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The failed antireflux procedure: analysis of risk factors and morbidity
D A Caniano1, M E Ginn-Pease, D R King
1Department of Surgery, Ohio State University College of Medicine, Columbus.
Insights
Antireflux procedures (ARP) for gastroesophageal reflux (GER) in children had a 6% failure rate, with most recurrences within 28 months. Secondary ARP improved long-term GER control in 78% of cases.
Area of Science:
- Pediatric Surgery
- Gastroenterology
Background:
- Gastroesophageal reflux (GER) is a common condition in infants and children.
- Antireflux procedures (ARP) are surgical interventions to correct GER.
Purpose of the Study:
- To evaluate the failure rate and outcomes of antireflux procedures (ARP) in pediatric patients.
- To identify causes of ARP failure and assess the efficacy of reoperation.
Main Methods:
- Retrospective review of 364 pediatric patients undergoing Nissen or Thal ARP between 1976 and 1988.
- Analysis of reoperation rates, causes of failure, and outcomes following secondary ARP.
Main Results:
- A 6% failure rate for primary ARP was observed, with recurrent GER typically occurring within 28 months.
- Common causes of failure included "slipped" fundoplication and paraesophageal hernia.
- Secondary ARP achieved long-term GER control in 78% of patients, though reoperation was associated with increased morbidity.
Conclusions:
- Primary ARPs have a low failure rate, but recurrent GER necessitates reoperation in a subset of children.
- Reoperation for GER is effective in achieving long-term control, despite increased perioperative risks.
- Identifying the etiology of primary ARP failure is crucial for successful secondary surgical management.
Abstract:
Between 1976 and 1988 an antireflux procedure (ARP) was performed in 364 infants and children (Nissen, 358; Thal, 6). Recurrent gastroesophageal reflux (GER) necessitating reoperation occurred in 21 patients, a failure rate of 6%. Recurrent GER developed within 28 months of primary ARP in 18 (86%) children. The symptoms of GER became apparent following an episode of forceful emesis in 29% of patients, half of whom had a malpositioned gastrostomy tube. Recurrent GER developed in 28% of children with corrected esophageal atresia. A definitive etiology of ARP failure was identified in 18 (86%) cases: "slipped" fundoplication (15), no fundoplication visualized (2), and paraesophageal hernia (1). Perioperative morbidity, intraoperative blood loss, and length of surgery were significantly increased for secondary ARP. Mortality following reoperation was zero, but three late deaths occurred. Long-term control of GER has been achieved in 78% of children following the second operation.