Impact of laparoscopic anterior 270 degrees fundoplication on the quality of life and symptoms profile of neurodevelopmentally delayed versus neurologically unimpaired children and their parents

Assessment of quality of life after laparoscopic GERD surgery in children: a prospective study

The purpose of this study is to assess quality of life (QoL) after laparoscopic anti-reflux surgery (LARS) in children with gastroesophageal reflux disease (GERD) and to evaluate GERD symptoms and their impact on daily life and school. From June 2016 to June 2019, all children with GERD from 2 to 16 years of age, without neurologic impairment or malformation-related reflux, were prospectively included in a monocentric study. Patients (or their parents according to the age of the child) answered the Pediatric Questionnaire on Gastroesophageal Symptoms and QoL (PGSQ) before surgery and 3 and 12 months after surgery. Variables were compared by paired, bilateral Student t-test. Twenty-eight children (16 boys) were included. The median age at surgery was 77 months (IQR: 59.2-137) with median weight of 22 kg (IQR: 19.8-42.3). All had a laparoscopic Toupet fundoplication. Median duration of follow-up was 14.7 months (IQR: 12.3-22.5). One patient (4%) had a recurrence of GERD symptoms without abnormalities on follow-up examinations. Preoperative total PGSQ score was 1.42 (± 0.7) and decreased significantly 3 months (0.56 ± 0.6; p < 0.001) and 12 months after surgery (0.34 ± 0.4; p < 0.001). PGSQ subscale analysis revealed a significant decrease at 3 and 12 months for GERD symptoms (p < 0.001), impact on daily life (p < 0.001), and impact on school (p = 0.03).

CONCLUSION

There was a significant improvement in symptoms and their frequency after LARS in children, as well as an improvement of QoL, in the short and medium term. The impact of GERD should be taken into consideration in the treatment decision, given that surgery clearly improves the QoL.

WHAT IS KNOWN

• Laparoscopic anti-reflux surgery (LARS) is an established and effective treatment option in pediatric patients with severe GERD refractory to medical treatment. • Effect of LARS on the quality of life (QoL) has been mainly investigated in the adult population but there is very little data on the effect of LARS on the QoL in pediatric patients.

WHAT IS NEW

• Our prospective study was the first to analyze the effect of LARS on QoL in pediatric patients without neurologic impairment using validated questionnaires at two postoperative time points with a significant improvement in postoperative QoL at 3 and 12 months. • Our study emphasizes the importance of evaluating QoL and impact of GERD on all the aspects of daily life and of taking these into consideration in the treatment decision.

Five-Year Outcome of Laparoscopic Fundoplication in Pediatric GERD Patients: a Multicenter, Prospective Cohort Study

BACKGROUND

Gastroesophageal reflux disease (GERD) is a common disease in children. When drug treatment fails, laparoscopic anti-reflux surgery (LARS) is considered. Short-term follow-up studies report high success rates; however, few studies report long-term results. The aim of this study was to describe the long-term effects of LARS in pediatric patients.

METHODS

A prospective, multicenter study of 25 laparoscopic fundoplication patients was performed. At 3 months and 1, 2, and 5 years postoperatively, patients and caregivers were asked to complete the gastroesophageal reflux symptom questionnaire to assess symptoms and the PedsQL™ to assess health-related quality of life (HRQoL).

RESULTS

Reflux symptom severity was still significantly improved 5 years after LARS compared with preoperative levels (p < 0.0001). However, 26% of patients reported moderate or severe reflux symptoms. Dysphagia was reported in 13% of patients 5 years after LARS and was more common in children with neurologic impairment and children who underwent a Nissen procedure. The increase in HRQoL 3 months postoperatively appears to decline over time: 5 years after surgery, HRQoL was lower, though not significantly, than 3 months postoperatively. HRQoL at 5 years was still higher, though also not significantly, than preoperative levels. The presence of reflux symptoms after surgery was not significantly associated with lower HRQoL.

