Rectal foreign body removal: increasing incidence and cost to the NHS.

INTRODUCTION: Insertion of foreign objects into the rectum is a well-described phenomenon and not an uncommon referral to the general surgeon on call. Although usually not life-threatening, there can be consequences following migration of the object or perforation of the large bowel. This study looks at the incidence of removal of foreign objects from the rectum over the last decade and the financial burden it presents to the NHS. METHODS: Hospital Episode Statistics for 2010-2019 were used to calculate the number of rectal foreign bodies that required removal in hospital. Data for age groups and genders have been compared. RESULTS: A total of 3,500 rectal foreign bodies were removed over the course of 9 years. Males accounted for 85.1% of rectal foreign bodies whilst 14.9% were females. This equates to 348 bed-days per annum. Admission peaks were observed in the second and fifth decades of life. CONCLUSION: This study shows that the incidence of rectal foreign bodies is higher in men and has been increasing over the period studied. Most foreign bodies can be removed trans-anally with the use of anaesthesia, with only a small proportion of patients requiring hospital stay over 24 hours (mean length of stay = 24 hours). Nearly 400 rectal foreign body removals are performed each year with an annual cost of £338,819, illustrating the effect this has on NHS resources.

Costs and complications of hospital admissions for inferior vena cava filter malfunction.

OBJECTIVE: Inferior vena cava filter (IVCF) malfunction can result from penetration, fracture, or migration of the device necessitating retrieval. Endovascular and open retrieval of IVCF have been described in institutional series without comparison. This study examines national hospital admissions for IVCF malfunction and compares the outcomes of open and endovascular retrieval. METHODS: The National Inpatient Sample database (2016-2017) was reviewed for admissions with International Classification of Diseases, Tenth Revision (ICD-10) codes specific for IVCF malfunction. All ICD-10 procedural codes were reviewed, and patients were divided based on open or endovascular IVCF retrieval. Patient characteristics, outcomes, and costs of hospitalization were compared between the two groups. RESULTS: There were 665 patients admitted with a diagnosis of IVCF malfunction. Open IVCF retrieval was performed in 100 patients and endovascular removal in 90 patients. Of those undergoing open surgery, 45 patients (45%) required median sternotomy and 55 (55%) required abdominal surgeries. Most patients were white females with a mean age of 54.4 years (range, 49.3-59.6 years) with a history of deep venous thrombosis (55.3%) or pulmonary embolism (31.6%). Most patients with IVCF malfunction were treated in large (81.6%) or urban teaching (94.7%) hospitals situated most commonly in the South (42.1%) and Northeast (29.0%) with no difference in characteristics of the patients or the centers between the two groups. Patients undergoing open IVCF retrieval were more likely to undergo surgery on an elective basis compared with endovascular IVCF retrieval (75.0% vs 11.1%; P < .001). Open IVCF retrieval was associated with a higher likelihood of thromboembolic complication compared with endovascular retrieval (20% vs 0%; P = .04). There was a trend toward higher infectious complications and overall complications with endovascular removal, but this difference did not reach statistical significance. Open retrieval was associated with a mortality of 5.0% compared with no inpatient mortality with endovascular retrieval (P = .33). The mean hospital length of stay was no difference between the two groups. Open retrieval was associated with significantly higher hospital costs than endovascular retrieval ($34,276 vs $19,758; P = .05). CONCLUSIONS: Filter removal for patients with IVCF malfunction is associated with significant morbidity and cost, regardless of modality of retrieval. The introduction of specific ICD-10 codes for IVCF malfunction allows researchers to study these events. The development of effective tools for outpatient retrieval of malfunctioning IVCF could decrease related hospitalization and have potential savings for the healthcare system.

Permanent inferior vena cava filters offer greater expected patient utility at lower predicted cost.

