A 2-Stage Approach in Managing Diabetic Forefoot Ulcers.

BACKGROUND: Forefoot plantar ulcers in patients with diabetic neuropathy are considered to be primarily the result of increased shear forces applied over prominent plantar bony prominences. The purpose of this article is to describe a 2-stage treatment pathway utilizing an outpatient percutaneous tendon-Achilles lengthening (TAL) as the first stage procedure and subsequent proximal metatarsal osteotomy (MTO) as a second stage procedure for a persistent or recurrent ulcer. METHODS: A consecutive 112 patients (146 feet), who presented to our Multidisciplinary Diabetic Foot Team clinics since February 2019 with plantar nonischemic forefoot ulcers were included in this study. Excluding the patients who died or were lost to follow-up, 96 feet were followed for a minimum 12 months (range 12-36 months). After TAL, patients were encouraged to walk in a walking cast for 6 weeks and were followed for a minimum 12 months. Patients with persistent or recurrent ulcers were investigated with magnetic resonance imaging scan, and based on intramedullary osteomyelitis and septic destruction of distal metatarsal, we describe a second-stage MTO with the 3 most common clinical presentations. RESULTS: Of 96 feet, none had infection or wound-related problems following TAL. Complete transection of the tendon was noted in 4 patients (4%) and heel callosity in 1 patient. In 92 feet (96%), the ulcers healed within 10 weeks (±4 weeks) after TAL but, in 12 feet (10%), the ulcer failed to heal or recurred. At a minimum 12 months after the second-stage MTO, none in this subgroup had recurrence of ulcer or a transfer lesion. CONCLUSION: TAL followed with a walking cast as an outpatient procedure was effective in healing forefoot ulcers in 96% of feet. Comparable to the widely practiced hand surgery Wide Awake Local Anesthesia No Tourniquet (WALANT) procedure, our approach involved active control of the degree of ankle dorsiflexion by the patient, and the procedure was proven to be safe and well tolerated. When the second-stage MTO was required to offload the forefoot, in our small cohort, patients had ulcer-free outcome for a minimum 12 months. LEVEL OF EVIDENCE: Level IV, retrospective case series.

The effects of target vulnerabilities on social movement outcomes: Wage campaigns in U.S. cities.

How do target vulnerabilities affect social movement outcomes? Walsh (1986) and Jasper and Poulsen (1993) conceptualize target vulnerabilities as characteristics or practices of organizations that are inconsistent with relevant normative expectations (laws, professional codes, widely-held public expectations, etc.). Organizations' claims to legitimacy, and the access to resources that legitimacy bestows, are based on the presumption of adherence to those normative expectations, so credible threats to that presumption cannot be ignored. We draw on political process theories and the logic of policy change to analyze how target vulnerabilities affect movement outcomes in campaigns for living wages (1994-2003) and for increased minimum wages (2012-2017). For living wage campaigns, we model the effects of political elites' vulnerability to the threat of popular delegitimation and vulnerability to non-participation by municipal workers on the likelihood of city councils 1) holding a vote (access outcome) and 2) adopting a living wage ordinance (advantages outcome). Using sequential regression analyses of these outcomes in 596 U.S. cities, we find that the effects of target vulnerabilities vary across living wage ordinance outcomes: delegitimation vulnerabilities affect the likelihood of access outcomes, whereas adoption advantages are more likely in the presence of non-participation vulnerabilities. We test the generalizability of our model and measures in an analysis of local minimum wage ordinance campaigns. We show that contentious politics at the local level differs from the national-level in ways that render city political elites potentially vulnerable to movement threats of delegitimation and non-participation.

Surgical decompression for malignant cerebral oedema after ischaemic stroke.

