ABSTRACT
BACKGROUND AND AIMS: The 30-day readmission rate is a nationally recognized quality measure with nearly one-fifth of patients being readmitted. This study aims to evaluate frailty, as measured by the hospital frailty risk score (HFRS), as a prognostic indicator for 30-day readmission after inpatient ERCP. METHODS: We analyzed weighted discharge records from the 2017 Nationwide Readmissions Database (NRD) to identify patients undergoing ERCP between 01/01/2017 and 11/30/2017. Our primary outcome was the 30-day unplanned readmission rate in frail (defined as HFRS > 5) against non-frail (HFRS < 5) patients. A mixed effects multivariable logistic regression method was employed. RESULTS: Among 68,206 weighted hospitalized patients undergoing ERCP, 31.3% were frail. Frailty was associated with higher 30-day readmission (OR 1.23, 95% CI [1.16-1.30]). Multivariable analysis showed a greater risk of readmission with cirrhosis (OR 1.26, 95% CI [1.10-1.45]), liver transplantation (OR 1.36, 95% CI [1.08-1.71]), cancer (OR 1.58, 95% CI [1.48-1.69]), and male gender (OR 1.24, 95% CI [1.18-1.31]). Frail patients also had higher mortality rate (1.8% vs 0.6%, p < 0.01)], longer LOS during readmission (6.7 vs 5.6 days, p < 0.01), and incurred more charges from both hospitalizations ($175,620 vs $132,519, p < 0.01). Sepsis was the most common primary indication for both frail and non-frail readmissions but accounted for a greater percentage of frail readmissions (17.9% vs 12.4%, p < 0.01). CONCLUSIONS: Frailty is associated with higher readmission rates, mortality, LOS, and hospital charges for admitted patients undergoing ERCP. Sepsis is the leading cause for readmission. Independent risk factors for readmission include liver transplantation, cancer, cirrhosis, and male gender.
Subject(s)
Frailty , Neoplasms , Sepsis , Humans , Male , Patient Readmission , Retrospective Studies , Cholangiopancreatography, Endoscopic Retrograde , Risk Factors , Hospitals , Liver Cirrhosis , Length of StaySubject(s)
Adenocarcinoma , Biliary Tract Neoplasms , Endoscopy, Digestive System/methods , Adenocarcinoma/diagnosis , Adenocarcinoma/therapy , Bile Duct Neoplasms/diagnosis , Bile Duct Neoplasms/therapy , Bile Ducts, Intrahepatic , Biliary Tract Neoplasms/diagnosis , Biliary Tract Neoplasms/therapy , Cholangiocarcinoma/diagnosis , Cholangiocarcinoma/therapy , Cholangiopancreatography, Endoscopic Retrograde , Cholecystectomy/methods , Endoscopic Ultrasound-Guided Fine Needle Aspiration , Endosonography , Humans , Lymphoma/diagnosis , Lymphoma/therapy , Polyps/diagnosis , Polyps/therapyABSTRACT
BACKGROUND AND STUDY AIM: Currently colonoscopy quality indicators emphasize our ability to improve polyp detection (e.g., preparation quality, withdrawal times of ≥6 min). The completeness of a polyp resection may also be an important determinant of quality and efficient colonoscopy. The primary aim of this study was to determine the incidence of an incomplete polyp resection despite a perceived complete polypectomy. PATIENTS AND METHODS: This was a retrospective quality assurance project conducted at the San Diego Veterans Affair Medical Center and University of California San Diego Medical Center from July 2007 to April 2008. The patients recruited to this study were undergoing surveillance and screening colonoscopy. The resection quality was evaluated in 65 polyps of 47 patients. Twenty-two polyps were removed with standard biopsy forceps, jumbo forceps (18), hot snare (18), and cold snare (7). Biopsies were taken from the post-polypectomy site base and perimeter for histologic examination in order to confirm histologic absence of all polypoid appearing mucosa. RESULTS: The post-polypectomy sites of ten polyps (15%) were found to have residual polypoid tissue. Six were removed by standard biopsy forceps, jumbo forceps (2), hot snare (1), and cold snare (1). When compared to other polypectomy devices, standard biopsy forceps were more likely to result in an incomplete resection (27 vs. 9%; P = 0.076). CONCLUSIONS: The endoscopist may not be visually accurate in determining when a polyp is completely resected, and alternative devices and techniques for polyp resection should be considered.
