The Journal of Thoracic and Cardiovascular Surgery, Vol 92, 661-666, Copyright © 1986 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
Nissen fundoplication for gastroesophageal reflux in infants
JA St. Cyr, TB Ferrara, TR Thompson, DE Johnson and JE Foker
Some degree of gastroesophageal reflux is very common in infants and tends
to reverse with time. Therefore, the indications for an antireflux
operation are not well defined. Furthermore, the complication rate and the
ability of the fundoplication to grow remain to be determined. To answer
these questions, we reviewed the records of patients 6 months of age or
younger who underwent a Nissen fundoplication with gastrostomy tube
placement between 1979 and 1985. There were 45 patients (25 boys and 20
girls) with birth weights of 0.65 to 4.3 kg. The consequences of
gastroesophageal reflux were more varied than in older children. Severe
respiratory problems were common, including recurrent aspiration or
bronchopulmonary dysplasia in 60% and frequent apneic and bradycardiac
spells in 17%. Failure to gain weight was present in 20% and intractable
vomiting in 2.0%. As expected, 78% of these patients had congenital
anomalies or acquired problems which, in many cases, were important to the
prognosis. The diagnosis was confirmed by barium swallow in all but one
patient in whom gross reflux during feedings was present. Initially,
medical management was tried for 3 to 4 weeks. In one patient, however, the
severity of the respiratory problems precluded trial beyond 12 days. The
recommendation for operation was based only on the severity of symptoms
attributed to gastroesophageal reflux. All patients underwent Nissen
fundoplication with gastrostomy tube placement at 2 weeks to 6 months of
age and weighing 1.02 to 6.95 kg. The only surgical complication was one
gastrostomy leak. Prematurity or preexisting anomalies led to a 20%
incidence of late unrelated deaths between 2 weeks and 23 months
postoperatively. Improvement in symptoms occurred in our survivors with
follow-up of 5 to 72 months. We conclude: Significant gastroesophageal
reflux in infancy most frequently produces respiratory problems that can be
life threatening. Nissen fundoplication can be a safe and effective
procedure in infants 6 months of age or younger. Fundoplication appears to
have good growth potential, and no late complications or feeding problems
have occurred. Consequently, surgical correction can be recommended for
infants not responding to conservative medical therapy.
