Gastrointestinal hemorrhage in the setting of gastrointestinal cancer: Anatomical prevalence, predictors, and interventions.

BACKGROUND: Gastrointestinal hemorrhage (GIH) is a common complication with gastrointestinal cancers (GIC). There is no comprehensive research that examines GIH in different types of GIC. AIM: To study the prevalence, predictors, and interventions of GIH based on the anatomical location of GIC. METHODS: This is a retrospective analysis of the 2016-2018 National Inpatient Sample database, the largest inpatient care database in the United States. All adult inpatients (≥ 18-year-old) were included. ICD-10-CM codes were used to identify patients with GIH and GIC. Prevalence of GIH was obtained based on the anatomical location of GIC. Predictors of GIH in the GIC population were studied using multivariate analysis. Interventions including endoscopy were compared to the non-intervention group to determine the differences in inpatient mortality. RESULTS: Out of a total of 18173885 inpatients, 321622 (1.77%) cases had a diagnosis of GIC. Within GIC patients, 30507 (9.5%) inpatients had GIH, which was significantly (P < 0.001) more than the prevalence of GIH in patients without GIC (3.4%). The highest to lowest GIH rates are listed in the following order: Stomach cancer (15.7%), liver cancer (13.0%), small bowel cancer (12.7%), esophageal cancer (9.1%), colorectal cancer (9.1%), pancreatic cancer (7.2%), bile duct cancer (6.0%), and gallbladder cancer (5.1%). Within gastric cancer, the GIH rate ranged from 14.8% in cardia cancer to 25.5% in fundus cancer. Within small bowel cancers, duodenal cancers had a higher GIH rate (15.6%) than jejunal (11.1%) and ileal cancers (5.7%). Within esophageal cancers, lower third cancers had higher GIH (10.7%) than the middle third (8.0%) or upper third cancers (6.2%). When studying the predictors of GIH in GIC, socioeconomic factors such as minority race and less favorable insurances (Medicaid and self-pay) were associated with significantly higher GIH on multivariate analysis (P < 0.01). Chemotherapy and immunotherapy were also identified to have a lower risk for GIH [odds ratios (OR) = 0.74 (0.72-0.77), P < 0.001]. Out of 30507 GIC inpatients who also had GIH, 16267 (53.3%) underwent an endoscopic procedure, i.e., upper endoscopy or colonoscopy. Inpatient mortality was significantly lower in patients who underwent endoscopy compared to no endoscopy [5.5% vs 14.9%, OR = 0.42 (0.38-0.46), P < 0.001]. CONCLUSION: The prevalence of GIH in patients with GIC varies significantly based on the tumor's anatomical location. Endoscopy, which appears to be associated with a substantial reduction in inpatient mortality, should be offered to GIC patients with GIH. Nevertheless, the decision on intervention in the GIC population should be tailored to individual patient's goals of care, the benefit on overall care, and long-term survival.

Living Donor Liver Transplantation in the United States: Evolution of Frequency, Outcomes, Center Volumes, and Factors Associated With Outcomes.

Recent modifications in organ allocation policies and increases in chronic liver diseases may have resulted in important changes in living donor liver transplantation (LDLT) in the United States. We examined the trends, outcomes, and factors associated with outcomes in adult LDLT. United Network for Organ Sharing data on 2566 adult LDLT recipients who received transplants from January 1, 2010, through December 31, 2019, were analyzed. LDLT graft and patient survival rates were compared with propensity score-matched deceased donor liver transplantation recipients by the Kaplan-Meier curve estimator. The association between preceding LDLT frequency and subsequent outcomes were assessed by Cox proportional hazards mixed effects modeling. After a stable annual frequency of LDLTs from 2010 to 2014 (~200 per year), the number of LDLTs doubled to 440 in 2019. The 1-year and 5-year graft survival rates for LDLT recipients were 88.4% and 78.1%, respectively, compared with 92.5% and 80.7% in the propensity score-matched donation after brain death recipients (P = 0.005), respectively. Older donor age and recipient diabetes mellitus and life support requirement were significantly associated with graft failure among LDLT recipients (P values <0.05). Average preceding LDLT frequencies of <3 per year, 3 to 20 per year, and >20 per year resulted in 1-year graft survival rates of 82%, 88% to 89%, and 93%, respectively (P values <0.05). There were 3 living donor deaths (0.12%). The frequency of LDLTs has doubled during the past decade, with good outcomes and acceptable donor safety profiles. However, there appear to be varying threshold transplant frequencies (volume/unit time) associated with acceptable (88%-89%) and aspirational (93%) 1-year graft survival rates. These data should be reassuring and encourage LDLT practice as efforts continue to expand the donor pool.