BACKGROUND: Large territory middle cerebral artery (MCA) ischaemic strokes account for around 10% of all ischaemic strokes and have a particularly devastating prognosis when associated with malignant oedema. Progressive cerebral oedema starts developing in the first 24 to 48 hours of stroke ictus with an associated rise in intracranial pressure. The rise in intracranial pressure may eventually overwhelm compensatory mechanisms leading to a cascading secondary damage to surrounding unaffected parenchyma. This downward spiral can rapidly progress to death or severe neurological disability. Early decompressive craniectomy to relieve intracranial pressure and associated tissue shift can help ameliorate this secondary damage and improve outcomes. Evidence has been accumulating of the benefit of early surgical decompression in stroke patients. Earlier studies have excluded people above the age of 60 due to associated poor outcomes; however, newer trials have included this patient subgroup. This review follows a Cochrane Review published in 2012. OBJECTIVES: To assess the effectiveness of surgical decompression in people with malignant oedema after ischaemic stroke with regard to reduction in mortality and improved functional outcome. We also aimed to examine the adverse effects of surgical decompression in this patient cohort. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2022, Issue 7 of 12), MEDLINE Ovid, Embase Ovid, Web of Science Core Collection, Scopus databases, ClinicalTrials.gov, and the WHO ICTRP to July 2022. We also reviewed the reference lists of relevant articles. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing decompressive craniectomy with medical management to best medical management alone for people with malignant cerebral oedema after MCA ischaemic stroke. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the search results, assessed study eligibility, performed risk of bias assessment, and extracted the data. The primary outcomes were death and death or severe disability (modified Rankin Scale (mRS) > 4) at 6 to 12 months follow-up. Other outcomes included death or moderate disability (mRS > 3), severe disability (mRS = 5), and adverse events. We assessed the certainty of the evidence using the GRADE approach, categorising it as high, moderate, low, or very low. MAIN RESULTS: We included nine RCTs with a total of 513 participants included in the final analysis. Three studies included patients younger than 60 years of age; two trials accepted patients up to 80 years of age; and one trial only included patients 60 years or older. The majority of included trials (six) mandated a time from stroke ictus to treatment of < 48 hours, whilst in two of them this was < 96 hours. Surgical decompression was associated with a reduction in death (odds ratio (OR) 0.18, 95% confidence interval (CI) 0.12 to 0.27, 9 trials, 513 participants, P < 0.001; high-certainty evidence); death or severe disability (mRS > 4, OR 0.22, 95% CI 0.15 to 0.32, 9 trials, 513 participants, P < 0.001; high-certainty evidence); and death or moderate disability (mRS > 3, OR 0.34, 95% CI 0.22 to 0.52, 9 trials, 513 participants, P < 0.001; moderate-certainty evidence). Subgroup analysis did not reveal any significant effect on treatment outcomes when analysing age (< 60 years versus ≥ 60 years); time from stroke ictus to intervention (< 48 hours versus ≥ 48 hours); or dysphasia. There was a significant subgroup effect of time at follow-up (6 versus 12 months, P = 0.02) on death as well as death or severe disability (mRS > 4); however, the validity of this finding was affected by fewer participant numbers in the six-month follow-up subgroup. There was no consistent reporting of per-participant adverse event rates in any of the included studies, which prevented further analysis. AUTHORS' CONCLUSIONS: Surgical decompression improves outcomes in the management of malignant oedema after acute ischaemic stroke, including a considerable reduction in death or severe disability (mRS > 4) and a reduction in death or moderate disability (mRS > 3). Whilst there is evidence that this positive treatment effect is present in patients > 60 years old, it is important to take into account that these patients have a poorer prospect of functional survival independent of this treatment effect. In interpreting these results it must also be considered that the data demonstrating benefit are drawn from a unique patient subset with profound neurological deficit, reduced level of consciousness, and no pre-morbid disability or severe comorbidity.

Staged Common and External Carotid Artery Stenting Followed by Superficial Temporal Artery to Middle Cerebral Artery Bypass.

Superficial temporal artery (STA) to middle cerebral artery (MCA) bypass surgery for internal carotid artery (ICA) occlusive disease necessarily requires sufficient external carotid artery (ECA) blood flow. Surgical bypass is therefore precluded if there is common carotid artery (CCA) occlusion. Here we present two such cases: one patient had a CCA occlusion and the other had an ICA occlusion and ECA stenosis. Both had failed medical management, and were therefore treated with angioplasty and stenting of the ECA, followed by STA-MCA bypass. We describe the clinical and radiologic outcomes of these cases, and remark on the potential pitfalls associated with this novel approach.

The surgical management of intraoperative intracranial internal carotid artery injury in open skull base surgery-a systematic review.

Intraoperative internal carotid artery (ICA) injury during open skull base surgery is a catastrophic complication. Multiple techniques and management strategies have been reported for endoscopic skull base surgery; however, the literature on managing this complication in open skull base surgery is limited. To perform a systematic review and give an overview of the different techniques described to manage this complication intraoperatively, a systematic review was conducted in PubMed, Ovid Medline, Ovid Embase and Scopus for literature published until July 2021. Titles and abstracts were screened. Studies meeting prespecified inclusion criteria were reviewed in full. PRISMA guidelines were strictly adhered to. Out of 4492 articles, only 12 articles could be included, reflecting an underreporting of open skull base ICA injuries. Multiple techniques can be used depending on the location and size of the injury as well as the surgeon's experience. Described techniques include the following: a primary repair via a micro-suture or nonpenetrating clips; wrapping or plugging; coating; occlusion of the parent artery with or without a bypass; packing with further endovascular management. A treatment algorithm is proposed.

