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No need to be testy: a targeted evaluation of patients undergoing gastrostomy tube placement may reduce preoperative tests without adversely affecting postoperative outcomes.
Olivia A. Kozel
*1, Abigail Case
2, Rebecca Herbert
2, Elizabeth Renaud
31The Warren Alpert Medical School of Brown University, Orland Park, IL; 2Surgery, Rhode Island Hospital, Providence, RI; 3Pediatric Surgery, Hasbro Children's Hospital, Providence, RI
Background: Gastrostomy tubes provide lifesaving enteral feeding access for children. To detect gastroesophageal reflux disease (GERD) or intestinal malrotation, which can be comorbid conditions in patients requiring gastrostomy tubes, practitioners historically have performed upper gastrointestinal (UGI) fluoroscopy series and impedance probe studies during preoperative evaluation. However, their benefit for asymptomatic patients is controversial. Previously, our group found that routine preoperative evaluation with UGI and impedance study could increase healthcare costs without substantial benefit to patient care. As a result of this prior study, we developed a targeted preoperative evaluation to decrease testing and minimize cost and radiation exposure. This study compares the outcomes of this targeted evaluation to those from before the change in strategy.
Study Design: This retrospective chart review compared patients undergoing gastrostomy tube placement from October 1, 2003 to June 30, 2019, the time period prior to changes in preoperative workup (PRE), with those undergoing gastrostomy tube placement from January 1, 2020 to December 31, 2023, the period after implementation of the new preoperative evaluation strategy (POST). During the PRE period, UGI and impedance study were routinely performed on all patients receiving gastrostomy tube placement. In the POST period, only patients with symptoms consistent with reflux underwent impedance study, and UGI study was usually performed for patients with known syndromes or chromosomal anomalies. Demographics, preoperative testing, and postoperative outcomes were evaluated with Chi-square or independent t-tests . P values of ? 0.05 were considered significant.
Results: 537 patients underwent gastrostomy tube placement: 343 patients in PRE cohort and 194 in the POST cohort. The POST group was significantly younger at time of surgery (p<0.01) and more likely to experience symptoms concerning for reflux (p<0.01). Impedance studies were performed less commonly in the POST group [41.1% PRE vs. 0.5% POST, p<0.01], although there was no difference between groups in the proportion of patients undergoing UGI study (p=NS). Despite less frequent testing for GERD, a smaller proportion of the POST group required fundoplication later in life [p=0.011], and an equal proportion of each cohort required later GJ tube placement for feeding intolerance (p=0.143). A similar proportion of patients in each group required correction of malrotation.
Conclusions: After the development of a targeted preoperative evaluation strategy, patients with planned gastrostomy tube placement underwent impedance study less often without an increase in the need for later anti-reflux procedure. This decrease in preoperative testing may reduce delay in time to operation as well as overall cost associated with gastrostomy tube placement.
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