CONCLUSIONS

LARS is effective for therapy-resistant GERD in children. Five years after surgery, reflux symptoms are still improved. However, we observed a decline in symptom-free patients over time. The initial increase in HRQoL shortly after LARS appears to decline over time.

TRIAL REGISTRATION

Dutch national trial registry Identifier: 2934 ( www.trialregister.nl ).

Quality of Life Improves Following Laparoscopic Hemifundoplication in Neurologically Non-Impaired Children with Gastroesophageal Reflux Disease: A Propensity Score-Matched Analysis

BACKGROUND

Quality of life (QOL) data following pediatric fundoplication for gastroesophageal reflux disease (GERD) are rare. Present study assessed the QOL in neurologically non-impaired children before and after laparoscopic hemifundoplication (LHF) in comparison to healthy controls.

METHODS

PedsQL™ questionnaires assessed data on gastrointestinal symptoms (GIS) and general well-being (GWB) were compared in a propensity score-matched analysis (60 patients' pairs for time-point of surgery and 51 for follow-up).

RESULTS

Preoperatively, the LHF group had more GIS (72.2 ± 53.9 vs. 38.8 ± 31.6; p < 0.001) and a lower GWB (16.7 ± 5.5 vs. 23.8 ± 3.5, p < 0.001) compared with controls. Postoperatively, GIS decreased significantly (74.3 ± 52.9 vs. 36.3 ± 33.5; p < 0.001) and the GWB was significantly higher (16.2 ± 6.0 vs. 20.8 ± 5.8; p < 0.001). GIS were similar in the LHF and control groups (39.1 ± 36.4 vs. 40.1 ± 31.0; p = 0.885) but GWB was lower in the LHF group than the control group (20.5 ± 6.3 vs. 23.4 ± 3.9; p = 0.009).

CONCLUSIONS

QOL significantly improves after LHF in neurologically non-impaired children.

Nissen fundoplication and combined procedures to reduce recurrence of gastroesophageal reflux disease in neurologically impaired children

Neurologically impaired children account for almost half of the fundoplication procedures performed for gastroesophageal reflux disease. Aim of the present study was to report results of antireflux surgery in neurologically impaired children. A retrospective study of neurologically impaired children who underwent fundoplication over a 13-year period (1999–2012) was performed. Recurrence rate, major complications and parents/caregivers perceptions of their child's quality of life following antireflux surgery were analyzed. A total of 122 children (median age: 8 years 9 months; range: 3 months to 18 years) had open “tension-free” Nissen fundoplication, gastrostomy + /− pyloroplasty. Gastroesophageal reflux disease was in all cases documented by at least two diagnostic exams. Median duration of follow-up was 9.7 (1.9–13) years. Three (2.4%) recurrences were documented and required surgery re-do. Major complications were 6%. Seventy-nine of 87 (90%) caregivers reported that weight gain was improved after fundoplication with a median score of 1 (IQR: 1–2). Significant improvement was perceived in postoperative overall quality of life. In this series of fundoplication recurrence incidence was low, serious complications were uncommon and caregivers’ satisfaction with surgery was high. Accurate patient’s selection and creating a “low-pressure” surgical system are mandatory to obtain these results.

Two-Year Outcome after Laparoscopic Fundoplication in Pediatric Patients with Gastroesophageal Reflux Disease

Introduction: Many studies on short-term efficacy of laparoscopic antireflux surgery (LARS) have shown good to excellent results on reflux symptom control and health-related quality of life (HRQoL). Prospective studies on the long-term efficacy, however, are scarce and indicate that the efficacy of symptom control may decline over time. The aim of this study is to assess the 2-year outcome on reflux symptoms and HRQoL after LARS. Materials and Methods: Between 2011 and 2013, 25 children (12 males, median age 6 [2-18] years) with proton pump inhibitor-resistant gastroesophageal reflux disease were included in a prospective longitudinal cohort study. To assess reflux symptoms and HRQoL, patients and/or their caregivers were asked to fill out the validated age-appropriate gastroesophageal reflux symptom questionnaire and Pediatric Quality of Life Inventory™ before, 3 months, 1 year, and 2 years after LARS. Results: Two years after LARS, 29% of patients had moderate to severe reflux symptoms compared with 92% (P < .001) before operation and 12% 3-4 months after operation (P = .219). The significant increase in HRQoL shortly after fundoplication (80.0 compared with 69.5 (P = .004)) is not observed after 2 years (72.0 compared with 69.5, P = .312). Correlation between the impaired HRQoL scores and the recurrence of symptoms could not be verified. Conclusions: Although the efficacy of LARS tends to deteriorate after 2 years, LARS is still effective in controlling reflux symptoms in the majority of patients. The short-term improvement in HRQoL after LARS appears to be transient.

