Long-term Outcomes Following Pediatric Nissen Fundoplication

Long-term Outcomes Following
Pediatric Nissen Fundoplication

S Shekherdimian, MD, SL Lee, MD,
RM Sydorak, MD, H Applebaum, MD, PI Haigh, MD

Division of Pediatric Surgery and Department of Surgery
Kaiser Permanente, Los Angeles Medical Center
Los Angeles, CA

Background

• Gastroesophageal Reflux (GER)

– Common in infants and children
– Resolves

• Gastroesophageal Reflux Disease (GERD)

– Complications
– Medical management

Background

• Nissen fundoplication (NF)

– Respiratory symptoms
– Failure to thrive (FTT)

• Common procedure

– Associated neurologic disorders

• Unknown long-term impact

Hypothesis

• Nissen fundoplication (NF)

– Decreases use of anti-reflux and asthma
medication

– Decreases hospital admission for pulmonary
symptoms and FTT

Methods

• Retrospective cohort study using discharge
abstract data and pharmacy data

• 12 Kaiser Permanente hospitals in Southern
California

• Ten year period: 1996-2005

• Pediatric patients (< 18 years)

Methods

• Anti-reflux medication

– Proton-pump inhibitors
– H2 blockers

• Asthma Medication

• ICD-9 codes for hospital admissions

– Pneumonia (aspiration and other)
– Respiratory distress (apnea and cyanosis)
– Failure to thrive

Methods

• Age

• Associated neurologic disorders

• Statistical analysis

– McNemar Test
– Poisson Regression analysis

Results

Demographics

• 342 patients with ≥ 1 NF

– 336 patients with medication data

• Mean age 3.9 years

• Male:female = 1.2:1

• 45% with associated neurologic disorder

• Mean follow-up 4.5 years

Results

Use of Anti-reflux Medications

Anti-reflux Medications

Total Patients Pre-Nissen Post-Nissen
(n=336) 233 197
233 150
Previous Medications 0 47

No Previous Medications
(n=103)

Results

Neurologic Status and Use of Anti-reflux Medications

Anti-reflux Medications

Neurologic Status Pre-Nissen Post-Nissen

Neurologically Normal 140 101
(n=186)
140 85
Previous Medications
No Previous Medications 0 16

(n=46)

Results

Neurologic Status and Use of Anti-reflux Medications

Anti-reflux Medications

Neurologic Status Pre-Nissen Post-Nissen

Neurologically Impaired 93 96
(n=150)
93 65
Previous Medications
No Previous Medications 0 31

(n=57)

Results

Use of Inhaled Asthma Medications

Inhaled Asthma Medications

Total Patients Pre-Nissen Post-Nissen
(n=336) 168 227
168 140
Previous Medications 0 87

No Previous Medications
(n=168)

Results

Neurologic Status and Use of Inhaled Asthma
Medications

Inhaled Asthma Medications

Neurologic Status

Pre-Nissen Post-Nissen

Neurologically Normal 91 115
(n=186)

Previous Medications 91 75

No Previous Medications 0 40
(n=95)

Results

Neurologic Status and Use of Inhaled Asthma
Medications

Inhaled Asthma Medications

Neurologic Status

Pre-Nissen Post-Nissen

Neurologically Impaired 77 112
(n=150)

Previous Medications 77 65

No Previous Medications 0 47
(n=73)

Results

Use of Systemic Asthma Medications

Systemic Asthma Medications

Total Patients Pre-Nissen Post-Nissen
(n=336) 102 150
102 70
Previous Medications 0 80

No Previous Medications
(n=234)

Results

Neurologic Status and Use of Systemic Asthma
Medications

Systemic Asthma Medications

Neurologic Status

Pre-Nissen Post-Nissen

Neurologically Normal 59 75
(n=186)

Previous Medications 59 38

No Previous Medications 0 37
(n=127)

Results

Neurologic Status and Use of Systemic Asthma
Medications

Systemic Asthma Medications

Neurologic Status

Pre-Nissen Post-Nissen

Neurologically Impaired 43 75
(n=150)

Previous Medications 43 32

No Previous Medications 0 43
(n=107)

Results

Aspiration and Other Pneumonia

Hospital Admission

Aspiration and Other
Pneumonia

Pre-Nissen Post-Nissen

Total Patients 110 113

Previous Admission 110 50

No Previous Admission 0 63

Results

Respiratory Distress and Apnea

Respiratory Distress Hospital Admission
and Apnea
Pre-Nissen Post-Nissen

Total Patients 129 120

Previous Admission 129 65

No Previous Admission 0 55

Results

Failure to Thrive

Hospital Admission

Failure to Thrive

Pre-Nissen Post-Nissen

Total Patients 127 118

Previous Admission 127 72

No Previous Admission 0 46

Results

Regression Analysis

• Nissen fundoplication had no effect

– Pneumonia, respiratory distress, FTT

• Neurologic disorder increased

– Pneumonia, respiratory distress, FTT

• Age decreased

– Respiratory distress and FTT

Results

Recurrence and Mortality

• 26 (7.6%) patients had more than one NF

• 51(14.9%) patients died

– 2 pneumonia
– 2 respiratory distress

Conclusions

• NF decreased the use of anti-reflux
medication by 37%

• NF increased the overall use of asthma
medications

• Neurologically normal children showed the
greatest decrease in medication use after NF

Conclusions

• Overall, no change in hospital admissions
after Nissen fundoplication for:

– Pneumonia, respiratory distress, and failure to
thrive

• Neurologic disorders increased risk for

– Pneumonia, respiratory distress, and failure to
thrive

• Increasing age decreased the risk for

– Respiratory distress and failure to thrive