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Dewan T, Avinashi V, Beaudry P, Doré-Bergeron MJ, Gaucher N, Nelson K. Antireflux Procedures in Children With Neurologic Impairment: A National Survey of Physician Perspectives. Hosp Pediatr 2024; 14:413-420. [PMID: 38738287 DOI: 10.1542/hpeds.2023-007643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/22/2024] [Accepted: 02/01/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVE Decision-making about antireflux procedures (ARPs) to treat gastroesophageal reflux disease in children with neurologic impairment and gastrostomy tubes is challenging and likely influenced by physicians' experience and perspectives. This study will explore physician attitudes about ARPs and determine if there are relationships to clinical practice and personal characteristics. METHODS This is a national observational cross-sectional study that used an electronic questionnaire addressing reported practice, attitudes regarding the ARPs, and responses to clinical vignettes. Participants were physicians in Canadian tertiary-care pediatric settings. Descriptive statistics were used to analyze physician attitudes. Multivariable logistic regression modeling was used to determine associations between physician and practice characteristics and likelihood to consider ARP. RESULTS Eighty three respondents represented 12 institutions, with a majority from general or complex care pediatrics. There was a wide disparity between likelihood to consider ARP in each clinical scenario. Likelihood to consider ARP ranged from to 19% to 78% depending on the scenario. Two scenarios were equally split in whether the respondent would offer an ARP. None of the demographic characteristics were significantly associated with likelihood to consider ARP. Often, gastrojejunostomy tubes alone were considered (56% to 68%). CONCLUSIONS There is considerable variability in physician attitudes toward and recommendations regarding ARPs to treat gastroesophageal reflux disease. We did not find a significant association with clinical experience or location of practice. More research is needed to define indications and outcomes for ARPs. This is a scenario where shared decision-making, bringing together physician and family knowledge and expertise, is likely the best course of action.
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Affiliation(s)
| | - Vishal Avinashi
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Nathalie Gaucher
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Kate Nelson
- Department of Paediatrics, University of Toronto, Toronto, Ontario
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Bouchard ME, Stewart DH, Hall M, Many BT, Vacek JC, Papastefan S, Van Arendonk K, Abdullah F, Goldstein SD. Trends in gastrostomy tube placement with concomitant Nissen fundoplication for infants and young children at Pediatric Tertiary Centers. Pediatr Surg Int 2021; 37:617-625. [PMID: 33486562 DOI: 10.1007/s00383-020-04845-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/27/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE In infants and toddlers, gastrostomy tube placement (GT) is typically accompanied by consideration of concomitant Nissen fundoplication (NF). Historically, rates of NF have varied across providers and institutions. This study examines practice variation and longitudinal trends in NF at pediatric tertiary centers. METHODS Patients ≤ 2 years who underwent GT between 2008 and 2018 were identified in the Pediatric Health Information System database. Patient demographics and rates of NF were examined. Descriptive statistics were used to evaluate the variation in the proportion of GT with NF at each hospital, by volume and over time. RESULTS 40,348 patients were identified across 40 hospitals. Most patients were male (53.8%), non-Hispanic white (49.5%) and publicly-insured (60.4%). Rates of NF by hospital varied significantly from 4.2 to 75.2% (p < 0.001), though were not associated with geographic region (p = 0.088). Rates of NF decreased from 42.8% in 2008 to 14.2% in 2018, with a mean annual rate of change of - 3.07% (95% CI - 3.53, - 2.61). This trend remained when stratifying hospitals into volume quartiles. CONCLUSION There is significant practice variation in performing NF. Regardless of volume, the rate of NF is also decreasing. Objective NF outcome measurements are needed to standardize the management of long-term enteral access in this population.
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Affiliation(s)
- Megan E Bouchard
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA.