Efficacy of antireflux surgery in children with or without neurological impairment: a systematic review

BACKGROUND

Antireflux surgery is commonly performed in children, yet evidence for its efficacy is limited. The aim of this review was to determine the effect of antireflux surgery with regard to objective measures of quality of life (QoL) and value of upper gastrointestinal investigations in neurologically normal (NN) and neurologically impaired (NI) children.

METHODS

A systematic review was conducted of articles reporting children undergoing antireflux surgery in whom preoperative and postoperative objective testing was performed. Primarily, Embase, CINAHL, MEDLINE and PubMed were searched from inception to April 2019. Methodological Index for Non-randomized Studies (MINORS) criteria were used to assess article quality.

RESULTS

Of 789 articles, 14 met the eligibility criteria, 12 prospective observational and 2 retrospective studies. The median MINORS score was 59·4 (i.q.r. 39 to 62·5) per cent. Seven studies reported assessment of validated QoL measures before and after antireflux surgery in 148 children. Follow-up ranged from 1 to 180 months. All studies confirmed significant improvements in QoL measures among NN and NI children at all follow-up points. Eleven studies reported on preoperative and postoperative investigations in between 416 and 440 children children. Follow-up ranged from 0·5 to 180 months. Nine studies confirmed improvements in gastro-oesophageal reflux using 24-h oesophageal pH monitoring with or without manometry, but conflicting results were identified for four studies reporting gastric emptying. No studies reported fluoroscopy or endoscopy adequately.

CONCLUSION

Based on the results of studies of low-to-moderate quality, antireflux surgery improved QoL and reduced oesophageal acid exposure in NN and NI children in the short and medium term. Although antireflux surgery is a common elective operation, the lack of rigorous preoperative and postoperative evaluation(s) in the majority of patient-reported studies is striking.

Psychologic Distress and Anxiety in Mothers of Children With Gastroesophageal Reflux Undergoing Antireflux Surgery

OBJECTIVES

Parents of children with a chronic illness are at risk for impaired psychosocial functioning. Gastroesophageal reflux disease (GERD) is such a disease, and no studies have investigated effects of antireflux surgery on parental psychological distress. The aims of this study were to assess psychological distress and state and trait anxiety in mothers of children with GERD, and to explore possible changes after antireflux surgery.

METHODS

Mothers of children referred for antireflux surgery were included in this prospective study. Standardized questionnaires were used to evaluate psychological distress and state and trait anxiety before and 12 months after antireflux surgery.

RESULTS

Of 87 eligible mothers of children with GERD, 62 (71%) agreed to participate. All children had objectively verified GERD by 24-hour pH-monitoring and/or upper gastrointestinal contrast study and unsatisfactory symptom relief of pharmacological treatment. Thirty-one (50%) mothers returned questionnaires postoperatively. Preoperatively, mothers of children undergoing antireflux surgery reported high levels of psychological distress and state anxiety, and 54% had scores indicating clinically significant psychological distress. None of the preoperative child characteristics were found to significantly influence maternal psychological distress or state anxiety. Twelve months postoperatively, both psychological distress and state anxiety were reduced.

CONCLUSIONS

Mothers of children undergoing antireflux surgery reported reduced levels of psychological distress and state anxiety 12 months after the operation.

