J. Wu1, S. Lee1, D. A. DeUgarte1 1UCLA And Harbor-UCLA,Department Of Surgery – Division Of Pediatric Surgery,Los Angeles, CA, USA
Introduction: Several non-operative strategies have been described to repair gastroschisis including ‘sutureless’, ‘ward reduction’, ‘plastic’, and ‘flap’ techniques. Non-operative strategies have the potential advantages of avoiding intubation and general anesthesia, decreasing pain, and improving cosmesis. Their disadvantage is that the majority of patients without formal fascial closure will develop hernias, a proportion of which will require delayed repair. We hypothesized that routine utilization of non-operative strategy results in cost-savings in uncomplicated cases of gastroschisis.
Methods: We constructed a decision tree to compare three different strategies for the management of uncomplicated gastroschisis: non-operative management, primary operative closure, and routine silo placement. Model variables (including probability of management failure and hernia development as well as anticipated length of stay and treatment costs) were abstracted from a literature review and the Medicare Physician Fee schedule. Uncertainty surrounding model parameters was assessed via one-way and probabilistic sensitivity analyses.
Results: According to our model, non-operative management of uncomplicated gastroschisis was the least costly strategy, which cost $198,085 per patient. Primary closure cost $208,763 per patient. Routine silo placement was the most costly, $239,038 per patient. One-way sensitivity analysis suggested the cost of primary closure would be less costly than non-operative management if the initial success rate of non-operative management was less than 35.4% or if the initial success rate of primary operative closure was greater than 87.8%. Probabilistic sensitivity analysis found that non-operative management was the least costly strategy among 97.4% of 10,000 Monte Carlo simulations.
Conclusion: Non-operative management of uncomplicated gastroschisis appears to be more cost-effective than attempted primary closure and routine silo placement strategies. Furthermore, given the potential for avoiding general anesthesia, routine adoption of non-operative management of uncomplicated gastroschisis should be considered and deserves prospective evaluation.