This study aimed to evaluate the indications, techniques, and outcomes of fundoplication in pediatric patients with gastroesophageal reflux disease treated at a tertiary hospital in Yemen. The findings provide valuable insights into the effectiveness of fundoplication and highlight the importance of specific indications for achieving optimal outcomes.
The demographic characteristics of our study population, with a median age of 2 years and nearly equal gender distribution (56% males, 44% females), are consistent with other studies on pediatric patients with GERD undergoing fundoplication. This demographic consistency strengthens the reliability of our findings and their applicability to similar patient populations.15
The primary indications for fundoplication in our study population included GERD with hiatal hernia (44.4%), persistent symptoms despite medical management (20%), recurrent chest infections associated with neurological disorders (15.6%), esophageal stricture (17.8%), and the presence of both hiatal hernia and esophageal stricture (2.2%). These indications align with those reported in the literature, where fundoplication is commonly indicated for severe GERD symptoms unresponsive to medical therapy, anatomical abnormalities, and GERD-related respiratory complications.12,16 This underscores the necessity of surgical intervention in patients with these specific conditions to prevent further complications and improve quality of life.
In terms of outcomes, our study found that 68.89% of patients experienced complete symptom resolution after surgery. This success rate is comparable to those reported in other recent studies, which reported symptom resolution rates ranging from 60% to 90% among pediatric patients with GERD undergoing fundoplication.15,17 Postoperative complications were observed in 15 patients (33.3% of cases). Dysphagia due to postoperative esophageal stricture was the most common complication, affecting 13 patients (29%). Of these, 9 patients had preoperative esophageal stricture, while 4 developed dysphagia after Nissen fundoplication with hiatal hernia repair. This finding highlights the need for careful patient selection and postoperative management.18,19
Our structured dilatation protocol for managing postoperative esophageal strictures played a crucial role in the success of our fundoplication procedures. Specifically, 30.8% of patients showed improvement after a single session, 46.2% improved after regular sessions, and 23.1% did not improve after irregular sessions. These findings can be contextualized by comparing them with several relevant studies on post-fundoplication dilatation. For instance, Malhi-Chowla et al. (2002) reported that 91% of patients who underwent esophageal dilation after fundoplication experienced symptomatic relief, highlighting the efficacy of regular dilatation sessions in managing postoperative strictures. 20 Similarly, Spivak et al. (1998) emphasized the importance of follow-up and regular intervention by noting that postoperative re-dilatation was necessary for achieving satisfactory outcomes in managing strictures. 21 Koivusalo and Pakarinen (2018) analyzed pediatric fundoplication and found that postoperative esophageal strictures were managed effectively with a structured follow-up protocol, which aligns with our findings that regular sessions yield better outcomes compared to irregular management.22 In contrast, El-Serag and Sonnenberg (1999) indicated that postoperative dysphagia and strictures were common complications that required consistent and often aggressive management to prevent recurrence and improve patient outcomes.23 Additionally, Csendes et al. (2019) conducted a long-term follow-up study on patients who underwent laparoscopic Nissen fundoplication and found that esophageal strictures, while a frequent complication, were effectively managed through timely and regular dilatation procedures.24 These studies reinforce the importance of a structured postoperative care plan, such as ours, to mitigate the risks associated with esophageal strictures and ensure optimal patient outcomes.
In our study, the comparison between Nissen and Thal fundoplication demonstrated that Thal had better outcomes, with fewer cases of dysphagia (p=0.08) and a higher rate of complete symptom resolution (p=0.06). These results may be partially explained by our approach where Nissen fundoplication was performed on patients with preoperative esophageal stricture and Thal fundoplication was used for patients with smaller stomachs. This clinical decision-making, although systematic, could be perceived as a form of selection bias contributing to the observed better outcomes with Thal compared to Nissen. However, it is important to note that these differences did not reach statistical significance.
Comparative studies have shown that while Nissen fundoplication is effective, it is associated with a higher incidence of postoperative complications, such as dysphagia and bloating, compared with other techniques.25 These findings suggest that alternative fundoplication techniques may offer advantages in terms of reducing specific complications although overall success rates remain comparable.26,27
The observed mortality rate of 5.56% in our study, with two deaths occurring six months post-Nissen fundoplication in patients with cerebral palsy, underscores the significant risk associated with this surgical intervention in neurologically impaired individuals. These fatalities were due to recurrent chest infections related to their underlying neurological conditions rather than GERD recurrence or esophageal stricture. This finding aligns with previous studies that have documented the heightened vulnerability of neurologically impaired patients to respiratory complications following fundoplication, emphasizing the need for comprehensive preoperative assessment, vigilant postoperative monitoring, and a multidisciplinary approach to manage both GERD and respiratory risks effectively. 28,29
A strength of this study is the comprehensive inclusion of various indications for fundoplication, providing a detailed overview of its efficacy across different patient subsets. However, these limitations include the lack of 24-h esophageal pH monitoring and the reliance on barium studies and endoscopies, which may limit the precision of our findings. Socioeconomic factors influenced adherence to postoperative protocols, particularly regular dilatation, which may have affected outcomes. Additionally, the study's observational nature and single-center setting may limit the generalizability of the results.
The findings have important clinical implications. Fundoplication should be considered a viable option for pediatric patients with GERD who are unresponsive to medical management. Early diagnosis and intervention, along with regular postoperative follow-up and dilatation protocols, are crucial for improving outcomes, especially in patients with preoperative esophageal stricture. Surgeons should consider individual patient anatomy and clinical conditions when selecting the type of fundoplication. Additionally, addressing socioeconomic barriers to adherence could further enhance patient outcomes.
Future research should focus on the long-term outcomes of fundoplication in pediatric patients, including quality of life assessments and the identification of predictors of successful outcomes. Comparative studies comparing different fundoplication techniques and the roles of minimally invasive approaches in pediatric populations could provide valuable insights. Strategies to improve adherence to postoperative protocols, particularly in low-resource settings, should also be explored. Multicenter studies could enhance the generalizability of findings and provide a broader perspective on the effectiveness of fundoplication in diverse populations.