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The failed fundoplication
1University of Toronto, Department of Pediatric General Surgery, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
Insights
Fundoplication surgery for pediatric gastroesophageal reflux (GER) can fail, especially in high-risk children. Careful patient selection and surgical technique are key to preventing and managing fundoplication failure to improve quality of life.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Surgical Outcomes
Background:
- Fundoplication is the standard surgical treatment for pediatric gastroesophageal reflux (GER).
- Despite its success, fundoplication carries risks of complications and failure, particularly in high-risk pediatric populations.
- Failure can manifest as persistent symptoms, surgical complications, or anatomical issues like para-esophageal hernia.
Purpose of the Study:
- To review strategies for preventing and managing failed fundoplication in children.
- To emphasize the importance of patient selection and surgical technique in optimizing outcomes.
- To outline treatment options for children experiencing fundoplication failure.
Main Methods:
- Review of current literature and clinical practices regarding pediatric fundoplication.
- Analysis of factors contributing to fundoplication failure in high-risk pediatric patients.
- Discussion of surgical and non-surgical management options for failed fundoplication.
Main Results:
- Careful patient selection, individualized surgical approaches, and meticulous technique are crucial for preventing fundoplication failure.
- High-risk factors include associated anomalies, motility disorders, chronic pulmonary disease, and young infant age.
- Treatment options for failed fundoplication include medical management, jejunal feeding, revision surgery, or esophagogastric dissociation.
Conclusions:
- Preventing fundoplication failure through optimized surgical planning and execution is paramount.
- Revision of failed fundoplication requires adherence to the same principles of careful patient selection and technique.
- The ultimate goal of GER treatment in children is to enhance their and their family's quality of life.
Abstract:
Fundoplication is the standard surgical approach to gastroesophageal reflux (GER) in a child. Although successful in many patients, there is a significant risk of complications and failure, especially in high-risk patients such as those with certain types of associated anomalies, diffuse motility disorders, chronic pulmonary disease, neurologic impairment, and young infants. Fundoplication failure can take the form of persistent reflux-related symptoms, symptoms that are caused by complications of the surgery, or anatomic problems such a para-esophageal hernia or migration of the wrap into the mediastinum. The most effective strategy for treatment of the child undergoing fundoplication is to prevent failure by careful patient selection, individualization of the operation based on the patient's anatomy and physiology, and meticulous attention to the technical details of the operation. Options for the child with a failed fundoplication include medical management, jejunal feeding using a percutaneous tube or a Roux-en-Y jejunostomy, revision of the fundoplication, or esophagogastric dissociation. If the fundoplication is to be revised, the same principles of patient selection, individualization of the operation, and attention to technique must be used to optimize the chance of success. The primary goal in the treatment of GER is to improve quality of life for the patient and the family.
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