Gastroesophageal reflux in children with neurological impairment: a systematic review and meta-analysis

Neurologically impaired children (NIC) suffer severe gastroesophageal reflux (GER) with poor fundoplication outcome. Aims of the study were: (1) to determine the recurrence of GER after fundoplication in NIC; (2) to compare fundoplication versus gastro-jejunal tube feeding insertion (GJ) and fundoplication versus total esophagogastric dissociation (TEGD) in primarily treating GER in NIC. Using defined search strategy, two investigators identified all comparative studies reporting the mentioned procedures to primarily treat GER in NIC. The study was conducted under PRISMA guidelines. The meta-analysis was performed using RevMan 5.3. Data are mean +/- SD. Of 3840 titles/abstracts screened, 14 studies on fundoplication (2716 pts.) reported a recurrence/persistence of GER higher in NIC (14.2 +/- 8.3%) than in neurologically normal (9.4 +/- 5.2%; p=0.0001), with an increased incidence of re-do fundoplication (12.6 +/- 7.0% versus 9.1 +/- 4.5%; p<0.01). Three studies revealed a similar risk of undergoing subsequent fundoplication after GJ (4.9 +/- 2.1%) or initial fundoplication (12.0 +/- 0.6%; p=ns). Four studies showed a lower recurrence of GER following TEGD (1.4 +/- 1.1%) than fundoplication (24.8 +/- 1.4%; p=0.002). NIC are at risk of recurrence/persistence of GER after fundoplication or GJ. TEGD seems more effective to primarily treat GER in NIC. Prospective randomized controlled trials are necessary to establish which is the ideal treatment of GER in NIC.