Outcome and management of endoscopic retrograde cholangiopancreatography perforations: A community perspective.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) carries a small but significant risk of perforation. Recent data suggest that select patients can be managed non-operatively. We sought to evaluate the management of ERCP perforations at our community medical center. METHODS: ERCPs performed from 2004 to 2015 were reviewed. RESULTS: Twenty-one of 2423 patients who underwent ERCP had a perforation (0.9%). ERCP procedures included balloon sweep with/without sphincterotomy and pancreatic duct stent (71%), common bile duct brushing (10%), and pancreatic duct stenting (5%). Duodenal diverticula were present in 3 (14%), and altered anatomy was present in 6 (29%). Seventeen patients were treated nonoperatively; 3 (14%) underwent percutaneous drain placement. Two patients failed nonoperative treatment and required surgery. Four patients required ICU stay, and median post-ERCP LOS was 5 days. The 30-day mortality rate was 1/21 (4.8%). CONCLUSIONS: Perforations remain a rare, but serious, complication of ERCPs. Nonoperative management is highly successful in carefully selected patients. Early recognition with initiation of antibiotics is paramount. Our community-based practice patterns are similar to those previously published for successful nonoperative management of ERCP perforations.

Does neoadjuvant chemotherapy affect morbidity, mortality, reoperations, or readmissions in patients undergoing lumpectomy or mastectomy for breast cancer?

BACKGROUND: The influence of neoadjuvant chemotherapy (NAC) prior to breast cancer surgery on postoperative complications is unclear. Our objective was to determine whether NAC was associated with postoperative outcomes in patients undergoing lumpectomy or mastectomy without reconstruction. METHODS: Patients meeting inclusion criteria were identified from the National Surgical Quality Improvement Program (NSQIP) database participant user files from 2005 through 2012, after which NSQIP discontinued the NAC variable. Primary outcome measures included a composite measure of morbidity and mortality (M&M) and reoperations and readmissions within 30 days of the index procedure. Rates of postoperative complications stratified by receipt of NAC were compared by χ2. A logistic regression model was then built that included confounding factors for M&M. RESULTS: There were 30,309 patients meeting inclusion criteria. NAC was not associated with any postoperative outcomes from 2005 through 2012, but it was associated with higher M&M in lumpectomy patients during 2011 to 2012 [P=0.011, odds ratio (OR) 2.579; 95% confidence interval (CI), 1.239-5.368]. CONCLUSIONS: The finding that NAC was associated with higher M&M in lumpectomy patients during 2011 to 2012 warrants further investigation. Therefore, we recommend that the NSQIP database reinstitute the NAC variable to allow monitoring during anticipated changes in chemotherapy agents and protocols.

Implementation of an Enhanced Recovery After Surgery Program for Colorectal Surgery at a Community Teaching Hospital.

INTRODUCTION: Perioperative programs aimed at decreasing surgical stress to colorectal patients can reduce hospital length of stay and morbidity while improving the patient's perception of the surgical experience. Our goal was to transform patient care from a perioperative platform based on individual physician and nurse choice to a standardized evidence-based Enhanced Recovery After Surgery (ERAS) protocol for all patients undergoing elective colorectal resections. METHODS: An institutional review board-approved retrospective review was performed for the first 12 months of ERAS protocol-driven patient care in 2014 and compared to the prior 12 months (2013) of individual choice managed care. RESULTS: Ninety-nine patients and 92 patients underwent elective colorectal surgery in the post- ERAS and pre-ERAS period, respectively. The post-ERAS group experienced a shorter length of stay (4.9±2.7 vs 6.2±4.0 days, P=0.001), were more likely to advance to a general diet on postoperative day 1 (72% vs 9%, P<0.001), and had quicker return of bowel function (2.3±1.8 vs 2.8±1.1 days, P<0.0001) compared to the pre-ERAS group. Thirty-day complications were similar between the post-ERAS and pre-ERAS groups and included anastomotic leak (4% vs 0%, P=0.120), surgical site infections (4% vs 8%, P=0.990), and abscess (3% vs 3%, P=0.990). Eleven (11%) post-ERAS patients and 7 (8%) pre-ERAS patients were readmitted within 30 days postoperative (P=0.410). CONCLUSION: We implemented change through a new system of care based upon standardized evidence-based ERAS protocols through the preoperative, intraoperative, and postoperative patient experience. In the first year of the ERAS program, patients experienced a reduced length of stay without a significant difference in morbidity or mortality.

Stapled versus hand-sewn anastomoses in emergency general surgery: a retrospective review of outcomes in a unique patient population.

BACKGROUND: Recent studies have identified unique clinical and physiologic characteristics of emergency general surgery (EGS) patients and called for outcomes data in this population. There are no data in the US literature analyzing the impact of technique on anastomotic failure rates in EGS patients. The purpose of the current study was to compare outcomes of hand-sewn (HS) versus stapled (ST) bowel anastomoses in EGS patients. METHODS: A retrospective chart review of all patients admitted by our EGS service undergoing bowel resection for emergent indications from January 2007 to July 2011 was performed. Time from surgery to diagnosis of anastomotic failure was recorded as were the diagnostic modality and treatment of each anastomotic failure. Specific data on damage-control techniques, if used, were also collected. RESULTS: There were 100 HS (43%), and 133 ST (57%) anastomoses in 231 patients. Operative times were shorter in ST anastomosis technique (205 minutes for HS vs. 193 minutes for ST, p = 0.02). Anastomotic failures were identified in 26 patients (11%) and were significantly higher in the ST group than the HS group (15.0% vs. 6.1%, p = 0.003). A multivariate logistic regression analysis, controlling for age and preoperative nutritional status, revealed ST technique to be an independent risk factor for anastomotic failure (odds ratio, 2.65; 95% confidence interval, 1.08-6.50; p = 0.034). CONCLUSION: Anastomotic failures are more than twice as likely with ST than HS anastomoses in the EGS population. This is true even when controlling for markers of preoperative nutrition and demographics. These data suggest that the HS anastomosis should be the preferred method of reconstruction after bowel resection in EGS patients.