Esophagogastric Dissociation for GERD in Severe Neurodisability
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- Esophagogastric dissociation had 4% failure rate vs 21% for Nissen fundoplication in neurologically impaired patients with severe GERD.
- Post-op anti-reflux medication requirement was significantly lower after dissociation (17%) compared to Nissen (54%), p<0.05.
- Caregiver-reported quality of life scores showed no significant difference between esophagogastric dissociation and Nissen groups.
- Study underpowered to detect operative failure differences; multi-center trial needed to confirm dissociation superiority.
- Perioperative morbidity (OR time, LOS, ICU stay) higher for dissociation, but leak/stricture rates not reported—key safety gap.
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This is Todd Ponsky from the Journal of Pediatric Surgery, and today we're going to discuss the topic about Nissen fundopliccation and esophagogastric dissociation. The dissociation was thought of historically as sort of the last resort operation, the big operation when a Nissan won't work, where we dissociate the esophagus from the stomach. But more recently, people are suggesting that the esophagogastric dissociation could be an upfront primary operation for a small subset of patients who have severe neurologic impairment. And so there was a study recently in the Journal of Pediatric Surgeony that looked at this. Discussing the article today is Ian Glenn, who is the pediatric surgery research fellow here at Akron Children's. He's a general surgery resident at the Cleveland Clinic. Ian, what did the article show? What this study did was they took patients who had severe GERD and were neurologically disabled, and half the patients underwent oesophagogastric dissociation, and the other half of the patients underwent laparoscopic Nissan. Primary outcome was operative failure, which they defined as either recurrence of their preoperative reflux symptoms or a requirement of an additional uh anti-reflux surgery. So that was found to be, there was a 4% failure rate in the esophagogastric dissociation group, there was a 21% failure rate in the Nissen group. However, that wasn't statistically significant. Other things they looked at were a continued requirement for anti-reflux medications after surgery. Uh, 17% of the patients in the esophagogastric dissociation group continued to require them, whereas 54% required it in the Nissan group, um, and that was statistically significant. Also, they had the caregivers evaluate quality of life and symptom scores for the patients, and those were the same between the two groups. So there's no statistically significant difference there. All right, so in summary, it sounds like they looked at. Needing meds after surgery and failure of the operation, both were better in the esophageal dissociation group, but only the meds was statistically significant. Right? And the authors brought up that this could potentially be a type 2 error where there was actually a difference between the two groups and the sample size was just a little bit too small to detect that. Yeah, so we'll probably need to do a multi-center study to really understand this. Agreed. They also didn't really look at complication rate. About leaks and strictures, which are really the concern of why most of us don't do this big operation. Yeah, it's definitely a much bigger surgery. They looked at perioperative factors such as time in the OR, uh, length of stay in the hospital, need for an ICU stay, time to full feeds, and there were statistically significant differences in those groups following the trends you'd expect. But no, they didn't talk about leaks or strictures or a long term requirement for additional surgeries other than anti-reflux operations. Great, perfect. Ian Glenn, thank you very much. Thanks, doc.