Gastroesophageal reflux in children with neurological impairment: a systematic review and meta-analysis

Neurologically impaired children (NIC) suffer severe gastroesophageal reflux (GER) with poor fundoplication outcome. Aims of the study were: (1) to determine the recurrence of GER after fundoplication in NIC; (2) to compare fundoplication versus gastro-jejunal tube feeding insertion (GJ) and fundoplication versus total esophagogastric dissociation (TEGD) in primarily treating GER in NIC. Using defined search strategy, two investigators identified all comparative studies reporting the mentioned procedures to primarily treat GER in NIC. The study was conducted under PRISMA guidelines. The meta-analysis was performed using RevMan 5.3. Data are mean ± SD. Of 3840 titles/abstracts screened, 14 studies on fundoplication (2716 pts.) reported a recurrence/persistence of GER higher in NIC (14.2 ± 8.3%) than in neurologically normal (9.4 ± 5.2%; p = 0.0001), with an increased incidence of re-do fundoplication (12.6 ± 7.0% versus 9.1 ± 4.5%; p < 0.01). Three studies revealed a similar risk of undergoing subsequent fundoplication after GJ (4.9 ± 2.1%) or initial fundoplication (12.0 ± 0.6%; p = ns). Four studies showed a lower recurrence of GER following TEGD (1.4 ± 1.1%) than fundoplication (24.8 ± 1.4%; p = 0.002). NIC are at risk of recurrence/persistence of GER after fundoplication or GJ. TEGD seems more effective to primarily treat GER in NIC. Prospective randomized controlled trials are necessary to establish which is the ideal treatment of GER in NIC.

Analysis of Growth, Nutritional Status and Hospital Visitation Scores Associated with Reflux After Nissen Fundoplication in Neurologically Impaired Children with Gastroesophageal Reflux

BACKGROUND

Neurologically impaired children (NIC) often experience swallowing difficulties and gastroesophageal reflux disease (GERD). Although these conditions could place children in a state of poor nutritional status and prevent them from thriving, there is insufficient research evaluating growth and nutritional status following fundoplication in these patients.

METHOD

This is a retrospective study of patients who were neurologically impaired and underwent Nissen fundoplication between April 2001 and March 2015. Seventy-six patients were enrolled, and the follow-up period was 12 months or longer. Growth was measured by the change in body weight and height. Nutritional status was measured by the change in body mass index, serum albumin and protein level.

RESULTS

Median age at operation was 1.85 years old, and median body weight was 10 kg. The respective Z scores for weight and height showed significant improvements after 1 year since the operation compared to 1 year within the operation (-2.42 ± 2.19 vs. -1.31 ± 1.96, P < 0.001) (-1.6 ± 2.16 vs. -1.05 ± 1.69, P = 0.002). The respective Z scores for body mass index, albumin and protein also showed improvements after 1 year since the operation compared to 1 year within the operation (-2.07 ± 2.99 vs. -0.89 ± 2.1, P < 0.001) (3.55 ± 0.48 vs. 3.86 ± 0.45, P < 0.001) (6.22 ± 0.76 vs. 6.65 ± 0.51, P < 0.001). Hospital visitation scores associated with reflux were significantly lower after the operation (4.1 ± 3.43 vs. 1.18 ± 1.67, P < 0.001).

CONCLUSIONS

In summary, after Nissen fundoplication in NIC with GER, growth and nutritional status improved significantly. Also, hospital visitation scores associated with reflux decreased after the operation.

Long-Term Outcomes of Transoral Incisionless Fundoplication in a High-Risk Pediatric Population

INTRODUCTION

Laparoscopic Nissen fundoplication (LNF) is the standard for surgical treatment of gastroesophageal reflux disease (GERD), but postoperative complications and pain are common in patients with severe neurological impairment (NI) and those undergoing reoperative procedures. Transoral incisionless fundoplication (TIF) is an endoscopic alternative to treat GERD. Long-term results in pediatric populations are unknown.

