Original article Total esophagogastric dissociation in adult neurologically impaired patients with severe gastroesophageal reflux: an alternative approach E. J. Hazebroek, 1 F. W. J. Hazebroek, 2 S. Leibman, 1 G. S. Smith 1 1 Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, NSW, Australia; and 2 Department of Pediatric Surgery, Erasmus MC-Sophia Children’s Hospital, Rotterdam, the Netherlands SUMMARY. Patients with neuromuscular impairment, such as cerebral palsy or myotonic dystrophy, often suffer from oropharyngeal neuromuscular incoordination and severe gastresophageal reflux (GER). In 1997, Bianchi proposed total esophagogastric dissociation (TEGD) as an alternative to fundoplication and gastrostomy to eliminate totally the risk of recurrence of GER in neurologically impaired children. Little information exists about the best management for adult patients with severe neurological impairment in whom recurrent GER develops after failed fundoplication. We present our experience in three adult patients with neurological impairment in whom TEGD with Roux-en-Y esophagojejunostomy and feeding gastrostomy was performed for permanent treatment of GER. KEY WORDS: esophagogastric dissociation, gastresophageal reflux, neurologically impaired. INTRODUCTION Patients with neuromuscular impairment, such as cerebral palsy or myotonic dystrophy, often suffer from oropharyngeal neuromuscular incoordination and severe gastroesophageal reflux (GER). The prevalence of GER in children with severe neurologi- cal impairment is reported to be between 33% and 75%. 1,2 Fundoplication and gastrostomy may be effective in facilitating nutrition, reducing the risk of aspiration pneumonia, and thus improving quality of life of these patients. However, the incidence of failure of the fundoplication in neurologically impaired children with subsequent recurrence of symptoms has been reported to be between 5% and 25%. 3,4 Recurrence rates after redo-fundoplication are even higher than the initial operation and carry a greater risk of complications. 5,6 In 1997, Bianchi pro- posed total esophagogastric dissociation (TEGD) as an alternative to fundoplication and gastrostomy to eliminate totally the risk of recurrence of GER in neurologically impaired children. 7 More recently, it has been suggested that TEGD can be used as a primary treatment of choice for severely neurologi- cally impaired children who are experiencing GER and are completely dependent on tube feeds. 8,9 Little information exists about the best manage- ment for adult patients with severe neurological impairment in whom recurrent GER develops after failed fundoplication. This report considers the potential role of TEGD with Roux-en-Y esophagojejunostomy and feeding gastrostomy for permanent treatment of GER in adult patients with neurological impairment. CASE REPORTS Between 2004 and 2007, TEGD with Roux-en-Y esophagojejunostomy and feeding gastrostomy was performed in three adult patients with neurologically impairment. The procedure is performed through an upper midline abdominal incision. After mobilization of the left liver lobe, access to the gastroesophageal junction (GEJ) is obtained. If previous fundoplica- tion was performed, the wrap is unravelled. The proximal part of the stomach is mobilized by division of the left gastroepiploic vessels and short gastric vessels. After isolation of the subdiaphragmatic esophagus, the esophagus is transected above the Address correspondence to: Dr Garett Smith, MS FRACS, Department of Upper Gastrointestinal Surgery, Level 2, Vindin House, Royal North Shore Hospital, St. Leonards, Sydney, NSW 2065, Australia. Email: garetts@med.usyd.edu.au Diseases of the Esophagus (2008) 21, 742–745 DOI: 10.1111/j.1442-2050.2008.00834.x © 2008 Copyright the Authors Journal compilation © 2008, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus 742