Benign stricture of bilioenteric anastomosis after Whipple withsynthetic polypropylene suture

To the Editor:Biliary stricture formation at the bilioenteric anastomosis is an infrequent complication(2%-3%)after pancreaticoduodenectomy;the average presentation is within 13-14 months(range from 1 month to 9 years)after surgery[1,2].While the etiology is unknown,development of biliary stricture has shown to be more likely if a bile leak occurs in the postoperative period[3,4]and with younger patients[5].

Better Than You Think—Appropriate Use of Implantable Cardioverter-Defi brillators at a Single Academic Center:A Retrospective Review

Background:Implantable cardioverter-defi brillators(ICDs)can be life-saving devices,although they are expensive and may cause complications.In 2013,several professional societies published joint appropriate use criteria(AUC)assessing indications for ICD implantation.Data evaluating the clinical application of AUC are limited.Previous registry-based studies estimated that 22.5%of primary prevention ICD implantations were“non-evidence-based”implantations.On the basis of AUC,we aimed to determine the prevalence of“rarely appropriate”ICD implantation at our institution for comparison with previous estimates.Methods:We reviewed 286 patients who underwent ICD implantation between 2013 and 2016.Appropriateness of each ICD implantation was assessed by independent review and rated on the basis of AUC.Results:Of 286 ICD implantations,two independent reviewers found that 89.5%and 89.2%,respectively,were appropriate,5.6%and 7.3%may be appropriate,and 1.8%and 2.1%were rarely appropriate.No AUC indication was found for 3.5%and 3.4%of ICD implantations,respectively.Secondary prevention ICD implantations were more likely rarely appropriate(2.6%vs.1.2%and 3.6%vs.1.1%)or unrated(6.0%vs.1.2%and 2.7%vs.0.6%).The reviewers found 3.5%and 3.4%of ICD implantations,respectively,were non-evidence-based implantations.The difference in rates between reviewers was not statistically signifi cant.Conclusion:Compared with prior reports,our prevalence of rarely appropriate ICD implantation was very low.The high appropriate use rate could be explained by the fact that AUC are based on current clinical practice.The AUC could benefi t from additional secondary prevention indications.Most importantly,clinical judgement and individualized care should determine which patients receive ICDs irrespective of guidelines or criteria.

Association of latitude and altitude with adverse outcomes in patients with COVID-19: The VIRUS registry

BACKGROUND The coronavirus disease 2019(COVID-19)course may be affected by environmental factors.Ecological studies previously suggested a link between climatological factors and COVID-19 fatality rates.However,individual-level impact of these factors has not been thoroughly evaluated yet.AIM To study the association of climatological factors related to patient location with unfavorable outcomes in patients.METHODS In this observational analysis of the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study:COVID-19 Registry cohort,the latitudes and altitudes of hospitals were examined as a covariate for mortality within 28 d of admission and the length of hospital stay.Adjusting for baseline parameters and admission date,multivariable regression modeling was utilized.Generalized estimating equations were used to fit the models.RESULTS Twenty-two thousand one hundred eight patients from over 20 countries were evaluated.The median age was 62(interquartile range:49-74)years,and 54%of the included patients were males.The median age increased with increasing latitude as well as the frequency of comorbidities.Contrarily,the percentage of comorbidities was lower in elevated altitudes.Mortality within 28 d of hospital admission was found to be 25%.The median hospital-free days among all included patients was 20 d.Despite the significant linear relationship between mortality and hospital-free days(adjusted odds ratio(aOR)=1.39(1.04,1.86),P=0.025 for mortality within 28 d of admission;aOR=-1.47(-2.60,-0.33),P=0.011 for hospital-free days),suggesting that adverse patient outcomes were more common in locations further away from the Equator;the results were no longer significant when adjusted for baseline differences(aOR=1.32(1.00,1.74),P=0.051 for 28-day mortality;aOR=-1.07(-2.13,-0.01),P=0.050 for hospital-free days).When we looked at the altitude’s effect,we discovered that it demonstrated a non-linear association with mortality within 28 d of hospital admission(aOR=0.96(0.62,1.47),1.04(0.92,1.19),0.49(0.22,0.90),and 0.51(0.27,0.98),for the altitude points of 75 MASL,125 MASL,400 MASL,and 600 MASL,in comparison to the reference altitude of 148 m.a.s.l,respectively.P=0.001).We detected an association between latitude and 28-day mortality as well as hospital-free days in this worldwide study.When the baseline features were taken into account,however,this did not stay significant.CONCLUSION Our findings suggest that differences observed in previous epidemiological studies may be due to ecological fallacy rather than implying a causal relationship at the patient level.

Turnkey algorithmic approach for the evaluation of gastroesophageal reflux disease after bariatric surgery

Bariatric surgeries are often complicated by de-novo gastroesophageal reflux disease(GERD)or worsening of pre-existing GERD.The growing rates of obesity and bariatric surgeries worldwide are paralleled by an increase in the number of patients requiring post-surgical GERD evaluation.However,there is currently no standardized approach for the assessment of GERD in these patients.In this review,we delineate the relationship between GERD and the most common bariatric surgeries:sleeve gastrectomy(SG)and Roux-en-Y gastric bypass(RYGB),with a focus on pathophysiology,objective assessment,and underlying anatomical and motility disturbances.We suggest a stepwise algorithm to help diagnose GERD after SG and RYGB,determine the underlying cause,and guide the management and treatment.