Belgian week of gastroenterology edition:24 location:Oostende, Belgium date:10 February 2012 Belgian surgical week edition:13 location:Spa, Belgium date:9-12 May 2012 ESTS European Congres on General Thoracic Surgery edition:20 location:Essen, Germany date:10-13 June 2012
Preventive anti-reflux surgery at the moment of congenital diaphragmatic hernia repair has been suggested by some authors, especially in subgroups with a liver herniated in the chest or patch requirement. We evaluated the incidence and associated factors of gastroesophageal reflux disease and the need for subsequent anti-reflux surgery in our congenital diaphragmatic hernia patients.
We retrospectively reviewed our congenital diaphragmatic hernia database. Demographics, prenatal assessment of severity, prenatal treatment, type of repair, intra-operative findings and incidences of gastroesophageal reflux and anti-reflux surgery were recorded.
Between July 1993 and November 2009, congenital diaphragmatic hernia repair was performed in 77 infants. Eight died after repair. Seven were lost to follow-up. The median follow-up was 4.0 (0.16-14.88) years. Fourteen out of these 62 patients were prenatally treated with fetoscopic endoluminal tracheal occlusion because of severe pulmonary hypoplasia. Post congenital diaphragmatic hernia repair gastroesophageal reflux disease was diagnosed in 31 patients. In all of them medical anti-reflux treatment was started. 13 patients (42%) needed anti-reflux surgery at a median age of 63.5 (37-264) days. One year after starting medical treatment, 14 patients (45%) were completely off anti-reflux medication. In congenital diaphragmatic hernia subgroups with patch repair, liver herniated in the chest or previous fetoscopic endoluminal tracheal occlusion, the incidences of gastroesophageal reflux and anti-reflux surgery were 61% and 32%, 73% and 38%, and 71% and 43%, respectively. Univariate analysis of associated potentially predisposing factors shows that patch repair, liver herniated in the chest, pulmonary hypertension, high frequency oscillatory ventilation and fetoscopic endoluminal tracheal occlusion are associated with subsequent anti-reflux surgery. On multivariable analysis liver herniated in the chest was the only independent predictor for both gastroesophageal reflux and anti-reflux surgery.
Of all congenital diaphragmatic hernia patients, 50% developed gastroesophageal reflux and 21% required anti-reflux surgery. Routine anti-reflux surgery at the time of congenital diaphragmatic hernia repair seems not to be justified despite the higher likelihood of gastro-esophageal reflux and anti-reflux surgery in certain subgroups. Fetal endoluminal tracheal occlusion creates a new cohort of survivors with an increased risk for undergoing anti-reflux surgery. The surgical group in particular reflects a more complex gastroesophageal reflux physiopathology.