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How many tests does it take? Minimizing preoperative testing prior to surgical placement of gastrostomy tubes in
Elizabeth W Tindal1, Margaret Willis2, Aldo Recinos Soto2
1Department of Surgery, Brown University, Rhode Island Hospital, Providence, Rhode Island, USA.
Insights
Routine preoperative upper gastrointestinal series and impedance studies for children needing gastrostomy tubes are often unnecessary, increasing costs and radiation exposure. A targeted, symptom-based approach is more efficient for evaluating these patients.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Diagnostic Imaging
Background:
- Gastrostomy tubes (GTs) are vital for enteral access in children.
- Preoperative evaluation for gastroesophageal reflux disease (GERD) or malrotation using upper gastrointestinal (UGI) series and impedance studies (ISs) in asymptomatic patients is debated.
- This study assesses the value of routine preoperative testing for GT placement.
Purpose of the Study:
- To investigate the utility of routine preoperative UGI series and IS for children undergoing GT placement.
- To determine if specific patient characteristics can guide selective use of these diagnostic studies.
- To analyze the impact of routine testing on healthcare costs and patient management.
Main Methods:
- Retrospective review of pediatric patients who underwent GT placement between 2003 and 2019.
- Evaluation of patient demographics, preoperative testing results, and postoperative outcomes.
- Analysis of cost savings and radiation exposure associated with preoperative testing.
Main Results:
- Of 343 patients, 61% had preoperative testing. UGI series identified malrotation in 4% and IS identified severe GERD in 28%.
- Only malrotations altered surgical management; few GERD cases prompted intervention. Age <1 year was linked to positive UGI results.
- Eliminating non-actionable tests could save significant costs and avoid radiation exposure.
Conclusions:
- Routine preoperative UGI series and IS increase healthcare costs without significantly changing patient care.
- Selective, symptom-based preoperative evaluation is recommended to streamline care, reduce costs, and minimize radiation exposure.
- Infants under 1 year may be the only subgroup benefiting from routine UGI series.
Background:
Gastrostomy tubes (GTs) provide life-saving enteral access for children. Although upper gastrointestinal (UGI) series and impedance studies (ISs) detect gastroesophageal reflux disease (GERD) or malrotation, their benefit for preoperative evaluation of asymptomatic patients requiring GT placement is controversial. This study investigated the value of routine preoperative testing and whether specific patient characteristics could guide the selective use of these studies.
Methods:
The charts of children who underwent GT placement from 2003 to 2019 were reviewed retrospectively. Demographics, preoperative evaluation, and postoperative course were evaluated.
Results:
Three hundred forty-three patients underwent GT placement, 61% with preoperative testing. Seven of 190 UGI (4%) series demonstrated malrotation, and 39 of 141 (28%) ISs revealed severe GERD. Although all malrotations were surgically addressed, only 59% (23/39) of IS-proven GERD cases prompted simultaneous fundoplication. Age <1 year was associated with a positive UGI series (6.7% positive vs 1.0%; P < 0.05), but no other patient characteristics were associated with either positive UGI series or IS. Elimination of the 96% of UGI series that did not alter care represented a cost savings of $89,487-$229,665 and avoided the radiation exposure from testing; elimination of the 84% of ISs that did not alter eventual treatment would have saved $127,776-$266,563.
Conclusion:
Routine preoperative evaluation with UGI series and IS can increase healthcare costs without substantially altering care. The only patients potentially benefiting from routine UGI series were <1 year old. Instead, a targeted, symptom-based preoperative evaluation may streamline the process by decreasing preoperative testing and minimizing cost and radiation exposure.
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