METHODS

Eleven patients who underwent TIF between January 2008 and September 2010 were included. A retrospective chart review was performed to evaluate long-term patient outcomes. Median follow-up was 5.6 years (range = 0.42-8.76 years).

RESULTS

Average patient age was 16.5 ± 5.1 years. Severe NI was present in 81.8% (9/11) of patients, and 63.6% (7/11) had undergone one or more prior fundoplication attempts. Overall, symptomatic reflux recurred or persisted in 54.5% (6/11) of patients. Recurrent symptoms were more common among those who had previous fundoplications than those who did not (71.4% [5/7] vs. 25% [1/4]). Four patients went on to require reoperation, including one laparoscopic Nissen and three disconnects. At last follow-up, 81.8% (9/11) of patients were still on antireflux medications.

CONCLUSIONS

This is the first report of long-term outcomes for treatment of GERD using TIF in a pediatric population. The recurrence rate was high, likely related to the fact that the population treated was extremely high risk. Recurrence was higher in patients with a prior fundoplication, perhaps identifying prior antireflux operations as a relative contraindication to TIF. Nevertheless, complications were low, and a subset of patients did receive a durable benefit from the procedure.

Laparoscopic antireflux surgery increases health-related quality of life in children with GERD

INTRODUCTION

Improving health-related quality of life (HRQoL) is increasingly recognized as an essential part of patient care outcome. Little is known about the effect of laparoscopic antireflux surgery (LARS) on the HRQoL in the pediatric patients. The aims of this study were to evaluate the effect of LARS on HRQoL in children with gastroesophageal reflux disease (GERD) and to identify predictors that influence HRQoL outcome after LARS.

METHODS

Between 2011 and 2013, 25 patients with therapy-resistant GERD [median age 6 (2-18) years] were included prospectively. Caregivers and children with normal neurodevelopment (>4 years) were asked to fill out the validated PedsQL 4.0 Generic Core Scales before and 3-4 months after LARS.

RESULTS

The PedsQL was completed by all caregivers (n = 25) and 12 children. HRQoL total score improved significantly after LARS, both from a parental (p = 0.009) and child's perspective (p = 0.018). The psychosocial health summary and physical health summary scores also improved significantly after LARS. HRQoL before and after LARS was significantly lower in children with impaired neurodevelopment (p < 0.001). However, neurodevelopment did not influence the effect of LARS on HRQoL. The only significant predictor for improvement in HRQoL after LARS was age at the time of operation (p = 0.001).

CONCLUSIONS

HRQoL significantly improves after LARS. Although children with impaired neurodevelopment had lower overall HRQoL, neurodevelopment by itself does not predict inferior improvement in HRQoL after LARS. Older children have a more favorable HRQoL outcome after LARS compared to younger children. This may suggest caution when considering LARS in younger GERD patients.

Nissen fundoplication in children with and without neurological impairment: A prospective cohort study

BACKGROUND

It is assumed that children with neurological impairment (NI) have inferior results after fundoplication compared to those without NI (non-NI). The aim of this study was to assess outcome after fundoplication in children with and without NI.

METHODS

87/105 patients (46 NI, 41 non-NI) undergoing fundoplication between 2003 and 2009 were included in this prospective two-center cohort study. Complications occurring within the first 30days were scored from 0 to 100 by the comprehensive complication index (CCI). Follow-up included clinical examination, upper gastrointestinal contrast study and 24-h pH monitoring 6months postoperatively, then phone-interviews 1, 2 and 4years later.

RESULTS

There were no statistical differences in age (NI 3.1 years [0.2-15.2] vs non-NI 5.0 years [0.4-15], p=.14) or in total CCI score (NI 20.9 [0-44.9] vs non-NI 8.7 [0-40.6], p=.57). Hospital stay was longer for NI children (9days [4-57] vs non-NI: 4days [2-16], p<0.001). More than 90% of parents in both groups reported that the fundoplication had improved the child's overall condition. Recurrence of gastroesophageal reflux disease (GERD) was diagnosed in 12 NI and 7 non-NI patients (p=.31).

