Efficacy of antireflux surgery in children with or without neurological impairment: a systematic review

Assessment of quality of life after laparoscopic GERD surgery in children: a prospective study

The purpose of this study is to assess quality of life (QoL) after laparoscopic anti-reflux surgery (LARS) in children with gastroesophageal reflux disease (GERD) and to evaluate GERD symptoms and their impact on daily life and school. From June 2016 to June 2019, all children with GERD from 2 to 16 years of age, without neurologic impairment or malformation-related reflux, were prospectively included in a monocentric study. Patients (or their parents according to the age of the child) answered the Pediatric Questionnaire on Gastroesophageal Symptoms and QoL (PGSQ) before surgery and 3 and 12 months after surgery. Variables were compared by paired, bilateral Student t-test. Twenty-eight children (16 boys) were included. The median age at surgery was 77 months (IQR: 59.2-137) with median weight of 22 kg (IQR: 19.8-42.3). All had a laparoscopic Toupet fundoplication. Median duration of follow-up was 14.7 months (IQR: 12.3-22.5). One patient (4%) had a recurrence of GERD symptoms without abnormalities on follow-up examinations. Preoperative total PGSQ score was 1.42 (± 0.7) and decreased significantly 3 months (0.56 ± 0.6; p < 0.001) and 12 months after surgery (0.34 ± 0.4; p < 0.001). PGSQ subscale analysis revealed a significant decrease at 3 and 12 months for GERD symptoms (p < 0.001), impact on daily life (p < 0.001), and impact on school (p = 0.03).

CONCLUSION

There was a significant improvement in symptoms and their frequency after LARS in children, as well as an improvement of QoL, in the short and medium term. The impact of GERD should be taken into consideration in the treatment decision, given that surgery clearly improves the QoL.

WHAT IS KNOWN

• Laparoscopic anti-reflux surgery (LARS) is an established and effective treatment option in pediatric patients with severe GERD refractory to medical treatment. • Effect of LARS on the quality of life (QoL) has been mainly investigated in the adult population but there is very little data on the effect of LARS on the QoL in pediatric patients.

WHAT IS NEW

• Our prospective study was the first to analyze the effect of LARS on QoL in pediatric patients without neurologic impairment using validated questionnaires at two postoperative time points with a significant improvement in postoperative QoL at 3 and 12 months. • Our study emphasizes the importance of evaluating QoL and impact of GERD on all the aspects of daily life and of taking these into consideration in the treatment decision.

Is Roux-en-Y Feeding Jejunostomy a Safe and Effective Operation in Children? A Systematic Review Exploring Outcomes

OBJECTIVES

Roux-en-Y jejunostomy (REYJ) may establish feeding in children with foregut dysmotility or severe gastro-esophageal reflux disease (GERD). Nevertheless, concerns have been raised about safety and efficacy. We, therefore, evaluated outcomes of REYJ by systematic review to determine if this was a satisfactory option for achieving enteral autonomy in children with complex nutritional needs.

METHODS

A PRISMA-adherent systematic review was conducted of studies reporting children undergoing feeding REYJ. Two authors performed processes independently; the senior author resolved disagreements. Embase, CINAHL and Medline were searched (inception-01/21). Additional databases, references, and 'grey' literature were searched. Methodological Index for Non-randomized Studies (MINORS) and a bespoke system assessed methodological quality.

RESULTS

Of 362 articles, 10 met eligibility criteria (9 retrospective series; 1 conference proceeding). Unpublished data were also attained. Interobserver agreement for MINORS (kappa = 0.47) and bespoke scoring (kappa = 0.58) were moderate. After consensus, median MINORS score was 37.5% (IQR 6.3%) and bespoke 50% (IQR 20.8%), indicating poor methodological quality. One hundred sixty-four patients were reported (age range: 2 months to 19 years). Time to full feeds and length of stay were inadequately reported but most achieved enteral autonomy. No studies reported patient/caregiver-questionnaires. Seventy-six complications were documented (Clavien-Dindo grading was infeasible). Morbidity included peristomal leakage (N = 26), internal hernia/volvulus (N = 8), and SSI (N = 7). Thirty-eight patients died (2 procedure-attributable) during follow-up (range: 1 month to 15 years).

