FAST Discharge for Laparoscopic G-tube

This is Todd Ponsky, and for today's journal review, we actually have a new reviewer, Doctor Ray Hanke. She's a pediatric surgery research fellow here at Cincinnati Children's Hospital, and you'll be getting to know her pretty well over the next couple of years. G-tube placement is one of the most common procedures pediatric surgeons perform, and more frequently this is being done laparoscopically. Previous studies have examined when to start feeds after percutaneous G-tube placement, but there's little data on the efficacy of early feeding after laparoscopic G-tube placement. At Children's Mercy Hospital in Kansas City, lead author Richard J. Hendrickson and senior author Doctor Oyen Tuji set out to evaluate the feasibility and safety of an early feeding and expedited recovery discharge pathway. They performed a retrospective review of 545 patients, excluding inpatients or those without prior nasal gastric feeding. Final analysis included 122 patients. Following the institution protocol, patients underwent standardized laparoscopic GT placement, recovered in PACU postoperatively, and were started on a feeding. Within 4 hours of transfer to the floor bed, Patients were started at full or partial feeds, which is 1/2 to 1/3 depending on the surgeon. For patients with bolus feeds, the volume was increased to goal over the next 2 feed cycles. For patients with continuous feeds, they were advanced to goal volume every 2 to 3 hours. Feeds were held if the patient became intolerant, which was defined as abdominal distention, abdominal discomfort unrelieved by pain medications, emesis, respiratory difficulties, or hemodynamic instability. Overall, they found median operative length was 19 minutes. Median time to initiation of feeds was 2.8 hours from arrival on the floor. 33% of patients reached full volume within 1 hour of starting feeds, 70% within 12 hours, and 97% of their patients reached full enteral nutrition within 24 hours. Median length of stay was 26 hours. 4 patients had difficulties with early. Initiation of feeding, and all were able to resume feeds after negative G tube studies. This retrospective review from Kansas City concluded that for patients undergoing elective laparoscopic G tube placement and already had established nasogastric feeding regimens, a standardized pathway of starting feeds right after recovery in PACU and advancing to goal quickly is well tolerated and safe. It also can lead to decreased length of stay.