Introduction

Esophageal stents (ES) are usually placed to relieve malignant obstructions however other non-malignant indications exists. Complications and readmissions after ES continue to pose a significant issue for gastroenterologists and have a significant burden on our health-care system.

Aims & Methods

Retrospective review of the National Readmission Database (NRD) of the year 2019 of adult patients that underwent ES placement during an index admission (IA) from the month of January to November and were readmitted within 30-days of discharge. ICD-10CM/PCS codes were utilized to identified the procedures and comorbidities. The primary outcome was readmission of any cause. Secondary outcomes were mortality, resource utilization (length of stay (LOS), total hospitalization costs and charges) associated with readmission. Independent risk factors for readmission were identified using Cox regression analysis.

Results

A total of 6,079 patients underwent ES placement in 2019. The most common indication was malignant obstruction (19.1%). A total of 1,642 patients (27.1%) were readmitted within 30-days of discharge and the most common cause of readmission was sepsis (9.3%). Patients that underwent ES placement during IA had a mean age of 65.1 years, 39.8% patients were females, 54.1% of patients had a Charlson Comorbidity Index (CCI) score of ≥3 and 45.9% of patients had associated malnutrition. Readmitted patients were younger (62.5 vs. 66.1 years, P<0.01), more likely to have associated malnutrition (49.1 vs. 44.6%, P=0.04) and there was no difference in the proportion of readmitted females (). The mortality rate during IA was 6.6% and the readmission mortality rate was 8.6% (P<0.01). The mean LOS, hospitalization charges and costs were 7.6 days, $91,543 and $21,310 respectively. Readmission was associated with a total cumulative LOS of 12,514 days and a total $150 million in charges and $34.9 in costs.
After performing a Cox regression analysis younger age [adjusted Hazard Ratio [aHR] 0.98; 95% Confidence Interval [CI] (0.97-0.99)] and undergoing ES placement for non-malignant obstruction [aHR 0.84; (0.72-0.99)] were associated with less risk of readmission. A CCI score ≥3 [aHR 1.38; (1.08-1.77)] had higher risk for readmission.

Conclusion

Early readmissions after ES placement are high (27.1%) and readmission is associated with increased mortality. The most common indication for ES placement is malignant obstruction however undergoing ES placement for benign obstruction is associated with 26% less risk of readmission. Efforts should be put in place to decrease readmission rates and future studies should focus on evaluating risk factors for development and prevention of sepsis post ES placement.

Clinical Case Summary

Clinical presentation: A 45-year-old male with a history of recurrent episodes of variceal bleeding due to decompensated liver cirrhosis of unknown etiology and esophageal variceal ligation (EVL) elsewhere two weeks ago presented to our emergency department with large volume hematemesis and hemodynamic instability.
Therapeutic approach: Immediate resuscitation was offered, with airway intubation and management as per massive bleeding protocol. Somatostatin and antibiotics iv were also administered. Urgent upper gastrointestinal endoscopy was performed once the patient was stabilized, and it revealed active bleeding from a deep, large ulcer at a large esophageal varix just above the gastroesophageal junction. EVL was unsuccessfully attempted twice, due to the disproportionately big size of the variceal ulcer compared to the band device. Emergency transjugular intrahepatic portosystemic shunt (TIPS) and dedicated esophageal stents for varices were not available at the time in our Unit. A decision was made to use an over-the scope clip (OTSC®) as a rescue therapy in this life-threatening condition. OTSC® was successfully applied on variceal ulcer bed and hemostasis was immediately achieved. The patient remained hemodynamically stable after the procedure without clinical signs of further bleeding. He underwent a second endoscopy 48 hours later without endoscopic signs of bleeding or clinically relevant lumen stenosis, while OTSC® was in place. TIPS was planned for the following day.
Discussion: We report the successful use of an over-the-scope clip as a rescue therapy for a patient with massive esophageal variceal bleeding in the absence of established rescue therapies. No clip-related adverse events occurred at the post-treatment period.

References

3 endoscopic images of active variceal bleeding and over-the scope clip placement.