Esophagogastric Dysfunction and Recurrent Symptoms in Neurologically Impaired Children with an Intact Nissen Fundoplication

BACKGROUND: Neurologically impaired children frequently experience recurrent gastroesophageal reflux symptoms after laparoscopic Nissen fundoplication, even when the fundoplication remains anatomically intact. Esophagogastric dysfunction may contribute to these recurrences but is often underrecognized. AIM: To analyze the causes of recurrent gastroesophageal reflux symptoms in neurologically impaired children with an intact Nissen fundoplication attributable to esophagogastric dysfunction and to describe their management and outcomes. METHODS: We conducted a retrospective descriptive study of neurologically impaired children who underwent laparoscopic Nissen fundoplication between 2010 and 2025 and subsequently developed recurrent gastroesophageal reflux-related symptoms. All patients were evaluated with contrast upper gastrointestinal studies and upper gastrointestinal endoscopy; gastric emptying scintigraphy was performed when gastric atony was suspected. Demographic data, neurological diagnosis, Gross Motor Function Classification System level, nutritional status, symptoms, time to recurrence, imaging findings, treatment, and follow-up were recorded. RESULTS: A total of 124 children were included (96 with cerebral palsy, 18 with traumatic brain injury, and 10 with brain tumors). At 36-month follow-up, 82 patients achieved complete symptom remission. Forty-two children, all with cerebral palsy, developed recurrent symptoms between 10 and 48 months after surgery. Recurrence was due to paraesophageal hernia in 15 patients, all of whom underwent successful laparoscopic redo fundoplication. The remaining 27 children had an anatomically intact fundoplication: 10 presented bile reflux with duodenitis and improved with medical management, and 17 had gastric, pyloric, or duodenal dysfunction requiring laparoscopic pyloroplasty, esophagogastric disconnection, or gastrojejunostomy, with subsequent resolution of symptoms. CONCLUSIONS: In neurologically impaired children, esophagogastric dysfunction unrelated to wrap failure is a frequent and surgically treatable cause of recurrent symptoms after Nissen fundoplication.