Patterns of readmission and reoperation within 90 days after Roux-en-Y gastric bypass

BackgroundHealth insurance payors harbor concerns regarding the cost of bariatric procedures that are chiefly related to early readmissions and reoperations. We have attempted to identify the avoidable causes of readmission.MethodsWe retrospectively reviewed the indications for short-term (<90-d) emergency department (ED) visits, readmissions, and reoperations from August 2004 through May 2007 for patients undergoing primary Roux-en-Y gastric bypass (RYGB) for morbid obesity at a tertiary care teaching hospital. The electronic medical record of the primary hospital was reviewed, as well as the electronic medical records of 9 local hospitals serving the area, allowing the incorporation of data from 35 locoregional hospitals.ResultsA total of 1222 consecutive patients underwent RYGB, 1051 laparoscopically. Of these 1222 patients, 173 had 252 ED visits, readmissions, and/or reoperations; 147 (58%) visits were to the primary institution and 105 (42%) occurred at a local or regional hospital. No age difference was found between the patients who underwent ED visits, hospital readmissions, or reoperations and those who did not (mean age 43 yr for both groups, P > .05). Patients who were seen in the ED, readmitted to the hospital, or underwent reoperation had had a greater body mass index (50 kg/m² versus 48 kg/m², P = .001). On average, the readmissions occurred 27.3 days (range 2–88) postoperatively, and the mean hospital length of stay for readmitted patients was 3.3 days (range 1–16). Patients who presented for ED visits, readmission, or reoperations were more likely to have undergone open RYGB than laparoscopic RYGB (P = .002). The <90-day all-cause ED visit, readmission, and reoperation rate was 21% (n = 252). Considering all 1222 patients, the incidence of nausea, vomiting, and dehydration, abdominal pain, and wound issues was 5% (n = 65), 4% (n = 50), and 2% (n = 21), respectively. Considering only the 173 patients with ED visits, readmissions, or reoperations (n = 252), the admitting diagnosis was nausea, vomiting, and dehydration in 26%, abdominal pain in 20%, and wound issues in 8%. The unemployed, disabled, or retired were more likely to have been seen in the ED or readmitted compared with the employed, nondisabled, or not retired (P = .01).ConclusionA considerable number of patients are affected by nausea, vomiting, and dehydration, abdominal pain, and wound issues <90 days postoperatively. Socioeconomic and functional status might have an effect on the rate of ED visits and readmissions. By ensuring that the appropriate outpatient mechanisms for management of these problems are available, early ED visits and readmission rates should significantly decrease.     

How successful is the conservative management of pelvi‐ureteric junction obstruction in adults?

OBJECTIVE

To assess the conservative management of pelvi‐ureteric junction obstruction (PUJO), according to severity, accepted in paediatric urology but rarely reported in adults.

PATIENTS AND METHODS

A series of 23 patients (median age 58 years, 17 men and six women) with asymptomatic or minimally symptomatic PUJO were managed conservatively. The patients’ age, preference and comorbidities were considered. The diagnosis of PUJO was based on intravenous urography and isotopic renography. After stringently reviewing the renograms based on relative renal function (RRF) and output efficiency (OE), 15 patients had an OE consistent with definitive PUJO. One patient had no further imaging due to associated comorbidities. Ten patients had right PUJO, three left and one with bilateral PUJO, with unilateral conservative management. The follow‐up included annual renography and clinical consultation. Laparoscopic pyeloplasty was considered for patients with a >10% loss of RRF and/or <40% RRF during the follow‐up.

RESULTS

Overall, 14 of 15 patients had renograms during the follow‐up. The mean RRF of the affected kidney at diagnosis was 48.6% which marginally decreased to 46.7% after a median (range) follow‐up of 44 (23–75) months. The RRF of 11 patients remained stable and in three decreased significantly (median 11% RRF), requiring pyeloplasty. None of the patients became symptomatic throughout the follow‐up.

CONCLUSION

In asymptomatic adults the conservative management of PUJO appears to be safe during a short‐ to medium‐term follow‐up. We recommend that patients are regularly followed with renography and seen promptly should they become symptomatic. A longer follow‐up is needed in a larger group to confirm these findings.     

