Goretsky M F, Johnson N, Farrell M, Ziegler M M
Division of Pediatric Surgery, Children's Hospital Medical Center, Cincinnati, OH 45229-3039 USA.
J Am Coll Surg. 1996 Mar;182(3):233-40.
In the era of managed care, the operative procedure applied to solve a given problem should vary with the status of the patient, the training and experience of the specialist, an analysis of morbidity and mortality rates, and a cost analysis of therapeutic alternatives. The purpose of this study was to critically analyze three different techniques for gastric feeding access in children.
A retrospective analysis of patients who underwent primary feeding gastrostomy was performed at our institution. Patients who underwent gastrostomy placement concurrently with another major procedure were excluded.
Over a 36-month period, 98 children underwent placement of a feeding gastrostomy by one of three alternative techniques: an open Stamm gastrostomy (Stamm, n=47), a pull-out percutaneous endoscopic gastrostomy (PEG, n=32), or an antegrade percutaneous fluoroscopically guided gastrostomy (PFGG, n=19). An open gastrostomy was performed more frequently in younger patients (average age, 49.7+/-11.9 months for PFGG). The sex distribution and indication for tube placement were similar in all groups (altered mental status: Stamm 43 percent, PEG 19 percent, and PFGG 38 percent; mechanical feeding difficulty: Stamm 66 percent, PEG 13 percent, and PFGG 21 percent; or failure to thrive Stamm 58 percent, PEG 17 percent, and PFGG 25 percent). Complications were most common in this high-risk patient population with PEG (19 percent), when compared with PFGG (16 percent) and Stamm (11 percent), although these were not statistically significant. Whereas reflux was frequent (Stamm 6 percent, PEG 9 percent, and PFGG 21 percent), only three patients in the entire series required a subsequent antireflux operation during the observation period. The three procedures were similar on hospital charge analysis (Stamm $1,316,29+/-63.33. PEG $1,130.04+/-94.88, and PFGG $1,079.83+/-109.12). When professional fees were included, the PFGG may be more economical than both the PEG and Stamm gastrostomy (Stamm $3,101.29+/-73/33. PEG $3,314.04+/-94.88, and PFGG $1,485.77+/-74.41, p<0.05). However, this may be misleading because the radiologist's fee was absorbed into the hospital charge is some cases, and therefore could not be fully accounted for in the total professional fee.
The data from our institution demonstrate that there is no significant difference in these three feeding-access techniques when comparing procedural cost-effectiveness, indications for tube placement, or morbidity rates. The choice of procedure should be individualized giving consideration to the overall health of the child, the comfort of the specialist peforming the given procedure, and the institutional experience.
在管理式医疗时代，用于解决特定问题的手术方法应根据患者状况、专科医生的培训与经验、发病率和死亡率分析以及治疗方案的成本分析而有所不同。本研究的目的是对三种不同的儿童胃造口术喂养方法进行批判性分析。
对在我们机构接受初次喂养胃造口术的患者进行回顾性分析。同时进行胃造口术与另一项主要手术的患者被排除。
在36个月期间，98名儿童通过以下三种替代技术之一接受了喂养胃造口术：开放式 Stamm 胃造口术（Stamm，n = 47）、拔出式经皮内镜胃造口术（PEG，n = 32）或顺行性经皮荧光镜引导胃造口术（PFGG，n = 19）。开放式胃造口术在较年轻患者中更常施行（PFGG的平均年龄为49.7±11.9个月）。所有组的性别分布和置管指征相似（精神状态改变：Stamm组43%，PEG组19%，PFGG组38%；机械性喂养困难：Stamm组66%，PEG组13%，PFGG组21%；或发育不良：Stamm组58%，PEG组17%，PFGG组25%）。与PFGG（16%）和Stamm（11%）相比，PEG在这一高风险患者群体中并发症最为常见（19%），尽管差异无统计学意义。反流很常见（Stamm组6%，PEG组9%，PFGG组21%），但在整个观察期内整个系列中只有3名患者需要后续抗反流手术。三种手术在住院费用分析方面相似（Stamm组1316.29±63.33美元，PEG组1130.04±94.88美元，PFGG组1079.83±109.12美元）。当计入专业费用时，PFGG可能比PEG和Stamm胃造口术更经济（Stamm组3101.29±73.33美元，PEG组3314.04±94.88美元，PFGG组1485.77±74.41美元，p<0.05）。然而，这可能会产生误导，因为在某些情况下放射科医生的费用已包含在住院费用中，因此在总专业费用中无法完全核算。
我们机构的数据表明，在比较手术成本效益、置管指征或发病率时，这三种喂养方法没有显著差异。手术选择应个体化，要考虑儿童的整体健康状况、实施特定手术的专科医生的舒适度以及机构经验。
