Maximizing success in single-session EUS-directed transgastric ERCP: a retrospective cohort study to identify predictive factors of stent migration.

BACKGROUND AND AIMS: EUS-directed transgastric ERCP (the EDGE procedure) is a simplified method of performing ERCP in Roux-en-Y gastric bypass patients. The EDGE procedure involves placement of a lumen-apposing metal stent (LAMS) into the excluded stomach to serve as a conduit for passage of the duodenoscope for pancreatobiliary intervention. Originally a multistep process, urgent indications for ERCP have led to the development of single-session EDGE (SS-EDGE) with LAMS placement and ERCP performed in the same session. The goal of this study was to identify predictive factors of intraprocedural LAMS migration in SS-EDGE. METHODS: We conducted a multicenter retrospective review that included 9 tertiary medical centers across the United States. Data were collected and analyzed from 128 SS-EDGE procedures. The primary outcome was intraprocedural LAMS migration. Secondary outcomes were other procedural adverse events such as bleeding and perforation. RESULTS: Eleven LAMS migrations were observed in 128 procedures (8.6%). Univariate analysis of clinically relevant variables was performed, as was a binary logistic regression analysis of stent diameter and stent dilation. This revealed that use of a smaller (15 mm) diameter LAMS was an independent predictor of intraprocedural stent migration (odds ratio, 5.36; 95% confidence interval, 1.29-22.24; P = .021). Adverse events included 3 patients who required surgery and 2 who experienced intraprocedural bleeding. CONCLUSIONS: Use of a larger-diameter LAMS is a predictive factor for a nonmigrated stent and improved procedural success in SS-EDGE. Although larger patient cohorts are needed to adequately assess these findings, performance of LAMS dilation and fixation may also decrease risk of intraprocedural LAMS migration and improve procedural success.

Prevalence of Homelessness in the Emergency Department Setting.

INTRODUCTION: According to the National Alliance to End Homelessness, the national rate of homelessness has been cited as 17.7 homeless people/10,000 people in the general population, and 24.8 homeless veterans/10,000 veterans in the general population. However, it is unknown what the prevalence of homelessness is in the emergency department (ED) setting. We set out to determine the prevalence of homelessness or at risk for homelessness in the ED setting. METHODS: Using a five-question screening tool derived from the U.S. Department of Housing and Urban Development, Health and Human Services and the Veterans Administration definition for homelessness, we surveyed all patients meeting inclusion/exclusion criteria on scheduled shifts in one of three EDs in Northeastern Pennsylvania. To participate, subjects had to be a registered patient in the ED, be 18 years or older, speak English, have the capacity to answer survey questions, not be critically ill, be willing to participate, and not have taken the survey before. We selected two survey periods to represent seasonal variations. RESULTS: We included 4,395 subjects in the analysis. The mean age of those who screened positive for homelessness or at risk for homelessness was 43.1 (SD 16.6). Overall, 136 (3.1%) participants screened positive for at risk for homelessness and 309 (7.0%) screened positive for homelessness. A total of 103 subjects (9.8%) screened positive for homelessness or at risk for homelessness on weekends and 312 (10.3%) on weekdays (p=0.64). The proportion of those screening positive for homelessness or at risk for homelessness varied by site: 145 (7.5%) at the trauma center, 151(9.1%) at the suburban site, and 149 (18.7%) at the center city site, p<0.001.There was no statistical significance to the difference between the trauma center and the suburban site (p=.088), but there was statistical significance between both the suburban and the trauma center when compared to the center city site (both p<0.0001). The proportion of those screening positive for homelessness in the summer months (156, 7.5%) was similar to those in the winter months (153, 6.6%), p=0.23. CONCLUSION: In our study, the overall prevalence of homelessness or at risk for homelessness was 10.1 percent. This prevalence did not seem to vary between weekdays and weekends. Additionally, summer months had a prevalence that was as concerning as winter months. The prevalence does, however, seem to vary by institutional characteristics even in the same geographic region. Understanding the patterns of prevalence of homelessness is a step toward considering possible interventions to assist this vulnerable population.

Life-Threatening Retropharyngeal Hemorrhage Secondary to Rupture of the Inferior Thyroid Artery.

Inferior thyroid artery (ITA) rupture is rare and may progress to life-threatening conditions. We present a patient who visited the emergency department after an episode of syncope and dizziness in which he had a mechanical fall that resulted in abrasions and a hematoma to his left forehead. The patient presented with dysphagia and anterior neck swelling that progressed rapidly into airway compromise requiring endotracheal intubation. Emergent computed tomography revealed a large retropharyngeal hematoma, with active arterial extravasation that was thought to be arising from the thyrocervical trunk on the left. The hematoma measured approximately 6.7 cm transversely and 3.2 cm anteroposteriorly and extended from the level of the lower nasopharynx, down the neck into the retropharyngeal and danger space and into the mediastinum posterior to the esophagus, overall approximately 25 cm. The larynx was deviated anteriorly and there was esophageal compression. An emergent arteriogram and catheterization confirmed bleeding from branches of the ITA, and successful embolization was performed. It is important to recognize the ITA rupture as a potential etiology of an acute airway compromise. In emergent situations, while securing an airway is a priority, rapidly initiating diagnostic testing to confirm the diagnosis and arranging for arterial embolization can be life-saving.