Concomitant fundoplication increases morbidity of gastrostomy tube placement ☆ , ☆☆ ,★,★★ Loren Berman a, ⁎, Iman Sharif a , David Rothstein b , Jobayer Hossain a , Charles Vinocur a a Nemours-A.I. duPont Hospital for Children, Wilmington, DE b Division of Pediatric Surgery, Women and Children's Hospital of Buffalo, Buffalo, NY abstract article info Article history: Received 6 June 2014 Received in revised form 23 July 2014 Accepted 27 July 2014 Available online xxxx Key words: Reflux Gastrostomy Fundoplication Morbidity Length of stay Surgical decision making Background: Fundoplication is often performed in conjunction with gastrostomy tube (GT) placement in children, but there is a great deal of variation in rates of and indications for this procedure. Little is known about the impact of fundoplication on peri-operative outcomes. This study examines a national cohort of pediatric patients to compare risk-adjusted surgical outcomes in patients undergoing GT placement with or without concomitant fundoplication. Methods: We identified all patients undergoing GT placement in the 2012 National Surgical Quality Improvement Program – Pediatric. We evaluated demographics, comorbidities, complications, and length of stay for GT with fundoplication versus GT alone. We defined composite morbidity as a dichotomous variable for the presence of any complication. Logistic regression was performed to identify predictors of morbidity after adjusting for covariates. Results: 1289 GT patients were identified, and 148 (11.5%) underwent concurrent fundoplication. The fundoplication patients were more likely to be younger, have cardiac risk factors, and be on respiratory support. They also had higher rates of surgical site infection (7.4% vs 3.7%, p = 0.03) and composite morbidity (16.9% vs 8.7%, p = 0.001), and longer LOS (median 5 vs 3 days, p = b 0.0001) compared to GT only. After adjusting for covariates, fundoplication was a predictor of composite morbidity and increased LOS. Conclusion: Concomitant fundoplication is an independent risk factor for 30-day post-operative morbidity in patients undergoing GT placement. These findings do not negate the value of fundoplication but underscore the importance of careful patient selection, and should be taken into consideration when discussing risks and benefits with families. © 2014 Elsevier Inc. All rights reserved. About 14,400 gastrostomy tubes (GT) were placed in children in the United States in 2009, making it one of the most common elective operations performed on the alimentary tract in children [1]. Gastrostomy tube placement is an operation plagued by complica- tions ranging from insertion site granulation tissue to intra-abdominal leakage requiring reoperation, with published complication rates ranging from 2% to 20% [2–6]. It is difficult to compare results of single institution series, however, because of the lack of a uniform definition of complications and varied methods of data collection and case selection. Whether or not to perform fundoplication at time of GT placement is a difficult decision in some cases, and the added morbidity of concurrent fundoplication is not well understood. In order to describe outcomes of GT placement and identify predictors of morbidity in a generalizable fashion it would be ideal to use a national database, but administrative databases are limited in their ability to provide reliable data because of inconsistent definitions and data entry of comorbidities and outcomes [7]. The American College of Surgeons National Surgical Quality Improvement Program – Pediatric (NSQIP-P) contains validated outcomes data from 50 children’s hospitals across the country and can be used to describe complication rates and identify risk factors for these complications. This dataset provides a unique opportunity to evaluate risk-adjusted outcomes at children’s hospitals for children undergoing GT place- ment with or without fundoplication. Failure of medical therapy for gastro-esophageal reflux disease (GERD) is perhaps the most common indication for fundoplication, but some practitioners recommend prophylactic fundoplication for patients with certain comorbidities who may be prone to developing reflux or are at risk for complications such as aspiration pneumonia [8]. Multiple single institution series have reported extremely low complication rates after fundoplication, and especially laparoscopic Journal of Pediatric Surgery xxx (2014) xxx–xxx Abbreviations: ASA, American Society of Anesthesiologists; GT, gastrostomy tube; GERD, gastro-esophageal reflux disease; LOS, length of stay; NSQIP-P, National Surgical Quality Improvement Program - Pediatric; PUF, participant user file; SSI, surgical site infection. ☆ Funding Source: No funding was secured for this study. ☆☆ Financial Disclosure: The authors have no financial relationships relevant to this article to disclose. ★ Conflict of Interest: The authors have no conflicts of interest to disclose. ★★ Clinical Trial Registration: N/A. ⁎ Corresponding author at: Department of Surgery, A.I. duPont Hospital for Children, 1600 Rockland Rd., Wilmington, DE 19803. Tel.: +1 302 651 5888. E-mail address: loren.berman@nemours.org (L. Berman). http://dx.doi.org/10.1016/j.jpedsurg.2014.07.013 0022-3468/© 2014 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg Please cite this article as: Berman L, et al, Concomitant fundoplication increases morbidity of gastrostomy tube placement, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.07.013