A preoperative gastrointestinal optimization protocol to improve outcomes after intrathecal baclofen pump surgery 

A preoperative gastrointestinal optimization protocol to improve outcomes after intrathecal baclofen pump surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A preoperative gastrointestinal optimization protocol to improve outcomes after intrathecal baclofen pump surgery Amanda Mosher, Emma Hartman, Marcella Ruppert-Gomez, Steven Staffa, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5368309/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Mar, 2025 Read the published version in Child's Nervous System → Version 1 posted 7 You are reading this latest preprint version Abstract Purpose Pediatric Cerebral Palsy patients carry frequent medical comorbidities and disproportionately consume hospital resources after neurosurgical procedures. We implemented an institutional preoperative gastrointestinal (GI) optimization protocol to improve outcomes and decrease resource utilization. Methods All 323 intrathecal baclofen surgeries from 2000–2023 were categorized relative to protocol implementation on July 1st, 2017. Outcomes and resource utilization were compared. Results The protocol change resulted in significantly fewer hospital readmissions (p = 0.001) for constipation, eliminating them and GI-related emergency visits. There was a reduction of 27 hospital days for constipation-related readmission (median 1 day per patient, IQR: 1, 2 days). No differences were reported between the experimental groups including demographics or GI comorbidities. Post-operative complications within 30-days were comparable between groups regarding urinary tract infections, surgical-site infections, and spinal fluid leak. There were no differences in postoperative length of stay between groups. Conclusion A GI optimization protocol can eliminate a frequent source of hospital readmissions and GI-related emergency department visits after baclofen pump surgery, even accounting for baseline GI comorbidities. Preventing readmissions and emergency visits translates to lower hospital resource utilization and improves quality of care. Future efforts are warranted to improve outcomes and care efficiency for our most complex and resource-intensive patients. cerebral palsy constipation intrathecal baclofen pump GI optimization Introduction Cerebral Palsy (CP) is one of the most prevalent pediatric neurologic disorders, occurring in 2 to 3 out of 1000 births globally and imparting physical disability due to elevated tone and spasticity [ 1 – 3 ]. Up to 98.4% of patients with spastic CP have at least one medical comorbidity, with increased comorbidities occurring in patients with a Gross Motor Function Classification Scores of IV or V [ 4 , 5 ]. 4,5 Common gastrointestinal (GI) comorbidities include constipation, gastroesophageal reflux (GERD), malnutrition and dysphagia, with the most prevalent being constipation in as many as 90% of pediatric CP patients [ 6 , 7 ]. Intrathecal baclofen therapy remains one of few standard treatment options for CP patients with medically refractory tone. However, baclofen usage has also been associated with increased rates of constipation as a side effect [ 8 , 9 ]. Compared to the general population, pediatric CP patients have increased post-operative complications, longer length of stay (LOS) and readmissions, with similar reports in the adult literature [ 1 , 10 , 11 ]. These additional hospital days and higher likelihood of complications draw upon increasingly limited hospital resources and are costly for medical systems and families alike. Hospital spending and resource allocation, specifically for constipation related needs, is proportionally higher in patients with complex conditions [ 12 ]. Up to 70.9% of all inpatient constipation care was solely for these complex patients in one representative study [ 12 ]. An institutional GI optimization protocol was established in July of 2017 for prospective bowel management. A multi-disciplinary team provided families with peri-operative guidelines for this care with checkpoints pre-operatively, each day before discharge and within the two weeks post-surgery to ensure proper management. Gastrointestinal complications can considerably impact the quality of life of patients and caregivers of those with ITB therapy for CP. While previous literature has described the rate of constipation in pediatric CP patients as high as 90%, there has yet to be a standardized Enhanced Recovery After Surgery protocol to optimize these patients’ recovery after surgery [ 13 ]. The aim of our study is to understand the impact of our GI optimization protocol on patient outcomes and hospital resources. Materials and Methods A retrospective chart review comprising all patients who underwent baclofen pump insertion, revision, replacement, or removal for CP from 2000 until 2023 was conducted at Boston Children’s Hospital. The electronic medical records (EMR) of all patients were reviewed and 47 cases that did not have complete surgical records and at least one follow-up were excluded from this series. Demographic information, GI comorbidities, operative characteristics, abdominal radiographs, and post-operative findings were collected from the EMR. Patients were divided into two categories, the “pre-protocol” and the “post-protocol” cohorts. In July of 2017, the Baclofen Pump Program at Boston Children’s Hospital (BCH) implemented a pre-operative GI optimization protocol that starts when nurse practitioners on the team educate families undergoing baclofen pump procedures about post-operative constipation complications. A pre-operative phone call to the family identified their usual home laxative medication or dietary supplements and asked them to double their home routine starting three days before surgery. Patients followed this medication plan for three days before the procedure unless diarrhea resulted, in which case they returned to their regular routine. If bowel movement did not result before admission, an enema would be given in the hospital on the evening before surgery. Within the post operative hospital period, patients were required to stool prior to discharge. On the day of surgery, all home constipation medications were given through g-tube, even when lying supine. If the patient did not have a g-tube, laxatives were held for the first 24 hours until the patient could sit up to avoid aspiration during the flat bed rest period. On post-operative day 2, laxative treatment would increase if needed to include osmotic laxatives including polyethylene glycol 3350 or lactulose initially, but if still not stooling after these, stimulant laxatives (senna) were administered. Finally, an enema was given on post-operative day three if the constipation had not yet resolved. Patients maintained their increased laxative treatments for two weeks after their procedure. Pertinent demographic information including age, sex, race, and body mass index (BMI) as well as pre-operative characteristics such as GMFCS (Gross Motor Function Classification System), ASA grade, etiology of spasticity, and topographical distribution of spasticity were collected at the time of surgery. GI comorbidities including GERD, gastric and intestinal dysmotility, neurogenic bowel, gastritis, gastro-reflux, and constipation were collected along with g-tube and tracheostomy. Pre-operative constipation status was determined by whether a patient regularly took laxative medications. Procedure type as well as post-operative characteristics including total, floor, and intensive care unit LOS, post-operative constipation, radiographic stool burden, and post-operative complications were obtained. Post-operative constipation while in the hospital was defined by the need for an enema prior to discharge. Stool burden was classified as “mild, moderate, and severe” and was determined based on the radiology reports for routine post operative abdominal baclofen x-rays. Complications including spinal fluid leak, surgical site and urinary tract infection (UTI) within a 30-day post-operative window were included in our data extraction. Constipation-related phone calls to the baclofen pump nurse practitioner team, return to emergency department (ED), and readmission within a 30-day window were also recorded. This study was approved by the Boston Children’s Hospital Institutional Review Board (IRB). In accordance with the IRB approval and the retrospective nature of this study, individual patient consent was waived. Statistical Methods Continuous data are presented as median and interquartile range, and categorical data are presented as frequency and percentage. Denominators are presented for variables with missing data. The comparison of preoperative characteristics and postoperative outcomes the pre-protocol and post-protocol groups was performed using the nonparametric