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

Clinical algorithm for G-tube consultation: if requested for mouth/swallowing issues only, decide between NG tube or G-tube; if requested for vomiting/reflux, obtain upper GI and trial NG feeds—if tolerated place G-tube, if not tolerated place NJ tube and consider fundoplication or GJ tube if NJ feeds tolerated

According to 2018 NASPGHAN/ESPGHAN guidelines, no complementary study (barium imaging, ultrasonography, endoscopy, biomarkers, manometry, scintigraphy) is sufficient to diagnose gastroesophageal reflux disease requiring fundoplication

Even with best settings and resources, there is no good laboratory test or radiological test to determine need for fundoplication in GERD

Aspiration pneumonia episode indicates that feeding into the stomach in its current form is not sufficient, assuming patient has been maximized on medical therapy

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

The 2013 JAMA Pediatrics fundoplication study used propensity score matching to create two comparable groups of 1,027 infants each (gastrostomy alone vs gastrostomy with fundoplication)

There is no prospective study comparing gastrostomy alone versus gastrostomy with fundoplication; the 2013 JAMA Pediatrics retrospective study with 42 hospitals and 4000 patients is the best available evidence

Performing fundoplication in a patient who is aspirating from above (oral secretions) will make aspiration worse

Nasal jejunal tube trial can serve as a helpful diagnostic tool: if NJ tube stops aspiration, patient may be candidate for fundoplication or GJ tube

Percutaneous endoscopic gastrostomy (PEG) was invented before laparoscopy was advanced in pediatrics

Laparoscopic gastrostomy allows visualization when grasping and pulling up stomach, rather than blind approach of PEG

According to June 2022 Pediatrics systematic review of 58 publications comparing gastrostomy techniques, complication rates significantly favored laparoscopic approach (1.2%) over PEG (5.4%)

The 1.2% vs 5.4% complication rate comparison in the 2022 systematic review included only major complications requiring reoperation (colonic perforation, colocutaneous fistula), not minor complications like leaks, dislodgements, or granulomas

The 2022 Pediatrics systematic review comparing PEG versus laparoscopy included 12 studies with more than 2000 patients

Current practice has evolved from admitting patients overnight and starting feeds the next day to initiating feeds immediately after gastrostomy placement, sometimes with same-day discharge

According to randomized prospective study from Mott Children's Hospital 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

Patients will need bolus feeding at home after discharge, so there is no reason to start with continuous feeding as a ramp-up to bolus—can go straight to bolus