A novel over-the-scope deployment method for enteral stent placement

Background

Over the last two decades, self-expanding enteral stents have gained popularity and shown therapeutic potential for strictures, obstructions, fistulae, and perforations of the gastrointestinal (GI) tract. Currently available stent delivery systems make deployment in many locations in the GI tract difficult due to the inability to traverse curves or impossible due to the size requirements of the deployment systems.

Methods

A 67-year-old male presented to our hospital with severe gallstone pancreatitis, requiring a prolonged intensive care unit course. Two days after discharge to a rehabilitation facility he developed acute abdominal pain and pneumoperitoneum. Operative exploration failed to identify a perforation. Subsequently, a left-upper-quadrant abscess developed that was drained percutaneously, yielding coliform bacteria. The drain produced several hundred milliliters of stool a day. A barium enema demonstrated a perforation in the descending colon from an old colo-colic anastomosis site. We proposed a novel over-the-scope (OTS) stent deployment method. Utilizing a heat-activated polymer sheath, the stent was affixed to the endoscope. A modified speed-banding attachment was created to permit release of the polymer sheath once endoscopic and fluoroscopic confirmation of the correct position was obtained.

Results

Utilizing this method of OTS stent deployment, a fully covered 23 × 155 mm self-expanding metal stent (WallFlex, Boston Scientific, Natick, MA) was placed in the colon. Endoscopic and fluoroscopic evaluation following stent placement confirmed stent coverage of the perforation with no ongoing evidence of leak. The patient was discharged to his home state 2 weeks after stent placement in stable condition.

Conclusion

We have developed a novel method of OTS stent placement that permits deployment of a variety of enteral stents on any available endoscope. This method permits placement of fully covered stents in locations in the GI tract not reachable with currently available delivery systems.     

Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions

Objective

Unplanned hospital readmissions following surgical interventions are associated with adverse events and contribute to increasing health care costs. Despite numerous studies defining risk factors following lower extremity bypass surgery, evidence regarding readmission after endovascular interventions is limited. This study aimed to identify predictors of 30-day unplanned readmission following infrainguinal endovascular interventions.

Predictors of 30-day hospital readmission after coronary artery bypass

BACKGROUND: Risk factors for 30-day hospital readmission following coronary artery bypass grafting (CABG) have not been established. METHODS: We prospectively followed 485 consecutive patients who underwent isolated primary CABG at our institution in 1997. Patients were contacted by telephone at 30 days following operation to determine readmission status. RESULTS: The overall readmission rate was 16% (76 of 485). Female gender (25% versus 11%, p = 0.001) and diabetes (22% versus 12%, p = 0.005) were associated with significantly higher readmission rates. The relationship between female gender and readmission persisted after correcting for age and other comorbidities. Congestive heart failure trended towards a significant relationship with increased readmission rate (22% versus 14%, p = 0.09). There were no significant associations between 30-day readmission rate and age, hypertension, chronic obstructive pulmonary disease, history of myocardial infarction, peripheral vascular disease, creatinine level of > or = 1.4 mg/dL, or decreased left ventricular ejection fraction (< 40%). CONCLUSIONS: These data show that most of the classic risk factors for postoperative mortality are not necessarily associated with increased readmission. However, female gender and diabetes are associated with greater than twice the risk of 30-day readmission following CABG.     

A systematic review and meta-analysis of 30-day readmission rates following burns

