Total Oesophagogastric Dissociation in Neurologically Impaired Children

Abstract

Objectives: Total oesophagogastric dissociation (TOGD) is an alternative antireflux surgery for neurologically impaired children because of a 16% to 38% fundoplication failure rate. This study evaluates TOGD's feasibility and its long-term efficacy both as a Primary and as a “Rescue” procedure after failed fundoplication. Methods: Thirty patients (18 boys) who underwent TOGD between 2000 and 2018 in 2 Italian Centres were retrospectively reviewed. Twenty-three were Primary procedures and 7 were “Rescue” ones. Inclusion criteria were severe neurodisability, intractable gastroesophageal reflux, and dysphagia. Results: Preoperatively, all children had regurgitation, vomiting or retching, and 93% had unsafe swallowing and aspiration, with recurrent chest infections/aspiration pneumonia. Median relative weight was 77% (48%--118%). All patients were taking antireflux medication before surgery. Median age at TOGD was 6.48 years (0.69--22.18). Median follow-up was 3.5 years (0.6–17.7). No recurrence of gastroesophageal reflux (GER) and vomiting was recorded. The number of chest infections and length of hospital stay showed a significative decrease (P value <0.0001 for both), whereas median relative weight reached 101% (P value 0.002). Parents’/caregivers’ perception of outcome showed a significative improvement. Six patients (20%) experienced early complications and 3 required surgical intervention. Three late complications (10%) also required surgery. There was no surgery-related mortality. Conclusion: TOGD is an effective procedure with an acceptably low complication rate for children with severe neurological impairment and is followed by a major improvement in general health and quality of life for children and families. There was no substantial difference in outcome between Primary and “Rescue” procedures.

Clinical characteristics of children with severe neurologic impairment: A scoping review

“…The 102 published clinical studies about children with SNI fall into seven clinical topics. Gastroesophageal reflux and feeding tubes ( n = 57, 56%) was the most common topic, with subtopics of gastroesophageal reflux ( n = 7), 7,42–44,102–104 gastrostomy tube outcomes ( n = 24), 9,39,45,46,56–65,81–84,105–110 and antireflux procedures ( n = 26) 8,47–55,66–71,85,86,111–118 . Other topics included aspiration and respiratory issues ( n = 13, 13%) 72,73,87–93,119–122 ; symptoms, palliative care, and quality of life ( n = 12, 12%) 38,41,74–77,94–97,123,124 ; growth and endocrinology ( n = 10, 10%) 78,98,99,125–131 ; caregivers and care burden ( n = 7, 7%) 10,37,40,79,80,100,132 ; other ( n = 2, 2%) 101,133 ; and musculoskeletal ( n = 1, 1%) 134 .…”

“…Gastroesophageal reflux and feeding tubes (n = 57, 56%) was the most common topic, with subtopics of gastroesophageal reflux (n = 7), 7,[42][43][44][102][103][104] gastrostomy tube outcomes (n = 24), 9,39,45,46,[56][57][58][59][60][61][62][63][64][65][81][82][83][84][105][106][107][108][109][110] and antireflux procedures (n = 26). 8,[47][48][49][50][51][52][53][54][55][66][67][68][69][70][71]85,86,[111][112]…”

Long-Term Analysis of Respiratory-Related Complications Following Gastrostomy Placement with or without Fundoplication in Neurologically Impaired Children: A Retrospective Cohort Study

“…Another available alternative in NI patients is TOGD. Despite being initially used as a rescue procedure, TOGD is currently encouraged by many centers as a primary procedure in severely NI children [24]. Reviews of the technique quote a 20% risk of major complication following TOGD, with 5% mortality of the procedure [25].…”

Modified Oesophago-Gastric Dissociation (M-OGD) — a technical modification

“…TOGD has been used more commonly in Europe [5][6][7], but there are only limited reports for this approach in the United States [8,9] or other non-EU [10,11] countries. However, for a very specific and complex patient population, this procedure has a high likelihood of permanently eliminating recurrent reflux and aspiration, and of improving the quality of life for the patients and their caregivers by reducing healthcare visits and hospital readmissions, and improving feeding habits [12].…”