  CrossrefPubMedGoogle Scholar
• 19 Rothenberg SS, Chin A. Laparoscopic Collis-Nissen for recurrent severe reflux in pediatric patients with esophageal atresia and recurrent hiatal hernia. J Laparoendosc Adv Surg Tech A 2010; 20 (9) 787-790
  CrossrefPubMedGoogle Scholar
• 20 Rothenberg SS. Laparoscopic redo Nissen fundoplication in infants and children. Surg Endosc 2006; 20 (10) 1518-1520
  CrossrefPubMedGoogle Scholar
• 21 Pacilli M, Eaton S, Maritsi D , et al. Factors predicting failure of redo Nissen fundoplication in children. Pediatr Surg Int 2007; 23 (5) 499-503
  CrossrefPubMedGoogle Scholar
• 22 Lopez M, Kalfa N, Forgues D, Guibal MP, Galifer RB, Allal H. Laparoscopic redo fundoplication in children: failure causes and feasibility. J Pediatr Surg 2008; 43 (10) 1885-1890
  CrossrefPubMedGoogle Scholar