Subject(s)
Colonic Polyps/surgery , Colonoscopy/methods , Quality Assurance, Health Care/standards , Aged , Colonic Polyps/diagnosis , Colonic Polyps/epidemiology , Colonoscopy/instrumentation , Female , Humans , Incidence , Male , Middle Aged , Retrospective Studies , Treatment OutcomeSubject(s)
Choledocholithiasis/diagnosis , Choledocholithiasis/therapy , Endoscopy, Digestive System , Catheterization/methods , Cholangiopancreatography, Endoscopic Retrograde/adverse effects , Cholangiopancreatography, Endoscopic Retrograde/methods , Cholecystectomy, Laparoscopic , Choledocholithiasis/surgery , Humans , Laparoscopy , Lithotripsy , Sphincterotomy, Endoscopic/adverse effects , Sphincterotomy, Endoscopic/methodsSubject(s)
Duodenal Obstruction/therapy , Endoscopy, Gastrointestinal , Gastric Outlet Obstruction/therapy , Gastroparesis/therapy , Adult , Child , Duodenal Obstruction/diagnosis , Enteral Nutrition , Gastric Emptying , Gastric Outlet Obstruction/diagnosis , Gastric Outlet Obstruction/etiology , Gastrointestinal Motility , Gastroparesis/diagnosis , Gastrostomy , Humans , Intestinal Diseases/drug therapy , Intestinal Diseases/therapy , Prosthesis Implantation/adverse effects , StentsSubject(s)
Duodenal Ulcer/therapy , Endoscopy, Digestive System , Evidence-Based Medicine , Stomach Ulcer/therapy , Anti-Inflammatory Agents, Non-Steroidal/administration & dosage , Anti-Inflammatory Agents, Non-Steroidal/adverse effects , Biopsy , Diagnosis, Differential , Duodenal Neoplasms/diagnosis , Duodenal Neoplasms/pathology , Duodenal Neoplasms/therapy , Duodenal Ulcer/chemically induced , Duodenal Ulcer/diagnosis , Duodenal Ulcer/pathology , Duodenum/pathology , Gastric Mucosa/pathology , Gastric Outlet Obstruction/chemically induced , Gastric Outlet Obstruction/diagnosis , Gastric Outlet Obstruction/pathology , Gastric Outlet Obstruction/therapy , Helicobacter Infections/complications , Helicobacter Infections/diagnosis , Helicobacter Infections/pathology , Helicobacter Infections/therapy , Helicobacter pylori , Humans , Intestinal Mucosa/pathology , Peptic Ulcer Hemorrhage/chemically induced , Peptic Ulcer Hemorrhage/diagnosis , Peptic Ulcer Hemorrhage/pathology , Peptic Ulcer Hemorrhage/therapy , Peptic Ulcer Perforation/chemically induced , Peptic Ulcer Perforation/diagnosis , Peptic Ulcer Perforation/pathology , Peptic Ulcer Perforation/therapy , Stomach Neoplasms/diagnosis , Stomach Neoplasms/pathology , Stomach Neoplasms/therapy , Stomach Ulcer/chemically induced , Stomach Ulcer/diagnosis , Stomach Ulcer/pathologySubject(s)
Colonic Diseases/therapy , Colonic Neoplasms/therapy , Colonic Pseudo-Obstruction/therapy , Colonoscopy , Evidence-Based Medicine , Intestinal Obstruction/therapy , Colonic Diseases/diagnosis , Colonic Neoplasms/diagnosis , Colonic Pseudo-Obstruction/diagnosis , Diagnosis, Differential , Humans , Intestinal Obstruction/diagnosis , Palliative CareABSTRACT
