Reevaluation of recurrence mechanisms after Nissen fundoplication

Abstract

Objective: Nissen fundoplication is the most frequently performed surgery for the gastroesophageal reflux disease (GERD), however recurrence is frequent in neurologically impaired patients. Anatomic deformation of the fundoplication wrap is the classically defined presentation. The putative risk factors exist in most of cases and but they are unable to define the pathology of failure. We aimed to analyze failure mechanisms after fundoplication. Method: Children with GERD who had undergone fundoplication between January 2011 and February 2014 were included in the study. Ongoing reflux symptoms after surgery were considered as recurrence of gastroesophageal reflux disease (rGERD). Correlation between development of disease recurrence and gender, age, failure to thrive, neurological status, hiatus hernia, scoliosis, surgical methods, gastrostomy and oropharyngeal symptoms was investigated. Variables were studied by logistic regression analysis. P<0.05 was considered statistically significant. Results: Sixty-seven children (male 40, female 27) were included in the study. Mean age of the patients was 57.10±52.22 months and follow up time was 19.64±7.75 months. Reflux recurrence was detected in 16 (23.8%) children. In barium contrast studies, fundoplication wrap was deformed in only one (6.2%) patient. In endoscopic examination loose wrap adherence (n=7) and intermittent wrap relaxation (n=3) activities were observed as the etiologic mechanisms of recurrence that were correlated with severe swallowing dysfunction and gagging, respectively. Conclusion: We assume that despite an anatomically intact fundoplication, persistent lower esophageal sphincter relaxations and loose wrap configurations might be the etiologic factors for recurrence in some of neurologically impaired patients. Also the relationship of these fundoplication findings with some oropharyngeal symptoms implies a complex failure mechanism. Oropharyngeal symptoms might be helpful in prediction of the development of risk preoperatively.