Wilcoxon rank sum test for continuous data, and the Chi-square test or Fisher’s exact test for categorical data. A multivariable logistic regression model was fit to explore the independent factors associated with the post-protocol group, with results presented as adjusted odds ratios with corresponding 95% confidence intervals (CI) and P values. Stata version 17.1 (StataCorp LLC, College Station, TX) was used for all statistical analyses. A two-tailed P < 0.05 was considered statistically significant. Results Demographic and Pre-operative Patient Characteristics (Table 1 ) Table 1 Preoperative characteristics Characteristics Pre-protocol n = 174 Post-protocol n = 149 P-Value Sex Male 111 (63.8%) 97 (65.1%) 0.807 Female 63 (36.2%) 52 (34.9%) Race White 119/173 (68.8%) 86 (57.7%) 0.132 African American/Black 13/173 (7.5%) 10 (6.7%) Hispanic 3/173 (1.7%) 3 (2%) Asian 6/173 (3.5%) 4 (2.7%) Other 32/173 (18.5%) 46 (30.9%) Age at Surgery (yr) 12.6 (7.6, 16.3) 15.3 (11.5, 20) < 0.001* BMI at Surgery 18 (15.9, 22.2) n = 139 21.9 (17.6, 28.3) n = 134 < 0.001* GMFCS 5 (4, 5) n = 167 5 (4, 5) n = 136 0.71 ASA I 0/170 (0%) 0/148 (0%) < 0.001* II 40/170 (23.5%) 12/148 (8.1%) III 124/170 (72.9%) 118/148 (79.7%) IV 6/170 (3.5%) 18/148 (12.2%) Etiology of Spasticity Prematurity 67 (38.5%) 49 (32.9%) 0.479 Stroke 9 (5.2%) 8 (5.4%) TBI 15 (8.6%) 11 (7.4%) Hypoxic Event 36 (20.7%) 27 (18.1%) Genetic 15 (8.6%) 20 (13.4%) Infection 6 (3.5%) 10 (6.7%) Unknown 20 (11.5%) 22 (14.8%) Other 6 (3.5%) 2 (1.3%) Topographical Distribution of Spasticity Dystonic 4 (2.3%) 5 (3.4%) 0.558 Diplegic 10 (5.8%) 7 (4.7%) Mixed 3 (1.7%) 7 (4.7%) Quadraplegic 152 (87.4%) 127 (85.2%) Hemiplegic, mono, triplegic 5 (2.9%) 3 (2%) GI Comorbidity 153 (87.9%) 135 (90.6%) 0.441 G-Tube Placed 112 (64.4%) 105 (70.5%) 0.244 Tracheostomy 13 (7.5%) 9 (6%) 0.663 Pre-operative Constipation 139 (79.9%) 137 (92%) 0.002* Abbreviations: BMI = Body mass index, GMFCS = Gross motor function classification system, ASA = American Society of Anesthesiologists Classification, TBI = Traumatic brain injury, GI = Gastrointestinal. Data are presented as n(%) or median (interquartile range). Denominators are presented for variables with missing data. P values were calculated using the Chi-square test, Fisher's exact test, or the Wilcoxon rank sum test. *Statistically significant. All 323 surgical procedures conducted at Boston Children’s Hospital between 2000 and 2023 fit our inclusion criteria. Of these, 174 cases were categorized as pre-protocol, having occurred before July 1st, 2017, and 149 were characterized as post-protocol. Across the series, 64.4% of the patients were male (n = 208). 63.5% of participants were white (n = 205) followed by 7.1% black (n = 23), 3.1% Asian (n = 10), 1.9% Hispanic (n = 6), and 24.1% grouped as other or unknown (n = 78). There were no significant differences in sex or race between pre- and post-protocol groups. Patients in the post-protocol cohort were significantly older, with a median age at surgery of 15.3 years (IQR: 11.5, 20 years) compared to pre-protocol, with a median of 12.3 years of age (IQR: 7.6, 16.3 years) (p < 0.001). Post-protocol patients also had a higher BMI than those of the pre-protocol group (post-protocol: 21.9 versus pre-protocol: 18, p < 0.001). There was no significant difference in GMFCS with the median score of 5 for both groups (IQR: 4, 5), nor in topographic distribution of spasticity, with most patients having spastic quadriplegia in both cohorts. Those in the post-protocol group had a higher ASA score compared to the pre-protocol group (p < 0.001). There was no difference in GI comorbidity between pre- and post-protocol groups (87.9% versus 90.6%, p = 0.441). Pre- and post-protocol cohorts were comparable in g-tube and tracheostomy placement with 67.2% of all patients in this series having a g-tube and 6.8% with tracheostomy at the time of surgery. The post-protocol group had significantly higher rates of constipation before surgery (post-protocol: 92% versus pre-protocol: 79.9%, p = 0.002). Operative and Short-term Postoperative Characteristics (Table ) Table 2 Postoperative outcomes Abbreviations: ICU = Intensive care unit, UTI = Urinary tract infection, CSF = Cerebrospinal fluid, ED = Emergency department. Data are presented as n(%) or median (interquartile range). Denominators are presented for variables with missing data. P values were calculated using the Chi-square test, Fisher's exact test, or the Wilcoxon rank sum test. *Statistically significant. Characteristics Pre-protocol n = 174 Post-protocol n = 149 P-Value Procedure type Insertion 114 (65.5%) 58 (38.9%) < 0.001* Revision/replacement 52 (29.9%) 78 (52.4%) Removal 8 (4.6%) 13 (8.7%) Length of stay (total) 4 (2, 6) n = 171 4 (2, 6) n = 148 0.612 Length of stay (ICU) 0 (0, 1) n = 159 0 (0, 2) n = 146 0.241 Length of stay (floor) 3 (2, 5) n = 154 3 (2, 5) n = 145 0.173 Post-operative constipation 114/168 (67.9%) 85/148 (57.4%) 0.055 Stool burden on post-op imaging Mild 66/119 (55.5%) 70/123 (56.9%) 0.244 Moderate 40/119 (33.6%) 32/123 (26%) Severe 13/119 (10.9%) 21/123 (17.1%) Postoperative complications within 30-days Constipation phone call 13 (7.5%) 8 (5.4%) 0.503 Post-operative UTI 4 (2.3%) 5 (3.4%) 0.738 Post-operative CSF Leak 6 (3.5%) 3 (2%) 0.514 Return to ED for Constipation 3 (1.7%) 0 (0%) 0.252 Readmission for Constipation 14 (8.1%) 0 (0%) < 0.001* Readmission for Other 36 (20.7%) 32 (21.5%) 0.863 There was a significant difference in procedure type between the two groups (p < 0.001) with many baclofen pump index insertion procedures in the pre-protocol group (65.5%, n = 114), while the most common procedures in the post-protocol group were revisions or replacements (52.4%, n = 78) with significant difference in procedure type between the two groups (p < 0.001). The total length of hospital stay was a median of 4 days (IQR: 2, 6 both groups), 0 days in the ICU (IQR, pre-protocol: 0, 1 versus post-protocol: 0, 2) and 3 days on the floor (IQR: 2, 5 both groups) without a difference between groups. Notably the pre-protocol group trended towards significance in having more post-operative constipation when compared to the post-protocol group (p = 0.055). Post-operative radiographic imaging showed no difference in stool burden between cohorts, with over half of reports stating a mild stool burden. Postoperative Outcomes (Table ) While uncommon, there were nine total urinary tract infections in the first 30-days after surgery, four of which were pre-protocol and five post-protocol. There were nine patients with spinal fluid leak across the series, six pre-protocol and three post-protocol groups. Statistically, there was no difference in UTI or spinal fluid leak nor in hospital readmission for reasons aside from constipation amongst the two cohorts. There was a surgical site infection rate of 5.9% in this series, with no significant difference between groups (pre-protocol: n = 6 versus post-protocol: n = 13, p = 0.057). Regarding constipation related complications, there were no significant differences in post-operative phone calls made with specific concerns of constipation nor in return to the ED between the cohorts. However, there were no return to ED visits in the post-protocol group (0%, n = 0). In terms of readmission for constipation, the post-protocol group was not only significantly less likely to be readmitted for constipation related concerns or workup but had eliminated readmissions for constipation completely (p < 0.001). Patients in the pre-protocol group readmitted for a constipation workup had a median LOS of 1 day (IQR: 1, 2 days) and 27 total hospital days (about 4 weeks) amongst the group. Multivariable regression of Post-protocol Revision Status (Table 3 ) Table 3 Multivariable Logistic Regression Analysis of Post-Protocol Covariate Adjusted Odds Ratio (95% CI) P value Age at Surgery (yr) 1.05 (0.99, 1.11) 0.116 BMI at Surgery 1.02 (0.99, 1.05) 0.223 ASA II Reference III 2.91 (1.33, 6.36) 0.007* IV 7.78 (2.29, 26.4) 0.001* Pre-operative Constipation 1.53 (0.68, 3.47) 0.307 Procedure type Insertion Reference Revision/replacement 2.69 (1.46, 4.94) 0.001* Removal 2.09 (0.7, 6.25) 0.189 Readmission for Constipation within 30 days Cannot calculate due to 0 patients post-protocol with readmission for constipation Abbreviations: BMI = Body Mass Index, ASA = American Society of Anesthesiologists Classification. P-values were calculated using a multivariable logistic regression model. *Statistically significant. In a univariate analysis, characteristics including age, BMI, ASA status, preoperative constipation, procedure type and post-operative constipation were all significantly different amongst groups. When adjusting for all variables in a multivariable analysis, higher ASA and revision/replacement procedure type versus insertion are independently associated with the post-protocol