IntroductionUnplanned hospital readmissions in surgical areas account for high costs and have become an area of focus for health care providers and insurance companies. The aim of this systematic review is to identify the rate and common reasons for unplanned 30-day readmission following burns.MethodsThis study was performed following the PRISMA guidelines. Pubmed, Web of Science and CENTRAL databases were searched for publications without date or language restrictions. Extracted outcomes included 30-day readmission rate and reasons for readmission. Pooled 30-day readmission rate was estimated from weighted individual study estimates using random-effect models. Pooled estimates for risk factors are reported as odds ratios (ORs) and 95% confidence intervals (CIs).ResultsA total of eight studies were included into qualitative analysis and six (four adults, two children) into quantitative analysis. The overall readmission rate was 7.4% (95% CI 4.1–10.7) in adults and 2.7% (95% CI 2.2–3.2) in children. Based on two studies in 112,312 adult burn patients, burn size greater than 20% total body surface area (TBSA) was not a significant predictor of readmission rate (OR 1.75, 95% CI 0.64–4.75; NS). The most common reasons were infection/sepsis, wound healing complications, and pain in both adults and children.DiscussionUnplanned readmissions following burns are generally low and appear more common in adults than in pediatric patients. However, only few studies are reporting on 30-day readmission rates following burns. Evidence is limited to support a significant association between greater burn size and higher readmission rates. Since cost effectiveness and utilized hospital capacity are becoming an area of focus for improvement in health care, future studies should assess the risk factors of unplanned readmission following burns. Follow-up assessments and outpatient resources, even if not underlined by this data, could reduce readmission rates.Systematic review registrationPROSPERO: CRD42019117649.     

Factors that predict 30-day readmission after bariatric surgery: experience of a publicly funded Canadian centre

BackgroundHospital readmissions after bariatric surgery can significantly increase health care costs. Rates of readmission after bariatric surgery have ranged from 0.6% to 11.3%, but the rate of complications and the factors that predict readmission have not been well characterized in Canada. The objective of this study was to characterize readmission rates and the factors that predict 30-day readmission in a Canadian centre.MethodsA retrospective study was performed on all patients who underwent bariatric surgery between 2010 and 2015 in a single Canadian centre. Procedures included laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB). Prospectively collected data were extracted from an administrative database. Multivariable logistic regression analysis was performed to determine which factors predict 30-day readmission.ResultsA total of 1468 patients had bariatric surgery (51.0% LRYGB, 40.5% LSG, 8.6% LAGB) during the 6-year study period, with an overall 30-day readmission rate of 7.5%. LRYGB was associated with a higher readmission rate (11.4%) than LSG (3.7%) or LAGB (1.6%). Common reasons for readmission were infection (24.8%), pain (17.4%) and nausea or vomiting (10.1%). Multivariable analysis identified 3 factors that independently predicted readmission: length of stay greater than 4 days (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.03–4.63, p = 0.042), LRYGB (OR 5.21, 95% CI 1.19–22.73, p = 0.028) and acute renal failure (OR 14.10, 95% CI 1.07–186.29, p = 0.045).ConclusionReadmissions after bariatric surgery were most commonly caused by potentially preventable factors, such as pain, nausea or vomiting. Strategies to identify and address factors associated with readmission may reduce readmissions and health care costs after bariatric surgery in a publicly funded health care system.     

Factors associated with 30-day complication,reoperation, readmission,and length of stay after primary total elbow arthroplasty: a database study of 555 patients

BackgroundThe indications for total elbow arthroplasty (TEA) have dramatically evolved in recent years, and factors associated with episode-of-care outcomes after TEA are not well-described in contemporary patients. The primary objective of this study was to identify factors associated with 30-day postoperative complication following primary TEA. Secondary objectives of this study were to identify factors associated with reoperation, hospital readmission, and hospital length of stay.MethodsA retrospective case-control study was performed using the American College of Surgeons National Surgical Quality Improvement Program database by querying the Current Procedural Terminology code for TEA from 2014 to 2020. The resultant cohort of 555 patients who underwent primary TEA during the study period was included. The primary outcome was a composite variable encompassing all 30-day complication metrics measured by the National Surgical Quality Improvement Program, and secondary outcome variables were reoperation, readmission, and length of stay. A bivariate screen was performed for explanatory variables associated with our outcome variables, and variables with P < .1 in the bivariate screen were included in multivariable regression models.ResultsOf the 555 patients in our cohort, 53 patients (9.5%) developed a complication, 32 patients (5.8%) developed a complication not including blood transfusion, 22 patients (4.0%) underwent reoperation, and 28 patients (5.1%) were readmitted during the 30-day postoperative period. Of the 364 patients who underwent inpatient TEA, median hospital length of stay was 2 days. Multivariable logistic regression analysis showed longer operative time and diabetes mellitus were associated with complication, and lower body mass index was associated with readmission. Male sex was associated with reoperation in the bivariate analysis, and no other variables qualified for inclusion in a multivariable logistic regression model. Multivariable regression analysis showed that higher American Society of Anesthesiologists classification was associated with longer hospital length of stay.ConclusionShort-term postoperative complications following primary TEA are associated with operative time, which may represent surgical difficulty and/or surgeon experience, and diabetes mellitus. Male patients are at higher risk for reoperation, and patients with lower body mass index are at higher risk for hospital readmission. When TEA is performed as an inpatient procedure, length of stay is associated with patient comorbidities. We identified no differences among various indications for TEA in episode-of-care outcomes. Our findings are relevant for preoperative risk stratification and counseling.     

