A Mobile Phone App Improves Patient-Physician Communication and Reduces Emergency Department Visits After Colorectal Surgery.

BACKGROUND: Emergency visits after colorectal surgery are common and require significant health care resources. However, many visits may be avoidable with alternative access to care. Mobile health technologies can facilitate patient access to health care providers. OBJECTIVE: We hypothesized that a mobile app for postdischarge monitoring with patient-provider communication ability would reduce emergency visits after elective abdominopelvic colorectal surgery. DESIGN: This is a prospective cohort study with a regression analysis after coarsened exact matching. SETTING: The study was conducted at a single colorectal referral center from May 2019 to September 2020. PATIENTS: A total of 114 patients were recruited to the intervention and were matched to a retrospective cohort of 608 patients from the 24 months before the study. All patients were managed according to an enhanced recovery pathway. INTERVENTIONS: A mobile phone app comprised of patient education material, daily questionnaires assessing postdischarge recovery, and patient-provider chat function was used. MAIN OUTCOME MEASURES: The primary outcomes included potentially preventable 30-day emergency visits defined according to a validated algorithm. Secondary outcomes included length of stay, complications, total emergency department visits, readmissions, and app usability. RESULTS: Coarsened-exact matching resulted in a matched sample of 94 prospective intervention patients and 256 retrospective control patients. The prospective group was associated with fewer preventable emergency department visits (incidence rate ratio 0.34; p = 0.043) and shorter length of stay (-1.62 days; p = 0.011). There were no differences in 30-day complications, total number of emergency visits, or readmissions. Patient-reported usability of the mobile app was high, with 88% of patients reporting that the app improved their ability to communicate with their surgeon. LIMITATIONS: We did not account for patient activation or perform a cost-analysis. CONCLUSION: Use of a mobile app was associated with fewer potentially preventable emergency visits and shorter length of stay after major elective colorectal surgery, which may be due to enhanced postdischarge monitoring and patient-provider communication. See Video Abstract at http://links.lww.com/DCR/B878 . APLICACIN DE TELFONO MVIL MEJORA LA COMUNICACIN ENTRE MDICO Y PACIENTE Y REDUCE LAS VISITAS AL DEPARTAMENTO DE EMERGENCIAS DESPUS DE CIRUGA COLORECTAL: ANTECEDENTES:Las visitas de emergencia después de la cirugía colorrectal son frecuentes y requieren importantes recursos sanitarios. Sin embargo, muchas visitas pueden evitarse con un acceso alternativo a la atención. Las tecnologías de salud móviles pueden facilitar el acceso de los pacientes a los proveedores de atención médica.OBJETIVO:Se planteó la hipótesis de que una aplicación móvil para el seguimiento posterior al alta con capacidad de comunicación entre el paciente y el médico reduciría las visitas de emergencia después de cirugía colorrectal abdominopélvica electiva.DISEÑO:Este es un estudio de cohorte prospectivo con un análisis de regresión después de un emparejamiento exacto aproximado.ENTORNO CLINICO:El estudio se llevó a cabo en un solo centro de referencia colorrectal entre 05/2019 y 09/2020.PACIENTES:Se reclutó un total de 114 pacientes para la intervención y se emparejaron con una cohorte retrospectiva de 608 pacientes de los 24 meses anteriores al estudio. Todos los pacientes fueron tratados con protocolo de enhanced recovery .INTERVENCIONES:Se utilizó una aplicación para teléfono móvil compuesta de material educativo para el paciente, cuestionarios diarios que evalúan la recuperación posterior al alta y una función de chat entre el paciente y el médico.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios incluyeron visitas a la emergencia en 30 días potencialmente prevenibles, definidas según un algoritmo validado. Los resultados secundarios incluyeron la duración de la estancia, complicaciones, total de visitas al departamento de emergencias, reingresos y la usabilidad de la aplicación.RESULTADOS:El emparejamiento aproximado-exacto resultó en una muestra emparejada de 94 APP + y 256 APP-. APP + se asoció con menos visitas evitables al servicio de urgencias (IRR 0,34, p = 0,043) y una estancia más corta (-1,62 días, p = 0,011). No hubo diferencias en las complicaciones a los 30 días, número total de visitas de emergencia y reingresos. La usabilidad de la aplicación móvil informada por los pacientes fue alta, y el 88% de los pacientes informaron que la aplicación mejoró su capacidad para comunicarse con su cirujano.LIMITACIONES:No contabilizamos la activación del paciente ni realizamos un análisis de costos.CONCLUSIÓNES:El uso de una aplicación móvil se asoció con menos visitas a la emergencia potencialmente prevenibles y una estadía más corta después de una gran cirugía colorrectal electiva, lo que puede deberse a una mejor monitorización posterior al alta y a la comunicación entre el paciente y el médico. Consulte Video Resumen en http://links.lww.com/DCR/B878 . (Traducción-Dr. Francisco M. Abarca-Rendon ).

