THE FAILURE RATE OF SURGERY FOR GASTROESOPHAGEAL REFLUX

Purpose: The aim of this study was to document the presenting symptoma tology and radiological findings of failed fundoplication, to determin e the risk factors involved in recurrent gastro-oesophageal reflux, an d to assess the results of revisional surgery. Methods: Sixty-six pati ents requiring redo fundoplication during the past 15 years were studi ed. Sixty children had their initial fundoplication performed at our i nstitution. Results: The median time from initial fundoplication to th e diagnosis of failure was 1.5 years. The main presenting symptoms wer e severe retching (n = 33), recurrent vomiting and aspiration (n = 26) and intolerable gas bloat (n = 7). Severe dysphagia occurred in two c hildren with light Nissen fundoplications. Contrast radiographic studi es demonstrated fundoplication failure and correlated with the operati ve findings in 85% of cases. Risk factors for failure comprised hypert onic cerebral palsy, severe learning difficulties, oesophageal atresia , CHARGE syndrome, and tracheomalacia. The cause for the fundoplicatio n failure included herniation of the fundoplication into the posterior mediastinum (failed crural repair, n = 30), disruption of the wrap (n = 10), combination of herniation and disruption (n = 22), and a tight wrap (n = 4). After revisional surgery, 13 children had persisting sy mptoms, five of whom underwent a third antireflux procedure. Conclusio ns: The predominant cause of fundoplication failure is herniation into the posterior mediastinum, which occurred most frequently in children with hypertonic cerebral palsy. This may be prevented by meticulous a ttention to accurate apposition of the crura at initial procedure. Red o fundoplication failed to resolve the preoperative symptoms in 20%, w ith five children requiring a third fundoplication. Copyright (C) 1998 by W.B. Saunders Company.