Fundoplication for Pediatric Gastroesophageal Reflux Disease (GERD): Indications, Techniques, and Outcomes

Fundoplication for Pediatric Gastroesophageal Reflux Disease (GERD): Indications, Techniques, and Outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Fundoplication for Pediatric Gastroesophageal Reflux Disease (GERD): Indications, Techniques, and Outcomes Maimona Abdulmageed Al-Refaie, Mohammed Mohammed Alsurmi, Yasser Abdurabo Obadiel, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4814793/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: This study aimed to evaluate the indications, techniques, and outcomes of fundoplication in pediatric patients with gastroesophageal reflux disease (GERD) at a tertiary hospital in Yemen. Patients and Methods: This prospective cohort study was conducted at Al-Thawra Modern General Hospital, Sana’a, Yemen, between January 2015 and January 2022. The study included 45 pediatric patients under 18 years who underwent fundoplication for GERD. Data on demographic and clinical characteristics, surgical type, postoperative complications, and follow-up outcomes were collected and analyzed.. Results: The median age of the 45 pediatric patients was 2 years (range: 2 months to 10 years), with 56% males and 44% females. The primary indications for fundoplication included GERD with hiatal hernia (44.4%), persistent symptoms despite medical management (20%), recurrent chest infections associated with neurological disorders (15.6%), esophageal stricture (17.8%), and both hiatal hernia and esophageal stricture (2.2%). Nissen fundoplication was performed in 80% of patients, while Thal fundoplication was performed in 20%. Complete symptom resolution was achieved in 68.89% of patients. Dysphagia due to postoperative esophageal stricture was the most common complication, affecting 29% of patients. A structured dilatation protocol resulted in 30.8% improvement after a single session, 46.2% after regular sessions, and 23.1% after irregular sessions. The mortality rate was 5.56%, with two deaths occurring in patients with cerebral palsy due to recurrent chest infections unrelated to GERD recurrence or esophageal stricture. Conclusion: Fundoplication is a safe and effective surgical treatment for pediatric GERD, with a high success rate and manageable complication rate. A structured postoperative dilatation protocol is essential for managing esophageal strictures and improving outcomes. Early diagnosis and intervention, along with adherence to postoperative protocols, are crucial for optimal results. Further research with larger sample sizes and long-term follow-up is recommended to confirm these findings and improve clinical practice. Gastrointestinal Surgery Pediatrics Pediatric GERD fundoplication postoperative complications symptom resolution surgical outcomes Introduction Gastroesophageal reflux disease (GERD) is a common condition among pediatric patients and is characterized by the backward flow of stomach acid into the esophagus, causing discomfort and potential damage. 1 – 3 In severe cases, GERD can lead to complications such as esophageal stricture, Barrett’s esophagus, and aspiration pneumonia. Medical management is typically the first-line treatment, but a subset of patients fails to respond adequately to pharmacological interventions. For these patients, surgical options like fundoplication become necessary. 4 – 6 Fundoplication has been widely adopted as a surgical solution for pediatric GERD unresponsive to medical management. 7 The procedure involves wrapping the upper part of the stomach around the lower esophagus to reinforce the lower esophageal sphincter and prevent acid reflux. There are several variations of fundoplication, including Nissen (360-degree wrap), Thal (partial anterior wrap), and Toupet (partial posterior wrap). 4 , 5 The choice of technique depends on the patient's specific condition and the surgeon's preference. While fundoplication is generally considered safe and effective, the outcomes can vary based on several factors, including the presence of preoperative esophageal stricture, hiatal hernia, and the patient's overall health condition. 8 – 10 Previous studies have reported success rates ranging from 70–80%, with variations in postoperative complications, such as dysphagia and wrap migration. 11 – 13 However, comprehensive data on the indications, techniques, and outcomes of fundoplication in pediatric patients from resource-limited settings are scarce. This study aimed to fill this gap by evaluating the indications for fundoplication, surgical techniques employed, and postoperative outcomes in pediatric patients with gastroesophageal reflux disease treated at Al-Thawra Modern General Hospital in Sana’a, Yemen. By analyzing a cohort of patients over a 7-year period, we provide valuable insights into the effectiveness and safety of fundoplication in this specific context. Material and Methods Study Design and Setting This study employed a prospective longitudinal cohort design to investigate the indications, techniques, and outcomes of fundoplication in pediatric patients with GERD. The Study was conducted at the Al-Thawra Modern General Hospital, a tertiary hospital in Sana’a, Yemen, between January 2015 and January 2022. Participants The study included consecutive pediatric patients aged less than 18 years who underwent fundoplication for GERD at Al-Thawra Modern General Hospital. The inclusion criteria were pediatric patients diagnosed with GERD who failed medical management or had complications such as esophageal stricture or hiatal hernia. Patients with incomplete medical records or those who were lost to follow-up during the study period were excluded. Surgical Procedures All surgical procedures were performed by experienced pediatric surgeons at the Al-Thawra Modern General Hospital. The choice of surgical technique (nissen or Thal) was determined based on the patient's anatomical and clinical conditions. Nissen fundoplication, which involves wrapping the upper part of the stomach (fundus) 360° around the lower esophagus, was used to reinforce the lower esophageal sphincter and prevent acid reflux. This technique is widely recognized for its ability to control GERD symptoms. 12 , 14 Alternatively, Thal fundoplication, involving a partial (approximately 180 degrees) anterior wrap of the stomach around the esophagus, was performed in patients with smaller stomachs for whom a complete wrap was not feasible. This approach is effective in selected cases, with long-term outcomes comparable to those of the Nissen technique. 8 Both procedures were performed under general anesthesia with standard preoperative and postoperative care protocols to ensure optimal safety and recovery for the patients. Variables and Data Collection The primary variables of interest included demographic information, clinical presentation, type of fundoplication, intraoperative and postoperative complications, and follow-up outcomes. Data were collected using structured questionnaires and medical records review. Information was obtained from patient interviews and hospital records, including preoperative, intraoperative, and postoperative data. Follow-up assessments were conducted through outpatient visits, barium studies, and endoscopy within 1 year after surgery. The specific variables collected were age, sex, socioeconomic status, symptoms (vomiting, regurgitation, recurrent chest infections), diagnostic workup (barium studies, upper gastrointestinal endoscopies), type of fundoplication (Nissen or Thal), presence of hiatal hernia, intraoperative complications, postoperative outcomes (symptom resolution, chest infection, esophageal stricture), and need for postoperative dilatation. Outcome Measures The primary outcome measure was the success rate of fundoplication, which was defined as the proportion of patients experiencing symptom relief during the 1-year follow-up period. Secondary outcomes included the identification of procedure-related complications (e.g., chest infections, esophageal stricture). Postoperative Care and Follow-Up Postoperative care followed standard protocols for managing pediatric patients after fundoplication surgery, including routine monitoring and supportive care during the hospital stay. Follow-up assessments included clinical evaluation of symptoms such as vomiting and regurgitation, radiological assessment with barium studies conducted 2 months post-operation, and endoscopic assessment with upper gastrointestinal endoscopies performed 2–3 months post-operation and as needed for patients