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Poliwoda J, Neville A, Yadav K, Nemnom MJ, Walmsley CG, Stiell IG. Presentations, management and outcomes of postoperative bariatric patients seen in the emergency department. Am J Emerg Med 2024; 81:82-85. [PMID: 38677198 DOI: 10.1016/j.ajem.2024.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Bariatric surgery is becoming increasingly common and postoperative patients often present to the emergency department (ED) with complications. We sought to describe the presenting complaints, management, and outcomes of postoperative bariatric surgery patients seen in the ED. METHODS We conducted a health records review of 300 consecutive postoperative Roux-en-Y bypass surgery patients who presented to two tertiary care EDs of a major bariatric surgery center within one year of surgery. Cases were identified using a data analytic tool, and two evaluators abstracted clinical variables, imaging, treatments, and outcomes using the electronic health record. Attending emergency physicians verified the data and an experienced bariatric surgeon interpreted the computed tomography (CT) results and surgical procedures. RESULTS We included 300 patients with mean age 43.0 years, 89.7% female. Of these, 70.0% presented within 30 days of surgery and 41.7% were admitted to hospital. ED treatments included intravenous fluids (67.0%), antiemetics (53.3%), and analgesia (61.9%). Patients presenting within 30 days of surgery were more likely to undergo a CT (74.3% vs 63.3%; p = 0.06) and to have clinically important CT findings (31.9% vs 6.6%; p ≤0.001). More of the ≤30-day patients were admitted to hospital (46.2% vs 31.1%; p = 0.02). While a higher proportion of patients presenting after 30 days underwent a procedure, a large number of those were not directly related to bariatric surgery, such as appendectomy and cholecystectomy. Of the 34 patients undergoing a procedure, the majority presented with abdominal pain (76.5%). CONCLUSION This is the first detailed health records review of postoperative bariatric patients seen in the ED in the emergency medicine literature. Those presenting with abdominal pain were more likely to undergo CT abdomen and a surgical procedure. Similarly, those presenting within 30 days of surgery were more likely to have significant CT findings and require hospital admission. Others presenting with primarily nausea and vomiting may improve with ED symptom management and be discharged home with bariatric team follow-up.
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Affiliation(s)
| | - Amy Neville
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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Josephson M, Turbati MS, Gould JC, Kindel TL, Higgins RM. Sociodemographic factors leading to preventable emergency department visits after bariatric surgery: a single-institution analysis. Surg Obes Relat Dis 2024:S1550-7289(24)00642-7. [PMID: 38960826 DOI: 10.1016/j.soard.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 11/09/2023] [Accepted: 05/27/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND An important quality benchmark after bariatric surgery is 30-day emergency department (ED) visits. OBJECTIVES We aimed to identify risk factors for ED visits not requiring readmission and thus deemed preventable. SETTING University Hospital. METHODS Patients who underwent a minimally invasive sleeve gastrectomy between 2017 and 2022 at a single institution were identified. Among these patients, those who presented to the ED within 30 days after surgery were matched 3:1 to controls. Sociodemographic and clinical variables were collected from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database and the electronic medical record. Univariate conditional logistic regression analysis was performed to determine predictive factors of ED visits. RESULTS Overall, 648 patients underwent sleeve gastrectomy, of which 53 (8.2%) presented to the ED within 30 days postoperatively without requiring readmission. Patients who presented to the ED were more likely to be unemployed (42% versus 24%, P = .04) and have government insurance (68% versus 41%, P = .001). Significant risk factors included lower versus upper socioeconomic bracket (odds ratio [OR] 3.6, P = .042), primary care physician (PCP) outside the health system versus within (OR 2.15, P = .032), greater number of PCP visits within the past year (OR 1.27, P < .001), and greater number of postoperative clinic phone calls (OR 2.04, P < .001). The number of ED visits within 1 year before surgery was a significant risk factor, with an OR of 1.44 for each visit (P < .001). CONCLUSIONS Modifiable and unmodifiable risk factors contribute to ED visits after bariatric surgery. Identifying these risk factors can aid in the development of quality improvement initiatives.
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Affiliation(s)
- Michael Josephson
- Division of Minimally Invasive and Gastrointestinal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mia S Turbati
- Division of Minimally Invasive and Gastrointestinal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jon C Gould
- Division of Minimally Invasive and Gastrointestinal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tammy L Kindel
- Division of Minimally Invasive and Gastrointestinal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rana M Higgins
- Division of Minimally Invasive and Gastrointestinal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
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Roe C, Mahan M, Stanton J, Wang S, Falvo A, Petrick A, Parker D, Horsley R. Examining emergency department utilization following bariatric surgery. Surg Endosc 2024; 38:2746-2755. [PMID: 38561584 DOI: 10.1007/s00464-024-10763-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 02/21/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Emergency department (ED) utilization following surgery is poorly understood and places immense strain on the healthcare system, being responsible for up to $38 billion in wasteful spending annually. The aim of this study was to quantify ED utilization following bariatric procedures to identify causes and areas of improvement. MATERIALS AND METHODS A retrospective review of a prospectively maintained database was conducted for all patients who underwent metabolic bariatric surgery (MBS) between November 2006 and June 2019. The study includes 4703 patients across 8 hospitals in a single health system. Patients who returned to the ED within 30 and 90 days were analyzed for relation to surgery and preventability. RESULTS Of the 4703 patients that underwent MBS, 907 (19.3%) visited the ED at least once within 90 days and 350 (7.4%) required hospital readmission. The most common bariatric procedure performed was the Roux-en-Y Gastric Bypass (RYGB) (3716/4703) with an average BMI of 43.8. The median length between discharge and ED visit was 19 days. Under 50% of patients called prior to ED presentation and 61% of these ED visits resulted in discharge. CONCLUSION While hospital readmissions following MBS have been scrutinized in literature, investigation of ED utilization remains scarce. Our study is one of few to investigate postoperative ED utilization up to 90 days following bariatric intervention. A clear opportunity exists to improve discharge education and early post-discharge communication. This would additionally alleviate burden to allow focus on the acutely ill.
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Affiliation(s)
- Cullen Roe
- Geisinger Medical Center, 100 North Academy Avenue, Danville, PA, 17821, USA.
| | - Mark Mahan
- Geisinger Medical Center, 100 North Academy Avenue, Danville, PA, 17821, USA
| | - Jason Stanton
- Geisinger Medical Center, 100 North Academy Avenue, Danville, PA, 17821, USA
| | - Shengxuan Wang
- Geisinger Medical Center, 100 North Academy Avenue, Danville, PA, 17821, USA
| | - Alexandra Falvo
- Geisinger Medical Center, 100 North Academy Avenue, Danville, PA, 17821, USA
| | - Anthony Petrick
- Geisinger Medical Center, 100 North Academy Avenue, Danville, PA, 17821, USA
| | - David Parker
- Geisinger Medical Center, 100 North Academy Avenue, Danville, PA, 17821, USA
| | - Ryan Horsley
- Geisinger Medical Center, 100 North Academy Avenue, Danville, PA, 17821, USA
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Tugcan MO, Cetinkunar S, Sahan O, Yaprak GK, Tugcan Y, Avci BS, Ozturk HA, Kuvvetli A, Avci A. Analysis of postoperative emergency admission and hospitalization of patients who underwent bariatric surgery: A single-center experience. Asian J Surg 2024; 47:320-327. [PMID: 37659937 DOI: 10.1016/j.asjsur.2023.08.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/11/2023] [Accepted: 08/24/2023] [Indexed: 09/04/2023] Open
Abstract
BACKGROUND Bariatric surgery is a treatment with a low risk of complications that is becoming common in obesity treatment. OBJECTIVE The aim of this study is to evaluate postoperative visits to the emergency department by patients who underwent bariatric surgery and to investigate what postoperative conditions are encountered in these patients and what can be done to prevent emergency room admission and hospitalization. SETTING University Hospital. METHODS The study included 394 patients aged 18 years underwent bariatric surgery for obesity. Emergency department (ED) admissions and diagnoses of patients who underwent bariatric surgery were analyzed in two groups, surgery-related and surgery-unrelated. RESULTS It was found that 22% (n: 87) of patients visited the ED at least once; 4.8% (n: 19) of them were hospitalized; and 78.1% (n: 68) of 87 patients did not need to be hospitalized. Low preoperative iron, folic acid, and ferritin levels increase the number of visits to ED with a bariatric surgery-related complaint, urinary tract infection was the most common diagnosis and did not require hospitalization; the most common diagnosis of hospitalized patients was gastrointestinal perforation, pulmonary embolism, intra-abdominal abscess. CONCLUSION Despite the low risk of complications, bariatric surgery is a surgery associated with a high number of preventable postoperative emergency visits. ED visits can be reduced by calling these patients for more frequent outpatient check-ups, providing intravenous hydration therapy in outpatient clinics and, if necessary, providing prescribed treatment.
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Affiliation(s)
- Mustafa Oguz Tugcan
- Health Science University, Adana City Research and Training Hospital, Department of Emergency Medicine, Adana, Turkey.
| | - Suleyman Cetinkunar
- Health Science University, Adana City Research and Training Hospital, Department of Emergency Medicine, Adana, Turkey.
| | - Ozge Sahan
- Health Science University, Adana City Research and Training Hospital, Department of Emergency Medicine, Adana, Turkey.
| | - Gazi Kutalmis Yaprak
- Health Science University, Adana City Research and Training Hospital, Department of Emergency Medicine, Adana, Turkey.
| | - Yagmur Tugcan
- Cukurova University, Faculty of Medicine, Department of Anesthesiology and Reanimation, Adana, Turkey.
| | - Begum Seyda Avci
- Health Science University, Adana City Research and Training Hospital, Department of Emergency Medicine, Adana, Turkey.
| | - Huseyin Ali Ozturk
- Health Science University, Adana City Research and Training Hospital, Department of Emergency Medicine, Adana, Turkey.
| | - Adnan Kuvvetli
- Health Science University, Adana City Research and Training Hospital, Department of Emergency Medicine, Adana, Turkey.
| | - Akkan Avci
- Health Science University, Adana City Research and Training Hospital, Department of Emergency Medicine, Adana, Turkey.
