Posterior Gastric Perforation with an Opening in Transverse Mesocolon: A Rare Case Report.

Posterior gastric perforation is a very rare finding, difficult to diagnose due to the insidious onset of upper abdominal symptoms, and no air under the diaphragm on X-ray. Posterior gastric perforation which opens into transverse mesocolon is even rarer. This is a case report done to entail such a rare case, with only two cases reported in the past. We present the case of a 21-year-old female with pain in the epigastric region spreading to involve the whole abdomen, fever, vomiting, and anorexia. In our case, radiological findings revealed pneumoperitoneum. Intraoperatively, a tract was identified between the posterior wall of the stomach and transverse mesocolon. Tract was excised and primary repair was done using the Graham patch method.

A Rare Case of Cholecystoduodenal and Cholecystocolic Fistula with Gallstone Ileus.

Cholecystoduodenal and cholecystocolic fistula (CCF) is a rare condition, occurring in patients with cholelithiasis. Multiple complex fistulas are even rare. This is a case study done to detail such a rare case, very few such cases have been reported in the past studies, with cholecystoduodenal and CCF with gallstone ileus. We present the case of an 80-year-old, female diagnosed with intestinal obstruction. Intraoperatively, the gallbladder (GB) fundus forms a CCF and the body of the GB with the first part of the duodenum forms cholecystoduodenal fistula. Gallstone ileus found impacted in jejunum 35 cm distal to DJ junction. Resection of fistula tracts with primary repair of the transverse colon was done with Graham's patch repair of duodenum and fundus first cholecystectomy. Cholecysto-duodeno-colic fistulas complicated with gallstone ileus are very rare. In the case of gallstone ileus, the surgical treatment is an emergency and the only therapeutic option.

Structured training program on confocal laser endomicroscopy for pancreatic cystic lesions: a multicenter prospective study among early-career endosonographers (with video).

BACKGROUND AND AIMS: Data on how to teach endosonographers needle-based confocal laser endomicroscopy (nCLE)-guided histologic diagnosis of pancreatic cystic lesions (PCLs) are limited. Hence, we developed and tested a structured educational program to train early-career endosonographers in nCLE-guided diagnosis of PCLs. METHODS: Twenty-one early-career nCLE-naïve endosonographers watched a teaching module outlining nCLE criteria for diagnosing PCLs. Participants then reviewed 80 high-yield nCLE videos, recorded diagnoses, and received expert feedback (phase 1). Observers were then randomized to a refresher feedback session or self-learning at 4 weeks. Eight weeks after training, participants independently assessed the same 80 nCLE videos without feedback and provided histologic predictions (phase 2). Diagnostic performance of nCLE to differentiate mucinous versus nonmucinous PCLs and to diagnose specific subtypes were analyzed using histopathology as the criterion standard. Learning curves were determined using cumulative sum analysis. RESULTS: Accuracy and diagnostic confidence for differentiating mucinous versus nonmucinous PCLs improved as endosonographers progressed through nCLE videos in phase 1 (P < .001). Similar trends were observed with the diagnosis of PCL subtypes. Most participants achieved competency interpreting nCLE, requiring a median of 38 assessments (range, 9-67). During phase 2, participants independently differentiated PCLs with high accuracy (89%), high confidence (83%), and substantial interobserver agreement (κ = .63). Accuracy for nCLE-guided PCL subtype diagnoses ranged from 82% to 96%. The learned nCLE skills did not deteriorate at 8 weeks and were not impacted by a refresher session. CONCLUSIONS: We developed a practical, effective, and durable educational intervention to train early-career endosonographers in nCLE-guided diagnosis of PCLs.

Tofacitinib Appears Well Tolerated and Effective for the Treatment of Patients with Refractory Crohn's Disease.

