title: Pediatric surgeons and gastroesophageal reflux.
abstract: OBJECTIVE
  Better antacid medications and the introduction of laparoscopy destabilize the indications for fundoplication. This study aims at raising a discussion among pediatric surgeons on these indications, modalities, and the results of this operation.
  
  
  METHODS
  A total of 252 refluxing children operated between 1992 and 2006 were divided into groups according to predominant symptoms (93 digestive, 47 respiratory, and 68 neurologic) or to comorbidities (27 esophageal atresia, 10 diaphragmatic hernia, 5 abdominal wall defects, and 2 caustic stricture), and the indications, complications, mortality, and long-term results were reviewed. Features of open (n = 135) and laparoscopic (n = 117) approaches were compared, and long-term integrity of the wrap was analyzed using the Kaplan-Meier method.
  
  
  RESULTS
  Digestive, respiratory, and neurologic patients had more often laparoscopic plications, whereas all others rather had an open approach. The rate of complications was 22%, and they were more frequent in children operated by laparotomy (P < .05). Median follow up was 51.3 months (range, 6-160). Overall wrap integrity was maintained in 89% of the children, and the proportions for digestive, respiratory, and neurologic groups were 95%, 95%, and 87%, respectively. For esophageal atresia, congenital diaphragmatic hernia, abdominal wall defects, and caustic stricture, they were 72%, 77%, 100%, and 0%, respectively. The functional results were fully satisfactory in 83% of patients. There were 17 deaths (6.7%), but only 3 in the first postoperative month and only 1 related to the operation (0.4%).
  
  
  CONCLUSIONS
  Fundoplication is a powerful method of reflux control. It is indicated after failure of medical treatment in gastroesophageal reflux disease and in symptomatic refluxers with some particular comorbidities. Surgery should be offered only after diagnosis has been firmly established, and the indications must remain identical for open and laparoscopic procedures. High technical standards and rigorous report of the results are required for keeping a relevant place of pediatric surgery in the treatment of this disease.
authors.affiliation: Department of Pediatric Surgery, Hospital Universitario La Paz, 28046 Madrid, Spain. jatovar.hulp@salud.madrid.org
authors.forename: Juan A
authors.initials: JA
authors.lastname: Tovar
authors.forename: Ana L
authors.initials: AL
authors.lastname: Luis
authors.forename: Jose L
authors.initials: JL
authors.lastname: Encinas
authors.forename: Laura
authors.initials: L
authors.lastname: Burgos
authors.forename: Federica
authors.initials: F
authors.lastname: Pederiva
authors.forename: Leopoldo
authors.initials: L
authors.lastname: Martinez
authors.forename: Pedro
authors.initials: P
authors.lastname: Olivares
mesh_terms: D000367:Age Factors; D002648:Child; D002675:Child, Preschool; D004945:Esophagoscopy; D005260:Female; D005500:Follow-Up Studies; D018662:Fundoplication / Q000379:methods* / Q000401:mortality; D005746:Gastric Emptying / Q000502:physiology; D005764:Gastroesophageal Reflux / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D005773:Gastroscopy / Q000379:methods; D006801:Humans; D007223:Infant; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D007813:Laparotomy / Q000379:methods* / Q000401:mortality; D008297:Male; D008365:Manometry; D018579:Patient Selection; D010372:Pediatrics / Q000592:standards / Q000639:trends; D011183:Postoperative Complications / Q000175:diagnosis / Q000453:epidemiology; D011336:Probability; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016019:Survival Analysis; D016896:Treatment Outcome