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Citation: Jafarli I, Aljubab A, Smith L. Gastrostomy and fundoplication in neurologically impaired children: A benefit-risks
confrontation. Jr. med. res. 2021; 4(2):3-6. Jafarli et al © All rights are reserved. https://doi.org/10.32512/jmr.4.2.2021/3.6
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Background
For children with neurological impairment (NI) and swallowing incoordination
feeding gastrostomy is usually required. This procedure may cause or
aggravate preexisting gastroesophageal reflux disease (GERD). Fundoplication
has been advocated at the time of gastrostomy placement in these patients.
The purpose of this study is to evaluate clinical impact and risk-benefit balance
of fundoplication and gastrostomy tube placement in patients with NI due to
cerebral palsy, Hypoxic ischemic encephalopathy, brain tumors, and Dandy-
Walker syndrome.
Methods
This study is a ten-year retrospective analysis including 180 cases of gastric
tube placement in neurologically impaired children performed in a single
institution.
Results
One hundred eighty patients underwent gastrostomy tube (GT)placement (94
open versus 86 laparoscopic). Concomitant fundoplication was performed in
44 cases. Three different types of tube were used during the procedures. There
were differences between the two groups in gender but not in age distribution
or comorbidity. Fundoplication was laparoscopic in 29 cases (33.7%) and open
in 15 (16.0%). Postoperative diarrhea was more frequently observed with the
Mickey tube (p=0.008). the hospital stay was longer after Mic tube placement
(p=001). Sequelae after gastrostomy tube placement were observed in 21
cases (p=0.015). five postoperative cases of death were noted (p=0.015). The
recurrence rate of reflux was 71% and mortality rate was 63% on long term
follow-up.
Conclusions
In this study on NI and swallowing disorder unresponsive to medical treatment,
open or laparoscopic fundoplication and gastrostomy reduced nausea and pain
after feeding, but not Apparent life-threatening event in infancy (ALTE).
Potential increased risk of complications and the procedure results instability
may indicate the implementation of new management guidelines.
Key words
Fundoplication; Gastrostomy; Neurological impairment; Children, Outcome.
1: Department of pediatric surgery Guy’s and St
Thomas hospital, London, UK
2: Department of pediatric surgery King Fahad
Medical City, Riyadh, Saudi Arabia
3: College of medicine Cardiff University, Wales, UK
* Corresponding author
** Academic editor
Correspondence to: aljubab.a@gmail.com
Publication data:
Submitted: August 23, 2021
Accepted: October 29, 2021
Online: November 30, 2021
This article was subject to full peer-review.
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Jafarli Ilhama
1**
, Aljubab Abdulwahab
2*
, Smith Lucy
3
.
Abstract:
Original Article
Gastrostomy and fundoplication in neurologically impaired children: A benefit-risks confrontation.
Gastrostomy and fundoplication in neurologically impaired children: A benefit-risks confrontation
Citation: Jafarli I, Aljubab A, Smith L. Gastrostomy and fundoplication in neurologically impaired children: A benefit-risks
confrontation. Jr. med. res. 2021; 4(2):3-6. Jafarli et al © All rights are reserved.
Submit your manuscript: www.jmedicalresearch.com
Results
Gastrostomy Tube placement was performed for the 180 included
cases. The procedures were performed either laparoscopically
(47.8%) or open (52.2%). Sex ratio was 1.6. Most of the patients
were of Saudi nationality. The indication of the surgery was severe
GERD in more than half of the cases. Clinical patients data is
summarized in table 1.