North American multicentre evaluation of a same-day discharge protocol for minimally invasive colorectal surgery using mHealth or telephone remote post-discharge monitoring.

BACKGROUND: Same-day discharge (SDD) after colectomy is feasible but requires effective post-discharge remote follow-up. Previous studies have used in-person home visits or a mobile health (mHealth) phone app, but the use of simple telephone calls for remote follow-up has not yet been studied. Therefore, the objective of this study was to compare outcomes after SDD for minimally invasive colectomy using mHealth or telephone remote post-discharge follow-up. METHODS: A prospective cohort study was undertaken at two university-affiliated colorectal referral institutions from 02/2020 to 05/2021. Adult patients without significant comorbidities undergoing elective minimally invasive colectomy. Patients were discharged on the day of surgery based on set criteria. Post-discharge remote follow-up was performed using a mHealth app at site 1 and scheduled telephone calls at site 2 up to postoperative day (POD) 7. The main outcome for this study was the success rate of SDD, defined as discharge on POD0 without emergency department (ED) visit or readmission within the first 3 days. RESULTS: A total of 105 patients were recruited (site 1, n = 70; site 2, n = 35). Overall, 75% of patients were discharged on POD0 (site 1 81% vs. site 2 63%, p = 0.038), of which only two patients required an ED visit within the first 3 days, leading to an overall success rate of 73% (site 1 80% vs. site 2 60%, p = 0.029). The incidence of 30-day complications (16% vs. 20%, p = 0.583), ED visits (11% vs. 11%, p = 1.00), and readmissions (9% vs. 14%, p = 0.367) were similar between the two sites. There was only one patient at each study site that went to the ED without instructions through remote follow-up. CONCLUSIONS: A high proportion of patients planned for SDD were discharged on POD0 with few patients requiring an early unplanned ED visit. These results were similar with an mHealth app or telephone calls for post-discharge remote follow-ups, suggesting that SDD is feasible regardless of the method of post-discharge remote follow-up.

At least ninety days of follow-up are required to adequately detect wound outcomes after open incisional hernia repair.

INTRODUCTION: Incisional hernia repair (IHR) carries a high risk of wound complications. Thirty-day outcomes are frequently used in comparative-effectiveness research, but may miss a substantial number of surgical site occurrences (SSO) including surgical site infection (SSI). The objective of this study was to determine an optimal length of follow-up to detect SSI after IHR. METHODS: All adult patients undergoing open IHR at a single academic center over a 3 year period were reviewed. SSIs, non-infectious SSOs, and wound-related readmissions were recorded up to 180 days. The primary outcome was the proportion of SSIs detected at end-points of 30, 60, and 90 days of follow-up. Time-to-event analysis was performed for all outcomes at 30, 60, 90, and 180 days. Logistic regression was used estimate the relative risk of SSI for relevant risk factors. RESULTS: A total of 234 patients underwent open IHR. Median follow-up time of 102 days. Overall incidence of SSI was 15.8% with median time to occurrence of 23 days. Incidence of non-infectious SSO was 33.2%, and SSO-related readmission was 12.8%. At 30, 60, and 90 days sensitivity was 81.6%, 89.5%, and 92.1 for SSI, and 46.7%, 76.7%, and 83.3% for readmission. In regression analysis, body mass index (RR 1.08, 95% CI 1.00, 1.15, p = 0.04) anterior component separation (RR 4.21, 95% CI 2.09, 6.34, p = 0.003), and emergency surgery (RR 3.25, 95% CI 1.47, 5.02, p = 0.01), were independently associated with SSI after adjusting for age, sex, contamination class, and procedure duration. CONCLUSION: A considerable proportion of SSIs occurred beyond 30 days, but 90-day follow-up detected 92% of SSIs. Follow-up to 90 days captured only 83% of SSO-related readmissions. These results have implications for the design of trials evaluating wound complication after open IHR, as early endpoints may miss clinically relevant outcomes and underestimate the number needed to treat. Where possible, we recommend a minimum follow-up of 90 days to estimate wound complications following open IHR.