| | - Danielle Howard Stewart
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS, USA
| | - Benjamin T Many
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Jonathan C Vacek
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Steven Papastefan
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Kyle Van Arendonk
- Division of Pediatric Surgery, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, WI, USA
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
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Esparaz JR, Mathis MS, Russell RT. Curriculum Change Needed: A Decline in Antireflux Surgery in the Pediatric Surgery Fellowship. J Surg Res 2020; 255:9-12. [DOI: 10.1016/j.jss.2020.05.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/23/2020] [Accepted: 05/03/2020] [Indexed: 12/21/2022]
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Ingram M, Short HL, Sathya C, Fevrier H, Raval MV. Hospital-level factors associated with nonoperative management in common pediatric surgical procedures. J Pediatr Surg 2020; 55:609-614. [PMID: 31708206 DOI: 10.1016/j.jpedsurg.2019.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 09/18/2019] [Accepted: 10/19/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE Our purpose was to examine patient- and hospital-level factors associated with nonoperative management in common pediatric surgical diagnoses. METHODS Using the 2012 Kid's Inpatient Database (KID), we identified patients <20 years old diagnosed with cholecystitis (CHOL), bowel obstruction (BO), perforated appendicitis (PA), or spontaneous pneumothorax (SPTX). Logistic regression models were used to identify factors associated with nonoperative management. RESULTS Of 36,026 admissions for the diagnoses of interest, 7472 (20.7%) were managed nonoperatively. SPTX had the highest incidence of NONOP (55.9%; n = 394), while PA had the lowest incidence (9.2%; n = 1641). Utilization of operative management varied significantly between hospitals. Patients diagnosed with BO (OR 0.41; 95% CI 0.30-0.56) and SPTX (OR 0.28; 95% CI 0.14-0.56) had decreased odds of operative management when treated at an urban, teaching hospital compared to a rural hospital. Patients with PA had increased odds of operative management when treated at an urban, teaching hospital (OR 2.42; 95% CI 1.78-3.30). Hospital-level factors associated with decreased odds of nonoperative management included urban, nonteaching status (OR 0.54; 95% CI 0.31-0.91) and location in the South (OR 0.53; 95% CI 0.34-83) and West (OR 0.47; 95% CI 0.30-0.74). CONCLUSIONS Despite representing more than 20% of pediatric surgical care for several conditions, nonoperative management is an understudied aspect of care with significant variation that warrants further research. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Martha Ingram
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Chethan Sathya
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Helene Fevrier
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
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Casar Berazaluce AM, Gibbons AT, Hanke RE, Ponsky TA, Harmon CM. It Is a Wrap! Or Is It?: The Role of Fundoplication in Infant Feeding Intolerance. J Laparoendosc Adv Surg Tech A 2019; 29:1315-1319. [PMID: 31264917 DOI: 10.1089/lap.2019.0076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: Fundoplication is one of the most common procedures performed by pediatric surgeons, frequently for gastroesophageal reflux with feeding intolerance. No consensus exists in its management, with multiple institutions opting for medical therapy over surgical intervention. Methods: A case-based survey was administered at a national pediatric surgery conference. Clinical vignettes described former-premature infants with reflux and feeding intolerance with or without failure to thrive (FTT), neurological impairment, complex cardiopathy, and respiratory symptoms. Odds ratios (ORs) for fundoplication were calculated from participants' responses. Results: Surgeons elected to perform fundoplication in 14%-74% of cases. The OR for performing fundoplication in the presence of FTT was 1.84 (confidence interval [CI] 1.34-2.54, P = .0002) overall, achieving significance in subgroup analysis for cardiopathy (OR 3.56, CI 1.88-6.71, P = .0001) and neurological impairment (OR 1.79, CI 1.04-3.07, P = .04), but not in the absence of these comorbidities (OR 1.05, CI 0.61-1.83, P = .86). The OR for fundoplication in the presence of neurological impairment was 1.97 (CI 1.34-2.90, P = .0005) and that for cardiopathy was 1.70 (CI 1.20-2.40, P = .003), independent of FTT status. In subgroup analysis, the greatest predictors for fundoplication were neurological impairment with FTT (OR 2.63, CI 1.55-4.48, P = .0004) and complex cardiopathy with FTT and cough/syncope (OR 7.14, CI 4.05-12.58, P < .0001). Presence of cardiopathy without FTT had the overall lowest odds of fundoplication (OR 0.40, CI 0.21-0.78, P = .006). Conclusion: Surgeons tend to perform fundoplication in the presence of FTT and other comorbidities, particularly when these are concurrent. Respiratory symptoms are a strong predictor for fundoplication in patients with complex cardiopathies.
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Affiliation(s)
- Alejandra M Casar Berazaluce
- Department of Surgical Services, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alexander T Gibbons
- Department of Surgery, Division of Pediatric Surgery, Akron Children's Hospital, Akron, Ohio
| | - Rachel E Hanke
- Department of Surgical Services, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Todd A Ponsky
- Department of Surgical Services, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Surgery, Division of Pediatric Surgery, Akron Children's Hospital, Akron, Ohio
| | - Carroll M Harmon
- Department of Surgery, Division of Pediatric Surgery, Kaleida Health, John R. Oishei Children's Hospital, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
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