Prevalence of gastroesophageal reflux and risk factors for erosive esophagitis in obese patients considered for bariatric surgery.

BACKGROUND: Gastroesophageal reflux disease (GERD) is common in obese individuals. Prospective studies investigating validated GERD questionnaires and clinical parameters at identifying erosive esophagitis (EE) in this population are limited. OBJECTIVE: To prospectively evaluate the prevalence of GERD in obese patients considered for bariatric surgery and identify risk and predictive factors for EE. METHODS: Eligible patients completed two validated questionnaires: GERDQ and Nocturnal Symptom Severity Impact (N-GSSIQ) before routine esophagogastroduodenoscopy. RESULTS: 242 consecutive patients were enrolled (130 females; mean age 37.8 ± 11.8 years; mean BMI 40.4 ± 5.3 kg/m2). The overall prevalence of gastroesophageal reflux (GERDQ ≥ 8, EE and/or PPI use) was 62.4%. EE was identified in 82 patients (33.9%) including 13/62 (21.0%) receiving PPIs at baseline. Multivariate logistic regression identified GERDQ ≥ 8 (OR = 6.3, 95%CI 3.0-13.1), hiatal hernia (OR = 4.2, 95%CI 1.6-10.7), abnormal Hill grade (OR = 2.7, 95%CI 1.4-5.4), and tobacco use (OR = 2.5, 95%CI 1.2-4.9) as independent risk factors for EE. A pre-endoscopic composite assessment including GERDQ ≥ 8 and presence of severe nocturnal reflux symptoms had 90% specificity and 20.7% sensitivity in identifying EE (NPV 68.9% and PPV 51.5%). CONCLUSION: GERD is highly prevalent in obese patients. Anthropometric data and GERD questionnaires have limited accuracy at predicting erosive disease. Pre-operative endoscopic assessment in this population appears warranted.

Does intraoperative endoscopy decrease complications after bariatric surgery? Analysis of American College of Surgeons National Surgical Quality Improvement Program database.

BACKGROUND: Intraoperative endoscopy (IOE) has been proposed to decrease serious complications following bariatric surgeries such as leaks, bleeding, and stenosis. Such complications can lead to sepsis and eventually can be fatal. We aim to compare major postoperative complications in patients with and without IOE. METHODS: Data from the American College of Surgeons National Surgical Quality Improvement Program database years 2011 till 2016 were used to identify laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) patients. We compared outcomes of IOE and non-IOE using bivariate and multivariate analysis. Thirty-day outcomes included sepsis, organ space infection, unplanned reoperations, unplanned readmissions, prolonged hospital stay, bleeding, and mortality. RESULTS: Out of 62,805 cases of LSG and 50,047 cases of LRYGB, 17.9%, and 19.7% had IOE, respectively. Endoscopy-assisted LSG was associated with a decrease in sepsis [0.37% vs. 0.21%, adjusted odds ratio (AOR) = 0.55 (0.36, 0.84)], unplanned reoperation [0.58% vs. 0.38%, AOR = 0.61 (0.44, 0.85)], prolonged hospital stay [14.9% vs. 14.0%, AOR = 0.87 (0.82, 0.92)], and composite complications [1.43% vs. 1.17%, AOR = 0.78 (0.65, 0.94)]. Outcomes after LRYGB were similar in both groups, except for decreased prolonged hospital stay with IOE [22.4% vs. 20.6%, AOR = 0.89 (0.84, 0.94)]. CONCLUSIONS: IOE is generally underutilized in baraitric procedures. IOE is associated with decreased risk of postoperative complications particularly sepsis, unplanned reoperations, prolonged hospital stay, and composite complications after LSG; and hospital stay after LRYGB. Large multicenter prospective studies are needed to explore the benefits of IOE in bariatric surgery, particularly the intermediate or long-term benefits.

