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Published on: August 11, 2023
Anterior fundoplication at the time of congenital diaphragmatic hernia repair
Yigit S Guner1, Steven Elliott, Clifford C Marr
1Department of General Surgery, University of California Davis Medical Center, Sacramento, CA 95817, USA. yguner@chla.usc.edu
Insights
Modified fundoplication surgery in neonates with congenital diaphragmatic hernia (CDH) improved feeding outcomes. This surgical approach effectively addressed gastroesophageal reflux (GER) in high-risk infants, with no complications.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Neonatal Care
Background:
- Congenital diaphragmatic hernia (CDH) disrupts normal anatomy, increasing neonates' risk of gastroesophageal reflux (GER).
- GER can complicate post-operative feeding and overall recovery in infants with CDH.
Purpose of the Study:
- To evaluate the efficacy of adding a modified anterior fundoplication to CDH repair.
- To improve post-operative feeding and restore natural gastric/esophageal positioning in neonates with CDH.
Main Methods:
- A retrospective study of 13 neonates with high-risk CDH anatomy undergoing repair combined with anterior fundoplication (Boix-Ochoa) between 1997-2008.
- Indications included absent intra-abdominal esophagus, obtuse angle of His, and small, vertical stomach.
- Institutional Review Board approval was obtained from both participating centers.
Main Results:
- Ten of 13 patients survived to discharge, with eight achieving full oral nourishment.
- One patient required partial gastrostomy feeding for oral aversion but progressed to full oral intake.
- Two patients with GER and failure to thrive required conversion to a 360-degree wrap; no fundoplication-related complications occurred.
Conclusions:
- Modified fundoplication effectively addresses anatomical predictors of severe GER during CDH repair.
- This surgical technique should be considered for high-risk infants undergoing CDH repair to improve feeding outcomes.
Purpose:
The loss of normal anatomic barriers in neonates with congenital diaphragmatic hernia (CDH) can predispose children to gastroesophageal reflux (GER). In an attempt to improve post-operative feeding, we have added a modified anterior fundoplication to restore natural gastric and esophageal positioning.
Methods:
The institutional review board of both participating centers approved this study. Between 1997 and 2008, 13 neonates with high-risk anatomy underwent repair of CDH combined with an anterior fundoplication (Boix-Ochoa). The anatomic indications for concomitant fundoplication were absence of an intra-abdominal esophagus, an obtuse angle of His, and a small, vertically oriented stomach.
Results:
Ten patients survived to discharge and eight were on full oral nourishment. One required partial gastrostomy feedings for an improving oral aversion and quickly progressed to full oral feedings. One patient with chromosomal anomalies and swallowing dysfunction remained on long-term bolus gastrostomy feedings. Two with progressive symptoms of GER and failure to thrive required conversion to a 360 degrees wrap after 18 months of medical management. This was performed in conjunction with a planned, staged muscle flap reconstruction in one patient. There were no complications related to the fundoplication.
Conclusion:
Anatomic predictors of severe GER can be efficiently countered at the time of CDH repair. A modified fundoplication should be considered in the operative management of high-risk infants.