CONCLUSIONS

Up to 50% patients experience complications after REYJ (often minor) with 23% patients dying during follow-up, often comorbidity-attributable. REYJ can achieve enteral autonomy although parents/caregivers of children should be counselled accordingly.

Trends in gastrostomy tube placement with concomitant Nissen fundoplication for infants and young children at Pediatric Tertiary Centers

PURPOSE

In infants and toddlers, gastrostomy tube placement (GT) is typically accompanied by consideration of concomitant Nissen fundoplication (NF). Historically, rates of NF have varied across providers and institutions. This study examines practice variation and longitudinal trends in NF at pediatric tertiary centers.

METHODS

Patients ≤ 2 years who underwent GT between 2008 and 2018 were identified in the Pediatric Health Information System database. Patient demographics and rates of NF were examined. Descriptive statistics were used to evaluate the variation in the proportion of GT with NF at each hospital, by volume and over time.

RESULTS

40,348 patients were identified across 40 hospitals. Most patients were male (53.8%), non-Hispanic white (49.5%) and publicly-insured (60.4%). Rates of NF by hospital varied significantly from 4.2 to 75.2% (p < 0.001), though were not associated with geographic region (p = 0.088). Rates of NF decreased from 42.8% in 2008 to 14.2% in 2018, with a mean annual rate of change of - 3.07% (95% CI - 3.53, - 2.61). This trend remained when stratifying hospitals into volume quartiles.

CONCLUSION

There is significant practice variation in performing NF. Regardless of volume, the rate of NF is also decreasing. Objective NF outcome measurements are needed to standardize the management of long-term enteral access in this population.

Gastroesophageal Reflux Disease and Need for Antireflux Surgery in Children with Cystic Fibrosis: A Systematic Review on Incidence, Surgical Complications, and Postoperative Outcomes

INTRODUCTION

 Gastroesophageal reflux disease (GERD) is associated with accelerated decline in lung health in children with cystic fibrosis (CF). Thus, antireflux surgery (ARS) is offered to a selected CF cohort with refractory GERD, but outcomes remain poorly investigated. This study aimed to determine the incidence of GERD in children with CF and to evaluate complications and outcomes of ARS.

MATERIALS AND METHODS

 A systematic literature-based search was conducted using various online databases according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The number of GERD cases in pediatric CF cohorts who underwent diagnostic investigation(s) was recorded. Data on postoperative complications and outcomes (including symptoms, lung function, and nutritional status) following ARS were analyzed.

RESULTS

 Ten articles (n = 289 patients) met the defined inclusion criteria (51% male; age range, 0.5 month-36 years). The overall incidence of GERD was 46% (range, 19-81%), derived from seven studies (n = 212 patients). Four publications (n = 82 patients) reported on ARS due to uncontrolled GERD. All ARSs were Nissen fundoplication (majority with gastrostomy placement). Major postoperative complications occurred in 15 (18%) patients, two required redo-ARS. Median follow-up time was 2 years (range, 3 months-6 years); 59% showed symptom improvement, and pulmonary exacerbations and decline in lung function were reduced. Nutritional status mainly improved in milder CF cases. There were no deaths related to ARS.

CONCLUSION

 Approximately half of pediatric CF patients have GERD. Published data for children with CF are limited and heterogeneous in terms of GERD diagnosis and outcomes following ARS. However, ARS has shown to slow the deterioration of lung function in CF.

