Comparative Anti-Reflux Procedures in Neurologically Impaired Children

Inclusion Criteria: * patient is between 6 months and 18 years of age; AND * patient has functional impairment classified by either gross motor functional classification of 3, 4 or 5 OR impaired function in walking, crawling/standing, rolling/sitting, arm use, hand use, ability to hold head up; AND * patient has a gastrostomy; AND * patient has intolerance of feedings or other complications attributed to GERD as defined below; AND * patient has a positive GERD diagnostic evaluation as define below: * GERD diagnostic evaluation will include the following investigations; * endoscopy and biopsy for visual assessment and histology of the esophageal mucosa * pH study and/or multichannel intraluminal impedance (MII) probe to detect and quantify gastroesophageal reflux * GER demonstrated by: * Reflux Esophagitis: Endoscopic appearance of mucosal breaks in the distal esophagus with or without pathologist diagnosis based on one or more biopsy histologic features of: inflammatory cellular infiltrate, basal cell hyperplasia, elongation of the vascular papillae AND no infectious microorganisms and \< 15 eosinophils per high power field; OR * pH OR pH/multichannel intraluminal impedance(MII) probe evidence of pathologic GER: * pH probe: acid reflux index \> 7 % OR * pH/MII reflux symptom-associated acid or non-acid volume associated reflux events; * Upper GI will only be used to determine normal anatomy; AND * patient has either medically refractory GERD or severe GERD as defined below: * Medically refractory GERD - GERD that has not responded to 12 weeks of treatment with a proton pump inhibitor (PPI) (and verified gastric pH \> 4) and/or trial of continuous intragastric feedings and has one of the following complications: * Esophagitis: Endoscopic appearance of mucosal breaks in the distal esophagus with or without pathologist diagnosis based on one or more biopsy histologic features of: inflammatory cellular infiltrate, basal cell hyperplasia, elongation of the vascular papillae * Failure to thrive: diminishing weight percentile for age or weight for age z-score sustained over 6 months. * Pneumonia consistent with aspiration, * Acute life threatening event, * Severe GERD - at least one severe complication of GERD and patient cannot safely tolerate a trial of medical management due to one of the following life-threatening complications: * aspiration pneumonia, * acute life threatening event (ALTE), * complete loss of airway protection (absent cough/gag) AND, * Upper GI barium contrast study for anatomy; AND * Barium pharyngeal swallow study or modified barium swallow study or Flexible Endoscopic Evaluation of Swallowing (FEES) in past year; AND * the parent or legal guardian speaks English or Spanish (the only two languages in which the instruments are standardized) Exclusion Criteria: * Upper GI findings that would mandate a fundoplication including: hiatal hernia, esophageal stricture, Barret's esophagus; OR * Upper GI findings show uncorrected distal gastrointestinal obstruction including: gastric outlet obstruction, duodenal obstruction, malrotation; OR * Upper GI demonstrates structural foregut abnormalities that preclude a fundoplication including: microgastria, short esophagus, high anesthetic risk; OR * Diagnosis or history of congenital diaphragmatic hernia, esophageal atresia, chronic intestinal pseudoobstruction; OR * Endoscopy and biopsy demonstrates esophagitis from causes other than GER including: eosinophilic esophagitis, candida esophagitis, viral esophagitis); OR * Rapidly changing or indeterminate neurological including either a deteriorating neurological condition such as rapid loss of developmental milestones or improving, such as rapid recovery following severe neurological insult; OR * Patient has unacceptable general anesthetic risk; OR * A previous Nissen fundoplication; OR * Feeds delivered by GJ/NJ at the time of enrollment occurring for greater than 3 months.