Surgical Endoscopy

, Volume 32, Issue 5, pp 2201–2211 | Cite as

Hospital variation in rates of concurrent fundoplication during gastrostomy enteral access procedures

  • Anne M. Stey
  • Charles D. Vinocur
  • R. Lawrence Moss
  • Bruce L. Hall
  • Mark E. Cohen
  • Kari Kraemer
  • Clifford Y. Ko
  • Brian D. Kenney
  • Loren Berman



This study aimed to determine whether (1) the propensity for concurrent fundoplication during gastrostomy varies among hospitals, and (2) postoperative morbidity differs among institutions performing fundoplication more or less frequently.


Children who underwent gastrostomy with or without concurrent fundoplication were identified in the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS-NSQIP-P). A hierarchical multivariate regression modeled the excess effects that hospitals exerted over propensity for concurrent fundoplication adjusting for preoperative clinical variables. Hospitals were designated as low outliers (significantly lower-adjusted odds of concurrent fundoplication than the average hospital with similar patient mix), average hospitals, and high outliers based on their risk-adjusted concurrent fundoplication practice. The postoperative morbidity rates were compared among low-outlier, average, and high-outlier hospitals.


Between 2011 and 2013, 3775 children underwent gastrostomy at one of 54 ACS-NSQIP-P participating hospitals. The mean hospital concurrent fundoplication rate was 11.7% (range 0–64%). There was no significant difference in unadjusted morbidity rate in children with concurrent fundoplication, 11.0% compared to 9.7% in children without concurrent fundoplication. After controlling for clinical variables, 8 hospitals were identified as low outliers (fundoplication rate of 0.4%) and 16 hospitals were identified as high outliers (fundoplication rate of 34.6%). The average unadjusted morbidity rate among hospitals with low, average, and high odds of concurrent fundoplication were 9.6, 10.6, and 8.4%, respectively.


Hospitals vary significantly in propensity for concurrent fundoplication during gastrostomy yet postoperative morbidity does not differ significantly among institutions performing fundoplication more or less frequently.


Fundoplication Pediatric surgery Hospital variation 



American College of Surgeons’ National Surgical Quality Improvement Program Pediatric


American Society of Anesthesiologists


Current procedural terminology


Compliance with ethical standards


Anne Stey, Charles D. Vinocur, R. Lawrence Moss, Bruce L. Hall, Mark E. Cohen, Kari Kraemer, Clifford Y. Ko, Brian D. Kenney, and Loren Berman have no conflict of interest or financial ties to disclose.


