Is Prophylactic Fundoplication Necessary in Neurologically Impaired Children?

 

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Abstract

Background: Previously, concomitant antireflux surgery was performed in all neurologically impaired children undergoing gastrostomy tube placement in our department. This fundoplication procedure, not necessarily performed for symptomatic gastroesophageal reflux, increased the postoperative complications. This practice was changed and fundoplication was offered to only those children who had clear surgical indications for an antireflux procedure on follow-up after a feeding gastrostomy.

Methods: In the period from 1996 to 2007, all children who underwent gastrostomy with fundoplication were compared with those in whom feeding gastrostomy alone was done. The clinical symptoms, investigations and indications for gastrostomy and fundoplication were recorded. The children who underwent gastrostomy were followed up for symptoms of gastroesophageal reflux and the need for subsequent fundoplication was studied. The complications directly related to surgery were also studied and statistically analyzed.

Results: A total of 137 children had gastrostomy insertion, 60 of whom underwent fundoplication. Of these 60 children, 45 had concomitant fundoplication and gastrostomy. In the patients who had gastrostomy alone, a subsequent fundoplication procedure was required only in 17.1% (14 of 82). The complication rate as well as the severity of complications directly related to surgery was found to be higher in the gastrostomy+fundoplication group (18 of 60) compared with those who had only gastrostomy (12 of 82) (p=0.036).

Conclusion: Prophylactic fundoplication may not be necessary in neurologically impaired children undergoing gastrostomy for feeding purposes. It increases the postoperative morbidity compared to gastrostomy alone in this group of children. It should be offered selectively to children continuing to have reflux-related complications after gastrostomy. The technical difficulties with a pre-existing gastrostomy can be overcome in the hands of experienced laparoscopic surgeons.

References

• 1 Burd RS, Price MR, Whalen TV. The role of protective antireflux procedures in neurologically impaired children: a decision analysis.  J Pediatr Surg. 2002;  37 500-506
  Google Scholar
• 2 Langer JC, Wesson DE, Ein SH. et al . Feeding gastrostomy in neurologically impaired children: Is an antireflux procedure necessary?.  J Pediatr Gastroenterol Nutr. 1988;  7 837-841
  Google Scholar
• 3 Wheatley MJ, Wesley JR, Tkach DM. et al . Long-term follow-up of brain-damaged children requiring feeding gastrostomy: Should an antireflux procedure always be performed?.  J Pediatr Surg. 1991;  26 301-304
  Google Scholar
• 4 Borowitz SM, Sutphen JL, Hutcheson RL. Percutaneous endoscopic gastrostomy without an antireflux procedure in neurologically disabled children.  Clin Pediatr. 1997;  36 25-29
  Google Scholar
• 5 Atkinson J, Kim E, Mohan Marulaiah. Does PEG insertion induce gastroesophageal reflux? A prospective study. Paper presented at the 53rd Annual International Conference of the British Association of Paediatric Surgeons, 18–21st July 2006. Stockholm, Sweden;
  Google Scholar
• 6 Mollitt DL, Golladay ES, Seibert JJ. Symptomatic gastroesophageal reflux following gastrostomy in neurologically impaired patients.  Pediatrics. 1985;  75 1124-1126
  Google Scholar
• 7 Grunow JE, al-Hafidh A, Tunell WP. Gastroesophageal reflux following percutaneous endoscopic gastrostomy in children.  J Pediatr Surg. 1989;  24 42-44
  Google Scholar
• 8 Berezin S, Schwarz SM, Halata MS. et al . Gastroesophageal reflux secondary to gastrostomy tube placement.  Am J Dis Child. 1986;  140 699-701
  Google Scholar
• 9 Ramachandran V, Ashcraft KW, Sharp RJ. et al . Thal fundoplication in neurologically impaired children.  J Pediatr Surg. 1996;  31 819-822
  Google Scholar
• 10 Gauderer MW. Feeding gastrostomy or feeding gastrostomy plus antireflux procedure?.  J Pediatr Gastroenterol Nutr. 1988;  7 795-796
  Google Scholar
• 11 Launay V, Gottrand F, Turck D. Percutaneous endoscopic gastrostomy in children: influence on gastroesophageal reflux.  Pediatrics. 1996;  97 726-728
  Google Scholar
• 12 Wilson GJP, van der Zee DC, Bax NMA. Endoscopic gastrostomy placement in the child with gastroesophageal reflux: is concomitant antireflux surgery indicated?.  J Pediatr Surg. 2006;  41 1441-1445
  Google Scholar
• 13 Razeghi S, Lang T, Behrens R. Influence of percutaneous endoscopic gastrostomy on gastroesophageal reflux: a prospective study in 68 children.  J Pediatr Gastroenterol Nutr. 2002;  35 27-30
  Google Scholar
• 14 Rothenberg SS, Bealer JF, Chang JH. Primary laparoscopic placement of gastrostomy buttons for feeding tubes. A safer and simpler technique.  Surg Endosc. 1999;  13 995-997
  Google Scholar
• 15 Lewis D, Khoshoo V, Pencharz PB. Impact of nutritional rehabilitation on gastroesophageal reflux in neurologically impaired children.  J Pediatr Surg. 1994;  29 167-169
  Google Scholar
• 16 Fonkulsrud EW, Ashcraft KW, Coran AG. et al . Surgical treatment of Gastroesophageal reflux in children: A combined hospital study of 7 467 patients.  Pediatrics. 1998;  101 419-422
  Google Scholar
• 17 Cameron BH, Blair GK, Murphy JJ. et al . Morbidity in neurologically impaired children after percutaneous endoscopic versus Stamm gastrostomy.  Gastrointest Endosc. 1995;  42 41-44
  Google Scholar
• 18 Esposito C, Van Der Zee DC, Settimi A. Risks and benefits of surgical management of gastroesophageal reflux in neurologically impaired children.  Surg Endosc. 2003;  17 708-710
  Google Scholar
• 19 van der Zee DC, Bax NM, Ure BM. Laparoscopic secondary antireflux procedure after PEG placement in children.  Surg Endosc. 2000;  14 1105-1106
  Google Scholar
• 20 Jesch NK, Schmidt AI, Strassburg A. Laparoscopic fundoplication in neurologically impaired children with percutaneous endoscopic gastrostomy.  Eur J Pediatr Surg. 2004;  14 89-92
  Google Scholar
• 21 Khattak IU, Kimber C, Kiely EM. et al . Percutaneous endoscopic gastrostomy in paediatric practice: Complications and outcome.  J Pediatr Surg. 1998;  33 67-72
  Google Scholar
• 22 Sampson LK, Georgeson KE, Winters DC. Laparoscopic gastrostomy as an adjunctive procedure to laparoscopic fundoplication in children.  Surg Endosc. 1996;  10 1106-1110
  Google Scholar

Correspondence

Udaya Samarakkody

Waikato Hospital

Department of Paediatric

Surgery

Pembroke St

3200 Hamilton

New Zealand

Phone: +64 783 98 716

Fax: +64 783 98 765

Email: samaraku@waikatodhb.govt.nz