P1.075: Treatment Failure in Fundoplication versus Primary Gastrojejunostomy in Pediatric Surgery: A Retrospective Cohort Study

Background: Operative anti-reflux interventions are frequently required for pediatric patients with medically refractory reflux or gastric feeding intolerance. Management options include fundoplication and primary gastrojejunostomy (pGJ). In recent years, use of anatomy-altering fundoplication has declined, with increasing preference for pGJ due to its less invasive nature and potential to serve as a temporizing measure in children who may outgrow reflux. However, comparative data on morbidity and treatment failure between these approaches remain limited. This study aimed to examine rates of treatment failure among pediatric patients undergoing fundoplication versus pGJ.

Methods: This retrospective cohort study included pediatric surgical patients (0–18 years) who underwent fundoplication or pGJ placement for any indication in the Pediatric Health Information System (PHIS) database between 2017–2024. We defined post-discharge treatment failure as readmission for reflux, aspiration, or pneumonia. In the fundoplication group, treatment failure also included revisions or wrap failure. In the pGJ group, it included conversion to fundoplication or bowel obstruction or perforation. We used univariate analysis and mixed-effects multivariate logistic regression with random effects for site to assess the association between operation type and treatment failure across age groups. Covariates included age group ( < 1 year, 1-6 years, >6 years), age in months (used only in multivariate analysis), sex, total parenteral nutrition (TPN) use, mechanical ventilation, extracorporeal membrane oxygenation (ECMO), cardiac comorbidities, and neurologic comorbidities.

Results: Across 45 hospitals, 4,639 patients underwent fundoplication and 632 underwent pGJ placement. On univariate analysis, younger patients were more likely to undergo fundoplication (age < 1 year 51% vs 17%, p < 0.001; age 1-6 years 22 vs 16%, p < 0.001), as were males (54% vs 41%, p < 0.001), those with mechanical ventilation (35% vs 30%, p=0.005), ECMO (1.5% vs 0.5%, p=0.043), cardiac comorbidities (31% vs 21%, p< 0.001), and neurologic comorbidities (32% vs 18%, p< 0.001) (Table 1). Patients were more likely to undergo a pGJ if they had TPN use (37% vs 27%, p < 0.001), and patients with pGJs had shorter time from discharge to readmission for any composite morbidity event (38 vs 59 days, p=0.018). Patients undergoing fundoplication had higher rates of composite morbidity than those undergoing pGJs (28% vs 16%, p< 0.001). However, on multivariate analysis, this effect between anti-reflux operation and composite morbidity was no longer significant across age groups (Table 2).

Conclusion: This study demonstrated that there were no differences in rates of treatment failure among patients undergoing fundoplication versus pGJ placement after adjusting for relevant confounders. These results highlight that the choice of anti-reflux procedure may be based on factors such as perceived permanence of the patient’s reflux and surgeon judgement rather than the likelihood of morbidity events.