Use of an Endoscopic Suturing Platform for the Management of Staple Line Dehiscence After Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Management of staple line dehiscence following laparoscopic sleeve gastrectomy (LSG) varies based on local expertise and timing of presentation. We present our experience with an endoscopic suturing platform to treat patients with staple line dehiscence following LSG. METHODS: We included all patients who presented to our institution with a staple line dehiscence following LSG from 2005 through November 2017. All endoscopic suturing procedures were performed by a single interventional endoscopist. RESULTS: Five patients, ages 25-69 years, received treatment of staple line dehiscence at a median time of 22 days following LSG (range 13-335 days). Four out of the five patients received a stent at some point during their treatment. One patient with a chronic leak required gastrectomy and esophago-jejunostomy as a definitive treatment. The remaining four patients experienced resolution of the leak at a median of 48 days post-operatively (range 21-82 days). CONCLUSION: Endoscopic suturing may have a role in the management of leaks following LSG, as a primary treatment or as an adjunct to treatment with a stent. However, given that the technique requires considerable endoscopic expertise and in light of a number of other available therapeutic choices, further studies are required to better define the role of this technology in the algorithm of LSG-related leak management.

Creation of a Transposed Mature Arteriovenous Fistula Autograft: A Novel Approach to Treating Steal Syndrome.

BACKGROUND: Autogenous arteriovenous fistula (AVF) creation is the gold standard of hemodialysis access. However, autologous upper extremity AVFs continue to present significant clinical challenges including failure to mature and steal syndrome. We describe treating a patient with dialysis-associated steal syndrome (DASS) by ligating and then transposing a well-developed, mature upper arm cephalic vein AVF into the contralateral arm. METHODS: Our patient is a 76-year-old female with end-stage renal disease (ESRD) secondary to glomerulonephritis, who had a left arm brachiocephalic AVF created in 2007. She developed DASS in 2013, presenting with hand pain and ulcerations on her fingertips. A right brachial-cephalic AVF was created with plans of ligating the left AVF once mature. The right arm AVF did not mature so we created an arteriovenous graft (AVG) in the right arm utilizing the mature left arm cephalic vein as an autograft. RESULTS: The autograft was transposed and implanted in the right upper arm. The translocated AVF worked for 4 years and was eventually ligated due to right hand ischemia secondary to progression of small vessel peripheral arterial disease. CONCLUSIONS: Transposition of autogenous vein grafts using a mature AVF is a viable option for dialysis access in ESRD patients. We report successful utilization of this novel access option in the treatment of a patient with DASS. The mature autograft retains the natural matrix and endothelial lining and thus may potentially prove to offer improved patency and reduced infection rate compared to other available AVG options.

Cost Analysis of Direct Oral Anticoagulants Compared with Warfarin in Patients with Blunt Traumatic Intracranial Hemorrhages.

Direct oral anticoagulants (DOACs) are rapidly gaining popularity as alternatives to warfarin in the prevention of stroke or systemic embolic events because of the simplicity of their dosing and lack of monitoring requirement. Many physicians feared that these novel agents would be cost-prohibitive not only in their administration but also in their sequelae of bleeding, given the few reversal agents available. Whereas the medication itself is more expensive than traditional warfarin, the total cost of a hospital admission has not been compared between patients on DOACs and warfarin who have sustained a blunt traumatic intracranial hemorrhage (ICH). We conducted a retrospective review of our hospital's trauma database from June 2011 through September 2015 at our Level II trauma center of patients who suffered from an ICH who were anticoagulated at the time of their trauma. Patients who died during their hospital admission or were exclusively on antiplatelet agents were excluded. Of the 136 patients studied, 79 were on warfarin and 57 were on a DOAC at the time of their presentation for a traumatic ICH. The average charged cost for the hospital stay of a patient with an ICH was significantly higher for patients on warfarin compared with DOACs [$70,384.08 vs $49,226.66 (P = 0.02)]. The average reimbursement rate for the hospital was also significantly higher for those patients on warfarin as compared with those on DOACs [$23,922.93 vs $14,705.77 (P = 0.02)]. DOACs are associated with a significant cost benefit in patients admitted for blunt traumatic ICHs when compared with those on warfarin.