Bilateral cervical plexus block for anterior cervical spine surgery: study protocol for a randomised placebo-controlled trial.

BACKGROUND: There has been increasing focus to improve the quality of recovery following anterior cervical spine surgery (ACSS). Postoperative pain and nausea are the most common reasons for prolonged hospital stay and readmission after ACSS. Superficial cervical plexus block (SCPB) provides site-specific analgesia with minimal side effects, thereby improving the quality of recovery. The aim of our study was to investigate the effect bilateral cervical plexus block has on postoperative recovery in patients undergoing ACSS. METHODS: The study is a pragmatic, multi-centre, blinded, parallel-group, randomised placebo-controlled trial. 136 eligible patients (68 in each group) undergoing ACSS will be included. Patients randomised to the intervention group will have a SCPB administered under ultrasound guidance with a local anaesthetic solution (0.2% ropivacaine, 15mL); patients randomised to the placebo group will be injected in an identical manner with a saline solution. The primary outcome is the 40-item quality of recovery questionnaire score at 24 h after surgery. In addition, comparisons between groups will be made for a 24-h opioid usage and length of hospital stay. Neck pain intensity will be quantified using the numeric rating scale at 1, 3, 6 and at 24 h postoperatively. Incidence of nausea, vomiting, dysphagia or hoarseness in the first 24 h after surgery will also be measured. DISCUSSION: By conducting a blinded placebo trial, we aim to control for the bias inherently associated with a tangible medical intervention and show the true treatment effect of SCPB in ACSS. A statistically significant result will indicate an overall improved quality of recovery for patients; alternatively, if no benefit is shown, this trial will provide evidence that this intervention is unnecessary. TRIAL REGISTRATION: ClinicalTrials.gov ACTRN12619000028101. Prospectively registered on 11 January 2019 with Australia New Zealand Clinical Trials Registry.

Outcomes of Tendo-Achilles lengthening and weight-bearing total contact cast for management of early midfoot charcot neuroarthropathy.

AIM OF STUDY: To report outcomes of tendo-Achilles lengthening (TAL) followed by weight-bearing total contact cast (TCC) in the out-patient setting for patients presented with midfoot Charcot neuroarthropathy (CN) and, develop a new classification system for midfoot CN based on this experience. PATIENT AND METHODS: Published evidence suggests that tight Achilles-gastrocnemius-soleus complex is the deforming force in the initiation and progression of midfoot CN and TAL has shown to improve the range of ankle dorsiflexion and reduction of midfoot plantar pressures. We utilised this technique in the out-patient setting followed by weight-bearing TCC for all new patients who presented with a diagnosis of midfoot CN from February 2018.We report their outcomes after a 12 months follow-up and propose a new classification system based on the clinical and radiographic parameters. RESULTS: TAL followed by weight-bearing TCC was performed in 33 feet. In 30 feet, the disease progression either stopped or receded to a lower stage on the new classification system. The procedure was well tolerated by patients in an out-patient setting and there were no reported complications such as wound healing, complete transaction of tendon or deep vein thrombosis. At 12 months follow-up, 30 of 33 pts returned to their pre-procedure level of mobilisation with their usual walking aids or customised shoes. The inter-observer agreement was k = 0.86 for read 1 and k = 0.96 for read 2; and intra-observer agreement ranged from 0.93 to 1.00 for the double read indicating excellent inter-observer and intra-observer agreement. CONCLUSION: TAL followed by weight-bearing TCC is a safe and well tolerated procedure when performed in an out-patient setting. The Charcot disease of the midfoot slowed in the early stages of midfoot CN and in some cases, receded. The new classification system is easy to use, reliable, reproducible and sensitive enough to detect changes in the disease progression.

Orthosis versus no orthosis for the treatment of thoracolumbar burst fractures: A systematic review.