Table 1: Patients clinical characteristics
Variables
Categories
n (%)
Gender
Male
111 (61.7%)
Female
69 (38.3%)
Nationality
Saudi
177 (98.3%)
Non - Saudi
3 (1.7%)
Previous Surgery
Yes
6 (3.3%)
No
174 (96.7%)
Fundoplication
Yes
44 (24.4%)
No
136 (75.6%)
Indication
GERD
51 (28.3%)
Feeding Intolerance
6 (3.3%)
Swallowing disorder
40 (22.2%)
More than one indication
83 (46.1%)
Procedure type
Open
94 (52.2%)
Laparoscopic
86 (47.8%)
ASA Status
ASA I
11 (6.1%)
ASA II
62 (34.4%)
ASA III
106 (58.9%)
ASA IV
1 (0.6%)
Type of GT used
Foley Cath
113 (62.8%)
Mickey Tube
56 (31.1%)
Mic Tube
11 (6.1%)
Three types of GT were used: Foley catheter (62.8%), Mickey Tube
(31.1%), Mic Tube (6.1%). There was no statistically different
distribution with the gender (p=0.670), age (p=0.223), weight
(p=0.420), and previous abdominal surgery (p=0.521). The tube
was inserted by laparoscopic surgery in almost half of the cases.
The operative time was comparable in open vs laparoscopic group
(p=0.665). Hospital stay was significantly longer in case of open
procedure (p=0.005). Concomitant fundoplication was performed
in 44 cases mostly associated with laparoscopic GT insertion
(p=0.006). Feeding was started earlier in laparoscopic group (0.94
± 1.16 p=0.175).
Procedure’s outcomes were variable. Uneventful recovery was
observed in 77.8% of cases. Complicated postoperative course was
noted in 19.4% of cases. The death rate was 2.8 % in our study.
Leakage from the insertion point and diarrhea were the most
frequent postoperative complications (22.8 and 15% respectively).
Tube insertion revision was needed in 10 of our patients. The
analysis showed a significantly increased risk of leakage and tube
revision with the Foley catheter (p=0.036 and 0.34 respectively).
The Mic tube was associated with longer hospitalizations
(p=0.008). However logistic regression did not confirm that as
independent factor (p=0.162). The Mickey tube was the most
associated with postoperative diarrhea (p=0.008) and appear as
independent in the analytic study (0.0012).
Postoperative aggravation of the neurological symptoms was
frequently noted in the postoperative course. It was transitory in
more than 90%of cases. Severe neurological aggravation was
significantly associated with complicated GT insertion (p=0.015)
and led to death in all the cases (p=0.002). GT leakage appears as
independent factor leading to general and neurological status
deterioration (p<0.01). All cases of death recorded were in patients
with complicated postoperative course.
Patients and Methods
Study design
This study is a single institution retrospective analytic study which
assessed the indications and outcomes of GT placement performed
for NI children in the department of pediatric surgery king Fahad
Medical City Riyadh, Kingdom of Saudi Arabia over 10 years (2010-
2019).
Population
One hundred eighty patients were included in the study. Patients
aged below one year and over 14 years were excluded as well as
the NI patients with GT placement who responded favorably to anti-
reflux medications. Medical records were retrospectively reviewed
and analyzed. Data collected included sex, age, nationality,
diagnosis circumstances, and indications for procedure. The type of
the procedure (Open Stamm GT Placement, Laparoscopic GT
Placement, Concomitant Fundoplication), the gastric tube used
(Foley Catheter, Mickey Tube, Mic Tube), and the perioperative
courses were noted.
Data analysis
Data was analyzed using the Statistical Package for Social Sciences
(SPSS) version 22.0 (IBM Corp., Armonk, NY, USA). The Chi-square
test (X2) was used for the comparative study. Significance was
retained for P value <0.05. Discrete variables such as sex, past
medical history, and indications for the procedure were presented
as numbers and percentages. Continuous variables such as age,
weight, operative time, and length of hospital stay were expressed
as a mean, with standard deviation. Outcomes of procedures
performed were evaluated using ANOVA test, comparing the
indications for the procedure, comorbidities, and postoperative
complications.
Bibliographic review
We reviewed literature using several search engines and databases:
Pub Med, Medline, Scopus, Science Direct, and Google scholar using
the following keywords: Fundoplication; Gastrostomy; Neurological
impairment; Children, Outcome. Twenty relevant papers published
over the past fifteen years were collected and reviewed.
