Fundoplication in neurologically impaired children: Nissen or Thal?

Abstract

Background/purpose Gastroesophageal reflex disease (GERD) is a highly prevalent problem in infants and children with severe neurological impairment (33–75%). It occurs in 44–67% of children undergoing antireflux surgery. This study is conducted to compare the results of fundoplication, according to the Nissen and Thal procedure for management of GERD in neurologically impaired children.
Materials and methods Between May 2007 and January 2011, 69 neurologically impaired children with severe GERD underwent fundoplication (Nissen= 32, Thal= 37) with construction of a Stamm gastrostomy tube in 58 patients. The male-to-female ratio was 1.6 : 1; the mean age was 1.8 years. Preoperative workup of the patients included upper gastrointestinal tract contrast series, upper gastrointestinal tract endoscopy, and a 24-h pH study.
Results Perinatal asphyxia was the most common cause of neurological impairment (30.4%). Feeding dysfunction represented the most common indication for surgery (52.2%). Recurrence of symptoms was found in 14 patients (20.3%); 10 patients (14.5%) died because of respiratory failure. Acid pH-metry showed a statistically significant difference between preoperative and postoperative data; however, this difference was insignificant on comparing the postoperative parameters of the Nissen fundoplication group with the Thal fundoplication group.
Conclusion GERD in neurologically impaired children is a very common problem associated with a high failure rate after properly performed fundoplication. In our series, the outcome of Thal fundoplication showed an insignificant difference when compared with that of Nissen fundoplication with less dissection and less dysphagia or gas bloat. Long-term evaluation is needed as incidence of recurrence increases with time secondary to the persistent comorbidities. Further refinement of management strategies is required to decrease incidence of recurrence and to improve the overall quality of life. 

Keywords: fundoplication, gastroesophageal reflux disease, neurological impairment