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Marcotte JH, Moncman RF, Branche MJ, Siegal TL, Patel RA, Turtz AR. Tension pneumocephalus following bariatric surgery: case report. Br J Neurosurg 2023; 37:1315-1318. [PMID: 33393846 DOI: 10.1080/02688697.2020.1866166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 12/15/2020] [Indexed: 10/22/2022]
Abstract
Bariatric surgery is an effective treatment for patients with idiopathic intracranial hypertension (IIH), a condition that is associated with skull base defects. A 55-year-old woman presented with symptoms of intractable nausea and vomiting, followed by headache and confusion two weeks after an elective laparoscopic vertical sleeve gastrectomy procedure. She had a presumed diagnosis of IIH and a remote history of CSF oto/rhinorrhea treated with a lumbar peritoneal (LP) shunt. Computed tomography (CT) scan of the head revealed tension pneumocephalus with midline shift and dehiscence of the tegmen. The patient underwent emergent craniotomy for decompression of the air-filled temporal lobe, clamping of the LP shunt, and repair of the skull base defect. Caution should be exercised in obese patients with a history of CSF leak secondary to a middle fossa skull base defect when being evaluated for bariatric surgery.
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Affiliation(s)
- Joseph H Marcotte
- Department of General Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Ryan F Moncman
- Department of Neurological Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Marc J Branche
- Department of Radiology, Cooper University Hospital, Camden, NJ, USA
| | - Todd L Siegal
- Department of Radiology, Cooper University Hospital, Camden, NJ, USA
| | - Rohit A Patel
- Department of Bariatric Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Alan R Turtz
- Department of Neurological Surgery, Cooper University Hospital, Camden, NJ, USA
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Ferreri CA, Benvenuto A, Cassidy DE, McGee LM, Gamsarian VA, Daignault-Newton S, Ivancic V, Park JM, Sack BS, Streur CS, Wan J, Kraft KH. The role of a photographic atlas in reducing unanticipated healthcare utilization following circumcision. J Pediatr Urol 2023; 19:642.e1-642.e6. [PMID: 37481429 DOI: 10.1016/j.jpurol.2023.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 07/24/2023]
Abstract
INTRODUCTION Circumcision is a common procedure that can evoke caregiver anxiety in the postoperative period due to unfamiliarity with the healing process. To mitigate unnecessary healthcare utilization such as phone calls and unanticipated clinic or emergency department (ED) visits, photographic atlases have been developed to better prepare caregivers for the recovery process. The objective of our study is to further investigate the efficacy of a photographic atlas in its ability to decrease postoperative healthcare utilization using an increased sample size and extended study period compared to previous studies. MATERIALS AND METHODS In this study, we compared a prospective intervention cohort of patients undergoing circumcision at our institution who received a photographic atlas during postoperative teaching to a retrospective cohort of patients who had not received it. Our primary outcome was unanticipated healthcare utilization, defined as postoperative telephone calls and unanticipated presentations to the urology clinic or ED. RESULTS The retrospective no-atlas cohort included 105 patients, and the prospective intervention atlas cohort included 80 patients. Both groups were similar with respect to age (p = 0.47) and other demographics. There was no statistically significant difference in healthcare utilization between the no-atlas and atlas cohort. Specifically, we identified no difference in the number of phone calls to clinic staff (12 [11.4%] vs. 11 [13.8%], p = 0.64) or unanticipated postoperative clinic or ED visits (2 [1.9%] vs. 4 [5.0%], p = 0.41). DISCUSSION The use of a photographic atlas as part of caregiver support for circumcision patients did not demonstrate a statistically significant reduction in either postoperative phone calls or clinic/ED visits. The decrease in absolute number of caregiver phone calls was minimal (12-11), with a small increase in follow-up presentations (2-4). The lack of significant change may be due to the already infrequent occurrence of these events following circumcision, as demonstrated by the no-atlas cohort. Other potential advantages of the atlas, such as improved caregiver confidence and satisfaction, may have been present, but were not measured in this study. CONCLUSIONS Adding to the mixed results of previous studies, these findings do not support that photographic atlases decrease unanticipated healthcare utilization in children undergoing a circumcision. However, utilization was found to be low. Additionally, further studies are needed to determine other significant benefits of this form of education, such as improved caregiver confidence and satisfaction.
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Affiliation(s)
- C A Ferreri
- University of Michigan Medical School, Ann Arbor, MI, USA.
| | - A Benvenuto
- University of Michigan Medical School, Ann Arbor, MI, USA.
| | - D E Cassidy
- University of Michigan Medical School, Ann Arbor, MI, USA.
| | - L M McGee
- Department of Urology, Oregon Health & Science University, Portland, OR, USA.
| | - V A Gamsarian
- University of Michigan Medical School, Ann Arbor, MI, USA.
| | - S Daignault-Newton
- Division of Pediatric Urology, Department of Urology, University of Michigan, Ann Arbor, MI, USA.
| | - V Ivancic
- Division of Pediatric Urology, Department of Urology, University of Michigan, Ann Arbor, MI, USA.
| | - J M Park
- Division of Pediatric Urology, Department of Urology, University of Michigan, Ann Arbor, MI, USA.
| | - B S Sack
- Division of Pediatric Urology, Department of Urology, University of Michigan, Ann Arbor, MI, USA.
| | - C S Streur
- Division of Pediatric Urology, Department of Urology, University of Michigan, Ann Arbor, MI, USA.
| | - J Wan
- Division of Pediatric Urology, Department of Urology, University of Michigan, Ann Arbor, MI, USA.
| | - K H Kraft
- Division of Pediatric Urology, Department of Urology, University of Michigan, Ann Arbor, MI, USA.
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Langer S, Xu Y, Kong S, Puddy J, Quan ML. Investigating Factors Associated with Postmastectomy Emergency Department Visits: A Population-Based Analysis. Ann Surg Oncol 2023; 30:6499-6505. [PMID: 37454012 DOI: 10.1245/s10434-023-13727-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 05/23/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND In 2016, a multi-pronged pathway was implemented across 13 hospitals to improve the mastectomy perioperative care experience with one objective being to safely allow same day surgery mastectomy. While the pathway successfully increased same day mastectomy rates from 1.7 to 73.0%, the rate of postoperative emergency department (ED) visits remained high at > 20%, despite focused interventions to enhance perioperative support. AIM To investigate potential factors associated with high postoperative ED visits following mastectomies in Alberta, Canada. METHODS Data was collected using the Discharge Abstract Database and the National Ambulatory Care Reporting System database. Eligible patients included all women over 18 years old who underwent a mastectomy province-wide between 2004 and 2020. Patient demographics were collected. Primary outcome of interest was ED visit within 30 days of mastectomy. Univariate and multivariable analyses were performed to identify independent predictors for post-operative ED visits. RESULTS A total of 19,974 patients had mastectomy during the study period, of which 4590 (23%) had an ED visit within 30 days of surgery. Independent factors associated with ED visits were increasing age, overnight stay mastectomy, reconstruction, certain comorbidities, and living rurally. CONCLUSIONS Post-operative ED visits remain high despite initiating a province-wide surgical pathway in 2016 which emphasizes patient education and improved perioperative care and supports. Currently, the majority of ED visits are manageable in non-emergent settings. Patient populations at higher risk for ED visits groups may benefit from additional targeted support and resources to reduce unplanned ED visits.
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Affiliation(s)
- Steven Langer
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
| | - Yuan Xu
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Shiying Kong
- Alberta Health Services, Department of Analytics, University of Calgary, Calgary, Canada
| | - Jennifer Puddy
- Department of Emergency Medicine, University of Calgary, Calgary, Canada
| | - May Lynn Quan
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Callaway Kim K, Argetsinger S, Wharam JF, Zhang F, Arterburn DE, Fernandez A, Ross-Degnan D, Wallace J, Lewis KH. Acute Care Utilization and Costs Up to 4 Years After Index Sleeve Gastrectomy or Roux-en-Y Gastric Bypass: A National Claims-based Study. Ann Surg 2023; 277:e78-e86. [PMID: 34102668 PMCID: PMC8648857 DOI: 10.1097/sla.0000000000004972] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare acute care utilization and costs following sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). SUMMARY BACKGROUND DATA Comparing postbariatric emergency department (ED) and inpatient care use patterns could assist with procedure choice and provide insights about complication risk. METHODS We used a national insurance claims database to identify adults undergoing SG and RYGB between 2008 and 2016. Patients were matched on age, sex, calendar-time, diabetes, and baseline acute care use. We used adjusted Cox proportional hazards to compare acute care utilization and 2-part logistic regression models to compare annual associated costs (odds of any cost, and odds of high costs, defined as ≥80th percentile), between SG and RYGB, overall and within several clinical categories. RESULTS The matched cohort included 4263 SG and 4520 RYGB patients. Up to 4 years after surgery, SG patients had slightly lower risk of ED visits [adjusted hazard ratio (aHR): 0.90; 95% confidence interval (CI): 0.85,0.96] and inpatient stays (aHR: 0.80; 95% CI: 0.73,0.88), especially for events associated with digestive-system diagnoses (ED aHR: 0.68; 95% CI: 0.62,0.75; inpatient aHR: 0.61; 95% CI: 0.53,0.72). SG patients also had lower odds of high ED and high total acute costs (eg, year-1 acute costs adjusted odds ratio (aOR) 0.77; 95% CI: 0.66,0.90) in early follow-up. However, observed cost differences decreased by years 3 and 4 (eg, year-4 acute care costs aOR 1.10; 95% CI: 0.92,1.31). CONCLUSIONS SG may have fewer complications requiring emergency care and hospitalization, especially as related to digestive system disease. However, any acute care cost advantages of SG may wane over time.