with esophageal stricture. For patients with detected esophageal stricture, a structured dilatation protocol was implemented. The initial dilatation was performed in the operating theater immediately after the fundoplication surgery. Approximately one-month post-operation, a small dilator number was used to start the dilatation, increasing the size until some difficulty was encountered with the passage of the safari dilator, at which point the dilatation stopped at that number. Subsequent dilatation sessions were performed weekly until an acceptable dilator number (12–13 safari dilator) was reached. Once this acceptable number was achieved, defined as two consecutive sessions where the dilator passed easily with no complaints from the patient, monthly dilatation was performed for four months. Following this period, dilatation continued every two months for the rest of the year, with follow-up evaluations by endoscopy and barium studies to monitor the response and assess the stricture.. Bias Efforts were made to minimize selection bias by including all eligible patients who met the inclusion criteria. Data collection was standardized using structured questionnaires to reduce information bias. Potential confounders, such as socioeconomic status and postoperative protocol adherence, were considered during analysis. Statistical Analysis Data analysis was performed using IBM SPSS Statistics version 26.0. Descriptive statistics were used to summarize the data. Continuous variables are presented as means with standard deviation or medians with interquartile ranges, depending on their distribution. Categorical variables are presented as frequencies and percentages. The chi-square test was used to assess the association between categorical variables, and p 0.05 was considered statistically significant. Ethical Considerations The study was approved by the ethics committee of the Al-Thawra Modern General Hospital. Written informed consent was obtained from the parents or guardians of all participating patients. Patient confidentiality was maintained throughout the study, with personal information being used solely for research. Results Demographic and Clinical Characteristics A total of 45 pediatric patients underwent fundoplication for GERD at Al-Thawra Modern General Hospital between January 2015 and January 2022. The median age was 2 years (range: 2 months to 10 years), with 56% males and 44% females. The primary symptoms were vomiting (100%) and regurgitation (47%) (Table 1). Table 1: Demographic and Clinical Characteristics of the Study Population Variable N % Gender Female 20 44 Male 25 56 Age < 1 year 8 18 1-3 years 16 36 3-6 years 1 2 6-12 years 20 44 Clinical Symptoms Vomiting 45 100 Regurgitation 21 47 Recurrent chest infection 7 16 Epigastric Pain 2 4.5 Comorbidity Neurological disorder (cerebral palsy) 7 15.6 Preoperative esophageal stricture 9 20 Preoperative Investigation Upper Endoscopy 35 78 Barium Swallow 45 100 Preoperative Diagnosis GERD with hiatal hernia 20 44 GERD without esophageal stricture 16 36 GERD with esophageal stricture 8 18 GERD with hiatal hernia and esophageal stricture 1 2 Abbreviations: GERD, gastroesophageal reflux disease; N, number of patients; %, percentage. Indications for Fundoplication The primary indications for fundoplication were GERD with hiatal hernia (44.4%), persistent symptoms despite medical management (20%), recurrent chest infections associated with neurological disorders (15.6%), esophageal stricture (17.8%), and both hiatal hernia and esophageal stricture (2.2%) (Table 2). Table 2 . Indications for Fundoplication among the Study Population (n=45) Indication N % GERD with hiatal hernia 20 44.4 GERD with persistent symptoms despite medical management 9 20 GERD in patients with cerebral palsy and recurrent chest infections 7 15.6 GERD with esophageal stricture 8 17.8 GERD with hiatal hernia and esophageal stricture 1 2.2 Abbreviations: GERD, gastroesophageal reflux disease; N, number of patients; %, percentage. Surgical Details Nissen fundoplication was performed in 80% of patients, while Thal fundoplication was performed in 20%. Fundoplication with hiatal hernia repair was performed in 44% of the cases, fundoplication alone in 36%, and fundoplication with postoperative dilatation in 18% (Table 3). Table 3. Distribution of Surgical Procedures according to the Type of Fundoplication Surgical procedures Nissen Fundoplication (n=36, 80%) Thal Fundoplication (n=9, 20%) Total (n=45) Fundoplication with hiatal hernia repair 14 (39%) 6 (67%) 20(44%) Fundoplication alone 13 (36%) 3 (33%) 16(36%) Fundoplication with postoperative dilatation 8 (22%) 0 8 (18%) Fundoplication with hiatal hernia repair and postoperative dilatation 1(3%) 0 1(2%) Postoperative Complications Postoperative complications were observed in 44% of patients. The most common complication was dysphagia due to postoperative esophageal stricture, affecting 28.89% of patients. Other complications included epigastric pain (4.44%), chest infections (8.89%), and fullness (2.22%) (Table 4). Table 4. Postoperative Complications Among the Study Popluation (n=45) Postoperative Complications Frequency Percentage (%) Epigastric Pain 2 4 Fullness 1 2 Chest infection 4 9 Dysphagia (esophageal stricture) 13 29 Total 20 44% Outcomes During the 1-year follow-up, 69% of patients experienced complete symptom resolution. Among those who required postoperative dilatation, 30.8% improved after a single session, 46.2% improved after regular sessions, and 23.1% did not improve after irregular sessions. There was a 5.56% mortality rate, with two deaths occurring in patients with cerebral palsy due to recurrent chest infections unrelated to GERD recurrence or esophageal stricture (Table 5). Table 5. Postoperative Outcomes Among the Study Popluation (n=45) Postoperative Outcomes Frequency Percentage (%) Complete symptom improvement 31 69 Need for Postoperative stricture dilation 13 29 Postoperative dilatation outcomes (n=13) Improved after single session 4 30.8 Improved after regular sessions 6 46.2 Not improved after irregular sessions 3 23.1 Redo operation 1 2 Mortality 2 4 Comparison of Nissen and Thal Fundoplication Nissen fundoplication resulted in a 36.11% incidence of dysphagia, compared to 0% in Thal fundoplication (p=0.08). Complete symptom resolution was achieved in 61.11% of Nissen patients and 100% of Thal patients (p=0.06). Postoperative dilatation was required in 36.11% of Nissen patients and 0% of Thal patients (p=0.08). The overall success rate for both procedures was high, with Thal fundoplication showing slightly better outcomes (Table 6). Table 6. Comparison of Postoperative Outcomes Between Nissen and Thal Procedures in the Study Population Variable Nissen Fundoplication (n=36, 80%) Thal Fundoplication (n=9, 20%) Total (n =45) P-Value Postoperative Complications Dysphagia 13 (36.11%) 0 (0.00%) 13 (29%) 0.08 Epigastric pain 1 (2.78%) 1 (11.11%) 2 (4%) 0.85 Fullness 1 (2.78%) 0 (0.00%) 1 (2%) 1.0 Chest infection 4 (11.11%) 0 (0.00%) 4 (9%) 0.69 Postoperative Outcomes Complete resolution of symptoms 22 (61.11%) 9 (100.00%) 31 (69%) 0.06 Redo operation 1 (2.78%) 0 (0.00%) 1 (2%) 1.0 Need for postoperative dilatation 13 (36.11%) 0 (0.00%) 13 (29%) 0.08 Improvement after dilation 10 (27.78%) 0 (0.00%) 10 (22%) 0.17 Mortality 2 (5.56%) 0 (0.00%) 2 (4%) 1.0 Discussion This study aimed to evaluate the indications, techniques, and outcomes of fundoplication in pediatric patients with gastroesophageal reflux disease treated at a tertiary hospital in Yemen. The findings provide valuable insights into the effectiveness of fundoplication and highlight the importance of specific indications for achieving optimal outcomes. The demographic characteristics of our study population, with a median age of 2 years and nearly equal gender distribution (56% males, 44% females), are consistent with other studies on pediatric patients with GERD undergoing fundoplication. This demographic consistency strengthens the reliability of our findings and their applicability to similar patient populations. 15 The primary indications for fundoplication in our study population included GERD with hiatal hernia (44.4%), persistent symptoms despite medical management (20%), recurrent chest infections associated with neurological disorders (15.6%), esophageal stricture (17.8%), and the presence of both hiatal hernia and esophageal stricture (2.2%). These indications align with those reported in the literature, where fundoplication is commonly indicated for severe GERD symptoms unresponsive to medical therapy, anatomical abnormalities, and GERD-related respiratory complications. 