BACKGROUND: Active Crohn's disease increases the risk of strictures, fistulas, and abscesses. Less than 30% of patients with Crohn's disease achieve endoscopic remission on any therapy. Tofacitinib may be a therapeutic option for patients with refractory Crohn's disease. AIMS: We aimed to evaluate the safety and effectiveness of off-label tofacitinib for refractory Crohn's disease. METHODS: We retrospectively assessed adverse events and clinical/endoscopic response after therapy. RESULTS: Forty-four patients were included in the safety analysis and 35 were included in the clinical and/or endoscopic assessments. The mean age was 41.8 years and the mean disease duration was 17.4 years. All patients had prior biologic exposure. Adverse events were reported in 52.3% of patients; 13.6% had ≥ 1 serious adverse event after a median 54.6 weeks of treatment. Seventy percent achieved clinical response after a mean 29.4 (SD 15.1) weeks, and 33.3% achieved clinical remission after a mean 33.4 (SD 17.6) weeks of therapy. Endoscopic improvement occurred in 25.0%, endoscopic remission in 12.5%, and endoscopic healing in 4.2% of patients after a mean 52.0 (SD 15.0) weeks of therapy. The mean Simple Endoscopic Score in Crohn's disease significantly improved from 23.1 ± 3.7 to 18.0 ± 13.7 after treatment (P = .02). CONCLUSIONS: In the short term, tofacitinib appears well tolerated. The most common adverse event was minor infection. One serious infection and one colorectal cancer occurred. While half of patients reported adverse events, this likely reflects the severe refractory disease in this population and no new safety events were observed. Tofacitinib achieved clinical and endoscopic improvement in some patients with refractory Crohn's disease. Further research is needed to understand the long-term safety and efficacy of tofacitinib in Crohn's disease.

Safety and Efficacy of Tofacitinib in Combination With Biologic Therapy for Refractory Crohn's Disease.

BACKGROUND: The majority of patients with Crohn's disease (CD) will not achieve endoscopic remission on current therapy. Addition of tofacitinib to biologics may improve remission rates. METHODS: We retrospectively assessed safety and clinical and endoscopic effectiveness of off-label tofacitinib and biologics for CD. RESULTS: We identified 19 patients treated with tofacitinib and a biologic for refractory CD between 2017 and 2019. Tofacitinib was added for luminal disease on colonoscopy (n = 13), luminal disease on capsule (n = 3), and pyoderma gangrenosum (n = 3). The mean age was 41.2 years (28-62), mean disease was duration 16.9 years (6-36), and prior exposure to biologics was a median of 4 (1-6). Mean treatment duration was 9.6 months (SD, 3.3). Adverse events (AEs) were reported in 36.8% of patients, most commonly minor infection or CD flare, and no patients had a serious AE; 80.0% (n = 8) achieved clinical response, and 60.0% (n = 6) achieved clinical remission based on Harvey-Bradshaw Index. Endoscopic improvement occurred in 54.5% (n = 6), endoscopic remission in 18.2% (n = 2), and endoscopic healing in 18.2% (n = 2) of patients. Mean Simple Endoscopic Score in CD significantly improved from 13.6 ±â€…5.2 to 6.5 ±â€…4.0 after treatment (P < .01). CONCLUSIONS: In patients treated with tofacitinib in combination with a biologic, no new safety signals were observed. Combination tofacitinib and a biologic was effective in achieving clinical and endoscopic improvement in some patients with severe, refractory CD, although a larger sample size is needed to further assess the efficacy and long-term safety of this treatment strategy.

Prevalence, risk factors, and surveillance patterns for gastric intestinal metaplasia among patients undergoing upper endoscopy with biopsy.

BACKGROUND AND AIMS: Gastric intestinal metaplasia (GIM) is an important precursor lesion to gastric cancer (GC), the second leading cause of cancer death worldwide. There exist few data regarding the prevalence of, risk factors for, and clinical practice patterns regarding GIM in the United States. Furthermore, there are currently no U.S. guidelines regarding screening/surveillance for GIM. METHODS: All consecutive upper endoscopic procedures from 2 academic medical centers in Seattle between 1999 and 2014 were reviewed. Demographic, clinical, and endoscopic covariates were recorded at time of endoscopy. Procedures with gastric biopsy were matched to final the histologic diagnoses, including the presence of Helicobacter pylori. Cases of GIM and dysplasia were recorded and compared with non-GIM controls using univariate and multivariable regression. Surveillance patterns for cases of GIM were recorded. RESULTS: Data from 36,799 upper endoscopies, 17,710 gastric biopsies, 2073 cases of GIM, 43 cases of dysplasia, and 78 cases of GC were captured. The point prevalence of GIM was 11.7% in patients who underwent gastric biopsy. Non-white race (P < .001), increasing age (P < .001), and presence of H pylori (P < .001) were associated with GIM. If GIM was present, increasing age (P < .001) and male gender (P < .001) were associated with progression, and the presence of H pylori (P < .001) was inversely associated with progression to dysplasia/GC. Few cases of GIM/dysplasia/GC were identified during procedures for GIM screening/surveillance. Only 16% of patients with a diagnosis of GIM received a recommendation for surveillance. CONCLUSIONS: There is a high prevalence of GIM among non-white and Hispanic Americans. Risk factors for development of GIM may be distinct from the risk factors for progression to GC.

