Archives ofDisease in Childhood 1993; 68: 347-351

ORIGINAL ARTICLES

Operation for gastro-oesophageal reflux associatedwith severe mental retardation

L Spitz, K Roth, E M Kiely, R J Brereton, D P Drake, P J Milla

AbstractOne hundred and seventy six children withsevere mental retardation underwent a fundo-plication for considerable gastro-oesophagealreflux. There were six 'early' (3%) deathsand five 'late' deaths. Major complicationsdeveloped in 17 (10%) children whereas 86(49%) had 'minor' complications. A revisionoperation was required in 27 patients. Overali142 (81%) children achieved a good result.

In spite ofthe high complication rate and theneed for a secondary operation in 15% of thepatients, the quality of life for these childrenand their parents and carers is greatlyimproved by antireflux surgery.(Arch Dis Child 1993; 68: 347-351)

The Hospital for SickChildren, Great OrmondStreet, London WC1 3JH,Department of SurgeryL SpitzK RothE M KielyR J BreretonD P Drake

Department ofGastroenterologyP J MillaCorrespondence to:Professor Spitz.Accepted 6 November 1992

The association between gastro-oesophagealreflux and cerebral palsy was first reported byAbrahams and Burkitt in 1970.' Previously,Neuhauser and Berenberg in 19472 and Gross in19533 had noted that infants with severe mentalretardation generally responded poorly toconservative treatment. Even Carre (1985),4 aprotagonist of conservative treatment of hiatalhernia, recognised that a higher proportion ofmentally handicapped children with gastro-oesophageal reflux required surgical treatmentdue to 'delay in diagnosis and the difficulty incarrying out postural therapy in this group ofpatients'. Vomiting, failure to thrive, recurrentrespiratory infections, and periods of irritabilityand pain are widely accepted as being part of thedisability of severe mental retardation. If fullyinvestigated, a significant proportion of thesechildren will be found to have gastro-oesophagealreflux.II The high failure rate of medicalmeasures in this special category of patientsjustifies an aggressive surgical approach, butonly after the medical treatment has been given afair trial.The aims of this study were (a) to analyse the

results of the surgical treatment of gastro-oesophageal reflux in children with severemental impairment, (b) to document the compli-cations of the procedure, and (c) to assess theeffect of the operation on their quality of life.

Patients and methodsA total of 495 Nissen fundoplications wereperformed at the Hospital for Sick Children,Great Ormond Street, London in the period

1980-90. More than one third of these patientshad severe mental retardation, the case notes of176 of whom were available for retrospectiveanalysis. Children with mild retardation(developmental delay, absent corpus callosum,hyperactivity) were excluded from the study.There was a male preponderance of 110 boys to66 girls, reflecting the higher frequency ofchromosomal abnormalities and syndromes inboys.

Table 1 gives the aetiology of the cerebraldysfunction. Major associated anomalies wererecognised in 62 (35%) patients, being morecommon in those with a chromosomal abnor-mality (53%) or a recognised syndrome (65%).Before the fundoplication 67 (38%) had under-gone an operation for the correction of anothermalformation such as diaphragmatic hernia(two), oesophageal atresia (five), cardiac malfor-mation (11), or airway procedures (10).

SYMPTOMATOLOGYSymptoms of gastro-oesophageal reflux werenoted soon after birth in 45% of the patients,

Table I Aetiology ofcerebral dysfunction in 176 children

EndocrineHypothyroidism

MetabolicLeigh's encephalopathyEncephalopathy of unknown originGlutaric aciduria type 1

Rett's syndromePhenylketonuria

Cerebral malformationMicrocephalyPorencephalyHydrocephalusTuberous sclerosisEncephalocoele

Chromosomal abnormalityDown's syndromeTrisomyTranslocationDeletion disorder

SyndromeCHARGECornelia de LangeRiley-DayRubenstein-TaybeWilliam'sOpitz GNoonan'sOthers*

Cerebral palsyBirth asphyxiaAcquired brain damageEpilepsyMiscellaneous

21

5

21124

22

927124

2

9

4211

4

3

3

3

2

1 1

80459

206

*Angelman's, congenital varicella, Goltz's. Marshall Smith,Mobius', Mohr's, Robinow's, Rudinger's, Smith-Lemli-Opitz.Sotos's, VACTERL.

