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Children with neurological disorders do not always need fundoplication concomitant with percutaneous endoscopic
J W Puntis1, R Thwaites, G Abel
1University of Leeds, The General Infirmary at Leeds, Neonatal Unit, UK. 100677.2423@compuserve.com
Insights
Routine antireflux surgery is often unnecessary for children with neurological disorders undergoing gastrostomy. Most children do not require fundoplication after percutaneous endoscopic gastrostomy (PEG) insertion, even if they develop reflux symptoms.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Neurology
Background:
- Neurological disorders in children often necessitate gastrostomy for nutritional support.
- The risk of gastroesophageal reflux (GER) in these children raises questions about concurrent antireflux surgery.
- Screening for occult GER is proposed to guide the need for fundoplication during gastrostomy.
Purpose of the Study:
- To evaluate the necessity of routine antireflux surgery in children with neurological disorders undergoing percutaneous endoscopic gastrostomy (PEG).
- To determine if fundoplication is required in neurologically impaired children without pre-existing severe GER symptoms after PEG insertion.
Main Methods:
- Retrospective analysis of 29 children with neurological disorders who underwent PEG without fundoplication.
- Inclusion criteria: no clinical evidence of severe GER before PEG insertion.
- Follow-up duration: median of 2.6 years.
Main Results:
- PEG insertion was successful in 26 of 29 children.
- 14 of 26 children developed symptomatic GER post-PEG; 5 had no pre-PEG reflux on pH monitoring.
- Medical management resolved symptoms in 12 children; 2 required subsequent fundoplication.
Conclusions:
- Fundoplication is unlikely to be necessary for neurologically impaired children without severe GER symptoms undergoing PEG.
- Routine GER investigation can be avoided in children without severe vomiting, reducing the need for antireflux procedures.
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.