group. Post-procedure readmission constipation was unable to be calculated on a multivariable model as there were no patients with post-operative readmission for constipation in the post-protocol group. Discussion Our study conducted a review of 323 baclofen pump procedures at Boston Children’s Hospital to understand how a GI optimization protocol impacts postoperative outcomes and associated hospital resources. This series found that both pre- and post-protocol groups had comparable GI-related comorbidities preoperatively, and even with significantly more preoperative constipation, the post-protocol group had eliminated the need for return to ED and readmission to the hospital within 30-days postoperative for constipation-related comorbidities. In terms of hospital resources, the post-protocol group totaled 27 fewer hospital days due to constipation related readmission. Additionally, the emergency department is an incredibly valuable resource in a hospital system and is increasingly at or above capacity in both adult and pediatric facilities [ 14 – 16 ]. Employing preoperative measures to reduce the likelihood of patients returning to the emergency department is key in decompressing ED volume and improving the opportunities to care for additional patients. Although gastrointestinal dysfunction is known to be a major challenge for CP patients, few studies have focused on treatment options to improve quality of life measures for these patients. A literature review conducted by Vande Velde et. al in 2018 reported only seven studies that reported on treatment options and concluded that stages of treatment should begin with fiber intake to improve gut motility, followed by osmotic and stimulant laxatives for constipation, and finally treating with enema if necessary[ 17 ]. Patients undergoing intrathecal baclofen therapy are expected to have particularly decreased motility during their postoperative recovery and as seen in our series, can benefit from incorporating a proactive regimen while preparing for their procedure. A similar bowel management strategy for pediatric patients was reported by Bokova et. al that included patients in their series with functional constipation[ 18 ]. In this study, a one-week program conducted by a multi-disciplinary team that incorporated an antegrade enema was found to reduce emergency department visits and hospital readmissions for their patients. While Bokova et. al reports on a different patient population, the similar management strategies and hospital resource outcomes support the idea that minor changes in bowel regimen can have impactful results. No studies to our knowledge have reported on constipation treatment in surgical CP patients to manage postoperative complications prior to our series. As part of an institutional standard of care, all patients with ITB procedures undergo a post-operative abdominal x-ray to assess the new hardware baseline. In a quality improvement study conducted by McSweeney et. al, researchers found that after decreasing the use of abdominal radiographs in an outpatient setting, patient outcomes did not change and a marked decrease in hospital costs resulted[ 19 ]. 19 Similar results have been shown for pediatric patients in an emergency setting [ 20 , 21 ]. In our series, we found that this imaging was not significantly different between pre- and post-protocol groups even though rates of postoperative constipation were significantly different amongst groups. The lack of standardized radiographic scales for constipation may also have limited assessment. As this series is retrospective by nature, the data collected were limited to what was found within the EMR. Secondly, there is no consistent way of reporting bowel patterns or metrics in abdominal x-ray notes at this institution, and future research may benefit from this addition. Finally, index insertion procedures were more common in the pre-protocol group which may have created slight differences in the surgical time and amount of anesthesia needed between groups. This is apparent in a multivariable analysis with the ASA grade and procedure type being different amongst groups. Additional baseline characteristics were different between groups such as age and BMI, which can be attributed to patients getting older and growing as the patient population matured over the study. Future prospective studies across multiple institutions would be valuable in solidifying the associations between this protocol change and postoperative outcomes. Conclusion Pediatric CP patients have complex medical needs and require substantial hospital resources. This study revealed that a straightforward preoperative GI optimization protocol can significantly reduce or eliminate GI-related emergency visits and readmissions after baclofen pump surgeries. These efforts can improve the quality of patient care and lower hospital resource utilization. Efforts to improve the outcomes of CP patients and the efficiency of their care are needed after surgical interventions, and future studies in this regard are warranted. Declarations Author Contribution WN, SM, KB, and AM contributed to conception and design. AM, EH and MRG contributed to acquisition of data. SS, AM, EH, MRG contributed to the analysis and interpretation of data. SS conducted statistical analysis. AM, EH, MRG, WN drafted manuscript. All authors critically reviewed the manuscript. WN approved final manuscript on behalf of all authors. Acknowledgement The authors would like to thank Dylan Keusch for his support in data collection for this patient series, and the Kids@Heart Organization for their support of Cerebral Palsy research. Data Availability Statement: The datasets generated during and/or analyzed during the current study are not publicly available due to patient privacy reasons. Author Disclosures: The authors have no competing interests, funding sources, or financial benefits to disclose. Previous Presentations: An abstract on this work was presented in June 2024 to the New England Neurosurgical Society. References Skertich NJ, Ingram MCE, Sullivan GA, Grunvald M, Ritz E, Shah AN (2022) Postoperative complications in pediatric patients with cerebral palsy. J Pediatr Surg 1(3):424–429 Oskoui M, Coutinho F, Dykeman J, Jetté N, Pringsheim T (2013) An update on the prevalence of cerebral palsy: a systematic review and meta-analysis. Dev Med Child Neurol 55(6):509–519. 10.1111/dmcn.12080 K NB ND, A G LSDC (2016) Birth Prevalence of Cerebral Palsy: A Population-Based Study. Pediatrics 1(1):e20152872 Hollung SJ, Bakken IJ, Vik T, Lydersen S, Wiik R, Aaberg KM (2020) Comorbidities in cerebral palsy: a patient registry study. Dev Med Child Neurol 62(1):97–103 Shevell MI, Dagenais L, Hall N (2009) Comorbidities in cerebral palsy and their relationship to neurologic subtype and GMFCS level. Neurology 16(24):2090–2096 Quitadamo P, Thapar N, Staiano A, Borrelli O (2016) Gastrointestinal and nutritional problems in neurologically impaired children. Eur J Paediatr Neurol 1(6):810–815 The effect of different dietary structure on gastrointestinal dysfunction in children with cerebral palsy and epilepsy based on gut microbiota - ClinicalKey [Internet. https://www-clinicalkey-com.ezp-prod1.hul.harvard.edu/#!/content/playContent/1-s2.0-S038776042030276X?scrollTo=%23b0010 Patti F, Pappalardo A, Lo Fermo S, Cimino V, Castiglione A, Zappia M (2008) Life-Threatening Constipation Induced by Intrathecal Baclofen Therapy. 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JAMA Surg 1(3):292–298 Adriani L, Dall’Oglio I, Brusco C, Gawronski O, Piga S, Reale A (2022) Reduction of Waiting Times and Patients Leaving Without Being Seen in the Tertiary Pediatric Emergency Department: A Comparative Observational Study. Pediatr Emerg Care May; 38(5):219 Phillips JL, Jackson BE, Fagan EL, Arze SE, Major B, Zenarosa NR (2017) Overcrowding and Its Association With Patient Outcomes in a Median-Low Volume Emergency Department. J Clin Med Res (v; 9(11):911–916 Sartini M, Carbone A, Demartini A, Giribone L, Oliva M, Spagnolo AM (2022) Overcrowding in Emergency Department: Causes, Consequences, and Solutions—A Narrative Review. Healthc Basel Aug 25(9):1625 S VV, K R, M W, R B, S B. Constipation and fecal incontinence in children with cerebral palsy. Overview of literature and flowchart for a stepwise approach [Internet. https://www.ageb.be/ageb-journal/previous-issues/ageb-volume/ageb-type/ageb-article/ Bokova E, Svetanoff WJ, Levitt MA, Rentea RM (2023) Pediatric Bowel Management Options and Organizational Aspects. Child Basel 28(4):633 McSweeney ME, Chan Yuen J, Meleedy-Rey P, Day K, Nurko S (2022) A Quality Improvement Initiative to Reduce Abdominal X-ray use in Pediatric Patients Presenting with Constipation. J Pediatr 251:127–133 Freedman SB, Thull-Freedman J, Rumantir M, Eltorki M, Schuh S (2014) Pediatric constipation in the emergency department: evaluation, treatment, and outcomes. J Pediatr Gastroenterol Nutr Sep; 59(3):327–333 Moriel G, Tran T, Pham PK, Liberman DB (2020) Reducing Abdominal Radiographs to Diagnose Constipation in the Pediatric Emergency Department. J Pediatr 225:109–116 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Mar, 2025 Read the published version in Child's Nervous System → Version 1 posted Editorial decision: Revision requested 18 Feb, 2025 Reviews received at journal 15 Feb, 2025 Reviewers agreed at journal 06 Feb, 2025 Reviewers invited by journal 05 Dec, 2024 Editor assigned by journal 01 Nov, 2024 Submission checks completed at journal 01 Nov, 2024 First submitted to journal 31 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5368309","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":372851919,"identity":"54f81793-4bf3-4617-b4f7-75e70016f58e","order_by":0,"name":"Amanda Mosher","email":"","orcid":"","institution":"Boston Children's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Amanda","middleName":"","lastName":"Mosher","suffix":""},{"id":372851920,"identity":"5d2c6ed5-7854-4b6a-b28a-9f010b5572ab","order_by":1,"name":"Emma Hartman","email":"","orcid":"","institution":"Boston Children's 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Hospital","correspondingAuthor":false,"prefix":"","firstName":"Scellig","middleName":"","lastName":"Stone","suffix":""},{"id":372851927,"identity":"5249e134-bc1c-42bf-a292-570ff36cc404","order_by":8,"name":"Weston Northam","email":"data:image/png;base64,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","orcid":"","institution":"Boston Children's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Weston","middleName":"","lastName":"Northam","suffix":""}],"badges":[],"createdAt":"2024-10-31 16:53:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5368309/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5368309/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00381-025-06797-2","type":"published","date":"2025-03-24T15:57:20+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79604843,"identity":"7ca30dda-1b04-4cad-ba7f-36a75b96bbdc","added_by":"auto","created_at":"2025-03-31 16:07:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":961078,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5368309/v1/be6a4193-5cce-4955-97c1-85a322625d48.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A preoperative gastrointestinal optimization protocol to improve outcomes after intrathecal baclofen pump surgery ","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCerebral Palsy (CP) is one of the most prevalent pediatric neurologic disorders, occurring in 2 to 3 out of 1000 births globally and imparting physical disability due to elevated tone and spasticity [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Up to 98.4% of patients with spastic CP have at least one medical comorbidity, with increased comorbidities occurring in patients with a Gross Motor Function Classification Scores of IV or V [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003csup\u003e4,5\u003c/sup\u003e Common gastrointestinal (GI) comorbidities include constipation, gastroesophageal reflux (GERD), malnutrition and dysphagia, with the most prevalent being constipation in as many as 90% of pediatric CP patients [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIntrathecal baclofen therapy remains one of few standard treatment options for CP patients with medically refractory tone. However, baclofen usage has also been associated with increased rates of constipation as a side effect [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Compared to the general population, pediatric CP patients have increased post-operative complications, longer length of stay (LOS) and readmissions, with similar reports in the adult literature [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. These additional hospital days and higher likelihood of complications draw upon increasingly limited hospital resources and are costly for medical systems and families alike. Hospital spending and resource allocation, specifically for constipation related needs, is proportionally higher in patients with complex conditions [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Up to 70.9% of all inpatient constipation care was solely for these complex patients in one representative study [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAn institutional GI optimization protocol was established in July of 2017 for prospective bowel management. A multi-disciplinary team provided families with peri-operative guidelines for this care with checkpoints pre-operatively, each day before discharge and within the two weeks post-surgery to ensure proper management.\u003c/p\u003e \u003cp\u003eGastrointestinal complications can considerably impact the quality of life of patients and caregivers of those with ITB therapy for CP. While previous literature has described the rate of constipation in pediatric CP patients as high as 90%, there has yet to be a standardized Enhanced Recovery After Surgery protocol to optimize these patients\u0026rsquo; recovery after surgery [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The aim of our study is to understand the impact of our GI optimization protocol on patient outcomes and hospital resources.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eA retrospective chart review comprising all patients who underwent baclofen pump insertion, revision, replacement, or removal for CP from 2000 until 2023 was conducted at Boston Children\u0026rsquo;s Hospital. The electronic medical records (EMR) of all patients were reviewed and 47 cases that did not have complete surgical records and at least one follow-up were excluded from this series. Demographic information, GI comorbidities, operative characteristics, abdominal radiographs, and post-operative findings were collected from the EMR.\u003c/p\u003e \u003cp\u003ePatients were divided into two categories, the \u0026ldquo;pre-protocol\u0026rdquo; and the \u0026ldquo;post-protocol\u0026rdquo; cohorts. In July of 2017, the Baclofen Pump Program at Boston Children\u0026rsquo;s Hospital (BCH) implemented a pre-operative GI optimization protocol that starts when nurse practitioners on the team educate families undergoing baclofen pump procedures about post-operative constipation complications. A pre-operative phone call to the family identified their usual home laxative medication or dietary supplements and asked them to double their home routine starting three days before surgery. Patients followed this medication plan for three days before the procedure unless diarrhea resulted, in which case they returned to their regular routine. If bowel movement did not result before admission, an enema would be given in the hospital on the evening before surgery.\u003c/p\u003e \u003cp\u003eWithin the post operative hospital period, patients were required to stool prior to discharge. On the day of surgery, all home constipation medications were given through g-tube, even when lying supine. If the patient did not have a g-tube, laxatives were held for the first 24 hours until the patient could sit up to avoid aspiration during the flat bed rest period. On post-operative day 2, laxative treatment would increase if needed to include osmotic laxatives including polyethylene glycol 3350 or lactulose initially, but if still not stooling after these, stimulant laxatives (senna) were administered. Finally, an enema was given on post-operative day three if the constipation had not yet resolved. Patients maintained their increased laxative treatments for two weeks after their procedure.\u003c/p\u003e \u003cp\u003ePertinent demographic information including age, sex, race, and body mass index (BMI) as well as pre-operative characteristics such as GMFCS (Gross Motor Function Classification System), ASA grade, etiology of spasticity, and topographical distribution of spasticity were collected at the time of surgery. GI comorbidities including GERD, gastric and intestinal dysmotility, neurogenic bowel, gastritis, gastro-reflux, and constipation were collected along with g-tube and tracheostomy. Pre-operative constipation status was determined by whether a patient regularly took laxative medications.\u003c/p\u003e \u003cp\u003eProcedure type as well as post-operative characteristics including total, floor, and intensive care unit LOS, post-operative constipation, radiographic stool burden, and post-operative complications were obtained. Post-operative constipation while in the hospital was defined by the need for an enema prior to discharge. Stool burden was classified as \u0026ldquo;mild, moderate, and severe\u0026rdquo; and was determined based on the radiology reports for routine post operative abdominal baclofen x-rays. Complications including spinal fluid leak, surgical site and urinary tract infection (UTI) within a 30-day post-operative window were included in our data extraction. Constipation-related phone calls to the baclofen pump nurse practitioner team, return to emergency department (ED), and readmission within a 30-day window were also recorded.