Comparison of success and cost after retrieval of two inferior vena cava filters.

OBJECTIVE: The objective of this study was to help guide inferior vena cava (IVC) filter choices by better understanding the retrieval characteristics, complications, and total costs between two commonly used IVC filters. METHODS: All patients who underwent retrieval or attempted retrieval of Denali (Bard Peripheral Vascular) or Option (Argon Medical Devices) IVC filters were identified between March 2016 and October 2021 at a single tertiary care center. Those with imaging studies that permitted evaluation of filter placement, presence or degree of tilt, and/or hooking of the filter into the IVC wall were included in the present study. Filter retrieval success, number of attempts, use of advanced techniques, and fluoroscopy and procedural times were recorded and compared between the two filters. RESULTS: A total of 87 patients presented for retrieval of 52 Denali and 35 Option Elite filters during the study period. Denali filters were more likely to be successfully retrieved at the first attempt (94% vs 77%; P = .019). The procedural and fluoroscopy times were shorter for Denali filters (29 minutes vs 63 minutes [P < .001] and 7 minutes vs 25 minutes [P < .001], respectively). Denali filters were less likely to be significantly tilted (≥15○) at retrieval (12% vs 29%; P < .001) or to have the filter hook embedded in the IVC wall (6% vs 40%; P < .001). Tilting of the filter of ≥15○ had no significant effects on the retrieval success rate (no tilt or tilt <15○ vs tilt of ≥15○: 98% vs 100%; P = .58). In contrast, filter hook penetration into the IVC wall significantly reduced successful recovery (41% vs 99%; P < .001). CONCLUSIONS: The findings from this study suggest that although the filter designs are similar, a benefit exists in the ease of retrievability of the Denali over the Option filter. We found that tilting and hooking of the filter in the IVC wall occurred significantly more with the Option filter. These factors likely made retrieval more difficult and contributed to the longer procedure and fluoroscopy times.

Understanding radiation exposure and improving safety for vascular surgery trainees.

OBJECTIVE: Despite having robust radiation safety education procedures and policies in place, we discovered that the trainees at our Accreditation Council for Graduate Medical Education-approved integrated vascular surgery residency and fellowship program were exceeding the annual radiation exposure limits. In the present report, we have described our quality improvement project to identify the root causes and implement policies to improve radiation safety education, oversite, and, ultimately, the exposure levels of our trainees. METHODS: A committee of faculty, fellows, radiology nurses, and radiation safety officers from each of the programs affiliated hospitals convened to identify the potential root causes of the increased radiation exposure and potential modifiable actions. The radiation exposure reports for postgraduate year 4 to 7 trainees were evaluated before and after the interventions. RESULTS: Excessive radiation exposure was found to be more prevalent than anticipated, with multiple trainees surpassing the annual exposure limits. The committee classified the factors at play and interventions into four categories: policies and procedures, curriculum, environment, resources, and equipment. The multisite status of our program was a key factor associated with the increased radiation exposure. In addition, we found that excessive radiation levels were occurring primarily at a single hospital site. After the interventions, the monthly average levels at this site had decreased considerably from 936 mrem to 272 mrem. CONCLUSIONS: We found it alarming that the safety policies in place at vascular residency and fellowship programs were inadequate in securing the safety of their trainees. We found interventions such as inventorying and ensuring the availability of safety equipment, hands-on instruction to complement traditional didactics, lowering the default frame rates, and converting to real-time dosimetry to be effective measures for reducing radiation exposure.

National survey of vascular surgery residents and fellows on radiation exposure and safety practices.

