Incidence of Non-variceal Upper Gastrointestinal Bleeding Worsens Outcomes with Acute Coronary Syndrome: Result of a National Cohort.

INTRODUCTION: Upper gastrointestinal bleeding (UGIB) is a feared complication of acute coronary syndrome (ACS) and has been shown to increase morbidity and mortality. Our aim was to assess the incidence of non-variceal UGIB in patients with ACS in a national cohort and its impact on in-hospital mortality, length of stay (LOS), and cost of hospitalization. METHODS: This was a retrospective cohort study analyzing the 2016 Nationwide Inpatient Sample (NIS) utilizing ICD 10 CM codes. Principal discharge diagnoses of ACS (STEMI, NSTEMI, and UA) in patients over 18 years old were included. Non-variceal UGIB with interventions including endoscopy, angiography, and embolization were also evaluated. Primary outcome was the national incidence of concomitant non-variceal UGIB in the setting of ACS. Secondary outcomes included in-hospital mortality, length of stay, and cost of stay. RESULTS: A total of 661,404 discharges with principal discharge diagnosis of ACS in 2016 were analyzed. Of the included cohort, 0.80% (n = 5324) were complicated with non-variceal UGIB with increased frequency in older patients (OR 1.03, 95% CI 1.03-1.04; p = 0.0001). Despite endoscopic evaluation, 17.35% (n = 744) underwent angiography. After adjustment of confounders, inpatient mortality was significantly higher in patients with UGIB (OR 2.07, 95% CI 1.63-2.63, p = 0.0001). Non-variceal UGIB also led to significantly longer LOS (10.38 days vs 4.37 days, p = 0.0001) and cost of stay ($177,324 vs $88,468, p = 0.0001). DISCUSSION: Our study shows that the national incidence of non-variceal UGIB complicating ACS is low at less than 1%, but resulted in significantly higher inpatient mortality, LOS, and hospitalization charges.

Performance of a new preloaded fiducial needle to guide radiation therapy of upper gastrointestinal cancers.

BACKGROUND: Insertion of fiducials to outline the targeted lesion allows image-guided radiotherapy, and is best achieved by endoscopic ultrasound (EUS). This study is a performance comparison of the new EUS-guided preloaded fiducial needle against Visicoil fiducials. METHODS: Technical success, visibility score, procedural time, costs, and complications for patients who underwent EUS-guided fiducial placement in upper gastrointestinal malignancies were prospectively collected. RESULTS: 60 patients with upper gastrointestinal cancers had fiducials (14 Visicoil; 46 preloaded fiducials) inserted for image-guided radiotherapy. Technical success was 100 %, with a shorter mean (standard deviation) insertion time of 0.94 minutes (0.28 minutes) vs. 5.5 minutes (1.9 minutes; P < 0.001) and higher visibility score on fluoroscopy of 2 vs. 1.18 (P < 0.001) in the preloaded group. Neither group had major complications related to fiducial insertion. The cost of consumables per patient was lower in the preloaded group at US$480 (US$124) vs. US$643 (US$123; P < 0.001). CONCLUSION: Fiducial insertion for image-guided radiotherapy using the new preloaded needle is associated with 100 % technical success, shorter insertion time, and higher visibility, and is more cost-effective than the Visicoil system.

Upper gastrointestinal series after Roux-en-Y gastric bypass for morbid obesity: effectiveness in leakage detection. a systematic review of the literature.

The aim of this study is to evaluate the results of routine and selective postoperative upper gastrointestinal series (UGIS) after Roux-en-Y gastric bypass (RYGB) for morbid obesity in different published series to assessing its utility and cost-effectiveness. A search in PubMed's MEDLINE was performed for English-spoken articles published from January 2002 to December 2012. Keywords used were upper GI series, RYGB, and obesity. Only cases of anastomotic leaks were considered. A total of 22 studies have been evaluated, 15 recommended a selective use of postoperative UGIS. No differences in leakage detection or in clinical benefit between routine and selective approaches were found. Tachycardia and respiratory distress represent the best criteria to perform UGIS for early diagnosis of anastomotic leak after a RYGB.

The utility of routine postoperative upper gastrointestinal swallow studies following laparoscopic sleeve gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) has grown in popularity in recent years for the treatment of morbid obesity. Controversy exists regarding the usefulness of upper gastrointestinal (UGI) swallow studies on the first postoperative day in detecting possible complications. The aim of our study was to determine the efficacy and cost benefit of routine UGI studies on the first postoperative day following LSG. We retrospectively reviewed the hospital's records to identify patients who underwent LSG between January 2012 and June 2013. All patients had iodine-based contrast swallow study on the first postoperative day. Reports from all imaging studies and medical files were retrospectively reviewed, and complications were recorded. The Institutional Review Board waived the requirement for informed consent. During the study period, 722 patients underwent LSG. Mean BMI was 43 kg/m(2) (range 25-70). Of the 722 UGI studies, 721 were normal. The 1 abnormal study showed complete obstruction due to an incarcerated hiatal hernia. Five patients presented with a leak (0.7%). UGI swallow studies failed to detect any of the leaks resulting in a sensitivity of 0%. All leaks were apparent on computed tomography (CT) scans on postoperative days 2, 5, 7, 23, and 90. The total cost of the UGI swallow studies was $180,500. Performing routine UGI studies on the first postoperative day following LSG is clearly not cost beneficial. UGI contrast studies are not efficient to screen for suture line leaks. We recommend obtaining a CT scan when there is clinical suspicion for a complication.

