Is prophylactic fundoplication necessary in neurologically impaired children?

Previously, concomitant antireflux surgery was performed in all neurologically impaired children undergoing gastrostomy tube placement in our department. This fundoplication procedure, not necessarily performed for symptomatic gastroesophageal reflux, increased the postoperative complications. This practice was changed and fundoplication was offered to only those children who had clear surgical indications for an antireflux procedure on follow-up after a feeding gastrostomy.

In the period from 1996 to 2007, all children who underwent gastrostomy with fundoplication were compared with those in whom feeding gastrostomy alone was done. The clinical symptoms, investigations and indications for gastrostomy and fundoplication were recorded. The children who underwent gastrostomy were followed up for symptoms of gastroesophageal reflux and the need for subsequent fundoplication was studied. The complications directly related to surgery were also studied and statistically analyzed.

A total of 137 children had gastrostomy insertion, 60 of whom underwent fundoplication. Of these 60 children, 45 had concomitant fundoplication and gastrostomy. In the patients who had gastrostomy alone, a subsequent fundoplication procedure was required only in 17.1% (14 of 82). The complication rate as well as the severity of complications directly related to surgery was found to be higher in the gastrostomy+fundoplication group (18 of 60) compared with those who had only gastrostomy (12 of 82) (p=0.036).

Prophylactic fundoplication may not be necessary in neurologically impaired children undergoing gastrostomy for feeding purposes. It increases the postoperative morbidity compared to gastrostomy alone in this group of children. It should be offered selectively to children continuing to have reflux-related complications after gastrostomy. The technical difficulties with a pre-existing gastrostomy can be overcome in the hands of experienced laparoscopic surgeons.