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Affiliation(s)
- Katherine Callaway Kim
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical, School, Boston, Massachusetts
| | - Stephanie Argetsinger
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical, School, Boston, Massachusetts
| | - James Frank Wharam
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical, School, Boston, Massachusetts
| | - Fang Zhang
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical, School, Boston, Massachusetts
| | - David E Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle,Washington
| | - Adolfo Fernandez
- Department of Surgery,Wake Forest University Health Sciences,Winston-Salem, North Carolina
| | - Dennis Ross-Degnan
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical, School, Boston, Massachusetts
| | - Jamie Wallace
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical, School, Boston, Massachusetts
| | - Kristina H Lewis
- Department of Surgery,Wake Forest University Health Sciences,Winston-Salem, North Carolina
- Department of Epidemiology and Prevention, Department of Implementation Science, Division of Public Health Sciences, Wake Forest University Health Sciences, Winston-Salem, North Carolina
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9
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Shetty PN, Guarino GM, Zhang G, Sanghavi KK, Giladi AM. Risk Factors for Preventable Emergency Department Use After Outpatient Hand Surgery. J Hand Surg Am 2022; 47:855-864. [PMID: 35843760 DOI: 10.1016/j.jhsa.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/30/2022] [Accepted: 05/18/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE Emergency department (ED) visits for postoperative concerns that could be safely addressed in outpatient clinics have an impact on cost, quality measures, and care workflows. Patient-reported data (PRD) may give unique insights into individual-level factors that predict overuse of health care resources, and guide opportunities for intervention and prevention. We investigated the relationship between preoperative PRD and preventable ED use after outpatient hand surgery to determine whether the preoperative PRD can be used to identify patients at higher odds of having preventable ED visits. METHODS All adult patients undergoing outpatient surgery at our hand center between January 1, 2018, and December 31, 2019, were included. Questionnaires, including the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) and pain interference (PI) scales, were completed before surgery. We used our regional health information exchange to identify ED visits within 90 days of surgery. RESULTS Our cohort included 2,819 patients. Within 90 days after surgery, 106 (3.8%) had preventable ED visits. Race, insurance status, and transportation issues increased odds of a preventable ED visit. Multivariable models found that each 1-point increase in the preoperative PROMIS UE score was associated with 4% decreased odds of ED presentation (odds ratio, 0.96; 95% confidence interval, 0.94-0.99), and each 1-point increase in the preoperative PROMIS PI score was associated with 4% increased odds of ED presentation (odds ratio, 1.04; 95% confidence interval, 1.0-1.1). Any PROMIS UE or PI scores ≥1SDs worse than population norms increased the probability of a preventable ED visit, independent of other factors. CONCLUSIONS Worse preoperative PROMIS UE and PI scores were associated with increased odds of preventable ED visits. Preoperative PRD may allow for identification of outliers at higher risk for preventable ED use, and facilitate preventative interventions. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Pragna N Shetty
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Gianna M Guarino
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Gongliang Zhang
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; MedStar Health Research Institute, Hyattsville, MD
| | - Kavya K Sanghavi
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; MedStar Health Research Institute, Hyattsville, MD
| | - Aviram M Giladi
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
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10
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Lupoli R, Lembo E, Giosuè A, Schiavo L, Capaldo B. Clinical insights into management options for recurrent type 2 diabetes and cardiovascular risk after metabolic-bariatric surgery. Nutr Metab Cardiovasc Dis 2022; 32:1335-1342. [PMID: 35365370 DOI: 10.1016/j.numecd.2022.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/21/2022] [Accepted: 02/27/2022] [Indexed: 10/18/2022]
Abstract
AIMS Long-term clinical trials evaluating the effects of metabolic-bariatric surgery (MBS) on type 2 diabetes (T2D) demonstrate that a significant proportion of patients either fail to achieve remission or experience T2D recurrence over time. Furthermore, patients with recurrent T2D might require reinstitution of pharmacotherapy to control comorbidities (hypertension, dyslipidemia). This paper reviews therapeutic options in patients with T2D relapse. DATA SYNTHESIS Although presently there is no recommended pharmacological strategy, the available data support GLP-1 analogues (GLP-1a) as the most suitable option to control hyperglycemia post-MBS. Beside their efficacy in lowering glycemia and body weight while preserving lean mass, GLP-1a exert cardiovascular/renal-protection and are also safe and well tolerated in surgical patients. In addition, the s.c. route of administration of these medications circumvents the problem of changes in oral drugs bioavailability following MBS. Of note, the available data refers to liraglutide and needs to be confirmed with weekly GLP-1a agents. Information regarding the impact of MBS on the pharmacokinetics of lipid lowering and anti-hypertensive drugs is scarce and inconclusive. The findings indicate that timing from intervention is particularly important because of adaptive intestinal mechanisms. CONCLUSIONS The recurrence of T2D following MBS is a clinically relevant issue. GLP-1a therapy represents the best option to improve glycemic and weight control with good tolerability. Long-term clinical trials will clarify the impact of these drugs on cardiovascular outcomes. A close monitoring of MBS patients is advised to guide drug dosage adjustments and ensure the control of cardiovascular risk factors.
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Affiliation(s)
- Roberta Lupoli
- Department of Molecular Medicine and Medical Biotechnology, Federico II University, Naples, Italy
| | - Erminia Lembo
- Department of Clinical Medicine and Surgery University Federico II Naples, Italy
| | - Annalisa Giosuè
- Department of Clinical Medicine and Surgery University Federico II Naples, Italy
| | - Luigi Schiavo
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Italy
| | - Brunella Capaldo
- Department of Clinical Medicine and Surgery University Federico II Naples, Italy.
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Sweet AL, Sutton TL, Curtis KA, Knapp N, Sheppard BC, Zink KA. Characterizing 30-d Postoperative Acute Care Visits: A National Surgical Quality Improvement Program Collaborative Analysis. J Surg Res 2022; 276:1-9. [PMID: 35325679 DOI: 10.1016/j.jss.2022.01.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/15/2021] [Accepted: 01/24/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Many postoperative acute care visits (PACVs) are likely more appropriately addressed in lower acuity settings; however, the frequency and nature of PACVs are not currently tracked by the National Surgical Quality Improvement Program (NSQIP), and the overall burden to emergency departments and urgent care centers is unknown. METHODS NSQIP collaborative data were augmented to prospectively capture 30-d PACVs for 1 y starting October 2018 across all NSQIP specialties, including visit reason and disposition. Data were analyzed using binomial logistic regression. RESULTS A total of 9933 patients were identified; 12.0% (n = 1193) presented to an acute care setting over 1413 visits, most commonly for surgical pain (15.4%) in the absence of an identified complication. Visits most commonly resulted in discharge (n = 817, 68.5%) or admission (n = 343, 24.3%). Variables independently associated with visits resulting in discharge included age (odds ratio [OR] 0.99 per year, P < 0.001), increasing comorbidities (1-2 [OR 1.55, P < 0.001]; 3-4 [OR 2.51, P < 0.001]; 5+ [OR 2.79 P < 0.001]), operative duration (OR 1.08 per hour, P = 0.001), and nonelective (OR 1.20, P = 0.01) or urologic (OR 1.46, P = 0.01) procedures. CONCLUSIONS PACVs are an overlooked burden on emergency medicine providers and healthcare systems; most do not require admission and could be potentially triaged outside of the acute care setting with improved perioperative care infrastructure. Younger patients, those with multiple comorbidities, and those undergoing nonelective procedures deserve special attention when designing initiatives to address postoperative acute care utilization. Data regarding PACVs can be routinely collected with minor modifications to current NSQIP workflows.
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Affiliation(s)
- Ashley L Sweet
- Department of Surgery, Oregon Health & Science University, Portland, Oregon
| | - Thomas L Sutton
- Department of Surgery, Oregon Health & Science University, Portland, Oregon
| | - Krista A Curtis
- Legacy Emanuel Medical Center, Oregon Health & Science University Health Systems, Portland, Oregon
| | - Nathan Knapp
- Department of Surgery, Oregon Health & Science University, Portland, Oregon
| | - Brett C Sheppard
- Department of Surgery, Oregon Health & Science University, Portland, Oregon
| | - Karen A Zink
- Department of Surgery, Providence Portland Medical Center, Portland, Oregon.
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Feral-Pierssens AL, Matta J, Rives-Lange C, Goldberg M, Zins M, Carette C, Czernichow S. Health care use by adults with obesity: A French cohort study. Obesity (Silver Spring) 2022; 30:733-742. [PMID: 35142072 DOI: 10.1002/oby.23366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 11/21/2021] [Accepted: 11/23/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Studies on obesity costs have focused on global costs of people with obesity but scarcely investigated their precise use of health care. The aim of this study is to document real-life health care use across obesity classes. METHODS Data of participants with obesity and enrolled in the CONSTANCES cohort were analyzed. Health care use was defined as ≥1 visit to general practitioners, specialists, emergency departments, and inpatient hospital admissions versus none over a 3-year period prior to enrollment and was obtained from the Universal Health Insurance database. Multivariate regression models were conducted and adjusted for comorbidities and social deprivation markers with medical visits as the outcome variables and compared people with class II and III obesity versus class I obesity. RESULTS Out of the 10,774 participants with obesity, 613 (5.7%) had class III obesity, and 2,076 (19.3%) had class II obesity. Compared with participants with class I obesity, class III obesity participants had higher odds of visiting emergency departments (OR = 1.31; 95% CI: 1.07-1.61) and various specialist physicians (pneumologists, endocrinologists, cardiologists) but lower odds of visiting gynecologists (OR = 0.69; 95% CI 0.55-0.87). Participants with class II obesity had lower odds of visiting general practitioners, dentists, and psychiatrists. There was no difference with regard to hospital admissions. CONCLUSION Health care use by people with obesity differs across classes.
