A different type of perforation: appendicitis after colonoscopy.

Physicians who perform colonoscopy should consider appendicitis in the differential diagnosis of post procedure abdominal pain. Diagnostic laparoscopy is a safe adjunct for evaluation in patients with suspected perforation after colonoscopy. It is important that all physicians be aware of this complication to ensure prompt diagnosis and intervention.

Distracting injury defined: does an isolated hip fracture constitute a distracting injury for clearance of the cervical spine?

OBJECTIVES: As the population within the USA ages, the number of hip fractures seen yearly in the emergency department is expected to rise. According to the NEXUS criteria, many of these patients receive computerized tomographic scan (CT) evaluation of the cervical spine because a hip fracture may constitute a distracting injury. The objective of this study is to determine if an isolated hip fracture constitutes a distracting injury which requires imaging of the cervical spine. METHODS: Data were prospectively collected on 158 trauma patients with isolated hip fractures between April 1, 2015 and March 9, 2016. Patient demographics were analyzed and compared to the National Emergency X-Radiography Utilization Study (NEXUS). RESULTS: Patients with isolated hip fractures were predominantly elderly, on average 78.6 +/- 15.9 years old, and 94.3% of these injuries occurred after a fall from standing. Only one patient also had a cervical spine fracture which was not clinically significant. When compared to the established rate of cervical spine injury of 2.4%, the absolute risk reduction (ARR) was 0.35% (95% CI, - 1.06 to 1.75%) and the number needed to treat (NNT) was 290. CONCLUSION: In the case of an elderly patient with an isolated hip fracture and no cervical midline tenderness, cervical spine imaging may be reserved for those who have other NEXUS criteria for further workup.

Over the hill and falling down: Can the NEXUS criteria be applied to the elderly?

INTRODUCTION: The National Emergency X-Radiography Utilization Study (NEXUS) criteria have been criticized due to the presumed unreliability of the clinical exam in elderly patients. The objective of this study was to determine if the NEXUS criteria can be safely applied to this vulnerable group of patients. METHODS: 596 trauma patients over the age of 65 were enrolled in a prospectively designed study between April 1, 2015 and October 1, 2016. The study was designed to encourage the use of the NEXUS criteria for all trauma patients including the elderly. NEXUS-negative patients (n = 226) were defined as individuals fulfilling none of the low risk criteria. The specificity and sensitivity of the NEXUS criteria were calculated based on any cervical spine injuries which were missed in NEXUS-positive patients (n = 129) who met one or more criteria. RESULTS: Out of the 596 included elderly patients, 355 patients underwent computed tomography (CT) of the cervical spine. 129 patients were NEXUS-positive and in this group ten nonoperative cervical spine injuries were detected. There were no NEXUS-positive patients who did not undergo CT scans of the cervical spine. No cervical spine injuries were detected in the 226 NEXUS-negative patients. In elderly patients, the NEXUS criteria had a sensitivity of 100% and specificity of 100%. CONCLUSION: The NEXUS criteria have been criticized in prior literature as less sensitive in elderly patients. Based on the current study, the use of the NEXUS criteria may lead to decreased radiation exposure and healthcare costs allowing for better allocation of resources for patients who warrant imaging of the cervical spine.

Readmission Following Laparoscopic Sleeve Gastrectomy.

BACKGROUND AND OBJECTIVES: Prior studies have established a 1.7-4.33% readmission rate for laparoscopic sleeve gastrectomy (LSG), a rate that falls within the reported range for other bariatric procedures. The current report describes the incidence of 30-day readmission after primary LSG procedures performed at a single bariatric center of excellence (COE) and examines factors that may be associated with readmission. METHODS: Data on 343 consecutive LSG operations performed from February 2010 to May 2014 by a single surgeon (PG) were analyzed. Patients readmitted within 30 d were compared to the remaining patients by using Student's t test for continuous variables and the χ2 test for categorical variables. RESULTS: All LSGs were completed laparoscopically with no conversions to open procedures. There were no reoperations, leaks, perioperative hemorrhages, or mortalities. Twelve patients (3.5%) were readmitted; 1 was readmitted twice. There were no identified risk factors for readmission, including patient demographics, comorbidities, and perioperative factors. Notably, 7 (7%) readmissions occurred in the initial 100 patients and 5 (2%) in the remaining 243 patients (P = .04). Clinical pathways were modified after the initial 100 patients; routine contrast esophagograms were no longer performed, and a 1-day routine postoperative stay was adopted. Operative time also decreased from 94.2 ± 23.8 to 78.2 ± 20.0 min (P < .001). CONCLUSIONS: Readmission rates after LSG remain in a range similar to those described for other laparoscopic bariatric procedures. Larger prospective studies are needed to identify patterns of complications and readmissions in patients undergoing LSG that may differ from other bariatric procedures.