Revisiting fundoplication in esophageal atresia: Implications for nutrition, stricture management, and wrap type

Patients with esophageal atresia with or without tracheoesophageal fistula (EA-TEF) frequently require fundoplication to manage gastroesophageal reflux disease (GERD). Data is limited on whether fundoplication improves GERD-related outcomes and if outcomes vary by type of fundoplication.

This is a retrospective cohort study of patients <18 years-old who underwent EA-TEF repair and fundoplication at a single institution from January 2013 to September 2025. In the first aim, we compared GERD symptoms, medications, nutrition, and esophageal stricture dilation rate before and after fundoplication. In the second aim, we compared outcomes between partial and complete fundoplication at 12 months after surgery.

Of 226 children with EA-TEF repair, 36 (15.9%) underwent fundoplication, with 14 (38.8%) complete and 22 (61.1%) partial fundoplication. The median age at fundoplication was 7.3 [3.7, 15.9] months. Most patients (69.4%) had Type C EA-TEF. The most common indication was refractory GERD (88.9%). There were no statistical differences in GERD-related symptoms - oral aversion, dysphagia, retching, and vomiting - and medication use when comparing pre-to post-fundoplication. Fundoplication significantly reduced the need for post-pyloric feeds (67% vs 11%, P < 0.001) and improved weight-for-age z-scores (-1.94 vs -1.03, P < 0.001). Fundoplication also decreased the need for stricture dilation (3.07 vs. 1.36 dilations/year, P = 0.001). There were no differences in outcomes between partial and complete fundoplication. Eight patients required fundoplication revision, four from each group.

In our EA-TEF cohort, fundoplication facilitated conversion from post-pyloric to gastric feeds, decreased stricture burden, and improved nutritional status. Outcomes were not impacted by the type of fundoplication performed.