BACKGROUND & AIMS: The nodal staging of esophageal cancer accounts for the absence or presence of metastatic lymph nodes (N0 or N1, respectively). Surgical data suggest that patients have worse survival when esophagectomy specimens contain higher numbers of regional malignant lymph nodes. It has been proposed that the staging system for esophageal cancer be modified to include the number of malignant lymph nodes. The aim of this study was to determine the influence of the number of malignant-appearing regional lymph nodes detected on endoscopic ultrasonography (EUS) on survival in patients with esophageal adenocarcinoma. METHODS: Historical case series involved patients with esophageal adenocarcinoma who underwent EUS staging at a single center between 1994 and 2004. Endoscopy reports were reviewed to determine the number of malignant-appearing periesophageal lymph nodes seen on EUS examination. Subjects were categorized as having 0, 1-2, or >2 periesophageal lymph nodes. A regional cancer registry prospectively obtained survival data. RESULTS: Among 85 patients with esophageal adenocarcinoma, the Kaplan-Meier curves showed distinct survival advantages in those with fewer malignant-appearing regional lymph nodes (P=.0008). The median survivals were 66 months, 14.5 months, and 6.5 months for 0, 1-2, and >2 malignant-appearing lymph nodes, respectively. Survival was also influenced by celiac lymph nodes and tumor length, both of which were associated with increased number of malignant nodes. CONCLUSIONS: The number of malignant-appearing periesophageal lymph nodes detected by EUS is associated with improved survival stratification in patients with esophageal adenocarcinoma and should be considered in the presurgical staging of esophageal cancer.
Subject(s)
Adenocarcinoma/mortality , Adenocarcinoma/secondary , Esophageal Neoplasms/mortality , Esophageal Neoplasms/pathology , Lymph Nodes/diagnostic imaging , Lymph Nodes/pathology , Adenocarcinoma/diagnostic imaging , Adenocarcinoma/pathology , Adult , Aged , Aged, 80 and over , Analysis of Variance , Endosonography/methods , Esophageal Neoplasms/diagnostic imaging , Female , Humans , Lymphatic Metastasis , Male , Middle Aged , Predictive Value of Tests , Prognosis , Proportional Hazards Models , Registries , Retrospective Studies , Risk Assessment , Sensitivity and Specificity , Survival AnalysisABSTRACT
We report our experience with an ultrasound system to measure esophageal varix pressure in an in vitro model. The ultrasound system consists of a 12.5 MHz frequency intraluminal ultrasound probe, a water infusion catheter, and a manometry catheter, all contained within a nondistensible latex bag. Esophagi and external jugular veins were harvested from five pigs. The vein and ultrasound system were placed inside the esophagus. One end of the vein was connected to a water reservoir to modulate its pressure; the other end was connected in two different ways to simulate hydrodynamic and hydrostatic flow conditions. The bag was inflated with water until vein occlusion was discernible on the ultrasound images. The influences of vein pressure, vein cross-sectional area and esophageal elasticity on the ultrasound measurement of vein pressure were assessed. A total of 108 trials were performed at nine different vein pressures. Complete vein occlusion occurred when the bag pressure was slightly greater (1.4 +/- 0.7 mmHg) than the vein pressure. For a vein pressure of 25 mmHg, the average occlusion and opening pressures were 27 +/- 0.2 and 25.7 +/- 0.3 mmHg, respectively (P < .05) suggesting that the vein opening pressure on the ultrasound images is more accurate than the vein closing pressure. In conclusion, the ultrasound technique can accurately measure intravariceal pressure in vitro. The bag pressure at the point of vein reopening is the best determinant of the vein pressure.