12,16 This underscores the necessity of surgical intervention in patients with these specific conditions to prevent further complications and improve quality of life. In terms of outcomes, our study found that 68.89% of patients experienced complete symptom resolution after surgery. This success rate is comparable to those reported in other recent studies, which reported symptom resolution rates ranging from 60% to 90% among pediatric patients with GERD undergoing fundoplication. 15,17 Postoperative complications were observed in 15 patients (33.3% of cases). Dysphagia due to postoperative esophageal stricture was the most common complication, affecting 13 patients (29%). Of these, 9 patients had preoperative esophageal stricture, while 4 developed dysphagia after Nissen fundoplication with hiatal hernia repair. This finding highlights the need for careful patient selection and postoperative management. 18,19 Our structured dilatation protocol for managing postoperative esophageal strictures played a crucial role in the success of our fundoplication procedures. Specifically, 30.8% of patients showed improvement after a single session, 46.2% improved after regular sessions, and 23.1% did not improve after irregular sessions. These findings can be contextualized by comparing them with several relevant studies on post-fundoplication dilatation. For instance, Malhi-Chowla et al. (2002) reported that 91% of patients who underwent esophageal dilation after fundoplication experienced symptomatic relief, highlighting the efficacy of regular dilatation sessions in managing postoperative strictures. 20 Similarly, Spivak et al. (1998) emphasized the importance of follow-up and regular intervention by noting that postoperative re-dilatation was necessary for achieving satisfactory outcomes in managing strictures. 21 Koivusalo and Pakarinen (2018) analyzed pediatric fundoplication and found that postoperative esophageal strictures were managed effectively with a structured follow-up protocol, which aligns with our findings that regular sessions yield better outcomes compared to irregular management. 22 In contrast, El-Serag and Sonnenberg (1999) indicated that postoperative dysphagia and strictures were common complications that required consistent and often aggressive management to prevent recurrence and improve patient outcomes. 23 Additionally, Csendes et al. (2019) conducted a long-term follow-up study on patients who underwent laparoscopic Nissen fundoplication and found that esophageal strictures, while a frequent complication, were effectively managed through timely and regular dilatation procedures. 24 These studies reinforce the importance of a structured postoperative care plan, such as ours, to mitigate the risks associated with esophageal strictures and ensure optimal patient outcomes. In our study, the comparison between Nissen and Thal fundoplication demonstrated that Thal had better outcomes, with fewer cases of dysphagia (p=0.08) and a higher rate of complete symptom resolution (p=0.06). These results may be partially explained by our approach where Nissen fundoplication was performed on patients with preoperative esophageal stricture and Thal fundoplication was used for patients with smaller stomachs. This clinical decision-making, although systematic, could be perceived as a form of selection bias contributing to the observed better outcomes with Thal compared to Nissen. However, it is important to note that these differences did not reach statistical significance. Comparative studies have shown that while Nissen fundoplication is effective, it is associated with a higher incidence of postoperative complications, such as dysphagia and bloating, compared with other techniques. 25 These findings suggest that alternative fundoplication techniques may offer advantages in terms of reducing specific complications although overall success rates remain comparable. 26,27 The observed mortality rate of 5.56% in our study, with two deaths occurring six months post-Nissen fundoplication in patients with cerebral palsy, underscores the significant risk associated with this surgical intervention in neurologically impaired individuals. These fatalities were due to recurrent chest infections related to their underlying neurological conditions rather than GERD recurrence or esophageal stricture. This finding aligns with previous studies that have documented the heightened vulnerability of neurologically impaired patients to respiratory complications following fundoplication, emphasizing the need for comprehensive preoperative assessment, vigilant postoperative monitoring, and a multidisciplinary approach to manage both GERD and respiratory risks effectively. 28,29 A strength of this study is the comprehensive inclusion of various indications for fundoplication, providing a detailed overview of its efficacy across different patient subsets. However, these limitations include the lack of 24-h esophageal pH monitoring and the reliance on barium studies and endoscopies, which may limit the precision of our findings. Socioeconomic factors influenced adherence to postoperative protocols, particularly regular dilatation, which may have affected outcomes. Additionally, the study's observational nature and single-center setting may limit the generalizability of the results. The findings have important clinical implications. Fundoplication should be considered a viable option for pediatric patients with GERD who are unresponsive to medical management. Early diagnosis and intervention, along with regular postoperative follow-up and dilatation protocols, are crucial for improving outcomes, especially in patients with preoperative esophageal stricture. Surgeons should consider individual patient anatomy and clinical conditions when selecting the type of fundoplication. Additionally, addressing socioeconomic barriers to adherence could further enhance patient outcomes. Future research should focus on the long-term outcomes of fundoplication in pediatric patients, including quality of life assessments and the identification of predictors of successful outcomes. Comparative studies comparing different fundoplication techniques and the roles of minimally invasive approaches in pediatric populations could provide valuable insights. Strategies to improve adherence to postoperative protocols, particularly in low-resource settings, should also be explored. Multicenter studies could enhance the generalizability of findings and provide a broader perspective on the effectiveness of fundoplication in diverse populations. Conclusion This study confirms that fundoplication is an effective surgical treatment for pediatric patients with GERD who do not respond to medical management. Thal fundoplication demonstrated better outcomes than Nissen, with fewer cases of dysphagia and higher rates of symptom resolution, although differences were not statistically significant. A structured dilatation protocol was crucial for managing postoperative esophageal strictures, highlighting the importance of regular and timely interventions. The observed mortality in patients with cerebral palsy underscores the need for comprehensive preoperative assessment and vigilant postoperative monitoring. Further research should explore long-term outcomes, comparative techniques, and strategies to improve adherence to postoperative protocols to enhance patient care and outcomes. Declarations Disclosure The authors declare no conflicts of interest. Acknowledgments Not Applicable. References Esposito C, Roberti A, Turrà F et al (2015) Management of gastroesophageal reflux disease in pediatric patients: a literature review. 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J Gastrointest Surg 25(6):1412–1418 Ngerncham M, Barnhart DC, Haricharan RN, Roseman JM, Georgeson KE, Harmon CM (2007) Risk factors for recurrent gastroesophageal reflux disease after fundoplication in pediatric patients: a case-control study. J Pediatr Surg 42(9):1478–1485. https://doi.org/10.1016/j.jpedsurg.2007.04.002 Lauriti G, Lisi G, Lelli Chiesa P, Zani A, Pierro A (2018) Gastroesophageal reflux in children with neurological impairment: a systematic review and meta-analysis. Pediatr Surg Int 34(11). 