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

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

J Pediatr Surg

. 2022 Apr 27;S0022-3468(22)00323-2. doi: 10.1016/j.jpedsurg.2022.04.017. Online ahead of print. https://pubmed.ncbi.nlm.nih.gov/35618494/

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

Louise Montalva 1Elisabeth Carricaburu 2Rony Sfeir 3Virginie Fouquet 4Naziha Khen-Dunlop 5Frederic Hameury 6Nicoleta Panait 7Alexis Arnaud 8Hubert Lardy 9Françoise Schmitt 10Christian Piolat 11Frederic Lavrand 12Quentin Ballouhey 13Aurélien Scalabre 14Erik Hervieux 15Jean-Luc Michel 16Isabelle Germouty 17Philippe Buisson 18Frederic Elbaz 19Jean-Francois Lecompte 20Thierry Petit 21Audrey Guinot 22Olivier Abbo 23Emmanuel Sapin 24François Becmeur 25Dominique Forgues 26Maguelonne Pons 27Arnaud Fotso Kamdem 28Nicolas Berte 29Marie Auger-Hunault 30Alexandra Benachi 31Arnaud Bonnard 2French Center for Rare Diseases “Congenital Diaphragmatic Hernia”Affiliations expand

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.

Level of evidence: II – Prospective Study.

Keywords: CDH; Congenital disease; Gastrostomy; Nissen; Pediatric surgery; Standardized care.

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