Effectiveness of Fundoplication at the Time of Gastrostomy in Infants With Neurological Impairment

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1. Copyright restrictions may apply JAMA Pediatrics Journal Club Slides: Fundoplication at the Time of Gastrostomy Barnhart DC, Hall M, Mahant S, et al. Effectiveness of fundoplication at the time of gastrostomy in infants with neurological impairment. JAMA Pediatr. Published online August 5, 2013.
2. Copyright restrictions may apply • Background – Infants and children with neurological impairment often experience dysfunctional swallowing and gastroesophageal reflux disease (GERD); both conditions put children at risk for aspiration pneumonia, which is the most common cause of death in this group. – Rates of simultaneous gastrostomy tube (GT) placement and fundoplication have increased by 25% in the last decade; 2 large multicenter studies indicated that fundoplication led to decreases in GERD-related hospitalizations among children with neurological impairment. • Study Objective – To compare GERD-related hospitalizations among children with neurological impairment, for those who underwent GT placement with fundoplication vs GT placement alone. Introduction
3. Copyright restrictions may apply • Study Design – Retrospective, observational cohort. • Data Set: Pediatric Health Information System administrative database (42 not-for-profit, freestanding children’s hospitals), with 4 inclusion criteria: – (1) Birth date in 2005 to 2010. – (2) Admission to neonatal intensive care unit within first 90 days of life. – (3) International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code for neurological impairment (eg, cerebral palsy, hydrocephalus, leukodystrophy, epilepsy). – (4) Procedural code for GT placement during the initial neonatal intensive care unit admission. • Follow-Up: For 1 year after GT placement. Participants – 2759 Children underwent GT placement only. – 1404 Children underwent GT placement with concomitant fundoplication. Methods
4. Copyright restrictions may apply Methods • Outcomes Main Outcomes –GERD-related hospitalization: • Gastrointestinal – Esophagitis, GERD. • Pulmonary – Pneumonia, aspiration pneumonia, requirement for mechanical ventilation. Analysis –Regression analyses to compare counts for GERD-related hospitalizations over 1 year of follow-up, for GT placement with fundoplication vs GT placement only. –Adjusted for potential differences between infants who underwent GT placement only vs GT placement with fundoplication, using propensity score matching.
5. Copyright restrictions may apply Results Demographics and Conditions During Initial Hospitalization for All Infants
6. Copyright restrictions may apply Results Demographics and Conditions During Initial Hospitalization for All Infants (Continued)
7. Copyright restrictions may apply Results • In propensity-matched analyses, there were no differences in GERD-related hospitalizations for GT placement with fundoplication vs GT placement only: – Overall. – For pneumonia. – For aspiration pneumonia. – For esophagitis. – For GERD. – For requirement for mechanical ventilation.
8. Copyright restrictions may apply • Although reflux-related hospitalizations initially appear higher among children who underwent GT placement with fundoplication, there are also differences in the associated comorbidities that likely determine choice of procedure. • Application of propensity score matching (ie, accounting for the differences that likely influence procedural choices) allowed the investigators to more precisely understand the clinical impact of concomitant fundoplication with GT placement vs GT placement alone. • This study adds to the literature by indicating no significant benefit of concomitant fundoplication in children with neurological impairment, when the primary outcome is GERD-related hospitalization. Comment
9. Copyright restrictions may apply • Considerable practice variation exists in GT placement with vs without fundoplication. • This study may help guide clinical practice, but health care providers may want to compare GT placement with fundoplication vs GT placement alone in a randomized clinical setting before widespread adoption of the findings in this study. • Limitations – Retrospective nature of this study. – Potential for propensity scores to incompletely adjust for factors that predispose to receiving one procedure vs another. Comment
10. Copyright restrictions may apply • If you have questions, please contact the corresponding author: –Douglas C. Barnhart, MD, MSPH, Department of Surgery, Primary Children’s Medical Center, University of Utah, 100 N Mario Capecchi Dr, Ste 2600, Salt Lake City, UT 84113 (douglas.barnhart@imail.org). Conflict of Interest Disclosures • None reported. Contact Information