Validation of Tokyo guidelines 2018 for safety and mortality benefit from urgent ERCP in acute cholangitis across different age groups.

BACKGROUND: The 2018 Tokyo Guidelines (TG18) recommend urgent endoscopic biliary drainage based on acute cholangitis (AC) severity. Therefore, we evaluated the safety and mortality benefits of urgent endoscopic retrograde cholangiopancreatography (ERCP) in different age groups. METHODS: Using International Classification of Diseases-10 (ICD-10) codes, we sampled adult AC patients from National Inpatient Sample. TG18 definition of cholangitis severity was used to identify patients with severe and nonsevere (mild or moderate) AC. Age categories were 18-64, 65-79, and 80 and above. Multivariate linear or logistic regression was used as appropriate. We used Stata, version 14.2, to perform analyses considering two-sided p < .05 as statistically significant. RESULTS: Among 137 100 patients, there were 93 365 (68.09%) patients with nonsevere cholangitis and 43 735 (31.91%) patients with severe cholangitis. Urgent ERCP (within 24 h) resulted in decreased mortality in all age groups for both severe and nonsevere AC. Post-sphincterotomy bleeding was more common in patients ≥80 years of age, whereas post-ERCP acute cholecystitis was more common in patients 65-79 years. The rates of post-ERCP pancreatitis, bile duct perforation, and duodenal perforation did not differ among the age groups. In addition, there were no differences in the rate of sedation-related complications between different age groups who underwent urgent ERCP. CONCLUSION: This study demonstrates the mortality benefit from urgent ERCP for AC in different age groups and describes the safety of performing urgent ERCP in patients of various ages. Therefore, we recommend that urgent ERCP be performed according to the TG18 guidelines regardless of age.

Does the Route of Cocaine Use Affect the Mortality and Outcomes of Cocaine-Induced Intestinal Ischemia? A Systematic Review.

Intestinal ischemia results from diminished perfusion of the colon resulting in tissue hypoxia. Anecdotal reports suggest that cocaine-induced intestinal ischemia has the highest mortality and longer length of stay among the vasoconstrictors. The present study aimed to summarize the available studies in the literature to assess the effect of routes of consumption on the outcomes of cocaine-induced intestinal ischemia. We conducted a systematic search of MEDLINE from inception through October 2019. Studies of cocaine-induced intestinal ischemia were included if data were available on comorbidities, mortality, and hospital length of stay (LOS). The study's primary outcomes were mortality and need for surgery, while secondary outcomes included the hospital length of stay, LACE index, and hospital score. Statistical tests used included linear and binary logistic regression. STATA 2015 was used, and P < 0.05 was statistically significant. Of the 304 studies, 8 case series and 45 case reports (n = 69 patients) met the inclusion criteria. Different routes of cocaine use had similar mortality odds and the need for surgery for intestinal ischemia. Hospital LOS showed significant difference among the subgroups. Readmission scores (LACE and hospital score) were higher for intravenous and smoking than ingestion and intranasal use (P < 0.05). In conclusion, different routes of cocaine use appear to have similar mortality odds for intestinal ischemia, which vary significantly among the different routes of cocaine consumption for the length of stay and readmission scores. Prompt recognition of the route of cocaine use is vital to improve the outcome. Large-scale and well-designed observational studies are needed to investigate this topic further.

Preoperative Endoscopic and Radiologic Evaluation of Bariatric Patients: What Do They Add?

BACKGROUND: Preoperative esophagogastroduodenoscopy (EGD) and barium swallow (BS) are commonly performed for evaluation in bariatric surgery patients. The routine use of these modalities has been controversial. METHODS: A retrospective review of a prospectively maintained database was performed to include primary bariatric surgery patients between March 2013 and August 2016. RESULTS: Two hundred nine patients were included. All the patients underwent preoperative EGD and BS. The mean age was 43.12 years and BMI 46.4 kg/m2. Reflux symptoms were present in 58.5% of patients. Preoperative EGD revealed abnormalities in 87.5% of patients: esophagitis (54.5%), Barrett's esophagus (5.3%), dysplasia (1%), and gastritis (51%). Endoscopic evidence of HH was documented in 52.2% of patients while only 34% of patients had evidence of HH in their BS. Of the asymptomatic patients, 80.2% had abnormal EGD. Helicobacter pylori on biopsy was found in 17.2% patients, out of which 47.2% were asymptomatic. Based on EGD findings, the choice of surgical procedure was changed in 3.34% of patients. Repair of HH was performed in 107 patients, with 68.2% (n = 73) symptomatic patients and 31.8% (n = 34) asymptomatic patients. On ROC analysis, EGD was better predictive of the presence of HH (AUC = 0.802, OR 5.20, p  =   < 0.0001) and symptoms were a poor indicator for GERD. CONCLUSIONS: Preoperative EGD is abnormal in the majority of patients regardless of their symptoms. EGD is the only modality that can provide tissue sample, which can potentially determine the type of bariatric surgery. Given the low diagnostic accuracy of BS, its routine use can be eliminated.

Enhanced Recovery in Bariatric Surgery: A Study of Short-Term Outcomes and Compliance.

INTRODUCTION: The implementation of Enhanced Recovery After Surgery (ERAS) guidelines has been widely studied among various surgical specialties. We aimed at comparing the perioperative outcomes and compliance with ERAS protocol in bariatric surgery at our center. METHODS: An observational review of a prospectively maintained database was performed. Patients who underwent primary bariatric surgery (gastric bypass or sleeve gastrectomy) between January 2011 and June 2018 were included. Patients were divided into pre- and post-ERAS groups. Data including basic demographic information, length of hospital stay, 30-day perioperative complications, and readmission rates were collected. Compliance with elements of ERAS was assessed using a combination of chart review and a prospectively implemented checklist. P < 0.05 was chosen to be statistically significant. RESULTS: A total of 435 patients were included: 239 patients in the pre-ERAS group and 196 patients in the post-ERAS group. There were no statistical differences in baseline demographics and major comorbidities between the 2 groups. The post-ERAS group had shorter length of hospital stay (2.23 vs 1.23, p < 0.001) and lower rates of 30-day postoperative morbidity (8.7 vs 4%, p = .04). There was no significant difference between the 2 groups with respect to readmissions rates. There was no mortality in either group. Overall compliance rates with ERAS elements were 85%; compliance increased significantly with the implementation of a checklist (p < 0.001). CONCLUSIONS: Implementation of ERAS program for bariatric surgery is safe and feasible. It reduces hospital stay and postoperative morbidity. Easy to implement strategies such as checklists should be encouraged in bariatric programs to aid in implementation and compliance with ERAS elements for perioperative care.