RESUMO
BACKGROUND: Children requiring gastrostomy tubes (GT) have high resource utilization. In addition, wide variation exists in the decision to perform concurrent fundoplication, which can increase the morbidity of enteral access surgery. We implemented a hospital-wide standardized pathway for GT placement. METHODS: The standardized pathway included mandatory preoperative nasogastric feeding tube (FT) trial, identification of FT medical home, and standardized postoperative order set, including feeding regimen and parent education. An algorithm to determine whether concurrent fundoplication was indicated was also created. We identified children referred for GT placement from 2015 to 2018 and compared concurrent fundoplication rates and outcomes pre- and postimplementation. RESULTS: We identified 332 patients who were referred for GT. Of these, 15 avoided placement. Concurrent fundoplication decreased postpathway (48% vs 22%, pâ¯<â¯0.0001). After adjusting for reflux and cardiac disease, prepathway patients were 3.5 times more likely to undergo concurrent fundoplication. ED visits (46% vs 27%, pâ¯=â¯0.001) and postoperative LOS (median (IQR) 10â¯days (5-36) to 5.5â¯days (1-19), pâ¯=â¯0.0002) decreased. CONCLUSIONS: A standardized pathway for GT placement prevented unnecessary GT placement and fundoplication with reduction in postoperative LOS and ED visits. This approach can significantly reduce resource utilization while improving outcomes. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: Level II.
Assuntos
Atenção à Saúde/normas , Intubação Gastrointestinal/estatística & dados numéricos , Procedimentos Desnecessários/estatística & dados numéricos , Criança , Procedimentos Clínicos/normas , Serviços Médicos de Emergência/estatística & dados numéricos , Fundoplicatura/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricosRESUMO
BACKGROUND: Necrotizing enterocolitis is the leading case of gastrointestinal-related morbidity in premature infants. Necrotizing enterocolitis totalis is an aggressive form of necrotizing enterocolitis, which has traditionally been managed with comfort care. Recent advances in management of short bowel syndrome have resulted in some reported long-term survival. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, studies that reported outcomes in children with necrotizing enterocolitis totalis were identified. The definition of necrotizing enterocolitis totalis was captured along with length of follow-up, patient demographics, and outcomes. RESULTS: A total of 766 articles were screened, of which 166 were selected for full article review. Of these, 32 articles included data on 414 patients with necrotizing enterocolitis totalis. In the majority of studies (52%), necrotizing enterocolitis totalis was not defined. Aggressive surgical therapy (defined as bowel resection or fecal diversion) was undertaken in 32 patients (7.7%), with a mortality rate of 68.8%. In contrast, nonaggressive surgical therapy was undertaken in 382 patients (92.3%), and the mortality in these patients was 95%. Long-term outcomes for necrotizing enterocolitis totalis survivors, such as length of time on parenteral nutrition, progression to liver and/or small bowel transplant, and quality of life, were not reported. CONCLUSION: We found that there is no accepted definition of necrotizing enterocolitis totalis. Aggressive surgical therapy is rarely pursued, which likely drives the overall high mortality rate. This study underscores the importance of standardizing the definition of necrotizing enterocolitis totalis and capturing short and long-term outcomes prospectively. With more aggressive surgical therapy, more infants are likely to survive this abdominal catastrophe, which was once thought to be uniformly fatal.