10.1007/s00383-018-4335-0 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4814793","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":332645884,"identity":"4dd1ff5f-e0ff-49fa-bb94-72d5b8f45ffe","order_by":0,"name":"Maimona Abdulmageed Al-Refaie","email":"","orcid":"https://orcid.org/0009-0000-8627-3939","institution":"Department of General Surgery, Thawra Modern General Hospital, Sana’a, Yemen","correspondingAuthor":false,"prefix":"","firstName":"Maimona","middleName":"Abdulmageed","lastName":"Al-Refaie","suffix":""},{"id":332645885,"identity":"74fe1fe1-f429-4991-a1d8-62909f902302","order_by":1,"name":"Mohammed Mohammed Alsurmi","email":"","orcid":"","institution":"Department of General Surgery, Thawra Modern General Hospital, Sana’a, Yemen","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"Mohammed","lastName":"Alsurmi","suffix":""},{"id":332645886,"identity":"1925e8d8-9406-4610-bc35-8377e1a29d6c","order_by":2,"name":"Yasser Abdurabo Obadiel","email":"","orcid":"","institution":"Department of Surgery, Faculty of Medicine and Health Sciences, Sana’a University, Sana’a, Yemen","correspondingAuthor":false,"prefix":"","firstName":"Yasser","middleName":"Abdurabo","lastName":"Obadiel","suffix":""},{"id":332645887,"identity":"7502161b-1d56-4cec-8c0c-6d3fbaf2de5c","order_by":3,"name":"Khaled Mohammed Alsharafy","email":"","orcid":"","institution":"Department of Surgery, Faculty of Medicine and Health Sciences, Sana’a University, Sana’a, Yemen","correspondingAuthor":false,"prefix":"","firstName":"Khaled","middleName":"Mohammed","lastName":"Alsharafy","suffix":""},{"id":332645888,"identity":"c005e66f-3ef7-470d-af80-f3cb90541376","order_by":4,"name":"Haitham Mohammed Jowah","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYBACAwaGBCB1QA7M4yFFizFJWkDgQGID0VrMGRgePuapuZM+f0YC44O3bQyJ/YS0WDYwJBvzHHuWu+FGArPhXKCWmQ2EHHaAIU06h+1w7gaJBDZpXqCWDQeI0vLvcLr8jAT23yAt+4nSktt2OIHhRgIbM9gWQn4xOAz0y9++w4YbzjxslpxzTsJ4BkFbjvckPpzx7bC8fHvywQ9vymxk+xsIWcPMkwBlMYLUSjgS1MHAwI7qEHvCOkbBKBgFo2CkAQCEAUMIrb03fgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0009-0008-3815-3017","institution":"Department of Surgery, Faculty of Medicine and Health Sciences, Sana’a University, Sana’a City, Yemen","correspondingAuthor":true,"prefix":"","firstName":"Haitham","middleName":"Mohammed","lastName":"Jowah","suffix":""}],"badges":[],"createdAt":"2024-07-28 02:09:09","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4814793/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4814793/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":61455439,"identity":"b3223dac-cba8-41c0-bbeb-421eec49ab56","added_by":"auto","created_at":"2024-07-31 03:20:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":732029,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4814793/v1/3db96e20-4b85-4801-878f-56493882b1e1.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eFundoplication for Pediatric Gastroesophageal Reflux Disease (GERD): Indications, Techniques, and Outcomes\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGastroesophageal reflux disease (GERD) is a common condition among pediatric patients and is characterized by the backward flow of stomach acid into the esophagus, causing discomfort and potential damage.\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e In severe cases, GERD can lead to complications such as esophageal stricture, Barrett\u0026rsquo;s esophagus, and aspiration pneumonia. Medical management is typically the first-line treatment, but a subset of patients fails to respond adequately to pharmacological interventions. For these patients, surgical options like fundoplication become necessary. \u003csup\u003e\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFundoplication has been widely adopted as a surgical solution for pediatric GERD unresponsive to medical management. \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e The procedure involves wrapping the upper part of the stomach around the lower esophagus to reinforce the lower esophageal sphincter and prevent acid reflux. There are several variations of fundoplication, including Nissen (360-degree wrap), Thal (partial anterior wrap), and Toupet (partial posterior wrap). \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e The choice of technique depends on the patient's specific condition and the surgeon's preference.\u003c/p\u003e \u003cp\u003eWhile fundoplication is generally considered safe and effective, the outcomes can vary based on several factors, including the presence of preoperative esophageal stricture, hiatal hernia, and the patient's overall health condition. \u003csup\u003e\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Previous studies have reported success rates ranging from 70\u0026ndash;80%, with variations in postoperative complications, such as dysphagia and wrap migration.\u003csup\u003e\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e However, comprehensive data on the indications, techniques, and outcomes of fundoplication in pediatric patients from resource-limited settings are scarce.\u003c/p\u003e \u003cp\u003eThis study aimed to fill this gap by evaluating the indications for fundoplication, surgical techniques employed, and postoperative outcomes in pediatric patients with gastroesophageal reflux disease treated at Al-Thawra Modern General Hospital in Sana\u0026rsquo;a, Yemen. By analyzing a cohort of patients over a 7-year period, we provide valuable insights into the effectiveness and safety of fundoplication in this specific context.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eThis study employed a prospective longitudinal cohort design to investigate the indications, techniques, and outcomes of fundoplication in pediatric patients with GERD. The Study was conducted at the Al-Thawra Modern General Hospital, a tertiary hospital in Sana\u0026rsquo;a, Yemen, between January 2015 and January 2022.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe study included consecutive pediatric patients aged less than 18 years who underwent fundoplication for GERD at Al-Thawra Modern General Hospital. The inclusion criteria were pediatric patients diagnosed with GERD who failed medical management or had complications such as esophageal stricture or hiatal hernia. Patients with incomplete medical records or those who were lost to follow-up during the study period were excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSurgical Procedures\u003c/h2\u003e \u003cp\u003eAll surgical procedures were performed by experienced pediatric surgeons at the Al-Thawra Modern General Hospital. The choice of surgical technique (nissen or Thal) was determined based on the patient's anatomical and clinical conditions. Nissen fundoplication, which involves wrapping the upper part of the stomach (fundus) 360\u0026deg; around the lower esophagus, was used to reinforce the lower esophageal sphincter and prevent acid reflux. This technique is widely recognized for its ability to control GERD symptoms.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Alternatively, Thal fundoplication, involving a partial (approximately 180 degrees) anterior wrap of the stomach around the esophagus, was performed in patients with smaller stomachs for whom a complete wrap was not feasible. This approach is effective in selected cases, with long-term outcomes comparable to those of the Nissen technique.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Both procedures were performed under general anesthesia with standard preoperative and postoperative care protocols to ensure optimal safety and recovery for the patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eVariables and Data Collection\u003c/h2\u003e \u003cp\u003eThe primary variables of interest included demographic information, clinical presentation, type of fundoplication, intraoperative and postoperative complications, and follow-up outcomes. Data were collected using structured questionnaires and medical records review. Information was obtained from patient interviews and hospital records, including preoperative, intraoperative, and postoperative data. Follow-up assessments were conducted through outpatient visits, barium studies, and endoscopy within 1 year after surgery. The specific variables collected were age, sex, socioeconomic status, symptoms (vomiting, regurgitation, recurrent chest infections), diagnostic workup (barium studies, upper gastrointestinal endoscopies), type of fundoplication (Nissen or Thal), presence of hiatal hernia, intraoperative complications, postoperative outcomes (symptom resolution, chest infection, esophageal stricture), and need for postoperative dilatation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eOutcome Measures\u003c/h2\u003e \u003cp\u003eThe primary outcome measure was the success rate of fundoplication, which was defined as the proportion of patients experiencing symptom relief during the 1-year follow-up period. Secondary outcomes included the identification of procedure-related complications (e.g., chest infections, esophageal stricture).