CONCLUSIONS

Early complications, GERD recurrence, and long-term parental satisfaction after fundoplication did not differ between NI and non-NI patients.

Nonoral feeding for children and youth with developmental or acquired disabilities

The decision to initiate enteral feedings is multifaceted, involving medical, financial, cultural, and emotional considerations. Children who have developmental or acquired disabilities are at risk for having primary and secondary conditions that affect growth and nutritional well-being. This clinical report provides (1) an overview of clinical issues in children who have developmental or acquired disabilities that may prompt a need to consider nonoral feedings, (2) a systematic way to support the child and family in clinical decisions related to initiating nonoral feeding, (3) information on surgical options that the family may need to consider in that decision-making process, and (4) pediatric guidance for ongoing care after initiation of nonoral feeding intervention, including care of the gastrostomy tube and skin site. Ongoing medical and psychosocial support is needed after initiation of nonoral feedings and is best provided through the collaborative efforts of the family and a team of professionals that may include the pediatrician, dietitian, social worker, and/or therapists.

Outcomes of pediatric laparoscopic fundoplication: a critical review of the literature

BACKGROUND/OBJECTIVE

Laparoscopic fundoplication for gastroesophageal reflux disease (GERD) is one of the most common procedures performed in children. A critical literature review was performed to evaluate the level and quality of evidence supporting the efficacy of this procedure.

METHODS

Systematic reviews of the EMBASE, PubMed and CENTRAL databases were conducted to retrieve all articles published over a 15-year period (1996 to 2010) reporting medium- to long-term outcomes (minimum six months follow-up) of laparoscopic fundoplication for the treatment of pediatric GERD. Articles were critically appraised using the Newcastle-Ottawa quality assessment scale and the Cochrane risk of bias assessment tool. Extracted outcomes included GERD recurrence, need for reoperation, postoperative morbidity and mortality.

RESULTS

A total of 5302 articles were retrieved. Thirty-six studies met inclusion and exclusion criteria, including five prospective (level 2b), four retrospective comparative (level 3b) and 27 case series (level 4). No studies compared laparoscopic fundoplication with medical treatment. Thirty-six per cent of studies did not describe the symptoms used to suspect GERD; 11% did not disclose the diagnostic modalities used; and 41% did not report the findings of diagnostic modalities. Only 17% of studies provided a definition of recurrence, and only 14% attempted to control for confounding variables. The follow-up intervals were inconsistently reported, ranging between two months and nine years. Significant heterogeneity among studies limited the ability to pool outcomes. Mean (± SD) recurrence rates varied between 0% and 48±19.6% of patients. Reoperation was required in 0.69±0.95% to 17.7±8.4% of patients. Mortality ranged between 0% and 24±16.7%.

CONCLUSION

The level and quality of the evidence supporting laparoscopic fundoplication are extremely poor. Higher-quality data are required before the procedure can be considered to be an effective intervention in the treatment of pediatric GERD.

Morbidity and mortality in total esophagogastric dissociation: a systematic review

BACKGROUND/PURPOSE

Total esophagogastric dissociation has been described as both a primary and a rescue procedure for patients with severe gastroesophageal reflux. Although most commonly used in the neurologically impaired, it has also been used in those with no neurological impairment. The main objective of this study was to determine morbidity and mortality for this procedure.

METHODS

All published cases of esophagogastric dissociation in children were identified. Series were updated where possible by personal communication with the author. Patient characteristics, indications, morbidity, and mortality were analyzed.

RESULTS

One hundred eighty-one cases were identified. One hundred seventeen were primary operations and 64 were rescue procedures. There were 29 (16.0%) early complications and 28 (15.5%) late complications with 6 (3.3%) deaths related to the procedure of a total of 35 deaths. Twenty-one patients (11.6%) required re-operation in the study periods.

CONCLUSIONS

Esophagogastric dissociation has an acceptable morbidity and mortality. It is useful as both a primary and a rescue procedure.