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Affiliation(s)
- Anne-Laure Feral-Pierssens
- Population-based Epidemiological Cohorts Unit, INSERM UMS 11, Villejuif, France
- Assistance Publique Hôpitaux de Paris, Emergency Department, Georges Pompidou European Hospital, Paris, France
- IMPEC Federation, Paris, France
| | - Joane Matta
- Population-based Epidemiological Cohorts Unit, INSERM UMS 11, Villejuif, France
| | - Claire Rives-Lange
- Assistance Publique Hôpitaux de Paris, Nutrition Department, Georges Pompidou European Hospital, Centre Spécialisé Obésité, Paris, France
- Université de Paris, Paris, France
- INSERM, UMR 1153 Epidemiology and Biostatistics Sorbonne Paris Cité Center (CRESS), METHODS team, Paris, France
| | - Marcel Goldberg
- Population-based Epidemiological Cohorts Unit, INSERM UMS 11, Villejuif, France
- Université de Paris, Paris, France
| | - Marie Zins
- Population-based Epidemiological Cohorts Unit, INSERM UMS 11, Villejuif, France
- Université de Paris, Paris, France
| | - Claire Carette
- Assistance Publique Hôpitaux de Paris, Nutrition Department, Georges Pompidou European Hospital, Centre Spécialisé Obésité, Paris, France
- Université de Paris, Paris, France
- INSERM, CIC 1418, Georges Pompidou European Hospital, Paris, France
| | - Sébastien Czernichow
- Assistance Publique Hôpitaux de Paris, Nutrition Department, Georges Pompidou European Hospital, Centre Spécialisé Obésité, Paris, France
- Université de Paris, Paris, France
- INSERM, CIC 1418, Georges Pompidou European Hospital, Paris, France
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Analysis of Emergency Department Visits and Unplanned Readmission After Bariatric Surgery: An Experience From a Tertiary Referral Center. SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2021; 32:107-113. [PMID: 34653112 DOI: 10.1097/sle.0000000000001011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/12/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Bariatric surgery is the most effective treatment of morbid obesity. As the number of bariatric procedures performed has increased, visits to the emergency department (ED) and readmissions have subsequently increased. The present study aimed to assess the rates and indications for of ED visits and readmission after bariatric surgery and to identify the predictors of hospital readmission. PATIENTS AND METHODS This was a retrospective cohort study on patients who underwent bariatric surgery from January 2018 to April 2020. The percentage of ED visits and unplanned readmission was estimated and the indications and management of each were analyzed. The association of age, sex, body mass index, and type of procedure with readmission was assessed. RESULTS Of 582 patients who underwent bariatric surgery in the study period, 204 (35%) required ED visits, and 42 (7.2%) required readmission. The mean age of patients was 33 years, and the mean body mass index was 43 kg/m2. The most common indication for ED visits was abdominal pain (41.2%). In all, 64.8% of ED visits and 43% of readmissions were unrelated to bariatric surgery complications. A total of 94.1% of patients who required ED visits and 71.4% of readmitted patients were managed conservatively. The most common procedure followed by readmission was laparoscopic sleeve gastrectomy (50%) then one-anastomosis gastric bypass (21.4%). Age, sex, body mass index, and procedure type were not significantly associated with higher readmission. CONCLUSIONS The rates of ED visits and readmission in our cohort were 35% and 7.2%, respectively. Most cases of ED visits were not related to adverse effects of bariatric surgery and the majority of which were managed conservatively.
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14
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High incidence of potentially preventable emergency department visits after major elective colorectal surgery. Surg Endosc 2021; 36:2653-2660. [PMID: 33959806 DOI: 10.1007/s00464-021-08514-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 04/17/2021] [Indexed: 10/21/2022]
Abstract
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.
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Samuels JM, Helmkamp L, Carmichael H, Rothchild K, Schoen J. Determining the incidence of postbariatric surgery emergency department utilization: an analysis of a statewide insurance database. Surg Obes Relat Dis 2021; 17:1465-1472. [PMID: 34024737 DOI: 10.1016/j.soard.2021.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/02/2021] [Accepted: 04/21/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Prior studies have found rates of emergency department (ED) visits after bariatric surgery approach 15% with the majority (>60%) not requiring admission. The timeframe for which ED utilization remains elevated postoperatively remains unknown. We hypothesize that ED utilization following bariatric surgery remains elevated for months after surgery with the majority of visits not requiring admission. OBJECTIVE No study has determined the impact bariatric surgery has on health care resource utilization in the two years following surgery. The aim of this study is to determine the frequency of ED visitation in the 2 years following bariatric surgery. SETTINGS Database study, single state-wide insurance database. METHODS We queried the Colorado All Payers Claim Database. Patients with data 1 year before and 2 years after surgery were included. Primary outcomes of interest were ED visits or readmissions during the 2-year period. Bariatric surgeries were identified using CPT codes. Diagnoses for an ED visit or readmission were determined by ICD codes. RESULTS A total of 5399 patients underwent bariatric surgery from January 2013-November 2017. Of these, 59% underwent sleeve gastrectomy, 38% Roux-en-Y, 2% gastric band, and 1% another surgery. Median age was 44 (IQR 35-54) years, and 82% were female. Overall, 3103 patients (57%) visited the ED at least once with a total of 12,988 visits, 1267 of which (9.8%) resulted in admission. ED use was highest in the 30 days following surgery (17%) but remained above presurgery baseline for 8 months (7.4% at 8 mo compared with baseline mean 6.4% [95% CI 6.0%-6.8%]). CONCLUSIONS ED visits remain elevated for 8 months post bariatric surgery with over 90% of visits not requiring an admission. Interventions that prevent emergency department utilization should be key focus of quality improvement projects to limit health care resource utilization following bariatric surgery.
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Affiliation(s)
- Jason M Samuels
- Department of Surgery, University of Colorado Anschutz, Aurora, Colorado.
| | - Laura Helmkamp
- The Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz, Aurora, Colorado
| | - Heather Carmichael
- Department of Surgery, University of Colorado Anschutz, Aurora, Colorado
| | - Kevin Rothchild
- Department of Surgery, University of Colorado Anschutz, Aurora, Colorado
| | - Jonathan Schoen
- Department of Surgery, University of Colorado Anschutz, Aurora, Colorado
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Wojcikiewicz T, Nkhoma J, James E, Johannsson H, Cousins J, Kynoch M. A Prospective Observational Study of High-Dose Intrathecal Diamorphine in Laparoscopic Bariatric Surgery: a Single-Centre Experience. Obes Surg 2021; 30:1814-1819. [PMID: 32006237 DOI: 10.1007/s11695-020-04384-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Post-operative pain management following laparoscopic bariatric surgery can be challenging. There are concerns regarding the use of opioids. The rate of cardiorespiratory problems following neuraxial opioids is unclear. There is little published data on their use in bariatric surgery. This study aimed to assess technique feasibility, pain outcomes, patient acceptability, and the side effects and complications of a 'high-dose' (1.0 mg) intrathecal diamorphine technique for patients undergoing primary laparoscopic bariatric surgery. MATERIALS AND METHODS Fifty patients were included. Eleven patients (22%) had a diagnosis of OSA. All patients had a spinal anaesthetic with 2.0 mL of 0.25% isobaric bupivacaine containing 1.0 mg diamorphine. General anaesthesia followed together with multi-modal analgesia and anti-emesis. Post-operative pain scores, complications, and side effects in the first 24 h post-operative period were documented. Patients were followed up 6 to 8 weeks after discharge. RESULTS All patients had a working spinal anaesthetic with thirty-nine insertions (78%) on the first attempt. Pain scores were similar to previously published data where they were found to be superior to a non-spinal analgesic regime. The median 24 h post-operative oral morphine equivalent consumption was 5 mg. Eight patients (16%) required urinary catheterisation. Four patients (8%) complained of pruritus. Eighteen patients (36%) had post-operative nausea or vomiting. Thirty-three patients (66%) responded to the follow-up request. Thirty of the thirty-three patients (91%) stated they would have the spinal anaesthetic again. CONCLUSION We have demonstrated that neuraxial blockade is a simple, practical, and feasible technique to adopt. Our case series demonstrated a high level of patient acceptability.
