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1.
Dig Liver Dis ; 51(11): 1557-1561, 2019 11.
Article in English | MEDLINE | ID: mdl-31272934

ABSTRACT

INTRODUCTION: Lumen apposing metal stents (LAMS) have been used increasingly for drainage of pancreatic fluid collections (PFC). We present an international, multicenter study evaluating the safety and efficacy of LAMS in PFCs. METHODS: Consecutive patients undergoing LAMS placement for PFC at 12 international centers were included (ClinicalTrials.gov NCT01522573). Demographics, clinical history, and procedural details were recorded. Technical success was defined as successful LAMS deployment. Clinical success was defined as PFC resolution at three-month follow-up. RESULTS: 192 patients were included (140 males (72.9%), mean-age 53.8 years), with mean follow-up of 4.2 months ±â€¯3.8. Mean PFC size was 11.9 cm (range 2-25). The median number of endoscopic interventions was 2 (range 1-14). Etiologies for PFC were gallstone (n = 82, 42.7%), alcohol (n = 50, 26%), idiopathic (n = 26, 13.5%), and other (n = 34, 17.7%). Technical success was achieved in 189 patients (98.4%). Clinical success was observed in 125 of 135 patients (92.6%). Adverse events included bleeding (n = 11, 5.7), infection (n = 2, 1%), and perforation (n = 2, 1%). Three or more endoscopy sessions were a positive predictor for PFC resolution and the only significant predictor for AEs. CONCLUSION: LAMS has a high technical and clinical success rate with a low rate of AEs. PFC drainage via LAMS provides a minimally invasive, safe, and efficacious procedure for PFC resolution.


Subject(s)
Drainage/instrumentation , Hemorrhage/etiology , Pancreatic Pseudocyst/surgery , Stents/adverse effects , Adult , Aged , Body Fluids , Debridement , Drainage/adverse effects , Endoscopy/methods , Endosonography , Female , Humans , Internationality , Logistic Models , Male , Metals , Middle Aged , Multivariate Analysis , Necrosis/surgery , Pancreas/pathology , Pancreas/surgery , Prospective Studies , Prosthesis Failure , Prosthesis Implantation/adverse effects , Treatment Outcome , Ultrasonography, Interventional
2.
Qual Manag Health Care ; 27(2): 63-68, 2018.
Article in English | MEDLINE | ID: mdl-29596265

ABSTRACT

OBJECTIVE: To design and implement a discharge timeout checklist, and to assess its effects on patients' understanding as well as the potential impact on preventable medical errors surrounding hospital discharges to home. METHODS: Based on the structure successfully used for surgical procedures and using the Model for Improvement framework, we designed a discharge checklist to review and assess patients' understanding of discharge medications, catheters, home care plans, follow-up, symptoms, and who to call with problems after discharge. In parallel, we developed a process of integrating the checklist into the discharge process after routine discharge procedures were completed. We used the checklists to assess patients' level of understanding and need for additional education as well as changes in discharge documentation; we also noted whether good catches of significant errors in the discharge process occurred. RESULTS: Over 6 months of study, 190 discharge timeouts out of 429 eligible discharges were completed. Additional education was provided in 53 of 190 discharge timeouts (27.8%), with 62% of this education being related to medications. Twenty-one (11.1%) discharge timeouts resulted in at least one change to the discharge documentation or a good catch. CONCLUSIONS: A multidisciplinary discharge timeout directly involving the patient can be effective in targeting additional areas for patient education and in potentially reducing preventable adverse events.


