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

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.

Fundoplication without esophagocrural sutures: Long-term follow-up of a randomized clinical trial

INTRODUCTION

We previously conducted a randomized trial that showed a lack of need for esophagocrural (EC) sutures during fundoplication when no esophageal dissection was performed. There was no difference in wrap herniation or other complications in the group without EC sutures at a median 1.5 years of follow-up. In this follow-up study, we aim to evaluate long-term symptom control and complication profiles in these patients.

METHODS

106 patients were randomized and participated in the original trial. We were primarily concerned with identification of late complications and persistence of symptoms. Presently, we conducted a retrospective chart review and a telephone follow-up survey at a minimum of 6.5 years after fundoplication.

RESULTS

100 patients were alive at late follow-up and 70% of caregivers responded to the telephone survey. 53% of patients were male; 76% were Caucasian. Of these children, 39 (56%) received four EC sutures, while 31 (44%) did not. Follow-up was conducted at a median of 8.7 years [IQR 8.2,9.7] post-fundoplication. Late wrap herniation was not demonstrated radiographically on chart review or caregiver report in either group. The rate of residual reflux symptoms, post-operative hospitalizations for pneumonia, failure to thrive (FTT), and brief resolved unexplained event (BRUE) were also similar between groups.

CONCLUSION

Long-term follow-up in children who underwent fundoplication without esophagocrural sutures demonstrates no difference in symptom management or subsequent hospitalizations at a minimum of 6.5-year follow-up.

LEVEL OF EVIDENCE

II (follow-up of a randomized controlled trial).

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 ).