E. A. Gilliam1,2, R. Wilson1, A. McIntire2, S. Polites1,2, S. Krishnaswami1, K. S. Azarow1, E. Fialkowski1 1Oregon Health And Science University, Pediatric Surgery, Portland, OR, USA 2Legacy Emmanuel Children’s Hospital, Pediatric Surgery, Portland, Oregon, USA
Introduction:
Gastrostomy placement is a common elective procedure in pediatric surgery, but there is wide variation in time to initiating feeds post-operatively. We previously reported outcomes of our post-gastrostomy feeding protocol as part of our Minimizing Variance in Pediatric Surgery program, with decreased postoperative length of stay (LOS) post-implementation. This feeding protocol was updated to include earlier initiation of feeds with rapid titration to goal at two tertiary children’s hospitals (Figure).
Methods:
We conducted a retrospective review of patients admitted for elective gastrostomy placement for full enteral feeds. Our pre-update period spanned from January 2016 to December 2017 (n=141). From January 2019 to December 2020, we managed patients with our new protocol (n=109) which includes feed initiation at four hours postoperatively. Primary endpoints included LOS and total hospital cost (TC). Secondary outcomes included return visits to the emergency department, re-admissions, surgical site infections, and re-operations within 30 days. We also collected data on virtual visits for post-operative gastrostomy teaching during the COVID-19 pandemic. Statistical analysis was performed with STATA with a p-value < 0.05 as significant. Compliance criteria included feed initiation within five hours and rapid feed advancement per protocol unless otherwise recommended by dietician.
Results:
There were no differences in gender (47% female) or median age (1.8 years vs 1.7 years). Laparoscopic gastrostomy button placement was the dominant procedure in both time periods (94% vs 96%), with fewer patients also receiving a Nissen fundoplication post-update (9 vs 4). LOS decreased by a mean of 5.7 hours (p = 0.017) and median of 1.4 hours (p = 0.003) after protocol implementation. TC decreased by a mean of $1,162 (p = 0.013) and median of $775 (p < 0.001). There was no difference in post-operative LOS noted for the subset of Nissen fundoplication patients between time periods (median 26.4 vs 25.6 hours). There was no difference in complications or in successful follow-up for post-operative gastrostomy teaching. Protocol compliance was 82%.
Conclusion:
We found that our modified post-gastrostomy feeding protocol with earlier initiation of feeds and rapid titration to goal was safe, effective, had high compliance, and decreased postoperative length of stay and total hospital cost. These findings may be especially relevant for patient throughput given capacity concerns across children's hospitals. Despite bridging the COVID-19 era, we observed equivalent follow-up rates using virtual appointments with no increased complications.
