A recent study questions the value of fundoplication in children with neurologic impairment who undergo gastrostomy tube placement (JAMA Pediatr doi:10.1001/jamapediatrics.2013.334).
This paper’s findings are limited by the study’s design as a retrospective, observational cohort study. However, the study has several strengths as well. First of all, this was a large study which identified 4163 neurologically-impaired infants who underwent either tube placement with (n=1404) or without fundoplication (n=2759). This population was drawn from 42,796 infants admitted to neonatal intensive care units from 42 children’s hospitals. Thus, a second advantage of this study was looking at a broad range of children from the same NICU population.
- Infants who underwent fundoplication did not have a reduced rate of reflux-related hospitalizations. The authors tried to control for differences in the population with propensity score-matched analysis.
- Only a small number had a significant preoperative GERD workup. In total, 9.4% of infants had pH probes and 4.3% had endoscopies preoperatively.
- Mean number of reflux-related admissions (Table 3 in study) within 1 year after discharge from NICU: overall: for gtube 0.92 compared with 1.02 for gtube/fundo, for pneumonia 0.18 (Gtube) compared with 0.23 (Gtube/fundo), aspiration pneumonia was 0.08 for both groups.
The authors note that two previous studies had shown a reduction in reflux-related hospitalizations for children who had admissions due to reflux-related conditions. However, they note that in their study, these patients had fundoplication performed prophylactically based on clinical judgement.
But, “clinical symptoms, including dysfunctional swallowing and intolerance of gastric feedings, likely influence the decision to perform a concomitant fundoplication; however, these were unavailable in the database.” As such, the authors propensity score model could have failed to account for factors that are essential in deciding whether a concomitant fundoplication is worthwhile.
Bottom-line: A fundoplication may not effectively prevent reflux-related hospitalizations in neurologically-impaired infants; its expected benefits may be overstated. The only way to definitively determine how useful (or how ineffective) a fundoplication is would be a prospective study.
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