Risk factors and natural history of bedside percutaneous endoscopic versus fluoroscopy-guided gastrostomy tubes in intensive care unit patients.

INTRODUCTION: There is a paucity of literature comparing patients receiving bedside placed percutaneous endoscopic gastrostomy (PEG) versus fluoroscopic-guided percutaneous gastrostomy tubes (G-tube) in an intensive care unit (ICU) setting. This study aims to investigate and compare the natural history and complications associated with PEG versus fluoroscopic G-tube placement in ICU patients. METHODS: All adult patients admitted in the ICU requiring feeding tube placement at our center from 1/1/2017 to 1/1/2022 with at least 12-month follow up were identified through retrospective chart review. Adjusting for patient comorbidities, hospital factors, and indications for enteral access, a 1-to-2 propensity score matched Cox proportional-hazards model was fitted to evaluate the treatment effect of bedside PEG tube placement versus G-tube placement on patient 1-year complication, readmission, and death rates. Major complications were defined as those requiring operative or procedural intervention. RESULTS: This study included 740 patients, with 178 bedside PEG and 562 fluoroscopic G-tube placements. The overall rate of complication was 22.3% (13% PEG, 25.2% G-tube, P = 0.003). The major complication rate was 11.2% (8.5% PEG, 12.1% G-tube, P = 0.09). Most common complications were tube dysfunction (16.7% PEG; 39.4% G-tube; P = 0.04) and dislodgement (58.3% PEG; 40.8% G-tube). After propensity score matching, G-tube recipients had significantly increased risk for all-cause (HR 2.7, 95% CI 1.56-4.87, P < 0.001) and major complications (HR 2.11, 95% CI 1.05-4.23, P = 0.035). There were no significant differences in 1-year rates of readmission (HR 0.90, 95% CI 0.58-1.38, P = 0.62) or death (HR 1.00, 95% CI 0.70-1.44, P = 0.7). CONCLUSIONS: The overall rate of complications for ICU patients requiring feeding tube in our cohort was 22.3%. ICU patients receiving fluoroscopic-guided percutaneous gastrostomy tube placement had significantly elevated risk of 1-year all-cause and major complications compared to those undergoing bedside PEG.

The choice of primary repair or mesh repair for paraesophageal hernia: a decision analysis based on utility scores.

BACKGROUND: Controversy exists on the use of mesh in the repair of paraesophageal hernias (PEH). This debate centers around the type of mesh used, its value in preventing recurrence, its short- and long-term complications, and the consequences of those complications compared with primary repair. Decision analysis is a method to account for the important aspects of a clinical decision. The purpose of this study was to determine whether or not the addition of mesh would be superior in PEH repair. METHODS: A decision analysis model of the choice between primary repair and mesh repair of a PEH was constructed. The essential features of the decision were the rate of perioperative complications, PEH recurrence rate, reoperation rate after recurrence, rate of symptomatic recurrence, and type of outcome after reoperation. The literature was reviewed to obtain data for the decision analysis and the average rates used in the baseline analysis. A utility score was used as the outcome measure, with a perfect outcome receiving a score of 100 and death 0. Sensitivity analysis was used to determine if changing the rates of recurrence or reoperation changed the dominant treatment. RESULTS: Using the baseline analysis, mesh repair was slightly superior to primary repair (utility score 99.59 vs 99.12, respectively). However, if recurrence rates were similar, primary repair would be slightly superior; whereas if reoperation rates were similar, mesh repair would be superior. Using sensitivity analysis, there are combinations of recurrence rates and reoperation rates that would make one repair superior to the other. However, these differences are relatively small. CONCLUSIONS: Depending on what the decision-maker accepts as the recurrence and reoperation rates for these types of repair, either mesh or primary repair may be the treatment of choice. However, the differences between the two are small, and, perhaps, clinically inconsequential.

Octogenarian abdominal surgical emergencies: not so grim a problem with the acute care surgery model?

BACKGROUND: As the aging population continues to increase, the surgical needs of the elderly will increase. The acute care surgery model has been developed in which the trauma team also manages all general surgical emergencies to improve patient outcomes. We retrospectively reviewed our elderly acute care surgery population during the past 5 years to determine the variables affecting major abdominal surgery outcomes. METHODS: Patients aged 80 years and older who received an emergent major abdominal operation by our Acute Care Surgery team between July 2000 and November 2006 were included. We assessed after-hours operations, length of stay, duration of operation, gender, comorbidities, and mortality. Administrative, operating room, and corporate databases were used for demographics, comorbidities, admission logistics, American Society of Anesthesiologists (ASA) score, and mortality. We performed SPSS, chi2, and logistic regression analyses. RESULTS: A total of 183 operations were performed with a mortality of 15%. Significant predictors were ASA score and female gender, with increasing ASA scores leading to worse outcomes and women faring worse than men as an independent variable. Neither operative duration nor off-hours surgery was associated with increased mortality. CONCLUSIONS: This is the first study to report mortality data and expected survival curves for major abdominal surgery in the octogenarian population. Our data prove that it is safer than previously thought to operate on the elderly. Our mortality data and survival curves provide real data for the surgeon to be able to risk stratify and discuss predicted outcomes with consultants, patients, and families.

Predictors of critical care-related complications in colectomy patients using the National Surgical Quality Improvement Program: exploring frailty and aggressive laparoscopic approaches.

BACKGROUND: Colectomy patients experience a broad set of adverse outcomes. Complications requiring critical care support are common in this group. We hypothesized that as frailty increases, the risk of Clavien class IV and V complications will increase in colectomy patients. METHODS: Using the National Surgical Quality Improvement Program (NSQIP) participant use files for 2005-2009, we identified patients who underwent laparoscopic and open colectomies by Current Procedural Terminology code. Using the Clavien classification for postoperative complications, we identified NSQIP data points most consistent with Clavien class IV requiring intensive care unit (ICU) care or class V complications (death). We used a modified frailty index with 11 variables based on mapping the Canadian Study of Health and Aging Frailty Index and existing NSQIP variables. Logistic regression was performed to acuity adjust the findings. RESULTS: A total of 58,448 colectomies were identified. As frailty index increased from 0 to 0.55, the proportion of those experiencing Clavien class IV or V complications increased from 3.2% at baseline to 56.3%. Variables found to be significant by logistic regression (odds ratio) were frailty index (14.4; p = 0.001), open procedure (2.35; p < 0.001), and American Society of Anesthesiologists class 4 (3.2; p = 0.038) or 5 (7.1; p = 0.001) while emergency operation and wound classification 3 or 4 were not. CONCLUSIONS: Complications requiring ICU care represent a significant morbidity in the colectomy patient population. Frailty index seems to be an important predictor of ICU-level complications and death, and laparoscopy seems to be protective.