W1078 Should Fundoplication Be Added at the Time of Gastrostomy Placement in Profoundly Handicapped Patients With Dysphagia?

Abstract

Background: Handicapped patients with advanced neurological impairment and dysphagia require gastrostomy feeding and are associated with gastroesophageal reflux disease (GERD). Concurrent fundoplication is often recommended at the time of gastrostomy placement (GP) in those patients because of avoiding long-term anti-reflux medication or preventing future reflux symptoms. Fundoplication has recently been thrown doubts about its indication in those patients because of unignorable complications and the high incidence of recurrence of GERD. It was aimed in this study to conduct a retrospective review of the outcome of handicapped patients with GP alone. Methods: The subjects consisted of 60 profoundly handicapped patients requiring tube feeding, aged 1 yr to 33 yrs (median 9 yrs), who underwent GP alone. The operative criteria included no or medically controllable reflux symptoms. Operative procedure was laparoscopic in 53 and open in 7. They were divided into two groups based on % esophageal total time pH<4.0 (reflux index:RI) evaluated with preoperative 24-hour esophageal pH monitoring; Group I (GI, n=37): RI<5.0 %, median age 7 yrs (2yrs-33 yrs), Group II (GII, n=23): RI≥5.0 %, median age 11yrs(1yr -21 yrs). Postoperative pH monitoring was performed in 26 GI patients and 20 GII. Follow-up period ranged 2 yrs to 8 yrs(median 4 yrs). Data are expressed as medians and ranges. Results: Postoperative medical management of GERD succeeded in 3 of 4 GI patients and 12 of 13 GII with lansoprazole, famotidine, and a herbal medicine, rikkunshito. A GI patient with chromosomal anomaly required fundoplication after GP because of intractable emesis. A GII with Cockayne Syndrome required gastrojejunal continuous feeding because of emesis and diarrhea. Other patients were successfully nourished with gastrostomy bolus feeding. Respiratory symptoms were ameliorated in a GI patient and 3 GII presumably due to the removal of stimulation by nasogastric tubes. Chronic gastric volvulus was corrected in 4. The postoperative RI increased significantly in GI patients (2.0% [0%-4.8%] vs. 4.1%[0.2%11.9%], P=0.002), whereas decreased significantly in GII (11.8% [5.9%-67.2%] vs. 9.7%[1.0%-68.7%], P=0.048). Conclusions: Reflux symptoms and pathological esophageal acid exposure rarely deteriorate after GP in profoundly handicapped patients with dysphagia. GP alone is a less invasive and effective procedure to improve the quality of life in those patients. Concomitant fundoplication is unnecessary in most of them with adequate medical control of reflux symptoms.