OBJECTIVE: The objective of the present study was to evaluate radiation safety practices, radiation training, and radiation exposure among senior vascular residents and fellows in Accreditation Council for Graduate Medical Education-accredited programs across the United States. METHODS: Anonymous surveys were sent to all Accreditation Council for Graduate Medical Education program directors to be distributed to postgraduate year 4 to 7 vascular trainees for completion. The survey questions focused on program type (single vs multiple hospital site), familiarity with their radiation officer, formal radiation training, frequency of radiation feedback, use of safety equipment, and adherence to as low as reasonably achievable principles. RESULTS: A total of 95 trainees responded (27% response rate). Of the 95 trainees, 49 (51.6%) had reported they had never met their radiation safety officer, 74 (77.9%) reported they had received formal radiation safety education, 50 (53%) reported receiving feedback regarding their monthly radiation exposure, and 24 (25%) reported never having received such feedback. All the findings were more common among the multiple hospital site program respondents. CONCLUSIONS: It should be of significant concern that such a high number of trainees have been exceeding radiation exposure limits. Programs should strive to reduce radiation exposure through formal training, provision of safety equipment, modeling by attendings of adherence to as low as reasonably achievable principles, and timely feedback on radiation exposure.

Venous thromboembolism in patients with COVID-19 infection: risk factors, prevention, and management.

Venous thromboembolic complications have emerged as serious sequelae in COVID-19 infections. This article summarizes the most current information regarding pathophysiology, risk factors and hematologic markers, incidence and timing of events, atypical venous thromboembolic complications, prophylaxis recommendations, and therapeutic recommendations. Data will likely to continue to rapidly evolve as more knowledge is gained regarding venous events in COVID-19 patients.

Association of same-day discharge with hospital readmission after pediatric thyroidectomy.

BACKGROUND: Studies have demonstrated that same-day discharge (SDD) following thyroid resection is safe and feasible in adults but there are no similar studies in the pediatric age group. The purpose of this study is to evaluate the influence of SDD on 30-day readmission rates following thyroid surgery in pediatric patients. METHODS: This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database to evaluate 30-day readmission rates among patients < 19 years of age who underwent thyroid resection between 2012 and 2017. Patients excluded were those discharged more than 2 days after surgery. The main exposure variable was SDD and the primary outcome was 30-day readmission. Secondary outcomes included wound complications, unplanned reoperation and death. Patient characteristics were compared using chi-squared testing and odds ratios for readmission were calculated using multivariate logistic regression. RESULTS: Of the 1125 patients (79% female, median age 15 years), 122 (11%) were discharged on the day of surgery. Total or near-total thyroidectomy represented the majority of operations (714, 63.5%) and patients undergoing these operations were less likely to be discharged on the same day as surgery compared to those undergoing thyroid lobectomy (4.3 vs. 22.1%, P < 0.001). Twenty-nine patients were readmitted within 30 days (3 in the same day group, 26 in the later group). There was no difference in the odds of readmission between the two groups (adjusted odds ratio in SDD compared to later discharge 1.04 [95% CI 0.29-3.75, P = 0.96; readmission rate, 2.46 vs. 2.59%). Wound complications were reported in two patients, both in the later discharge group. CONCLUSION: Same-day discharge in pediatric patients undergoing thyroidectomy is not associated with an increase in 30-day readmissions or wound complications when compared to patients discharged 1 or 2 days after surgery. In selected patients, SDD may be an appropriate alternative to traditional overnight stay.

Low Complication Rates Using Closed-Incision Negative-Pressure Therapy for Panniculectomies: A Single-Surgeon, Retrospective, Uncontrolled Case Series.

