Repair Of Tracheoesophageal Fistula Research Articles

The Use of Biosynthetic Mesh to Separate the Anastomoses During the Thoracoscopic Repair of Esophageal Atresia and Tracheoesophageal Fistula

Recurrent tracheoesophageal fistula following the repair of esophageal atresia and tracheoesophageal fistula (EA/TEF) is a difficult complication to manage, which makes prevention the dominant concern of surgeons performing the primary repair. To this end, the surrounding pleural tissues are usually brought over the tracheal closure to prevent the development of a recurrence during the open repair. This maneuver is not usually feasible when using the thoracoscopic approach. Therefore, in this paper, we describe a case in which we interposed a biosynthetic mesh between the esophageal and tracheal suture lines during the thoracoscopic repair of EA/TEF on a 2.9-kg newborn girl.

Reduced Neuronal Innervation in the Distal End of the Proximal Esophageal Atretic Segment in Cases of Esophageal Atresia with Distal Tracheoesophageal Fistula

Esophageal dysmotility is a common occurence after surgical repair of proximal esophageal atresia (EA) and distal tracheoesophageal fistula (TEF). The etiology of this motility disorder, however, remains controversial. Esophageal dysmotility also is present in isolated TEF or EA before surgery, suggesting a congenital cause. However, there is no information available in the literature with regard to the intramural nervous system of the human esophagus in EA-TEF. We examined the distal end of proximal esophageal atretic segment of neonates undergoing EA-TEF repair for intrinsic neuronal innervation. Using specific antibodies, we studied neuronal markers of specimens from nine cases of EA-TEF and 9 cases of normal esophagus by immunohistochemistry using neurofilament (NF), synaptophysin (SY), S100, and glial cell line-derived neurotrophic factor (GDNF). In the atretic segment, specimens staining with hematoxylin and eosin showed that there were marked hypoganglionosis and immature ganglion cells in the myenteric plexus. GDNF immunoreactivity in the atretic esophagus were markedly reduced in both the muscular layer and myenteric plexus. SY and NF-immunorective nerve fibers were distributed throughout the myenteric plexus of the normal esophagus, but the scarcity of these immunoreactive nerve fibers in the atretic esophagus was apparent. In contrast, the density of immunorective nerve fibers for S100 in the myenteric plexus and muscular layer was increased in the distal end of the atretic esophagus. We concluded that the distribution of ganglion cells and some nerve fibers in the distal end of the atretic esophageal segment is deficient. Inadequate and abnormal neuronal innervation of the esophagus could be related to the esophageal dysmotility seen in EA. Because GDNF is a survival factor for central and peripheral neurons, defective expression of GDNF could have an important role in the defective and/or abnormal neuronal innervation of atretic esophageal segment.

An unusual cause of salivary leak post tracheoesophageal fistula repair

LB was a male infant born via spontaneous vaginal delivery at term in a peripheral centre. A provisional diagnosis of oesophageal atresia (OA) with tracheoesophageal fistula (TOF) was made and the child was transferred to a tertiary centre for further evaluation. On day two of life he underwent repair of his oesophageal atresia and division of his distal tracheoesophageal fistula. The upper and lower oesophageal segments were brought together with average tension. An extrapleural drain was inserted with the tip sutured close to the anastomosis. His post-operative course was complicated by two failed extubations secondary to respiratory distress and the development of a salivary leak. Despite repositioning of the extrapleural drain on two separate occasions, the salivary leak continued. Day 25 post-operatively he underwent direct laryngoscopy, bronchoscopy and oesophagoscopy. The extrapleural drain was found to be causing tracheal compression and the tip of the drain was located within the lumen of the oesophagus. Saliva leak is not an uncommon complication of this oesophageal atresia repair. This is the first report of an extrapleural drain being found in the oesophagus causing salivary leak and tracheal compression. These complications may have been prevented by ensuring the drain did not impinge on the anastomosis site, by pulling the drain back at an earlier time or by not having used an extrapleural drain at all.

