Nissen fundoplication and gastrostomy in severely neurologically impaired children with gastroesophageal reflux

KM Cheung, HW Tse, PWT Tse, KH Chan
Department of Paediatrics, Caritas Medical Centre, 111 Wing Hong Street, Shamshuipo, Hong Kong

OBJECTIVES. To study the effect of Nissen fundoplication and gastrostomy in severely neurologically impaired children.

DESIGN. Prospective observational study.

SETTING. Developmental Disabilities Unit of a regional medical centre in Hong Kong.

PATIENTS. Children with severe neurological impairment and gastroesophageal reflux who were institutionalised between 1999 and 2004 inclusive.

MAIN OUTCOME MEASURES. Incidence of vomiting, gastro-intestinal bleeding, and pneumonia in the baseline year and consecutive years following surgery; 24-hour oesophageal pH monitoring; recurrence rate (determined by 24-hour oesophageal monitoring); body weight; complications of surgery; and mortality.

RESULTS. Twenty children, with a mean age at surgery of 8.5 (standard deviation, 3.5) years, were recruited. Nissen fundoplication was performed in nine children and 11 children underwent laparoscopic fundoplication. Children were monitored for 1.3 to 5.7 years (median, 3.5 years) after surgery. The incidence of vomiting and gastro-intestinal bleeding was significantly decreased following surgery (P<0.001 and P=0.001, respectively; Friedman's test). There was no difference between the preoperative and postoperative incidence of pneumonia (P=0.973, Friedman's test). The median reflux index was reduced from 5.7% to 0.15% after surgery but six (30%) patients had recurrent gastroesophageal reflux. The mean body weight was 17.4 kg (standard deviation, 4.7 kg) at baseline and 22.8 kg (standard deviation, 4.4 kg) at the end of follow-up (P<0.05, Student's t test). One patient had mild dumping syndrome soon after fundoplication. One patient had one episode of intestinal obstruction. Four patients died 1.9 to 5.0 years following surgery due to respiratory disease.

CONCLUSION. Our results indicate that in severely neurologically impaired children with gastroesophageal reflux, vomiting, gastro-intestinal bleeding, and reflux indices based on 24-hour oesophageal pH monitoring were significantly reduced following fundoplication and gastrostomy. The incidence of pneumonia was unchanged. The recurrence rate of reflux was 30% and mortality rate was 20%.

Hong Kong Med J 2006;12:282-8

Key words: Child; Fundoplication; Gastroesophageal reflux; Mental retardation; Recurrence

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