Feasibility of intraoperative angioembolization for trauma patients using C-arm digital subtraction angiography.

PURPOSE: Hemodynamically unstable trauma patients who would benefit from angioembolization (AE) typically also require emergent surgery for their injuries. The critical decision of transferring a patient to the operating room versus the interventional radiology (IR) suite can be bypassed with the advent of intra-operative AE (IOAE). Previously limited by the availability of costly rooms termed RAPTOR (resuscitation with angiography, percutaneous techniques and open repair) suites, it has been suggested that using C-arm digital subtraction angiography (DSA) is a comparable alternative. This case series aims to establish the feasibility and safety of IOAE. METHODS: We conducted a retrospective analysis of all trauma patients at our level 1 trauma center who underwent IOAE with a concomitant surgical intervention from January 2011 to May 2019. Descriptive analyses were conducted. RESULTS: A total of 49 patients (80% male, 44 ± 17 years, 92% blunt) underwent IOAE using the C-arm DSA during the study period. All but one patient underwent exploratory laparotomy, 56% of which underwent an additional surgical procedure (ex. exploratory thoracotomy, orthopedic). Either Gelfoam® (Pfizer, New York, USA) (90%), coils (2.0%), or a combination (8.2%) were used for embolization. Internal iliac embolization was performed in 88% of cases (59% bilateral). IOAE was successful in all but four cases (8.2%) and thirty-day mortality was 31%. CONCLUSION: IOAE appears to be a feasible and safe management option in severe trauma patients with the advantage of concurrent operative intervention and ongoing active resuscitation with good success in hemorrhage control.

High incidence of potentially preventable emergency department visits after major elective colorectal surgery.

INTRODUCTION: Emergency department (ED) visits after surgery represent a significant cost burden on the healthcare system. Furthermore, many ED visits are related to issues of healthcare delivery services and may be avoidable. Few studies have assessed the reasons for ED visits after colorectal surgery. The main objectives of this study were to: (1) identify the reasons why patients presented to the ED within 30 postoperative days and (2) determine if these visits were potentially preventable. METHODS: A retrospective chart review was conducted on elective major colorectal surgery cases performed in a single center between 01/2017 and 07/2019. Data collected included demographics, medical history, intraoperative details, postoperative complications, ED visits within 30 postoperative days, and readmissions. Each ED visit was assessed by two reviewers and graded on a scale adapted from the New York University ED algorithm. The gradings were: (1) non-emergent, (2) emergent but treatable in an ambulatory setting, (3) emergent/ED-care required but preventable if timely outpatient care was available, and (4) emergent/ED-care required and non-preventable. Grades 1-3 were deemed potentially preventable. Logistic regression identified independent predictors of potentially preventable visits. RESULTS: Six hundred and twenty five patients were included in the final analysis. 110 (17.6%) patients presented to the ED within 30 days. The most common cause of ED visit were ileus/small bowel obstruction (SBO) (16.4%), superficial wound infection (15.5%), genitourinary issues (10.9%), and non-infectious gastrointestinal issues (nausea, malnutrition, diarrhea, high output stomas) (10.9%). After review, 51.8% of visits were considered potentially preventable (Grade 1-3). The most common causes of preventable ED visits were superficial wound infection (24.6%), non-infectious gastrointestinal issues (19.3%), and minor bleeding (14.0%). Creation of a new stoma was the only independent risk factor for potentially preventable ED visits (OR 2.14, 95%CI 1.03-4.47). CONCLUSION: Approximately half of ED visits within 30 days of discharge were potentially preventable. These findings indicate a need to improve access to outpatient care to reduce preventable ED visits after elective colorectal surgery.

Enhanced Recovery 2.0 - Same Day Discharge With Mobile App Follow-up After Minimally Invasive Colorectal Surgery.

