[size=20px]A 3-year old boy has severe developmental delay, cerebral palsy, and chronic seizure disorder. He often chokes when fed thick liquids and purees. His weight is currently at the 3rd percentile. He has been maintained on proton pump inhibitors, but still required 3 admissions for aspiration pneumonia over the last year. The parents inquire about the effects of fundoplication on weight gain, discontinuation of reflux medications and hospital admissions. The most adequate response to these queries is that the fundoplication is likely to result in:

 

 

A weight gain and discontinuation of medications

 

B weight gain with continuation of medications

 

C no weight gain and continuation of medications

 

D no weight gain, but discontinuation of medications[/size]

A

correct answer

B weight gain with continuation of medications

 

Gastroesophageal reflux disease (GERD) is a common indication for pediatric surgical referral, and fundoplication is one of the most common procedures performed by pediatric surgeons in the United States. Despite this frequency, evidence supporting its efficacy is extremely weak, as shown in recent systematic reviews from the American Pediatric Surgical Association and guidelines published by the North American and European Societies for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN and ESPGHAN). This lack of evidence has led to great variability in the surgical treatment of gastroesophageal reflux between individual pediatric surgeons, institutions, and regions of the country.

 

 

Neurologically impaired patients, such as the one presented here, constitute 30-50% of the pediatric population undergoing fundoplication. These patients present a particular challenge. They have stronger indications for fundoplication, but also have significantly higher failure rates and need for re-operation as shown in a recent systematic review and meta-analysis. Fundoplication and gastrostomy in these patients should be expected to improve weight gain, mostly due to the more reliable provision of calories through the gastrostomy. However, studies that have looked at specific outcomes, such as discontinuation of pre-operative medications, decrease in hospitalizations, and decrease in the frequency of aspiration pneumonia have failed to demonstrate improvement in these outcomes after fundoplication. These patients suffer from global foregut dysfunction, including decreased esophageal clearance, decreased gastric emptying, and global dysmotility. Their underlying conditions often include components of spasticity, scoliosis, and deformities, which may further predispose to GERD.

 

 

A fundoplication should be considered a palliative operation in these patients. Other options for palliation include gastrostomy insertion, gastro-jejunal feeding tube insertion, and esophagogastric disconnection. Each of these procedures has its own risk profile. Provision of medical palliative care during presentation with a life-threatening complication in these patients is a reasonable alternative, which has not been explored sufficiently in the surgical literature.