Opioid Use Is Associated With Higher Health Care Costs and Emergency Encounters in Inflammatory Bowel Disease.

BACKGROUND: We aimed to examine opioid use among adult patients with inflammatory bowel disease (IBD) in the United States and the impact of extended opioid use on emergency health care services and health care costs among patients. METHODS: We conducted a retrospective cohort study using medical claims data from the Truven Health MarketScan research databases, consisting of patients across the United States with employer-based health insurance. Subjects with IBD were identified in 2009. The occurrence of an emergent encounter in 2010 and health care costs were assessed. RESULTS: There were 76,171 subjects with 35,993 emergent encounters among the study population, for an overall rate of 0.47 per patient-year. However, these encounters were confined to 6.9% of patients overall. The median total charges per patient in 2010 were $5372. Extended opioid use in 2009 was associated with a higher odds of an emergent encounter in 2010 (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.67-1.98), higher incidence rate of emergent encounters (incidence rate ratio, 2.07; 95% CI, 1.91-2.24), and higher odds of being in the top quartile of cost in 2010 (OR, 1.90; 95% CI, 1.79-2.02). Depression was a strong predictor of extended opioid use (OR, 2.64; 95% CI, 2.49-2.81; P < 0.001). CONCLUSIONS: Extended opioid use among patients with IBD is an important predictor of emergent encounters and is associated with higher total health care costs. Psychosocial comorbidities are significant predictors of extended opioid use in patients with IBD.

Efficacy of Infliximab in Crohn's Disease Patients with Prior Primary-Nonresponse to Tumor Necrosis Factor Antagonists.

BACKGROUND: Tumor necrosis factor antagonists (TNFs) are effective for moderate-severe Crohn's disease (CD). Approximately one-third of patients have primary-nonresponse to TNFs, which is reported to predict worse response to subsequent TNF therapy. However, this is based on treatment with subcutaneously (SC) administered, fixed-dose TNFs after failure of intravenously (IV) administered, weight-based TNFs. No study has specifically assessed the clinical and endoscopic effectiveness of IV TNFs following primary-nonresponse to SC TNFs. We hypothesize that IV, weight-based TNF dosing offers advantages over SC, fixed-dose TNFs and may be effective despite primary-nonresponse to previous SC fixed-dose TNFs. METHODS: This retrospective cohort study identified patients with moderate-severe CD with primary-nonresponse to one or more SC TNFs who subsequently received the IV TNF, infliximab for ≥ 12 weeks. We described baseline characteristics, and clinical, endoscopic and biochemical response to therapy. RESULTS: Key characteristics of 17 patients are described in Table 1. After ≥ 12 weeks of infliximab, 11 of 15 (73.3%) patients with clinical data reported clinical response and remission. Of 11 patients with endoscopic data, restaging colonoscopy revealed mucosal improvement in seven (63.6%) patients. Of these, five (45.5%) had endoscopic remission and three (27.3%) had mucosal healing. Table 1 Baseline characteristics of CD patients with primary-nonresponse to subcutaneous (SC) tumor necrosis antagonists (TNF), subsequently treated with intravenous (IV) TNF therapy Characteristics N 17 Mean age, years (range) 37.5 (18-67) Mean BMI, kg/m2 (range) 26.6 (17.8-40.6) Mean albumin prior to infliximab, g/dL (range) RR: 3.5-5.2 g/dL 3.57 (2.5-4.2) Female sex [n (%)] 7 (41.2) Tobacco use [n (%)]  Never 15 (88.2)  Former 1 (5.88)  Current 1 (5.88) Age at diagnosis [n (%)]  Less than 17 2 (11.8)  17-40 11 (64.7)  Over 40 4 (23.5) Mean disease duration, yrs (range) 7.76 (1-24) Disease extent [n (%)]  Ileal 2 (11.8)  Colonic 5 (29.4)  Ileocolonic 10 (64.7) Disease behavior [n (%)]  Nonstenosing, nonpenetrating 10 (58.8)  Stenosing 3 (17.6)  Penetrating 2 (11.8)  Stenosing and penetrating 2 (11.8) History of gastrointestinal surgery [n (%)] 4 (23.5)  Ileocecal resection (n) 2  Hemicolectomy (n) 2 Prior therapy [n (%)]  IV corticosteroids 3 (17.6)  Oral corticosteroids 14 (82.4)  5-ASA 12 (70.6)  Thiopurine 14 (82.4)  Methotrexate 10 (58.8) Prior biologic therapy  Adalimumab only 12 (70.6)  Certolizumab pegol only 2 (11.8)  Adalimumab and certolizumab pegol 2 (11.8)  Adalimumab, certolizumab pegol and golimumab 1 (5.88) Dose escalation of prior SC TNF [n (%)]  Adalimumab 9 (52.9)  Certolizumab pegol 0 (0.0)  Golimumab 0 (0.0) During infliximab, concomitant therapy [n (%)]  Immunomodulator 13 (76.5)  Corticosteroid 5 (29.4) CONCLUSIONS: Patients with moderate-severe CD with prior primary-nonresponse to SC, fixed-dose TNFs, subsequently treated with IV, weight-based TNF have high rates of clinical and endoscopic response and remission. Therefore, despite primary-nonresponse to SC TNFs, patients may benefit from IV TNF therapy and may not require a change to a different class of biologic therapy.