Pediatric Robotic Surgery: Lessons from a Clinical Experience

Robotic surgery may improve minimally invasive surgery at high magnification by tremor filtration, motion-scaling, and improved dexterity with the provision of a wrist at the end of the robotic instrument. We chose the Zeus Microwrist robotic surgical system as more applicable to small children than the competing da Vinci surgical system. We attempted 57 surgical procedures and completed 54. Completed procedures included Nissen fundoplication (n = 25), cholecystectomy (n = 18), Heller myotomy (n = 2), splenectomy (n = 2), Morgagni hernia repair (n = 2), and single cases of complex pyloroplasty in the chest, bowel resection, left Bochdalek congenital diaphragmatic hernia repair, esophageal atresia and tracheoesophageal fistula repair, and choledochal cyst excision. There were no complications related to the use of the robot. The mean time for the surgeon at the console using the robot was 117 +/- 39 minutes for Nissen fundoplication, and the total operating room time was 250 +/- 60 minutes. Surgeons found dissection, suturing, and knot tying easier than with conventional laparoscopy. None of the surgeons thought the lack of touch feedback (haptics) was crucial. Robotic surgery offers increased dexterity to the pediatric minimally invasive surgeon, but procedures require more time, and there is no defined patient benefit. The fact that robotic surgery digitalizes minimally invasive surgery creates exciting possibilities for training surgeons, planning operations, and performing surgery at great distances from the operator.

A gasless abdomen does not exclude distal tracheoesophageal fistula: the value of a repeat x-ray

A “gasless abdomen” in babies with esophageal atresia (EA) has traditionally been thought to imply absence of a distal tracheoesophageal fistula (TEF). We present 3 neonates with a provisional diagnosis of EA, who had a gasless abdomen on an initial x-ray taken within the first 4 hours of life. These children were subsequently shown to have gas in the stomach associated with a distal TEF. Two children were examined on subsequent repeat x-ray of the abdomen, when gas was demonstrated in the stomach. Another child had a laparotomy for a gastrostomy when a distended stomach was found. This baby went on to have a thoracotomy and a routine repair of the distal TEF and an esophageal anastamosis. Based on our data of 65 cases of EA and distal TEF, it is recommended that an x-ray of the abdomen is repeated before surgery is undertaken if the gasless abdomen is documented during the first 4 hours of life.

Management of symptomatic tracheal pouches

Acquired tracheal pouches arise following tracheoesophageal fistula (TEF) repair, but are usually asymptomatic. Symptomatic tracheal pouches are rare, and the optimal management strategy debated. The evolution of our management to this challenging problem is presented. A case series over a 5-year period. A tertiary care pediatric hospital. Children with a past history of TEF repair in whom severity of pouch-related respiratory symptomatology warranted surgical intervention. Symptomatology, bronchoscopic findings, number and type of surgical interventions required, complications, and outcomes. Eleven patients required surgical intervention for a symptomatic tracheal pouch. Symptoms were due to stasis of secretions with associated pulmonary soiling in three children, severe tracheomalacia in six children, and respiratory obstruction related to the tip of a tracheotomy tube or endotracheal tube being displaced intermittently into the pouch in six children. Surgical management of the pouch included one fulguration with the CO(2) laser, one with microlaryngeal instruments, Bugbee cautery in two, open resection in one, and transcervical division in another. The final five children had endoscopic pouch division with Clickline biopsy forceps. All children have had resolution of their pouch-related symptoms, although two remain tracheotomy-dependent. Symptomatic tracheal pouches are rare. Surgical intervention to divide the common party wall between the trachea and the pouch may alleviate associated respiratory symptomatology. The Clickline biopsy forceps is a safe, rapid, and effective method of dividing a tracheal pouch.