Ethical considerations
This study was performed according to the guidelines of the
Scientific Research Committee at the king Fahad Medical city.
4
Gastrostomy and fundoplication in neurologically impaired children: A benefit-risks confrontation
Citation: Jafarli I, Aljubab A, Smith L. Gastrostomy and fundoplication in neurologically impaired children: A benefit-risks
confrontation. Jr. med. res. 2021; 4(2):3-6. Jafarli et al © All rights are reserved.
Submit your manuscript: www.jmedicalresearch.com
t w
Discussion
Undernutrition in children with neurological impairments is
frequently related to feeding difficulties. It may alter the quality
of patient life and constitute a further comorbidity factor that
interfere directly with the survival [4]. Aspiration pneumonia is
the most common cause of death in children with NI. Feeding
GT placement is performed to enhance nutritional status and to
reduce aspiration risk. Fundoplication is usually associated to
prevent or treat preexisting GERD especially due to the high
failure rate of reflux medical management in this group of
patients [5].
Considerable postoperative life-threatening complications have
been widely described in the literature [6,7]. This may call into
question whether this procedure should be performed routinely.
Our study did not demonstrate objective difference in outcome
between patients who underwent concomitant fundoplication
and those who did not. The reflux recurrence rate was high in
long term follow up and the procedures done did not improve
the overall survival. The reflux symptoms were improved only
for patients with severe pre-existing GERD. Some studies
investigated about the reflux-related hospitalization rate which
was found to be similar with or without gastrojejunostomy and
fundoplication. Most of the rehospitalization were indicated due
to postoperative complications and sequelae. [8].
5
Concomitant fundoplication was associated with postoperative status
improvement in all the laparoscopic cases. However, that appear
independent only for patients with previous severe GERD (p=0.028).
Open fundoplication was significantly associated with longer operative
time and feeding pain (p=0.03 and 0.016 respectively). The analysis
showed higher overall morbidity of 19.4%. The morbidity seems to
be higher in the open procedures group and after Nissen
fundoplication (33% and 22% respectively). However, no significance
was retained(p=0.236). The recurrence rate of reflux was 71% and
mortality rate was 63% on long term follow-up.
Table 2 summarized the outcomes of different procedures.
Table 2: Procedure outcomes
Outcomes
p
Death
Uneventful
Complicated
Gender
Male
-
88 (62.9%)
23 (65.7%)
0.115
Female
5 (100.0%)
52 (37.1%)
12 (34.3%)
Age (months)
48.00 ± 30.1
40.27 ± 3.18
27.52 ± 5.01
0.164
Weight (kg)
5.3 ± 2.46
10.28 ± 0.47
9.76 ± 1.05
0.138
Previous Surgery
Yes
0 (0.0%)
5 (3.6%)
1 (2.9%)
0.895
No
5 (100.0%)
135 (96.4%)
34 (97.1%)
Fundoplication
Yes
5 (100.0%)
39 (27.9%)
5 (14.3%)
0.108
No
-
101 (72.1%)
30 (85.7%)
Indications
GERD
-
38 (27.1%)
13 (37.1%)
0.277
Intolerance
-
6 (4.3%)
-
SD
2 (40.0%)
34 (24.3%)
4 (11.4%)
>1
3 (60.0%)
62 (44.3%)
18 (51.4%)
Operative Time
60.00 ± 0.1
76.75 ± 13.91
89.44 ± 7.96
0.683
Preoperative Albumin
26.6 ± 9.4
25.29 ± 1.87
28.4 ± 4.01
0.789
ASA Status
ASAI
-
9 (6.4%)
2 (5.7%)
0.390
ASA II
2 (40.0%)
42 (30.0%)
18 (51.4%)
ASAIII
3 (60.0%)
88 (62.9%)
15 (42.9%)
ASA IV
-
1 (0.7%)
0 (0.0%)
Ileus
Yes
-
5 (3.6%)
2 (5.7%)
0.759
No
5 (100.0%)
135 (96.4%)
33 (94.3%)
Diarrhea
Yes
-
23 (16.4%)
4 (11.4%)
0.483
No
5 (100.0%)
117 (83.6%)
31 (88.6%)
Feeding pain
Yes
2 (40.0%)
2 (1.4%)
2 (5.7%)
< 0.001
No
3 (60.0%)
138 (98.6%)
33 (94.3%)
Deterioration
Yes
5(100%)
27 (19.3%)