\u003c/p\u003e \u003cp\u003eThis study was approved by the Boston Children\u0026rsquo;s Hospital Institutional Review Board (IRB). In accordance with the IRB approval and the retrospective nature of this study, individual patient consent was waived.\u003c/p\u003e \u003cp\u003eStatistical Methods\u003c/p\u003e \u003cp\u003eContinuous data are presented as median and interquartile range, and categorical data are presented as frequency and percentage. Denominators are presented for variables with missing data. The comparison of preoperative characteristics and postoperative outcomes the pre-protocol and post-protocol groups was performed using the nonparametric Wilcoxon rank sum test for continuous data, and the Chi-square test or Fisher\u0026rsquo;s exact test for categorical data. A multivariable logistic regression model was fit to explore the independent factors associated with the post-protocol group, with results presented as adjusted odds ratios with corresponding 95% confidence intervals (CI) and P values. Stata version 17.1 (StataCorp LLC, College Station, TX) was used for all statistical analyses. A two-tailed P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDemographic and Pre-operative Patient Characteristics (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreoperative characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-protocol\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;174\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-protocol\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;149\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111 (63.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97 (65.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.807\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63 (36.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 (34.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119/173 (68.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (57.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.132\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfrican American/Black\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13/173 (7.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3/173 (1.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6/173 (3.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (2.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32/173 (18.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (30.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge at Surgery (yr)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.6 (7.6, 16.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.3 (11.5, 20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI at Surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (15.9, 22.2)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.9 (17.6, 28.3)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGMFCS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (4, 5)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (4, 5)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0/170 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0/148 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40/170 (23.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12/148 (8.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e124/170 (72.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e118/148 (79.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6/170 (3.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18/148 (12.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEtiology of Spasticity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrematurity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67 (38.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 (32.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e0.479\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (5.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTBI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (8.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypoxic Event\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (20.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (18.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGenetic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (8.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (13.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (3.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (11.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (14.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (3.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTopographical Distribution of Spasticity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDystonic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.558\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiplegic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (5.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (4.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMixed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (4.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuadraplegic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e152 (87.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e127 (85.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemiplegic, mono, triplegic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (2.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGI Comorbidity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e153 (87.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e135 (90.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.441\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eG-Tube Placed\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e112 (64.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105 (70.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.244\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTracheostomy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (7.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.663\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePre-operative Constipation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e139 (79.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e137 (92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eAbbreviations: BMI\u0026thinsp;=\u0026thinsp;Body mass index, GMFCS\u0026thinsp;=\u0026thinsp;Gross motor function classification system, ASA\u0026thinsp;=\u0026thinsp;American Society of Anesthesiologists Classification, TBI\u0026thinsp;=\u0026thinsp;Traumatic brain injury, GI\u0026thinsp;=\u0026thinsp;Gastrointestinal. Data are presented as n(%) or median (interquartile range). Denominators are presented for variables with missing data. P values were calculated using the Chi-square test, Fisher's exact test, or the Wilcoxon rank sum test. *Statistically significant.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAll 323 surgical procedures conducted at Boston Children\u0026rsquo;s Hospital between 2000 and 2023 fit our inclusion criteria. Of these, 174 cases were categorized as pre-protocol, having occurred before July 1st, 2017, and 149 were characterized as post-protocol. Across the series, 64.4% of the patients were male (n\u0026thinsp;=\u0026thinsp;208). 63.5% of participants were white (n\u0026thinsp;=\u0026thinsp;205) followed by 7.1% black (n\u0026thinsp;=\u0026thinsp;23), 3.1% Asian (n\u0026thinsp;=\u0026thinsp;10), 1.9% Hispanic (n\u0026thinsp;=\u0026thinsp;6), and 24.1% grouped as other or unknown (n\u0026thinsp;=\u0026thinsp;78). There were no significant differences in sex or race between pre- and post-protocol groups. Patients in the post-protocol cohort were significantly older, with a median age at surgery of 15.3 years (IQR: 11.5, 20 years) compared to pre-protocol, with a median of 12.3 years of age (IQR: 7.6, 16.3 years) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Post-protocol patients also had a higher BMI than those of the pre-protocol group (post-protocol: 21.9 versus pre-protocol: 18, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There was no significant difference in GMFCS with the median score of 5 for both groups (IQR: 4, 5), nor in topographic distribution of spasticity, with most patients having spastic quadriplegia in both cohorts. Those in the post-protocol group had a higher ASA score compared to the pre-protocol group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eThere was no difference in GI comorbidity between pre- and post-protocol groups (87.9% versus 90.6%, p\u0026thinsp;=\u0026thinsp;0.441). Pre- and post-protocol cohorts were comparable in g-tube and tracheostomy placement with 67.2% of all patients in this series having a g-tube and 6.8% with tracheostomy at the time of surgery. The post-protocol group had significantly higher rates of constipation before surgery (post-protocol: 92% versus pre-protocol: 79.9%, p\u0026thinsp;=\u0026thinsp;0.002).