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Nissen fundoplication in children with profound neurologic disability. High risks and unmet goals
C D Smith1, H B Othersen, N J Gogan
1Department of Surgery, Medical University of South Carolina, Charleston 29425.
Insights
Anti-reflux procedures like Nissen fundoplication in neurologically impaired children with GERD show high complication rates, including pneumonia and death. These procedures may not be established as safe or effective for this vulnerable population.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Neurology
Background:
- Anti-reflux procedures (ARP) are used in children with profound neurologic disability and gastroesophageal reflux (GERD).
- Goals include improved care, reduced pneumonia/vomiting, and better health/survival.
- Historically, these procedures had low reported risks.
Purpose of the Study:
- To retrospectively review outcomes of fundoplication in nonverbal, nonambulatory pediatric patients.
- To assess the efficacy and safety of ARP in severely neurologically impaired children.
Main Methods:
- Retrospective review of 35 pediatric patients undergoing 39 fundoplications (37 Nissen, 1 Thal, 1 Belsey) over 11 years.
- Patients were nonverbal and nonambulatory with various causes of neurologic impairment.
Main Results:
- 17% perioperative complications and 12% early postoperative deaths.
- High rates of late complications: 40% recurrent pneumonia, 31% recurrent vomiting, 23% choking-gagging-retching, 9% bowel obstruction.
- 20% had recurrent GERD, and 17% required a second ARP.
- 40% late mortality.
Conclusions:
- While ARPs can achieve goals in some children, Nissen fundoplication's established safety and efficacy for resolving swallowing disorder complications in this complex group is not demonstrated.
- The high complication and mortality rates challenge the established low-risk profile for this specific patient population.
Abstract:
Anti-reflux procedures have been advocated in children with profound neurologic disability referred for feeding gastrostomy when gastroesophageal reflux is present. Facilitation of care, reduction in pneumonia and vomiting, and improvement in the general health and survival of these children have been major goals of fundoplication and gastrostomy. In large pediatric series, these procedures have been reported to have low risk and negligible mortality rates. Recent reports, however, document an increased incidence of sequelae of fundoplication in children with profound neurologic disability. This paper retrospectively reviews a series of 35 nonverbal, nonambulatory pediatric patients undergoing a total of 39 fundoplications (37 Nissen, 1 Thal, and 1 Belsey) over an 11-year period. Neurologic impairment of 17 (49%) patients was acquired, 13 (37%) congenital, and 5 (14%) due to a syndrome. Perioperative complications occurred in six (17%). Three additional complications led to early postoperative death. A fourth early death was unexplained. Fourteen (40%) had recurrent pneumonia, 11 (31%) recurrent vomiting, 8 (23%) choking-gagging-retching complex, and 3 (9%) bowel obstruction requiring laparotomy. Recurrent gastroesophageal reflux was documented in seven (20%) patients. A second ARP was performed in six (17%). There were 14 (40%) late deaths. Although the major goals of anti-reflux procedure are clearly achieved in many severely impaired children with gastroesophageal reflux, the use of Nissen fundoplication to resolve the complications of swallowing disorders and improve outcome with an acceptably low risk in this complex set of patients does not appear to be established.