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Spitz, Roth, Kiely, Brereton, Drake, Milla

Table 2 Symptomatology ofthe children

No(%)of No(%)ofchildren with children indisorder whom present

Vomiting 108 (61) 162 (92)Haematemesis 35 (20)

Feeding/swallowing problems 27 (15) 113 (64)Recurrent respiratory infections 25 (14) 84 (48)Failure to thrive 6(3) 148 (84)Anaemia (haemoglobin <I00 g/l) 5 (3) 29(16)Pain or irritability, or both 4(2) 50(28)Asthma 1(1) 1(1)Constipation 45 (26)

especially in 70% of infants affected by a namedsyndrome (table 2). Overall, two thirds of thepatients developed symptoms during the firstyear of life. Children with epilepsy or acquiredcerebral damage presented with symptoms afterthe second year of life (mean age 8 2 years). Themost common and significant symptom wasvomiting (92%), followed by failure to thrive(84%), swallowing difficulties (64%), and recur-rent respiratory infections (48%). The presenceof 'coffee grounds' or fresh blood in the vomituswas noted at some time in 20% of patients.Vomiting generally tended to occur after feedsbut in some children it was almost continuous.The combination of malodorous clothing withsoiled carpets and furniture isolated manyfamilies and profoundly affected the socialdevelopment of siblings. Failure to gain weightand to thrive was often considered to be aprimary feature of the underlying mental handi-cap/disorder rather than being attributed to theassociated gastro-oesophageal reflux. The vomit-ing made it impossible to estimate the amount ofdrugs absorbed, and often led to poor controlof convulsions and other medical disorders.Swallowing problems, due to cricopharyngealincoordination or dysphagia secondary to refluxoesophagitis or strictures, or both, were presentin 64% of patients. The inability to swallow wasthe main symptom in eight of 11 children withCHARGE association7 and two of the four withRiley-Day dysautonomia.8 Recurrent respira-tory infections, which occurred in 48% of child-ren, had been ascribed to chest deformitiesresulting from scoliosis and to general lack ofmobility rather than to recurrent, often occult,aspiration episodes.Owing to the inability of these children to

communicate, the true incidence of pain second-ary to reflux was difficult to determine. Theparents of 50 (28%) children were convinced thatpain was a considerable problem. Two childrenhad severe bouts of pain and screaming accom-panied at night by small vomits, which oftencontained 'coffee ground' material. Severe irondeficiency anaemia due to chronic blood lossfrom ulcerative oesophagitis was present in fivechildren, and some degree of anaemia was docu-mented in 16% of patients.

INVESTIGATIONSThe barium meal examination did not showgastro-oesophageal reflux in 36 (20%) patients.The reflux was classified as grade III, affectingthe full length of the oesophagus, in 87 (65%) ofthe remaining 134 patients. A hiatal hernia waspresent in 90 (51%) patients.

Pharyngo-oesophageal incoordination withtracheobronchial aspiration was a commonoccurrence in children with a defined syndrome.In 13 (7%) children a midgut malrotation wasdiagnosed on the barium follow through exami-nation.pH studies were performed in only 63 patients

but were pathological in 57 (90%) with a pH lessthan 4 for more than 5% of the total recordedtime. Upper gastrointestinal endoscopy was per-formed in 150 children. There was no evidenceof oesophagitis on endoscopy in 54 (36%)patients whereas 45 (30%) had advancedoesophageal mucosal damage in the form ofulcerative oesophagitis or established strictureformation. Endoscopic biopsy samples weretaken in 32 patients, 17 of whom showedinflammatory changes on histopathologicalexamination.Only one patient was diagnosed as having

Barrett's oesophagitis.9 Oesophageal mano-metric studies in 12 of the children with severeoesophagitis showed considerable neuropathicactivity with lower oesophageal sphincter pres-sures (1I87 (0 93) v controls 2 93 (0-53) kPa) andslow acid clearance (4 5 (0 9) v controls 0 7 (0 1)minutes).