Increased adverse outcomes after laparoscopic sleeve gastrectomy in older super-obese patients: analysis of American College of Surgeons National Surgical Quality Improvement Program Database.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) has become the most popular bariatric operation over the last decade. Extreme obesity and increasing age have been generally associated with higher risks of complications after bariatric surgery. The postoperative risk for complications after SG has not been previously presented according to simultaneous grouping of body mass index (BMI) and age. OBJECTIVE: We aim to explore the association of age and BMI in determining the postoperative risk of SG from a national perspective. SETTING: The American College of Surgeons National Surgical Quality Improvement Program database. METHODS: We analyzed patient characteristics and operative outcomes of the 2010 to 2013 SG cohort available in the American College of Surgeons National Surgical Quality Improvement Program (N = 21,131). Patients were grouped based on age and BMI: young-obese (N = 10,291; <50 yr, BMI <0 kg/m2; reference group), young-super-obese (N = 3594; <50 yr and BMI ≥50 kg/m2), older-obese (N = 5636; ≥50 yr, BMI <0 kg/m2), and older-super-obese (N = 1610; ≥50 yr, BMI ≥50 kg/m2). Composite morbidity and/or mortality (M&M) was used as the primary outcome and risk-adjusted odds ratios (AOR[M&M]) were derived by logistic regression. M&M was a composite of surgical site, renal, neurologic, cardiac, thromboembolic, respiratory, septic and bleeding complications, unplanned readmissions, prolonged stay, and death. RESULTS: Overall operative mortality was low (.1%) but significantly worse in older-super-obese patients (.37%; P = .005). M&M rates were lowest in young-obese (5.8%), similarly worse in young-super-obese (7.0%) and older-obese (7.0%), and highest for older-super-obese (10.1%; P < .001). After comprehensive covariate risk adjustment, the composite M&M outcome after SG was significantly increased (42%) only in older-super-obese patients (AOR = 1.42 [1.16-1.73]), while older age alone (AOR = 1.09 [.94-1.25]) and super obesity alone (AOR = 1.09 [.93-1.28]) did not. CONCLUSIONS: Analysis of the American College of Surgeons National Surgical Quality Improvement Program showed that super obesity is associated with increased complications in older patients undergoing SG. Older-super-obese patients should be appropriately counseled about increased SG perioperative risks within the context of expected long-term benefits.

Correction to: Comparison of Early Morbidity and Mortality Between Sleeve Gastrectomy and Gastric Bypass in High-Risk Patients for Liver Disease: Analysis of American College of Surgeons National Surgical Quality Improvement Program.

The authors regret that some of the article text, which was in the original manuscript and was intended for and addressed to the reviewers during the review process of this article, was mistakenly overlooked during the proofs stage and remains in the published article.

Comparison of Early Morbidity and Mortality Between Sleeve Gastrectomy and Gastric Bypass in High-Risk Patients for Liver Disease: Analysis of American College of Surgeons National Surgical Quality Improvement Program.

INTRODUCTION: Chronic liver disease is prevalent in obese patients presenting for bariatric surgery and is associated with increased postoperative morbidity and mortality (M&M). There are no comparative studies on the safety of different types of bariatric operations in this subset of patients. OBJECTIVE: The aim of this study is to compare the 30-day postoperative M&M between laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-Y-gastric bypass (LRYGB) in the subset of patients with a model of end-stage liver disease (MELD) score ≥ 8. METHODS: Data for LSG and LRYGB were extracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from years 2012 and 2013. MELD score was calculated using serum creatinine, bilirubin, INR, and sodium. Postoperative M&M were assessed in patients with a score ≥ 8 and compared for the type of operation. This was followed by analysis for MELD subcategories. Multiple logistic regression was performed to adjust for confounders. RESULTS: Out of 34,169, 9.8% of cases had MELD ≥ 8 and were included. Primary endpoint, 30-day M&M, was significantly lower post-LSG (9.5%) compared to LRYGB (14.7%); [AOR = 0.66(0.53, 0.83)]. Superficial wound infection, prolonged hospital stay, and unplanned readmission were more common in LRYGB. M&M post-LRYGB (30.6%) was significantly higher than LSG (15.7%) among MELD15-19 subgroup analysis. CONCLUSION: LRYGB is associated with a higher postoperative risk than LSG in patients with MELD ≥ 8. The difference in postoperative complications between procedures was magnified with higher MELD. This suggests that LSG might be a safer option in morbidly obese patients with higher MELD scores, especially above 15.

Intestinal obstruction caused by a strangulating adnexa: a rare complication of ovarian sparing hysterectomy.

Intestinal obstruction caused by a remnant fallopian tube from previous hysterectomy is a rare entity that has been reported once in the literature. We report the case of a 61-year-old woman who presented with both small and large bowel obstructions caused by a strangulating remnant fallopian tube. She had an ovarian sparing hysterectomy 16 years ago and was diagnosed with antiphospholipid syndrome. Our case report will discuss the clinical presentation, imaging and outcome of the patient. It will also briefly tackle other rare causes of bowel obstruction.