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Open versus laparoscopic approach to gastric fundoplication in children with cardiac risk factors
Ilan Igor Maizlin1, Michelle C Shroyer1, Elizabeth A Beierle1
1Division of Pediatric Surgery, Children's Hospital of Alabama, University of Alabama, Birmingham, Alabama.
Insights
Laparoscopic fundoplication (LF) is safer for children with cardiac risk factors (CRFs) compared to open fundoplication (OF). OF is associated with higher morbidity, especially in younger children and those with significant CRFs.
Area of Science:
- Pediatric surgery
- Cardiology
- Surgical outcomes
Background:
- Gastric fundoplication is a common procedure for children with congenital heart disease.
- Prior studies suggest laparoscopy is safe, but the impact of cardiac risk factors (CRFs) on surgical approach and outcomes is less understood.
Purpose of the Study:
- To investigate the association between cardiac risk factors (CRFs) and the choice between laparoscopic fundoplication (LF) and open fundoplication (OF) in children.
- To compare postoperative morbidity between LF and OF in pediatric patients with varying degrees of CRFs.
Main Methods:
- Analysis of the 2013 National Surgical Quality Improvement Program-Pediatrics Public-Use-File.
- Stratification of pediatric patients undergoing fundoplication based on the presence and severity of CRFs (none, minor, major, severe).
- Multivariate logistic regression to identify predictors of surgical approach and postoperative outcomes.
Main Results:
- Open fundoplication (OF) was more common in patients with minor, major, or severe CRFs, younger children (≤ 1 year), and those with tracheostomies.
- Patients undergoing OF experienced significantly higher overall postoperative morbidity compared to those undergoing LF.
- Children with minor or major CRFs had more complications after OF than after LF.
Conclusions:
- OF is disproportionately used in pediatric patients with higher CRFs, younger age, and tracheostomy.
- Laparoscopic fundoplication (LF) should be strongly considered for children with minor and major CRFs due to lower complication rates.
- OF in children with CRFs is linked to increased pulmonary, infectious, and hematological complications.
Background:
Gastric fundoplication is the most common noncardiac operation in children with congenital cardiac disease. While prior studies validated safety of laparoscopy in this population, we hypothesize that children with cardiac risk factors (CRFs) are likelier to undergo open fundoplication (OF) but experience greater morbidity than after laparoscopic fundoplication (LF).
Materials And Methods:
Utilizing 2013 National Surgical Quality Improvement Program-Pediatrics Public-Use-File, pediatric patients undergoing LF and OF were stratified to none, minor, major, or severe CRFs. Multivariate logistic regression determined preoperative variables and postoperative outcomes associated with LF or OF.
Results:
A total of 1501 fundoplication patients were identified with 92% undergoing LF. OF patients were likelier to have minor (odds ratio [OR]: 2.36, P < 0.001), major (OR: 2.41, P = 0.003), and severe CRFs (OR: 4.36, P < 0.001). Children ≤ 1 y (OR: 3.38, P = 0.048) and those with tracheostomy were likelier to have OF (OR: 2.3, P = 0.006). Overall, the OF group had higher postoperative morbidity (OR: 2.41, P < 0.001). Specifically, children with minor or major CRFs experienced more complications following OF compared to LF.
Conclusions:
OF is more common in patients ≤1 y old; patients with minor, major, or severe CRFs; and those with tracheostomy. LF should be considered in children with minor and major CRFs, as OF in those patients results in greater pulmonary, infectious, and hematological sequelae.
