Keith S. Gersin

The burden of Clostridium difficile in surgical patients in the United States.

BACKGROUNDnClostridium difficile colitis is the predominant hospital-acquired gastrointestinal infection in the United States and has emerged as an important nosocomial cause of morbidity and death. Although several institutional studies have examined the effects of C. difficile on hospitalized patients, its nationwide impact on surgical patients has yet to be defined.nnnMETHODSnTo provide a national estimate of the burden of C. difficile, we performed a five-year retrospective analysis of the Agency for Healthcare Research and Qualitys National Inpatient Sample Database, which represents a stratified 20% sample of hospitals in the United States, from 1999 to 2003. All surgical inpatient discharge data from 997 hospitals in 37 states were analyzed to determine the association of C. difficile infections with patient demographics, hospital characteristics, surgical procedure, length of stay (LOS), total charges, and in-hospital mortality rate. Univariate analysis was performed to identify any association between the presence of C. difficile infection and the outcome variables using chi-square contingency table analysis or the Student t-test following the exclusion of patients with other medical complications. Multivariate regression analysis was used to determine whether the presence of C. difficile infection was an independent predictor of increased LOS, total charges, and in-hospital mortality rate when controlling for surgery type, age, sex, payor, and hospital characteristics.nnnRESULTSnClostridium difficile infection was reported as a discharge diagnosis for 8,113 (0.52%) of all 1,553,597 inpatients who had undergone a general surgical procedure. The incidence increased significantly in 2002 (34% higher than in 2001; p < 0.0001). The following patient and hospital characteristics were associated with the highest incidence of C. difficile infection (all p < 0.0001): Age > 64 years (0.95%); Medicare beneficiary status (0.94%); north-eastern hospital location (0.73%); and large (0.55%), urban (0.56%), or teaching hospital (0.61%). Patients undergoing an emergency operation were at higher risk than those having operations performed electively (0.8% vs. 0.3%; p < 0.0001). Colectomy, small-bowel resection, and gastric resection were associated with the highest risk of C. difficile infection (incidence after colectomy 1.11%; odds ratio [OR] 2.77, 95% confidence interval [CI] 2.65, 2.89, p < 0.0001; small-bowel resection 1.17%, OR 2.40, 95% CI 2.26, 2.54, p < 0.0001; gastric resection 1.02%, OR 2.26, 95% CI 2.03, 2.52, p < 0.0001). Patients undergoing cholecystectomy and appendectomy had the lowest risk of C. difficile infection (cholecystectomy 0.41%, OR 0.37, 95% CI 0.35, 0.39, p < 0.0001; appendectomy 0.20%, OR 0.45, 95% CI 0.42, 0.49, p < 0.0001). Multivariable analysis demonstrated that C. difficile was an independent predictor of LOS, which increased by 16.0 days (95% CI 15.6, 16.4 days; p < 0.0001) in the presence of infection. Total charges increased by

Weight Loss and Metabolic Improvement in Morbidly Obese Subjects Implanted for 1 Year With an Endoscopic Duodenal-Jejunal Bypass Liner

77,483 (95% CI

Missed lipoma of the spermatic cord. A pitfall of transabdominal preperitoneal laparoscopic hernia repair.

75,174,

7225 Enteroscopic treatment of early postoperative bowel obstruction.

79,793; p < 0.0001), and there was a 3.4-fold increase in the mortality rate (95% CI 3.02, 3.77; p < 0.0001) compared with patients who did not acquire C. difficile.nnnCONCLUSIONSnEpidemiologic data suggest that the incidence of C. difficile infection is increasing in U.S. surgical patients and that the infection is most prevalent after emergency operations and among patients having intestinal tract resections. Infection with C. difficile is an independent predictor of increased LOS, total charges, and mortality rate after surgery and represents a considerable burden to both patients and hospitals. Preventing C. difficile infection offers a potentially significant improvement in patient outcomes, as well as a reduction in hospital costs and resource expenditures.

