American Academy of Pediatrics – Section on Surgery

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November 4, 2019

Avoid performing antireflux operations (fundoplications) during gastrostomy insertion in most children who are otherwise growing and thriving with gastric feedings.

 

There is significant hospital-related variation in rates of concurrent fundoplication at time of gastrostomy placement.1 Despite recommendations that anti-reflux surgery should be considered only for children who have persistent symptoms despite medical management or are unable to be weaned from medical therapy, many patients undergo surgery without a trial of medical therapy.2

This is especially true in children with cardiac, pulmonary and neurologic comorbidities, for whom some surgeons may recommend prophylactic fundoplication. There are insufficient data to support the concept of fundoplication in the absence of reflux, regardless of patient comorbidities. In fact, neurologically impaired patients are at higher risk for post-operative complications and/or fundoplication failure,3-5 and fundoplication does not lead to reduction in reflux-related admissions compared to gastrostomy alone.6 Definitive evidence supporting the effectiveness of fundoplication in children is lacking.7  Expert opinion-based guidelines2 state that fundoplication can be considered in infants and children with GERD who also meet any of the following criteria: 1) life threatening complications (e.g., cardiorespiratory failure) of GERD after failure of optimal medical treatment, 2) symptoms refractory to optimal therapy, 3) chronic conditions (i.e. neurologically impaired, cystic fibrosis) with a significant risk of GERD-related complications, 4) the need for chronic pharmacotherapy for control of signs and/or symptoms of GERD.


These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

Members of the American Academy of Pediatrics Section on Surgery Subcommittee on Education and Delivery of Surgical Care submitted the top 5 topics for Choosing Wisely items based on a review of the literature and expert opinion. The items were refined, ranked and approved by the Section on Surgery leadership. The list was then reviewed and approved by more than a dozen relevant AAP Committees, Councils and Sections. The AAP Executive Committee granted final approval of the list.

AAP’s disclosure and conflict of interest policy can be found at www.aap.org.

Sources

Goldin AB, Garrison M, Christakis D. Variations between hospitals in antireflux procedures in children. Archives of Pediatrics & Adolescent Medicine. 2009;163(7):658-663.

Rosen R, Vandenplas Y, et al. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). Journal of Pediatric Gastroenterology and Nutrition. 2018. March 66(3):516-554

Albanese CT, Towbin RB, et al.. Percutaneous gastrojejunostomy versus Nissen fundoplication for enteral feeding of the neurologically impaired child with gastroesophageal reflux. The Journal of Pediatrics. 1993;123(3):371-375.

Fonkalsrud EW, Ashcraft KW, et al. Surgical treatment of gastroesophageal reflux in children: a combined hospital study of 7467 patients. Pediatrics. 1998;101(3 Pt 1):419-422.

Smith CD, Othersen HB, Jr., et al. Nissen fundoplication in children with profound neurologic disability. High risks and unmet goals. Annals of Surgery. 1992;215(6):654-658; discussion 658-659.

Barnhart DC, Hall M, et al. Effectiveness of fundoplication at the time of gastrostomy in infants with neurological impairment. JAMA Pediatrics. 2013;167(10):911-918.

Jancelewicz T, Lopez ME, et al. Surgical management of gastroesophageal reflux disease (GERD) in children: A systematic review. Journal of Pediatric Surgery. 2017;52(8):1228-1238.