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Affiliation(s)
- T Wojcikiewicz
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK.
| | - J Nkhoma
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - E James
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - H Johannsson
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - J Cousins
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - M Kynoch
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
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Leonard-Murali S, Nasser H, Ivanics T, Genaw J. Predictors of postoperative emergency department visits after laparoscopic bariatric surgery. Surg Obes Relat Dis 2020; 16:1483-1489. [DOI: 10.1016/j.soard.2020.05.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 04/02/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022]
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18
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Liu N, Funk LM. Comment on: Predictors of postoperative emergency department visits without readmission after laparoscopic bariatric surgery. Surg Obes Relat Dis 2020; 16:1489-1490. [PMID: 32753301 PMCID: PMC7541776 DOI: 10.1016/j.soard.2020.06.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 06/27/2020] [Indexed: 11/23/2022]
Affiliation(s)
- Natalie Liu
- Department of Surgery, University of Wisconsin School of
Medicine and Public Health, Madison, WI
| | - Luke M. Funk
- Department of Surgery, University of Wisconsin School of
Medicine and Public Health, Madison, WI
- William S. Middleton Memorial Veterans Administration,
Madison, WI
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Emergency Department Visits Following Suboccipital Decompression for Adult Chiari Malformation Type I. World Neurosurg 2020; 144:e789-e796. [PMID: 32956886 PMCID: PMC7500401 DOI: 10.1016/j.wneu.2020.09.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Postoperative emergency department (ED) visits following suboccipital decompression in Chiari malformation type I (CM-1) patients are not well described. We sought to evaluate the magnitude, etiology, and significance of postoperative ED service utilization in adult CM-1 patients at a tertiary referral center. METHODS A prospectively maintained database of CM-1 patients seen at our institution between January 1, 2006 and December 31, 2019 was used. ED visits occurring within 30 days after surgery were tracked for postoperative patients, while comparing clinical, imaging, and operative characteristics between patients with and without an ED visit. Clinical improvement at last follow-up was also compared between both groups of patients in a univariable and multivariable analysis using the Chicago Chiari Outcome Scale (CCOS). RESULTS In 175 surgically treated patients, 44 (25%) visited an ED in the 1-month period after surgery. The most common reason for seeking care was isolated headache (41%), and concentration disturbance at presentation was the only factor significantly associated with a postoperative ED visit (P = 0.023). The occurrence of a postoperative ED visit was independently associated with a lower chance of clinical improvement at last follow-up (adjusted odds ratio of CCOS ≥13 = 0.35, P = 0.021; adjusted odds ratio of CCOS ≥14 = 0.38, P = 0.016). CONCLUSIONS Adult CM-1 patients undergoing surgery at a tertiary referral center have an elevated rate of postoperative ED visits, which are mostly due to pain-related complaints. Such visits are hard to predict but are associated with worse long-term clinical outcome. Interventions that decrease the magnitude of postoperative ED service utilization are warranted.
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20
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Use of the MMPI-2 personality profile in predicting 30-day ED-visits and readmissions following primary bariatric surgery. Surg Endosc 2020; 35:4725-4737. [DOI: 10.1007/s00464-020-07944-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 08/25/2020] [Indexed: 01/09/2023]
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21
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Examining emergency department utilization in the post-foregut surgery patient. Surg Endosc 2020; 35:4563-4568. [PMID: 32804264 DOI: 10.1007/s00464-020-07877-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/05/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The purpose of this study was to examine emergency department (ED) utilization following minimally invasive foregut surgery and determine its impact on costs. Furthermore, we sought to determine their relationship to the index procedure, whether they are preventable, and describe strategies for decreasing unnecessary ED visits. METHODS A retrospective review was conducted for all patients undergoing foregut procedures from January 2018 through June 2019. ED utilization was examined from 0 to 90 days. The proportion of visits related to surgery, preventable visits, and median ED costs were compared between visits occurring 0-30 days (early) versus 31-90 days (delayed) postoperatively as well as occurring from 8 am to 5 pm versus 5 pm to 8 am. RESULTS Of 458 patients who underwent foregut surgery, 72.5% were female and the mean age was 60 years old. 92 patients (20%) presented to the ED within 90 days. Of these, 59 patients (64.1%) presented to the ED early versus 33 patients (35.9%) delayed. 56.5% of ED visits occurred during clinic hours. 56 (60.9%) ED visits were related to the procedure and 20 (35.7%) were preventable. The median ED return cost was $970. Early ED visits were significantly more likely to be related to surgery (72.9% vs 39.4%, p = 0.0016). There was no significant difference in the proportion of visits that were preventable (32.6% vs 46.2%, p = 0.3755) and ED return cost did not vary significantly ($995 vs $965, p = 0.43) between early and delayed visits. CONCLUSIONS ED visits are common after foregut surgery and represent a financial burden on healthcare. Most visits occur early and are more likely to be related to surgery. Importantly, more than one-third of ED visits related to surgery were preventable and most occurred during clinic hours on weekdays. Providers should consider implementation of strategies to improve outpatient utilization and decrease unnecessary ED visits.
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Edwards MA, Fagenson AM, Mazzei M, Zhao H. Bariatric Surgery in Prior Solid Organ Transplantation Patients: Is Race a Predictor of Adverse Outcomes? Obes Surg 2020; 30:4381-4390. [PMID: 32617920 PMCID: PMC7331490 DOI: 10.1007/s11695-020-04813-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 06/18/2020] [Accepted: 06/22/2020] [Indexed: 12/13/2022]
Abstract
Purpose Metabolic and bariatric surgery (MBS) is increasingly performed in patients with previous solid organ transplantation (PSOT). In addition, controversy remains about whether racial disparity in outcomes following MBS exists. Therefore, the aim of this analysis was to determine if race independently predicts outcomes in MBS patients with PSOT. Materials and Methods Patients with PSOT undergoing sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) were identified in the 2017 Metabolic and Bariatric Surgery Accreditation Quality and Improvement Project (MBSAQIP) database. Patients were stratified by race (Black and White). Propensity score matching was utilized to adjust for multiple demographic variables. Multivariable logistic regression analyses were performed for overall and bariatric-related morbidity. Results Of 335 MBS patients with PSOT, 250 (75%) were white and 85 (25%) were black patents. Procedure-type and surgical approach (p > 0.1) were similarly distributed. Black patients were more likely (p < 0.05) to have hypertension dialysis-dependent chronic kidney disease, and be on chronic steroids). Mortality and morbidity were similar. Black patients had significantly (p < 0.05) higher rates of renal failure, pulmonary complications, and emergency department visits in unmatched analysis. After propensity score matching, 82 patients in each cohort were identified and were similar at baseline (p > 0.5). In the matched analysis, black patients had higher overall (17% vs. 10%, p = 0.12) and bariatric-related morbidity (14% vs. 7.2%, p = 0.05). In addition, black patients had significantly (p < 0.05) higher rates of postoperative pneumonias, progressive renal insufficiency, and emergency department visits. On multivariable regression analysis, black race did not independently predict overall or bariatric-related morbidity. Conclusion MBS in racial cohorts with PSOT is safe, with very low rates of overall morbidity and mortality. Black race trended toward increased postoperative morbidity. Larger cohort studies are needed to validate our findings. Electronic supplementary material The online version of this article (10.1007/s11695-020-04813-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael A Edwards
- Department of Surgery, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA.
| | - Alexander M Fagenson
- Department of Surgery, Temple University Hospital, Suite , 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Michael Mazzei
- Department of Surgery, Temple University Hospital, Suite , 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Huaqing Zhao
- Department of Clinical Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, 19140, USA
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De Simone B, Ansaloni L, Sartelli M, Kluger Y, Abu-Zidan FM, Biffl WL, Heyer A, Coccolini F, Baiocchi GL, Catena F. The Operative management in Bariatric Acute abdomen (OBA) Survey: long-term complications of bariatric surgery and the emergency surgeon's point of view. World J Emerg Surg 2020; 15:2. [PMID: 32005129 PMCID: PMC6945511 DOI: 10.1186/s13017-019-0281-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 12/16/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The number of bariatric procedures is increasing worldwide. No consensus or guidelines about the emergency management of long-term complications following bariatric surgery are currently available. The aim of this study is to investigate by a web survey how an emergency surgeon approaches this unique group of patients in an emergency medical scenario and to report their personal experience. METHOD An international web survey was sent to 197 emergency surgeons with the aim to collect data about emergency surgeons' experience in the management of patients admitted in the emergency department for acute abdominal pain after bariatric surgery. The survey was conceived as a questionnaire composed by 26 (multiple choice and open) questions and approved by a steering committee. RESULTS One hundred seventeen international emergency surgeons decided to join the project and answered to the web survey with a response rate of 59.39%. CONCLUSIONS The aim of this WSES web survey was to highlight the current management of patients previously submitted to bariatric surgical procedures by ES. Emergency surgeons must be mindful of postoperative bariatric surgery complications. CT scan with oral intestinal opacification may be useful in making a diagnosis if carefully interpreted by the radiologist and the surgeon. In case of inconclusive clinical and radiological findings, when symptoms fail to improve, surgical exploration for bariatric patients presenting acute abdominal pain, by laparoscopy if expertise is available, is mandatory in the first 12-24 h, to have good outcomes and decrease morbidity rate.
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Affiliation(s)
- Belinda De Simone
- Department of General and Emergency Surgery, Azienda Usl Reggio Emilia IRCCS, Reggio Emilia, Italy
| | - Luca Ansaloni
- Department of Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata’s Hospital, Macerata, Italy
| | - Yoram Kluger
- Department of Emergency and Trauma Surgery, Rambam Health Campus, Haifa, Israel
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Walter L. Biffl
- Department of Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, California USA
| | - Arianna Heyer
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania USA
| | | | | | - Fausto Catena
- Department of Emergency and Trauma Surgery, Parma University Hospital, Parma, Italy
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24
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Characterizing the preventable emergency department visit after bariatric surgery. Surg Obes Relat Dis 2019; 16:48-55. [PMID: 31744733 DOI: 10.1016/j.soard.2019.10.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/04/2019] [Accepted: 10/11/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patients who present to the emergency department (ED) after bariatric surgery may incur significant costs with no additional benefit. OBJECTIVES To characterize patients who presented to the ED but could have been treated in an alternative setting. SETTING University hospital, United States. METHODS We identified 131 patients who underwent primary bariatric surgery at a single-center academic institution between 2006 and 2016 who also presented to the ED within 30 days of surgery. Preventable ED visits were identified by excluding patients with life-threatening presentations and/or use of emergent ED-specific resources. Patients with preventable ED visits were matched 1:1 to controls (no ED visit) based on procedure type and preoperative patient characteristics. Independent risk factors among patients with preventable ED visits were identified. RESULTS A total of 80 patients (61%) were identified as having a preventable ED visit after bariatric surgery. After multivariable logistic regression, independent risk factors associated with preventable ED visits included anxiolytic prescription at discharge (odds ratio [OR] 5.4 [95% confidence interval 1.6-18.6]; P = .007), electrolyte abnormalities (OR 4.3 [1.9-9.6]; P < .0001), and leukocytosis (OR 2.2 [1.0-4.9]; P = .048) at discharge, and number of ED visits preoperatively (OR 2.0 [1.3-3.1]; P = .001). Severe complications, reoperation rates, and 1-year patient reported outcomes did not differ between patients with preventable ED visits and their matched cohort. CONCLUSIONS Preventable ED visits are common after bariatric surgery and are associated with risk factors that can be identified perioperatively. Identifying and triaging patients at risk for preventable ED visits may decrease unnecessary and costly visits to the ED after bariatric surgery.
