Independent original article
Predicting the need for fundoplication at the time of congenital diaphragmatic hernia repair

https://doi.org/10.1016/j.jpedsurg.2007.01.046Get rights and content

Abstract

Purpose

This study was conducted to examine the preoperative factors predictive of subsequent intervention for gastroesophageal reflux (GER) in children with congenital diaphragmatic hernia (CDH).

Methods

We conducted a retrospective cohort study on children who underwent repair of a CDH between January 1, 1995, and December 31, 2002 with follow-up continuing to September 1, 2005. Excluded in the study were children who died during their first admission, or who underwent fundoplication at the time of CDH repair. Univariate and multivariate logistic regressions were performed to examine preoperative factors predictive of subsequent intervention (fundoplication or gastrojejunal tube placement).

Results

Of 86 children, 13 underwent intervention (fundoplication, 10; gastrojejunal tube, 3) for GER. Univariate predictors included the following: right-sided CDH, use of nonconventional ventilation, liver within the chest, and patch closure of the CDH. However, only liver within the chest and patch closure of the CDH were significant predictors in a multiple variable analysis. The positive and negative predictive values of the multivariate model were 69.2% and 87.7%, respectively.

Conclusions

Infants with CDH who have liver within the chest or require patch closure of their hernia are at increased risk for subsequent intervention for GER. These children may represent a subpopulation that would benefit from fundoplication at the time of CDH repair.

Section snippets

Method

We performed a retrospective cohort study on all patients who underwent repair of a posterolateral (Bochdalek) CDH between January 1, 1995, and December 31, 2002 at the Hospital for Sick Children in Toronto. The observation period continued until September 31, 2005 to ensure adequate capture of patients who received intervention for symptomatic GER. Children were excluded from the cohort if they died during the same admission as their CDH repair, or if they underwent a concurrent antireflux

Results

A total of 108 children underwent CDH repair during the index time period. Nineteen of these children died during their initial hospitalization, and 3 underwent fundoplication at the time of CDH repair. These 22 children were excluded, and therefore the retrospective cohort comprised 86 children.

Thirty-eight patients (44%) received pharmacologic therapy for GER. Thirty-six (42%) children received acid suppression, whereas 33 (38%) were prescribed prokinetic medications. Of the 86 children, 13

Discussion

Gastroesophageal reflux was only identified as a significant problem in survivors of CDH in the 1990s [2], [3], [4]. Estimates of the incidence of GER within the CDH population range from 12% to 69% [6]. However, an incidence of up to 81% has been demonstrated in those who received extracorporeal membrane oxygenation (ECMO) before repair of their CDH [7]. A number of mechanisms for the development of GER in this population have been proposed. Most of these relate to developmental consequences

Acknowledgments

The authors would like to thank Robin Vaughan for her assistance with this project. Ivan Diamond was supported by the Surgeon Scientist Training Program, Department of Surgery, University of Toronto.

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