TREATMENTAll patients had received drugs for gastro-oesophageal reflux before referral but a furtherintensive trial of medical treatment was under-taken in 130 (74%) children. This consisted ofthickening of feeds and upright positioning,whenever possible, combined with one or moreof the following drugs: alginates and antacids(usually Gaviscon), prokinetic drugs (metoclo-pramide, domperidone, cisapride), or H2 block-ers (cimetidine, ranitidine). The duration of theconservative trial was at least one month butmore often several months before proceeding toan operation.

Despite the early onset of symptoms, opera-tions were performed on only four infants (twoeach with Opitz G and CHARGE association)within the first month of life and a further 36infants during the first year (fig 1). The mean ageat operation was 4'25 years, being earlier in thechromosomal (2 5 years) and syndrome groups(3 years), and later in the epilepsy group (7 5years). Symptoms had been present for more

JOOnset of symptoms80 bOperation

60

0)

~ 0

z.~

Years

Figure I Distribution ofpatients by age according to onset ofsymptoms and age at operation.

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Operationfor gastro-oesophageal reflux associated with severe mental retardation

Table 3 Early complications after the operation

Complication No (%)

Major 17(10)Intraoperative cardiac arrest 1 (1)Postoperative necrotising enterocolitis 1 (1)Leakage of gastrostomy requiring reoperation 3 (2)Adhesion intestinal obstruction 12 (7)

Other 86 (49)Gasbioat 46 (26)Retching 40 (23)Diarrhoea 12 (7)Dumping (major) 9 (5)Gastrostomy site infection 14 (8)Wound sepsis 5 (3)Respiratory complication 14 (8)Retained foreign body 4 (2)

than one year in 104 (59%) children before theoperation.A Nissen fundoplication was carried out in 172

patients as a primary procedure and in four as asecondary procedure after the failure of anti-reflux surgery performed elsewhere. Theoperative procedure consisted of a short, floppyfundoplication using two layers of non-absorb-able sutures. The hiatal crura were repaired in93% of patients. Eight patients had a pyloro-plasty and five a pyloromyotomy for delayedgastric emptying as assessed on the bariumfollow through study. In six children duodenalbands were divided and in 20 a Ladd's procedurecarried out for associated midgut malrotation, ofwhich 13 were diagnosed on the barium mealexamination and seven at laparotomy. Ten of thechildren with malrotation occurred among the 42with a recognised syndrome whereas theremainder were equally distributed among theother groups. A Stamm gastrostomy was per-formed in 38% of patients and is currentlyroutinely performed in all children with a

176 Children(severe mental retardation undergoing fundoplication)

6 'Early' deaths

3 Cardiorespiratory 3 Du

142 (86%) Good outcome -

e toprimaryconditior

170 - 7 Lost to follow up

17 (10%) 86 (58%)Major Minor

complications complicationsIL --I

163

123 (75%) 40-Primary good result Unsatisfactory

5 Deaths

19 27- Secondary good Revision

result surgery

swallowing problem. Mouth or gastrostomyfeeds were begun on the third to fifth day afterthe operation and the children were generallydischarged on the seventh to tenth day after theoperation. Children with recurrent respiratoryinfections had intensive physiotherapy beforeand after the operation and all received pro-phylactic perioperative antibiotics.

