The recognition of complications in the early postoperative period is mandatory. The treatment of early complications is often more straight forward and does not necessarily prolong hospital stay. Up to date there is no generally accepted algorithm for early postoperative follow-up after pediatric fundoplication available, especially information on NI children following laparoscopic fundoplication is lacking. Particularly with NI children the assessment of abdominal pain and other symptoms suggestive for GER can be challenging, especially in the early postoperative period. With pain being one of the most frequent signs of recurrent reflux (besides vomiting or regurgitation as obvious signs for GER), the early postoperative follow-up in NI patients has its pitfalls. Thus, it was our practice to perform a scheduled UGI contrast study within the first postoperative days to evaluate early postoperative outcome. Early postoperative follow-up of patients following fundoplication varies across practices and is frequently not reported in pediatric literature. Different strategies can be deduced from published data in different study groups. Lopez et al. [12] reported their case series of 417 patients (NI children 149; 36%) with laparoscopic fundoplication in which they performed elective UGI contrast studies one month after surgery. Celik et al. [13] mention that postoperative contrast studies were done selectively in 9 of their 72 children. In a prospective cohort study by Knatten et al. [14], the authors scheduled the first UGI contrast study six months after fundoplication.

In our series of 103 patients, postoperative UGI studies were carried out in 65 children within the first five postoperative days (63% of all cases). If the patients were discharged on weekends, the postoperative UGI study was postponed to the following week or to the next outpatient appointment. Nevertheless, all but one were performed within the first postoperative month.

However, in the present study we were able to identify early postoperative complications necessitating re-operation in only 1% of our cases. In contrast, 12 patients requiring redo fundoplication due to wrap failure and/or intrathoracal wrap herniation did not show any pathology at early UGI contrast studies.

Kvello et al. [7] very recently reported 28 children with redo Nissen fundoplications. One patient presented with severe postoperative pain due to a herniated Nissen wrap on postoperative day one, and underwent re-fundoplication on postoperative day two. In addition, a retrospective study reported three early wrap herniations on the first postoperative day in 106 children following laparoscopic Nissen fundoplications [8]. Two wrap herniations appeared in NI children, and one in a neurologically normal child. In all three patients the intrathoracal wrap herniation was detected on a UGI contrast study on postoperative day one, and all three underwent redo surgery.

In accordance with our patient, all the reported children underwent immediate reoperations. In contrast to the one case reported by Kvello et al. [7], our patient did not show any clinical signs of reflux or abdominal compromise and might have been undiagnosed without the scheduled UGI contrast study. Unfortunately, Mathei et al. [8] did not report on the clinical symptoms in their three patients. Defining the criteria for the selective use of contrast studies is difficult, because the symptoms are highly subjective, and their assessment may vary between clinicians. However, except for one patient who underwent an early redo fundoplication on postoperative day six due to a herniated wrap, we did not identify any other early postoperative complications which needed further interventions. We therefore changed our institutional postoperative algorithm and no longer perform scheduled early postoperative UGI studies in NI patients, unless there are clear symptoms suggestive of postoperative GER.

The incidence of redo fundoplications in the present study is in line with previously published data. In a large multicenter study, the incidence of redo Nissen fundoplication was 12.2% and 21.6% in those with complete follow-up. The mean time to first redo fundoplication was 27.6 months [15]. A prospective study reported herniation of the wrap in 19.6% of NI children (9 of 46) compared with 4.8% (2 of 41 patients) in non-NI children [14].

In our patients collective, two out of thirteen patients (15%) required a second redo-operation. The time between initial fundoplication and first redo was 196 and 140 days, respectively. These findings are in line with Desai et al. [16], who postulated an increased likelihood of failure necessitating a second redo in cases of a shorter time between initial fundoplication and redo surgery.

To refine surgical technique in laparoscopic Nissen fundoplication there is growing evidence that esophageal dissection and mobilization is associated with increased incidence of intrathoracal wrap migration [17,18]. Initial outcomes were identical with 15% herniation in both NI and non-NI patients. However, long term follow-up showed a rise of the incidence of wrap herniation of 36.5% in the patients who received extensive esophageal mobilization compared with 12.2% in the minimal mobilization group. The long-term follow-up of their study did not stratify in NI and non-NI patients [17]. In continuation with leaving the esophagogastric membrane intact, St. Peter et al. [19] demonstrated the absence of wrap herniation after one year follow-up in 120 patients. Although the authors did not stratify in NI and non-NI patients, over 70% of their patients either had concomitant gastrostomy placement or had a gastrostomy prior to fundoplication. Another recent study further advocated the minimal dissection to prevent wrap transmigration in Nissen fundoplication [18]. Unfortunately, neurologic impairment was an exclusion-criteria in their study. Despite impressive short-term outcome data on wrap migration and warp failure with minimal esophagogastric dissection, the positive effect in NI children needs to be further elucidated.

Different reports examine factors associated with redo Nissen fundoplications in children. A typical combined procedure during laparoscopic fundoplication is the simultaneous placement of a gastrostomy, especially in NI children [20]. There is certainly a lack of data investigating a potential impact of pre-existing gastrostomy or concomitant placement of a gastrostomy during laparoscopic Nissen fundoplication in NI patients.

In our study, 12 out of 13 patients with redo operations had either an existing gastrostomy or underwent concomitant gastrostomy placement during initial fundoplication. A retrospective case series by Lopez et al. [12] reported a simultaneous gastrostomy placement in 88 of 149 NI children (59%) during initial laparoscopic fundoplication. Re-operations were done in 10 (7%) patients; with 7 of these patients having concomitant gastrostomy placement. Pre-existing gastrostomies at initial fundoplication were not quoted and not evaluated as a possible factor for redo operations.

In a prospective randomized trial which aimed to evaluate surgical technique to reduce the occurrence of postoperative wrap herniation, 17 patients had pre-existing gastrostomies and 72 patients underwent concomitant gastrostomy placement during initial fundoplications [19]. Patients were not stratified according to neurological impairment and redo operations were not evaluated according to simultaneous gastrostomy placement.

A very recent study reports on short and long term outcomes after pediatric redo fundoplications [7] in 24 patients. Most of these redo patients were neurologically impaired (16 of 24; 67%), a possible association with a pre-existing gastrostomy had not been reported.

Considering our observations, and inconsistent published data, a larger series is needed to investigate the potential association of gastrostomies with increased incidence of redo fundoplications especially after laparoscopic procedures in NI children.