Management of patients with thoracolumbar burst fractures who do not have a neurologic injury has historically been controversial. Whilst management with an orthosis has gained popularity over surgical management, more recent evidence has suggested that even an orthosis may be unnecessary. A systematic review of the literature comparing orthosis with no orthosis in the management of thoracolumbar burst fractures in patients without neurological deficit was conducted. A risk of bias assessment was performed according to the Cochrane Collaboration Back Review Group. The quality of evidence was assessed according to the GRADE system. Two trials met the eligibility criteria. The functional outcomes, radiologic measures of kyphosis, pain scores, and quality of life scores were equivalent between the orthosis and the no orthosis groups. The level of evidence ranged from very low to moderate for the outcomes evaluated. The rate of complications and the rate of failure of treatment requiring surgery was low. Evidence from two small randomised controlled trials suggests that there are equivalent outcomes between treatment with and without an orthosis. Larger trials are needed to assess the treatment effect with greater confidence.

When the fat hits the brain-salvage STA-MCA bypass for an intracranial ICA occlusion due to a fat embolus.

BACKGROUND: Large fat embolus is a rare but potential reversible cause of ischaemic stroke. METHODS AND RESULTS: We describe the neurosurgical management of a complete right internal carotid artery occlusion due to a large fat embolus, caused by a mitral valve replacement. CONCLUSION: Knowledge of acute cerebral ischaemia due to large fat embolism and its hallmark 'hypodense artery' is mandatory. Extracranial to intracranial bypass is a feasible rescue treatment after failure of endovascular embolectomy.

Magnetic Resonance Spectroscopic Assessment of Isocitrate Dehydrogenase Status in Gliomas: The New Frontiers of Spectrobiopsy in Neurodiagnostics.

BACKGROUND: In the era of integrated genomic-histologic analysis of brain tumors, new biomarkers have been introduced as diagnostic, prognostic, and therapeutic indicators. The analysis of the mutation in the isocitrate dehydrogenase (IDH) genes IDH1 and IDH2 has provided important diagnostic and prognostic information for patients affected by diffuse glioma (i.e., the presence of the mutation has been related to an increased survival rate). The reference standard of IDH mutation detection has been its assessment in surgical specimens, immunohistochemistry, and/or genetic sequencing. Knowing the IDH status information preoperatively would be of great importance, because it has been related to tumor progression and the response to treatment. The oncometabolite 2-hydroxyglutarate (2HG), accumulated in gliomas with IDH mutation status, can be detected in vivo using magnetic resonance spectroscopy (MRS). METHODS: The 2HG-MRS technique remains technically challenging. We have summarized the results of the first pilot study in Australia, which included 10 patients affected by glioma. The data recorded from May 2017 to November 2018 were analyzed. RESULTS: In our exploratory study, we reached a sensitivity and specificity of 100%, confirming the strong predictive role of 2HG, as detected using MRS, in the diagnosis of glioma. CONCLUSION: In the present study, we have focused on methodological tips and future perspectives of the technique in the neuroimaging and neuro-oncological scenario. We would advocate the integration of 2HG-MRS into standard clinical practice.

The Case of the Disappearing Colloid Cyst.

BACKGROUND: The natural history of colloid cysts is imperfectly understood, and controversies remain in defining broad management strategies for incidental colloid cysts. The gradual asymptomatic regression of a colloid cyst has not been reported. CASE DESCRIPTION: We present a unique case demonstrating the clinically silent, gradual regression of a colloid cyst over many years. CONCLUSIONS: Gradual regression of a colloid cyst is possible. The philosophical and practical implications of this case on the neurosurgeon's approach to managing patients with colloid cysts are discussed.

Kinked Perforator Due to Clipping of Parent Vessel Aneurysm: Technical Note and Lessons Learned.

BACKGROUND: Adverse outcomes after aneurysm clipping can be potentially reversible, when managed appropriately. METHODS: This is a case report describing kinking of a perforator due to clipping of parent vessel aneurysm. RESULTS: Complete recovery of a high-grade motor deficit was achieved after instant reintervention with application of smaller clips in combination with gelfoam soaked in papaverine. CONCLUSION: Use of evoked potentials and intraoperative digital subtraction angiography are recommended and may help in preclinical diagnosis. Knowledge of delayed perforator kinking as a complication may lead to a more rapid diagnosis and management.

Genomic Profiling for KRAS, NRAS, BRAF, Microsatellite Instability, and Mismatch Repair Deficiency Among Patients With Metastatic Colon Cancer.