OBJECTIVE: To investigate the feasibility of SDD protocol with postdischarge follow-up using a mobile phone app in patients undergoing elective minimally-invasive colectomy. SUMMARY OF BACKGROUND DATA: Discharge before gastrointestinal recovery and use of mobile health technology for remote follow-up may allow for SDD after minimally-invasive colectomy within an ERP. METHODS: Adult patients undergoing elective laparoscopic colectomy or loop ileostomy reversal from February 2020 to November 2020 were screened for eligibility. Patients were eligible if they lived within a 30-minute drive from the hospital, had an adequate support system at home, and owned a smart phone. Patients were discharged from the recovery room on the day of surgery based on set criteria with postdischarge remote follow-up using a mobile application. Feasibility was defined as discharge on the day of surgery without emergency department (ED) visit or readmission within the first 3 days. 30-day complications, ED visits, and readmissions were compared to a non-SDD historical cohort (May 2019-March 2020) also remotely followed-up using the same mobile phone app (standard ERP group). RESULTS: A total of 48 patients were recruited to SDD, of which 77% were discharged on the day of surgery without subsequent ED visit in the first 72 hours. There were 11 patients that could not be discharged, including 7 for failure of discharge criteria and 4 for intraoperative complications/concerns. Overall 30-day complications in the SDD group (17%) was similar to the standard ERP group (15%, P = 0.813). ED visits (SDD10% vs standard ERP8%, P = 0.664) and readmissions (6% vs 4%, P = 0.681) were also similar. CONCLUSIONS AND RELEVANCE: Findings from this study support the feasibility of a SDD protocol in select patients undergoing minimally-invasive colorectal resection. SDD colectomy protocols may represent the next evolution of ERP and postoperative recovery.

Do postoperative telemedicine interventions with a communication feature reduce emergency department visits and readmissions?-a systematic review and meta-analysis.

INTRODUCTION: Emergency department (ED) visits and readmissions after surgery are common and represent a significant cost-burden on the healthcare system. A notable portion of these unplanned visits are the result of expected complications or normal recovery after surgery, suggesting that improved coordination and communication in the outpatient setting could potentially prevent these. Telemedicine can improve patient-physician communication and as such may have a role in limiting unplanned emergency department visits and readmissions in postoperative patients. METHODS: Major electronic databases were searched for randomized controlled trials and cohort studies in surgical patients examining the effect of postoperative telemedicine interventions with a communication feature on 30-day readmissions and emergency department visits as compared to current standard postoperative follow-up. All surgical subspecialties were included. Two independent reviewers assessed eligibility, extracted data, and evaluated risk of bias using standardized tools. Our primary outcomes of interest were 30-day ED visits and readmissions. Our secondary outcomes were patient satisfaction with the intervention. RESULTS: 29 studies were included in the final analysis. Fourteen studies were RCTs, and the remaining fifteen were cohort studies. Eighteen studies reported 30-day ED visit as an outcome. There was no overall reduction in 30-day ED visit in the telemedicine group (RR: 0.89, 95%CI: 0.70-1.12). Twenty-two studies reported 30-day readmission as an outcome. The overall pooled estimate did not show a difference in this outcome (RR: 0.90, 95%CI: 0.74-1.09). Fifteen studies reported a metric of patient satisfaction regarding utilization of the telemedicine intervention. All studies demonstrated high levels of satisfaction (> 80%) with the telemedicine intervention. DISCUSSION: This review fails to demonstrate a clear reduction ED visits and readmissions to support use of a telemedicine intervention across the board. This may be in part explained by significant heterogeneity in the proportions of potentially preventable visits in each surgical specialty. As such, targeting interventions to specific surgical settings may prove most useful.

S116: Impact of incisional negative pressure wound therapy on surgical site infection after complex incisional hernia repair: a retrospective matched cohort study.

INTRODUCTION: Incisional negative pressure wound therapy (iNPWT) may reduce surgical site infections (SSI), which can have devastating consequences after incisional hernia repair. Few comparative studies investigate the effectiveness of this wound management strategy in this population. The objective of this study is to determine the effect of iNPWT on the incidence of SSI after complex incisional hernia repair. METHODS: All adult patients undergoing open incisional hernia repair at a single center from 2016 to 2019 were reviewed. A commercial iNPWT dressing was used at the discretion of the surgeon. Patients were grouped by type of dressing; iNPWT and standard sterile dressings (SSD). Coarsened exact matching was used to create balanced cohorts for comparison using age, sex, American Society of Anesthesiologists classification, wound classification, and surgical urgency. The primary outcome was the composite incidence of superficial and deep SSI within 30 days. Secondary outcomes included non-infectious surgical site occurrences (SSO), overall complications, length of stay (LOS), emergency department visits, and readmission at 30 days. RESULTS: 134 patients underwent complex hernia repair, with 114 patients included after matching (34 iNPWT, 51 SSD). Composite incidence of superficial and deep SSI was 19.3% (11.8% vs. 27.5%, p = 0.107), with significantly lower rates of deep SSI in patients receiving iNPWT (2.9% vs. 17.6%, p = 0.045). After accounting for residual differences between groups, iNPWT was associated with decreased incidence of composite SSI (RR 0.36, 95% CI [0.16, 0.87]). Median LOS was longer in patients with iNPWT (7 vs. 5 days, p = 0.001). There were no differences in SSO, overall complications, readmission, or emergency department visits. CONCLUSION: In patients undergoing incisional hernia repair, the use of iNPWT was associated with a lower incidence of SSI at 30 days. Future studies should focus on cost effectiveness of iNPWT, its impact on long-term hernia recurrences, and the identification of patient selection criteria in this population.

