Update Course Rewind: Who to Send Home from the OR: Gastrostomy 2023

Global cast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello pediatric surgery family, I'm Cecilia Higuena, a research fellow from Cincinnati Children's Hospital Medical Center. Our 11th annual update course in pediatric surgery was held this past August. In this session, the surgeons discussed in round table fashion, who can go home from the OR on the same day of their procedure. Let's hear what they had to say about gastrostomy tubes. Two year old male in OR needs a G-tube. There's still a persistent fistula, he undergoes elective gastrocutaneous fistula closure. What would you do? The majority of surgeons sent the patients home from PACU. However, in Argentina, it's common practice to admit them to the floor and discharge them the next day. So, why do they need to stay overnight? We were always waiting to make sure that they tolerated things well. It's a visceral operation. You're closing viscera. I'm giving you the argument why people probably admit. It's bowel surgery. So, you're stitching the stomach closed. You're dropping it down in the abdomen with a stitch line. So, the question is, is that safe to send home right away and start feeding them right away and letting them go? Without proper separation and closure, there was perceived risk of refistilization through the abdominal wall. However, in practice, that doesn't seem to be a primary complication. I think the other issue is some people do additional antibiotics. That would be the other reason some people may keep them. Historically, gastrostomy closure used to be done in the office with cautery, and patients were sent home from there. However, not all of the fistulas closed properly. I I'll just say that William Beaumont sent Alexis St. Martin home same day from the wilderness, the guy who invented gastrostomies. Let's go ahead and put the poll on. Still about half send them home from the PACU. And a lot still send it home the following day. You know, maybe we will have some impact on practice here across the world. And what kind of diet do these kids go home on? Regular diet. So if you ask me, there's only two kinds of diets: NPO and regular. Now, let's look at the data that supports same day's discharge for these patients. But we actually had an opportunity to look at Nsquip and for gastrocutaneous fistula closures. About 80% were going home the same day versus 20% going home at day one or two or later. And what strategies works best for sending these patients home from the PACU? I think you just set the expectation with the family. It's a same day procedure, you're going home after. That's it. And I think just adequate pain control, making sure they get on a schedule of Tylenol, ibuprofen, potentially other adjuncts as well. If there are going to be wound complications, they typically aren't seen in the first 24 hours. So it's still safe to send them home. Let's move on to our second case. 3 year old male with feeding intolerance, dependence on NG feeds, undergoes a lap G-tube without complications. So what do we all do after a lap G-tube? In Poland, the surgeon, there was about 42% versus 41 of those who kept the patients overnight versus those that discharged when goal feeds were met somewhere between three and four. We do start feeds two to four hours, but we tend to get to full feeds overnight so they go home the following morning. Yeah. I think this is the same thing about setting the expectations. Mostly our PACU nurses fought back because they're not used to advancing the G-tube feeds. So in these kids, we send them to the floor, but then try to get them up on feeds and still send them home the same day. Let's look at the data to support same day discharge for these patients. Dr. Oyatuinji and his colleagues collected data on 62 patients who underwent laparoscopic gastrostomy tube placement. They discharged 82% of these patients home on the same day as their procedure. So this was what we published. It's been three years now, which is the same day discharge protocol. Just like you said, is a matter of setting expectations, but there's a lot of work that goes on the front end before you send these kids home. You need the dietician to see them. You need to have a plan. You set the expectation that they will potentially be going home same day. Feeds were started within four hours and they were discharged home before reaching goal feeds. When they follow up with families regarding their satisfaction with the same day surgery, 98% of families expressed satisfaction. Do you have a goal as far as feeds for what you want to get to before you're comfortable, are they get one feed and you're good? No, they don't get one feed. They start and once they ramp up without problems, the kid is not throwing up, then we're fine. And they can be discharged. That's past the goal. That's not. If the parents are comfortable with it, most of those parents are pretty experienced. So once they see the kid is doing fine, they're like, okay, we're fine, and they're ready to go. A common theme among surgeons was the importance of setting expectations with families. In Dr. Oyatunji's clinic, much of the teaching is done pre-operatively with the dietician and nursing teams. They are comfortable with how to administer feeds and typically do quite well going home the same day. The ideal candidate are those that are already on home feeds. And so they're just unhooking it from here and hooking it up there, which means we're not shooting to get to goal feeds. Just get the pain controlled, they're looking okay, parents are comfortable, then they can go home because it's going to be a matter of tolerating feeds at home like it is for the other operations. The other ideal group are those patients who only need a supplemental feed because you can fit them one time and then send them home. They found that when the parents were given the choice of either staying overnight or going home, most will want to go home and less than 5% of families come back within 24 hours. In this session, pediatric surgeons discussed the safety and incidence of same day discharge and gastrostomy tube placement and plus gastrocutaneous fistula closure. Nearly half of surgeons are already sending their patients home on the same day. Setting expectations with the family prior to the procedure has helped with acceptance of same day discharge. And there are very few patients who come back within 24 hours of procedure. Thank you for watching. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.