A multicenter study of the incidence and factors associated with redo Nissen fundoplication in children

doi:10.1016/j.jpedsurg.2013.03.028

Journal of Pediatric Surgery

Volume 48, Issue 6, June 2013, Pages 1306-1311

https://doi.org/10.1016/j.jpedsurg.2013.03.028 Get rights and content

Abstract

Aim

The objective of this study was to identify the incidence and factors associated with redo Nissen fundoplication in children.

Methods

After Institutional Review Board approval (5100277), data for children under 18 years of age from two children's hospitals with fundoplication performed between January 1994 and December 2010 were reviewed. Children with one fundoplication were compared to those with redos to identify factors associated with redo.

Variables were compared using t-tests for continuous and chi-square tests for categorical variables. Logistic regression evaluated for independence.

Results

There were 823 patients and 54.7% were male. A redo fundoplication was required in 100 (12.2% of cohort); 82 had 1 redo, 14 had 2 redos, and 4 had 3 redos. Follow-up ranged from 0.01 to 16.9 years (median: 2.9 years).

Factors associated with redo were: younger age at first fundoplication, (p = 0.002), hiatal dissection (p < 0.001), and male gender (p = 0.008). Independent predictors of redo were: hiatal dissection at first fundoplication, OR: 8.45 (95% CI: 2.45–29.11), retching, OR: 3.59 (95% CI: 1.56–8.25) and younger age at first fundoplication, OR: 0.98 (95% CI: 0.97–0.98).

Conclusion

The incidence of redo fundoplication in children is 12.2%. The risk of redo is significantly increased if patients are younger, have retching, and if the esophageal hiatus is dissected at the first fundoplication.

Section snippets

Methods

After Institutional Review Board approval (5100277), a retrospective review was conducted on children less than 18 years of age from Loma Linda University Children's Hospital and Kansas City Children's Mercy Hospital who underwent Nissen fundoplication between January 1994 and December 2010. Follow-up data were collected from clinic and hospital records to December 2011. Children who underwent one Nissen fundoplication were compared to those requiring redo Nissen fundoplication to identify

Results

There were 823 patients identified which were 54.7% male. Follow-up ranged from 0.01 to 16.9 years (median: 2.9 years). Complete follow-up data to December 2011 were available for 464 (56.4%). Complete data and follow-up were available for 234 (28.4%). The median follow-up time for the 234 was 26.8 months. For the 197 without redo fundoplication, the median follow-up time was 30.0 months and for the 37 with redo it was 27.2 months.

A redo fundoplication was performed in 100, 12.2% of cohort and 21.6%

Discussion

The incidence of redo Nissen fundoplication in children in this large multicenter cohort is 12.2% and 21.6% in those with complete follow-up. The mean time to first redo fundoplication is 27.6 months. The risk of redo Nissen fundoplication is significantly increased if patients are younger and are retching before the first fundoplication. Dissection of the esophageal hiatus at the first fundoplication, increases the risk of redo fundoplication.

An overall redo fundoplication incidence of 12% is

References (27)

A. Celik et al.
Revision Nissen fundoplication can be completed laparoscopically with a low rate of complications: a single-institution experience with 72 children
J Pediatr Surg
(2006)
C. Kimber et al.
The failure rate of surgery for gastro-esophageal reflux disease
J Pediatr Surg
(1998)
M. De Onis et al.
WHO growth standards for infants and young children
Arch Pediatr
(2009)
C.A. Richards et al.
Retching and vomiting in neurologically impaired children after fundoplication: predictive preoperative factors
J Pediatr Surg
(2001)
S.D. St. Peter et al.
Minimal versus extensive esophageal mobilization during laparoscopic fundoplication: a prospective randomized trial
J Pediatr Surg
(2011)
M. Lopez et al.
Laparoscopic redo fundoplication in children: failure causes and feasibility
J Pediatr Surg
(2008)
M. Ngerncham et al.
Risk factors for recurrent gastroesophageal reflux disease after fundoplication in pediatric patients: a case–control study
J Pediatr Surg
(2007)
T. Hirata et al.
Survival and outcome of infants 501 to 750 gm: a six-year experience
J Pediatr
(1983 May)
S.D. St Peter et al.
The use of biosynthetic mesh to enhance hiatal repair at the time of redo Nissen fundoplication
J Pediatr Surg
(2007)
R.K. Cribbs et al.
Gastric fundoplication is effective in promoting weight gain in children with severe congenital heart defects
J Pediatr Surg
(2008)

H. Okuyama et al.

The efficacy and long-term outcome of laparoscopic Nissen fundoplication in neurologically impaired children

Pediatr Endosurg Innov Tech

(2004)

D.M. Diaz et al.