Outcomes of Infected versus Symptomatic Sterile Walled-Off Pancreatic Necrosis Treated with a Minimally Invasive Therapy.

Background/Aims: Acute pancreatitis complicated by walled-off necrosis (WON) is associated with high morbidity and mortality, and if infected, typically necessitates intervention. Clinical outcomes of infected WON have been described as poorer than those of symptomatic sterile WON. With the evolution of minimally invasive therapy, we sought to compare outcomes of infected to symptomatic sterile WON. Methods: We performed a retrospective cohort study examining patients who were undergoing dual-modality drainage as minimally invasive therapy for WON at a high-volume tertiary pancreatic center. The main outcome measures included mortality with a drain in place, length of hospital stay, admission to intensive care unit, and development of pancreatic fistulae. Results: Of the 211 patients in our analysis, 98 had infected WON. The overall mortality rate was 2.4%. Patients with infected WON trended toward higher mortality although not statistically significant (4.1% vs 0.9%, p=0.19). Patients with infected WON had longer length of hospitalization (29.8 days vs 17.3 days, p<0.01), and developed more spontaneous pancreatic fistulae (23.5% vs 7.8%, p<0.01). Multivariate analysis showed that infected WON was associated with higher odds of spontaneous pancreatic fistula formation (odds ratio, 2.65; 95% confidence interval, 1.20 to 5.85). Conclusions: This study confirms that infected WON has worse outcomes than sterile WON but also demonstrates that WON, once considered a significant cause of death, can be treated with good outcomes using minimally invasive therapy.

Chyluria-a review of literature and a modified sclerotherapy regimen.

Chyluria, described as passage of milky white urine, has been recognized as a urological manifestation of the lymphatic system due to abnormal connection between the blocked and dilated lymphatics and the renal pelvicaliceal systems. We report the case of a 36-year-old female from an endemic area of filariasis in India who presented with chyluria. In addition to medical therapy, intermittent sclerotherapy of renal pelvis with 0.2% povidone iodine was carried out with a dose schedule different from the ones in practice earlier. The idea of intermittent sclerotherapy was to create pyelolymphatic and pyelosinus reflux so as to sclerose the communicating channel between the lymphatic and urinary systems. This method proved to be curative for the patient and she was relieved from her 8-year-old problem and subsequently remained asymptomatic.

Bilateral Metachronous Breast Carcinoma: A Rare Case Report.