ResultsThere were six early deaths (3%) - that is, withinsix weeks of the operation. Three of the deathsoccurred as a consequence of cardiorespiratoryproblems in the first 24 hours after the operation,whereas the remaining three deaths were due tothe primary disorder and unrelated to the opera-tion.Major complications were encountered in 17

(10%) patients (table 3). One child with acomplex cardiac malformation had an intra-operative cardiac arrest but was successfullyresuscitated. Twelve (7%) patients developedadhesive intestinal obstruction which requiredoperative lysis. Two children with intraperi-toneal catheters (ventriculoperitoneal shunt,Tenkoff catheter) developed sepsis necessitatingthe establishment of alternative drainage sites.The gastrostomy tube was misplaced into theperitoneal cavity after early replacement forblockage in one child and revision of the gastro-stomy was necessary in a further two.Of the minor complications (table 3), gasbloat

was the most common, developing in 46 (26%) ofpatients. It was mild and transient in 21, butpersisted for several months in 22 and was asignificant problem lasting for more than oneyear in three children. Retching lasting forseveral months occurred in 31 patients andcontinued to be a problem for a year or more infive. Diarrhoea and dumping usually respondedpromptly to medical treatment and dietarymanipulation. Overgrowth of granulation tissueat the gastrostomy site was problematic in 15(9%) children but responded rapidly to the localapplication of a steroid/antibiotic ointment(Sofradex). Respiratory infections developeddespite intensive physiotherapy in 14 (8%)patients and was more a reflection of the debili-tated state of the children than a complicationafter the operation.

FOLLOW UPExcluding the six early deaths and seven patientslost to follow up, 163 patients were available forevaluation (fig 2). The mean follow up periodwas 2 5 years. A good result was achieved in 123(70%) patients who experienced no feeding pro-blems (by mouth or via gastrostomy), achievedsatisfactory weight gain, and had a considerableimprovement in their presenting symptoms. Inaddition, a further 19 patients responded wellbut only after a secondary operation; 17 requiredrevision of the fundoplication and one eachrequired a gastrostomy and pyloroplasty. Over-all 142 (86%) of the 163 survivors had a highlysatisfactory outcome.The primary outcome was unsatisfactory in 40

children. There were a further five deaths in thisFigure 2 Clinical outcome ofthe patients.

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Spitz, Roth, Kiely, Brereton, Drake, Milla

group, three in children with spastic diplegia andepilepsy and two with CHARGE syndrome. Allhad developed recurrent symptoms of refluxthree months to one year after the operation.Two of these had recently undergone a revision-ary operation.Twenty five (14%) patients had to have a

repeat operation on the fundoplication for recur-rent symptoms such as vomiting (15), swallow-ing problems (six), aspiration episodes (six), pain(four), retching (three), and gasbloat (three).The revision procedure was carried out betweentwo months and seven years (mean 1-75 years)after the operation. At operation the most com-mon finding was prolapse of the wrap into theposterior mediastinum through an enlargedhiatus (19) with or without an associated para-oesophageal hernia (16). In two patients thewrap was too tight and in only two instances hadthe wrap partially disrupted leading to recurrentreflux. The outcome after the revision operationwas good in 17 (68%) children.

DiscussionRecurrent vomitingoccurs in 10-15% ofmentallyretarded children.56 The vomiting is oftenregarded as part of the neurological problem. Iffully investigated up to 75% of these children canbe shown to have gastro-oesophageal reflux withor without associated hiatal hernia.' 6A number offactors contribute to the increased

incidence of reflux among retarded children.The lower oesophageal sphincter pressure isconsiderably reduced, especially in the presenceof severe oesophagitis, compared with normalsubjects.610 The level of reduction in loweroesophageal sphincter pressure has been used topredict the need for an operation." None of thepatients with pressures less than 10 mm Hg inthe series of Sondheimer and Morris6 respondedto medical treatment. In addition, dysmotility ofthe oesophagus, shown by reduced acid clear-ance, predisposes to mucosal damage. 12 Theintra-abdominal pressure is often increased inseverely retarded patients due to spasticity of theabdominal musculature, scoliosis, and recurrentseizures. Many of these patients spend longperiods in the supine position so that posturaltreatment for the reflux is impractical. It is thusevident that a number of factors combine to