14 (40.0%)
0.015
No
-
113 (80.7%)
21 (60.0%)
Leakage
Yes
5 (100.0%)
25 (17.9%)
11 (31.4%)
< 0.001
No
-
115 (82.1%)
24 (68.6%)
Tube revision
Yes
-
7 (5.0%)
3 (8.6%)
0.612
No
5 (100.0%)
133 (95.0%)
32 (91.4%)
High residue
Yes
2 (40.0%)
11 (7.9%)
-
0.004
No
3 (60.0%)
129 (92.1%)
35 (100.0%)
Hospital stays
3.8 ± 1.49
7.26 ± 0.97
27.61 ± 15.88
0.017
The morbidity of surgical gastric tube insertion might be related
essentially to the tube site such as disinsertion, leakage, and
infection. However, the value of the own anti-reflux procedure
morbidity cannot be assessed due to the lack of comparative
trials and metaanalysis [9].
In our study, the operative time was longer in the cases with
complicated postoperative course. Complex procedures in such
fragile underlying conditions might lead to complications.
However, no significance was retained in our analysis. With
more involvement of the patient family and the care givers,
perceptible overall life quality improvement may be observed in
the first year after the procedure according to other studies
[10,11]. The laparospic access is associated with higher parent
satisfaction. There was no difference between three type of
fundoplication valves in recent studies which attributed the
postoperative specific morbidity to the learning curve [12,13].
Aside from the surgery related morbidity, the aim of GT
insertion should allow a successful transition to oral feedings
over time. This has never been described specially for severely
impaired children [14]. Due to the absence of management
guidelines and the consistency of surgical morbidity which may
affect the overall survival of these young patients, alternatives
for surgery have been proposed since a decade [15,16].
Percutaneous gastro-jejunal tube (GJT) insertion is the most
cited procedure in the management of feeding difficulties in
these patients. This radiologically-guided procedure does not
require general anesthesia and seems to be effective in the
management of feeding difficulties and improve partially the
reflux symptoms with acceptable grade of evidence [17]. The
endoscopy contributed to the precision of the tube insertion.
Percutaneous endoscopic gastrostomy (PEG) may be a
reasonable and safer nutritional option for patients with
impaired enteral feeding [18].
Gastrostomy and fundoplication in neurologically impaired children: A benefit-risks confrontation
Citation: Jafarli I, Aljubab A, Smith L. Gastrostomy and fundoplication in neurologically impaired children: A benefit-risks
confrontation. Jr. med. res. 2021; 4(2):3-6. Jafarli et al © All rights are reserved.
Submit your manuscript: www.jmedicalresearch.com
Fundoplication is becoming questionable due to the instability of the
long term results and the progress of non-surgical techniques in GERD
treatment [19].
Management of reflux and undernutrition in neurologically impaired
children require balanced decision-making process [20]. The available
options are life-changing and require great support from patient family
and highly qualified caregivers.
Conflict of interest: None
6
Conclusion
Neurological impairment is a global condition which includes several
neurologic syndromes. This condition has been creating heterogeneity in
all published patients series and generated multiple analysis biases. The
ethical limits and difficulties of securing parental consent for prospective
randomized comparative management trials made us far from any
evidence or guidelines. A comprehensive treatment approach should be
assigned and adapted for each NI pediatric case. It should be done better
in a multidisciplinary team including the parents and the caregivers.
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