The occurrence of bilateral breast cancer is rare. A second primary in the contralateral breast can either be synchronous or metachronous. Lobular carcinoma of the breast is known for its multicentricity and bilateral spread. The synchronous mixed pattern of carcinoma of the breast has also been reported in the same breast. The family history of breast carcinoma, estrogen receptor negativity, and human epidermal growth factor receptor-2 positivity are risk factors for the development of contralateral breast malignancy. In metachronous, bilateral breast cancer (MBBC) usually a single histological variant is seen at different time periods. However, we report a rare case of MBBC in a 66-year-old female patient with positive family history who had infiltrating lobular carcinoma (ILC) in the left breast followed by infiltrating ductal carcinoma in the right breast after a span of 2½ years, even after undergoing modified radical mastectomy with adjuvant chemotherapy followed by hormonal therapy for ILC of left breast.

Patent Vitellointestinal Duct with Patent Urachus Presenting as Umbilical Discharge.

Patent urachus with patent vitellointestinal duct is a rare combination to present in the same patient. We present a rare case of one year old male child with such a condition presenting with complaint of discharge from umblicus along with severe anaemia and an umblical granuloma. On exploratory laparotomy, patent tracts joining umblicus to ileum and umblicus to apex of urinary bladder were found. Both the tracts were excised and appropriate closure was done. Patient had been under follow up and is doing well.

A comparison between modified Alvarado score and RIPASA score in the diagnosis of acute appendicitis.

Acute appendicitis is a common but elusive surgical condition and remains a diagnostic dilemma. It has many clinical mimickers and diagnosis is primarily made on clinical grounds, leading to the evolution of clinical scoring systems for pin pointing the right diagnosis. The modified Alvarado and RIPASA scoring systems are two important scoring systems, for diagnosis of acute appendicitis. We prospectively compared the two scoring systems for diagnosing acute appendicitis in 50 patients presenting with right iliac fossa pain. The RIPASA score correctly classified 88 % of patients with histologically confirmed acute appendicitis compared with 48.0 % with modified Alvarado score, indicating that RIPASA score is more superior to Modified Alvarado score in our clinical settings.

An Unusual Lesser Sac Collection Causing Gastric Outlet Obstruction with Coincidental Occurrence of Leriche's Syndrome: A Case Report.

Gastric outlet obstruction in adults is usually caused by pyloric stenosis secondary to peptic ulcer disease or malignancy. However, there are few other causes such as a foreign body and external compression due to pseudocyst pancreas. We present a rare aetiology of a large collection of pus in the lesser sac in our patient causing gastric outlet obstruction. A perforated peptic ulcer was suspected in our patient who had symptoms of sudden onset pain in epigastric region which was referred to back. This was followed by pain in upper abdomen, vomiting, constipation and fever for which patient was being managed conservatively before being referred to us. The CECT didn't show any leakage of contrast to the lesser sac making the possibility of healed perforation likely as all other causes were ruled out at the time of presentation to our hospital. The CECT scan ruled out other causes of gastric outlet obstruction with normal wall thickness of the stomach and duodenum along with normal looking liver, pancreas and no lymphadenopathy. The liver function tests and serum amylase were within normal limits. Along with this, there was another unrelated rare coincidental finding of aortoiliac occlusive disease termed as Leriche's syndrome. Ultrasound guided percutaneous drainage was done following which the patient's obstruction was relieved and patient was referred to the department of vascular surgery for the mangement of aortoiliac occlusive disease.

Mixed Germ Cell Tumour in an Infertile Male Having Unilateral Cryptorchidism: A Rare Case Report.

Mixed germ cell tumours with multiple components occur more frequently than the pure varieties of germ cell tumours. Embryonal carcinoma and teratoma together form the most common components of the mixed germ cell tumour but the yolk sac tumour is usually seen as a minor component in patients presenting with mixed germ cell tumour. We report a rare case of 27-year-old Hepatitis C positive male presenting with pain in left lower abdomen with associated history of same sided undescended testis and infertility. Right sided testis lying in scrotal sac appeared normal on ultrasonography but patient was azoospermic. He had raised levels of serum markers, alpha feto protein and beta HCG. Examination showed a large mass in left lower abdomen involving the sigmoid colon with the absence of left testis in left scrotum which was confirmed on CT scan. Excision of the mass was done and histopathology examination revealed it as a malignant mixed germ cell tumour composed predominantly of a yolk sac tumour, with minor component as seminoma and embryonal carcinoma in an undescended testis. Following this, the level of serum markers came down. The patient is now undergoing adjuvant chemotherapy and is doing well.

