Concurrent fundoplication in patients with neurological impairment may not be appropriate

Anti-reflux surgery with gtubes are no longer standard of care but frequently in children with neurological impairment a fundoplication may still done concurrently with gtube placement. The evidence for this is insufficient. A single children’s hospital in France followed 326 pediatric patients (56% with neurological impairment) after PEG placement to determine the presence of GERD long-term. GERD was defined as clinical symptoms requiring treatment (medication or surgery) or presence of complications of GERD. GERD was present in 74% of this population prior to surgery. In this prospective observational study, they found that 11% of patients developed GERD after PEG placement and that 25% of patients with preexisting GERD had aggravation of symptoms after surgery. It was not reported if any patients’ GERD improved after PEG. Despite this, only 16% of all patients required antireflux surgery after PEG.

After multivariate analysis, only neurological impairment was the only factor significantly associated with need for antireflux surgery. Even though this population is high risk, the authors state that only 20% of patients with neurological impairment required a fundoplication therefore presuming anti-reflux surgery at time of gtube placement is needed would make 80% of this group undergo an unneeded procedure and be at risk for complications.

Comments: Though I rarely have a patient who has a fundoplication at time of gtube placement, I have always wondered if I should be suggesting this in my children with neurological impairment. This study has put this question to rest. One thing I did find interesting which they did not report on was that it did not seem any patient’s GERD improved with PEG placement which is often suggested by medical providers. Some patients’ GERD (or lack of GERD) remained stable in this study but it was not clear if anything was improved. It is very clear that patients who qualify for gtubes often are at increased risk for GERD therefore it is no surprise some children developed GERD after PEG and it is reassuring to know that very few patients in the end require anti-reflux surgery.

Kristie Malik, MD Complex Care, Children’s Hospital at Montefiore

Aumar M. Influence of Percutaneous Endoscopic Gastrostomy on Gastroesophageal Reflux Disease in Children. J Pediatr. 2018 Apr 11