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Anti-reflux surgery in children with congenital diaphragmatic hernia: A prospective cohort study on a controversial
Louise Montalva1, Elisabeth Carricaburu2, Rony Sfeir3
1Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, AP-HP, Paris, France; Sorbonne University, Paris, France.
Insights
Preventive fundoplication in congenital diaphragmatic hernia (CDH) patch repair does not reduce the need for later surgery. This approach is linked to poorer gastro-intestinal outcomes, including failure to thrive and oral aversion in children.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Neonatal Care
Background:
- Gastro-esophageal reflux disease (GERD) is a common long-term issue for congenital diaphragmatic hernia (CDH) survivors.
- The role of preventive fundoplication during CDH repair is debated.
- This study investigates the practice patterns, predictive factors, and outcomes of preventive fundoplication in CDH.
Purpose of the Study:
- To analyze the variation in preventive fundoplication practices for CDH.
- To identify factors predicting the need for fundoplication.
- To assess the impact of preventive fundoplication on GI outcomes in pediatric CDH patch repair.
Main Methods:
- Prospective multi-institutional cohort study of 762 neonates with CDH (2010-2018).
- Data collected on CDH repair type (patch vs. no patch), fundoplication (preventive/curative), and GI outcomes.
- Outcomes measured: need for curative fundoplication, tube feeding, failure to thrive, and oral aversion.
Main Results:
- Preventive fundoplication is performed in only 31% of centers, but these centers have higher rates of both curative and overall fundoplication.
- Predictive factors for preventive fundoplication include prenatal diagnosis, intra-thoracic liver, fetal tracheal occlusion, CDH grade C-D, and patch repair.
- In CDH patch repair, preventive fundoplication did not lower the need for curative fundoplication and was associated with increased failure to thrive, tube feeding, and oral aversion.
Conclusions:
- Children with CDH patch repair face a high risk of requiring curative fundoplication.
- Preventive fundoplication in this population does not reduce the need for subsequent curative procedures.
- Preventive fundoplication is linked to worse gastro-intestinal outcomes in pediatric CDH patients.
Introduction:
Gastro-esophageal reflux disease (GERD) is the most frequent long-term morbidity of congenital diaphragmatic hernia (CDH) survivors. Performing a preventive fundoplication during CDH repair remains controversial. This study aimed to: (1) Analyze the variability in practices regarding preventive fundoplication; (2) Identify predictive factors for fundoplication. (3) Evaluate the impact of preventive fundoplication on gastro-intestinal outcomes in children with a CDH patch repair; METHODS: This prospective multi-institutional cohort study (French CDH Registry) included CDH neonates born in France between January 1st, 2010-December 31st, 2018. Patch CDH was defined as need for synthetic patch or muscle flap repair. Main outcome measures included need for curative fundoplication, tube feed supplementation, failure to thrive, and oral aversion.
Results:
Of 762 CDH neonates included, 81 underwent fundoplication (10.6%), either preventive or curative. Median follow-up was 3.0 years (IQR: 1.0-5.0). (1) Preventive fundoplication is considered in only 31% of centers. The rates of both curative fundoplication (9% vs 3%, p = 0.01) and overall fundoplication (20% vs 3%, p < 0.0001) are higher in centers that perform preventive fundoplication compared to those that do not. (2) Predictive factors for preventive fundoplication were: prenatal diagnosis (p = 0.006), intra-thoracic liver (p = 0.005), fetal tracheal occlusion (p = 0.002), CDH-grade C-D (p < 0.0001), patch repair (p < 0.0001). After CDH repair, 8% (n = 51) required curative fundoplication (median age: 101 days), for which a patch repair was the only independent predictive factors identified upon multivariate analysis. (3) In neonates with patch CDH, preventive fundoplication did not decrease the need for curative fundoplication (15% vs 11%, p = 0.53), and was associated with higher rates of failure to thrive (discharge: 81% vs 51%, p = 0.03; 6-months: 81% vs 45%, p = 0.008), tube feeds (6-months: 50% vs 21%, p = 0.02; 2-years: 65% vs 26%, p = 0.004), and oral aversion (6-months: 67% vs 37%, p = 0.02; 1-year: 71% vs 40%, p = 0.03).
Conclusions:
Children undergoing a CDH patch repair are at high risk of requiring a curative fundoplication. However, preventive fundoplication during a patch repair does not decrease the need for curative fundoplication and is associated with worse gastro-intestinal outcomes in children.
Level Of Evidence:
II - Prospective Study.
