title: Outcome of Surgery for Pediatric Gastroesophageal Reflux: Clinical and Endoscopic Follow-up after 300 Fundoplications in 279 Consecutive Patients.
abstract: OBJECTIVE
  Clinical and endoscopic assessment of the outcome after fundoplication for pediatric gastroesophageal reflux.
  
  
  METHODS
  Hospital records of 279 consecutive patients who underwent fundoplication for gastroesophageal reflux from 1991 to 2014 were reviewed. Underlying disorders, clinical and endoscopic findings, imaging studies, pH monitoring, and surgical technique were assessed. Main outcome measures were patency of fundoplication, control of symptoms and esophagitis, complications, redo operations, and predictive factors of failures.
  
  
  RESULTS
  A total of 279 patients underwent 300 fundoplications (277 primaries and 23 redos). Underlying disorders in 217 (72%) patients included neurological impairment (28%) and esophageal atresia (22%). Indications for fundoplication included recalcitrant gastroesophageal reflux symptoms (44%), failure to thrive (22%), respiratory symptoms (15%), esophageal anastomotic stricture (4%), apneic spells (2%), and regurgitation (2%). Preoperative endoscopy was performed in 92% and pH monitoring in 49% of patients. Median age at primary fundoplication was 2.2 ((IQR = 0.5-7.5)) years. Fundoplication was open in 205 (74%; Nissen n = 63, Boix-Ochoa n = 97, Toupet n = 39, and other n = 6), laparoscopic in 72 (24%; Nissen n = 67 and Toupet n = 5), and included hiatoplasty in 73%. Clinical follow-up was a median of 3.9 (IQR = 1.2-9.9) years. Mortality related to surgery was 0.3%. Symptom control was achieved in 87% of patients, and esophagitis rate decreased from 65% to 29% (p < 0.001). Fundoplication failed in 41 (15%) patients. Failure was predicted by esophageal atresia risk ratio = 3.9 (95% confidence interval = 1.3-11, p = 0.01), any underlying disorder risk ratio = 3.1 (95% confidence interval = 1.1-9.1, p = 0.04), and hiatoplasty risk ratio = 2.6 (95% confidence interval = 1.1-6.6, p = 0.03). Of the 23 redo-fundoplications, 32% failed.
  
  
  CONCLUSIONS
  The majority of patients who underwent fundoplication had an underlying disorder. Primary fundoplication provided control of symptoms in almost 90% of patients and also reduced the rate of esophagitis. Failure of primary fundoplication occurred in 15% of patients, and an underlying disorder, esophageal atresia, and hiatoplasty increased the risk of failure.
authors.affiliation: Section of Paediatric Surgery, Children's Hospital, Helsinki University Hospital, Helsinki, Finland.
authors.forename: A I
authors.initials: AI
authors.lastname: Koivusalo
authors.affiliation: Section of Paediatric Surgery, Children's Hospital, Helsinki University Hospital, Helsinki, Finland.
authors.forename: M P
authors.initials: MP
authors.lastname: Pakarinen
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D015897:Comorbidity; D016208:Databases, Factual; D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D018662:Fundoplication / Q000009:adverse effects / Q000379:methods*; D005764:Gastroesophageal Reflux / Q000175:diagnosis* / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D007813:Laparotomy / Q000379:methods; D008297:Male; D010372:Pediatrics; D016016:Proportional Hazards Models; D012008:Recurrence; D012086:Reoperation / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D016896:Treatment Outcome
keywords: Gastroesophageal reflux; esophagitis; fundoplication