OBJECTIVE: Retrievable inferior vena cava (IVC) filters were first approved for use in the United States in 2003 to address the long-term complications of migration, thrombosis, fracture, and perforation observed with permanent IVC filter implantation. Although Food and Drug Administration approval of retrievable IVC filters includes permanent implantation, the incidence of complications from long-term implantation appears to be greater than that reported with existing permanent IVC filters. Also, only a small fraction of such retrievable IVC filters are ever retrieved. The purpose of the present study was to determine the threshold retrieval rate at which the use of retrievable IVC filters could be justified. METHODS: A Markov decision tree was constructed comparing retrievable and permanent IVC filters regarding their effectiveness and cost. A review of the reported data provided outcome probabilities, and the Tufts Medical Center Cost-Effectiveness Analysis Registry was the source of the utility values for the various potential outcomes. Medicare reimbursement rates served as a proxy for costs. A sensitivity analysis was performed for various parameters, primarily to determine the retrieval rate threshold at which the use of retrievable IVC filters would outperform the use of permanent IVC filters. RESULTS: Base case analysis demonstrated a greater predicted effectiveness for permanent compared with retrievable IVC filter implantation (5.41 quality-adjusted life-years [QALY] vs 5.33 QALY) at a lower cost ($2070 vs $4650). Monte Carlo simulation at 10,000 iterations confirmed the expected utility (5.4 ± 3.0 QALY vs 5.3 ± 3.0 QALY; P = .0002) and cost ($1900 ± $7400 vs $4800 ± 9900; P < .0001) to be statistically superior for permanent IVC filters. A sensitivity analysis for the filter retrieval rate demonstrated that the strategy of using a retrievable IVC filter was never preferable for utility or cost. The superiority of permanent IVC filter placement for effectiveness and cost persisted, regardless of anticipated patient-predicted annual mortality. A two-way sensitivity analysis for both IVC filter removal rate and annual patient mortality confirmed the superiority of permanent IVC filter placement at all levels. CONCLUSIONS: The predicted effectiveness of permanent IVC filters was greater and the predicted cost lower than those for retrievable IVC filters, regardless of the IVC filter retrieval rate. This interpretation of existing reported data using Markov decision analysis modeling supports the argument that unless the long-term complication rate of retrievable IVC filters can be significantly improved, their use should be abandoned in favor of currently available permanent IVC filters.

Intravascular catheter migration: A cross-sectional and health-economic comparison of adhesive and subcutaneous engineered stabilisation devices for intravascular device securement.

The Infusional Services Team at a large cancer centre in Belfast, Northern Ireland, performed a cross-sectional analysis of two catheter securement technologies to address an area of frequent, but underestimated concern - peripherally inserted central catheter migration and dislodgement. Healthcare practitioner and patient feedback, along with economic impact, were assessed. The costs associated with catheter replacement during the adhesive device group study period were calculated using an average cost per insertion, based on material costs required for the procedure. Other factors were the replacement cost of the adhesive engineered securement device with each dressing change. In the subcutaneous securement group, the material costs were adjusted for use of the subcutaneous device as it remained in situ for the duration of the catheters' dwell time. This review found that subcutaneous securement offers both patient and facilities a safe, effective and economical alternative for device securement with patients who are unable to tolerate or have successful securement with adhesive securement devices. The use of subcutaneous devices provided for reduced risks for peripherally inserted central catheters in terms of dislodgement, migration or malposition, alleviating the potential risks to develop catheter-related thrombosis and device-related infection.

Repositioning of central venous access devices using a high-flow flush technique - a clinical practice and cost review.

BACKGROUND: Malpositioned central venous access device (CVAD) tip locations can cause significant mechanical and chemical vessel-related injuries and complications if left in inappropriate positions.The aim of this study is to determine the use of a high-flow flush technique (HFFT) in successful correction of malpositioned catheters into the lower superior vena cava or cavoatrial junction and provide a cost comparison to interventional/fluoroscopic-based repositioning. METHODS: This is a retrospective chart and radiographic review of all inserted CVADs found malpositioned between 1996-2014 in a multi-specialty 1000-bed tertiary trauma center in Sydney, Australia.7450 CVADs placed by a nurse-led vascular access service were reviewed. Catheters repositioned pre-2010 were excluded owing to radiology repositioning interventions. RESULTS: There were 3996 peripherally inserted central catheters (PICCs) and 3454 centrally inserted central catheters (CICCs) placed. Seventy-four were malpositioned post-2010. Of these, 53 devices were repositioned using the studied technique; 86% (46/53) of catheters were successfully repositioned on the first HFFT attempt. There was supportive evidence that device insertion side is important in potential catheter malposition. CONCLUSIONS: Clinical outcomes suggest that CICCs and PICCs may be successfully repositioned utilizing this technique, with no adverse events associated and a prospective cost saving benefit when compared to interventional-based repositioning procedures.

Antiretropulsion devices.

PURPOSE OF REVIEW: Stone migration during the treatment of ureteral stones can prove frustrating and increases both healthcare cost and patient morbidity. Antiretropulsion devices have been engineered to prevent stone migration. RECENT FINDINGS: Improvements in antiretropulsion devices allow for efficient prevention of stone migration during ureteroscopic lithotripsy with minimal adverse effects or complications. Multiple devices are now available each with advantages and disadvantages. New devices are currently engineered to prevent stone migration and maintain ureteral access. Antiretropulsion devices appear to be cost-effective to prevent stone migration during intracorporeal lithotripsy. SUMMARY: Antiretropulsion devices have been safely and effectively used during ureteroscopic procedures. These tools increase stone-free rates, decrease morbidity and new studies have demonstrated their cost-effectiveness.

A simple and cost-effective method of fixation of deep brain stimulation (DBS) electrode.

Unplanned migration of a deep brain stimulation (DBS) electrode after accurate placement at the intended target can result in a poor surgical outcome and added cost to the procedure. There are various fixation methods described in the literature. The authors describe the use of a modified burr-hole cover which serves as a simple and cost-effective method of fixation of the DBS lead with excellent results.