Case-Based Journal Review: G-Tube & Fundoplication for GERD 2023

The 2018 North American and European Society for Pediatric Gastroenterology joint guideline found that no complementary study (barium imaging, ultrasonography, endoscopy, biomarkers, manometry, scintigraphy) is sufficient to diagnose gastroesophageal reflux disease requiring fundoplication

Aspiration pneumonia in a patient on NG feeds indicates that feeding into the stomach in its current form will not be sufficient

After aspiration pneumonia and assuming maximum medical therapy, the next step is either post-pyloric feeding or fundoplication

In the 2013 JAMA Pediatrics study of 42 children's hospitals and over 4000 infants, those with neurological impairment who underwent fundoplication at the time of gastrostomy placement did not have a reduced rate of reflux-related hospitalization during the first year compared to those who underwent gastrostomy placement alone

The 2013 JAMA Pediatrics study used propensity score matching to create two comparable groups of 1027 infants each (gastrostomy alone versus gastrostomy plus fundoplication)

There is no prospective study comparing gastrostomy alone versus gastrostomy plus fundoplication; the 2013 JAMA Pediatrics retrospective study is the best available evidence

Performing fundoplication in someone who is aspirating from above (saliva) will make them worse

A nasal jejunal tube trial can be a helpful diagnostic tool: if it stops aspiration, that indicates the aspiration was from gastric reflux rather than oral secretions

Laparoscopic gastrostomy allows better visualization (grabbing the stomach and pulling it up with a camera) compared to the blind percutaneous endoscopic approach

In a 2022 systematic review of 58 publications and over 2000 patients comparing PEG versus laparoscopy, major complication rates significantly favored laparoscopy (1.2% versus 5.4%)

The major complications in the 2022 systematic review did not include leaks, dislodgements, or granulomas; they were re-operation for colonic perforation or colocutaneous fistula

Postoperative feeding advancement after G-tube placement has become faster over time; some centers now start feeds immediately after surgery and send patients home the same day

In a randomized prospective study comparing bolus versus continuous feeding post-gastrostomy, patients receiving bolus feeding had more leakage and more feeding modifications but achieved total feeds in the same timeframe

There is no significant difference in patient outcomes between bolus and continuous feeding regimens after gastrostomy placement

There is no reason to start with continuous feeds as a ramp-up to bolus feeds; clinicians can go straight to bolus feeding postoperatively