title: Concomitant fundoplication increases morbidity of gastrostomy tube placement.
abstract: 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=<0.0001) compared to GT only. After adjusting for covariates, fundoplication was a predictor of composite morbidity and increased LOS.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Nemours-A.I. duPont Hospital for Children, Wilmington, DE. Electronic address: loren.berman@nemours.org.
authors.forename: Loren
authors.initials: L
authors.lastname: Berman
authors.affiliation: Nemours-A.I. duPont Hospital for Children, Wilmington, DE.
authors.forename: Iman
authors.initials: I
authors.lastname: Sharif
authors.affiliation: Division of Pediatric Surgery, Women and Children's Hospital of Buffalo, Buffalo, NY.
authors.forename: David
authors.initials: D
authors.lastname: Rothstein
authors.affiliation: Nemours-A.I. duPont Hospital for Children, Wilmington, DE.
authors.forename: Jobayer
authors.initials: J
authors.lastname: Hossain
authors.affiliation: Nemours-A.I. duPont Hospital for Children, Wilmington, DE.
authors.forename: Charles
authors.initials: C
authors.lastname: Vinocur
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D015897:Comorbidity; D005260:Female; D018662:Fundoplication / Q000009:adverse effects* / Q000379:methods; D005764:Gastroesophageal Reflux / Q000601:surgery; D005774:Gastrostomy / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods; D006801:Humans; D007223:Infant; D016015:Logistic Models; D008297:Male; D009017:Morbidity; D012121:Respiration, Artificial; D012307:Risk Factors
keywords: Fundoplication; Gastrostomy; Length of stay; Morbidity; Reflux; Surgical decision making