Tourniquet use in the prehospital setting: Are they being used appropriately?

OBJECTIVE: The objective of this study was to evaluate tourniquet use in the Hartford prehospital setting during a 34-month period after the Hartford Consensus was published, which encouraged increasing tourniquet use in light of military research. DESIGN: This was a retrospective review of patients with bleeding from a serious extremity injury to determine appropriateness of tourniquet use or omission. SETTING: Level II trauma center between April 2014 and January 2017. PARTICIPANTS: Eighty-four patients met inclusion criteria and were stratified based on tourniquet use during prehospital care. MAIN OUTCOME MEASURES: Five of the 84 patients received a tourniquet. All five of those tourniquets (100 percent of the group, 6.0 percent of the population) were not indicated and deemed inappropriate. Three of the 84 patients did not receive a tourniquet when one was indicated (3.8 percent of the group, 3.6 percent of the population) and these omissions were also deemed inappropriate. Total error rate was 9.5 percent (8/84). RESULTS: There was a significant association between Mangled Extremity Severity Score (MESS) and likelihood of requiring a tourniquet (p = 0.0013) but not between MESS and likelihood of receiving a tourniquet (p = 0.1055). There was also a significant association between wrongly placed tourniquets and the type of providers who placed them [first responders, p = 0.0029; Emergency Medicine Technicians (EMTs), p = 0.0001]. CONCLUSIONS: Tourniquets are being used inappropriately in the Hartford prehospital setting. Misuse is associated with both EMTs and first responders, highlighting the need for better training and more consistent protocols.

Readmissions in Patients with Anticoagulated Intracranial Hemorrhage: A Retrospective Review.

OBJECTIVE: To determine the effect of direct oral anticoagulants (DOACs) compared with warfarin on the 30-day readmission rates in patients with traumatic intracranial hemorrhage (ICH). METHODS: We conducted a retrospective review of patients from our hospital's trauma database admitted between June 2011 and October 2015 to our level II trauma center after sustaining a traumatic ICH while receiving anticoagulant therapy. Patients were stratified based on the anticoagulation drug (DOAC or warfarin) prescribed on admission. The readmission rates between the 2 groups were compared using χ2 analysis and multivariate logistic regression. Patients who died during their initial admission were excluded. RESULTS: Over the 4-year period, 160 patients were admitted with traumatic ICH. Seventy-nine were receiving warfarin and 57 were receiving a DOAC at admission. Data collected included age, sex, injury severity score, admission Glasgow Coma Score, Abbreviated Injury Scale (head), mechanism of injury, hospital and intensive care unit lengths of stay, discharge destination (eg, home, rehabilitation facility, nursing facility), comorbidities, operative interventions, readmissions, and reasons for the readmissions. The rate of readmission for rebleeding of ICH was significantly lower in the DOAC group compared with the warfarin group (5.3% vs. 17.7%; P = 0.04). Multivariate logistic regression suggests that warfarin use, but not DOAC use, is associated with increased readmission both for all causes and for ICH rebleeding. CONCLUSIONS: Warfarin use is associated with higher readmission rates in patients with intracranial bleeding for both all-cause readmissions and for intracranial rebleeding.

Gamified Twitter Microblogging to Support Resident Preparation for the American Board of Surgery In-Service Training Examination.