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative Care and Follow-Up\u003c/h2\u003e \u003cp\u003ePostoperative care followed standard protocols for managing pediatric patients after fundoplication surgery, including routine monitoring and supportive care during the hospital stay. Follow-up assessments included clinical evaluation of symptoms such as vomiting and regurgitation, radiological assessment with barium studies conducted 2 months post-operation, and endoscopic assessment with upper gastrointestinal endoscopies performed 2\u0026ndash;3 months post-operation and as needed for patients with esophageal stricture.\u003c/p\u003e \u003cp\u003eFor patients with detected esophageal stricture, a structured dilatation protocol was implemented. The initial dilatation was performed in the operating theater immediately after the fundoplication surgery. Approximately one-month post-operation, a small dilator number was used to start the dilatation, increasing the size until some difficulty was encountered with the passage of the safari dilator, at which point the dilatation stopped at that number. Subsequent dilatation sessions were performed weekly until an acceptable dilator number (12\u0026ndash;13 safari dilator) was reached. Once this acceptable number was achieved, defined as two consecutive sessions where the dilator passed easily with no complaints from the patient, monthly dilatation was performed for four months. Following this period, dilatation continued every two months for the rest of the year, with follow-up evaluations by endoscopy and barium studies to monitor the response and assess the stricture..\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eBias\u003c/h2\u003e \u003cp\u003eEfforts were made to minimize selection bias by including all eligible patients who met the inclusion criteria. Data collection was standardized using structured questionnaires to reduce information bias. Potential confounders, such as socioeconomic status and postoperative protocol adherence, were considered during analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData analysis was performed using IBM SPSS Statistics version 26.0. Descriptive statistics were used to summarize the data. Continuous variables are presented as means with standard deviation or medians with interquartile ranges, depending on their distribution. Categorical variables are presented as frequencies and percentages. The chi-square test was used to assess the association between categorical variables, and p 0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003e The study was approved by the ethics committee of the Al-Thawra Modern General Hospital. Written informed consent was obtained from the parents or guardians of all participating patients. Patient confidentiality was maintained throughout the study, with personal information being used solely for research.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003ch2\u003eDemographic and Clinical Characteristics\u003c/h2\u003e\n\u003cp\u003eA total of 45 pediatric patients underwent fundoplication for GERD at Al-Thawra Modern General Hospital between January 2015 and January 2022. The median age was 2 years (range: 2 months to 10 years), with 56% males and 44% females. The primary symptoms were vomiting (100%) and regurgitation (47%) (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Demographic and Clinical Characteristics of the Study Population\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1-3 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3-6 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6-12 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical Symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVomiting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRegurgitation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRecurrent chest infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEpigastric Pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNeurological disorder (cerebral palsy)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePreoperative esophageal stricture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative Investigation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUpper Endoscopy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBarium Swallow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative Diagnosis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGERD with hiatal hernia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGERD without esophageal stricture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGERD with esophageal stricture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGERD with hiatal hernia and \u0026nbsp;esophageal stricture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: GERD, gastroesophageal reflux disease; N, number of patients; %, percentage.\u003c/p\u003e\n\u003ch2\u003eIndications for Fundoplication\u003c/h2\u003e\n\u003cp\u003eThe primary indications for fundoplication were GERD with hiatal hernia (44.4%), persistent symptoms despite medical management (20%), recurrent chest infections associated with neurological disorders (15.6%), esophageal stricture (17.8%), and both hiatal hernia and esophageal stricture (2.2%) (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e. Indications for Fundoplication among the Study Population (n=45)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGERD with hiatal hernia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGERD with persistent symptoms despite medical management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGERD in patients with cerebral palsy and recurrent chest infections\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGERD with esophageal stricture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGERD with hiatal hernia and esophageal stricture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: GERD, gastroesophageal reflux disease; N, number of patients; %, percentage.\u003c/p\u003e\n\u003ch2\u003eSurgical Details\u003c/h2\u003e\n\u003cp\u003eNissen fundoplication was performed in 80% of patients, while Thal fundoplication was performed in 20%. Fundoplication with hiatal hernia repair was performed in 44% of the cases, fundoplication alone in 36%, and fundoplication with postoperative dilatation in 18% (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Distribution of Surgical Procedures according to the Type of Fundoplication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical procedures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNissen Fundoplication (n=36, 80%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eThal Fundoplication\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=9, 20%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (n=45)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFundoplication with hiatal hernia repair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14 (39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20(44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFundoplication alone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13 (36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16(36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFundoplication with postoperative dilatation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFundoplication with hiatal hernia repair and \u0026nbsp;postoperative dilatation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1(3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1(2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003ePostoperative Complications\u003c/h2\u003e\n\u003cp\u003ePostoperative complications were observed in 44% of patients. The most common complication was dysphagia due to postoperative esophageal stricture, affecting 28.89% of patients. Other complications included epigastric pain (4.44%), chest infections (8.89%), and fullness (2.22%) (Table 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003ePostoperative Complications Among the Study Popluation\u003cstrong\u003e\u0026nbsp;(n=45)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.57575757575758%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative Complications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.2020202020202%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.57575757575758%\" valign=\"top\"\u003e\n \u003cp\u003eEpigastric Pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.2020202020202%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.57575757575758%\" valign=\"top\"\u003e\n \u003cp\u003eFullness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.2020202020202%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.57575757575758%\" valign=\"top\"\u003e\n \u003cp\u003eChest infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.2020202020202%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.57575757575758%\" valign=\"top\"\u003e\n \u003cp\u003eDysphagia (esophageal stricture)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.2020202020202%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.57575757575758%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.2020202020202%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e20\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e44%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eOutcomes\u003c/h2\u003e\n\u003cp\u003eDuring the 1-year follow-up, 69% of patients experienced complete symptom resolution. Among those who required postoperative dilatation, 30.8% improved after a single session, 46.2% improved after regular sessions, and 23.1% did not improve after irregular sessions. There was a 5.56% mortality rate, with two deaths occurring in patients with cerebral palsy due to recurrent chest infections unrelated to GERD recurrence or esophageal stricture (Table 5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5.\u0026nbsp;\u003c/strong\u003ePostoperative Outcomes Among the Study Popluation (n=45)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.57575757575758%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative Outcomes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.2020202020202%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.57575757575758%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplete symptom improvement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.2020202020202%\" valign=\"top\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.57575757575758%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeed for Postoperative stricture dilation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.2020202020202%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.57575757575758%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative dilatation outcomes (n=13)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.2020202020202%\" valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\" valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.57575757575758%\" valign=\"top\"\u003e\n \u003cp\u003eImproved after single session\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.2020202020202%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e30.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.57575757575758%\" valign=\"top\"\u003e\n \u003cp\u003eImproved after regular sessions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.2020202020202%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e46.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.57575757575758%\" valign=\"top\"\u003e\n \u003cp\u003eNot improved after irregular sessions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.2020202020202%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e23.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.57575757575758%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRedo operation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.2020202020202%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"57.57575757575758%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMortality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.2020202020202%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eComparison of Nissen and Thal Fundoplication\u003c/h2\u003e\n\u003cp\u003eNissen fundoplication resulted in a 36.11% incidence of dysphagia, compared to 0% in Thal fundoplication (p=0.08). Complete symptom resolution was achieved in 61.11% of Nissen patients and 100% of Thal patients (p=0.06). Postoperative dilatation was required in 36.11% of Nissen patients and 0% of Thal patients (p=0.08). The overall success rate for both procedures was high, with Thal fundoplication showing slightly better outcomes (Table 6).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6. Comparison of Postoperative Outcomes Between Nissen and Thal Procedures in the Study Population\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"594\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.42495784148398%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.596964586846543%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNissen Fundoplication\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(n=36, 80%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.741989881956155%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eThal Fundoplication\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=9, 20%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.97301854974705%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(n =45)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.263069139966273%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.42495784148398%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative Complications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.596964586846543%\" valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.741989881956155%\" valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.97301854974705%\" valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.263069139966273%\" valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.42495784148398%\" valign=\"top\"\u003e\n \u003cp\u003eDysphagia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.596964586846543%\" valign=\"top\"\u003e\n \u003cp\u003e13 (36.11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.741989881956155%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.97301854974705%\" valign=\"top\"\u003e\n \u003cp\u003e13 (29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.263069139966273%\" valign=\"top\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.42495784148398%\" valign=\"top\"\u003e\n \u003cp\u003eEpigastric pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.596964586846543%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2.78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.741989881956155%\" valign=\"top\"\u003e\n \u003cp\u003e1 (11.11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.97301854974705%\" valign=\"top\"\u003e\n \u003cp\u003e2 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.263069139966273%\" valign=\"top\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.42495784148398%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Fullness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.596964586846543%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2.78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.741989881956155%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.97301854974705%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.263069139966273%\" valign=\"top\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.42495784148398%\" valign=\"top\"\u003e\n \u003cp\u003eChest infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.596964586846543%\" valign=\"top\"\u003e\n \u003cp\u003e4 (11.11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.741989881956155%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.97301854974705%\" valign=\"top\"\u003e\n \u003cp\u003e4 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.263069139966273%\" valign=\"top\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.42495784148398%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative Outcomes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.596964586846543%\" valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.741989881956155%\" valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.97301854974705%\" valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.263069139966273%\" valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.42495784148398%\" valign=\"top\"\u003e\n \u003cp\u003eComplete resolution of symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.596964586846543%\" valign=\"top\"\u003e\n \u003cp\u003e22 (61.11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.741989881956155%\" valign=\"top\"\u003e\n \u003cp\u003e9 (100.