Background

Anti-reflux procedures (ARP) in esophageal atresia (EA) patients can be challenging and prone to failure. These challenges become more evident with increasing complexity of EA. We sought to determine predictors of ARP failure in complex EA patients.

Methods

Single-institution retrospective review of complex EA patients (e.g. long-gap EA, esophageal strictures, hiatal hernia, and reoperative ARP) who underwent an ARP from 2002 to 2019. ARP failure was defined as hiatal hernia recurrence, wrap migration/loosening, or need for reoperation. Predictors of failure were evaluated using univariate and multivariable time-to-event analysis.

Results

121 patients underwent 140 ARP at a median age of 13.5 months (IQR 7, 26.5). Nissen fundoplication (89%) was the most common ARP. Mesh (bovine pericardium) reinforcement was used in 41% of the patients. Median follow-up was 3.2 years (IQR 0.9, 5.8); 44 instances of ARP failure occurred (31%), though only 20 (14%) required reoperation. Median time to failure was 8.7 months (IQR 3.2, 25). Though fewer mesh-reinforced ARP failed (21% with vs 39% without, p = 0.02), on multivariable analysis only partial fundoplication (aHR 2.22 [95% CI 1.01–4.78]) and minimally invasive repair (aHR 2.57 [95% CI 1.12–6.01]) were significant predictors of ARP failure.

Conclusion

In our practice of complex EA patients, where ARP fail in nearly one third of cases, a Nissen fundoplication performed via laparotomy provided the lowest risk of ARP failure.

中文翻译：

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复杂食管闭锁患者抗反流手术失败的预测因素

背景

食管闭锁 (EA) 患者的抗反流手术 (ARP) 可能具有挑战性并且容易失败。随着 EA 复杂性的增加，这些挑战变得更加明显。我们试图确定复杂 EA 患者 ARP 失败的预测因子。

方法

对 2002 年至 2019 年接受 ARP 的复杂 EA 患者（如长间隙 EA、食管狭窄、食管裂孔疝和再手术 ARP）进行单机构回顾性分析。ARP 失败定义为食管裂孔疝复发、包裹移位/松动或需要再次手术。使用单变量和多变量事件发生时间分析评估失败的预测因素。

结果

121 名患者在中位年龄 13.5 个月（IQR 7, 26.5）时接受了 140 次 ARP。Nissen 胃底折叠术 (89%) 是最常见的 ARP。41% 的患者使用了网状（牛心包）加固。中位随访时间为 3.2 年（IQR 0.9、5.8）；发生了 44 次 ARP 故障 (31%)，但只有 20 次 (14%) 需要重新操作。中位失败时间为 8.7 个月 (IQR 3.2, 25)。虽然较少的网状增强 ARP 失败（21% 对 39% 没有，p  = 0.02），但在多变量分析中仅部分胃底折叠术（aHR 2.22 [95% CI 1.01-4.78]）和微创修复（aHR 2.57 [95% CI 1.12–6.01]）是 ARP 失败的重要预测因素。

结论

在我们对复杂 EA 患者的实践中，近三分之一的病例 ARP 失败，通过剖腹手术进行的 Nissen 胃底折叠术提供了最低的 ARP 失败风险。