Fundoplication in children: experience with 106 cases

Outcomes of fundoplication for paediatric gastroesophageal reflux disease

PURPOSE

Outcomes of fundoplication in children.

METHODS

In this monocentric retrospective study, chart review was performed on children who underwent fundoplication between 2006 and 2013. Outcomes were defined as the need for redo fundoplication and recommencement of anti-reflux medication (ARM) at 6-month follow-up.

RESULTS

119 patients underwent fundoplication with a mean age of 4.76 years and 55.5% of these were male. At 6-month follow-up, 21 (17.6%) required redo fundoplication and 64 (53.8%) were recommenced on ARM. Post-operative complications occurred in 50 (42.2%) of children; 30% of those with complications had surgery at less than 1 year of age, and 36% had an associated comorbid condition. Neither being under the age of one nor associated comorbidity was significantly associated with a poor outcome. Concurrent gastrostomy was associated with a higher risk of being back on ARM at 6-month follow-up (p = 0.003). Neither gastrointestinal or respiratory symptoms pre-surgery nor abnormal pre-operative investigations including pH monitoring and endoscopy were predictive of poor outcome post-fundoplication.

CONCLUSION

Although fundoplication has a role in the treatment of severe GORD in children, the majority of children in this study needed to restart their anti-reflux medications within 6 months of surgery.

Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition

Gastroesophageal reflux (GER), defined as passage of gastric contents into the esophagus, and GER disease (GERD), defined as symptoms or complications of GER, are common pediatric problems encountered by both primary and specialty medical providers. Clinical manifestations of GERD in children include vomiting, poor weight gain, dysphagia, abdominal or substernal pain, esophagitis and respiratory disorders. The GER Guideline Committee of the North American Society for Pediatric Gastroenterology and Nutrition has formulated a clinical practice guideline for the management of pediatric GER. The GER Guideline Committee, consisting of a primary care pediatrician, two clinical epidemiologists (who also practice primary care pediatrics) and five pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. The Committee examined the value of diagnostic tests and treatment modalities commonly used for the management of GERD, and how those interventions can be applied to clinical situations in the infant and older child. The guideline provides recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management and indications for consultation by a specialist. The guideline also provides recommendations for management by the pediatric gastroenterologist. This document represents the official recommendations of the North American Society for Pediatric Gastroenterology and Nutrition on the evaluation and treatment of gastroesophageal reflux in infants and children. The American Academy of Pediatrics has also endorsed these recommendations. The recommendations are summarized in a synopsis within the article. This review and recommendations are a general guideline and are not intended as a substitute for clinical judgment or as a protocol for the management of all patients with this problem.

Is epidural analgesia associated with an improved outcome following open Nissen fundoplication?

Postoperative epidural analgesia is increasingly popular in paediatric practice, although evidence of its benefit is scarce. We performed a retrospective analysis of a series of 104 consecutive open Nissen fundoplications, to determine whether mode of analgesia, epidural (n=65) or opioid infusion (n=39), influenced certain outcome measures, including intensive care utilization, duration of hospital stay, morbidity and mortality. The two groups were similar in terms of demographic characteristics and associated pathologies. Overall, morbidity and mortality (2%) rates were low. Mean duration of hospital stay was significantly greater for the opioid group, compared to those receiving epidural analgesia (13 vs. 8 days, P < 0.05). The number of patients who remained in hospital for more than 7 days was also significantly greater in the opioid group. Accepting the limitations of a retrospective study, these data suggest that epidural analgesia might be associated with an improved outcome following Nissen fundoplication and this merits a prospective study.