Subject(s)
Checklist/standards , Comprehension , Continuity of Patient Care/organization & administration , Patient Discharge/standards , Patient Education as Topic/standards , Home Care Services/organization & administration , Humans , Medical Errors/prevention & control , Patient Safety , Quality Improvement/organization & administration , United States
3.
Clin Gastroenterol Hepatol ; 15(4): 504-510, 2017 Apr.
Article in English | MEDLINE | ID: mdl-28017845

ABSTRACT

BACKGROUND & AIMS: Endoscopic sleeve gastroplasty (ESG) is an incisionless, minimally invasive bariatric procedure that reduces the length and width of the gastric cavity to facilitate weight loss. We performed a prospective study to evaluate the effects of ESG on total body weight loss and obesity-related comorbidities. METHODS: We collected data from 91 consecutive patients (mean age, 43.86 ± 11.26 years; 68% female) undergoing ESG from August 2013 through March 2016. All patients had a body mass index (BMI) greater than 30 kg/m2 and had failed noninvasive weight-loss measures or had a BMI greater than 40 kg/m2 and were not considered as surgical candidates or refused surgery. All procedures were performed with a cap-based flexible endoscopic suturing system to facilitate a triangular pattern of sutures to imbricate the greater curvature of the stomach. Patients were evaluated after 6 months (n = 73), 12 months (n = 53), and 24 months (n = 12) for anthropometric features (BMI, weight, waist circumference, blood pressure) and underwent serologic (hemoglobin A1c), lipid panel, serum triglycerides, and liver function tests. The primary outcomes were total body weight loss at 6, 12, and 24 months. Secondary outcomes were the effects of ESG on metabolic factors (blood pressure, diabetes, hyperlipidemia, steatohepatitis) and safety. RESULTS: The patients' mean BMI before the procedure was 40.7 ± 7.0 kg/m2. Patients had lost 14.4% of their total body weight at 6 months (80% follow-up rate), 17.6% at 12 months (76% follow-up rate), and 20.9% at 24 months (66% follow-up rate) after ESG. At 12 months after ESG, patients had statistically significant reductions in levels of hemoglobin A1c (P = .01), systolic blood pressure (P = .02), waist circumference (P < .001), alanine aminotransferase (P < .001), and serum triglycerides (P = .02). However, there was no significant change in low-density lipoprotein after vs before ESG (P = .79). There was one serious adverse event (1.1%) (perigastric leak) that occurred that was managed non-operatively. CONCLUSIONS: ESG is a minimally invasive and effective endoscopic weight loss intervention. In addition to sustained total body weight loss up to 24 months, ESG reduced markers of hypertension, diabetes, and hypertriglyceridemia.


Subject(s)
Body Mass Index , Diabetes Mellitus/epidemiology , Gastroplasty/methods , Hypertension/epidemiology , Hypertriglyceridemia/epidemiology , Obesity/complications , Obesity/surgery , Adult , Aged , Female , Humans , Male , Middle Aged , Prospective Studies , Treatment Outcome , Young Adult
5.
Surg Endosc ; 31(3): 1414-1419, 2017 03.
Article in English | MEDLINE | ID: mdl-27495331

ABSTRACT

BACKGROUND: Endoscopic placement of fully covered self-expanding metal stents (FCSEMS) to treat malignant dysphagia in patients with esophageal cancer significantly improves dysphagia; however, these stents have a high migration rate. AIM: To determine whether FCSEMS fixation using an endoscopic suturing device treated malignant dysphagia and prevented stent migration in patients with locally advanced esophageal cancer receiving neoadjuvant therapy when compared to patients with FCSEMS placement alone. METHOD: A review of patients with locally advanced esophageal cancer who underwent FCSEMS placement at 3 centers was performed. Patients were divided into two groups: Group A (n = 26) was composed of patients who underwent FCSEMS placement with suture placement, and Group B (n = 67) was composed of patients with FCSEMS placement alone. RESULTS: There were no significant differences between Groups A and B in demographics, and tumor characteristics. The technical success rate for stent placement was 100 %. There was no difference between Groups A and B in the median stent diameter and stent lengths. Mean dysphagia score obtained at 1 week after stent placement had improved significantly from baseline (2.4 and 1, respectively, p < 0.001). Patients had a median follow-up of 4 months. Immediate adverse events were mild chest discomfort in 4 patients in Group A and 2 patients in Group B (p = 0.05), and significant acid reflux in 3 patient in Group A compared to 2 patients in Group B (p = 0.1). The stent migration rate was significantly lower in Group A compared to compared to Group B (7.7 vs 26.9 %, respectively, p = 0.004). There was a delayed perforation in 1 patient and 1 death due to aspiration pneumonia in Group B. CONCLUSION: Fixation of esophageal FCSEMSs by using an endoscopic suturing device in patients receiving neoadjuvant therapy was shown to be feasible, safe, and relatively effective at preventing stent migration compared to those who had stent placed alone.