Treatment of mycotic superior mesenteric vein pseudoaneurysm via placement of covered endovascular stent.

Vascular pseudoaneurysms are a rare yet life-threatening complication of untreated pancreatic pseudocysts related to their high risk of rupture and bleeding. Several studies and reports have established endovascular approaches as a successful first-line therapy in the management of arterial pancreatic pseudoaneurysms. However, no reports have been published describing endovascular repair of a venous pseudoaneurysm that developed after infection of a chronically stable pancreatic pseudocyst, most likely due to its rare occurrence. We report in this technical note the treatment of a superior mesenteric vein pseudoaneurysm that developed as a result of an infected small pancreatic pseudocyst, by radiologic placement of a covered endovascular stent.

Casting A Wide Net On Surgery: The Central Role of Neutrophil Extracellular Traps.

: Since their discovery, neutrophil extracellular traps (NETs) have been implicated in a broad array of functions, both beneficial and detrimental to the host. Indeed, NETs have roles in infection, sepsis, wound healing, thrombotic disease, and cancer propagation, all of which are directly implicated in the care of surgical patients. Here we provide an updated review on the role of NETs in the perioperative period with specific emphasis on perioperative infections, wound healing, vascular complications, cancer propagation, as well as discussing ongoing, and future therapeutic targets. Surgeons will benefit from understanding the latest discoveries in neutrophil biology and how these novel functions affect the care of surgical patients. Furthermore, novel anti-NET therapies are being developed which may have profound effects on the care of surgical patients.

Enhanced recovery after pulmonary surgery.

The concept of surgical recovery encompasses the entire perioperative phase of the patient, beginning with the preoperative baseline and culminating in the long-term rehabilitation of the patient in the post-operative phase. Enhanced recovery pathways (ERPs) aim to encompass all phase of the patient trajectory, including the preoperative, perioperative, and postoperative management of surgical patients. While significant literature exists on standardizing and optimizing the perioperative phase, standardizing the pre and post-operative phases remains a topic of debate. Furthermore, with regards to pulmonary surgery, the available data on enhanced recovery remains limited, with no consensus on which components to include within the ERP. The difficulty in identifying specific factors to include within a pathway is in part due to the lack of representative metrics of recovery. Secondly, the strength of ERPs usually lies in the agglomeration of multiple components rather than the individual components themselves. This review provides a brief review on current developments in ERPs in pulmonary surgery, emphasizing novel components in the pre and post-operative care of patients. Furthermore, we discuss the limitations of current metrics used to study recovery, and what steps can be taken to direct future studies that aim to enhance patient recovery after pulmonary surgery.

In vivo tungsten exposure alters B-cell development and increases DNA damage in murine bone marrow.

High environmental tungsten levels were identified near the site of a childhood pre-B acute lymphoblastic leukemia cluster; however, a causal link between tungsten and leukemogenesis has not been established. The major site of tungsten deposition is bone, the site of B-cell development. In addition, our in vitro data suggest that developing B lymphocytes are susceptible to tungsten-induced DNA damage and growth inhibition. To extend these results, we assessed whether tungsten exposure altered B-cell development and induced DNA damage in vivo. Wild-type mice were exposed to tungsten in their drinking water for up to 16 weeks. Tungsten concentration in bone was analyzed by inductively coupled plasma mass spectrometry and correlated with B-cell development and DNA damage within the bone marrow. Tungsten exposure resulted in a rapid deposition within the bone following 1 week, and tungsten continued to accumulate thereafter albeit at a decreased rate. Flow cytometric analyses revealed a transient increase in mature IgD(+) B cells in the first 8 weeks of treatment, in animals of the highest and intermediate exposure groups. Following 16 weeks of exposure, all tungsten groups had a significantly greater percentage of cells in the late pro-/large pre-B developmental stages. DNA damage was increased in both whole marrow and isolated B cells, most notably at the lowest tungsten concentration tested. These findings confirm an immunological effect of tungsten exposure and suggest that tungsten could act as a tumor promoter, providing leukemic "hits" in multiple forms to developing B lymphocytes within the bone marrow.