Complications of Gastroesophageal Antireflux Surgery in Neurologically Impaired Versus Neurologically Normal Children By R.H.
Pearl,
D.K.
Robie,
S.H.
Ein,
B. Shandling, J.A.
D.E.
O’Connor,
Washington,
DC and
0 Antireflux surgery was performed in 234 children over a Iyear period; 153 were neurologically impaired (Nlj and 81 were neurologically normal (NN). Initial presentation, demographic data, and type of antireflux operation were similar in the two groups. Eighty-six percent of the NI group versus 30% of the NN group had gastrostomy tubes placed. The incidence of late postoperative complications was 28% in the NI group and 12% in the NN group (P < .Ol I. During the late postoperative period, NI children underwent reoperation four times as frequently as NN children (19% Y 5%. respectively; P < .Ol). Wrap herniation accounted for 38% of complications and 59% of reoperations in the late postoperative period. Mortality due to aspiration occurred in 9% of the NI group versus 1% of the NN group. Combined failure rate (reoperation plus aspiration-induced deaths) was 28% in NI and 8% in NN (P < .Ol). We conclude that neurological status is the major predictor of operative success and that wrap herniation due to crural disruption is the most common cause of operative failure. 0 1990 by W. B. Saunders Company. INDEX dures.
WORDS:
Gastroesophageal
reflux.
surgical
R. Superina,
R.M.
Toron
K. Mctaggart,
V.F.
Garcia,
Filler to,
Ontario
and respiratory. Respiratory problems included recurrent pneumonia and respiratory arrest. Nutritional problems were vomiting and failure to thrive (FIT) (Table 2). GER was diagnosed in over 90% of patients by an upper gastrointestinal (GI) series. Additional studies (milk scan, 24-hour pH monitoring, endoscopy) were required in approximately 10% of patients. A Nissen fundoplication with posterior approximation of the crura and 360“ fundic wrap about the distal esophagus was performed in 57 NN and 121 NI children. A Dor-Nissen (Thal, partial wrap) with anterior crural approximation, recreation of the angle of His by approximating cardia to esophageal wall, and a 210° anterior fundic wrap about the distal esophagus was performed in 24 NN and 3 1 NI children. Choice of operation was the preference of the operating surgeon and not influenced by neurological status of the child. Gastrostomy tubes were placed in 132 NI children as compared with 24 NN patients. Follow-up was achieved by clinic interviews, phone contact, and review of old records and clinic charts (Table 3). Results were analyzed using x2 test with Yates’ correction. To adjust for multiple comparisons, a P < .Ol (two-sided) was considered significant.’
proceRESULTS
P
ATHOLOGICAL gastroesophageal reflux (GER) is increasingly recognized as the cause for many nutritional and respiratory problems in the pediatric population. Surgical intervention is required in many children when standard medical therapy fails to eradicate symptomatic reflux. Several operations have become popular; however, the Nissen fundoplication is most commonly performed. We noted, over several years’ observation at two medical centers, that postoperative complications occurred much more frequently in neurologically impaired children than in neurologitally normal children. The purpose of this study is to compare the results of antireflux surgery stratified for neurological status and to identify the causes of operative failure. MATERIALS
AND
METHODS
The charts of 234 children who underwent an antireflux operation at The Hospital for Sick Children, Toronto (n = 184) and Walter Reed Army Medical Center (WRAMC) in Washington, DC (n = 50) over a 5-year period from 1984 to 1989 were reviewed. Eighty-one were neurologically normal (NN) and 153 were neurologically impaired (ND. NI children had a variety of diagnoses. The two most common were cerebral palsy (CP)/asphyxia (n = 54) and developmental delay (n = 43), primarily related to prematurity with associated severe medical problems (Table 1). Mean age for the NN group was 2.0 years and for the NI group 3.0 years; ages ranged from 2 weeks to 18 years. The presenting complaints and indication for surgery, after failed medical therapy, were principally nutritional Journal
Wesson,
and
of Pediatric
Surgery,
Vol 25,
No
11 (November),
1990:
pp 1169-l
