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Nissen fundoplication in children with GERD reduces need for antireflux medication, researchers find

Thursday, October 16 2008 | Comments
Evidence Grade 3 What's This?
Nissen fundoplication in children with gastroesophageal reflux disease (GERD) appears to reduce the use of antireflux medication following the procedure, and neurologically healthy children experience the biggest decrease in medication use, according to the results of a multicenter cohort study.

Although medical management remains the primary treatment for GERD, when the condition is accompanied by pulmonary complications, apnea, and failure to thrive, antireflux surgery is often required. Minimally invasive Nissen fundoplication is now one of the most common operations performed by pediatric surgeons, with >30,000 antireflux operations performed annually, the researchers of the study noted. They added that an advantage of this surgery is that it may obviate the need for medical management throughout the patient's life.

In this retrospective review, which is based on data from the Southern California Kaiser Permanente Discharge Abstract Database, the investigators identified 342 pediatric patients at 12 centers who underwent Nissen fundoplication from 1996 to 2005. The primary endpoint of the study was use of antireflux medication. The mean patient age at the time of surgery was 3.9 years, and 154 patients (45.0%) had an associated neurological disorder. Mean follow-up was 4.5 years.

Antireflux medication was administered to 233 patients before surgery and to 197 patients after surgery. Of those who received the therapy after surgery, 150 had been using it prior to the procedure, whereas the remaining 47 patients had no history of antireflux medication use.

Within 1 year following Nissen fundoplication, 75.6% of the 233 children who were using antireflux drugs prior to the procedure were restarted on the medication. Use of antireflux medication decreased in the neurologically healthy patients, but there was no significant change in use among the neurologically impaired children.

Although the literature contains some studies that show a beneficial relationship between Nissen fundoplication and the symptoms of GERD, there is little long-term data following the procedure in children. In addition, the preoperative evaluation for children undergoing surgery is inconsistent, making it difficult to accurately assess the effect following Nissen fundoplication. Despite these drawbacks, the authors found that the use of antireflux medication decreased after surgery.

"Neurologically healthy children showed the biggest decrease in antireflux medication use after Nissen fundoplication," the study authors commented.

Since the use of antireflux medication among children with underlying neurological disorders did not change following the procedure, the researchers suggested that GERD severity, recurrence of related complications, and antireflux medication use following the surgery "may be more affected by a patient's underlying neurologic status than by performing Nissen fundoplication." (Lee SL, et al. Arch Surg 2008;143:873-876.)

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