Anti-reflux surgery in children with congenital diaphragmatic hernia: A prospective cohort study on a controversial practice

Introduction: Gastro-esophageal reflux disease (GERD) is the most frequent long-term morbidity of con-genital diaphragmatic hernia (CDH) survivors. Performing a preventive fundoplication during CDH repair remains controversial. This study aimed to: (1) Analyze the variability in practices regarding preventive fundoplication; (2) Identify predictive factors for fundoplication. (3) Evaluate the impact of preventive fundoplication on gastro-intestinal outcomes in children with a CDH patch repair; Methods: This prospective multi-institutional cohort study (French CDH Registry) included CDH neonates born in France between January 1st, 2010-December 31st, 2018. Patch CDH was defined as need for syn-thetic patch or muscle flap repair. Main outcome measures included need for curative fundoplication, tube feed supplementation, failure to thrive, and oral aversion. Results: Of 762 CDH neonates included, 81 underwent fundoplication (10.6%), either preventive or cura-tive. Median follow-up was 3.0 years (IQR: 1.0-5.0). (1) Preventive fundoplication is considered in only 31% of centers. The rates of both curative fundo-plication (9% vs 3%, p = 0.01) and overall fundoplication (20% vs 3%, p < 0.0 0 01) are higher in centers that perform preventive fundoplication compared to those that do not. (2) Predictive factors for preventive fundoplication were: prenatal diagnosis ( p = 0.006), intra-thoracic liver ( p = 0.005), fetal tracheal occlusion ( p = 0.002), CDH-grade C-D ( p < 0.0 0 01), patch repair ( p < 0.0 0 01). After CDH repair, 8% ( n = 51) required curative fundoplication (median age: 101 days), for which a patch repair was the only independent predictive factors identified upon multivariate analysis. (3) In neonates with patch CDH, preventive fundoplication did not decrease the need for curative fundoplication (15% vs 11%, p = 0.53), and was associated with higher rates of failure to thrive (discharge: 81% vs 51%, p = 0.03; 6-months: 81% vs 45%, p = 0.008), tube feeds (6-months: 50% vs 21%, p = 0.02; 2-years: 65% vs 26%, p = 0.004), and oral aversion (6-months: 67% vs 37%, p = 0.02; 1-year: 71% vs 40%, p = 0.03). Conclusions: Children undergoing a CDH patch repair are at high risk of requiring a curative fundoplica-tion. However, preventive fundoplication during a patch repair does not decrease the need for curative fundoplication and is associated with worse gastro-intestinal outcomes in children. Level of evidence: II - Prospective Study. (c) 2022 Elsevier Inc. All rights reserved.