Long-term outcomes following failure of Nissen fundoplication

Infographic · Jun 2022 · 1 min read

In brief

Retrospective study of 190 pediatric patients requiring intervention after failed Nissen fundoplication found that 63% underwent redo fundoplication, with success rates declining after each attempt. Patients previously managed with gastro-jejunal feeding had significantly higher rates of redo fundoplication failure, suggesting surgical intervention should be avoided in this group when symptom-free on jejunal feeds.

23% of pediatric Nissen fundoplications require further intervention for recurrent GOR at median 21 months post-op.
Success rates decline with each redo fundoplication; prior gastro-jejunal tube placement predicts higher failure risk (p=0.005).
Patients symptom-free on GJ feeds should avoid further anti-reflux surgery; 74% remained on GJ feeds long-term (median 48 months).
Only 2% required emergency wrap revision within 4 days; most failures occurred months to years later (median 15 months).
After third fundoplication failure, options narrow to continued GJ feeding, esophagogastric dissociation, or gastric pacing.

Written by the GCMD Library team from the infographic.

A horizontal flowchart with four stomach diagrams showing progressive surgical attempts. Each stage displays failure percentages in large blue numbers (23%, 40%, 46%) with arrows indicating patient flow between repeat procedures and alternative treatments. Red X marks the initial failed procedure, and numbered circles (2-4) mark subsequent attempts. The final stage shows a gastrojejunal feeding tube illustration.

Abstract

Purpose

To determine the management and outcomes of patients with gastro-oesophageal reflux (GOR) that requires 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 are 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 gastro-jejunal 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 3rd NF, 4 continued GJ feeding, 2 of had oesophagogastric dissociation; 2 had 4th 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.

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