Tracheoscopy assisted repair of tracheo‐esophageal fistula (TARTEF): a 10‐year experience

Fiberoptic tracheoscopy assisted repair of tracheoesophageal fistula (TARTEF) has been reported to be useful for the surgeon with regards to identification of the fistula and proper fistula ligation. The aim of this article is to report our 10-year experience using TARTEF with intermittent positive pressure ventilation (IPPV) during tracheoesophageal fistula (TEF) repair in newborns. With ethical committee approval, we included all patients undergoing TARTEF from 1995-2005. Variables of interest were (1) respiratory deterioration caused by gastric inflation because of IPPV during surgery and endoscopy; (2) detection of additional airway anomalies; (3) success of intubation of the fistula; (4) other side effects or adverse events. Data are given in median and range. Forty-seven neonates with TARTEF were included. Mean gestational age was 37 weeks (31-42) and mean weight was 2.5 kg (1.1-3.8). The patients were intubated with tracheal tubes size 2.5-3.5 mm ID. Appropriately sized fiberoptic bronchoscopes with an outer diameter of 2.0, 2.4 and 2.8 mm were used; passed through the lumen of the tracheal tube (TT) thereby requiring the use of IPPV to ensure adequate ventilation. No respiratory deterioration was noted as a consequence of intraoperative fiberoptic manipulation within the trachea or because of gastric hyperinflation with IPPV. In all patients, the TEF was successfully penetrated with the fiberscope and this clearly helped the surgeon to rapidly identify and dissect the fistula. In two patients a tracheal bronchus was identified. In two patients accidental extubation occurred during endoscopic confirmation of successful fistula repair. While fiberoptic TARTEF through the tracheal tube with IPPV did expedite and facilitate surgery, it did not cause clinically relevant impairment of ventilation. Careful manipulation during fiberoptic assessment is required to avoid tube displacement.

Successful early repair of a traumatic tracheoesophageal fistula after blunt chest trauma

Successful early repair of a traumatic tracheoesophageal fistula after blunt chest trauma

Severe systemic vasculitis in a neonate

A full-term male newborn, the child of a healthy Swiss woman with normal urinalysis and negative tests for hepatitis B, hepatitis C and human immunodeficiency virus, was referred for surgical repair of esophageal atresia and distal tracheoesophageal fistula at the age of 2 days. Three days later, the diagnosis of anastomotic leak and infected right-sided pneumothorax was made, which required parenteral antimicrobial treatment with clindamycin and amoxicillin based on positive cultures for both viridans streptococci and coagulase-negative staphylococci. In spite of that the child developed a severe pleural empyema, which was treated with thoracotomy and decortication. The antimicrobial medication was continued up to the age of 21 days. Two days later, the condition of the child deteriorated, as indicated by the appearance of tachypnea, progressive cyanosis, and reduced diuresis. Chest x-ray findings disclosed intraalveolar fluid accumulation. Laboratory values were as follows: hemoglobin, 91 g/l (reference range, 100–150 g/l); white blood cell count, 19.8×10/l (reference range, 5.0–12.5×10/l); platelets, 39×10/l (reference range, 150–300×10/l); C-reactive protein, 118 mg/l (reference range, ≤5 mg/l); creatinine, 92 μmol/l (reference range, ≤47 μmol/l). A blood film disclosed a moderate eosinophilia of 3.9×10/l (reference range: ≤0.8×10/l). Urinalysis disclosed severe proteinuria, hematuria and red blood cell casts. Two days later, a generalized maculopapular rash was noted. Antineutrophil cytoplasmic and antinuclear autoantibodies, and antibodies against the Ro and La particle were not present in either the patient or his mother. The tentative diagnosis of systemic vasculitis was confirmed by a skin biopsy demonstrating a characteristic leucocytoclastic vasculitis with marked eosinophilia (Fig. 1). Immunofluorescence studies with antisera against immunoglobulins were not performed. Medical treatment with methylprednisolone 3 mg/kg body weight daily was followed within 24 hour by polyuria Eur J Pediatr (2007) 166:381–382 DOI 10.1007/s00431-006-0242-9