Efficacy and Safety of CAR-Modified T Cell Therapy in Patients with Relapsed or Refractory Multiple Myeloma: A Meta-Analysis of Prospective Clinical Trials

Background: In recent years, chimeric antigen receptor-modified T (CAR-T) cell therapy for B-cell leukemia and lymphoma has shown high clinical efficacy. Similar CAR-T clinical trials have also been carried out in patients with refractory/relapsed multiple myeloma (RRMM). However, no systematic review has evaluated the efficacy and safety of CAR-T cell therapy in RRMM. The purpose of this study was to fill this literature gap. Methods: Eligible studies were searched in PUBMED, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), CNKI, and WanFang from data inception to December 2019. For efficacy assessment, the overall response rate (ORR), minimal residual disease (MRD) negativity rate, strict complete response (sCR), complete response (CR), very good partial response (VGPR), and partial response (PR) were calculated. The incidence of any grade cytokine release syndrome (CRS) and grade ≥3 adverse events (AEs) were calculated for safety analysis. The effect estimates were then pooled using an inverse variance method. Results: Overall, 27 studies involving 497 patients were included in this meta-analysis. The pooled ORR and MRD negativity rate were 89% (95% Cl: 83-94%) and 81% (95% Cl: 67-91%), respectively. The pooled sCR, CR, VGPR, and PR were 14% (95% Cl: 5-27%), 13% (95% Cl: 4-26%), 23% (95% Cl: 14-33%), and 15% (95% Cl: 10-21%), respectively. Subgroup analyses of ORR by age, proportion of previous autologous stem cell transplantation (ASCT), and target selection of CAR-T cells revealed that age ≤ 55 years (≤55 years vs. > 55 years, p = 0.0081), prior ASCT ≤70% (≤70% vs. > 70%, p = 0.035), and bispecific CAR-T cells (dual B-cell maturation antigen (BCMA)/BCMA + CD19 vs specific BCMA, p = 0.0329) associated with higher ORR in patients. Subgroup analyses of remission depth by target selection suggested that more patients achieved a better response than VGPR with dual BCMA/BCMA + CD19 CAR-T cells compared to specific BCMA targeting (p = 0.0061). In terms of safety, the pooled incidence of any grade and grade ≥ 3 CRS was 76% (95% CL: 63-87%) and 11% (95% CL: 6-17%). The most common grade ≥ 3 AEs were hematologic toxic effects. Conclusion: In heavily treated patients, CAR-T therapy associates with promising responses and tolerable AEs, as well as CRS in RRMM. However, additional information regarding the durability of CAR-T cell therapy, as well as further randomized controlled trials, is needed.

Quality of Life Improves Following Laparoscopic Hemifundoplication in Neurologically Non-Impaired Children with Gastroesophageal Reflux Disease: A Propensity Score-Matched Analysis

BACKGROUND

Quality of life (QOL) data following pediatric fundoplication for gastroesophageal reflux disease (GERD) are rare. Present study assessed the QOL in neurologically non-impaired children before and after laparoscopic hemifundoplication (LHF) in comparison to healthy controls.

METHODS

PedsQL™ questionnaires assessed data on gastrointestinal symptoms (GIS) and general well-being (GWB) were compared in a propensity score-matched analysis (60 patients' pairs for time-point of surgery and 51 for follow-up).

RESULTS

Preoperatively, the LHF group had more GIS (72.2 ± 53.9 vs. 38.8 ± 31.6; p < 0.001) and a lower GWB (16.7 ± 5.5 vs. 23.8 ± 3.5, p < 0.001) compared with controls. Postoperatively, GIS decreased significantly (74.3 ± 52.9 vs. 36.3 ± 33.5; p < 0.001) and the GWB was significantly higher (16.2 ± 6.0 vs. 20.8 ± 5.8; p < 0.001). GIS were similar in the LHF and control groups (39.1 ± 36.4 vs. 40.1 ± 31.0; p = 0.885) but GWB was lower in the LHF group than the control group (20.5 ± 6.3 vs. 23.4 ± 3.9; p = 0.009).

CONCLUSIONS

QOL significantly improves after LHF in neurologically non-impaired children.