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Abstract
PURPOSE OF REVIEW The number of bariatric surgeries for patients with type 1 or type 2 diabetes continues to grow. Clinicians are challenged to choose therapies that reach glycemic targets without inducing adverse effects in post-bariatric patients without published guidelines. This review evaluates data supporting the best strategies for diabetes management in patients undergoing bariatric surgery. RECENT FINDINGS Though few clinical trials have evaluated the safety and effectiveness of different glucose-lowering therapies following bariatric surgery, remission of diabetes or reduced medications is an established benefit of bariatric surgery. Adverse events including diabetic ketoacidosis in post-bariatric patients on sodium-glucose co-transporter 2 (SGLT2) inhibitors or inadequate insulin have been reported in patient's with both type 1 and type 2 diabetes. Metformin, glucagon-like peptide-1 (GLP-1) agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, SGLT2 inhibitors, insulin, and sulfonylureas have been used successfully in the perioperative period for other surgeries and guidelines recommend adjusting the doses of these medications especially in the perioperative period. Clinicians should favor weight-neutral or weight-loss promoting therapies in post-bariatric surgery patients such as medical nutrition therapy, metformin, GLP-1 agonists, SGLT2 inhibitors, and DPP-4 inhibitors.
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Affiliation(s)
- Christopher M Mulla
- Division of Endocrinology, Landstuhl Regional Medical Center, US Army, Landstuhl, Germany.
- Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA.
| | - Harris M Baloch
- Division of Endocrinology, Landstuhl Regional Medical Center, US Army, Landstuhl, Germany
| | - Samar Hafida
- Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA
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Financial impact of improving patient care setting selection after bariatric surgery. Surg Obes Relat Dis 2019; 15:1994-2001. [PMID: 31648980 DOI: 10.1016/j.soard.2019.06.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/10/2019] [Accepted: 06/21/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Potentially avoidable emergency department (ED) visits are a significant source of excess healthcare spending. Despite improvement in postoperative readmissions, 20% of bariatric surgery patients use the ED postoperatively. Many of these visits may be appropriately managed in lower-acuity centers. OBJECTIVE We sought to evaluate the economic impact of shifting potentially avoidable ED visits after bariatric surgery to lower-acuity centers. SETTING Statewide quality improvement collaborative. METHODS We performed an observational study of patients who underwent bariatric surgery between 2011 and 2017 using a linked data registry, including clinical data from a large-quality improvement collaborative and payment data from a statewide value collaborative. Postoperative ED visits and readmission rates were determined. Ninety-day ED and urgent care center (UCC) visit claims were matched to a clinical registry. Price-standardized payments for UCC and ED visits without admission were compared. RESULTS Among the 36,071 patients who underwent bariatric surgery, 8.4% presented to the ED postoperatively. Approximately 50% of these visits resulted in readmission. Three hundred eighty-eight ED visits without readmission (i.e., potentially avoidable ED visits) and 110 UCC encounters with claims data were identified. Triaging a potentially avoidable ED visit to an UCC would generate a savings of $4238 per patient, reducing spending in this cohort by $1.6 million. CONCLUSION Shifting potentially avoidable ED visits after bariatric surgery could result in significant cost savings. Efforts to improve patients' selection of healthcare setting and increase utilization of lower-acuity centers may serve as a template for appropriately meeting the needs of patients and containing spending after bariatric surgery.
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Ivanics T, Nasser H, Leonard-Murali S, Genaw J. Dehydration risk factors and impact after bariatric surgery: an analysis using a national database. Surg Obes Relat Dis 2019; 15:2066-2074. [PMID: 31601534 DOI: 10.1016/j.soard.2019.09.054] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 08/02/2019] [Accepted: 09/02/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Dehydration is a common complication after bariatric surgery and often quoted as the reason for emergency department (ED) visits and readmission. OBJECTIVE We sought to investigate risk factors for dehydration after bariatric surgery and evaluate its impact on ED visits and readmission. SETTING The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. METHODS We used the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database to identify patients who underwent laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2016 through 2017. The primary outcome was need for outpatient treatment of dehydration within 30 days postsurgery. Secondary outcomes were association between need for outpatient dehydration therapy and 30-day readmission or ED evaluation not resulting in admission. RESULTS Of 256,817 patients, 73% underwent laparoscopic sleeve gastrectomy and 27% LRYGB. Of 9592 patients who required dehydration treatment, they were more often younger than age 40, female, black, had a ≥3-day length of stay during their index admission, and experienced a postoperative complication. More patients receiving LRYGB than laparoscopic sleeve gastrectomy required treatment for dehydration. On multivariable analysis, independent-risk factors for postoperative dehydration treatment included LRYGB, length of stay ≥3 days, gastroesophageal reflux disease, hypertension, previous deep vein thrombosis, chronic steroid/immunosuppression, and a postoperative complication. Patients who developed dehydration requiring treatment compared with those that did not had adjusted odds ratio of 3.7 (95% confidence interval: 3.44-3.96; P < .001) and 22 (95% confidence interval: 21.05-23.06; P < .001) of readmission and ED visit. CONCLUSION Dehydration is a strong risk factor for postoperative ED visits and readmission. Closer surveillance and proactive measures for those at higher risk may prevent the development of postoperative dehydration.
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Affiliation(s)
- Tommy Ivanics
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Hassan Nasser
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan.
| | | | - Jeffrey Genaw
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan
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The impact of nausea on post-operative outcomes in bariatric surgery patients. Surg Endosc 2019; 34:3085-3091. [DOI: 10.1007/s00464-019-07058-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 07/31/2019] [Indexed: 01/31/2023]
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Patterns of hospital utilization after elective minimally invasive foregut surgery. Surg Endosc 2019; 34:2149-2157. [PMID: 31300909 DOI: 10.1007/s00464-019-06953-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/26/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Post-operative non-urgent hospital visits (NUR-HV) are an important quality target for reducing unnecessary healthcare utilization. The primary objective of this study was to characterize 90-day post-operative hospital use and determine independent predictors for NUR-HV and urgent (UR)-HV after elective laparoscopic paraesophageal hernia repair (LPEHR) and Nissen Fundoplication (LNF). METHODS Five hundred and sixty-two primary LPEHR and LNF patients were retrospectively reviewed at a single institution. Ninety-day NUR-HV and UR-HV were compared to patients without post-operative HV using baseline medical and demographic data, preoperative work-up (manometry, pH testing, disease-specific quality of life and symptom scale scores (GERSS), and hospital course. Multiple logistic models were created using univariate associations (p < 0.1) to model independent predictors of NUR-HV and UR-HV. RESULTS NUR-HV accounted for 52% (n = 30) of all 90-HV, while the remaining were UR-HV (n = 28, 48.3%). Compared to controls, NUR-HV were younger (51.2 ± 16.8 years vs. 57.6 ± 15.2, p = 0.05), had a lower baseline BMI (28.2 ± 6.4 vs. 31.3 ± 5.4, p = 0.003) and ASA scores (p = 0.02), presented with higher GERSS (46 (28-60) vs. 35 (19-48), p = 0.02) and dysphagia scores (3 (1-5) vs. 2 (0-4), p = 0.02), were associated with LNF (77.7% vs. 54.6%, p = 0.02), and experienced more post-operative dysphagia (13.3% vs. 4.6%, p = 0.06). UR-HV were older (64.0 ± 13.2 vs. 57.6 ± 15.2, p = 0.03), associated with LPEHR (67.9% vs. 45.4%, p = 0.02), longer hospital stay (2 (1-3) vs. 1 (1-2), p = 0.003), and increased overall (39.3% vs. 15.1%, p = 0.001) and urgent complications (34.6% vs. 8.3%, p < 0.005). Positive predictors of NUR-HV included ASA score < 3 (OR 4.4, p = 0.02), increasing GERSS (1.04, p = 0.01), and reduced peristalsis (OR 4.7, p = 0.01), while UR-HV were independently predicted by urgent complications (5.0, p < 0.00005). CONCLUSIONS NUR-HV accounted for half of post-operative visits following LNF/LPEHR and were predicted by distinct characteristics compared to UR-HV. This stratification provides novel insight that will guide both preoperative counseling and post-operative quality initiatives.
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Trends in emergency department utilization following common operations in New York State, 2005-2014. Surg Endosc 2019; 34:1994-1999. [PMID: 31300908 DOI: 10.1007/s00464-019-06975-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 07/09/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND ED overutilization is a leading cause of increased healthcare costs and a key target for healthcare reform. ED utilization patterns following common operative procedures are unknown. METHODS Using the SPARCS New York (NY) statewide longitudinal administrative database, a longitudinal analysis on 746,633 patients who underwent cholecystectomy (n = 355,368), appendectomy (n = 142,797) or inguinal hernia repair (n = 248,468) from 2005 to 2014 was performed. ED revisits were identified via unique patient identifiers which allow for patient tracking across hospitals in NY State. RESULTS In total, 59,255 (7.9%) patients presented to the ED within 30-days of their operation of which 21,638 (36.5%) were admitted. The aggregated rate of ED utilization and admission from the ED were as follows: cholecystectomy (9.5%, 40%), appendectomy (9.1%, 33.1%), and inguinal hernia repair (5.1%, 26.2%), respectively. A longitudinal analysis demonstrated a relative slowing of the rate of increase in hospital readmissions for cholecystectomy and inguinal hernia repair but no change in the number of ED revisits for inguinal hernia repair. CONCLUSIONS Nearly 1 in 10 patients undergoing cholecystectomy and appendectomy, and 1 in 20 patients undergoing inguinal hernia repair will present to the ED following surgery. The majority of ED visits do not result in admission, calling their necessity into question. These data suggest possible overutilization of the ED following common operations and support the consideration of ED utilization as a quality indicator.