Subject(s)
Adenocarcinoma/surgery , Carcinoma, Squamous Cell/surgery , Deglutition Disorders/surgery , Esophageal Neoplasms/surgery , Postoperative Complications/epidemiology , Prosthesis Failure , Self Expandable Metallic Stents , Suture Techniques , Adenocarcinoma/complications , Adenocarcinoma/pathology , Aged , Carcinoma, Squamous Cell/complications , Carcinoma, Squamous Cell/pathology , Case-Control Studies , Deglutition Disorders/etiology , Esophageal Neoplasms/complications , Esophageal Neoplasms/pathology , Esophageal Perforation/epidemiology , Esophagoscopy , Female , Gastroesophageal Reflux/epidemiology , Humans , Male , Middle Aged , Neoadjuvant Therapy , Neoplasm Staging , Retrospective Studies
6.
Surg Endosc ; 30(12): 5500-5505, 2016 12.
Article in English | MEDLINE | ID: mdl-27129552

ABSTRACT

BACKGROUND: Patients with failed endoscopic retrograde cholangiopancreatography (ERCP) are conventionally offered percutaneous transhepatic biliary drainage (PTBD). While PTBD is effective, it is associated with catheter-related complications, pain, and poor quality of life. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a minimally invasive endoscopic option increasingly offered as an alternative to PTBD. We compare outcomes of EUS-BD and PTBD in patients with biliary obstruction at a single tertiary care center. METHODS: A retrospective review was performed in patients with biliary obstruction who underwent EUS-BD or PTBD after failed ERCP from June 2010 through December 2014 at a single tertiary care center. Patient demographics, procedural data, and clinical outcomes were documented for each group. The aim was to compare efficacy and safety of EUS-BD and PTBD and evaluate predictors of success. RESULTS: A total of 60 patients were included (mean age 67.5 years, 65 % male). Forty-seven underwent EUS-BD, and thirteen underwent PTBD. Technical success rates of PTBD and EUS-BD were similar (91.6 vs. 93.3 %, p = 1.0). PTBD patients underwent significantly more re-interventions than EUS-BD patients (mean 4.9 versus 1.3, p < 0.0001), had more late (>24-h) adverse events (53.8 % vs. 6.6 %, p = 0.001) and experienced more pain (4.1 vs. 1.9, p = 0.016) post-procedure. In univariate analysis, clinical success was lower in the PTBD group (25 vs. 62.2 %, p = 0.03). In multivariable logistic regression analysis, EUS-BD was the sole predictor of clinical success and long-term resolution (OR 21.8, p = 0.009). CONCLUSION: Despite similar technical success rates compared to PTBD, EUS-BD results in a lower need for re-intervention, decreased rate of late adverse events, and lower pain scores, and is the sole predictor for clinical success and long-term resolution. EUS-BD should be the treatment of choice after a failed ERCP.


Subject(s)
Cholangiopancreatography, Endoscopic Retrograde , Cholestasis/therapy , Drainage/methods , Endosonography/methods , Adult , Aged , Cholestasis/diagnostic imaging , Female , Follow-Up Studies , Humans , Male , Middle Aged , Quality of Life , Retrospective Studies , Treatment Outcome
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