OBJECTIVE: We sought to determine if a daily gamified microblogging project improves American Board of Surgery In-Service Training Examination (ABSITE) scores for participants. DESIGN: In July 2016, we instituted a gamified microblogging project using Twitter as the platform and modified questions from one of several available question banks. A question of the day was posted at 7-o׳clock each morning, Monday through Friday. Respondents were awarded points for speed, accuracy, and contribution to discussion topics. The moderator challenged respondents by asking additional questions and prompted them to find evidence for their claims to fuel further discussion. Since 4 months into the microblogging program, a survey was administered to all residents. Responses were collected and analyzed. After 6 months of tweeting, residents took the ABSITE examination. We compared participating residents׳ ABSITE percentile rank to those of their nonparticipating peers. We also compared residents׳ percentile rank from 2016 to those in 2017 after their participation in the microblogging project. SETTING: The University of Connecticut general surgery residency is an integrated program that is decentralized across 5 hospitals in the central Connecticut region, including Saint Francis Hospital and Medical Center, located in Hartford. PARTICIPANTS: We advertised our account to the University of Connecticut general surgery residents. Out of 45 residents, 11 participated in Twitter microblogging (24.4%) and 17 responded to the questionnaire (37.8%). RESULTS: In all, 100% of the residents who were participating in Twitter reported that daily microblogging prompted them to engage in academic reading. Twitter participants significantly increased their ABSITE percentile rank from 2016 to 2017 by an average of 13.7% (±14.1%) while nonparticipants on average decreased their ABSITE percentile rank by 10.0% (±16.6) (p = 0.003). CONCLUSIONS: Microblogging via Twitter with gamification is a feasible strategy to facilitate improving performance on the ABSITE, especially in a geographically distributed residency.

A multidisciplinary approach to improve the quality of care for patients with fragility fractures.

BACKGROUND: Fragility fractures have become a worldwide epidemic associated with significant morbidity and mortality. As the world population ages, the number of patients that experience these fractures is also expected to rise. A multidisciplinary team was assembled that was coordinated by the Acute Inpatient Medical Service and included orthopedic surgeons, geriatricians, anesthesiologists, cardiologists, nurses, trauma surgeons, emergency medicine physicians, physiatrists, and physical therapists. This team was formed with the expectation that geriatric fragility fracture complications, specifically hip fractures, could be reduced by identifying and implementing best practices using guidelines from the American Academy of Orthopedic Surgery and those from the International Geriatric Fracture Society. METHODS: We implemented a clinical pathway with a standardized approach with reduction in care variation and followed that by instituting performance improvement measures. The difference in outcome measurements as reported by TQIP for the year prior to implementation and the year following creation of the fragility fracture program was evaluated. RESULTS: Benchmarking data demonstrated improved outcomes for patients with fragility fractures. Length of stay was significantly below national average, mortality remained below national average, and complication rates for UTIs and pressure ulcers were both reduced from 2014 to 2015 and below the national average. CONCLUSION: The clinical pathway we adopted for the care of patients with fragility fractures has resulted in reduced lengths of stay, below average mortality, and improved discharge disposition.

Immediate Tube Feeding after Percutaneous Endoscopic Gastrostomy: Early Return to Goal Tube Feeds without Added Complications.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is frequently performed for delivery of nonoral enteral nutrition (EN) in critically ill patients. Tube-based supplement initiation is often delayed for a variety of reasons despite evidence that EN interruption results in worse outcomes. OBJECTIVE: To determine if early initiation of EN after PEG placement is safe and well-tolerated in critically ill patients and if early initiation of EN results in more goal-accomplished days of EN. DESIGN: A retrospective chart review of patients who underwent PEG and at least 24 hours of EN. Patients were stratified according to time to tube- feed initiation: immediate (< one hour), early (one to four hours), and late (four to 24 hours). RESULTS: 'Ihe three groups were similar with respect to demographics, comorbidities, and 30-day mortality. Sixty-one percent of patients in the immediate group were advanced to the previously-met goal EN rates compared to 24% and 18% in the early and delayed groups, respectively (P < .0001). CONCLUSION: Immediate reinitiation of nonoral EN after PEG procedure is safe and is associated with reaching goal nutrition faster.