Minimal access surgery in neonates and infants

Background Minimal access surgery (MAS) in small infants carries an important consideration. The tolerance of these small babies and the assumed physiological effect of MAS, in addition to the required anesthetic and surgical skills, have made it difficult to perform these types of procedures in many international centers. The present article reviews our experience with MAS in neonates and infants in the first year of life. Methods The medical records of all neonates and infants (<1 year) who underwent MAS over a period of 3 years were retrospectively reviewed for demographic information, procedures, operative time, complications, outcomes, and follow-up. Most of the operations were performed with 3-mm instruments and scopes and mean insufflation pressure of 10 mm Hg (range, 4-15 mm Hg). Result Seventy neonates and infants were included in this study: 19 females and 51 males. The weight ranged from 1.3 to 8.2 kg (mean, 4.3 kg). The mean age was 93 days (range, 1 day to 12 months). Twenty-four (34%) were neonates (first 30 days of life). Procedures performed included repair of tracheoesophageal fistula, lobectomy, repair of diaphragmatic or hiatus hernias, pull-through for imperforated anus and Hirschsprung's disease, plication of the diaphragm, Kasai procedure, excision of choledochal cyst, pyloromyotomy, Ladd's procedure, and reduction of intussusceptions. There were 2 conversions, both in neonates with tracheoesophageal fistula. All patients tolerated the procedure very well, with lesser degrees in neonates undergoing thoracoscopic procedures. Two neonates had postoperative hypothermia (<35°C) and 1 neonate had high P co 2 postoperatively. There was 1 mortality and no morbidities. The follow-up ranged from 1 month to 3 years (mean, 19 months). Conclusion Minimal access surgery in neonates and infants is safe and well tolerated. Intraoperative monitoring of end-tidal CO 2 and core temperature is essential in avoiding unwanted effects of performing these procedures, especially in neonates.

Thoracoscopic Repair of Esophageal Atresia and Tracheoesophageal Fistula: Lessons Learned

Repair of esophageal atresia and tracheoesophageal fistula has traditionally been performed via thoracotomy. This study aims to evaluate the feasibility and pitfalls of the thoracoscopic approach. Six consecutive patients with type C tracheoesophageal fistulae underwent thoracoscopic repair. The operation was approached through the right chest using a three-trocar technique (two 5-mm and one 3-mm) with the patient placed in a three-quarter prone position. Patient characteristics, operative time, duration of narcotic usage, conversion factors, postoperative complications, and long-term follow-up were recorded. Five of six patients were successfully operated on thoracoscopically. The average operative time was 143 minutes (range, 75-215 minutes) with repair of long-gap defects requiring significantly longer times than short-gap defects (200 vs. 129 minutes, P < 0.05). There were no intraoperative complications. Mean duration of narcotic use was 52 hours (range, 24-72 hours). There were no anastomotic leaks. One patient developed an anastomotic stricture at the third postoperative week, which resolved with two dilations. One patient died on the first postoperative day from respiratory failure. Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula is feasible, but is technically challenging. Long-gap defects require more extensive dissection and difficult anastomosis, and are therefore associated with longer operative times. More data are needed for further evaluation of this approach.

Complications of the tracheal diverticulum after division of congenital tracheoesophageal fistula

In 3 patients, recurrent respiratory symptoms after neonatal repair of congenital tracheoesophageal fistula (Gross type C in 2, D in 1) were associated with a large tracheal remnant of the fistula termed diverticulum. Symptoms resolved after resection of the diverticulum in 1 child with airway obstruction and 1 adult with recurrent tracheoesophageal fistula.

Esophageal atresia and situs inversus - an unusual association of abnormalities - a case report

We present a case report of a neonate with esophageal atresia and tracheoesophageal fistula. In the 31st week of gestation, maternal polyhydramnions was observed by prenatal ultrasonography. Postnatal insertion of an orogastric tube into the stomach was unsuccessful. On auscultation, the apex of the heart was heard at the right side of the thorax, while the liver was palpable 1 cm below the left rib cage. Esophageal atresia with tracheoesphageal fistula and situs inversus of the thoracic and abdominal organs was diagnosed During the first day of life, left transpleural thoracotomy was performed. The fistula was closed and esophageal anastomosis performed. One year after the operation the child had no difficulties when eating solid and liquid foods. More than 50% of infants with esophageal atresia have associated anomalies and the esophagogram showed good passage of contrast with anastomotic stricture. This was the first report of esophageal atresia with tracheoesophageal fistula repair in a patient with situs inversus treated in our Clinic.

