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.

Early decision of gastrostomy tube insertion in children with severe developmental disability: a current dilemma

“…over-granulation, irritation and tenderness), which were easily managed. Similar to other studies, anti-reflux techniques were required after PEG in several cases (Sulaeman et al, 1998;Puntis et al, 2000). The mortality rate was similar to that reported previously (Avitsland et al, 2006) and it was found to be related to the underlying disease, and not to the nutritional support itself.…”

Percutaneous endoscopic gastrostomy in children: a single center experience

“…It is known that the frequency of GER is increased in patients with neurological diseases (14). Some studies have supported the view that the severity of GER increases after PEG in these patients and some others have reported the opposite (15)(16)(17). However, Puntis et al (17) recommended that simultaneous antireflux operation should not be performed in these patients and investigations for GER should be avoided in patients without complaints.…”

Nonoral Feeding for Children and Youth With Developmental or Acquired Disabilities

“…53 In response to earlier suggestions for "the need for a 'protective' antireflux operation in children referred for feeding gastrostomy," 54 Puntis et al provided data "in the child with neurological disabilities without symptoms indicating severe gastroesophageal reflux" and their conclusions that "fundoplication is unlikely to be necessary as a consequence of percutaneous endoscopic gastrostomy" and that the number of antireflux surgical procedures should be reduced. 55 Similarly, the outcome reports of variations in fundoplication techniques (eg, open, laparoscopic) offer differences in respective advantages and disadvantages. 56,57 A number of complications and adverse effects have been described and attributed to fundoplication surgery: alterations in gastric tone (perhaps related to injury of the vagal nerve at operation); accelerated gastric emptying ("dumping syndrome"); delayed gastric emptying after surgery related to vagal nerve injury; and retching (potentially related to visceral afferent sensitivity and vagal nerve injury).…”