Utility of a real-time appropriate use criteria decision support application for percutaneous coronary interventions in non-acute coronary syndrome.

OBJECTIVES: The aim of this study was to test the feasibility and value of a real-time online appropriate use criteria (AUC) application for percutaneous coronary intervention (PCI) in patients without acute coronary syndrome. BACKGROUND: High rates of non-appropriate elective PCI in the National Cardiovascular Data Registry (NCDR) CathPCI Registry have created interest in integrating decision support tools into routine clinical care to improve the frequency of appropriate PCIs. METHODS: Patients undergoing diagnostic coronary angiography and subsequent PCI for non-ACS indications at a single center were scored using a real-time AUC application pre-procedure. Blinded angiographic review was performed subsequently for each case. Rates of appropriate, inappropriate, uncertain and not rated PCIs were tabulated according to specific clinical scenarios using information available both before and after the angiographic audit. RESULTS: Of 308 PCIs in 272 patients, 196 (63.6%) were deemed appropriate, 79 (25.6%) uncertain, and two (0.6%) inappropriate; 31 (10.1%) scenarios could not be rated. With angiographic audit, inappropriate PCIs increased to 9.7%. There was a significant improvement in the rate of appropriate PCI using the real-time AUC application compared with retrospective data collection for NCDR reporting (64% vs. 53%, P = 0.01). CONCLUSIONS: Use of a real-time AUC application together with angiographic audit may improve the accuracy of reporting PCI appropriateness. © 2015 Wiley Periodicals, Inc.

Multiple Giant Sebaceous Cysts of Scalp.

Sebaceous cyst is an epidermal cyst often found on the hairy areas of the body such as scalp, trunk and face. Though commonly encountered in surgical practice, its presentation as multiple giant sebaceous cysts over scalp is rare. However, in long standing cases malignant transformation has also been sparingly reported. We report a case of a 52-year-old male presenting with multiple large sized swellings on the scalp, seven in number. These were present since childhood and gradually progressed to the enormous size of largest measuring 10cm x 8cm. Excision of these cysts was undertaken and specimens were sent for histopathological examination which confirmed the nature of these cysts to be sebaceous cysts. No malignant changes were reported in any of the specimens. The patient was followed up and was doing well.

Multicenter Study Assessing Physician Recommendations Regarding the Continuation of Aspirin and/or NSAIDs Prior to Gastrointestinal Endoscopy.

BACKGROUND: In 2009 the American Society for Gastrointestinal Endoscopy (ASGE) guidelines advised that both aspirin and NSAIDs be continued prior to low-risk gastrointestinal endoscopic procedures. We sought to determine physician knowledge regarding these guidelines. METHODS: A survey questionnaire was developed based on the ASGE guidelines. Physicians were queried about whether they would continue/stop aspirin in a patient with cardiac disease and in a patient taking NSAIDs for arthritis whether they would continue/stop NSAIDs prior to endoscopy. The survey was administered at three academic medical centers. Demographic information: level of training, board certification, teaching trainees, percentage of time in clinical practice, year of medical school graduation, and location of medical school were all reviewed. The primary outcome was number of questions answered correctly and predictors of correct responses. RESULTS: The survey was administered to 941 participants with 12 declining to participate, while 80% (740/929) of the subjects completed the survey; 20% (150/740) respondents answered both questions correctly and 42% (310/740) answered one question correctly. There was no significant difference between institutions (p = 0.6) or between attendings and trainees (p = 0.75). Multivariate predictors of correct answers were self-reported familiarity with the guideline (-0.029; 95% CI -0.003 to -0.056, p < 0.031), level of training (0.050; 95% CI 0.012-0.088, p = 0.010), and specialty (0.108; 95% CI 0.058-0.159, p < 0.0001). Finally, there was an inverse, linear relationship between postgraduate year and percent questions correct. CONCLUSION: Physician knowledge of guidelines regarding the use of aspirin and NSAIDs prior to endoscopy is suboptimal. Interventions are necessary to improve knowledge of the current pre-procedure guidelines.