Anesthetic management of tracheoesophageal fistula repair in a newborn with hypoplastic left heart syndrome

We present a case of a newborn with hypoplastic left heart syndrome (HLHS) and tracheoesophageal fistula (TEF). The anesthesia management for the repair of the TEF is presented and the management of the unique pathophysiology of the HLHS circulation is discussed.

Impact of preoperative diagnosis of congenital heart disease on the treatment of esophageal atresia

Congenital heart disease (CHD) has a major impact on the survival of babies with esophageal atresia (EA). The present study assesses whether early diagnosis influences the management strategies in a large series of EA. Cases of EA treated between 1982 and 2002 were retrospectively divided into groups according to the presence or absence of CHD and to whether this was diagnosed or not prior to tracheo-esophageal fistula repair. Patients were also staged according to Spitz's classification in which major congenital heart disease (MCHD) are those associated with cyanosis and/or heart failure requiring surgery. Comparisons between groups of patients were made by standard statistical tests. Among 195 babies with EA (99 boys and 96 girls), 82 (42%) had CHD (31 boys, 39% and 51 girls, 61%, chi2 P < 0.05) and 43 out of these 82 (52%) had MCHD. Six children died without treatment. CHD was diagnosed prenatally in six cases and before EA repair in 26 cases. The diagnoses were missed in 12 instances (in five it was a MCHD). Regardless of preoperative diagnosis of right aortic arch in 3/6 cases, the oesophagus was approached from the right thorax in all cases and only in one of them the operation was not completed due to hemodynamic instability. There were 145/195 (75%) Spitz group I patients; 44/195 (22%) were group II and 6/195 (3%) group III. The mortality was respectively 9.5, 59 and 83%. We lost 15/113 (13%) babies with EA without CHD, 4/39 (10.2%) with EA and CHD and 26/43 (60%) with EA and MCHD. In children with CHD diagnosed prior to the esophageal operation 8/26 (30.7%) died and among those without diagnoses 3/12 (25%) died, (chi2 P > 0.1). 1. CHD was diagnosed after EA repair in one-third of cases. 2. Preoperative diagnosis of CHD changed the operative indication only in one case. 3. Survival after treatment for EA was not influenced by the moment or the accuracy of the diagnosis of CHD in this series. 4. With only a few exceptions, associated CHD should not change the strategies of EA repair.

Successful Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula in a Newborn with Single Ventricle Physiology

A neonate with VACTERL association including tricuspid atresia was scheduled for thoracoscopic esophageal atresia with tracheoesophageal fistula (EA/TEF) repair and laparoscopic gastrostomy tube placement. In addition to standard noninvasive monitoring, arterial blood pressure, central venous pressure, and cerebral oxygen saturation were monitored. Gastric distension resulting from positive pressure ventilation prevented laparoscopic gastrostomy tube placement. Thoracoscopy with a CO2 insufflation pressure of 6 mm Hg at low flow (1 L/min) was well tolerated hemodynamically despite hypercarbia and cerebral oxygen saturation was maintained. Careful monitoring and good communication were critical to the safe management of this single ventricle patient during thoracoscopic EA/TEF repair. Esophageal and tracheoesophageal fistula in conjunction with single ventricle physiology carries a significant risk of mortality. We present the anesthetic management of a neonate with unpalliated tricuspid atresia who underwent thoracoscopic tracheoesophageal fistula repair.

