Key messages
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In children and adolescents with neurological impairment, we are very uncertain about the effect of adding an antireflux procedure (fundoplication) on symptoms of gastro-esophageal reflux, death, and major surgical complications (perforation or peritonitis), when compared to gastrostomy alone or gastro-jejunal tubes.
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The addition of an antireflux procedure when performing a gastrostomy may result in little to no difference in the number of hospitalizations for respiratory disease (pneumonia).
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Further research is necessary. Better designed observational studies could help to improve our confidence in the evidence.
Why treat gastro-esophageal reflux in children with neurological impairment?
Because of damage to their central nervous system, children with neurological impairment are prone to vomiting and feeding difficulties, and are at increased risk of dying from lower respiratory tract infections, such as pneumonia. The treatment of gastro-esophageal reflux (where the stomach acid frequently flows back into the esophagus [food pipe] and causes heartburn) aims to prevent these symptoms and complications.
How is gastro-esophageal reflux that doesn't get better with medicine treated in these children?
The two most common procedures used to treat or prevent the consequences of gastro-esophageal reflux (antireflux procedures) in children with neurological impairment are fundoplication, where the stomach is wrapped around the lower esophageal sphincter, and the placement of a gastro-jejunal tube, which passes a feeding tube from the stomach into the small intestine (jejunum). These procedures differ in their surgical risks: fundoplication is more complex, requires more anesthesia (sedation), and involves a longer recovery period. Gastro-jejunal tubes are easier to place but require continuous feeding, which may increase caregiving needs and reduce the quality of life of children and their families.
What did we want to find out?
We wanted to find out if a fundoplication or passing of a gastro-jejunal tube is better than a gastrostomy (feeding tube entered directly into the stomach) alone to improve symptoms of gastro-esophageal reflux and number of deaths.
We also wanted to know if fundoplication caused more major surgical complications, and if antireflux procedures could prevent respiratory morbidity (pneumonia) in the long term.
What did we do?
We searched for studies comparing the two antireflux procedures (fundoplication or gastro-jejunal tubes) versus gastrostomy alone or versus each other in children and adolescents with neurological impairment.
We compared and summarized the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes.
What did we find?
We found 11 studies involving a total of 3122 children with neurological impairment. The children were followed up for between 9 months and 12 years.
Main results
Gastrostomy plus fundoplication compared to gastrostomy alone for gastro-esophageal reflux
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We are very uncertain about the effect on symptoms of gastro-esophageal reflux (3 studies, 180 children), death (3 studies, 415 children), major surgical complications within the first 30 days after surgery (3 studies, 412 children), and emergency department visits after surgery (1 study, 130 children).
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Gastrostomy plus fundoplication may result in little to no difference in number of hospitalizations for respiratory disease (pneumonia) (1 study, 2054 children).
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No studies looked at child's quality of life for this comparison. Length of stay after surgery was reported but not compared for gastrostomy plus fundoplication versus gastrostomy alone.
Gastro-jejunal tubes compared to gastrostomy alone for gastro-esophageal reflux
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We are very uncertain about the effect on death (1 study, 50 children) and child's quality of life (1 study, 50 children).
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No studies looked at symptoms of gastro-esophageal reflux, major surgical complications, length of stay after surgery, number of hospitalizations for respiratory disease (pneumonia), or number of emergency department visits after surgery for this comparison.
Gastrostomy plus fundoplication compared to gastro-jejunal tubes for gastro-esophageal reflux
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We are very uncertain about the effect on symptoms of gastro-esophageal reflux (3 studies, 1531 children), death (3 studies, 418 children), and major surgical complications during the first 30 days after surgery (2 studies, 190 children).
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Gastrostomy plus fundoplication may result in little to no difference in number of hospitalizations for respiratory disease (pneumonia) (1 study, 228 children).
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No studies looked at number of emergency department visits after surgery or child's quality of life for this comparison. Length of stay after surgery was reported but not compared for gastrostomy plus fundoplication versus gastro-jejunal tubes.
What are the limitations of the evidence?
We have little to very low confidence in the evidence. There were many problems with the methods of the included studies, such as incomplete reporting, differences among the participants in each group, and small study sizes that prevented the recording of events that don't occur very often during the follow-up period. Also, the included studies did not report all the outcomes we were interested in.
How up-to-date is this evidence?
The evidence is current to September 2024.
Key words: neurological impairment, children, adolescents, gastrostomy, tubes, fundoplication, gastro-jejunal, gastro-esophageal reflux disease, gastro-oesophageal reflux, GERD.
Leer el resumen científico
Objetivos
To assess the benefits and harms of the two most common enteral feeding tubes and associated antireflux procedures. We aimed to compare: 1) gastrostomy tube (GT) plus fundoplication, 2) gastrostomy plus insertion of a gastro-jejunal (GJ) tube, and 3) GT alone for treating or preventing GER in children and adolescents with NI.
Métodos de búsqueda
We searched CENTRAL, MEDLINE, Embase, six other databases, and two trials registers, together with reference checking and contact with two experts in the field, to identify studies for inclusion in the review. There were no restrictions on language. The latest search date was 17 September 2024.
Conclusiones de los autores
In children with NI, the evidence is very uncertain about the effect of GT plus fundoplication on symptoms of GER, mortality, major surgical complications, and LOS, when compared to GT alone or GJ tubes (very low-certainty evidence).
GT plus fundoplication may result in little to no difference in the number of hospitalizations for pneumonia when compared to GT alone or GJ tubes (low-certainty evidence).
The evidence is very uncertain about the effect of GT plus fundoplication on the number of ED visits when compared to GT alone (very low-certainty evidence).
The evidence is very uncertain about the effect of GJ tubes on mortality and child's QoL when compared to GT alone (very low-certainty evidence).
We found no RCTs, and our results should be interpreted with caution due to the limited number of studies and the limitations of NRSIs.
Additional research is necessary. It is likely that RCTs will be difficult to conduct; however, better-designed NRSIs could improve the quality of evidence in this area.
Financiación
This review was funded by Foundation Fresno, Universidad Católica de Chile, for librarian support only. The foundation had no role in the design or conduct of this review.
Registro
Protocol available via DOI: 10.1002/14651858.CD015007.