PURPOSE: Genomic testing is recognized in national guidelines as essential to guide appropriate therapy selection in metastatic colorectal cancer. Previous studies report adherence to testing guidelines is suboptimal, but current testing rates have not been assessed. This study reports testing rates in metastatic colon cancer (mCC) for guideline-recommended biomarkers in a US-based population. MATERIALS AND METHODS: A retrospective review of data extracted from electronic medical records was performed to identify patients with pathologically confirmed mCC and describe patterns of guideline-aligned biomarker testing. Data were extracted from the electronic health records of 1,497 patients treated at 23 practices across the United States. Both community and academic centers were represented. RESULTS: A total of 1,497 patients with mCC diagnosed between January 1, 2013 and December 31, 2017 were identified. Guideline-aligned biomarker testing rates for RAS, BRAF, and microsatellite instability/mismatch repair deficiency over this study period were 41%, 43%, and 51%, respectively. Patients were more likely to have guideline-aligned testing for RAS and BRAF if they were treated at an academic center, were diagnosed with de novo metastatic disease, and were female. In addition, patients < 65 years of age were more likely to have guideline-aligned RAS testing. Of the 177 patients (12% of cohort) who received anti-epidermal growth factor receptor therapy, only 50 (28%) had complete guideline-aligned biomarker testing. CONCLUSION: Despite guideline recommendations and significant therapeutic implications, overall biomarker testing rates in mCC remain suboptimal. Adherence to guideline-recommended biomarker testing would potentially reduce exposure to expensive and ineffective therapies, resulting in improved patient outcomes.

The Morel-Lavallée lesion in thoracolumbar spine trauma-two index cases.

The Morel-Lavallée lesion (MLL) is a closed degloving injury caused by traumatic separation of the subcutaneous tissue from the underlying fascia, without a break in the overlying skin. We present two cases that demonstrate a previously unrecognised association of the MLL with thoracolumbar spine fractures. The lesion is frequently missed, or its significance is overlooked, on initial evaluation. Awareness of this injury should allow tailored strategies to decrease the high risk of wound complications.

Bariatric surgery in patients with pulmonary hypertension.

BACKGROUND: Data regarding the outcomes of bariatric surgery in patients with pulmonary hypertension (PH) is limited. The aim of this study was to review our experience on bariatric surgery in patients with PH. SETTING: An academic medical center. METHODS: Patients with PH who underwent either a primary or revisional bariatric surgery between 2005 and 2015 and had a preoperative right ventricle systolic pressure (RVSP) ≥35 mm Hg were included. RESULTS: Sixty-one patients met the inclusion criteria. Fifty (82%) were female with the median age of 58 years (interquartile range [IQR] 49-63). The median body mass index was 49 kg/m2 (IQR 43-54). Procedures performed included the following: Roux-en-Y gastric bypass (n = 33, 54%), sleeve gastrectomy (n = 24, 39%), adjustable gastric banding (n = 3, 5%), and banded gastric plication (n = 1, 2%). Four patients (7%) underwent revisional bariatric procedures. Median operative time and length of stay was 130 minutes (IQR 110-186) and 3 days (IQR 2-5), respectively. The 30-day complication rate was 16% (n = 10) with pulmonary complications noted in 4 patients. There was no 30-day mortality. One-year follow-up was available in 93% patients (n = 57). At 1 year, median body mass index and excess weight loss were 36 kg/m2 (IQR 33-41) and 51% (IQR 33-68), respectively. There was significant improvement in the RVSP after bariatric surgery at a median follow-up of 22 months (IQR 10-41). The median RVSP decreased from 44 (IQR 38-53) to 40 mm Hg (IQR 28-54) (P = .03). CONCLUSION: Bariatric surgery can be performed without prohibitive complication rates in patients with PH. In our experience, bariatric patients with PH achieved significant weight loss and improvement in RVSP.

Spontaneous Acute Arterial Subdural Hematoma.

BACKGROUND: Spontaneous acute arterial subdural hematoma (SDH) is a rare entity caused by hemorrhage from a cortical perisylvian artery without a known precipitant. CASE DESCRIPTION: A 53-year-old man presented with a 2-day history of acute-onset headache and dysphasia. He had a generalized seizure on arrival to hospital and no history of trauma. A computed tomography demonstrated an acute left-sided SDH. A computed tomography angiogram and a digital subtraction angiogram demonstrated active contrast extravasation into the SDH. A craniotomy was performed to evacuate the hematoma; the bleeding perisylvian artery was visualized and coagulated. CONCLUSIONS: We report a rare case of acute SDH and present a review of the literature. The etiology, investigation, and management of this rare neurosurgical emergency are discussed.

Emotional Wellness of Current Musculoskeletal Radiology Fellows.

