Gastrostomy Tube Placement Research Articles

Foslevodopa/foscarbidopa Subcutaneous Infusion Maintains Similar Levodopa Exposure to Levodopa-Carbidopa Intestinal Gel Delivered to the Jejunum when Infused for 24-hours (P1-11.003)

<h3>Objective:</h3> To compare levodopa pharmacokinetics (PK) following subcutaneous (SC) infusion of foslevodopa/foscarbidopa and jejunal delivery of Levodopa-Carbidopa Intestinal Gel (LCIG) both administered for 24 hours in healthy volunteers. <h3>Background:</h3> Treatment with LCIG offers improved symptomatic control compared to oral levodopa/carbidopa in patients with advanced Parkinson’s disease (aPD); however, it requires percutaneous endoscopic gastrostomy tube placement for jejunal delivery. Foslevodopa/foscarbidopa is an investigational drug able to provide 24-hour therapeutic levels of levodopa following SC delivery. While a previous study compared the PK of levodopa between foslevodopa/foscarbidopa and LCIG, when LCIG was administered during waking hours, the current work characterizes the levodopa PK when both the SC infusion and intestinal gel are delivered continuously for 24 hours. <h3>Design/Methods:</h3> This study was a randomized, open-label, 2-way crossover study in 20 healthy volunteers. In each period, subjects received either 24-hour foslevodopa/foscarbidopa SC infusion to the abdomen or LCIG delivered for 24 hours to the jejunum through a nasogastric tube with jejunal extension. Serial blood samples were collected to assay for levodopa concentrations. PK parameters such as area under the curve (AUC) and degree of fluctuation (DOF) were determined and compared between the two regimens. <h3>Results:</h3> Foslevodopa/foscarbidopa SC infusion provided comparable levodopa levels to LCIG over the 24-hour delivery period as assessed by the AUC and DOF parameters. From the different AUC intervals explored, the differences of the mean ranged from 1 to 8% between the foslevodopa/foscarbidopa and the LCIG regimens. Additionally, the degree of fluctuation of levodopa was similar but lower for foslevodopa/foscarbidopa compared to LCIG (mean 0.32 vs 0.50). <h3>Conclusions:</h3> Foslevodopa/foscarbidopa SC infusion delivers comparable levodopa exposure to LCIG when delivered for 24 hours. The low variability of the levodopa PK profiles supports the strategy of maintaining levodopa exposure within a narrow therapeutic window when treating motor symptoms in aPD. <b>Disclosure:</b> Dr. Rosebraugh has received personal compensation for serving as an employee of AbbVie Inc. Dr. Rosebraugh has stock in AbbVie Inc.. Dr. Facheris has received personal compensation for serving as an employee of AbbVie Inc.. Dr. Facheris has stock in AbbVie Inc..

Operating Room Recycling: Opportunities to Reduce Carbon Emissions Without Increases in Cost

BackgroundThe healthcare industry is a major contributor to greenhouse gas emissions. Within the hospital, operating rooms are responsible for the largest proportion of emissions due to high resource utilization and waste generation. Our aim was to generate estimates of greenhouse gas emissions avoided and cost implications following implementation of a recycling program across operating rooms at our freestanding children's hospital. MethodsData were collected from three commonly performed pediatric surgical procedures: circumcision, laparoscopic inguinal hernia repair, and laparoscopic gastrostomy tube placement. Five cases of each procedure were observed. Recyclable paper and plastic waste was weighed. Emission equivalencies were determined using the Environmental Protection Agency Greenhouse Gas Equivalencies Calculator. Institutional cost of waste disposal was $66.25 United States Dollars (USD)/ton for recyclable waste and $67.00 USD/ton for solid waste. ResultsThe proportion of recyclable waste ranged from 23.3% for circumcision to 29.5% for laparoscopic gastrostomy tube placement. The amount of waste redirected from landfill to a recycling stream could result in annual avoidance of 58,500 to 91,500 kg carbon dioxide equivalent emissions, or 6583 to 10,296 gallons of gasoline. Establishing a recycling program would not require additional cost and could lead to modest cost savings (range $15 to 24 USD/year). ConclusionsIncorporation of recycling into operating rooms has the potential to reduce greenhouse gas emissions without increased cost. Clinicians and hospital administrators should consider operating room recycling programs as they work towards improved environmental stewardship. Level of EvidenceLevel VI – evidence form a single descriptive or qualitative study.

Fatal outcomes of endoscopy: an analysis from the coronerʼs point of view

Background and study aims This study was designed to provide a profound analysis of fatalities associated with endoscopic procedures. Methods Protocols of all autopsies performed within 20 years in a large Department of Forensic Medicine were retrospectively analyzed to identify all fatalities directly related to an endoscopic procedure. Data were further specified focusing on the type of endoscopy and the final cause of death. Results Of 22,615 autopsies performed between January 2000 and September 2019, 86 deaths were identified as complications of an endoscopic procedure. The average age of these 86 patients was 70.9 years (66.4 (range, 26-89) in males (n = 35) and 74.1 years (range, 22-94) in females (n = 51)). Endoscopic procedures included 29 endoscopic retrograde cholangeopancreatographies (ERCPs), 27 colonoscopies, 18 percutaneous endoscopic gastrostomy (PEG) tube placements, six gastroscopies, two upper endosopic ultrasonographies, and four transesophageal echocardiographies. ERCPs, colonoscopy and PEG procedures together accounted for 74 of 86 (86 %) endoscopy-related deaths. Focusing on the single procedures, post-ERCP pancreatitis (14/29, 48 %), colonoscopy-associated perforation (24/27, 89 %), and peritonitis after PEG placement (16/18, 88 %) were the most common causes of death. Conclusions Even in the thought-to-be-safe and screening endoscopic procedures fatalities do occur. This study gives an overview of endoscopy-related fatalities, stressing the role of ERCP, colonoscopy, and PEG.

770 Gastrostomy Sequence With Ventriculoperitoneal Shunting—Does it Matter?

INTRODUCTION: Patients who suffer neurologic injury that require ventriculoperitoneal shunt(VPS) placement often also require gastrostomy procedures for feeding access and nutritional support. The timing of these procedures in relation to each other has been debated in the literature, largely steaming from a proposed risk of infection and displacement resulting in a need for revision related to the presence of a gastrostomy. METHODS: In an all-payor database, patients undergoing index gastrostomy procedures and VPS placement between 1/2010-10/2020 were identified. Patients were stratified as undergoing gastrostomy placement before, on the same day as, and following the placement of a shunt. The primary outcome of the study was rates of revision All outcomes were evaluated within 30-months following index-shunting. Patients were matched based upon logistic-regression models that evaluated the independent effects of patient and procedural factors on the primary-outcome. RESULTS: A total of 4,290-patients were identified as undergoing VPS and gastrostomy procedures. Following a 1:1:1-match procedure, 852-patient records were analyzed. Patients undergoing gastrostomy and VPS on the same day or gastrostomy procedures before VPS (Odds Ratio [OR] 0.55, 95% Confidence Interval [CI] 0.33-0.91 vs. OR 0.60, 95% CI 0.36-0.97, respectively) were observed to have significantly lower rates of revision at 30-months following index shunting when compared to those patients who underwent gastrostomy placement after VPS. No significant differences were noted in rates of infection, mechanical complications, g-tube infections, or shunt displacement between the three approaches. CONCLUSIONS: Patients undergoing shunting and gastrostomy tube placement procedures may benefit from undergoing the procedures at the same time as patients undergoing these procedures at the same time are at a decreased risk of repeat requirement for anesthesia reduced rates of VPS revision following observed in comparison to patients undergoing gastrostomy placement after VPS.

Moderately hypo-fractionated radiotherapy combined with S-1 in inoperable locally advanced esophageal squamous cell carcinoma: A prospective, single-arm phase II study (GASTO-1045).

We launched this prospective phase II single-arm trial on the combination of moderately hypo-fractionated radiotherapy and S-1, to explore the safety and efficacy of the new potent regimen in inoperable locally advanced esophageal squamous carcinoma (LA-ESCC) patients. Patients with unresectable stage II-IVB LA-ESCC (UICC 2002, IVB only with metastatic celiac or supraclavicular lymph nodes) were included. Moderately hypofractionated radiotherapy (60Gy in 24 fractions) concurrent with S-1 was delivered. Meanwhile, gastrostomy tube placement by percutaneous endoscopic gastrostomy (PEG) was performed to provide nutritional support. Nutritional supplements were prescribed to meet requirements. The study outcomes included objective response rate (ORR), progression-free survival (PFS), overall survival (OS), locoregional progression-free survival (LRPFS), distant metastasis-free survival (DMFS), failure pattern, toxicities, nutritional status and treatment compliance. Endoscopy was routinely performed during post-treatment follow-up. Fifty-eight patients were included with a median follow-up of 24.4 months. The median age was 63 years (range 49-83 years) and 42 patients (72.4%) had stage III or IV diseases. The ORR was 91.3% and the CR rate was 60.3%. The estimated 2-year PFS rate and 2-year OS rate was 44.2% (95% confidence interval (CI), 31.3-57.1%) and 71.4% (95% CI, 59.4-83.4%), respectively. Radiation-induced esophagitis was the most common non-hematologic toxicity and 5 patients (8.6%) developed grade≥3 esophagitis. While, with PEG nutrition support, the nutrition-related indicators presented a clear trend toward a gradual improvement. Treatment-related death was not observed. The moderately hypo-fractionated radiotherapy combined with S-1 showed promising loco-regional disease control and survival benefit in inoperable LA-ESCC patients. Meanwhile, favorable nutritional status and low incidence of severe radiation-induced esophagitis were observed with PEG nutritional support. Moreover, endoscopy examination contributed to the early detection of recurrent esophageal lesions and timely salvage treatment. The efficacy and toxicity of the combined regimen deserved further evaluation. Clinicaltrials.gov, identifier NCT03660449.

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WEO Newsletter.

Outcomes of endoscopic percutaneous suture lateralization for neonatal and infantal bilateral vocal ford paralysis.

Bilateral Vocal Fold Paralysis (BVFP) is a rare but significant resource of respiratory distress in neonates and infants. The objective of this study was to evaluate the efficacy and functional outcomes of Endoscopic Percutaneous Suture Lateralization (EPSL) for the treatment of BVFP in neonates and infants. A case series study of nine patients undergoing EPSL for BVFP between January 2019 and June 2021 was conducted. All patients were candidates for tracheostomy prior to EPSL. Demographic features including gender, age at diagnosis and surgery, main symptoms, airway comorbidities, airway support, and etiology were collected preoperatively. Patients were evaluated for breathing, swallowing and phonation postoperatively. Surgical success was defined as the ability to avoid tracheostomy. Functional Endoscopic Evaluation of Swallowing (FEES) was conducted to identify aspiration. Voice evaluation was based on clinical observation. Nine patients underwent ten EPSL procedures (one in the left vocal fold, and nine in the right vocal fold). Eight patients (8/9) were able to successfully avoid tracheostomy and feed orally without aspiration after the procedure. One patient experienced clinical improvement in respiratory support requirements and underwent laparoscopic nissen and gastrostomy tube placement. At the last follow-up, two patients regained normal voice, two patients had mild dysphonia, and five patients had moderate dysphonia. Five patients showed partial return of the contralateral vocal fold function. EPSL is an effective and safe treatment for neonatal and infantal BVFP, which enables patients free from tracheostomy without significant impact on swallowing function or phonation. Level 4.

Abstract No. 178 The Effect of Stroke Severity on Timing-Related Outcomes in Gastrostomy Tube Placement

Abstract No. 178 The Effect of Stroke Severity on Timing-Related Outcomes in Gastrostomy Tube Placement

Gastrojejunal Fistula Following Gastrostomy Tube.

Gastrostomy tubes are often placed in patients with poor voluntary intake, oropharyngeal dysphagia, or chronic illness to provide definitive nutritional access. Despite the widespread use of gastrostomy tubes, some patients can experience complications associated with this procedure including gastrocolic-cutaneous fistula and dislodgement of gastrostomy tube. This case discusses an instance of gastrojejunal fistula formation over one year after gastrostomy tube placement likely due to tube dislodgement. Imaging showed gastrostomy tube traversing the posterior wall of the stomach and creating a fistula into the jejunum, with the balloon inflated within the jejunum. Gastrostomy tube was removed and replaced, with gastrostomy tube study showing no extravasation of contrast. Patient is now doing well-tolerating tube feeds at goal.

Percutaneous Endoscopic Gastrostomy Placement in Trauma Patients: Early vs Delayed Initiation of Enteral Feeding.

In critically ill trauma patients, adequate nutrition is essential for the body's healing process. Currently, there is no clinical standard for initiating feeds after percutaneous endoscopic gastrostomy (PEG) tube placement. We aimed to demonstrate that early enteral nutrition (EN) is as safe as delayed EN in patients who have undergone PEG tube insertion. We conducted a multi-center, retrospective cohort study of 384 patients from the Prisma Health Trauma Registries who received PEGs. Feeding intolerance was defined as high gastric residuals, nausea, emesis, sustained diarrhea, or ileus. The probability that a patient would experience intolerance was 11.7% in those fed within 6hours, 5.1% among patients fed between 6 and 12hours, 6.0% among patients fed between 12 and 24hours, and 7.6% among patients fed after 24hours, for which no statistically significant difference was detected. These findings support that early EN after PEG placement is safe in critically ill, trauma patients.

Prophylactic antireflux procedures are not necessary in neurologically impaired children undergoing gastrostomy placement

Fundoplication is frequently used in children with neurologic impairment even in the absence of reflux due to concerns for future gastric feeding intolerance, but supporting data are lacking. We aimed to determine the incidence of secondary antireflux procedures (fundoplicationor gastrojejunostomy (GJ)) post gastrostomy tube (GT) placement in children with and without neurologic impairment. Children under 18 undergoing a GT placement without fundoplication between 2010 and 2020 were identified utilizing the PearlDiver Mariner national patient claims database. Children with a diagnosis of cerebral palsy or a degenerative neurologic disease were identified and compared to children without these diagnoses. The incidence of delayed fundoplication or conversion to GJ were compared utilizing Kaplan-Meier and Cox proportional hazards regression analyses. A total of 14,965children underwent GT placement, of which 3712 (24.8%) had a diagnosis of neurologic impairment. The rate of concomitant fundoplication was significantly higher among children with a diagnosis of neurologic impairment as compared to those without (9.3% vs 6.4%, p < 0.001). While children with neurologic impairment had a significantly higher rate of fundoplication or GJ conversion at 5years compared to children without (12.6% [95% confidence interval (CI): 11.4%-13.8%] vs 8.6% [95% CI 8.0%-9.2%], p < 0.001), the overall incidence remained low. Although children with neurologic impairment have a higher rate of requiring an antireflux procedure or GJ conversion than other children, the overall rate remains less than 15%. Fundoplication should not be utilized in children without clinical reflux on the basis of neurologic impairment alone.

Assessment of factors affecting mortality in patients with percutaneous endoscopic gastrostomy tube placement in the intensive care unit

Aim: It was aimed to evaluate the clinical outcomes, complications, and factors affecting mortality of percutaneous endoscopic gastrostomy (PEG) applied to patients in the intensive care unit (ICU).Material and Method: PEG procedures which were performed in the ICU between January 2016 and January 2021 and patients' age, gender, comorbidities, trauma history, serum CRP, albumin levels, CRP albumin ratios (CAR), and PEG-related complications were reviewed. Patients were divided into two groups, patients without mortality (Group 1) and patients with mortality (Group 2), and a comparison between groups was made.Results: Of all patients, 49 (39.2%) patients had mortality. The mean age of the patients in group 2 was 69.57±16.78 years, which was higher than the other group (p&amp;lt;0.001). Nephrological diseases and diabetes were significantly more common in Group 2, whereas neurologic diseases were less common (p=0.005, p=0.005, 0.044, respectively). The median length of stay (LOS) of the patients in Group 1 was 50 days, while the median LOS of the patients in Group 2 was found to be significantly higher, with 81 days (&amp;lt;0.001). The mean CRP of Group 2 was 81.63±54.06, which was higher than the other group, while the mean of albumin was found to be 2.29±0.5 and was lower than Group 1 (p&amp;lt;0.001, p&amp;lt;0.001). The mean CAR of Group 1 was 15.96±16.81, which was significantly lower than that of Group 2 (p&amp;lt;0.001). The optimal CAR cut-off value for mortality discrimination was found to be 20,216 with a sensitivity of 73.5%, a specificity of 78.9%, a positive predictive value of 69.2%, a negative predictive value of 82.2%, and 76.8% test accuracy. A CAR value of ≥ 20.216 increased the odds of death 9.3-fold (OR 10.385, CI 95% 4.481-24.065, p&amp;lt;0.001). Conclusion: We suggest that CAR ratio, low albumin, and high CRP levels could be predictors of early mortality. Considering that PEG is an elective procedure, we believe that it can be a safe and effective procedure when nutritional support is provided by alternative means and appropriate conditions are met.

Association Between Birth Weight Z-Scores and Early Outcomes Following Truncus Arteriosus Repair.

In infants undergoing truncus arteriosus (TA) repair, we sought to determine associations between fetal growth restrictions as measured by birth weight Z-score and early outcomes. We utilized the Pediatric Health Information System (PHIS) database to identify infants < 90days old who underwent TA repair from 2004 to 2019. The primary exposure variable was birth weight Z-score, calculated based on gestational age at birth, gender, and birth weight. The primary outcome was postoperative hospital mortality. Secondary outcomes included major complications, prolonged postoperative length of hospital stay (LOS; > 30days), and hospital readmission within 1 year. Generalized estimating equation (GEE) models were used to identify adjusted associations between birth weight Z-score, small for gestational age (SGA) status, and mortality and included were 1039 subjects. Median birth weight was 2960g, gestational age at birth was 38weeks, and birth weight Z-score was -0.47. SGA was present in 21% of subjects. Hospital mortality occurred in 104 patients (10%). By multivariable analysis, lower birth weight Z-score was associated with higher hospital mortality [for each unit decrease in birth weight Z-score below -1.0, adjusted OR 1.71 (95% CI 1.10-4.25)]. SGA status was associated with increased hospital mortality (adjusted OR 2.17; 95% CI 1.39-3.40). Birth weight Z-scores and SGA status were not significantly associated with occurrence of cardiac arrest, ECMO use, gastrostomy tube placement, tracheostomy, seizures, infection, prolonged postoperative LOS, or hospital readmission. In infants undergoing TA repair, lower birth weight Z-scores and SGA status were strongly associated with increased hospital mortality.

Procedural and Surgical Interventions for Esophageal Stricture Secondary to Caustic Ingestion in Children

BackgroundEsophageal injury after caustic ingestion can vary in severity and may result in significant long-term morbidity due to stricture development. The optimal management remains unknown. We aim to determine the incidence of esophageal stricture due to caustic ingestion and quantify current procedural and operative management strategies. MethodsThe Pediatric Health Information System (PHIS) was utilized to identify patients 0–18 years old who experienced caustic ingestion from January 2007–September 2015 and developed subsequent esophageal stricture until December 2021. Post-injury procedural and operative management was identified utilizing ICD-9/10 procedure codes for esophagogastroduodenoscopy (EGD), esophageal dilation, gastrostomy tube placement, fundoplication, tracheostomy, and major esophageal surgery. Results1,588 patients from 40 hospitals experienced caustic ingestion of which 56.6% were male, 32.5% non-Hispanic White, and the median age at time of injury was 2.2 years (IQR: 1.4,4.8). Median length of initial admission was 1.0 day (IQR: 1.0, 3.0). 171/1,588 (10.8%) developed esophageal stricture. Among those who developed stricture, 144 (84.2%) underwent at least 1 additional EGD, 138 (80.7%) underwent dilation, 70 (40.9%) underwent gastrostomy tube, 6 (3.5%) underwent fundoplication, 10 (5.8%) underwent tracheostomy, and 40 (23.4%) underwent major esophageal surgery. Patients underwent a median of 9 dilations (IQR 3, 20). Major surgery was performed at a median of 208 (IQR: 74, 480) days after caustic ingestion. ConclusionMany patients with esophageal stricture after caustic ingestion will require multiple procedural interventions and potentially major surgery. These patients may benefit from early multi-disciplinary care coordination and the development of a best-practice treatment algorithm. Level of evidenceIII.