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Gondal AB, Hsu CH, Zeeshan M, Hamidi M, Joseph B, Ghaderi I. A frailty index and the impact of frailty on postoperative outcomes in older patients after bariatric surgery. Surg Obes Relat Dis 2019; 15:1582-1588. [PMID: 31451386 DOI: 10.1016/j.soard.2019.06.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 06/19/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND The prognostic value of frailty in the elderly surgical population has been well studied across surgical specialties. However, no studies have yet explored the effects of frailty across the full spectrum of adverse events after bariatric surgery. OBJECTIVES To study the impact of index-frailty on the full range of adverse short-term outcomes after bariatric surgery. METHODS Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data file for 2016 was used. Descriptive analyses, univariable, and multivariable regression models, assessed for discriminative and predictive capacities, were used to assess the effects of frailty on Clavien-Dindo categorized adverse outcomes within 30 days of bariatric surgery. Frailty index was modified from Canadian Study of Health and Aging Frailty Index. SETTING Data pooled from American Society for Bariatric Surgery-accredited bariatric surgery centers, United States. RESULTS A total of 21,426 patients aged ≥60 undergoing primary bariatric procedures were included. The prevalence of frailty as defined by the modified frailty index was 44.4%. Frail status was independently associated with higher odds of 30-day adverse events (Clavien-Dindo grades I, II, III, IV, and V). Frailty scores had weakly positive correlations with increasing age and increasing body mass index in the bariatric patients. CONCLUSION Frailty can be used as a risk stratification modality for patients before bariatric surgery. Further research should focus on exploring the relationship between obesity and frailty and the effects of weight loss on frailty status of bariatric patients.
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Affiliation(s)
- Amlish Bilal Gondal
- Banner-University Medical Centre, University of Arizona, Department of Surgery, Tucson, Arizona
| | - Chiu-Hsieh Hsu
- Banner-University Medical Centre, University of Arizona, Department of Surgery, Tucson, Arizona
| | - Muhammad Zeeshan
- Banner-University Medical Centre, University of Arizona, Department of Surgery, Tucson, Arizona
| | - Mohammad Hamidi
- Banner-University Medical Centre, University of Arizona, Department of Surgery, Tucson, Arizona
| | - Bellal Joseph
- Banner-University Medical Centre, University of Arizona, Department of Surgery, Tucson, Arizona
| | - Iman Ghaderi
- Banner-University Medical Centre, University of Arizona, Department of Surgery, Tucson, Arizona.
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Kleppe KL, Xu Y, Funk LM, Wang X, Havlena JA, Greenberg JA, Lidor AO. Healthcare spending and utilization following antireflux surgery: examining costs and reasons for readmission. Surg Endosc 2019; 34:240-248. [PMID: 30953200 DOI: 10.1007/s00464-019-06758-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 03/18/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND While clinical outcomes have been reported for anti-reflux surgery (ARS), there are limited data on post-operative encounters, including readmission, and their associated costs. This study evaluates healthcare utilization during the 90-day post-operative period following ARS including fundoplication and/or paraesophageal hernia (PEH) repair. METHODS Data were analyzed from the Truven Health MarketScan® Databases. Patients older than 16 years with an ICD-9 procedure code or Common Procedural Terminology (CPT) code for ARS and a primary diagnosis of GERD during 2012-2014 were selected. Healthcare spending and utilization on emergency department (ED) visits, performance of outpatient endoscopy, and readmission were examined. Reasons for readmission were classified based on ICD-9 code. RESULTS A total of 40,853 patients were included in the cohort with a mean age of 49 years and females comprising 76.0%. Mean length of stay was 1.4 days, and 93.0% of patients underwent a laparoscopic approach. The mean cost of the index surgical admission was $24,034. Readmission occurred in 4.2% of patients, and of those, 26.3% required a surgical intervention. Patients requiring one or more related readmissions accrued additional costs of $29,513. Some of the most common reasons for readmission were related to nutritional, metabolic, and fluid and electrolyte disorders. Presentation to the ED occurred in 14.0% of patients, and outpatient upper endoscopy was required in 1.5% of patients, but with much lower associated costs as compared to readmission ($1175). CONCLUSION The majority of patients undergoing ARS do not require additional care within 90 days of surgery. Patients who are readmitted accrue costs that almost double the overall cost of care compared to the initial hospitalization. Measures to attenuate potentially preventable readmissions after ARS may reduce healthcare utilization in this patient population.
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Affiliation(s)
- Kyle L Kleppe
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,Division of Minimally Invasive Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, 53792-7375, USA
| | - Yiwei Xu
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Luke M Funk
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,Division of Minimally Invasive Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, 53792-7375, USA.,Department of Surgery, William S. Middleton Veterans Affairs Memorial Hospital, Madison, WI, USA
| | - Xing Wang
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jeff A Havlena
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jake A Greenberg
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,Division of Minimally Invasive Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, 53792-7375, USA
| | - Anne O Lidor
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA. .,Division of Minimally Invasive Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, 53792-7375, USA.
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Borsuk DJ, Al-Khamis A, Geiser AJ, Zhou D, Warner C, Kochar K, Marecik SJ. S128: Active post discharge surveillance program as a part of Enhanced Recovery After Surgery protocol decreases emergency department visits and readmissions in colorectal patients. Surg Endosc 2019; 33:3816-3827. [PMID: 30859488 DOI: 10.1007/s00464-019-06725-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 03/01/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) programs aim to standardize perioperative care to reduce morbidity and cost. Our study examined an Active Post-Discharge Surveillance (APDS) program in reducing avoidable readmissions and emergency department (ED) visits in postoperative colorectal ERAS patients. METHODS Colectomy (right, subtotal and total) and low anterior resection cases performed at a tertiary care hospital between 2015 and 2018 were reviewed. ED visits, 30-day readmissions, and patients' APDS participation were assessed. Our APDS followed a modern text messaging paradigm offered to all patients free-of-charge. RESULTS Of 236 patients that underwent colectomy, 123 utilized APDS and 113 did not. Overall, both non-surveillance (NS) and active surveillance (AS) groups had similar preoperative characteristics. Length of hospital stay at index surgery was longer in the NS compared to AS group, 4.7 ± 2.6 vs. 2.6 ± 2.8 days, respectively (p < 0.001). In the NS group, 16 patients visited the ED, of which 14 (14/16, 87.5%) were ultimately readmitted. One patient was directly readmitted from the surgeon's office, resulting in a total of 15 (15/113, 13.3%) total patients readmitted by postoperative day (POD) 30. In the AS group, 9 patients visited the ED, of which 7 (7/9, 77.8%) were ultimately readmitted. One patient was directly readmitted, resulting in a total of 8 (8/123, 6.5%) total patients readmitted by POD 30. AS patients had significantly lower odds of visiting the ED when compared to NS patients (OR: 0.356; 95% CI: 0.138-0.919; p = 0.0328). Similarly, AS patients had significantly lower odds of readmission when compared to NS patients (OR: 0.343; 95% CI: 0.132-0.892; p = 0.0283). CONCLUSIONS APDS allows many postoperative issues to be resolved in outpatient settings without ER visits or readmission. This indicates APDS is a valuable ERAS adjunct by establishing a cost-effective and convenient communication line between patients and their surgical team.
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Affiliation(s)
- Daniel J Borsuk
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, 1550 N. Northwest Highway, Suite 107, Park Ridge, 60068, IL, USA. .,Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Ahmed Al-Khamis
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, 1550 N. Northwest Highway, Suite 107, Park Ridge, 60068, IL, USA
| | - Andrew J Geiser
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, 1550 N. Northwest Highway, Suite 107, Park Ridge, 60068, IL, USA
| | - Dimin Zhou
- Chicago Medical School, North Chicago, IL, USA
| | - Christina Warner
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, 1550 N. Northwest Highway, Suite 107, Park Ridge, 60068, IL, USA
| | - Kunal Kochar
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, 1550 N. Northwest Highway, Suite 107, Park Ridge, 60068, IL, USA
| | - Slawomir J Marecik
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, 1550 N. Northwest Highway, Suite 107, Park Ridge, 60068, IL, USA.,University of Illinois College of Medicine, Chicago, IL, USA
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Rates and reasons for emergency department presentations of patients wait-listed for public bariatric surgery in Tasmania, Australia. Obes Res Clin Pract 2019; 13:184-190. [PMID: 30683514 DOI: 10.1016/j.orcp.2019.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 11/23/2018] [Accepted: 01/10/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Demand for bariatric surgery in the public hospital setting in Australia is high with prolonged wait-list times. Policy-makers need to consider the consequences of expanding public bariatric surgery including on emergency department (ED) presentations. AIMS To describe and evaluate public ED presentation rates and reasons for presenting in a cohort of patients wait-listed for public surgery. METHODS All Tasmanians placed on the public wait-list for primary bariatric surgery in 2008-2013 were identified using administrative datasets along with their ED presentations in 2000-2014. The presentations were assigned to one of three periods: before wait-list placement, whilst on the wait-list, and after wait-list removal for publicly-funded surgery or drop-out. A negative binomial mixed-effects regression model was used to derive ED presentation incidence rate ratios (IRR) to compare observation periods and patient groups. RESULTS 652 wait-listed patients had 5149 public ED presentations. 178 patients had publicly-funded bariatric surgery - all as laparoscopically adjustable gastric banding (LAGB). Overall, ED presentation rates did not change significantly post-surgery compared with the waiting period (IRR 1.19, 95%CI 0.90-1.56). Presentation rates significantly increased for digestive system (IRR 2.02, 95%CI 1.19-3.45) and psychiatric diseases (IRR 4.85, 95%CI 1.06-22.26) after surgery. The likelihood of being admitted from the ED significantly increased after surgery (31.7%-38.9%, p<0.05). CONCLUSION ED presentations were common for patients wait-listed for public bariatric surgery and rates did not decrease over an average of three years post-LAGB. The likelihood of being admitted to the hospital from the ED increased after surgery.
