title: Reoperation after Nissen fundoplication in children with gastroesophageal reflux: experience with 130 patients.
abstract: OBJECTIVE
  The authors evaluate reoperation for recurrent gastroesophageal reflux (GER) after a failed Nissen fundoplication.
  
  
  BACKGROUND
  Nissen fundoplication is an accepted treatment for GER refractory to medical therapy. Wrap failure and recurrence of GER are noted in 8% to 12%.
  
  
  METHODS
  Medical records of 130 children undergoing a second antireflux operation for recurrent GER from January 1985 to June 1996 retrospectively were reviewed.
  
  
  RESULTS
  One hundred one patients (78%) were neurologically impaired (NI), 74 (57%) had chronic pulmonary disease, and 8 had esophageal atresia. Recurrent symptoms included vomiting (78%), growth failure (62%), choking-coughing-gagging (38%), and pneumonia (25%). Gastroesophageal reflux was confirmed by barium swallow, gastric scintigraphy, and endoscopy. Operative findings showed wrap breakdown (42%), wrap-hiatal hernia (30%), or both (21%). A second Nissen fundoplication was performed in 128 children. Complications included bowel obstruction (18), wound infection (10), pneumonia (6) and tight wrap (9). There were two postoperative (<30 days) deaths (1.5%). Of 124 patients observed long term, 89 (72%) remain symptom free. Eight were converted to tube feedings. Twenty-seven required a third fundoplication, and 19 (70%) were successful outcome. Two with repetitive wrap failure due to gastric atony underwent gastric resection and esophagojejunostomy.
  
  
  CONCLUSIONS
  Nissen fundoplication was successful in 91% of patients. In 9% with wrap failure, a second Nissen fundoplication was successful in 72%. Reoperation is justified in properly selectedpatients. Conversion to jejunostomy feedings is suggested for neurologically impaired after two wrap failures and a partial wrap in those with esophageal atresia and severe esophageal dysmotility. Repeated wrap failure due to gastric atony requires gastric resection and esophagojejunostomy.
authors.affiliation: Department of Surgery, Indiana University School of Medicine and the James Whitcomb Riley Hospital for Children, Indianapolis 46202, USA.
authors.forename: L K
authors.initials: LK
authors.lastname: Dalla Vecchia
authors.forename: J L
authors.initials: JL
authors.lastname: Grosfeld
authors.forename: K W
authors.initials: KW
authors.lastname: West
authors.forename: F J
authors.initials: FJ
authors.lastname: Rescorla
authors.forename: L R
authors.initials: LR
authors.lastname: Scherer
authors.forename: S A
authors.initials: SA
authors.lastname: Engum
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D016145:Endoscopy, Digestive System; D004941:Esophagitis / Q000150:complications / Q000175:diagnosis; D005260:Female; D018662:Fundoplication / Q000009:adverse effects; D005764:Gastroesophageal Reflux / Q000209:etiology / Q000601:surgery*; D006801:Humans; D007223:Infant; D008297:Male; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies