Declining Use and Shifting Drivers of Concurrent Fundoplication With Pediatric Gastrostomy

Abstract

Background: Studies have demonstrated practice variability in performing an antireflux procedure, concurrent fundoplication, at the time of gastrostomy tube (GT) placement. This study examines trends in sources of variation regarding the decision to perform a concurrent fundoplication versus GT alone.

Methods: This retrospective cohort study of children (0-17 years) who underwent GT placement with or without fundoplication from January 2013-December 2023 used the National Surgical Quality Improvement Program-Pediatric database. Variance component analysis quantified how much variability in treatment assignment was attributable to patient, surgeon, or hospital levels. Multivariate logistic regression identified associations between patient characteristics and the decision to perform concurrent fundoplication.

Results: Among 50 hospitals, rates of concurrent fundoplication with GT significantly decreased from 18.2 % (257/1411; CI 16.2-20.3 %) in 2014 to 2.2 % (57/2574; CI 1.7-2.9 %) in 2023. In 2018, non-patient-level variation accounted for 86 % of variance, and this declined to 49 % in 2023. On multivariate analysis, in 2018, patients with gastrointestinal disease (odds ratio [OR]: 7.21, confidence interval [CI]: 4.97-10.46) or structural pulmonary abnormalities (OR: 2.24, CI: 1.55-3.24) had higher odds of undergoing concurrent fundoplication or. In 2023, gastrointestinal disease remained associated with fundoplication (OR: 9.29, CI: 5.72-15.07) while patients with neurological impairment had lower odds of undergoing concurrent fundoplication (OR: 0.54, CI: 0.34-0.86).

Conclusions: The rate of concurrent fundoplication and the impact of non-clinical factors in the decision of whether to perform a concurrent fundoplication with GT has decreased over the past decade. Additionally, the specific patient factors associated with fundoplication have shifted over time, potentially reflecting evolving clinical judgment.

Keywords: Fundoplication; Gastrostomy tube; Variance component analysis.