Children with neurological disorders do not always need fundoplication concomitant with percutaneous endoscopic gastrostomy

Abstract

Whether antireflux surgery should be routinely performed at the time of gastrostomy in children with neurological disorders is debatable because of the risk of gastroesophageal reflux. Some argue that these children should be screened for occult gastroesophageal reflux as this will determine the need for fundoplication. This study retrospectively examines outcome in 29 children with neurological disorders who underwent percutaneous endoscopic gastrostomy (PEG) without concomitant fundoplication. Children were included if they had no clinical evidence of severe gastroesophageal reflux before PEG insertion. The median age of children at PEG insertion was 5.6 years (range 1.1 to 18.0). The children were followed for a median of 2.6 years (range 0.4 to 4.9). Insertion of PEG was technically impossible in two children; and an asymptomatic gastrocolic fistula in another child led to subsequent tube removal. Fourteen of the 26 remaining children developed symptomatic gastroesophageal reflux after PEG; five of these showed no reflux on pH monitoring prePEG. Control of symptoms was achieved by medical intervention in 12, but two required fundoplication. Our findings indicate that in the child with neurological disabilities without symptoms indicating severe gastroesophageal reflux, fundoplication is unlikely to be necessary as a consequence of PEG insertion. We conclude that routine investigation for gastroesophageal reflux in the child without severe vomiting can be avoided and the number of antireflux procedures reduced.

Endoscopic gastrostomy placement in the child with gastroesophageal reflux: is concomitant antireflux surgery indicated?

“…That gastrostomy formation can have an influence upon the presence and symptoms of GER is well described, and the proposition that a b protectiveQ antireflux procedure should be performed routinely in all patients at the time of gastrostomy placement has been repeatedly raised and discounted [2][3][4][5][6]8]. In the patient with proven GER, however, antireflux surgery simultaneous with gastrostomy placement is often performed [2,3,7].…”

“…The high incidence of GER in the neurologically impaired patient group has led to suggestion that bprotective Q antireflux surgery at the time of gastrostomy placement is warranted, even without preoperative evidence 0022 of GER. Although this may obviate the need for further surgery in a small number of patients, for most, it represents an unnecessary procedure carrying higher risks than gastrostomy placement alone [4][5][6].…”

Outcomes of Percutaneous Endoscopic Gastrostomy in Children

“…The evidence regarding an increase in GER in children with NI after PEG is mixed: the clinical severity of reflux was shown to increase in some studies, but not in others [26,37,40,41]. However, there seems to be agreement that concomitant antireflux surgery should not automatically be performed in these patients, and that routine investigation for GER in asymptomatic children should be avoided [41]. Further diagnostic assessment and antireflux surgery should be considered if symptoms progress after PEG [42].…”

Preoperative prediction of need for fundoplication before gastrostomy tube placement in children

“…In the absence of clinically significant GER, the literature supports performing gastrostomy tube placement without a concomitant antireflux procedure in most children [4,[19][20][21]. However, no study has attempted to identify preoperative indicators that would necessitate an antireflux procedure.…”

“…Upper gastrointestinal series and pH monitoring have also been shown to have low sensitivities for GER (16k-50k and 29k-49k, respectively) [13][14][15][16][17][18]. Despite their limitations, these studies are routinely used in the assessment of children needing enteral access and have resulted in a 7k to 12k failure rate in the recognition of the need for an antireflux procedure at the time of gastrostomy [19][20][21].…”