Long-term outcomes following failure of Nissen fundoplication

Abstract

Purpose: To determine the management and outcomes of patients with gastro-oesophageal reflux (GOR) that require further intervention following failure of Nissen Fundoplication (NF).Methods: After institutional audit department approval, a retrospective review of paediatric patients who had further intervention following failure of primary NF between January 2006 and December 2015 for GOR at our centre was performed. Data is presented as median (range).Results: Of 820 patients who underwent NF, 190 (23%) received further procedures for GOR management at a median of 21 months of age (6-186); 90/190 (47%) had gastrojejunal feeding (GJ). Of these 67 (74%) remained on GJ feeds up to a median of 48 months and 23/90 (26%) had a second NF after GJ feeding. 97/190 (51%) had a redo fundoplication without having had a GJ; thus 120/190 (63%) of patients having a further procedure went on to have a second NF after a median period of 15 months (1-70 months). Three patients (2%) had early emergency wrap revision 4 days after first fundoplication (we classed this as an 'early complication'). Of the seven patients who failed a 3 rd NF, 4 continued GJ feeding, 2 of had oesophogastric dissociation; 2 had 4 th NF of which 1 was successful and 1 patient had gastric pacemaker and is successfully feeding orally. Patients who were finally successfully managed with GJ underwent 2 (2-5) tube changes/year. We found patients who had a previous GJ were more likely to have failure of the redo fundoplication than those who had not to have the GJ (16/24 vs. 30/90, p=0.005). Conclusion:The chance of success decreases with every further attempt at fundoplication. The only factor significantly associated with failure of redo fundoplication was whether the patient previously had a GJ tube. In patients with failed fundoplications, when symptom free on jejunal feedings, further anti-reflux surgical intervention should be avoided. A randomized prospective study is needed for patient selection.

Enteral formula compared to Nissen-Fundoplication: Data from a retrospective analysis on tolerance, utility, applicability, and safeness in children with neurological diseases

“…Neurologically impaired children are at higher risk of death following NF and of failure of the surgery ( 15 ) and this should suggest the need for an alternative approach to NF in patients with ND and GERD. Interestingly, recently published data suggests that if NF fails and patients are free from GERD symptoms on jejunal feeding, further anti-reflux surgical intervention should be avoided ( 24 ). Another recent study suggests that EN alone, without combined surgery, could improve digestive symptoms ( 25 ).…”

“…Together with the modulation of formula feeding, a further important step that can improve tolerance to EN in patients with severe GERD is the switching from gastric to jejunal feeding (given continuously) ( 18 , 24 , 38 ) (see Figure 4 for details).…”

Robotic‐assisted versus laparoscopic redo antireflux surgery in children: A cost‐effectiveness study

“…For this reason, other authors have proposed other procedures such as esophagogastric dissociation followed by jejunal feeding (jejunostomy or gastrojejunostomy tube) for these cases. 21,22 However, it requires a continuous feeding regimen and additional procedures if the tube becomes dislodged, which has been described in more than 30% of these patients. 22 Economic costs are a major concern when comparing robotic surgery with laparoscopic surgery.…”

“…21,22 However, it requires a continuous feeding regimen and additional procedures if the tube becomes dislodged, which has been described in more than 30% of these patients. 22 Economic costs are a major concern when comparing robotic surgery with laparoscopic surgery. 23 The cost of robotic assisted operations are divided into fixed overhead costs and variable procedurerelated costs.…”

Total esophagogastric dissociation (TEGD) in neurologically impaired children: the floor to parents

“…Treatment of GERD in these patients represents a challenge since conservative management is often not sufficient. Although surgical treatments such as Nissen fundoplication must be considered, they have poor results in NIC, with even higher probability of failure in case of redo [2][3][4].…”