Anti-reflux surgery outcomes in pediatric gastroesophageal reflux disease

Am J Gastroenterolo

(2005)

K. Graziano et al.

Recurrence after laparoscopic and open Nissen fundoplication: a comparison of the mechanism of failure

Surg Endosc

(2003)

Cited by (35)

Short and long-term outcomes after pediatric redo fundoplication
2022, Journal of Pediatric Surgery
Citation Excerpt :
Only one patient in our study underwent a re-RF (4%), reflecting previous findings of re-RF in 6–26% of patients [7–12]. Many pediatricians and pediatric surgeons assume that the success rate is considerably lower after RF than after primary fundoplication [9,10,20]. Interestingly, the recurrence rate after RF was similar to the recurrence rate after primary fundoplication at our center, questioning the opinion of significantly poorer results after RF [15].
Redo fundoplication (RF) is the most common surgical treatment for recurrent gastroesophageal reflux disease (GERD) in children, but outcomes after RF are rarely reported. The aim of this study was to assess short- and long-term outcomes after RF in childhood.
The study is a follow-up study of patients undergoing RF from 2002 to 2020 at a teriary care center. Patients/parents were sent questionnaires recording symptoms of recurrent GERD, troublesome side-effects and satisfaction. Retrospective chart review was also performed.
24/28 (86%) patients were included median 9 (1.6 months–17.7 years) years after RF. 16 (67%) had neurologic impairment. Indications for RF was recurrence of GERD (n = 18), discomfort or dysphagia from a herniated wrap (n = 5) and dysphagia from a slipped fundoplication (n = 1). Median operating time was 128 (95–250) min. Six (25%) patients experienced early major complications, of which two were gastrostomy related.
Five (21%) patients experienced recurrence after RF. Three of these were symptom free at follow-up with medical treatment or re-RF. The most common symptom at follow-up was stomach pain (37%) and excessive flatulence (38%). 18/22 (95%) patients/parents would choose RF again, and 21/22 would recommend RF to someone in a similar situation.
RF is successful in treating recurrent GERD after primary fundoplication, and patient/parental satisfaction is high.
Trends in fundoplication volume for pediatric gastroesophageal reflux disease
2021, Journal of Pediatric Surgery
Fundoplication for gastro-esophageal reflux disease (GERD) has been commonly performed by pediatric surgeons, however there are no recent data documenting fundoplication trends. Changes in fundoplication volume impact pediatric surgical training and may reflect changes in care for children with severe GERD.
The Pediatric Health Information System (PHIS) was queried from 2010–2019 for children with ICD-9/ICD-10 codes for GERD, fundoplication, and gastrostomy. Institutional surgical volume and patient demographics were examined over time. A secondary analysis using the Accreditation Council for Graduate Medical Education case logs for pediatric surgery fellows was performed across the same years to assess effects upon surgical volume for trainees.
Mean institutional fundoplication case volume decreased from 50 in 2010 to 17 in 2019. Trends were similar between institutions with and without fellowship programs when corrected by total operative volume. Patient characteristics were relatively unchanged between 2010 and 2019. Fundoplication volume reported in fellow case logs decreased from 46 in 2010 to 26 in 2019, mirroring national data.
Institutional volume for fundoplication in children with GERD has seen a 3-fold decrease over the last decade, mirrored by an almost 2-fold decrease in case volume reported by pediatric surgery fellows.
Optimal management of gastrojejunal tube in the ENFit era — Interventions that changed practice
2021, Journal of Pediatric Surgery
We experienced a high incidence of jejunal tube (JEJ) displacement in children who underwent percutaneous endoscopic transgastric jejunostomy (PEGJ), ever since the introduction of ENFit connector (2017).
Two interventions were introduced in 2018 — fixative suture to PEGJ ENFit connector, and conversion to balloon transgastric–jejunal feeding device (Balloon GJ) whenever possible. Children receiving PEGJ and Balloon GJ in 2.8 years were categorized into 3 eras: 2016 (pre-ENFit), 2017 (ENFit) and 2018 (interventional), for comparison of complications and sequelae. Kaplan–Meier survival curves with log-rank test (P < 0.05) were applied.
100 children underwent 323 JEJ insertions — PEGJ (n = 237), Balloon GJ (n = 86). Complications occurred in 188 JEJs (58%), more frequently with PEGJ than Balloon GJ (69% vs. 29%, P < 0.0005). PEGJ had higher complication/1000-tube-days (6 vs. 0, P < 0.0005). In 2018, complication rate reduced from 76% to 30% (P < 0.0005) owing to effectiveness of PEGJ connector suture application (P = 0.019), and increased utilization of Balloon GJ (16% to 44%, P = 0.005). Balloon GJ showed better JEJ survival (P = 0.019), less morbidity (emergency attendance, X-ray) and greater cost-effectiveness than PEGJ.
Balloon GJ had better overall outcomes than PEGJ. Suture application to connector successfully reduced JEJ internal displacement in PEGJ; however, conversion to Balloon GJ should be strongly considered.
II
Postfundoplication retching: Strategies for management
2020, Journal of Pediatric Surgery