Table 4 Incidence ofcomplications from the large series published previously

No ofpatientswith central Wrapnervous Complication Intestinal hernia or

Reference system rate obstruction dysfunctionAuthors Year No impairment (%) (%) (%)

Wilkinson et al 1981 14 14 42 14Wesley et al 1981 15 22 9 10Byrne et al 1982 16 22 59 28Spitz 1982 17 20 50 10Vane et al 1985 18 57 12 2Schmitt et al 1986 19 35 57 11Dedensky et al 1987 20 297 8Changetal 1987 21 33 44 3 12Tuggle et al 1988 22 48 22Ashcraft 1988 23 120 10 4Fung et al 1990 24 121 22 8 2Pearl et al 1990 25 153 33 76 14Wheatley et al 1991 26 105 18 4 6Rice et al 1991 27 52 55 10 10Martinez et al 1992 28 198 46 8 15

increase the propensity of the severely retardedchild to develop symptomatic gastro-oesophagealreflux.The clinical features of gastro-oesophageal

reflux in retarded children are similar to those innormal subjects. Vomiting, which occurs in over90% of patients, varies from forceful vomits soonafter a meal to continual small regurgitationsthroughout the day. The presence of 'coffeegrounds' in the vomitus is an indication ofulcerative oesophagitis. Respiratory complica-tions are common and may be due either toincoordination of the swallowing mechanism orto aspiration of refluxed gastric content. As aresult of recurrent vomiting, poor swallowing,and delayed referral, 80% ofpatients are severelymalnourished by the time the diagnosis is estab-lished. At least 25% of parents report that theirchildren appear to be in pain and are excessivelyirritable. The irritability may be due to theburning pain of peptic oesophagitis or to hungerfrom inadequate nutritional intake. Theresponse to an effective antireflux operation inthese children is often dramatic - they rapidlybecome calmer and more responsive.

Investigations of vomiting in the neurologic-ally impaired child include an upper gastro-intestinal barium meal study in which the degreeof reflux, particularly aspiration of contrast, isrecorded as well as the presence of an anatomicalhiatus hernia, oesophagitis, oesophageal stric-ture, dysmotility, and gastric drainage.Oesophageal pH monitoring, the gold standardmeasure of reflux, is difficult to perform in thisgroup of patients as they do not tolerate theprobe being in situ for prolonged periods andtend to remove it at the least provocation.Routine endoscopy is important to document thedegree of oesophageal damage. Many of thepatients have respiratory insufficiency as a con-sequence of recurrent aspiration pneumonia. Inthese patients it is important to perform lungfunction studies before the operation and tocarry out prophylactic physiotherapy andadminister antibiotics to improve lung function.The 176 patients in this series constituted a

highly selected group referred to a tertiaryreferral centre for further evaluation andmanagement. They had all received somemedical treatment before referral and a furtherintensive trial of conservative management wasundertaken in 130 (74%) of these children. Thedecision to proceed to an antireflux operationwas based on (a) the severity of the symptoms -for example, haematemesis, malnutrition, recur-rent respiratory complications, (b) the effect ofthe recurrent vomiting on the well being of thechild and the social effect on the family, and (c)the demonstration of oesophageal complications- for example, ulcerative oesophagitis, strictureformation, large hiatal hernia.The operation consists of a standard 3600

Nissen fundoplication. It is important that thewrap is 'floppy' and short (I 5-3 cm) over thedistal oesophagus. The upper short gastricvessels are divided to achieve a loose wrap. Thecrura are approximated posterior to the oesopha-gus with a few non-absorbable sutures. A Stammgastrostomy is performed in a convenient part ofthe stomach and the tube brought out through a

