Question : Nissen

[Guest guest]

I for obvious reason am not a fan, it didnt work for us, but reading

through it has work great for others.

It is such a difficult call.

FAO LISA WEIR

you say 30% fail, out of what?

how many kids were studied?

and were they all charge kids, or special needs of all types of

conditions?

was this is Canada, USA or Worldwide?

I would be interested in the figures, especially during this decision

making period.

thanks Lesley

[Guest guest]

Lesley,

These numbers were quoted to me by docs here in Canada, more than one in

different hospitals. I'm not sure where their numbers came from, etc. I'm

assuming it's from a journal article written based on an empirical study. I

don't think it's something they just came up with. I am pretty sure it's 30% of

fundos for any child, not just CHARGE. Here's a quick abstract from one study I

found (which mentions CHARGE Syndrome!)

J Pediatr Surg. 1998 Jan;33(1):64-6. Related Articles,

Links

The failure rate of surgery for gastro-oesophageal reflux.

Kimber C, Kiely EM, Spitz L.

Department of Surgery, Institute of Child Health and Great Ormond Street

Hospital for Children, London, England.

PURPOSE: The aim of this study was to document the presenting symptomatology and

radiological findings of failed fundoplication, to determine the risk factors

involved in recurrent gastro-oesophageal reflux, and to assess the results of

revisional surgery. METHODS: Sixty-six patients requiring redo fundoplication

during the past 15 years were studied. Sixty children had their initial

fundoplication performed at our institution. RESULTS: The median time from

initial fundoplication to the diagnosis of failure was 1.5 years. The main

presenting symptoms were severe retching (n = 33), recurrent vomiting and

aspiration (n = 26) and intolerable gas bloat (n = 7). Severe dysphagia occurred

in two children with tight Nissen fundoplications. Contrast radiographic studies

demonstrated fundoplication failure and correlated with the operative findings

in 85% of cases. Risk factors for failure comprised hypertonic cerebral palsy,

severe learning difficulties, oesophageal atresia, CHARGE syndrome,

and tracheomalacia. The cause for the fundoplication failure included

herniation of the fundoplication into the posterior mediastinum (failed crural

repair, n = 30), disruption of the wrap (n = 10), combination of herniation and

disruption (n = 22), and a tight wrap (n = 4). After revisional surgery, 13

children had persisting symptoms, five of whom underwent a third antireflux

procedure. CONCLUSIONS: The predominant cause of fundoplication failure is

herniation into the posterior mediastinum, which occurred most frequently in

children with hypertonic cerebral palsy. This may be prevented by meticulous

attention to accurate apposition of the crura at initial procedure. Redo

fundoplication failed to resolve the preoperative symptoms in 20%, with five

children requiring a third fundoplication.

Here is another with very good outcomes for the Nissen (large study):

Surgical treatment of gastroesophageal reflux in children: a combined

hospital study of 7467 patients.

Fonkalsrud EW, Ashcraft KW, Coran AG, Ellis DG, Grosfeld JL, Tunell WP, Weber

TR.

Department of Surgery,UCLA School of Medicine, Los Angeles, California 90095,

USA.

OBJECTIVE: To review retrospectively the combined clinical experience with the

surgical treatment of persistently symptomatic gastroesophageal reflux (SGER) in

childhood from seven large children's surgery centers in the United States.

DESIGN: During the past 20 years, 7467 children <18 years of age underwent

antireflux operations for SGER at the seven participating hospitals. Fifty-six

percent were neurologically normal (NN) and 44% were neurologically impaired

(NI). The most frequent diagnostic studies were upper gastrointestinal series

(68%), esophageal pH monitoring (54%), gastric emptying study (32%), and

esophagoscopy (25%). The age at operation was under 12 months in 40% and 1 to 10

years in 48%. The type of fundoplication was Nissen (64%), Thal (34%), and

Toupet (1.5%). A gastric emptying procedure was performed on 11.5% of NN

patients and 40% of NI patients. Laparoscopic fundoplication was performed on

2.6% of patients. RESULTS: Good to excellent results were achieved in 95%

of NN and 84.6% of NI patients. Major complications occurred in 4.2% of NN and

12.8% of NI patients. The most frequent complications were recurrent reflux

attributable to wrap disruption (7.1%), respiratory (4.4%), gas bloat (3.6%),

and intestinal obstruction (2.6%). Postoperative death occurred in 0.07% of NN

and 0.8% of NI patients. Reoperation was performed in 3.6% of NN and 11.8% of NI

patients. The results and complications were similar among the participating

hospitals and did not seem related to the type of fundoplication used.

CONCLUSION: The excellent results (94% cure) and low morbidity with

gastroesophageal fundoplication with or without a gastric emptying procedure

from a large combined hospital study indicate that operation should be used

early for SGER in NN children and to facilitate enteral feedings and care in NI

children.

Lesley Chan wrote: I for obvious reason am not a

fan, it didnt work for us, but reading

through it has work great for others.

It is such a difficult call.

FAO LISA WEIR

you say 30% fail, out of what?

how many kids were studied?

and were they all charge kids, or special needs of all types of

conditions?

was this is Canada, USA or Worldwide?

I would be interested in the figures, especially during this decision

making period.

thanks Lesley

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