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOperative and Short-term Postoperative Characteristics (Table )\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative outcomes Abbreviations: ICU\u0026thinsp;=\u0026thinsp;Intensive care unit, UTI\u0026thinsp;=\u0026thinsp;Urinary tract infection, CSF\u0026thinsp;=\u0026thinsp;Cerebrospinal fluid, ED\u0026thinsp;=\u0026thinsp;Emergency department. Data are presented as n(%) or median (interquartile range). Denominators are presented for variables with missing data. P values were calculated using the Chi-square test, Fisher's exact test, or the Wilcoxon rank sum test. *Statistically significant.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-protocol\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;174\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-protocol\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;149\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProcedure type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInsertion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114 (65.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (38.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRevision/replacement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (29.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (52.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRemoval\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (4.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (8.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLength of stay (total)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2, 6)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;171\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (2, 6)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.612\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLength of stay (ICU)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0, 1)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0, 2)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.241\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLength of stay (floor)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2, 5)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2, 5)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.173\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost-operative constipation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114/168 (67.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85/148 (57.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.055\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStool burden on post-op imaging\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66/119 (55.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70/123 (56.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.244\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40/119 (33.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32/123 (26%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13/119 (10.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21/123 (17.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePostoperative complications within 30-days\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstipation phone call\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (7.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.503\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-operative UTI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.738\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-operative CSF Leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (3.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.514\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReturn to ED for Constipation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.252\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReadmission for Constipation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (8.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReadmission for Other\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (20.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (21.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.863\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThere was a significant difference in procedure type between the two groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) with many baclofen pump index insertion procedures in the pre-protocol group (65.5%, n\u0026thinsp;=\u0026thinsp;114), while the most common procedures in the post-protocol group were revisions or replacements (52.4%, n\u0026thinsp;=\u0026thinsp;78) with significant difference in procedure type between the two groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The total length of hospital stay was a median of 4 days (IQR: 2, 6 both groups), 0 days in the ICU (IQR, pre-protocol: 0, 1 versus post-protocol: 0, 2) and 3 days on the floor (IQR: 2, 5 both groups) without a difference between groups.\u003c/p\u003e \u003cp\u003eNotably the pre-protocol group trended towards significance in having more post-operative constipation when compared to the post-protocol group (p\u0026thinsp;=\u0026thinsp;0.055). Post-operative radiographic imaging showed no difference in stool burden between cohorts, with over half of reports stating a mild stool burden.\u003c/p\u003e\n\u003ch3\u003ePostoperative Outcomes (Table )\u003c/h3\u003e\n\u003cp\u003eWhile uncommon, there were nine total urinary tract infections in the first 30-days after surgery, four of which were pre-protocol and five post-protocol. There were nine patients with spinal fluid leak across the series, six pre-protocol and three post-protocol groups. Statistically, there was no difference in UTI or spinal fluid leak nor in hospital readmission for reasons aside from constipation amongst the two cohorts. There was a surgical site infection rate of 5.9% in this series, with no significant difference between groups (pre-protocol: n\u0026thinsp;=\u0026thinsp;6 versus post-protocol: n\u0026thinsp;=\u0026thinsp;13, p\u0026thinsp;=\u0026thinsp;0.057).\u003c/p\u003e \u003cp\u003eRegarding constipation related complications, there were no significant differences in post-operative phone calls made with specific concerns of constipation nor in return to the ED between the cohorts. However, there were no return to ED visits in the post-protocol group (0%, n\u0026thinsp;=\u0026thinsp;0). In terms of readmission for constipation, the post-protocol group was not only significantly less likely to be readmitted for constipation related concerns or workup but had eliminated readmissions for constipation completely (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Patients in the pre-protocol group readmitted for a constipation workup had a median LOS of 1 day (IQR: 1, 2 days) and 27 total hospital days (about 4 weeks) amongst the group.\u003c/p\u003e \u003cp\u003e \u003cem\u003eMultivariable regression of Post-protocol Revision Status\u003c/em\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariable Logistic Regression Analysis of Post-Protocol\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCovariate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdjusted Odds Ratio (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge at Surgery (yr)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.05 (0.99, 1.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.116\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI at Surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.02 (0.99, 1.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.223\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.91 (1.33, 6.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.007*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.78 (2.29, 26.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePre-operative Constipation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.53 (0.68, 3.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.307\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProcedure type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInsertion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRevision/replacement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.69 (1.46, 4.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRemoval\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.09 (0.7, 6.