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Operationforgastro-oesophageal reflux associated with severe mental retardation 351

separate stab incision lateral to the main midlineincision. Correction of any gastric outletobstruction - for example, pyloric stenosis ormalrotation - is carried out. An alternative toa gastrostomy catheter is to insert a silastic'gastrostomy button"3 at the initial procedure.Alternatively, a 'button' may be inserted at alater stage if requested by the parents.The mortality and particularly the morbidity

of an antireflux operation in neurologicallyimpaired patients is considerably higher than innormal subjects (table 4). Although Ashcraft,23Vane et al,'8 and Tuggle et a122 report no differ-ence in the complication rate in the retardedchildren compared with normal children, mostworkers document a much higher overall com-plication rate, particularly with reference towrap dysfunction. This latter complication maymanifest as recurrent gastro-oesophageal refluxwith all its attendant problems, such as vomit-ing, malnutrition, and respiratory complica-tions, or migration of the wrap into the posteriormediastinum or the development of a paraoeso-phageal hernia through a widened hiatus. Thesetwo complications lead to dysphagia rather thanrecurrent reflux.The incidence of small intestinal obstruction

due to adhesion formation after the operation isabout the same in neurologically impaired andnormal children. We have previously stressedthe need for close long term follow up of patientsundergoing Nissen fundoplication for thedevelopment of intestinal obstruction.2930 Thesechildren do not manifest the well known symp-tom of intestinal obstruction - that is, biliousvomiting - and there may be a dangerouslyprolonged delay in establishing the diagnosiswith resultant intestinal ischaemia. Deaths dueto a failure to recognise the presence of intestinalobstruction are reported in most of the largeseries of antireflux operations in children.Over the years we have developed a policy of

performing a gastrostomy on all neurologicallyimpaired children requiring an antireflux pro-cedure except in those children who have afunctionally normal swallowing mechanism.When a gastrostomy is only required for nutri-tional purposes and where gastro-oesophagealreflux has been excluded, percutaneous endo-scopic gastrostomy is the procedure of choice.3'

Despite the high complication rate of up to50% and the recurrence of gastro-oesophagealreflux in up to 15% of patients, a highly satis-factory result was obtained in 70-80% of severelyretarded children, even when a secondary opera-tion was required. Anecdotal remarks fromparents such as 'he is much calmer, happier andmore responsive', 'the procedure has changedour lives', 'why was the operation not offeredsooner?', 'medication for convulsions is moreeffective', 'he is no longer so distressed orirritable', make the procedure worthwhile andrewarding.

1 Abrahams P, Burkitt BFE. Hiatus hernia and gastro-oesophageal reflux in children and adolescents with cerebralpalsy. Australian Paediatric_Journal 1970; 6: 41-6.

2 Neuhauser EBD, Berenberg W. Cardio-esophageal relaxation(chalasia) as a cause of vomiting in infants. Radiology 1947;48: 480-3.

3 Gross RE. The surgery of infancy and childhood. Philadelphia:Saunders, 1953: 128.

4 Carre IJ. Management of gastro-oesophageal reflux. Arch DisChild 1985; 60: 71-5.

5 Ball TS, Hendricksen H, Clayton J. A special feeding tech-nique for chronic regurgitation. Am J Ment Defic 1974; 78:486-93.

6 Sondheimer JM, Morris BA. Gastroesophageal reflux amongseverely retarded children. J Pediatr 1979; 94: 710-4.

7 Pagon RA, Graham JM. Coloboma, congenital heart diseaseand choanal atresia with multiple anomalies: charge associa-tion. J Pediatr 1981; 99: 223-7.

8 Axelrod FB, Nachtigall R, Davis J. Familial dysautonemia:diagnosis, pathogenesis and management. In: Schulman I,ed. Advances in pediatrics 21. Chicago: Year Book MedicalPublishers, 1974: 75-96.

9 Barrett NR. Chronic peptic ulcer of the oesophagus and'oesophagitis'. BrJSurg 1950; 38: 175-82.

10 Vane D, Shiffler M, Grosfeldl JL, et al. Reduced loweresophageal sphincter (LES) pressure after acute and chronicbrain injury. J Pediatr Surg 1982; 17: 960-3.

11 Euler AR, Ament ME. Value of esophageal manometricstudies in the gastroesophageal reflux in infancy. Pediatrics1977; 58: 58-61.