Citation Excerpt :
Patients with preexisting dysmotility/emetic sensitization are predisposed to wrap disruption and are at risk of being caught in a downward spiral of worsening dysmotility and emetic symptoms. Children undergoing a redo fundoplication have a higher rate of symptom recurrence/wrap failure than those undergoing their first procedure, a higher rate of surgical complications, and may subsequently convert to jejunal feeding in order to manage feeding-related symptoms [118,124,125]. Baerg etal.
Retching is a common symptom in children following antireflux surgery, particularly in those with neurodisability. There is now a strong body of evidence that implicates retching as a major cause of wrap breakdown. Retching is not a symptom of gastroesophageal reflux disease; it is a component of the emetic reflex. In addition to causing wrap breakdown, it is indicative of the presence of nausea. It is a highly aversive experience and warrants treatment in its own right.
A framework was constructed for the management of postoperative retching, with strategies targeting different components of the emetic reflex. The impact of differing antireflux procedures upon retching was also considered.
Once treatable underlying causes have been excluded, the approach includes modifications to feeds and feeding regimens, antiemetics and motility agents. Neuromodulation and other, novel, therapies may prove beneficial in future.
Children at risk of postoperative retching may be identified before any antireflux surgery is performed. Fundoplication is inappropriate in these children because it does not treat their symptoms, which are not because of gastroesophageal reflux, and may make them worse. They are also at risk of wrap disruption. Alternative strategies for symptom management should be employed, and fundoplication should be avoided.
II–V
Does retching matter? Reviewing the evidence—Physiology and forces
2019, Journal of Pediatric Surgery
Citation Excerpt :
Retching is NOT a feature of GER or GERD [2,64]. Chronic retching is a commonly reported symptom in children following fundoplication [2,4–12]. In contrast to GER, retching and true vomiting are elicited by activation of the emetic (vomiting) reflex.
Failure of antireflux surgery is common in children with neurodisability, with a high incidence of persistent or recurrent symptoms, including retching. Anatomical disruption of the wrap is a frequent finding, but what forces underlie this disruption? This article reviews the forces generated during potential wrap-stressing episodes, putting them into the clinical context of wrap failure.
Historically, wrap failure has been attributed to pressures arising from a reduction in gastric capacity or compliance, with advocates for an additional, gastric emptying procedure, at the time of fundoplication. However, any postoperative pressure changes are small and insufficient to cause disruption, and evidence of benefit from gastric emptying procedures is lacking.
Diaphragmatic stressor events are common in the presence of neurodisability, and there is now increasing recognition of an association between diaphragmatic stressors and wrap breakdown. The analysis in this review demonstrates that the greatest forces on the fundoplication wrap are those associated with retching and vomiting. The direction and magnitude of these forces are sufficient to cause wrap herniation into the thorax, and wrap separation. Clinical series confirm that retching is consistently and strongly associated with wrap breakdown.
Retching needs to be addressed if we are to reduce the incidence of wrap failure.
Level of Evidence V.
Neurogastroenterology and motility disorders in pediatric population
2019, Clinical and Basic Neurogastroenterology and Motility
Motility of the gastrointestinal tract plays a critical role in the maintenance of its many physiological functions. These motility patterns, which vary along the gastrointestinal tract, are achieved by highly coordinated interactions between the neuromusculature of the gut (smooth muscle layers, enteric nervous system, interstitial cells of Cajal), central nervous system, autonomic nervous system, hormones, peptides and the microbiome. Other external factors such as diet, and age related changes in the gastrointestinal tract also, ultimately, affect gastrointestinal motility. A subtle change in any of the above factors could significantly impact on gastrointestinal function leading to pediatric gastrointestinal motility disorders. Here, we review common motility disorders in children and provide an indepth understanding of the pathophysiology and management of these problem.

View all citing articles on Scopus

View full text

A multicenter study of the incidence and factors associated with redo Nissen fundoplication in children

Abstract

Aim

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

J Pediatr Surg

J Pediatr Surg

Arch Pediatr

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr

J Pediatr Surg

J Pediatr Surg

The efficacy and long-term outcome of laparoscopic Nissen fundoplication in neurologically impaired children

Pediatr Endosurg Innov Tech

Anti-reflux surgery outcomes in pediatric gastroesophageal reflux disease

Am J Gastroenterolo

Recurrence after laparoscopic and open Nissen fundoplication: a comparison of the mechanism of failure

Surg Endosc