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.97301854974705%\" valign=\"top\"\u003e\n \u003cp\u003e31 (69%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.263069139966273%\" valign=\"top\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.42495784148398%\" valign=\"top\"\u003e\n \u003cp\u003eRedo operation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.596964586846543%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2.78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.741989881956155%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.97301854974705%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.263069139966273%\" valign=\"top\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.42495784148398%\" valign=\"top\"\u003e\n \u003cp\u003eNeed for postoperative dilatation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.596964586846543%\" valign=\"top\"\u003e\n \u003cp\u003e13 (36.11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.741989881956155%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.97301854974705%\" valign=\"top\"\u003e\n \u003cp\u003e13 (29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.263069139966273%\" valign=\"top\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.42495784148398%\" valign=\"top\"\u003e\n \u003cp\u003eImprovement after dilation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.596964586846543%\" valign=\"top\"\u003e\n \u003cp\u003e10 (27.78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.741989881956155%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.97301854974705%\" valign=\"top\"\u003e\n \u003cp\u003e10 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.263069139966273%\" valign=\"top\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.42495784148398%\" valign=\"top\"\u003e\n \u003cp\u003eMortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.596964586846543%\" valign=\"top\"\u003e\n \u003cp\u003e2 (5.56%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.741989881956155%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.97301854974705%\" valign=\"top\"\u003e\n \u003cp\u003e2 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.263069139966273%\" valign=\"top\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to evaluate the indications, techniques, and outcomes of fundoplication in pediatric patients with gastroesophageal reflux disease treated at a tertiary hospital in Yemen. The findings provide valuable insights into the effectiveness of fundoplication and highlight the importance of specific indications for achieving optimal outcomes.\u003c/p\u003e\n\u003cp\u003eThe demographic characteristics of our study population, with a median age of 2 years and nearly equal gender distribution (56% males, 44% females), are consistent with other studies on pediatric patients with GERD undergoing fundoplication. This demographic consistency strengthens the reliability of our findings and their applicability to similar patient populations.\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe primary indications for fundoplication in our study population included GERD with hiatal hernia (44.4%), persistent symptoms despite medical management (20%), recurrent chest infections associated with neurological disorders (15.6%), esophageal stricture (17.8%), and the presence of both hiatal hernia and esophageal stricture (2.2%). These indications align with those reported in the literature, where fundoplication is commonly indicated for severe GERD symptoms unresponsive to medical therapy, anatomical abnormalities, and GERD-related respiratory complications.\u003csup\u003e12,16\u003c/sup\u003e This underscores the necessity of surgical intervention in patients with these specific conditions to prevent further complications and improve quality of life.\u003c/p\u003e\n\u003cp\u003eIn terms of outcomes, our study found that 68.89% of patients experienced complete symptom resolution after surgery. This success rate is comparable to those reported in other recent studies, which reported symptom resolution rates ranging from 60% to 90% among pediatric patients with GERD undergoing fundoplication.\u003csup\u003e15,17\u003c/sup\u003e Postoperative complications were observed in 15 patients (33.3% of cases). Dysphagia due to postoperative esophageal stricture was the most common complication, affecting 13 patients (29%). Of these, 9 patients had preoperative esophageal stricture, while 4 developed dysphagia after Nissen fundoplication with hiatal hernia repair. This finding highlights the need for careful patient selection and postoperative management.\u003csup\u003e18,19\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur structured dilatation protocol for managing postoperative esophageal strictures played a crucial role in the success of our fundoplication procedures. Specifically, 30.8% of patients showed improvement after a single session, 46.2% improved after regular sessions, and 23.1% did not improve after irregular sessions. These findings can be contextualized by comparing them with several relevant studies on post-fundoplication dilatation. For instance, Malhi-Chowla et al. (2002) reported that 91% of patients who underwent esophageal dilation after fundoplication experienced symptomatic relief, highlighting the efficacy of regular dilatation sessions in managing postoperative strictures.\u003csup\u003e\u0026nbsp;20\u003c/sup\u003e Similarly, Spivak et al. (1998) emphasized the importance of follow-up and regular intervention by noting that postoperative re-dilatation was necessary for achieving satisfactory outcomes in managing strictures.\u003csup\u003e\u0026nbsp;21\u003c/sup\u003e Koivusalo and Pakarinen (2018) analyzed pediatric fundoplication and found that postoperative esophageal strictures were managed effectively with a structured follow-up protocol, which aligns with our findings that regular sessions yield better outcomes compared to irregular management.\u003csup\u003e22\u003c/sup\u003e In contrast, El-Serag and Sonnenberg (1999) indicated that postoperative dysphagia and strictures were common complications that required consistent and often aggressive management to prevent recurrence and improve patient outcomes.\u003csup\u003e23\u003c/sup\u003e Additionally, Csendes et al. (2019) conducted a long-term follow-up study on patients who underwent laparoscopic Nissen fundoplication and found that esophageal strictures, while a frequent complication, were effectively managed through timely and regular dilatation procedures.\u003csup\u003e24\u003c/sup\u003e These studies reinforce the importance of a structured postoperative care plan, such as ours, to mitigate the risks associated with esophageal strictures and ensure optimal patient outcomes.\u003c/p\u003e\n\u003cp\u003eIn our study, the comparison between Nissen and Thal fundoplication demonstrated that Thal had better outcomes, with fewer cases of dysphagia (p=0.08) and a higher rate of complete symptom resolution (p=0.06). These results may be partially explained by our approach where Nissen fundoplication was performed on patients with preoperative esophageal stricture and Thal fundoplication was used for patients with smaller stomachs. This clinical decision-making, although systematic, could be perceived as a form of selection bias contributing to the observed better outcomes with Thal compared to Nissen. However, it is important to note that these differences did not reach statistical significance.\u003c/p\u003e\n\u003cp\u003eComparative studies have shown that while Nissen fundoplication is effective, it is associated with a higher incidence of postoperative complications, such as dysphagia and bloating, compared with other techniques.\u003csup\u003e25\u003c/sup\u003e These findings suggest that alternative fundoplication techniques may offer advantages in terms of reducing specific complications although overall success rates remain comparable.\u003csup\u003e26,27\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe observed mortality rate of 5.56% in our study, with two deaths occurring six months post-Nissen fundoplication in patients with cerebral palsy, underscores the significant risk associated with this surgical intervention in neurologically impaired individuals. These fatalities were due to recurrent chest infections related to their underlying neurological conditions rather than GERD recurrence or esophageal stricture. This finding aligns with previous studies that have documented the heightened vulnerability of neurologically impaired patients to respiratory complications following fundoplication, emphasizing the need for comprehensive preoperative assessment, vigilant postoperative monitoring, and a multidisciplinary approach to manage both GERD and respiratory risks effectively.