12 Cucchiara S, Staiano A, Di Lorenzo C, et al. Esophageal motorabnormalities in children with gastroesophageal reflux andpeptic esophagitis. J Pediatr 1986; 108: 907-10.

13 Gauderer MWL, Picha GJ, Izant RI. The gastrostomy'button' - a simple, skin-level, non-refluxing device for long-term enteral feedings. J PediatrSurg 1984; 19: 803-5.

14 Wilkinson JD, Dudgeon DL, Sondheimer JM. A comparisonof medical and surgical treatment of gastroesophageal refluxin severely retarded children.J Pediatr 1981; 99: 202-5.

15 Wesley JR, Coran AG, Sarahan TM, Klein MD, White SJ.The need for evaluation of gastroesophageal reflux in brain-damaged children referred for feeding gastrostomy.JPediatrSurg 1981; 16: 866-71.

16 Byrne WJ, Euler AR, Ashcraft E, Nash DG, Seibert JJ,Golladay ES. Gastroesophageal reflux in the severelyretarded who vomit: criteria for and results of surgicalintervention in twenty-two patients. Surgery 1982; 91: 95-8.

17 Spitz L. Surgical treatment of gastrooesophageal reflux inseverely mentally retarded children. J R Soc Med 1982; 75:525-9.

18 Vane DW, Harmel RP, King DR, Boles ET. The effectivenessofNissen fundoplication in neurologically impaired childrenwith gastroesophageal reflux. Surgery 1985; 98: 662-6.

19 Schmitt M, Peiffert B, Pierre E, Barthelme H. L'interventionde Nissen chez l'enfant encephalopathe. Chir Pediatr 1986;27:138-42.

20 Dedensky GK, Vane DW, Black CT, Turner MK, West KW,Grosfeld JL. Complications and reoperation after Nissenfundoplication in childhood. AmJ Surg 1987; 153: 177-83.

21 Chang JHT, Coin CD, Strickland AD, Andersen JM. Surgicalmanagement of gastroesophageal reflux in severely mentallyretarded children. J7MentDeflc Res 1987; 31: 1-7.

22 Tuggle DW, Tunell WP, Hoelzer DJ, Ide Smith E. Theefficacy of Thal fundoplication in the treatment of gastro-esophageal reflux: the influence of central nervous systemimpairment.JPediatrSurg 1988; 23: 638-40.

23 Ashcraft K. In discussion of Tuggle et al22. J Pediatr Surg1988; 23:638-40.

24 Fung KP, Seagram G, Pasieka J, Trevenen C, Machida H,Scott B. Investigation and outcome of 121 infants andchildren requiring Nissen fundoplication for the manage-ment of gastroesophageal reflux. Clin Invest Med 1990; 13:237-46.

25 Pearl RH, Robie DK, Ein SH, et al. Complications ofgastroesophageal antireflux surgery in neurologicallyimpaired versus neurologically normal children. J PediatrSurg 1990; 25: 1169-73.

26 Wheatley MJ, Wesley JR, Tkach DM, Coran AG. Long-termfollow-up of brain-damaged children requiring feedinggastrostomy: should an antireflux procedure always beperformed?JPediatrSurg 1991; 26: 301-5.

27 Rice H, Seashore JH, Touloukian RJ. Evaluation of Nissenfundoplication in neurologically impaired children.JPediatrSurg 1991; 26: 697-701.

28 Martinez DA, Ginn-Pease ME, Caniano DA. Sequelae ofantireflux surgery in profoundly disabled children. J7 PediatrSurg 1992; 27: 267-73.

29 Spitz L, Kirtane J. Results and complications of surgery forgastro-oesophageal reflux. Arch Dis Child 1985; 60: 743-7.

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31 Gaunderer MWL, Ponsky JL, Izant RJ. Gastrostomy withoutlaparotomy: a percutaneous endoscopic technique. J PediatrSurg 1980; 15: 872-5.

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