BACKGROUND: Panniculectomies are associated with high complication rates (43 to 70 percent), particularly in patients with obesity, smoking, and diabetes mellitus. Closed-incision negative-pressure therapy can be used postoperatively to support healing by promoting angiogenesis and decreasing tension. The authors hypothesized that using it with panniculectomies would minimize complications, and that a longer duration of therapy would not increase the incidence of complications. The authors also evaluated whether closed-incision negative-pressure therapy malfunction was associated with complications. METHODS: This retrospective, uncontrolled case series analyzed 91 patients who underwent panniculectomies managed with closed-incision negative-pressure therapy performed by a single surgeon from 2014 to 2018. Patients were followed for 6 months; therapy duration and malfunction were recorded. Patients were placed into therapy duration groups (2 to 7, 8 to 10, or >10 days). Complications managed conservatively were minor and major if they required intervention. Odds ratios were performed with 95 percent confidence intervals and p values. RESULTS: Mean follow-up was 225.1 days and mean closed-incision negative-pressure therapy duration was 10.5 days. Major complications were reported in five patients (5.5 percent), infections in four (4.4 percent), dehiscence in two (2.2 percent), and seroma in four (4.4 percent). Patients with malfunction [n = 16 (17.6 percent)] were more likely to experience complications (OR, 3.3; p = 0.043). No significant increase in complications was found with therapy duration longer than 10 days, but potentially there is an increased risk of infection (OR, 4.0; p = 0.067). CONCLUSIONS: Although high complication rates have been associated with panniculectomies, the authors' results show that low complication rates can be achieved with closed-incision negative-pressure therapy. Randomized controlled trials need to be conducted evaluating different therapy systems and the optimal duration of therapy with panniculectomies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A Case of Isolated Gastrointestinal Histoplasmosis.

Histoplasmosis is a self-limited and asymptomatic disease in immunocompetent individuals. Patients with untreated human immunodeficiency virus (HIV) or immune suppression due to medications such as corticosteroids can present with disseminated and life-threatening infections. We present a case of a 60-year-old female that presented with recurrent diarrhea that was found to have isolated gastrointestinal (GI) histoplasmosis. The rarity of this case is due to the isolated colonic involvement and lack of respiratory symptoms (the portal of infection). In conclusion, clinicians should be aware of isolated histoplasmosis affecting the GI tract and careful endoscopic evaluation with adequate sampling is warranted to confirm the diagnosis.

Unusual complication of bladder prolapse with subsequent diagnosis of urothelial carcinoma leading to a necrotizing soft tissue infection after radical cystectomy.

There is lack of information in the literature on long-term complications of suprapubic catheters. The most common complications include urinary tract infection, bladder calculi, urine leakage and neoplastic changes. We report a case of an unusual complication of bladder prolapse, with subsequent diagnosis of urothelial carcinoma, leading to a necrotizing soft tissue infection after a radical cystectomy in a patient with long-term catheterization and its management. Due to the rarity of this complication, its management has not been well studied. In this particular case, the logical indication was radical cystectomy due to the presence of bladder necrosis.

A rare case of percutaneous endoscopic gastrostomy causing a small bowel obstruction and subsequent bowel erosion.

Gastrostomy tubes can be used to provide long-term nutrition and feeding when oral intake is not adequate. A rare but serious complication includes iatrogenic small bowel injury. The incidence of this is infrequent due to its position of the small bowel beneath the omentum, however, injury leading to obstruction and volvulus has been previously described in the literature. We present an unusual case of gastrostomy tube transection into omental fat causing a kink in the small bowel allowing for a transition point of obstruction and subsequent erosion of the gastrostomy tube into the small bowel.

Langerhans Cell Histiocytosis of the Gastrointestinal Tract - A Rare Entity.

Langerhans cell histiocytosis (LCH) is an idiopathic and rare disease that ranges in clinical severity based on location and organ involvement. LCH most commonly affects the skin and bones. The involvement of the gastrointestinal tract (GI) in adults is exceedingly rare and only 10 cases have been reported in the literature. We present the case of a 60-year-old male who was referred for a routine screening colonoscopy. Numerous 3-5 mm nodular lesions were present throughout the colon. A histopathological examination revealed diffuse aggregates of histiocytes within the lamina propria of the mucosa and immunohistochemical staining further confirmed the presence of Langerhans cells with a positive CD1-a stain. Although extremely rare, LCH involving the GI tract should be considered as a differential diagnosis when polyps or nodular lesions are witnessed on screening colonoscopies. In addition, the lesions must be biopsied to confirm the diagnosis of LCH and additional follow-up is essential to rule out systemic disease.