RATIONALE AND OBJECTIVES: Burnout is a psychological syndrome composed of emotional exhaustion, depersonalization, and sense of lack of personal accomplishment, as a result of prolonged occupational stress. The purpose of our study was to determine the prevalence of burnout among current musculoskeletal radiology fellows and to explore causes of emotional stress. MATERIALS AND METHODS: A 24-item survey was constructed on SurveyMonkey using the Maslach Burnout Inventory. We identified 82 musculoskeletal radiology fellowship programs. We recruited subjects indirectly through the program director or equivalent. RESULTS: Fifty-eight respondents (48 male, 10 female) identified themselves as current musculoskeletal radiology fellows and completed the survey. Comparison of the weighted subscale means in our data to the Maslach normative subscale thresholds for medical occupations indicates that musculoskeletal radiology fellows report relatively high levels of burnout with regard to lack of personal accomplishment and depersonalization, whereas emotional exhaustion levels in our sample are within the average range reported by Maslach. Although male musculoskeletal radiology fellows experience relatively high levels in two of the three dimensions of burnout (depersonalization and personal accomplishment), female musculoskeletal radiology fellows experience relatively high burnout across all three dimensions. Job market-related stress and the effort required providing care for dependents significantly affect personal accomplishment. Conversely, imbalances in the work-life relationship and feelings of powerlessness are significantly associated with depersonalization and emotional exhaustion. CONCLUSIONS: Musculoskeletal radiology fellows report relatively high levels of burnout. Because the consequences of burnout can be severe, early identification and appropriate intervention should be a priority.

Prevalence of burnout among musculoskeletal radiologists.

OBJECTIVE: Burnout is a job-related psychological syndrome with three aspects: emotional exhaustion, depersonalization, and perceived lack of personal accomplishment. Burnout is associated with deleterious effects on both workers and their work. When burnout affects physicians, their well-being, longevity, and care of patients are at risk. Recent studies concerning physician burnout treat specialists such as radiologists as one group. We studied burnout in musculoskeletal (MSK) subspecialist radiologists. MATERIALS AND METHODS: An institutional review board exemption was obtained. Society of Skeletal Radiology members received invitations to an anonymous survey that included questions from the Maslach Burnout Inventory ™ (MBI) measuring all three aspects of burnout. The response rate was 36.4% (433/1190). RESULTS: The prevalence of emotional exhaustion was 61.7% (255/413), of depersonalization 53.3% (219/411), and of perceived lack of personal accomplishment 39.6% (161/407). Only 19.5% (79/405) of MSK radiologists reported no burnout, while 80.5% (326/405) reported burnout along one or more dimensions. For all three dimensions, the prevalence was higher and the mean severity was worse for private practice compared with academic practice. The prevalence of burnout was affected more by practice setting than by gender. Burnout prevalence and severity also varied systematically with years since completion of training. CONCLUSION: Among MSK radiologists, we found a much higher prevalence and greater severity of burnout than has been previously reported for radiologists and other physicians. There were differences in prevalence and severity of burnout among practice settings, genders, and longevity cohorts.

Direct Percutaneous Endoscopic Jejunostomy (DPEJ) Tube Placement: A Single Institution Experience and Outcomes to 30 Days and Beyond.

INTRODUCTION: Patients with prior foregut surgery requiring long-term enteral access typically undergo operative jejunostomy tube placement; however, direct percutaneous endoscopic jejunostomy (DPEJ) is a viable alternative. METHODS: All de novo DPEJ procedures performed by surgical and advanced endoscopists from May 2003 to June 2015 were retrospectively reviewed following approval by the Institutional Review Board. There were 59 cases identified. RESULTS: Our cohort had a mean age of 50.3 ± 16.9 years and 35 (59.3%) were female. All but two patients previously had foregut surgery including 19 patients (34.5%) with prior bariatric surgery. The composite of malnutrition and dehydration was the indication for DPEJ in 29 patients (49.1%) and was the initial enteral access placed in 47 patients (79.7%). Moderate sedation was used in 32 cases (54.2%), and 29 procedures (49.2%) were performed in the operating room. Within 30 days, there were six complications in five patients, giving a peri-procedural complication rate of 12.5%. Beyond 30 days, the most common complications were peri-tube leakage and dislodgement (each 16.9%). The median time to complication was 197 days. CONCLUSIONS: In patients with surgically altered foregut anatomy, DPEJ offers a less invasive alternative to operative jejunostomy tube placement. DPEJ can be placed in the endoscopy suite or operating room with an acceptable risk of perioperative complications.