30-day all-cause hospital readmission after cystectomy: no worse for rural Medicare residents

Objective

To evaluate rural/urban disparities in 30-day all-cause hospital admission after cystectomy.

Comparing 30-day all-cause readmission rates between tibiotalar fusion and total ankle replacement

BackgroundEnd-stage ankle arthritis is a debilitating condition that negatively impacts patient quality of life. Tibiotalar fusion and total ankle replacement are treatment options for managing ankle arthritis. Few studies have examined short term readmission rates of these two procedures. The objective of this study was compare all-cause 30-day readmission rates between patients undergoing tibiotalar fusion vs. total ankle replacement.MethodsThis study queried the Nationwide Readmission Database (NRD) from 2013–2014 and used international classification of disease, 9th revision (ICD-9) procedure codes to identify all patients who underwent a tibiotalar fusion or a total ankle replacement. Comorbidities, insurance status, hospital characteristics, and readmission rates were statistically compared between the two cohorts. Risk factors were then identified for 30-day readmission.ResultsA total of 5660 patients were analyzed with 2667 in the tibiotalar fusion cohort and 2993 in the total ankle replacement cohort. Univariate analysis revealed that the readmission rate after tibiotalar fusion (4.4%) was statistically greater than after total ankle replacement (1.4%). Multivariable regression analysis indicated that deficiency anemia (OR 2.18), coagulopathy (OR 3.51), renal failure (OR 2.83), other insurance relative to private (OR 3.40), and tibiotalar fusion (OR 2.51) were all statistically significant independent risk factors for having a readmission within 30-days.ConclusionsThese findings suggest that during the short-term period following discharge from the hospital, patients who received a tibiotalar fusion are more likely to experience a 30-day readmission. These findings are important for decision making when a surgeon encounters a patient with end stage ankle arthritis.Level of evidence: Level III, cohort study.     

Predictors of 30-day hospital readmission after hip fracture: a systematic review

BackgroundEarly readmission to hospital after hip fracture is associated with increased mortality and significant costs to the healthcare system. There is growing interest in the use of 30-day readmission rates as a metric of hospital performance. Identifying patients at increased risk of readmission after hip fracture may enable pre-emptive action to mitigate this risk and the development of effective methods of risk-adjustment to allow readmission to be used as a reliable measure of hospital performance.MethodsWe conducted a systematic review of bibliographic databases and reference lists up to July 2016 to identify primary research papers assessing the effect of patient- and hospital-related risk factors for 30-day readmission to hospital after hip fracture.Results495 papers were found through electronic and reference search. 65 full papers were assessed for eligibility. 22 met inclusion criteria and were included in the final review.Medical causes of readmission were significantly more common than surgical causes, with pneumonia consistently being cited as the most common readmission diagnosis. Age, pre-existing pulmonary disease and neurological disorders were strong independent predictors of readmission. ASA grade and functional status were more robust predictors of readmission than the Charlson score or individual co-morbidities. Hospital-related risk factors including initial length of stay, hospital size and volume, time to surgery and type of anaesthesia did not have a consistent effect on readmission risk. Discharge location and the strength of hospital-discharge facility linkage were important determinants of risk.ConclusionsPatient-related risk factors such as age, co-morbidities and functional status are stronger predictors of 30-day readmission risk after hip fracture than hospital-related factors. Rates of 30-day readmission may not be a valid reflection of hospital performance unless a clear distinction can be made between modifiable and non-modifiable risk factors. We identify a number of deficiencies in the existing literature and highlight key areas for future research.     

