Declining Use and Shifting Drivers of Concurrent Fundoplication With Pediatric Gastrostomy

Area of Science:

• Pediatric surgery
• Gastroenterology
• Health services research

Background:

• Practice variability exists in performing antireflux procedures concurrently with gastrostomy tube (GT) placement.
• This study investigates the factors influencing the decision for concurrent fundoplication versus GT alone.

Purpose of the Study:

• To examine trends in concurrent fundoplication rates with GT placement.
• To analyze the sources of variation (patient, surgeon, hospital) in this surgical decision.
• To identify patient characteristics associated with fundoplication over time.

Main Methods:

• Retrospective cohort study (2013-2023) of pediatric patients (0-17 years) using the National Surgical Quality Improvement Program-Pediatric database.
• Variance component analysis to quantify variability sources.
• Multivariate logistic regression to identify associations between patient characteristics and fundoplication.

Main Results:

• Concurrent fundoplication rates decreased from 18.2% in 2014 to 2.2% in 2023.
• Non-patient-level variation decreased from 86% in 2018 to 49% in 2023.
• Gastrointestinal disease remained a predictor for fundoplication, while neurological impairment became a negative predictor by 2023.

Conclusions:

• The rate of concurrent fundoplication with GT placement has declined over the past decade.
• The influence of non-clinical factors on this decision has also decreased.
• Shifting patient factors suggest evolving clinical judgment in pediatric surgical practice.