Avinash Bhakta

Predictors of Hospital Readmission after Bariatric Surgery

BACKGROUND Identification of factors that might predict readmission after bariatric surgery could help surgeons target high-risk patients. The purpose of this study was to identify comorbidities, surgical variables, and postoperative complications associated with readmission. STUDY DESIGN Patients with bariatric surgery as their primary procedure were identified from the 2012 American College of Surgeons (ACS) NSQIP database. Patient variables, operative times, and major postoperative complications were analyzed for predictors of readmission. The ACS NSQIP estimated probability of morbidity (MORBPROB) was also considered. Chi-square tests and Poisson regression were used for statistical analysis to identify significant predictors. RESULTS There were 18,186 patients who met inclusion criteria. There were 1,819 who had a laparoscopic gastric band, 9,613 who had laparoscopic Roux-en-Y gastric bypass (RYGB), 6,439 who had gastroplasties (vertical banded gastroplasty and sleeve), and 315 who had open RYGB. Age, sex, BMI, American Society of Anesthesiologists (ASA) class, diabetes, hypertension, steroid use, type of procedure, and operative time all were significantly associated with readmission within 30 days of operation. All major postoperative complications were significant predictors of readmission. Patients expected to be at high risk based on the ACS NSQIP MORBPROB had a significantly higher rate of readmissions. The overall readmission rate for patients undergoing bariatric surgery was 5%. The readmission rate among patients with any major complication was 31%. CONCLUSIONS Bariatric surgery is a low-risk procedure. Complexity of operation, ASA class, prolonged operative time, and major postoperative complications are important determinants of high risk for readmission. The ACS NSQIP MORBPROB may be a useful tool to identify and target patients at risk for readmission.

Increased Incidence of Surgical Site Infection in IBD Patients.

BACKGROUND: Surgical site infection is a key hospital-level patient safety indicator. All risk factors for surgical site infection are not always taken into account and adjusted for. OBJECTIVE: This study aimed to measure the impact of IBD in comparison with diverticulitis and colorectal cancer on the national rates of surgical site infection. DESIGN: The American College of Surgeons National Surgical Quality Improvement Project database was queried for all patients undergoing elective colectomy for colon cancer, diverticulitis, and IBD from 2008 through 2012. OUTCOME MEASURES: The association between surgical site infection and IBD patients was assessed. Patient demographics, rates of surgical site infection, wound class, return to operating room, and various patient characteristics were analyzed. Logistic regression was performed to determine the association with surgical site infection. RESULTS: The query yielded 71,845 patients undergoing elective colectomy. Of these patients, 42,132 had colon cancer, 22,143 had diverticulitis, and 7570 had IBD. The rate of surgical site infection was 12.0% for colon cancer, 12.8% for diverticulitis, and 18.0% for IBD. Return to operating room within 30 days was 7.3% for IBD patients, 4.4% for patients with diverticulitis, and 4.9% for patients with colorectal cancer. Return to operating room within 30 days had the highest correlation to surgical site infection in both univariate and multivariable analysis. Other associative factors for surgical site infection common to both analyses included diabetes mellitus, smoking, open procedures, and obesity. LIMITATIONS: This study was limited by the data collection errors inherent to large databases, exclusion of emergent operations, and the inability to identify patients taking immunosuppressive agents. CONCLUSIONS: Patients with IBD undergoing elective colectomy have significantly increased rates of surgical site infection, specifically deep and organ/space infections. Given this information, risk adjustment models for surgical site infection may need to include IBD in their calculation.

Risk of catheter-associated deep venous thrombosis in inflammatory bowel disease.

BACKGROUND:Inflammatory bowel disease confers a hypercoagulable state. A large number of these patients require central venous access in the form of peripherally inserted central catheters for long-term intravenous therapies. Our clinical observations suggested that these patients had a higher incidence of catheter-associated deep venous thrombosis than that of the general population. OBJECTIVE:The aim of this study was to examine the relationship between IBD and catheter-associated deep venous thrombosis. DESIGN:A retrospective chart review was conducted of all patients who underwent peripherally inserted central catheter line placement between 2009 and 2011. SETTING:This study was performed at a single-institution tertiary referral center. PATIENTS:All patients who underwent peripherally inserted central catheter line placement were identified. OUTCOME MEASURES:The risk of catheter-associated deep venous thrombosis in IBD patients was assessed. This risk was compared with known risk factors such as malnutrition, malignancy, diabetes mellitus, and tobacco use. Multivariate analysis was performed. Catheter size, indication for placement, and vein location of catheter-associated deep venous thrombosis were identified in the IBD population. RESULTS:There were 7179 peripherally inserted central catheter lines placed during the study period; the overall incidence of catheter-associated deep venous thrombosis was 2.1% (148/7179). The incidence of catheter-associated deep venous thrombosis among patients with IBD was 6.8% (9/132). The incidence of catheter-associated deep venous thrombosis among non-IBD patients was 1.9% (139/7047) (relative risk, 3.5; 95% CI, 1.8–6.6; p < 0.001). The incidence of catheter-associated deep venous thrombosis was increased for patients with malnutrition (4.8%, 30/628, p < 0.001) and increasing age (95% CI, 1.01–1.12; p = 0.02). There was no increased incidence of catheter-associated deep venous thrombosis for patients with diabetes mellitus (1.6%, 25/1574, p < 0.14), malignancy (2.8%, 30/1041, p = 0.06), or tobacco use (1.6%, 31/1938, p = 0.10). After multivariate analysis, IBD, malnutrition, and increasing age were found to be significant risk factors for the development of catheter-associated deep venous thrombosis. LIMITATIONS:The inability to track the number of catheter days, the inaccuracy of administrative data, the lack of outpatient follow-up, and the small number of events in the study cohort were limitations of this study. CONCLUSIONS:This is the first study to demonstrate IBD as an independent risk factor to the development of catheter-associated deep venous thrombosis. The placement of a peripherally inserted central catheter line in IBD should be utilized selectively.

Non-operative management of water injection injury to the neck

Although rarely reported in the pediatric population, high-pressure injection injuries are a common occurrence in adult industrial workers. These injuries commonly exhibit physiologic patterns consistent with direct kinetic trauma, localized substance toxicity, and in later stages infection. The majority of reported cases describe injection injuries caused by caustic substances at high pressures frequently necessitating debridement. In this case, we present a 12-year old boy who sustained a Zone III penetrating neck injury after running in front of a commercial pressure washer. In our case presentation there was concern for vascular and aero-digestive injuries; however, following physical examination and advanced imaging, expectant management was successfully adopted.