Surgery for Ulcerative Colitis Is Associated with a High Rate of Readmissions at 30 Days.

BACKGROUND: Currently, the predictors of readmission after colectomy specifically for ulcerative colitis (UC) are poorly investigated. We sought to determine the rates and predictors of 30-day readmissions after colectomy for UC. METHODS: Patients undergoing total proctocolectomy and end ileostomy, abdominal colectomy with end ileostomy, proctocolectomy with ileoanal pouch anastomosis (IPAA) formation and diverting ileostomy, one stage IPAA, or abdominal colectomy with ileorectal anastomosis at a tertiary care center between January 2002 and January 2012 for UC were included. Patients were identified using ICD-9 code 556.x. Each record was manually reviewed. The electronic record system was reviewed for demographic information, medical histories, UC history, medications, and data regarding the admission and discharge. Charts were reviewed for readmissions within 30 days of surgery. Univariate and multivariate analyses were performed using Stata v.13. RESULTS: Two hundred nine patients with UC underwent a colectomy. Forty-three percent had a proctocolectomy with IPAA and diverting ileostomy and 32% had abdominal colectomy with end ileostomy. Seventy-six percent of surgeries were due to failure of medical therapy and 68% of patients were electively admitted for surgery. Thirty-two percent (n = 67/209) of the cohort was unexpectedly readmitted within 30 days. In multivariate model, proctocolectomy with IPAA and diverting ileostomy (odds ratio [OR] = 2.11; 95% CI, 1.06-4.19; P = 0.033) was the only significant predictor of readmission. Hospital length of stay >7 days (OR = 1.82; 95% CI, 0.98-3.41; P = 0.060), presence of limited UC (OR = 2.10; 95% CI, 0.93-4.74; P = 0.074), and steroid before admission (OR = 1.69; 95% CI, 0.90-3.2; P = 0.100) trended toward significance. CONCLUSIONS: Surgery for UC is associated with a high rate of readmission. Further prospective studies are necessary to determine the means to reduce these readmissions.

Current knowledge of antibiotic prophylaxis guidelines regarding GI open-access endoscopic procedures is inadequate.

BACKGROUND: The American Heart Association (AHA) guidelines from 2007 and the American Society for Gastrointestinal Endoscopy (ASGE) guidelines from 2008 recommended against antibiotic prophylaxis before GI endoscopic procedures to prevent bacterial endocarditis. OBJECTIVE: To determine physician knowledge regarding these guidelines and to identify physician subgroups for which knowledge was suboptimal. DESIGN: A survey questionnaire was developed based on AHA and ASGE guidelines regarding antibiotics before endoscopy. Physicians were queried about 10 theoretical scenarios as to whether or not they would recommend before-procedure antibiotics. SETTING: The survey was administered at 3 academic medical centers. PARTICIPANTS: Attending physicians and trainees in primary care and subspecialties. INTERVENTIONS: Survey. MAIN OUTCOME MEASUREMENTS: Percentage of the survey questions answered correctly and predictors of correct response. RESULTS: The survey was administered to 941 participants of whom 12 declined to participate. Eighty percent (n=740/929) of participants completed the survey. The median number of correct answers was 70% (interquartile range [IQR] 50%-90%) and was similar at each institution (P=.6). A total of 7.3% (n=54) of respondents answered all questions correctly. There was no significant difference in correct responses between attending physicians and trainees or between study centers (median 7, IQR 5-9; P=.75). Gastroenterologists were more likely to answer questions correctly than other subspecialists or primary care physicians (P<.0001). On multivariate analysis, physician knowledge correlated directly with self-reported familiarity with guidelines (0.21; 95% confidence interval [CI], 0.08-0.34; P=.002) and specialty (0.56; 95% CI, 0.30-0.82; P<.001) and inversely with year of medical school graduation (0.22; 95% CI, 0.07-0.37; P=.005). LIMITATIONS: Survey study that used theoretical scenarios. CONCLUSION: Physician knowledge of guidelines regarding antibiotic use before endoscopy is suboptimal. Further interventions are needed to improve the knowledge of before-procedure guidelines.