Chronic lung disease is the leading risk factor correlating with the failure (wrap disruption) of antireflux procedures in children

Abstract

Recurrent gastroesophageal reflux (GER) after antireflux procedures (ARP) has been correlated with significant neurological impairment (NI). Other major risk factors for recurrent GER have not been extensively characterized. The authors reviewed their experience with ARPs in children to better characterize the risk factors for recurrent GER and identify successful management strategies for these patients. The charts of 281 consecutively treated children who had an ARP at our institution (1985 to 1992) were reviewed. The neurological status of each child was assessed as normal or impaired (cerebral palsy, seizures, mental retardation, spasticity), and other medical diagnoses such as chronic pulmonary disorders (eg, interstitial disease, cystic fibrosis, bronchopulmonary dysplasia, asthma, etc), and congenital malformations and syndromes were identified. The average follow-up period was 3 years (range, 1 to 7.5 years). Patients with symptoms of recurrent GER were evaluated with an upper gastrointestinal study. Patients with a radiologically intact fundoplication and suspected GER were further evaluated with a 24-hour pH probe. Statistical analyses were performed using the Fisher's Exact Test. Of the 281 patients who underwent ARP, 39 had documented recurrent GER (average, 16 months after surgery). Twenty-five (64%) of these children had chronic pulmonary disease (CPD). Thirty-two percent of all children with CPD had recurrent GER after ARP, versus 7% of those without CPD ( P < .0001). For children with NI and CPD there was an increased risk ( P < .0001) of failure when compared with the risk in the normal subgroup (children without CPD or NI) who underwent ARP. Of the 39 failures, eight were successfully managed with thickened feeds, prokinetic agents, H 2 blockers and/or transgastric jejunostomy feedings. Thirty-one underwent a second operation (29 Nissens, 1 Thal, 1 jejunostomy tube). Of the reoperative ARP group, there were three (10%) failures; these cases were managed successfully with surgical jejunostomy tube (2), or medical management (1). Chronic lung disease is strongly correlated with failure of ARP. NI alone was not associated with an increased risk of recurrent GER. Children with NI and CPD had the highest risk of failure. In cases of recurrent GER, medical management and transgastric jejunostomy feedings were effective for patients considered to be a poor operative risk. Regardiess of risk factors, reoperative ARP is often successful and remains a viable therapeutic option. Surgical jejunostomy should be reserved for patients who have had two or more failed fundoplications or have significant surgical risk.