Fundoplication for Pediatric Patients with EA-TEF Repair History

Clinical Justification Based on Morbidity and Mortality Outcomes

The International Network on Oesophageal Atresia (INOEA) 2023 consensus guidelines state that in patients with GERD inadequately controlled medically, fundoplication may be necessary when chronic respiratory symptoms are thought to be secondary to reflux 1
This patient's recurrent respiratory illnesses represent significant morbidity directly attributable to reflux-related aspiration, with 4-5 episodes requiring oxygen since January, one requiring high-flow nasal cannula for weeks 1
The inability to transition from jejunal to gastric feeds due to reflux concerns is a critical functional limitation that fundoplication can address, potentially improving nutritional autonomy and quality of life 1, 2

Upper GI series (UGI) is essential to assess stomach size, given prolonged jejunal feeding may have resulted in a tubular/non-distended stomach 2, 3
24-hour multichannel intraluminal impedance-pH (MII-pH) monitoring is the gold standard for confirming GERD diagnosis before surgery 3, 4
Upper endoscopy must be performed to document any esophagitis, Barrett's esophagus, strictures, or ulceration 2, 3

Laparoscopic approach is the recommended surgical approach for anti-reflux surgery in EA-TEF patients 2, 5
The choice between total (Nissen) versus partial fundoplication should account for this patient's underlying esophageal dysmotility from EA-TEF repair 2, 3, 5

The family's understanding of "competing physiologic concerns of antireflux versus dysphagia issues" is appropriate and critical 1, 2
In EA-TEF patients, the balance between controlling reflux and avoiding worsening dysphagia from underlying dysmotility is delicate 1, 2
Fundoplications often loosen over time in this population, which may require revisional surgery 1

The primary goal is reducing respiratory morbidity and enabling transition to gastric feeds, which would significantly improve quality of life and reduce dependence on continuous jejunal feeding 1, 2
The patient's improving swallowing function could potentially expand further once reflux is controlled and gastric feeding becomes feasible 1