Abstract TP74: Reducing Complications From Gastrostomy Tube Insertion In Stroke Patients - Quality Improvement Project At An Academic Tertiary Hospital

Introduction: Percutaneous gastrostomy tubes are frequently required for patients with strokes due to dysphagia, malnutrition, and intestinal dysmotility. Though generally well tolerated, delayed detection of complications following percutaneous gastrostomy tube insertion (including dislodgement, infection and bleeding) can lead to increased morbidity and mortality. Methods: At a single academic tertiary hospital, a standardized protocol was instituted (September 2021) to enhance early detection and prevention of feeding tube complications on the neurology service, consisting predominantly of stroke patients. The protocol comprised of: 1) consistent documentation of feeding tube insertion by proceduralists, 2) universal abdominal binder application, 3) nursing driven delirium screening, 4) post procedural nursing assessment for high-risk feeding tube site changes, and 5) an escalation algorithm to address early complications. We compared rates of complications pre- (July 2020 - August 2021, 13 months) and post- (September 2021 - June 2022, 10 months) protocol implementation. Results: A total of 103 gastrostomy tube insertions were reviewed (64 pre and 39 post protocol implementation). Overall complication rates decreased from 12.5% (N = 8 of 64; 3 dislodgements, 3 infections, 2 insertion site bleeding) to 2.5% (N = 1 of 39; 1 dislodgment) following the intervention. Mortality from complications decreased from 1.6% to 0%. Conclusion: Complication rates of percutaneous gastrostomy tube placement may be reduced through implementation of standardized protocols on inpatient stroke patients. Further studies are warranted to assess its long-term effects and viability in other specialty services.

Neonatal stridor presents at home – vocal fold paralysis as rare presenting feature of CHARGE syndrome

Abstract Objectives To present an unusual presentation and diagnosis of CHARGE syndrome with vocal fold paralysis, a rarely associated congenital laryngeal anomaly, as the presenting feature. Case presentation A four-day old, full-term, male infant born via uncomplicated vaginal delivery with a nursery course significant for failed hearing screen presented to an emergency department (ED) with respiratory distress and worsening stridor. He was transferred to a level III neonatal intensive care unit (NICU) for further evaluation and required intubation due to progressive hypercarbia. Laryngoscopy revealed left-sided unilateral vocal fold paralysis (VFP). He underwent further evaluation that included a normal MRI brain, neck and chest. Genetics was consulted with concern for dysmorphic features on physical exam. Following gene panel testing, VFP was attributed to known association with CHARGE syndrome. Airway edema was noted on laryngoscopy that prevented extubation until two months of age. Further features of CHARGE syndrome identified included colobomas, glaucoma, sensorineural hearing loss, and genital abnormalities. He was discharged in room air and following gastrostomy tube placement with otolaryngology follow up. Conclusions Although choanal abnormalities are classically associated with CHARGE syndrome, other upper airway anomalies such as VFP may be present. VFP is a rarely reported anomaly in association with CHARGE syndrome (Naito Y, Higuchi M, Koinuma G, Aramaki M, Takahashi T, Kosaki K. Upper airway obstruction in neonates and infants with CHARGE syndrome. Am J Med Genet 2007;143A:1815–20; Morgan D, Bailey M, Phelps P, Bellman S, Grace A, Wyse R. Ear-nose-throat abnormalities in the CHARGE association. Arch Otolaryngol Head Neck Surg 1993;119:49–54).

"Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality, complications, or outcomes": Commentary.

In this commentary, we summarize some of the key points of the original paper "Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality, complications, or outcomes" and offer support for the proposed results. Specifically, we address how early percutaneous endoscopic gastrostomy (PEG) tube placement may reduce hospital length of stay and costs. We also discuss topics related to the article including PEG weaning and post-stroke nutritional formulation. However, we note that concerns purported by previous studies that early PEG placement may worsen outcomes are not fully addressed, and further research is needed.

Health Services in Huntington Disease: A Systematic Literature Review.