The postoperative results were divided into two time periods: perioperative (~30 days) and late postoperative (>30 days) (Table 4). During the perioperative period, two NN children died of nonaspiration-induced causes. One, with repaired tracheoesophageal fistula and anastomotic stricture, died 2 days postoperation of sepsis. The other child, with Pierre-Robin syndrome and tracheostomy, died of midgut volvulus 2 weeks postoperatively. Two NI children, one with craniofacial abnormalities and another with Arnold-Chiari syndrome, died of pulmonary dysmaturity and cardiac arrest, respectively, within 30 days of surgery. Eleven
From the Departments of Surgery, Walter Reed Army Medical Center, Washington. DC, and Hospital for Sick Children, Toronto, Ontario. Supported in part by the Department of Clinical Investigation. Walter Reed Army Medical Center. Washington, DC. Presented at the 2lst Annual Meeting of the Canadian Association of Paediatric Surgeons, Edmonton, Alberta, September 20-23, 1989. The opinions and conclusions are those of the authors and do not necessarily represent the views of the Army Medical Department, The Department of the Army, or any other US government agency. Address reprint requests to Richard H. Pearl, MD, Chic/. Pediatric Surgery Service, Department of Surgery, Walter Reed Army Medical Center, Washington, DC 20307. o 1990 by W.B. Saunders Company. 0022-3468/90/2511-0016$03.00/0 173
1169
1170
PEARL
Table
1. Cause
of Neurological
Impairment
Diagnosis Cerebral
Retardation Chromosomal
54
delay
10 7
abnormality
8 7 6
Seizures Trauma nervous
system
Total
in 234 Patients
Complications
NN (n = 81)
10 0 1
Total
3 (4%)
11 (7%)
3
18” 5
2. Presenting
Complaints/Indication
for
Surgery
Patients Presentation*
NN h = 81)
Respiratory Nutritional Vomiting
38 (47%) 47 (58%) 33 (41%)
F-I-T Esophageal
14(17%)
NI (n = 153) 94 112 62 50
(61%) (72%) (41%) (33%)
6 (4%)
5 (6%)
herniation failure
3 1 2
3.
Operative
two patients
end Follow-up
Data
6. Reason
PValue
Operation Nissen Dor Nissen G-tube
57 24 24 (30%)
121 31 132 (86%)
NS NS
Pearl,
D.K.
Robie,
S.H.
Ein,
B. Shandling, J.A.
D.E.
O’Connor,
Washington,
DC and
0 Antireflux surgery was performed in 234 children over a Iyear period; 153 were neurologically impaired (Nlj and 81 were neurologically normal (NN). Initial presentation, demographic data, and type of antireflux operation were similar in the two groups. Eighty-six percent of the NI group versus 30% of the NN group had gastrostomy tubes placed. The incidence of late postoperative complications was 28% in the NI group and 12% in the NN group (P < .Ol I. During the late postoperative period, NI children underwent reoperation four times as frequently as NN children (19% Y 5%. respectively; P < .Ol). Wrap herniation accounted for 38% of complications and 59% of reoperations in the late postoperative period. Mortality due to aspiration occurred in 9% of the NI group versus 1% of the NN group. Combined failure rate (reoperation plus aspiration-induced deaths) was 28% in NI and 8% in NN (P < .Ol). We conclude that neurological status is the major predictor of operative success and that wrap herniation due to crural disruption is the most common cause of operative failure. 0 1990 by W. B. Saunders Company. INDEX dures.
WORDS:
Gastroesophageal
reflux.
surgical
R. Superina,
R.M.
Toron
K. Mctaggart,
V.F.
Garcia,
Filler to,
Ontario
and respiratory. Respiratory problems included recurrent pneumonia and respiratory arrest. Nutritional problems were vomiting and failure to thrive (FIT) (Table 2). GER was diagnosed in over 90% of patients by an upper gastrointestinal (GI) series. Additional studies (milk scan, 24-hour pH monitoring, endoscopy) were required in approximately 10% of patients. A Nissen fundoplication with posterior approximation of the crura and 360“ fundic wrap about the distal esophagus was performed in 57 NN and 121 NI children. A Dor-Nissen (Thal, partial wrap) with anterior crural approximation, recreation of the angle of His by approximating cardia to esophageal wall, and a 210° anterior fundic wrap about the distal esophagus was performed in 24 NN and 3 1 NI children. Choice of operation was the preference of the operating surgeon and not influenced by neurological status of the child. Gastrostomy tubes were placed in 132 NI children as compared with 24 NN patients. Follow-up was achieved by clinic interviews, phone contact, and review of old records and clinic charts (Table 3). Results were analyzed using x2 test with Yates’ correction. To adjust for multiple comparisons, a P < .Ol (two-sided) was considered significant.’
