Frailty predicts mortality in patients with upper gastrointestinal bleed: a prospective cohort study.

BACKGROUND AND AIM: Evidence on the impact of frailty in patients with upper gastrointestinal bleed (UGIB) is limited. This study aims to define the role of frailty as defined by Canadian Study of Health and Aging clinical frailty scale (CSHA-CFS) in predicting mortality in UGIB. METHODS: A prospective single-center cohort study was conducted over 21 months on all consecutive patients with UGIB. Data on demographics, lab parameters, Glasgow Blatchford score, CSHA-CFS, Charlson Comorbidity Index, and AIMS65 score was recorded. The primary outcome was all-cause inpatient mortality. The secondary outcomes were all-cause 30-day mortality, 30-day rebleeding, 30-day readmission, hospital length of stay (LoS), intensive care unit (ICU) admission, need for repeat endoscopy, and need for blood transfusion. The data were evaluated using univariate and multivariate analysis. RESULTS: There were 298 eligible patients, of which 63% were males, median age was 68 years, 44% were from non-English-speaking background, and 72% had major comorbidities. The all-cause inpatient and 30-day mortality were 9.4% and 10.7%, respectively. In the multivariate analysis, CHSA-CFS was the independent predictor of all-cause inpatient mortality (OR 1.66; 95% CI 1.13-2.143; P = 0.010) and all-cause 30-day mortality (OR 1.83; 95% CI 1.26-2.67; P = 0.002). CHSA-CFS was not a significant predictor of 30-day rebleed, 30-day readmission, ICU admission, hospital LoS, or need for blood transfusion. CONCLUSION: Frailty is an important independent predictor of mortality in patients with UGIB. Frailty assessment can guide clinical decision making and allow targeting of health-care resource (Australia/New Zealand Clinical Trial Registry number: ACTRN12622000821796).

Drainage of pancreatic fluid collections using a lumen-apposing metal stent with an electrocautery-enhanced delivery system.

BACKGROUND AND AIM: Our aim was to evaluate the efficacy and safety of a lumen-apposing metal stent with an electrocautery-enhanced delivery system (EDS-LAMS) for endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) in regular clinical practice. METHODS: A retrospective and subsequent prospective analysis was undertaken of all patients who underwent EUS-guided drainage of their PFCs using the EDS-LAMS at 17 tertiary therapeutic endoscopy centers. RESULTS: Two hundred eight cases of EDS-LAMS deployment were attempted in 202 patients (mean age 52.9 years) at time of evaluation. Ninety-seven patients had pancreatic pseudocysts (PPs), 75 walled-off pancreatic necrosis (WOPN), 10 acute peripancreatic fluid collections (APFCs), 6 acute necrotic collections (ANCs), and 14 postoperative collections (POCs). Procedural technical success was achieved in 202/208 cases (97.1%). Maldeployment occurred in 7/208 cases (3.4%). Clinical success was achieved in 142/160 (88.8%) patients (PP 90%, WOPN 85.2%, APFC 100%, ANC 75%, POC 100%). Delayed adverse events included stent migration in 15/202 (7.4%), stent occlusion and infection in 16/202 (7.9%), major bleeding in 4/202 (2%), and buried EDS-LAMS in 2/202 (1%). PFC recurrence occurred in 13/142 (9.2%) patients; 9/202 (4.5%) required surgical or radiological intervention for PFC management after EDS-LAMS insertion. CONCLUSIONS: This large international multicenter study evaluating the EDS-LAMS for drainage of PFCs in routine clinical practice suggests that the EDS-LAMS are safe and effective for drainage of all types of PFCs; however, further endoscopic therapy is often required for WOPN. Major bleeding was a rare complication in our cohort.

Short-term outcomes of sleeve gastrectomy for morbid obesity: does staple line reinforcement matter?

BACKGROUND: Stand-alone laparoscopic sleeve gastrectomy (LSG) has been found to be effective in producing weight loss but few large, one-center LSG series have been reported. Gastric leakage from the staple line is a life-threatening complication of LSG, but there is controversy about whether buttressing the staple line with a reinforcement material will reduce leaks. We describe a single-center, 518-patient series of LSG procedures in which a synthetic buttressing material (GORE® SEAMGUARD® Bioabsorbable Staple Line Reinforcement) was used in the most recently treated patients. METHODS: We retrospectively reviewed the medical records of all patients who underwent LSG in our unit between September 2007 and December 2011. Patients treated before August 2009 did not receive the staple line reinforcement material (n = 186), whereas all patients treated afterward did (n = 332). RESULTS: The percentages of excess weight loss in the 518 patients (mean age, 41 years; 82% female; mean preoperative body mass index, 44 kg/m(2)) were 67% (79% follow-up rate) at 6 months postoperatively, 81% (64%) at 1 year, and 84% (30%) at 2 years. Type 2 diabetes resolved in 71 % of patients (91/128). Patients given reinforcement material had baseline characteristics similar to those in the no-reinforcement-material group, but had no postoperative staple line leaks or bleeding. The no-reinforcement group had three leaks (p = 0.045) and one case of bleeding. CONCLUSIONS: LSG resulted in substantial short-term weight loss. Use of the bioabsorbable staple line reinforcement material may decrease leaks after LSG.