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Antireflux surgery after congenital diaphragmatic hernia repair: a plea for a tailored approach
Tom Verbelen1, Toni Lerut, Willy Coosemans
1Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.
Insights
Congenital diaphragmatic hernia (CDH) repair can lead to gastro-oesophageal reflux disease (GERD) in 50% of infants, with 21% requiring antireflux surgery (ARS). Liver herniation into the chest is the main predictor for GERD and ARS in CDH patients.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Neonatal Care
Background:
- Congenital diaphragmatic hernia (CDH) is a serious condition requiring surgical repair.
- The optimal timing and necessity of preventive antireflux surgery (ARS) during CDH repair remain debated.
- Gastro-oesophageal reflux disease (GERD) is a common complication following CDH repair.
Purpose of the Study:
- To evaluate the incidence of GERD and the need for ARS in infants undergoing CDH repair.
- To identify factors associated with the development of GERD and the requirement for ARS after CDH repair.
Main Methods:
- Retrospective review of a CDH database including demographics, prenatal factors, and surgical repair details.
- Recording of incidences of GERD and ARS post-CDH repair.
- Statistical analysis to identify predictors of GERD and ARS.
Main Results:
- GERD was diagnosed in 50% of CDH patients, and 21% required ARS.
- Liver herniation into the chest was the sole independent predictor for both GERD and ARS.
- Patients treated with fetoscopic endoluminal tracheal occlusion (FETO) showed an increased risk for ARS.
Conclusions:
- Routine ARS at the time of CDH repair is not universally justified.
- Liver herniation is a key factor influencing GERD and ARS risk in CDH survivors.
- FETO treatment creates a cohort of survivors with a higher likelihood of needing ARS, suggesting complex reflux pathophysiology.
Objectives:
Preventive antireflux surgery (ARS) at the moment of congenital diaphragmatic hernia (CDH) repair has been suggested by some authors, particularly in subgroups with a liver herniated in the chest or patch requirement. We evaluated the incidence and associated factors of gastro-oesophageal reflux disease (GERD) and the need for subsequent ARS in our CDH patients.
Methods:
We retrospectively reviewed our CDH database. Demographics, prenatal assessment of severity, prenatal treatment, type of repair, intraoperative findings and incidences of gastro-oesophageal reflux and ARS were recorded.
Results:
CDH repair was performed in 77 infants between July 1993 and November 2009. Eight died after repair. Seven were lost to follow-up. The median follow-up was 4.0 (0.16-14.88) years. Fourteen of these 62 patients were prenatally treated with fetoscopic endoluminal tracheal occlusion (FETO) because of severe pulmonary hypoplasia. After CDH repair, GERD was diagnosed in 31 patients. In all of them, medical antireflux treatment was started. Thirteen (42%) patients needed ARS at a median age of 64 (37-264) days. One year after starting medical treatment, 14 (45%) patients were completely off antireflux medication. In CDH subgroups with patch repair, liver herniated in the chest or previous FETO, the incidences of gastro-oesophageal reflux and ARS were 61 and 32%, 73 and 38% and 71 and 43%, respectively. Univariable analysis of associated potentially predisposing factors shows that patch repair, liver herniated in the chest, pulmonary hypertension, high-frequency oscillatory ventilation and FETO are associated with subsequent ARS. On multivariable analysis, liver herniated in the chest was the only independent predictor for both gastro-oesophageal reflux and ARS.
Conclusions:
Of all CDH patients, 50% developed gastro-oesophageal reflux and 21% required ARS. For both, liver in the chest was the only independent predictor. Routine ARS in certain subgroups at the time of CDH repair seems not to be justified. Foetal endoluminal tracheal occlusion creates a new cohort of survivors with an increased risk for undergoing ARS. The surgical group, in particular, reflects a more complex gastro-oesophageal reflux physiopathology.
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