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.189\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReadmission for Constipation within 30 days\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCannot calculate due to 0 patients post-protocol with readmission for constipation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eAbbreviations: BMI\u0026thinsp;=\u0026thinsp;Body Mass Index, ASA\u0026thinsp;=\u0026thinsp;American Society of Anesthesiologists Classification. P-values were calculated using a multivariable logistic regression model. *Statistically significant.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn a univariate analysis, characteristics including age, BMI, ASA status, preoperative constipation, procedure type and post-operative constipation were all significantly different amongst groups. When adjusting for all variables in a multivariable analysis, higher ASA and revision/replacement procedure type versus insertion are independently associated with the post-protocol group. Post-procedure readmission constipation was unable to be calculated on a multivariable model as there were no patients with post-operative readmission for constipation in the post-protocol group.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study conducted a review of 323 baclofen pump procedures at Boston Children\u0026rsquo;s Hospital to understand how a GI optimization protocol impacts postoperative outcomes and associated hospital resources. This series found that both pre- and post-protocol groups had comparable GI-related comorbidities preoperatively, and even with significantly more preoperative constipation, the post-protocol group had eliminated the need for return to ED and readmission to the hospital within 30-days postoperative for constipation-related comorbidities. In terms of hospital resources, the post-protocol group totaled 27 fewer hospital days due to constipation related readmission. Additionally, the emergency department is an incredibly valuable resource in a hospital system and is increasingly at or above capacity in both adult and pediatric facilities [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Employing preoperative measures to reduce the likelihood of patients returning to the emergency department is key in decompressing ED volume and improving the opportunities to care for additional patients.\u003c/p\u003e \u003cp\u003eAlthough gastrointestinal dysfunction is known to be a major challenge for CP patients, few studies have focused on treatment options to improve quality of life measures for these patients. A literature review conducted by Vande Velde et. al in 2018 reported only seven studies that reported on treatment options and concluded that stages of treatment should begin with fiber intake to improve gut motility, followed by osmotic and stimulant laxatives for constipation, and finally treating with enema if necessary[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Patients undergoing intrathecal baclofen therapy are expected to have particularly decreased motility during their postoperative recovery and as seen in our series, can benefit from incorporating a proactive regimen while preparing for their procedure.\u003c/p\u003e \u003cp\u003eA similar bowel management strategy for pediatric patients was reported by Bokova et. al that included patients in their series with functional constipation[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In this study, a one-week program conducted by a multi-disciplinary team that incorporated an antegrade enema was found to reduce emergency department visits and hospital readmissions for their patients. While Bokova et. al reports on a different patient population, the similar management strategies and hospital resource outcomes support the idea that minor changes in bowel regimen can have impactful results. No studies to our knowledge have reported on constipation treatment in surgical CP patients to manage postoperative complications prior to our series.\u003c/p\u003e \u003cp\u003eAs part of an institutional standard of care, all patients with ITB procedures undergo a post-operative abdominal x-ray to assess the new hardware baseline. In a quality improvement study conducted by McSweeney et. al, researchers found that after decreasing the use of abdominal radiographs in an outpatient setting, patient outcomes did not change and a marked decrease in hospital costs resulted[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003csup\u003e19\u003c/sup\u003e Similar results have been shown for pediatric patients in an emergency setting [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In our series, we found that this imaging was not significantly different between pre- and post-protocol groups even though rates of postoperative constipation were significantly different amongst groups. The lack of standardized radiographic scales for constipation may also have limited assessment. As this series is retrospective by nature, the data collected were limited to what was found within the EMR. Secondly, there is no consistent way of reporting bowel patterns or metrics in abdominal x-ray notes at this institution, and future research may benefit from this addition. Finally, index insertion procedures were more common in the pre-protocol group which may have created slight differences in the surgical time and amount of anesthesia needed between groups. This is apparent in a multivariable analysis with the ASA grade and procedure type being different amongst groups. Additional baseline characteristics were different between groups such as age and BMI, which can be attributed to patients getting older and growing as the patient population matured over the study. Future prospective studies across multiple institutions would be valuable in solidifying the associations between this protocol change and postoperative outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePediatric CP patients have complex medical needs and require substantial hospital resources. This study revealed that a straightforward preoperative GI optimization protocol can significantly reduce or eliminate GI-related emergency visits and readmissions after baclofen pump surgeries. These efforts can improve the quality of patient care and lower hospital resource utilization. Efforts to improve the outcomes of CP patients and the efficiency of their care are needed after surgical interventions, and future studies in this regard are warranted.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eWN, SM, KB, and AM contributed to conception and design. AM, EH and MRG contributed to acquisition of data. SS, AM, EH, MRG contributed to the analysis and interpretation of data. SS conducted statistical analysis. AM, EH, MRG, WN drafted manuscript. All authors critically reviewed the manuscript. WN approved final manuscript on behalf of all authors.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank Dylan Keusch for his support in data collection for this patient series, and the Kids@Heart Organization for their support of Cerebral Palsy research.\u003c/p\u003e\u003ch2\u003eData Availability Statement:\u003c/h2\u003e \u003cp\u003eThe datasets generated during and/or analyzed during the current study are not publicly available due to patient privacy reasons.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAuthor Disclosures:\u003c/strong\u003e The authors have no competing interests, funding sources, or financial benefits to disclose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrevious Presentations:\u003c/strong\u003e An abstract on this work was presented in June 2024 to the New England Neurosurgical Society.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSkertich NJ, Ingram MCE, Sullivan GA, Grunvald M, Ritz E, Shah AN (2022) Postoperative complications in pediatric patients with cerebral palsy. J Pediatr Surg 1(3):424\u0026ndash;429\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOskoui M, Coutinho F, Dykeman J, Jett\u0026eacute; N, Pringsheim T (2013) An update on the prevalence of cerebral palsy: a systematic review and meta-analysis. Dev Med Child Neurol 55(6):509\u0026ndash;519. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/dmcn.12080\u003c/span\u003e\u003cspan address=\"10.1111/dmcn.12080\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eK NB ND, A G LSDC (2016) Birth Prevalence of Cerebral Palsy: A Population-Based Study. Pediatrics 1(1):e20152872\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHollung SJ, Bakken IJ, Vik T, Lydersen S, Wiik R, Aaberg KM (2020) Comorbidities in cerebral palsy: a patient registry study. Dev Med Child Neurol 62(1):97\u0026ndash;103\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShevell MI, Dagenais L, Hall N (2009) Comorbidities in cerebral palsy and their relationship to neurologic subtype and GMFCS level. Neurology 16(24):2090\u0026ndash;2096\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuitadamo P, Thapar N, Staiano A, Borrelli O (2016) Gastrointestinal and nutritional problems in neurologically impaired children. Eur J Paediatr Neurol 1(6):810\u0026ndash;815\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe effect of different dietary structure on gastrointestinal dysfunction in children with cerebral palsy and epilepsy based on gut microbiota - ClinicalKey [Internet. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www-clinicalkey-com.ezp-prod1.hul.harvard.edu/#!/content/playContent/1-s2.0-S038776042030276X?scrollTo=%23b0010\u003c/span\u003e\u003cspan address=\"https://www-clinicalkey-com.ezp-prod1.hul.harvard.edu/#!/content/playContent/1-s2.0-S038776042030276X?scrollTo=%23b0010\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatti F, Pappalardo A, Lo Fermo S, Cimino V, Castiglione A, Zappia M (2008) Life-Threatening Constipation Induced by Intrathecal Baclofen Therapy. Eur Neurol 60(2):95\u0026ndash;96. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1159/000138959\u003c/span\u003e\u003cspan address=\"10.1159/000138959\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKofler M, Matzak H, Saltuari L (2002) The impact of intrathecal baclofen on gastrointestinal function. \u003cem\u003eBrain Inj Internet\u003c/em\u003e. Published online January 1, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.tandfonline.com/doi/abs/10.1080/02699050210128898\u003c/span\u003e\u003cspan address=\"https://www.tandfonline.com/doi/abs/10.1080/02699050210128898\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDhiman N, Chi A, Pawlik TM, Efron DT, Haut ER, Schneider EB (2013) Increased complications after appendectomy in patients with cerebral palsy: Are special needs patients at risk for disparities in outcomes? Surgery 1(3):479\u0026ndash;485\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurphy NA, Hoff C, Jorgensen T, Norlin C, Young PC (2006) Costs and complications of hospitalizations for children with cerebral palsy. Pediatr Rehabil 9(1):47\u0026ndash;52\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStephens SJR (2017) Healthcare Utilization and Spending for Constipation in Children With Versus Without Complex Chronic Conditions. J Pediatr Gastroenterol Nutr 64(1):31\u0026ndash;36\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLjungqvist O, Scott M, Fearon KC (2017) Enhanced Recovery After Surgery: A Review. JAMA Surg 1(3):292\u0026ndash;298\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdriani L, Dall\u0026rsquo;Oglio I, Brusco C, Gawronski O, Piga S, Reale A (2022) Reduction of Waiting Times and Patients Leaving Without Being Seen in the Tertiary Pediatric Emergency Department: A Comparative Observational Study. Pediatr Emerg Care May; 38(5):219\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhillips JL, Jackson BE, Fagan EL, Arze SE, Major B, Zenarosa NR (2017) Overcrowding and Its Association With Patient Outcomes in a Median-Low Volume Emergency Department. J Clin Med Res (v; 9(11):911\u0026ndash;916\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSartini M, Carbone A, Demartini A, Giribone L, Oliva M, Spagnolo AM (2022) Overcrowding in Emergency Department: Causes, Consequences, and Solutions\u0026mdash;A Narrative Review. Healthc Basel Aug 25(9):1625\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eS VV, K R, M W, R B, S B. Constipation and fecal incontinence in children with cerebral palsy. Overview of literature and flowchart for a stepwise approach [Internet. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ageb.be/ageb-journal/previous-issues/ageb-volume/ageb-type/ageb-article/\u003c/span\u003e\u003cspan address=\"https://www.ageb.be/ageb-journal/previous-issues/ageb-volume/ageb-type/ageb-article/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBokova E, Svetanoff WJ, Levitt MA, Rentea RM (2023) Pediatric Bowel Management Options and Organizational Aspects. Child Basel 28(4):633\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcSweeney ME, Chan Yuen J, Meleedy-Rey P, Day K, Nurko S (2022) A Quality Improvement Initiative to Reduce Abdominal X-ray use in Pediatric Patients Presenting with Constipation. J Pediatr 251:127\u0026ndash;133\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFreedman SB, Thull-Freedman J, Rumantir M, Eltorki M, Schuh S (2014) Pediatric constipation in the emergency department: evaluation, treatment, and outcomes. J Pediatr Gastroenterol Nutr Sep; 59(3):327\u0026ndash;333\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoriel G, Tran T, Pham PK, Liberman DB (2020) Reducing Abdominal Radiographs to Diagnose Constipation in the Pediatric Emergency Department. J Pediatr 225:109\u0026ndash;116\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"childs-nervous-system","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cnsy","sideBox":"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)","snPcode":"381","submissionUrl":"https://submission.nature.com/new-submission/381/3","title":"Child's Nervous System","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"cerebral palsy, constipation, intrathecal baclofen pump, GI optimization","lastPublishedDoi":"10.21203/rs.3.rs-5368309/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5368309/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003ePediatric Cerebral Palsy patients carry frequent medical comorbidities and disproportionately consume hospital resources after neurosurgical procedures. We implemented an institutional preoperative gastrointestinal (GI) optimization protocol to improve outcomes and decrease resource utilization.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAll 323 intrathecal baclofen surgeries from 2000\u0026ndash;2023 were categorized relative to protocol implementation on July 1st, 2017. Outcomes and resource utilization were compared.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe protocol change resulted in significantly fewer hospital readmissions (p\u0026thinsp;=\u0026thinsp;0.001) for constipation, eliminating them and GI-related emergency visits. There was a reduction of 27 hospital days for constipation-related readmission (median 1 day per patient, IQR: 1, 2 days). No differences were reported between the experimental groups including demographics or GI comorbidities. Post-operative complications within 30-days were comparable between groups regarding urinary tract infections, surgical-site infections, and spinal fluid leak. There were no differences in postoperative length of stay between groups.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eA GI optimization protocol can eliminate a frequent source of hospital readmissions and GI-related emergency department visits after baclofen pump surgery, even accounting for baseline GI comorbidities. Preventing readmissions and emergency visits translates to lower hospital resource utilization and improves quality of care. Future efforts are warranted to improve outcomes and care efficiency for our most complex and resource-intensive patients.\u003c/p\u003e","manuscriptTitle":"A preoperative gastrointestinal optimization protocol to improve outcomes after intrathecal baclofen pump surgery ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-13 06:04:10","doi":"10.21203/rs.3.rs-5368309/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-18T11:49:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-16T01:17:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"328056032529182399986697695927517482084","date":"2025-02-07T00:06:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-12-05T17:47:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-01T05:49:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-01T05:46:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"Child's Nervous System","date":"2024-10-31T16:41:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"childs-nervous-system","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cnsy","sideBox":"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)","snPcode":"381","submissionUrl":"https://submission.nature.com/new-submission/381/3","title":"Child's Nervous System","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"829e175f-fef6-4c73-8fb0-a5ea5a7ac469","owner":[],"postedDate":"November 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-31T16:00:27+00:00","versionOfRecord":{"articleIdentity":"rs-5368309","link":"https://doi.org/10.1007/s00381-025-06797-2","journal":{"identity":"childs-nervous-system","isVorOnly":false,"title":"Child's Nervous System"},"publishedOn":"2025-03-24 15:57:20","publishedOnDateReadable":"March 24th, 2025"},"versionCreatedAt":"2024-11-13 06:04:10","video":"","vorDoi":"10.1007/s00381-025-06797-2","vorDoiUrl":"https://doi.org/10.1007/s00381-025-06797-2","workflowStages":[]},"version":"v1","identity":"rs-5368309","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5368309","identity":"rs-5368309","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}