  1. 1.
    Berezin S, Schwarz SM, Halata MS, Newman LJ (1986) Gastroesophageal reflux secondary to gastrostomy tube placement. Am J Dis Child 140:699–701PubMedGoogle Scholar
  2. 2.
    Mollitt DL, Golladay ES, Seibert JJ (1985) Symptomatic gastroesophageal reflux following gastrostomy in neurologically impaired patients. Pediatrics 75:1124–1126PubMedGoogle Scholar
  3. 3.
    Grunow JE, al-Hafidh A, Tunell WP (1989) Gastroesophageal reflux following percutaneous endoscopic gastrostomy in children. J Pediatr Surg 24:42–44 Discussion 44–45.CrossRefPubMedGoogle Scholar
  4. 4.
    Ramachandran V, Ashcraft KW, Sharp RJ, Murphy PJ, Snyder CL, Gittes GK, Bickler SW (1996) Thal fundoplication in neurologically impaired children. J Pediatr Surg 31:819–822CrossRefPubMedGoogle Scholar
  5. 5.
    Viswanath N, Wong D, Channappa D, Kukkady A, Brown S, Samarakkody U (2010) Is prophylactic fundoplication necessary in neurologically impaired children? Eur J Pediatr Surg 20:226–229CrossRefPubMedGoogle Scholar
  6. 6.
    Launay V, Gottrand F, Turck D, Michaud L, Ategbo S, Farriaux JP (1996) Percutaneous endoscopic gastrostomy in children: influence on gastroesophageal reflux. Pediatrics 97:726–728PubMedGoogle Scholar
  7. 7.
    Wilson GJ, van der Zee DC, Bax NM (2006) Endoscopic gastrostomy placement in the child with gastroesophageal reflux: is concomitant antireflux surgery indicated? J Pediatr Surg 41:1441–1445CrossRefPubMedGoogle Scholar
  8. 8.
    McAteer J, Larison C, LaRiviere C, Garrison MM, Goldin AB (2014) Antireflux procedures for gastroesophageal reflux disease in children: influence of patient age on surgical management. JAMA Surg 149:56–62CrossRefPubMedGoogle Scholar
  9. 9.
    Goldin AB, Garrison M, Christakis D (2009) Variations between hospitals in antireflux procedures in children. Arch Pediatr Adolesc Med 163:658–663CrossRefPubMedGoogle Scholar
  10. 10.
    Langer JC, Wesson DE, Ein SH, Filler RM, Shandling B, Superina RA, Papa M (1988) Feeding gastrostomy in neurologically impaired children: is an antireflux procedure necessary? J Pediatr Gastroenterol Nutr 7:837–841CrossRefPubMedGoogle Scholar
  11. 11.
    Fonkalsrud EW, Ashcraft KW, Coran AG, Ellis DG, Grosfeld JL, Tunell WP, Weber TR (1998) Surgical treatment of gastroesophageal reflux in children: a combined hospital study of 7467 patients. Pediatrics 101:419–422CrossRefPubMedGoogle Scholar
  12. 12.
    Srivastava R, Berry JG, Hall M, Downey EC, O’Gorman M, Dean JM, Barnhart DC (2009) Reflux related hospital admissions after fundoplication in children with neurological impairment: retrospective cohort study. BMJ 339:b4411CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Barnhart DC, Hall M, Mahant S, Goldin AB, Berry JG, Faix RG, Dean JM, Srivastava R (2013) Effectiveness of fundoplication at the time of gastrostomy in infants with neurological impairment. JAMA Pediatr 167:911–918CrossRefPubMedGoogle Scholar
  14. 14.
    Goldin AB, Sawin R, Seidel KD, Flum DR (2006) Do antireflux operations decrease the rate of reflux-related hospitalizations in children? Pediatrics 118:2326–2333CrossRefPubMedGoogle Scholar
  15. 15.
    Lasser MS, Liao JG, Burd RS (2006) National trends in the use of antireflux procedures for children. Pediatrics 118:1828–1835CrossRefPubMedGoogle Scholar
  16. 16.
    Raval MV, Dillon PW, Bruny JL, Ko CY, Hall BL, Moss RL, Oldham KT, Richards KE, Vinocur CD, Ziegler MM; Committee ANPS (2011) Pediatric American College of Surgeons National Surgical Quality Improvement Program: feasibility of a novel, prospective assessment of surgical outcomes. J Pediatr Surg 46:115–121Google Scholar