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Major P, Stefura T, Małczak P, Wysocki M, Witowski J, Kulawik J, Wierdak M, Pisarska M, Pędziwiatr M, Budzyński A. Postoperative Care and Functional Recovery After Laparoscopic Sleeve Gastrectomy vs. Laparoscopic Roux-en-Y Gastric Bypass Among Patients Under ERAS Protocol. Obes Surg 2018; 28:1031-1039. [PMID: 29058236 PMCID: PMC5880856 DOI: 10.1007/s11695-017-2964-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background The most commonly performed bariatric procedures are laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). There are major differences between LSG and LRYGB during postoperative period. Optimization of the postoperative care may be achieved by using enhanced recovery after surgery (ERAS) protocol, which allows earlier functional recovery. Purpose The aim was to assess differences in the course of postoperative care conducted in accordance with ERAS protocol among patients after LSG and LRYGB. Material and Methods Data concerning patients treated for morbid obesity were prospectively gathered in one academic center. Patients were divided into two groups: LSG (n = 364, 63.41%) and LRYGB (n = 210, 36.59%). Multiple factors were used as endpoints to determine the influence of the type of bariatric procedure on postoperative course. Results The rate of postoperative nausea and vomiting and incidence of intravenous fluid administration during the operation was higher in LSG group. LRYGB patients were able to tolerate higher oral fluid intake volumes during the first and the second postoperative day. Mean diuresis during the second and the third postoperative day was significantly higher in LRYGB group. Administration of diuretics and painkillers was comparable between groups, while the risk of fever after the operation was higher in LRYGB group. Mean length of stay was higher in LSG group (LRYGB vs. LSG, 3.46 days ± 1.58 vs. 3.64 days ± 4.41, p = 0.039). Conclusions In our opinion, postoperative treatment after LSG requires more supervision and longer time until functional recovery is achieved.
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Affiliation(s)
- Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Tomasz Stefura
- Students' Scientific Group at 2nd Department of Surgery, JUMC, Krakow, Poland.
| | - Piotr Małczak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Michał Wysocki
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland.,Students' Scientific Group at 2nd Department of Surgery, JUMC, Krakow, Poland
| | - Jan Witowski
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland.,Students' Scientific Group at 2nd Department of Surgery, JUMC, Krakow, Poland
| | - Jan Kulawik
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland
| | - Mateusz Wierdak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Magdalena Pisarska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Andrzej Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
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Li YX, Fang DH, Liu TX. Laparoscopic sleeve gastrectomy combined with single-anastomosis duodenal-jejunal bypass in the treatment of type 2 diabetes mellitus of patients with body mass index higher than 27.5 kg/m2 but lower than 32.5 kg/m2. Medicine (Baltimore) 2018; 97:e11537. [PMID: 30075520 PMCID: PMC6081088 DOI: 10.1097/md.0000000000011537] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 06/20/2018] [Indexed: 12/25/2022] Open
Abstract
This study aimed to introduce this surgical technique laparoscopic sleeve gastrectomy combined with single-anastomosis duodenal-jejunal bypass (LDJB-LSG), and to confirm this new surgical technique was safe in the treatment of type 2 diabetes mellitus (T2DM) of patients with body mass index (BMI) higher than 27.5 kg/m but lower than 32.5 kg/m.A total of 34 T2DM patients with (BMI) higher than 27.5 kg/m but lower than 32.5 kg/m were admitted to our department between January 2014 and October 2016, of whom 25 received laparoscopic gastric bypass surgery (LRYGB) and 9 received LDJB-LSG. The efficacy and safety were compared between the 2 groups.None in both groups died and had severe postoperative complications. All the surgeries were performed by laparoscopy, and none received switching to open surgery. Patients received regular follow-up after surgery and none were lost to follow-up.Our study indicates LDJB-LSG is similar to LRYGB in the improvements of the body weight, blood glucose, insulin resistance, islet β cell function, blood lipid profile and serum uric acid, and thus LDJB-LSG is applicable in T2DM patients with 27.5 kg/m ≤ BMI ≤ 32.5 kg/m and risk for gastric cancer. However, long-term therapeutic effects need to be evaluated by studies with multicenter, large sample size, and long-term follow-ups.
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Unplanned emergency department consultations and readmissions within 30 and 90 days of bariatric surgery. Cir Esp 2018; 96:221-225. [PMID: 29605451 DOI: 10.1016/j.ciresp.2017.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 10/31/2017] [Accepted: 12/07/2017] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Hospital readmission is used as a measure of quality healthcare. The aim of this study was to determine the incidence, causes, and risk factors related to emergency consultations and readmissions within 30 and 90 days in patients undergoing laparoscopic gastric bypass and laparoscopic sleeve gastrectomy. METHODS Retrospective study of 429 patients operated on from January 2004 to July 2015 from a prospectively maintained database and electronic medical records. Demographic data, type of intervention, postoperative complications, length of hospital stay and records of emergency visits and readmissions were analyzed. RESULTS Within the first 90 days postoperative, a total of 117 (27%) patients consulted the Emergency Department and 24 (6%) were readmitted. The most common reasons for emergency consultation were noninfectious problems related to the surgical wound (n=40, 34%) and abdominal pain (n=28, 24%), which was also the first cause of readmission (n=9, 37%). Postoperative complications, reintervention, associated surgery in the same operation and depression were risk factors for emergency consultation within the first 90 days of the postoperative period. CONCLUSIONS Despite the high number of patients who visit the Emergency Department in the first 90 days of the postoperative period, few require readmission and none surgical reoperation. It is important to know the reasons for emergency consultation to establish preventive measures and improve the quality of care.
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Kendall MC. Pain Control After Bariatric Surgery: We Still Need More Answers. Obes Surg 2018; 28:1417. [PMID: 29492751 DOI: 10.1007/s11695-018-3146-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Mark C Kendall
- Department of Anesthesiology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 393 Eddy Street, Providence, RI, 02903, USA.
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Stevens H, Wells E, Ross R, Stricklen A, Ghaferi AA. Patient perspectives on emergency department self-referral after bariatric surgery. Surg Obes Relat Dis 2018; 14:674-681. [PMID: 29496439 DOI: 10.1016/j.soard.2018.01.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 01/05/2018] [Accepted: 01/09/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Reducing avoidable emergency department (ED) visits is an increasingly important target of quality improvement and cost containment efforts in bariatric surgery. Administrative and clinical registry data provide an incomplete picture of the factors contributing to postoperative ED utilization. Patient-centered interviews can help identify intervention opportunities. OBJECTIVES We sought to understand the circumstances surrounding patient self-referral to the ED after elective, primary bariatric surgery. SETTING A quality improvement collaborative in Michigan. METHODS A prospective review of clinically abstracted data and patient interviews was completed across 40 hospitals participating in a statewide quality improvement collaborative. Trained nurses collected data on the circumstances surrounding patients' 30-day postoperative ED visits using a previously validated interview tool. Over a year, 201 of 633 total ED visits met the inclusion criteria, with 78% of those patients being interviewed. RESULTS The most common reported chief complaints were abdominal pain and nausea/vomiting. Patients reported high compliance with provider-driven perioperative measures to reduce ED visits. One third of patients stated urgency as the reason for not contacting their surgeon prior to their visit. A majority of patients believed their ED visit was both necessary and unavoidable. CONCLUSIONS Most patients experienced non-life-threatening symptoms but believed their concerns required immediate medical attention in an ED. Patients did not seek lower acuity alternatives despite the increasing availability of these lower cost options. Urgent care centers are one practical alternative for patients who need expeditious professional evaluation. Focused, patient-centered education and promotion of appropriate lower acuity options may decrease nonurgent ED utilization among postoperative bariatric patients.
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Affiliation(s)
- Haley Stevens
- Department of General Surgery, University of Michigan, Ann Arbor, Michigan; Michigan Bariatric Surgery Collaborative, Ann Arbor, Michigan.
| | - Emily Wells
- Department of General Surgery, University of Michigan, Ann Arbor, Michigan
| | - Rachel Ross
- Department of General Surgery, University of Michigan, Ann Arbor, Michigan; Michigan Bariatric Surgery Collaborative, Ann Arbor, Michigan
| | - Amanda Stricklen
- Department of General Surgery, University of Michigan, Ann Arbor, Michigan; Michigan Bariatric Surgery Collaborative, Ann Arbor, Michigan
| | - Amir A Ghaferi
- Department of General Surgery, University of Michigan, Ann Arbor, Michigan; Michigan Bariatric Surgery Collaborative, Ann Arbor, Michigan
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Bamgbade OA, Oluwole O, Khaw RR. Perioperative Antiemetic Therapy for Fast-Track Laparoscopic Bariatric Surgery. Obes Surg 2017; 28:1296-1301. [DOI: 10.1007/s11695-017-3009-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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