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Editor,—The annotation by Dr P Sullivan in the December 1999 issue of ADC on gastrostomy feeding in the disabled child and indications for an antireflux procedure, was timely and comprehensive. As nutritional needs of chronically ill children including the neurologically disabled are recognised, there have been ever increasing calls for gastrostomy. There is a trend, perhaps to “overdo” fundoplications in a few centres, particularly, but not exclusively, because of the relative ease of the laparoscopic technique. The facts, as aptly outlined by Dr Sullivan, all say that fundoplication as a treatment for gastro-oesophageal reflux disease is far from ideal. In the short term follow up studies he quoted, the failure and complication rates are high, more so in children with neurological disorders. The only firm indication for fundoplication, with or without gastrostomy, is clearly documented aspiration. This said, feeding via gastrostomy and discontinuing oral intake of fluids might cure recurrent aspiration in some children with palatopharyngeal discoordination. Medical treatment of oesophagitis has made major progress, as we now have effective acid suppression agents and prokinetics.1 In addition, there are the options of antireflux feeding methods before or after gastrostomy insertion—that is, continuous feeding and transgastricojejunal feeding. Pyloroplasty may be required, either alone or in conjunction with fundoplication, when delayed gastric emptying is documented.2 3
The management of feeding disorders and of gastro-oesophageal reflux disease should be approached carefully and requires thorough investigation of the mechanisms of feeding and of reflux. This should be a joint venture between paediatric gastroenterologists and paediatric surgeons. We should not allow the pendulum to swing to the extreme of automatically offering gastrostomy and fundoplication to children with disabilities.
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