Laparoscopic antireflux procedures in the management of gastroesophageal reflux following esophageal atresia repair

Objectives: The validity of open fundoplication after esophageal atresia (EA) repair is still disputed. The authors have retrospectively evaluated the results achieved in their centers using laparoscopic antireflux procedures (LARP) in children operated for EA at birth. Methods: From 1998 to 2002. 350 children underwent LARP. Of these, 21 (6%) underwent EA repair at birth. Our study focused only on the management of these 21 patients; 5 of them (23.8%) were neurologically impaired children (NIC). All underwent LARP, 9 patients according to Nissen, 9 according to Thal, and 3 according to Toupet. The 5 NIC with feeding problems underwent concomitant g-tube placement during the same procedure. Results: All the procedures were completed in laparoscopy, without intraoperative complications. The mean operative time was 65 minutes (range 45-140). We had no mortality in our series. Hospital stay varied from 2 to 9 days (median 3 days). At a maximum follow-up of 6 years, all patients were evaluated with a 24-hours pH-metry and barium swallow. The 16 neurologically normal children were free of symptoms at the last follow-up; five of them (31.2%) had mild dysphagia, which disappeared spontaneously within 3-6 months. One girl experienced an important episode of aspiration 2 years after the LARP, although there was no evidence of reflux at the follow-up examinations. As for the 5 NIC, one patient eats only through a g-tube, the other 4 undergo mixed feeding (g-tube and mouth),none have signs of GER, but two of them still present respiratory symptoms, and one has delayed gastric emptying. Conclusions: In our experience laparoscopic antireflux surgery is an appropriate treatment of GER in children operated for EA at birth, independently of the antireflux mechanism adopted; the 31.2% rate of short-term dysphagia presenting as residual respiratory symptoms may be due to a primary dysmotility of the esophagus consequent to the esophageal atresia.