  17. 17.
    Sharp NE, Knott EM, Iqbal CW, Thomas P, St Peter SD (2013) Accuracy of American College of Surgeons National Surgical Quality Improvement Program Pediatric for laparoscopic appendectomy at a single institution. J Surg Res 184:318–321CrossRefPubMedGoogle Scholar
  18. 18.
    Cohen ME, Ko CY, Bilimoria KY, Zhou L, Huffman K, Wang X, Liu Y, Kraemer K, Meng X, Merkow R, Chow W, Matel B, Richards K, Hart AJ, Dimick JB, Hall BL (2013) Optimizing ACS NSQIP modeling for evaluation of surgical quality and risk: patient risk adjustment, procedure mix adjustment, shrinkage adjustment, and surgical focus. J Am Coll Surg 217:336–346.e331CrossRefPubMedGoogle Scholar
  19. 19.
    Berman L, Sharif I, Rothstein D, Hossain J, Vinocur C (2015) Concomitant fundoplication increases morbidity of gastrostomy tube placement. J Pediatr Surg 50:1104–1108CrossRefPubMedGoogle Scholar
  20. 20.
    Burd RS, Price MR, Whalen TV (2002) The role of protective antireflux procedures in neurologically impaired children: a decision analysis. J Pediatr Surg 37:500–506CrossRefPubMedGoogle Scholar
  21. 21.
    Berman L, Sharif I, Rothstein D, Hossain J, Vinocur C: Concomitant fundoplication increases morbidity of gastrostomy tube placement. J Pediatr Surg 2014Google Scholar
  22. 22.
    Rothenberg SS (1998) Experience with 220 consecutive laparoscopic Nissen fundoplications in infants and children. J Pediatr Surg 33:274–278CrossRefPubMedGoogle Scholar
  23. 23.
    Yap BK, Nah SA, Chen Y, Low Y (2017) Fundoplication with gastrostomy vs gastrostomy alone: a systematic review and meta-analysis of outcomes and complications. Pediatr Surg Int 33:217–228CrossRefPubMedGoogle Scholar
  24. 24.
    Jancelewicz T, Lopez ME, Downard CD, Islam S, Baird R, Rangel SJ, Williams RF, Arnold MA, Lal D, Renaud E, Grabowski J, Dasgupta R, Austin M, Shelton J, Cameron D, Goldin AB: Surgical management of gastroesophageal reflux disease (GERD) in children: a systematic review. J Pediatr Surg 2016Google Scholar
  25. 25.
    Vane DW, Harmel RP, King DR, Boles ET (1985) The effectiveness of Nissen fundoplication in neurologically impaired children with gastroesophageal reflux. Surgery 98:662–667PubMedGoogle Scholar
  26. 26.
    Wockenforth R, Gillespie CS, Jaffray B (2011) Survival of children following Nissen fundoplication. Br J Surg 98:680–685CrossRefPubMedGoogle Scholar
  27. 27.
    Powers CJ, Levitt MA, Tantoco J, Rossman J, Sarpel U, Brisseau G, Caty MG, Glick PL (2003) The respiratory advantage of laparoscopic Nissen fundoplication. J Pediatr Surg 38:886–891CrossRefPubMedGoogle Scholar
  28. 28.
    Dalla Vecchia LK, Grosfeld JL, West KW, Rescorla FJ, Scherer LR, Engum SA (1997) Reoperation after Nissen fundoplication in children with gastroesophageal reflux: experience with 130 patients. Ann Surg 226:315–321 Discussion 321–313.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Fonkalsrud EW, Ament ME (1996) Gastroesophageal reflux in childhood. Curr Probl Surg 33:1–70CrossRefPubMedGoogle Scholar
  30. 30.
    Diaz DM, Winter HS, Colletti RB, Ferry GD, Rudolph CD, Czinn SJ, Cochran W, Gold BD, Board NCSA (2007) Knowledge, attitudes and practice styles of North American pediatricians regarding gastroesophageal reflux disease. J Pediatr Gastroenterol Nutr 45:56–64Google Scholar
  31. 31.
    Jolley SG, Smith EI, Tunell WP (1985) Protective antireflux operation with feeding gastrostomy. Experience with children. Ann Surg 201:736–740CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    LaRiviere CA, Parimi C, Huaco JC, Acierno SA, Garrison MM, Goldin AB (2011) Variations in preoperative decision making for antireflux procedures in pediatric gastroesophageal reflux disease: a survey of pediatric surgeons. J Pediatr Surg 46:1093–1098CrossRefPubMedGoogle Scholar
