Source: Gilger MA, Yeh C, Chiang J, et al. Outcomes of surgical fundoplication in children. Clin Gastroenterol Hepatology. 2004;2:978–984.A multidisciplinary team from Baylor College of Medicine, Houston, designed this study to assess outcomes of fundoplication in children. They reviewed the records of all children who underwent fundoplication during 1996–1999 at Texas Children’s Hospital, the largest children’s hospital in the country. The frequency of post-operative symptoms requiring medical evaluation and/or treatment following fundoplication was determined in children with or without associated medical disorders. Specifically, (1) post-operative complications, (2) post-operative symptoms, (3) procedures performed to evaluate post-operative symptoms, (4) medical treatment, and (5) repeat surgery were evaluated.The records of 176 of 198 children who underwent fundoplication and who were seen in follow-up within 2 months of surgery were reviewed. The mean age of the patients was 2.1 years (range 6 months to 18 years), and half were followed for greater than 2 years post surgery. Forty-six (26%) had no associated neurologic disorders. The remaining 130 had 1 or more associated disorders including 70% with neuromotor delay, 8% with cystic fibrosis, 8% with tracheo-esophageal fistula, 8% with bronchopulmonary dysplasia, and 35% with reactive airway disease. Post-operatively, when compared to those children without associated medical conditions, children with associated medical disorders had a higher frequency of post-operative lung infections (52% vs 22%) and dumping syndrome (2% vs 0%). Most children (63%) received evaluation and treatment for symptoms suggestive of recurrent reflux despite surgery. The authors concluded that 2 out of 3 children who received a fundoplication for GERD either continued to have symptoms attributable to GERD or needed to be treated pharmacologically for GERD at 2 months post-surgery.Dr. LeLeiko has disclosed no financial relationships relevant to this commentary.The surgical literature paints an unduly rosy picture of the efficacy of fundoplication for gastroesophageal reflux disease.1 On the other hand, my personal view, unsupported by evidence- based studies, is that any (neurologically normal) child who needs surgery will not do well, and any child who does well did not need the surgery. In an effort to shed some useful light on the subject, the authors examined the experience at Texas Children’s Hospital. Any discussion of this subject should recognize at least 2 distinct groups of patients, those without neurological impairment and those with neurological impairment, and distinguish those with no neurological impairment who have no associated medical disorders from those with no neurological impairment who do have medical conditions such as tracheo-esophageal fistula repair or bronchopulmonary dysplasia.2 This latter distinction is lacking from this otherwise very useful report.The pediatrician whose patient is referred for fundoplication should expect and prepare the patient’s family for the likelihood that continued symptoms and/or medication will be necessary post-operatively. This report contrasts sharply with a 1998 report that described a 95% symptom improvement in neurologically normal patients and an 84% improvement in neurologically impaired children following surgical repair.3Families of patients for whom fundoplication is being discussed deserve a clear understanding of what they can expect the surgery to accomplish. We will not have this information until a multi-center prospective study with clear inclusion criteria and defined outcome variables is undertaken. Since there is no immediate likelihood of such a study, we must evaluate the literature that exists, using that and the experience of the physicians involved to guide families’ decision-making.This study has major methodologic flaws. There was no consistent way of documenting that recurring reflux was in fact the cause of the recurrent symptoms after surgery. Endoscopy and pH probes were not used uniformly. Cost benefit of GERD management and quality of life measures were not performed, and only patients from 1 center were studied. We need to recognize that a chance to cut in the patient with gastroesophageal reflux may not be a chance to cure, acknowledging that this may be difficult for our surgical colleagues to stomach.
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