Utility of routine versus selective upper gastrointestinal series to detect anastomotic leaks after laparoscopic gastric bypass.

BACKGROUND: In up to 4% of laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures, anastomotic leaks occur. Early detection of gastrointestinal leakage is important for successful treatment. Consequently, many centers advocate routine postoperative upper gastrointestinal (UGI) series. The aim of this study was to determine the utility of this practice after LRYGB. METHODS: Eight hundred four consecutive patients undergoing LRYGB from June 2000 to April 2010 were analyzed prospectively. The first 382 patients received routine UGI series between the third and fifth postoperative days (group A). Thereafter, the test was only performed when clinical findings (tachycardia, fever, and drainage content) were suspicious for a leak of the gastrointestinal anastomosis (group B; n = 422). RESULTS: Overall, nine of 804 (1.1%) patients suffered from leaks at the gastroenterostomy. In group A, four of 382 (1%) patients had a leak, but only two were detected by the routine UGI series. This corresponds to a sensitivity of 50%. In group B, the sensitivity was higher with 80%. Specificities were comparable with 97% and 91%, respectively. Routine UGI series cost only 1.6% of the overall costs of a non-complicated gastric bypass procedure. With this leak rate and sensitivity, US $86,800 would have to be spent on 200 routine UGI series to find one leak which is not justified. CONCLUSIONS: This study shows that routine UGI series have a low sensitivity for the detection of anastomotic leaks after LRYGB. In most cases, the diagnosis is initiated by clinical findings. Therefore, routine upper gastrointestinal series are of limited value for the diagnosis of a leak.

Comparing upper gastrointestinal X-ray and endoscopy for gastric cancer diagnosis in Korea.

AIM: To compare the cost and accuracy of upper gastrointestinal (GI) X-ray and upper endoscopy for diagnosis of gastric cancer using data from the 2002-2004 Korean National Cancer Screening Program (NCSP). METHODS: The study population included 1,503,646 participants in the 2002-2004 stomach cancer screening program who underwent upper GI X-ray or endoscopy. The accuracy of screening was defined as the probability of detecting gastric cancer. We calculated the probability by merging data from the NCSP and the Korea Central Cancer Registry. We estimated the direct costs of the medical examination and the tests for upper GI X-ray, upper endoscopy, and biopsy. RESULTS: The probability of detecting gastric cancer via upper endoscopy was 2.9-fold higher than via upper GI X-ray. The unit costs of screening using upper GI X-ray and upper endoscopy were $32.67 and $34.89, respectively. In 2008, the estimated cost of identifying one case of gastric cancer was $53,094.64 using upper GI X-ray and $16,900.43 using upper endoscopy. The cost to detect one case of gastric cancer was the same for upper GI X-ray and upper endoscopy at a cost ratio of 1:3.7. CONCLUSION: Upper endoscopy is slightly more costly to perform, but the cost to detect one case of gastric cancer is lower.

Radiologic assessment of the upper gastrointestinal tract: does it play an important preoperative role in bariatric surgery?

BACKGROUND: The role of upper GI series (UGIS) before bariatric surgery is controversial. The aim of this study was to evaluate the diagnostic yield and cost of routine UGIS prior to bariatric surgery. METHODS: The medical records of consecutive obese patients who underwent UGIS before bariatric surgery between April 2001 and October 2002 were reviewed. UGIS reports were reviewed by 2 experienced gastroenterologists, and the findings were divided into 4 groups based on predetermined criteria: group 0 (normal study), group 1 (abnormal findings that neither changed the surgical approach nor postponed surgery), group 2 (abnormal findings that changed the surgical approach or postponed surgery), and group 3 (results which were an absolute contraindication to surgery). Clinically important findings included lesions in groups 2 and 3. The cost of an upper GI series (154.80 USD) was estimated from the published 2002 New York State Medicare reimbursement schedule. RESULTS: During the 18-month study period, 171 patients were evaluated by UGIS prior to bariatric surgery. One or more lesions were identified in 48.0% of patients, with only 5.3% having clinically important findings. The prevalence of radiologic findings using the classification system above was as follows: group 0 (52.0%), group 1 (42.7%), group 2 (5.3%), and group 3 (0.0%). The most common findings identified were esophageal reflux (21.6%) and hiatal hernias (18.7%). The cost of performing routine UGIS on all patients before bariatric surgery was 2,941.20 USD per clinically important finding detected. CONCLUSIONS: Routine preoperative upper GI series before bariatric surgery had a low diagnostic yield, rarely revealing pathology that changed the surgical approach or postponed surgery.