Tracheoesophageal fistula and associated congenital heart disease: implications for anesthetic management and survival

Infants with tracheoesophageal fistula (TEF) and/or esophageal atresia (EA) frequently have other associated congenital anomalies which can have a significant impact on their anesthetic care and survival to discharge. A medical record review and retrospective data analysis were performed in a university affiliated children's hospital of all infants undergoing TEF/EA repair between January 1998 and July 2004. The incidence of intraoperative complications during the TEF repair and overall survival to hospital discharge was compared in two groups of infants: 26 patients with TEF/EA and coexisting congenital heart disease (CHD), and 27 patients with TEF/EA and no CHD. The overall incidence of intraoperative critical events during repair of TEF/EA was significantly higher in infants with associated cardiac pathology (P = 0.003). Six of 53 infants died during hospitalization (overall mortality, 11.3%) and all had associated cardiac pathology. In comparison with nonductal-dependent lesions, the presence of a ductal-dependent cardiac lesion appeared to significantly increase patient mortality (57% vs. 10%, P = 0.028). Low birth weight (<1500 g) and associated cardiac pathology were found to be independent predictors of mortality in infants undergoing surgery for TEF/EA repair. The presence of a ductal-dependent cardiac lesion further increased the risk of morbidity and mortality, in addition to necessitating special anesthesia considerations.

Thoracoscopic Repair of Esophageal Atresia and Tracheoesophageal Fistula

For the past 60 years, successful repair of esophageal atresia (EA) and distal tracheoesophageal fistula (TEF) has been performed via a thoracotomy. However, a number of reports have described adverse musculoskeletal sequelae following thoracotomy in infants and young children. Until now, only a few scattered case reports have detailed an individual surgeon's success with thoracoscopic repair of EA/TEF. This multi-institutional review represents the largest experience describing the results with this approach. A cohort of international pediatric surgeons from centers that perform advanced laparoscopic and thoracoscopic operations in infants and children retrospectively reviewed their data on primary thoracoscopic repair in 104 newborns with EA/TEF. Newborns with EA without a distal TEF or those with an isolated TEF without EA were excluded. In these 104 patients, the mean age at operation was 1.2 days (+/-1.1), the mean weight was 2.6 kg (+/-0.5), the mean operative time was 129.9 minutes (+/-55.5), the mean days of mechanical ventilation were 3.6 (+/-5.8), and the mean days of total hospitalization were 18.1 (+/-18.6). Twelve (11.5%) infants developed an early leak or stricture at the anastomosis and 33 (31.7%) required esophageal dilatation at least once. Five operations (4.8%) were converted to an open thoracotomy and one was staged due to a long gap between the 2 esophageal segments. Twenty-five newborns (24.0%) later required a laparoscopic fundoplication. A recurrent fistula between the esophagus and trachea developed in 2 infants (1.9%). A number of other operations were required in these patients, including imperforate anus repair in 10 patients (7 high, 3 low), aortopexy (7), laparoscopic duodenal atresia repair (4), and various major cardiac operations (5). Three patients died, one related to the EA/TEF on the 20th postoperative day. The thoracoscopic repair of EA/TEF represents a natural evolution in the operative correction of this complicated congenital anomaly and can be safely performed by experienced endoscopic surgeons. The results presented are comparable to previous reports of babies undergoing repair through a thoracotomy. Based on the associated musculoskeletal problems following thoracotomy, there will likely be long-term benefits for babies with this anomaly undergoing the thoracoscopic repair.

Are patients who have had a tracheoesophageal fistula repair during infancy at risk for esophageal adenocarcinoma during adulthood?

The authors present a case of a 46-year-old woman who had esophageal adenocarcinoma after having had a tracheoesophageal fistula (TEF) repair as an infant. A Medline search, which identified 2 other patients in the world literature who developed esophageal cancer (squamous cell carcinoma [J Pediatr Surg 36(4) (2001) 629-630] and adenocarcinoma [J Pediatr Surg 24(8) (1989) 741-744]) after TEF repair, was performed. As such patients reach middle age, it is possible that they are at increased risk for the development of esophageal cancer. Practitioners should be aware of the possibility of increased risk in this population and perhaps the need for a study to screen patients who have had a TEF repair to assess the incidence of cancer.

Surgical Fundoplication: No Panacea for GERD

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.