The operative treatment of pressure wounds: a 10‐year experience in flap selection

This study sought to both assist in the selection of flaps for ischial pressure wound reconstruction and evaluate the overall complication rates associated with reconstruction. A retrospective medical record review was conducted for 78 patients following the surgical reconstruction of an ischial pressure sore. Records were reviewed for demographics, location of sores, methods of reconstruction and flap selection, as well as any complications and recurrences. A total of 72 wounds were reconstructed with an average of 1·4 flaps used per wound. An ischial flap complication rate of 16% was observed in flap follow‐up, with a recurrence rate of 7% recorded. The vast majority of complications went on to heal with 15% of patients requiring a second reconstruction. Our relatively large sample of ischial flaps allowed for a close comparison with previously published work. Both flap selection and site of reconstruction significantly affected the success rates for pressure sore coverage. The overall complication rates by flap and reconstructive site in this review are lower than previously published reports. Our experience with ischial reconstruction was extensive enough to suggest a posterior medial thigh fasciocutaneous flap combined with a biceps femoris muscle flap as a first choice in ischial pressure wound reconstruction.     

Leukocyte Depletion in Allogeneic Blood Transfusion Does Not Change the Negative Influence on Survival Following Transthoracic Resection for Esophageal Cancer

Background  Perioperative transfusion of allogeneic blood has been hypothesized to have an immunomodulatory effect and influence survival in several cancer types. This study evaluates the association between receipt of leucocyte-depleted and non-depleted allogeneic blood and survival following esophagectomy for cancer. Methods  A retrospective analysis was performed including 291 patients with esophageal cancers who underwent transthoracic en bloc esophagectomy and extended mediastinal lymphadenectomy. Neoadjuvant chemoradiation was administered in 152 (52.2%) patients. Perioperative blood transfusions were quantified and the potential prognostic cutoff for transfused units was calculated according to LeBlanc. Results  The median number of perioperative blood transfusions was 2 (0–24), and 106 patients (36.4%) received no transfusions. Patients with one or less blood transfusion showed a significantly improved survival compared to patients receiving more than one unit (p < 0.009). In multivariate analysis, blood transfusion categories showed significance (p < 0.015) next to pT, pN, pM category, and residual tumor categories (R-categories). Separate analysis of 183 patients treated after the mandatory introduction of leukocyte-depleted blood transfusions detected a strong tendency, but no significant difference in survival for patients getting one or less or more than one transfusion (p = 0.056). Receipt of leukocyte-depleted versus non-depleted units, however, had no influence on survival (p = 0.766). Conclusions  The need for perioperative allogeneic blood transfusions is significantly associated with poorer survival following resection for esophageal cancer by univariate and multivariate analysis. Our data suggest that the reduction of leukocytes in allogeneic transfusions is not sufficient to overcome the negative influence on survival. This paper was presented at DDW 2008 in the San Diego Convention Center, San Diego, CA, May 17–22, 2008.     

Preservation of Muscular and Elastic Artery Distensibility After an Intercontinental Cryoconserved Exchange: Theoretical Advances in Arterial Homograft Generation and Utilization

While the situation of tissue donation and transplantation differs between Latin American and European countries, a common problem is tissue deficiency. Hence, at present, there is a pressing need to generate alternatives so as to increase the possibilities of obtaining the requested materials. Consequently, it would be of significant interest to establish an intercontinental network for tissue exchange, to improve international cooperation, and to help patients that need tissue transplantation, and to evaluate the feasibility of using an intercontinental network for the exchange of cryopreserved arteries (cryografts), preserving the arterial distensibility and ensuring a reduced native artery–cryograft biomechanical mismatch. Distensibility was studied in ovine arteries divided into three groups: intact (in vivo tests, conscious animals), fresh control (in vitro tests immediately after the artery excision, Uruguay), and cryografts (in vitro tests of cryopreserved-transported-defrosted arteries, Spain). Histological studies were performed so as to analyze changes in the endothelial layer and elastic components. The comparison between fresh control and cryografts showed that neither the cryopreservation nor the exchange network impaired the distensibility, despite the expected histological changes found in the cryografts. The comparison between intact and cryografts showed that the cryografts would be capable of ensuring a reduced biomechanical mismatch. The cryopreservation and the intercontinental network designed for artery exchange preserved the arterial distensibility. It could be possible to transfer cryografts between Latin America and Europe to be used in cardiovascular surgeries and/or for tissue banking reprocessing, with basic biomechanical properties similar to those of the fresh and/or native arteries.     