Effectiveness of a transluminal endoscopic fundoplication for the treatment of pediatric gastroesophageal reflux disease

PURPOSE

Although laparoscopic Nissen fundoplication is the standard surgical treatment for gastroesophageal reflux disease (GERD), surgical complications and post-operative pain are not uncommon, especially for those patients who are neurologically impaired (NI) or undergoing re-operative procedures. To address this challenge, we utilized the transoral incisionless fundoplication (TIF) procedure to treat GERD via an endoscopic approach.

METHODS

Eleven TIF patients were included with an average age of 16.5 ± 5.1 years and weight of 45.7 ± 13.3 kg. NI was present in nine patients (82%), including a predominant number of patients with a history of seizures and gastrostomy tube feeding. Five patients had a history of a previous failed fundoplication requiring a re-operative procedure (45%). A retrospective chart review evaluated patient outcomes and post-operative complications.

RESULTS

The length of the TIF procedure was 113.3 ± 31.3 min with minimal blood loss. The length of stay was 1.2 ± 0.4 days, although one TIF patient was re-admitted for endoscopic clipping for gastric bleeding. At a follow-up of 8.2 ± 4.2 months, TIF effectively resolved GERD in 10 out of 11 children. A few of the patient's families reported complaints of gagging or dysphagia (30%, 3/11); however it was difficult to determine if complaints were due the procedures itself or baseline NI. All patients who had a follow-up upper GI or pH probe study showed no evidence of reflux. One TIF patient had no recurrent reflux but required an esophago-gastric disconnection for retching.

CONCLUSIONS

The TIF procedure can complement the current surgically and medically available options for children with GERD, especially in complicated patients such as those with NI. However, complications including hemorrhage emphasize the potential risk of the procedure. Further studies with more patients and a longer follow-up course must be conducted to better assess efficacy.

The effects and efficacy of antireflux surgery in children with gastroesophageal reflux disease: a systematic review

BACKGROUND

Antireflux surgery (ARS) for gastroesophageal reflux disease (GERD) is one of the most frequently performed major operations in children. Many studies have described the results of ARS in children, however, with a wide difference in outcome. This study aims to systematically review the efficacy of pediatric ARS and its effects on gastroesophageal function, as measured by gastroesophageal function tests. This is the first systematic review comprising only prospective, longitudinal studies, minimizing the risk of bias.

METHODS

Three electronic databases (Medline, Embase, and the Cochrane Library) were searched for prospective studies reporting on ARS in children with GERD.

RESULTS

In total, 17 eligible studies were identified, reporting on a total of 1,280 children. The median success rate after ARS was 86% (57-100%). The success rate in neurologically impaired children was worse in one study, but similar in another study compared to normally developed children. Different surgical techniques (total versus partial fundoplication, or laparoscopic versus open approach) showed similar reflux recurrence rates. However, less postoperative dysphagia was observed after partial fundoplication and laparoscopic ARS was associated with less pain medication and a shorter hospital stay. Complications of ARS varied from minimal postoperative complications to severe dysphagia and gas bloating. The reflux index (RI), obtained by 24-h pH monitoring (n = 8) decreased after ARS. Manometry, as done in three studies, showed no increase in lower esophageal sphincter pressure after ARS. Gastric emptying (n = 3) was reported either unchanged or accelerated after ARS. No studies reported on barium swallow x-ray, endoscopy, or multichannel intraluminal impedance monitoring before and after ARS.

CONCLUSION

ARS in children shows a good overall success rate (median 86%) in terms of complete relief of symptoms. Efficacy of ARS in neurologically impaired children may be similar to normally developed children. The outcome of ARS does not seem to be influenced by different surgical techniques, although postoperative dysphagia may occur less after partial fundoplication. However, these conclusions are bound by the lack of high-quality prospective studies on pediatric ARS. Similar studies on the effects of pediatric ARS on gastroesophageal function are also very limited. We recommend consistent use of standardized assessment tests to clarify the effects of ARS on gastroesophageal function and to identify possible risk factors for failure of ARS in children.