Intussusception After Pancreaticoduodenectomy.

Intussusception after pancreaticoduodenectomy (Whipple procedure) is exceedingly rare. We present a case of retrograde jejunal intussusception into the gastric lumen in a patient who previously underwent Whipple procedure. Diagnostic endoscopy may serve to confirm intussusception, identify a potential lead point, and, in some cases, endoscopically reduce the intussusception. Ultimately, however, surgical management is recommended due to a high rate of recurrence along with the potential to detect a lead point and associated malignancy.

A validated risk model for prediction of early readmission in patients with hepatic encephalopathy.

INTRODUCTION AND AIM: Hepatic encephalopathy (HE) is a common complication in cirrhotics and is associated with an increased healthcare burden. Our aim was to study independent predictors of 30-day readmission and develop a readmission risk model in patients with HE. Secondary aims included studying readmission rates, cost, and the impact of readmission on mortality. MATERIALS AND METHODS: We utilized the 2013 Nationwide Readmission Database (NRD) for hospitalized patients with HE. A risk assessment model based on index hospitalization variables for predicting 30-day readmission was developed using multivariate logistic regression and validated with the 2014 NRD. Patients were stratified into Low Risk and High Risk groups. Cox regression models were fit to identify predictors of calendar-year mortality. RESULTS: Of 24,473 cirrhosis patients hospitalized with HE, 32.4% were readmitted within 30 days. Predictors of readmission included presence of ascites (OR: 1.19; 95% CI: 1.06-1.33), receiving paracentesis (OR: 1.43; 95% CI: 1.26-1.62) and acute kidney injury (OR: 1.11; 95% CI: 1.00-1.22). Our validated model stratified patients into Low Risk and High Risk of 30-day readmissions (29% and 40%, respectively). The cost of the first readmission was higher than index admission in the 30-day readmission cohort ($14,198 vs. $10,386; p-value <0.001). Thirty-day readmission was the strongest predictor of calendar-year mortality (HR: 4.03; 95% CI: 3.49-4.65). CONCLUSIONS: Nearly one-third of patients with HE were readmitted within 30 days, and early readmission adversely impacted healthcare utilization and calendar-year mortality. With our proposed simple risk assessment model, patients at high risk for early readmissions can be identified to potentially avert poor outcomes.

Quality improvement measures lead to higher surveillance rates for hepatocellular carcinoma in patients with cirrhosis.

BACKGROUND: Cirrhosis is a major risk factor associated with the development of hepatocellular carcinoma (HCC). The American Association for the Study of Liver Diseases recommends surveillance for HCC in cirrhosis patients with ultrasound every six months. However, various studies suggest that surveillance rates in actual practice are quite low. AIM: The aims of this study were to evaluate the effectiveness of implementing quality improvement (QI) measures in increasing the rate of HCC surveillance among patients in a tertiary care facility. METHODS: Patients with cirrhosis were prospectively enrolled into a chronic disease management program, which integrates nursing-based protocols with automatic reminders when patients are due for surveillance. Patients enrolled in this program between March 2010 and April 2011 were compared to a prior cohort in 2008-2009. The primary endpoint was the receipt of at least one abdominal imaging study performed for the purposes of surveillance during the study period. RESULTS: Of the 355 patients enrolled, 331 (93 %) had imaging performed for HCC surveillance, compared to 119/160 (74 %) patients in the previous cohort (p < 0.001). Chart review revealed the most common reasons for failure to undergo surveillance were patients' lack of insurance and lack of follow-up on studies ordered at outside institutions. Six patients were diagnosed with HCC during the study period, of which three were at early stage. CONCLUSIONS: Implementation of QI measures incorporating automatic reminders of surveillance status for providers can significantly increase the rate of HCC surveillance among cirrhosis patients.