During the long-term follow-up of children operated on by me for congenital diaphragmatic hernia, most by laparotomy, I found a moderate gastro-esophageal reflux with gaping of the cardia in half of them. At this point the conservative therapy affects the reflux symptoms. But, with two children of the 11 receiving surgery for the last 10 years, I found necessary to perform a antireflux procedure (probably Toupet). The reason for this decision is an expressed erosive esophagitis and moderate peptic stricture seen in these two children. My question is: Is it not necessary to perform in selected cases a antireflux procedure as a separate stage of the surgery for congenital diaphragmatic hernia?
H prof. Ognyan Georgiev Brankov,if we find the His angle is wide in any operation of this area we have to perform antireflux surgery .
Regrds
Prof.alireza Mirshemirani
Hi prof. Ognyan Georgiev Brankov,if we find the His angle is wide in any operation of this area we have to perform antireflux surgery .
Regrds
Prof.alireza Mirshemirani
In infants operated on for CDH, the reported prevalence of gastroesophageal reflux ranges between 12% and 81%.
In patients with CDH, gastroesophageal reflux may be responsible (at least in part) for poorer outcomes, including delayed weaning from mechanical ventilation, longer hospital stay, failure to thrive, and oral aversion. As a consequence of the high prevalence of gastroesophageal reflux and the severity of its sequelae, antireflux procedures are needed in as many as more than 60% of infants operated on for CDH. This has led some authors to propose preventive fundoplication at the time of CDH repair, however, few studies have assessed the efficiency of this procedure.
Chamond et al. performed preventive anti-reflux surgery in 17 out of 36 left-sided CDH patients. Significantly fewer patients who had undergone preventive anti-reflux procedure had proven pathological gastroesophageal reflux in the first year of life, and patients with preventive anti-reflux surgery needed nasogastric tube feeding for a significantly shorter time. In less severe patients, artificial ventilation, parenteral nutrition, and hospitalization lasted longer in patients who had preventive anti-reflux surgery, reaching significance only in those with mild disease (defined as neither patch nor liver in the chest). Preventive anti-reflux surgery in more severe cases (liver in the chest and patch repair) was associated with shorter duration of artificial ventilation, parenteral nutrition, and hospitalization, although not reaching statistical significance due to the small numbers. Based on their findings the authors support preventive anti-reflux surgery only for severe cases, that is when the liver has protruded into the chest and when a patch repair is needed.
Guner et al. reported not any morbidity related to partial fundoplication at the time of CDH repair in 13 neonates and suggested improvement in post-operative oral feeding, although no mention is made of a control group. They recommend considering additional anterior fundoplication in high-risk cases, i.e. when the intra-abdominal oesophagus is absent, and when an obtuse His angle and a small and/or vertically oriented stomach are seen. They propose a modified Boix-Ochoa procedure, with no crural dissection, as microgastria is frequent in CDH patients. Apart from the high prevalence of gastroesophageal reflux in CDH patients, the suggested reasons for a preventive fundoplication are the increased difficulties in performing anti-reflux surgery later, after a previous laparotomy, due to adhesions, the presence of synthetic patch, and abnormal position of liver and spleen.
More recently, Dariel and colleagues reported the outcomes of 57 patients from the French CDH Study Group with patch repair of left CDH, 34 with preventive fundoplication and 23 without. They found improved growth in patients who had undergone preventive fundoplication. Therefore, they suggest that prophylactic fundoplication may prevent growth disorders in CDH patients requiring a patch repair.
The only prospective, randomized study on the efficacy of preventive fundoplication is from the University of Mannheim. The authors analysed the outcomes of 79 neonates with left-sided CDH, 36 randomized to receive preventive anti-reflux surgery and 43 without prophylactic fundoplication. At follow-up in the first two years of life they found no differences between the two groups in gastroesophageal reflux symptoms and severity and prevalence of failure to thrive. Based on their findings they do not recommend prophylactic anti-reflux surgery at the time of CDH repair.
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