Unplanned 30-day readmission in patients with diabetic foot wounds treated in a multidisciplinary setting

Objective

Readmission rates are known to be high for vascular surgery patients in general, but there are limited data describing the risk of surgical and nonsurgical readmission among patients with diabetic foot ulcers (DFUs). Our aim was to identify factors associated with unplanned readmission in DFU patients treated in a multidisciplinary setting.

Factors associated with readmission after laparoscopic gastric bypass surgery

BACKGROUND: Studies have demonstrated that laparoscopic Roux-en-Y gastric bypass (RYGB) is associated with the greatest readmission rate among bariatric surgeries. Some readmissions might be avoidable. We sought to evaluate the risk factors for readmission in a high-volume bariatric surgery program at a university hospital in the United States. METHODS: We performed a retrospective review of prospectively maintained data. Patients readmitted within 30 days of laparoscopic RYGB were randomly matched to control patients who had undergone RYGB in the same year but were not readmitted. The readmissions were categorized as technical complications (leak), wound infections, or malaise (nausea, dehydration, or benign abdominal pain). Patients with a wound infection treated in an outpatient setting were also evaluated and compared with the patients admitted with a wound infection. RESULTS: From July 2002 to July 2008, 450 patients underwent RYGB. Readmission occurred in 42 patients (9%). Of these 42 patients, 6 were admitted with wound infections (14%), 18 (43%) with malaise, and 18 (43%) with technical complications. The patients admitted with wound infections were similar to their controls, except that they were more likely to have publicly funded insurance (Medicare or Medicaid) and more likely to present for medical attention to the emergency department after clinic hours. The patients admitted with malaise reported a greater pain score at discharge and were also more likely to have public health insurance than controls. The patients with technical complications did not differ from the control patients in any examined variable. CONCLUSIONS: Patients with publicly funded insurance are at increased risk of readmission after RYGB. Outpatient mechanisms for managing wound infections and malaise might result in decreased readmissions.     

The impact of mental health disorders on 30-day readmission after bariatric surgery

Background

Mental health disorders are common among bariatric surgery patients. Mental health disorders, particularly depression, have been associated with poorer surgical outcomes, indicating the bariatric surgery patient population warrants special clinical attention.

30例老年食管癌晚期支架置入术的疗效观察

目的探讨食管支架置人术治疗老年晚期食管癌的临床疗效。方法对我院在2005年2月至2007年7月30例晚期食管癌支架置入术后生活质量及生存期进行回顾性分析。结果26例患者术后感到胸骨后不适及疼痛，在1-2周后均可缓解。术后16例能较正常地食。所有患者均可进食半流。本组有3例发生支架滑脱，经胃镜下调整后完全复位。术后30例均获得随访，其中6例分别手术后4—25个月死亡。死亡原因是肝转移3例，支气管食管瘘并发肺炎及败血症1例，脑血管意外1例及癌肿胃转移后恶液质全身衰竭1例。其余24例术后至今仍生存，生存最长者达23个月；支架仍然保持通畅。结论老年晚期食管癌行支架置入术能明显改善梗阻症状，减轻痛苦，延长生存期。     

30例老年食管癌晚期支架置入术的疗效观察

目的探讨食管支架置入术治疗老年晚期食管癌的临床疗效。方法对我院在2005年2月至2007年7月30例晚期食管癌支架置入术后生活质量及生存期进行回顾性分析。结果26例患者术后感到胸骨后不适及疼痛,在1-2周后均可缓解。术后16例能较正常地食。所有患者均可进食半流。本组有3例发生支架滑脱,经胃镜下调整后完全复位。术后30例均获得随访,其中6例分别手术后4-25个月死亡。死亡原因是肝转移3例,支气管食管瘘并发肺炎及败血症1例,脑血管意外1例及癌肿胃转移后恶液质全身衰竭1例。其余24例术后至今仍生存,生存最长者达23个月;支架仍然保持通畅。结论老年晚期食管癌行支架置入术能明显改善梗阻症状,减轻痛苦,延长生存期。     

Retrospective analysis of 30-day unplanned readmission after major abdominal surgery with reversal by sugammadex or neostigmine

Background

Sugammadex is associated with fewer postoperative complications, but its impact on 30-day unplanned readmission is unclear.