Anti-reflux surgery in children with Congenital Diaphragmatic Hernia (CDH) | 762 CDH neonates | 81 fundoplication | preventive or curative | Patch CDH = need for synthetic patch or muscle flap repair | Prospective study | Multi-institutional | Jan 2010 - Dec 2018 | Centers offering preventive fundoplication (31% of centers) have higher rates of curative and overall fundoplications. | Patch repair → single independent predictive factor for needing curative fundoplication | Predictive factors for preventive fundoplication: | Prenatal diagnosis | Fetal tracheal occlusion | Intra-thoracic liver | CDH-grade C-D | Patch repair | Preventive fundoplication didn't decrease the need for curative fundoplication, and was associated w/ higher rates of | failure to thrive | tube feeds | oral aversion | Conclusion: Performing a preventive fundoplication as part of the initial patch repair for CDH does not reduce the necessity for a curative fundoplication and is linked to unfavorable gastrointestinal results. | https://doi.org/10.1016/j.jpedsurg.2022.04.017 | Source: Montalva L et.al. | Department of Pediatric General Surgery and Urology, Robert-Debre University Hospital, AP-HP, Paris, France | @EmTombash | @StayCurrentMD | Cincinnati Children's | Journal of Pediatric Surgery
Anti-reflux surgery in children with congenital diaphragmatic hernia: A prospective cohort study on a controversial practice
Infographic · Feb 2023 · 2 min read
In brief
In brief
This French multi-center study of 762 CDH neonates found that preventive fundoplication during patch repair does not reduce need for later anti-reflux surgery and is associated with worse feeding outcomes including higher rates of failure to thrive and tube dependency. Findings challenge routine prophylactic fundoplication in CDH patients.
- Preventive fundoplication during CDH patch repair does not reduce need for later curative fundoplication (15% vs 11%, p=0.53).
- Preventive fundoplication associates with worse outcomes: higher failure to thrive (81% vs 51%), tube feeding (50% vs 21%), and oral aversion.
- Patch repair is the only independent predictor for requiring curative fundoplication after CDH repair (8% overall rate).
- Centers performing preventive fundoplication have higher overall fundoplication rates (20% vs 3%), suggesting practice variation drives outcomes.
- GERD is the most common long-term morbidity in CDH survivors; curative fundoplication typically needed at median 101 days post-repair.
Written by the GCMD Library team from the infographic.
The infographic uses a teal and yellow color scheme with illustrated icons including a calendar/clock, a baby in a blanket, and a healthcare provider. Information is organized in sections with headers, bullet points, and highlighted text boxes. Key findings are emphasized with arrows and contrasting background colors.
Louise Montalva, Elisabeth Carricaburu, Rony Sfeir, Virginie Fouquet, Naziha Khen-Dunlop, Frederic Hameury, Nicoleta Panait, Alexis Arnaud, Hubert Lardy, Françoise Schmitt, Christian Piolat, Frederic Lavrand, Quentin Ballouhey, Aurélien Scalabre, Erik Hervieux, Jean-Luc Michel, Isabelle Germouty, Philippe Buisson, Frederic Elbaz, Jean-Francois Lecompte, Thierry Petit, Audrey Guinot, Olivier Abbo, Emmanuel Sapin, François Becmeur, Dominique Forgues, Maguelonne Pons, Arnaud Fotso Kamdem, Nicolas Berte, Marie Auger-Hunault, Alexandra Benachi, Arnaud Bonnard, on behalf of theFrench Center for Rare Diseases “Congenital Diaphragmatic Hernia”
Introduction: Gastro-esophageal reflux disease (GERD) is the most frequent long-term morbidity of congenital diaphragmatic hernia (CDH) survivors. Performing a preventive fundoplication during CDH repair remains controversial. This study aimed to: (1) Analyze the variability in practices regarding preventive fundoplication; (2) Identify predictive factors for fundoplication. (3) Evaluate the impact of preventive fundoplication on gastro-intestinal outcomes in children with a CDH patch repair;
Methods: This prospective multi-institutional cohort study (French CDH Registry) included CDH neonates born in France between January 1st, 2010-December 31st, 2018. Patch CDH was defined as need for synthetic patch or muscle flap repair. Main outcome measures included need for curative fundoplication, tube feed supplementation, failure to thrive, and oral aversion.
Results: Of 762 CDH neonates included, 81 underwent fundoplication (10.6%), either preventive or curative. Median follow-up was 3.0 years (IQR: 1.0–5.0).
(1) Preventive fundoplication is considered in only 31% of centers. The rates of both curative fundoplication (9% vs 3%, p = 0.01) and overall fundoplication (20% vs 3%, p < 0.0001) are higher in centers that perform preventive fundoplication compared to those that do not.
(2) Predictive factors for preventive fundoplication were: prenatal diagnosis (p = 0.006), intra-thoracic liver (p = 0.005), fetal tracheal occlusion (p = 0.002), CDH-grade C-D (p < 0.0001), patch repair (p < 0.0001). After CDH repair, 8% (n = 51) required curative fundoplication (median age: 101 days), for which a patch repair was the only independent predictive factors identified upon multivariate analysis.
(3) In neonates with patch CDH, preventive fundoplication did not decrease the need for curative fundoplication (15% vs 11%, p = 0.53), and was associated with higher rates of failure to thrive (discharge: 81% vs 51%, p = 0.03; 6-months: 81% vs 45%, p = 0.008), tube feeds (6-months: 50% vs 21%, p = 0.02; 2-years: 65% vs 26%, p = 0.004), and oral aversion (6-months: 67% vs 37%, p = 0.02; 1-year: 71% vs 40%, p = 0.03).
Conclusions: Children undergoing a CDH patch repair are at high risk of requiring a curative fundoplication. However, preventive fundoplication during a patch repair does not decrease the need for curative fundoplication and is associated with worse gastro-intestinal outcomes in children.