Glutathione peroxidase 1 (GPX1) genetic polymorphism, erythrocyte GPX activity, and prostate cancer risk

Glutathione peroxidase 1 (GPX1) is a ubiquitously expressed selenium-dependent enzyme that protects cells against oxidative damage by reducing hydrogen peroxide and a wide range of organic peroxides. Some epidemiological studies have correlated low GPX activity or particular GPX1 polymorphisms with enhanced risk of cancer, although these correlations have not been consistently observed in all populations. Therefore, we conducted the present study to evaluate the possible association of GPX1 Pro198Leu polymorphism and erythrocyte GPX activity with the risk of developing prostate cancer and to clarify whether erythrocyte GPX activity levels were correlated with the GPX1 Pro198Leu genotype in the Macedonian population. The GPX1 Pro198Leu genotype was determined in 82 prostate cancer cases and 123 control individuals. We found an overall protective effect of the variant Leu allele of the GPX1 polymorphism on the prostate cancer risk. Heterozygous carriers of the variant Leu allele had a significantly lower risk of prostate cancer compared with homozygous wild-type individuals (OR, 0.38; 95% CI, 0.20–0.75; P = 0.004). Erythrocyte GPX activity was analyzed in 73 cases and 91 controls. The erythrocyte GPX activity in the cancer group was lower than in the healthy controls. Additionally, we compared the erythrocyte GPX activity in the control group of 90 subjects and found no significant differences by genotype. These findings suggest that individual susceptibility of prostate cancer may be modulated by GPX1 polymorphism and that the combination of genetic factors involved in oxidative response with environmental carcinogens may play an important role in prostate carcinogenesis.     

Establishment of a minimally invasive program at a Veterans' Affairs Medical Center leads to improved care in colorectal cancer patients

Background

Despite significant advantages to patients, less than 5% of all colorectal surgeries for cancer are performed laparoscopically. A minimally invasive colorectal cancer program was created in our Veterans' Affairs hospital with the intent of increasing access and improving quality of patient care while maintaining patient safety and oncologic standards.

Methods

Sixty consecutive laparoscopic colorectal cancer resections and 60 age-matched open resections were identified. Our prospective database was queried for demographic, clinical outcomes, and oncologic data.

Results

Patients undergoing laparoscopic resections experienced a shorter hospital stay and a quicker return of bowel function. Both groups had similar intraoperative blood loss and surgical times. Laparoscopic resections achieved equivalent lymph node retrieval and resection completeness compared with open resections. Laparoscopic resections resulted in fewer wounds and fewer complications requiring reoperation.

Conclusions

Establishment of a minimally invasive colorectal cancer program in a Veterans Affairs Medical Center leads to increased access to laparoscopic colorectal resections and improved patient care while maintaining patient safety.     

Arteriovenous fistula of the superior gluteal artery as a complication of posterior iliac crest bone graft harvesting: 3D-CT angiography and arterial embolization

Superior gluteal artery injuries are rare, but potentially serious complications that occur during posterior iliac crest bone graft harvesting. The authors reported an arteriovenous fistula of the superior gluteal artery, which occurred as a complication during posterior iliac crest bone graft harvesting and was diagnosed with 3D-CT angiography, then treated with arterial embolization.     

Intramuscular myxoma of the cervical paraspinal muscle

Myxoma is a neoplasm of mesenchymal origin composed of undifferentiated stellate cells in a myxoid stroma. This tumor can develop in a variety of locations. Myxomas that arise from skeletal muscles are called intramuscular myxomas. They usually occur in large skeletal muscles. Only ten cases of these benign tumors involving the neck muscles were reported in literature. Of them, only three were located at the paraspinal muscles. A 64-year-old woman presented with occiptal and neck pain over 5 years noted an expansive painful lesion located at posterior cervical region with progressive volume increase in the last 12 months. Image exams revealed a large mass located in the left posterior region of the neck in contact with the C2, C3 and C4 laminae with no invasion of the vertebrea. Tumor total removal was performed through normal muscle margins and the vertebral periosteum was scraped. The tumor was encapsuleted, lobulated with a gray-white appearance. The histological examination yielded the diagnosis of intramuscular myxoma. Follow-up at 1 year showed complete resolution of preoperative symptoms and no evidence of local recurrence. In conclusion, although rare, intramuscular myxoma should be included in differential diagnosis of cervical paraspinal tumors. We reported the fourth case of intramuscular myxoma in the paraspinal musculature of the neck. Despite its benign characteristics, local recurrence was reported after subtotal resection. Tumor total removal should be the goal of surgery.