Training guideline for use of propofol in gastrointestinal endoscopy

Objective:To evaluate safety, weight loss, and cardiometabolic changes in obese subjects implanted with the duodenal-jejunal bypass liner (DJBL) for 1 year. Background:The DJBL is an endoscopic implant that mimics the duodenal-jejunal bypass component of the Roux-en-Y gastric bypass. Previous reports have shown significant weight loss and improvement in type 2 diabetes for up to 6 months. Methods:Morbidly obese subjects were enrolled in a single arm, open label, prospective trial and implanted with the DJBL. Primary endpoints included safety and weight change from baseline to week 52. Secondary endpoints included changes in waist circumference, blood pressure, lipids, glycemic control, and metabolic syndrome. Results:The DJBL was implanted endoscopically in 39 of 42 subjects (age: 36 ± 10 years; 80% female; weight: 109 ± 18 kg; BMI: 43.7 ± 5.9 kg/m2); 24 completed 52 weeks of follow-up. Three subjects could not be implanted due to short duodenal bulb. Implantation time was 24 ± 2 minutes. There were no procedure-related complications and there were 15 early endoscopic removals. In the 52-week completer population, total body weight change from baseline was −22.1 ± 2.1 kg (P < 0.0001) corresponding to 19.9 ± 1.8% of total body weight and 47.0 ± 4.4% excess of weight loss. There were also significant improvements in waist circumference, blood pressure, total and low-density lipoprotein cholesterol, triglycerides, and fasting glucose. Conclusions:The DJBL is safe when implanted for 1 year, and results in significant weight loss and improvements in cardiometabolic risk factors. These results suggest that this device may be suitable for the treatment of morbid obesity and its related comorbidities. This study was registered at www.clinicaltrials.gov (NCT00985491).

Choledocholithiasis: evolving intraoperative strategies.

AbstractBackground: Missed lipoma of the spermatic cord is a pitfall unique to the transabdominal preperitoneal (TAPP) laparoscopic hernia repair. This problem occurs when a palpable inguinal mass is noted preoperatively, but no identifiable hernia defect is found at time of laparoscopy and the procedure is terminated.n Methods: Our group encountered six patients without intraperitoneal defects that had large cord lipomas on preperitoneal exploration. Two of these patients had undergone previous intraabdominal laparoscopy for a proposed TAPP repair, which was aborted when no defect was seen.n Results: Both patients were referred for continued symptomatic groin masses, which were subsequently treated by lipoma resection in conjunction with inguinal floor repair.n Conclusions: When patients present with a groin mass, exploration of the preperitoneal space and cord structures is indicated during TAPP repair, even in the presence of a normal-appearing abdominal floor. Abandoning a transabdominal approach without exploration of the preperitoneal structures may lead to a failure to identify symptomatic and/or palpable cord lipomas.

Alternative Site Entry for Laparoscopy in Patients with Previous Abdominal Surgery

Introduction: Early postoperative small bowel obstruction (EPSBO) occurs in nearly 1% of patients undergoing laparotomy and has a mortality rate exceeding 17%. Nasogastric (NG) decompression is successful in 78% of patients. Repeat laparotomy has been recommended when obstruction does not resolve after 14 days of NG decompression. We report 4 patients with EPSBO treated successfully with push enteroscopy after failed NG decompression. Methods: Four patients who failed NG decompression underwent push enteroscopy instead of repeat laparotomy. EPSBO was diagnosed if obstruction lasting more than 14 days developed after initial resolution of postoperative ileus or high NG output persisted postoperatively for 21 days in the absence of prolonged ileus or sepsis. Small bowel series or CT was utilized when radiographic assessment was necessary. The Olympus SIF 100 push enteroscope was introduced with an overtube using topical anesthesia and intravenous sedation. After maximal insertion, the enteroscope was withdrawn without evacuation of insufflated air. NG tubes were placed after enteroscopy, and the patients followed clinically. Flatus, defecation, and tolerance of diet defined resolution of EPSBO. Results: EPSBO resolved 24-36 hours following enteroscopy, and all patients were discharged on general diets 48 hours after return of bowel function. Readmission has not been necessary during 6-18 month followup. Conclusions: Our experience suggests that push enteroscopy is successful in treating EPSBO and should be considered prior to re-operation. Repeat laparotomy may not be necessary and push enteroscopy may reduce patient morbidity, cost, and hospital lengths of stay associated with this uncommon surgical complication.