Anti-reflux surgery in children with congenital diaphragmatic hernia: A prospective cohort study on a controversial practice

Infographic · May 2023 · 2 min read

In brief

French multi-center study of 762 CDH patients 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 at 2 years. Findings challenge routine prophylactic fundoplication in CDH repair.

Preventive fundoplication during CDH patch repair does not reduce need for later curative fundoplication (15% vs 11%, p=0.53)
Preventive fundoplication associated with worse outcomes: higher failure to thrive (81% vs 51%), tube feeds (50% vs 21%), oral aversion (67% vs 37%)
Patch repair is the only independent predictor for requiring curative fundoplication in CDH patients
Only 31% of centers perform preventive fundoplication, but those centers have higher overall fundoplication rates (20% vs 3%)
8% of CDH patients required curative fundoplication at median 101 days post-repair; patch repair patients are highest risk group

Written by the GCMD Library team from the infographic.

The infographic uses a red and white color scheme with anatomical illustrations of the stomach and diaphragm on the left. The center shows a patch repair icon plus a stomach illustration representing preventive fundoplication. The right side displays two outcome comparisons with stomach icons and statistical data, including a failure-to-thrive icon with baby footprints.

New infographic By Dr. Jose Campos and the Chilean Society of Pediatric Surgery

"Anti-reflux surgery in children with congenital diaphragmatic hernia: A prospective cohort study on a controversial practice"

Authors: Louise Montalva, Elisabeth Carricaburu, Rony Sfeir, Alexandra Benachi, Arnaud Bonnard, on behalf of theFrench Center for Rare Diseases “Congenital Diaphragmatic Hernia”

Full article: https://www.jpedsurg.org/article/S0022-3468(22)00323-2/ppt

Abstract

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.

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