  33. 33.
    Golski CA, Rome ES, Martin RJ, Frank SH, Worley S, Sun Z, Hibbs AM (2010) Pediatric specialists’ beliefs about gastroesophageal reflux disease in premature infants. Pediatrics 125:96–104CrossRefPubMedGoogle Scholar
  34. 34.
    Brook RH (2013) Health systems, heuristics, and comparative effectiveness research. J Gen Intern Med 28:172–173CrossRefPubMedGoogle Scholar
  35. 35.
    Fonkalsrud EW, Bustorff-Silva J, Perez CA, Quintero R, Martin L, Atkinson JB (1999) Antireflux surgery in children under 3 months of age. J Pediatr Surg 34:527–531CrossRefPubMedGoogle Scholar
  36. 36.
    Gilger MA, Yeh C, Chiang J, Dietrich C, Brandt ML, El-Serag HB (2004) Outcomes of surgical fundoplication in children. Clin Gastroenterol Hepatol 2:978–984CrossRefPubMedGoogle Scholar
  37. 37.
    Bourne MC, Wheeldon C, MacKinlay GA, Munro FD (2003) Laparoscopic Nissen fundoplication in children: 2-5-year follow-up. Pediatr Surg Int 19:537–539CrossRefPubMedGoogle Scholar
  38. 38.
    Esposito C, Montupet P, Amici G, Desruelle P (2000) Complications of laparoscopic antireflux surgery in childhood. Surg Endosc 14:622–624CrossRefPubMedGoogle Scholar
  39. 39.
    Wales PW, Diamond IR, Dutta S, Muraca S, Chait P, Connolly B, Langer JC (2002) Fundoplication and gastrostomy versus image-guided gastrojejunal tube for enteral feeding in neurologically impaired children with gastroesophageal reflux. J Pediatr Surg 37:407–412CrossRefPubMedGoogle Scholar
  40. 40.
    Dedinsky GK, Vane DW, Black T, Turner MK, West KW, Grosfeld JL (1987) Complications and reoperation after Nissen fundoplication in childhood. Am J Surg 153:177–183CrossRefPubMedGoogle Scholar
  41. 41.
    Caniano DA, Ginn-Pease ME, King DR (1990) The failed antireflux procedure: analysis of risk factors and morbidity. J Pediatr Surg 25:1022–1025 discussion 1025–1026.CrossRefPubMedGoogle Scholar
  42. 42.
    Goldin AB, Heiss KF, Hall M, Rothstein DH, Minneci PC, Blakely ML, Browne M, Raval MV, Shah SS, Rangel SJ, Snyder CL, Vinocur CD, Berman L, Cooper JN, Arca MJ (2016) Emergency department visits and readmissions among children after gastrostomy tube placement. J Pediatr 174:139–145.e132CrossRefPubMedGoogle Scholar
  43. 43.
    Hassall E (1995) Wrap session: is the Nissen slipping? Can medical treatment replace surgery for severe gastroesophageal reflux disease in children? Am J Gastroenterol 90:1212–1220PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Anne M. Stey
    • 1
    • 2
  • Charles D. Vinocur
    • 3
  • R. Lawrence Moss
    • 4
  • Bruce L. Hall
    • 5
    • 6
    • 7
    • 8
  • Mark E. Cohen
    • 8
  • Kari Kraemer
    • 8
  • Clifford Y. Ko
    • 2
    • 8
  • Brian D. Kenney
    • 4
  • Loren Berman
    • 3
  1. 1.Icahn School of Medicine at Mount Sinai Medical CenterNew YorkUSA
  2. 2.David Geffen School of MedicineUniversity of California Los AngelesLos AngelesUSA
  3. 3.Nemours/Alfred I. duPont Hospital for ChildrenJefferson Medical CollegeWilmingtonUSA
  4. 4.Nationwide Children’s HospitalThe Ohio State UniversityColumbusUSA
  5. 5.Department of Surgery, Olin Business School, and Center for Health PolicyWashington University School of Medicine in Saint LouisSt. LouisUSA
  6. 6.St Louis VA Medical CenterSt. LouisUSA
  7. 7.BJC Healthcare Saint LouisSt. LouisUSA
  8. 8.American College of SurgeonsChicagoUSA

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