P2D385: Unanticipated Healthcare Utilization Following Operative Management of Severe Gastroesophageal Reflux Disease: Results from a Multi-institutional Research Collaborative

Background: The operative management of children with severe gastroesophageal reflux disease (GERD) refractory to medical management remains controversial with limited evidence in the literature. The purpose of this study was to evaluate postoperative healthcare utilization and other outcomes following anti-reflux surgery in young children with severe GERD.

Methods: After IRB approval, a secure database was established by a multi-institutional consortium to capture retrospective cohort data from multiple children’s hospitals between 2010-2020. Inclusion criteria were patients less than 3 years of age who underwent Nissen fundoplication, surgical jejunostomy (SJ) or gastrojejunostomy (GJ) for GERD. Patients with concurrent other major abdominal surgeries, contraindications for Nissen fundoplication such as dysmotility or Barrett’s esophagus, were excluded. The primary outcome was unplanned healthcare visits within 1 year after anti-reflux surgery. Secondary outcomes were postoperative complications within 30 days including bleeding, peritonitis, anesthesia-related complications, mortality, and infection (local and organ space). Statistical analysis was performed via ANOVA for continuous and Chi-squared for categorical variables, respectively.

Results: There were 317 patients (median age 5.4 months) that underwent surgery for GERD amongst 9 institutions. 244 (77%) patients underwent fundoplication, 62 (19.5%) underwent GJ placement, and 11 (3.5%) had jejunostomy tubes placed. One year follow-up was available for 297 of those patients. GJ patients had a significantly higher number of unplanned visits (p-value =0.04) (Table 1). These patients also presented more often with pneumonia, emesis or feeding intolerance, although only feeding intolerance approached statistical significance. The most common complication in all patients in the immediate post-operative period was local wound infection (n=18, 5.7%) with the majority occurring in patients that underwent jejunostomy tube placement (n=11, 27.3%).

Conclusion: This large, multi-institutional consortium demonstrated that GJ placement as compared to Nissen fundoplication and jejunostomy tube is associated with increased healthcare visits in the first postoperative year from tube-related issues and pneumonia. This data shows a significant difference in healthcare burden for patients undergoing gastrojejunostomy placement and their family. Additionally, there is significant variability in practice patterns, decision making and pre-operative work up, emphasizing the need for a clear standard of care for the surgical management of neonates and young children with refractory or life-threatening GERD and associated complications. Further collection of patient data by our group will aim to develop clear guidelines for the surgical treatment of GERD in the pediatric population.