proceRESULTS
P
ATHOLOGICAL gastroesophageal reflux (GER) is increasingly recognized as the cause for many nutritional and respiratory problems in the pediatric population. Surgical intervention is required in many children when standard medical therapy fails to eradicate symptomatic reflux. Several operations have become popular; however, the Nissen fundoplication is most commonly performed. We noted, over several years’ observation at two medical centers, that postoperative complications occurred much more frequently in neurologically impaired children than in neurologitally normal children. The purpose of this study is to compare the results of antireflux surgery stratified for neurological status and to identify the causes of operative failure. MATERIALS
AND
METHODS
The charts of 234 children who underwent an antireflux operation at The Hospital for Sick Children, Toronto (n = 184) and Walter Reed Army Medical Center (WRAMC) in Washington, DC (n = 50) over a 5-year period from 1984 to 1989 were reviewed. Eighty-one were neurologically normal (NN) and 153 were neurologically impaired (ND. NI children had a variety of diagnoses. The two most common were cerebral palsy (CP)/asphyxia (n = 54) and developmental delay (n = 43), primarily related to prematurity with associated severe medical problems (Table 1). Mean age for the NN group was 2.0 years and for the NI group 3.0 years; ages ranged from 2 weeks to 18 years. The presenting complaints and indication for surgery, after failed medical therapy, were principally nutritional Journal
Wesson,
and
of Pediatric
Surgery,
Vol 25,
No
11 (November),
1990:
pp 1169-l
The postoperative results were divided into two time periods: perioperative (~30 days) and late postoperative (>30 days) (Table 4). During the perioperative period, two NN children died of nonaspiration-induced causes. One, with repaired tracheoesophageal fistula and anastomotic stricture, died 2 days postoperation of sepsis. The other child, with Pierre-Robin syndrome and tracheostomy, died of midgut volvulus 2 weeks postoperatively. Two NI children, one with craniofacial abnormalities and another with Arnold-Chiari syndrome, died of pulmonary dysmaturity and cardiac arrest, respectively, within 30 days of surgery. Eleven
From the Departments of Surgery, Walter Reed Army Medical Center, Washington. DC, and Hospital for Sick Children, Toronto, Ontario. Supported in part by the Department of Clinical Investigation. Walter Reed Army Medical Center. Washington, DC. Presented at the 2lst Annual Meeting of the Canadian Association of Paediatric Surgeons, Edmonton, Alberta, September 20-23, 1989. The opinions and conclusions are those of the authors and do not necessarily represent the views of the Army Medical Department, The Department of the Army, or any other US government agency. Address reprint requests to Richard H. Pearl, MD, Chic/. Pediatric Surgery Service, Department of Surgery, Walter Reed Army Medical Center, Washington, DC 20307. o 1990 by W.B. Saunders Company. 0022-3468/90/2511-0016$03.00/0 173
1169
1170
PEARL
Table
1. Cause
of Neurological
Impairment
Diagnosis Cerebral
Retardation Chromosomal
54
delay
10 7
abnormality
8 7 6
Seizures Trauma nervous
system
Total
in 234 Patients
Complications
NN (n = 81)
10 0 1
Total
3 (4%)
11 (7%)
3
18” 5
2. Presenting
Complaints/Indication
for
Surgery
Patients Presentation*
NN h = 81)
Respiratory Nutritional Vomiting
38 (47%) 47 (58%) 33 (41%)
F-I-T Esophageal
14(17%)
NI (n = 153) 94 112 62 50
(61%) (72%) (41%) (33%)
6 (4%)
5 (6%)
herniation failure
3 1 2
3.
Operative
two patients
end Follow-up
Data
6. Reason
PValue
Operation Nissen Dor Nissen G-tube
57 24 24 (30%)
121 31 132 (86%)
NS NS