Clinical trials for Huntington disease (HD) have primarily focused on managing chorea and, more recently, the development of disease-modifying therapies (DMTs). Nonetheless, understanding health services among patients with HD is essential for assessing new therapeutics, development of quality metrics, and overall quality of life of patients and families with HD. Health services assess health care utilization patterns, outcomes, and health care-associated costs, which can help shape the development of therapeutics and aid in policies that affect patients with a specific condition. In this systematic literature review, we analyze data of published studies looking at causes of hospitalization, outcomes, and health care costs in HD. The search yielded 8 articles published in the English language and comprising data from the United States, Australia, New Zealand, and Israel. The most common cause of hospitalization among patients with HD was dysphagia or dysphagia-related complications (e.g., aspiration pneumonia or malnutrition), followed by psychiatric or behavioral symptoms. Patients with HD had more prolonged hospitalizations than non-HD patients, and it was most prominent among those with advanced disease. Patients with HD were more likely to be discharged to a facility. A small percentage received inpatient palliative care consultation, and behavioral symptoms were a primary cause of discharge to another facility. Interventions such as gastrostomy tube placement had associated morbidity, and it was common among patients with HD with a diagnosis of dementia. Palliative care consultation and specialized nursing care were associated with more routine discharges and fewer hospitalizations. In terms of cost, patients with HD with private and public insurances had the highest expenditure with more advanced disease, and expenses were associated with hospitalization and medication costs. In addition to DMTs, HD clinical trial development should also consider the leading causes of hospitalization, morbidity, and mortality in patients with HD, including dysphagia and psychiatric disease. No research study, to our knowledge, has systematically reviewed health services research studies in HD. Evidence from health services research is needed to evaluate the efficacy of pharmacologic and supportive therapies. This type of research is also critical in understanding health care costs associated with the disease and to better advocate and shape policies that can benefit this patient population.

How many tests does it take? Minimizing preoperative testing prior to surgical placement of gastrostomy tubes in children.

Gastrostomy tubes (GTs) provide life-saving enteral access for children. Although upper gastrointestinal (UGI) series and impedance studies (ISs) detect gastroesophageal reflux disease (GERD) or malrotation, their benefit for preoperative evaluation of asymptomatic patients requiring GT placement is controversial. This study investigated the value of routine preoperative testing and whether specific patient characteristics could guide the selective use of these studies. The charts of children who underwent GT placement from 2003 to 2019 were reviewed retrospectively. Demographics, preoperative evaluation, and postoperative course were evaluated. Three hundred forty-three patients underwent GT placement, 61% with preoperative testing. Seven of 190 UGI (4%) series demonstrated malrotation, and 39 of 141 (28%) ISs revealed severe GERD. Although all malrotations were surgically addressed, only 59% (23/39) of IS-proven GERD cases prompted simultaneous fundoplication. Age <1 year was associated with a positive UGI series (6.7% positive vs 1.0%; P < 0.05), but no other patient characteristics were associated with either positive UGI series or IS. Elimination of the 96% of UGI series that did not alter care represented a cost savings of $89,487-$229,665 and avoided the radiation exposure from testing; elimination of the 84% of ISs that did not alter eventual treatment would have saved $127,776-$266,563. Routine preoperative evaluation with UGI series and IS can increase healthcare costs without substantially altering care. The only patients potentially benefiting from routine UGI series were <1 year old. Instead, a targeted, symptom-based preoperative evaluation may streamline the process by decreasing preoperative testing and minimizing cost and radiation exposure.

Balloon-assisted Jejunostomy Placement

Jejunal feeding is indicated in patients with functional or physical abnormalities that prevent gastrostomy tube placement or feeding. J-tubes are most often placed using one of four techniques: Open surgical, laparoscopic, needle catheter, or direct percutaneous placement, depending on the patient needs and expertise of the surgeon. Minimally invasive techniques are considered standard of care, and thus, J-tube placement most often occurs through laparoscopic methods. While percutaneous insertion using balloon dilation rather than serial dilation has shown greater success rates, lower complication rates, and alleviates patient discomfort in G-tube placement, this procedure has not been utilized for J-tube placement. Here, we report a balloon-assisted jejunostomy placement technique utilized to replace a previous surgical jejunostomy tube that the cutaneous tract had healed over.