\u0026nbsp;\u003csup\u003e28,29\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eA strength of this study is the comprehensive inclusion of various indications for fundoplication, providing a detailed overview of its efficacy across different patient subsets. However, these limitations include the lack of 24-h esophageal pH monitoring and the reliance on barium studies and endoscopies, which may limit the precision of our findings. Socioeconomic factors influenced adherence to postoperative protocols, particularly regular dilatation, which may have affected outcomes. Additionally, the study\u0026apos;s observational nature and single-center setting may limit the generalizability of the results.\u003c/p\u003e\n\u003cp\u003eThe findings have important clinical implications. Fundoplication should be considered a viable option for pediatric patients with GERD who are unresponsive to medical management. Early diagnosis and intervention, along with regular postoperative follow-up and dilatation protocols, are crucial for improving outcomes, especially in patients with preoperative esophageal stricture. Surgeons should consider individual patient anatomy and clinical conditions when selecting the type of fundoplication. Additionally, addressing socioeconomic barriers to adherence could further enhance patient outcomes.\u003c/p\u003e\n\u003cp\u003eFuture research should focus on the long-term outcomes of fundoplication in pediatric patients, including quality of life assessments and the identification of predictors of successful outcomes. Comparative studies comparing different fundoplication techniques and the roles of minimally invasive approaches in pediatric populations could provide valuable insights. Strategies to improve adherence to postoperative protocols, particularly in low-resource settings, should also be explored. Multicenter studies could enhance the generalizability of findings and provide a broader perspective on the effectiveness of fundoplication in diverse populations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study confirms that fundoplication is an effective surgical treatment for pediatric patients with GERD who do not respond to medical management. Thal fundoplication demonstrated better outcomes than Nissen, with fewer cases of dysphagia and higher rates of symptom resolution, although differences were not statistically significant. A structured dilatation protocol was crucial for managing postoperative esophageal strictures, highlighting the importance of regular and timely interventions. The observed mortality in patients with cerebral palsy underscores the need for comprehensive preoperative assessment and vigilant postoperative monitoring. Further research should explore long-term outcomes, comparative techniques, and strategies to improve adherence to postoperative protocols to enhance patient care and outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eDisclosure\u003c/h2\u003e \u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eNot Applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEsposito C, Roberti A, Turr\u0026agrave; F et al (2015) Management of gastroesophageal reflux disease in pediatric patients: a literature review. 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Annals Pediatr Surg 19(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s43159-022-00232-w\u003c/span\u003e\u003cspan address=\"10.1186/s43159-022-00232-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMauritz FA, Blomberg BA, Stellato RK, van der Zee DC, Siersema PD, van Herwaarden-Lindeboom MYA (2013) Complete Versus Partial Fundoplication in Children with Gastroesophageal Reflux Disease: Results of a Systematic Review and Meta-analysis. J Gastrointest Surg 17(10). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11605-013-2305-3\u003c/span\u003e\u003cspan address=\"10.1007/s11605-013-2305-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStellato RK, Colmer N, Tytgat SHA, van der Zee DC, van de Peppel-Mauritz FA, Lindeboom MYA (2020) Five-Year Outcome of Laparoscopic Fundoplication in Pediatric GERD Patients: a Multicenter, Prospective Cohort Study. J Gastrointest Surg 25(6):1412\u0026ndash;1418\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNgerncham M, Barnhart DC, Haricharan RN, Roseman JM, Georgeson KE, Harmon CM (2007) Risk factors for recurrent gastroesophageal reflux disease after fundoplication in pediatric patients: a case-control study. J Pediatr Surg 42(9):1478\u0026ndash;1485. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jpedsurg.2007.04.002\u003c/span\u003e\u003cspan address=\"10.1016/j.jpedsurg.2007.04.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLauriti G, Lisi G, Lelli Chiesa P, Zani A, Pierro A (2018) Gastroesophageal reflux in children with neurological impairment: a systematic review and meta-analysis. Pediatr Surg Int 34(11). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00383-018-4335-0\u003c/span\u003e\u003cspan address=\"10.1007/s00383-018-4335-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Sana'a University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pediatric GERD, fundoplication, postoperative complications, symptom resolution, surgical outcomes","lastPublishedDoi":"10.21203/rs.3.rs-4814793/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4814793/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eThis study aimed to evaluate the indications, techniques, and outcomes of fundoplication in pediatric patients with gastroesophageal reflux disease (GERD) at a tertiary hospital in Yemen.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients and Methods: \u003c/strong\u003eThis prospective cohort study was conducted at Al-Thawra Modern General Hospital, Sana’a, Yemen, between January 2015 and January 2022. The study included 45 pediatric patients under 18 years who underwent fundoplication for GERD. Data on demographic and clinical characteristics, surgical type, postoperative complications, and follow-up outcomes were collected and analyzed..\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe median age of the 45 pediatric patients was 2 years (range: 2 months to 10 years), with 56% males and 44% females. The primary indications for fundoplication included GERD with hiatal hernia (44.4%), persistent symptoms despite medical management (20%), recurrent chest infections associated with neurological disorders (15.6%), esophageal stricture (17.8%), and both hiatal hernia and esophageal stricture (2.2%). Nissen fundoplication was performed in 80% of patients, while Thal fundoplication was performed in 20%. Complete symptom resolution was achieved in 68.89% of patients. Dysphagia due to postoperative esophageal stricture was the most common complication, affecting 29% of patients. A structured dilatation protocol resulted in 30.8% improvement after a single session, 46.2% after regular sessions, and 23.1% after irregular sessions. The mortality rate was 5.56%, with two deaths occurring in patients with cerebral palsy due to recurrent chest infections unrelated to GERD recurrence or esophageal stricture.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eFundoplication is a safe and effective surgical treatment for pediatric GERD, with a high success rate and manageable complication rate. A structured postoperative dilatation protocol is essential for managing esophageal strictures and improving outcomes. Early diagnosis and intervention, along with adherence to postoperative protocols, are crucial for optimal results. Further research with larger sample sizes and long-term follow-up is recommended to confirm these findings and improve clinical practice.\u003c/p\u003e","manuscriptTitle":"Fundoplication for Pediatric Gastroesophageal Reflux Disease (GERD): Indications, Techniques, and Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-31 03:12:22","doi":"10.21203/rs.3.rs-4814793/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"05b1dc45-21cd-4e82-9c5d-7a0ba1efc3b1","owner":[],"postedDate":"July 31st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":35221725,"name":"Gastrointestinal Surgery"},{"id":35221726,"name":"Pediatrics"}],"tags":[],"updatedAt":"2024-07-31T03:12:22+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-31 03:12:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4814793","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4814793","identity":"rs-4814793","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}