Surgical management of gastroesophageal reflux in complex and medically fragile children: single-centre retrospective study and future perspectives.

INTRODUCTION: Gastroesophageal reflux disease (GERD) is a common pediatric condition that can significantly impair quality of life and lead to severe complications in medically fragile patients. Although conservative and pharmacological therapies are effective in most cases, some children require surgical intervention, which remains associated with non-negligible postoperative morbidity and the need for reoperation. This study aimed to evaluate the surgical management of pediatric gastrointestinal reflux in a tertiary referral center, focusing on surgical approaches, operative outcomes, postoperative complications, and the need for reintervention. In addition, factors associated with unfavorable surgical outcomes were investigated in order to identify potential areas for improvement in the management of medically fragile pediatric patients. METHODS: A retrospective observational study was conducted on pediatric patients undergoing surgical treatment for GERD, dysphagia, or both conditions at a tertiary pediatric center between December 2016 and December 2025. Demographic characteristics, comorbidities, nutritional status, ASA score, surgical procedures, operative times, postoperative complications, and reinterventions were analyzed. Associations between baseline risk factors and postoperative outcomes were explored using Fisher's exact test. Statistical significance was set at p < 0.05. RESULTS: A total of 67 patients were included in this study. The study population was characterized by a high prevalence of neurological impairment (79.1%), severe malnutrition (59.7% with weight percentile <3rd percentile), and elevated anesthesiologic risk (78.8% classified as ASA 3-4). Postoperative complications occurred more commonly among patients with severe malnutrition and high ASA scores. CONCLUSIONS: Pediatric patients undergoing surgical treatment for GERD represent a highly complex and medically fragile population. Although fundoplication remains an effective therapeutic option, postoperative complications and reinterventions continue to occur, particularly among patients with severe malnutrition and elevated anesthesiologic risk. The results of this study support the need for less invasive therapeutic strategies and further research into innovative approaches aimed at reducing the surgical burden in this high-risk population. Emerging evidence regarding autologous micro-fragmented adipose tissue therapies may offer a promising regenerative approach to reinforce lower esophageal sphincter function while minimizing surgical and anesthetic burden.