Obesity and pulmonary complications in critically injured adults

BACKGROUND

Pulmonary complications following injury significantly contribute to subsequent mortality. Obese patients have preexisting risk factors for pulmonary complications, and are at risk for these complications following elective surgery. Whether or not obesity contributes to pulmonary complications after critical injury is poorly understood.

METHODS

A secondary analysis of a prospective cohort study of critically injured adults requiring at least 48 h of intensive care was performed. Patients were classified into the following body mass index groups: < or = 18.5 kg/m2 (underweight); 18.5 to 24.9 kg/m2 (normal); 25 to 29.9 kg/m2 (overweight); 30.0 to 39.9 kg/m2 (obese); and > or = 40.0 kg/m2 (severely obese). Outcomes included the rates of ARDS and pneumonia, the placement of a tracheostomy tube, and in-hospital mortality rate.

RESULTS

A total of 1,291 patients were available for analysis, and 30% of these patients were classified as either obese or severely obese. The age-, gender-, and severity-adjusted rate of ARDS was lower in severely obese patients (odds ratio, 0.36; 95% confidence interval [CI], 0.13 to 0.99) compared to normal weight patients. The rates of pneumonia (37%), tracheostomy (10%), and in-hospital mortality (11%) did not differ among the groups. Despite no difference in pulmonary complications, the severely obese group had an ICU length of stay that was 4.8 days (95% CI, 1.8 to 7.7 days) longer than the normal weight group.

CONCLUSION

Obesity does not appear to be an independent risk factor for increased pulmonary complications after critical injury, but severely obese patients are likely to require longer ICU stays.

Cost-effectiveness of routine radiographs after emergent open cavity operations

BACKGROUND

Emergency surgery increases the risk of a retained surgical sponge (RSS) by 9-fold. In most cases, surgical counts are falsely reported as correct. We hypothesized that the institutional costs resulting from a RSS would make routine intraoperative radiography (IOR) more cost-effective than surgical counts in preventing RSS after emergent open cavity cases.

METHODS

A cost-effectiveness analysis was performed to compare routine IOR with surgical counts after emergent open cavity operations. Parameter estimates were obtained from the literature, expert opinion via a standardized survey, and existing institutional data.

RESULTS

Routine IOR was the preferred strategy ($705 vs $1155 per patient) under the assumptions of the base case. The surgical count strategy was dominated by the institutional costs incurred after a RSS. Routine IOR was preferential as long as the sensitivity of surgical counts was less than 98% and the legal fees were more than $44,000 per case of RSS.

CONCLUSIONS

Routine IOR is a simple, cost-effective option to reduce the occurrence of this preventable medical error. Institutional costs and legal fees associated with RSS dominate the cost of the surgical count strategy, making routine IOR a more cost-effective strategy than surgical counts given the best available parameter estimates.

Serum estradiol concentration as a predictor of death in critically ill and injured adults

BACKGROUND

Whereas animal models of sepsis demonstrate survival benefits for the pro-estrus state, human observational studies have failed to demonstrate a consistent survival advantage among female patients. Estrogen biosynthesis differs substantially in primate and non-primate animals, and estrogens have diverse immunologic actions. Estrogen concentrations are elevated in response to critical illness and injury (regardless of sex), and elevated concentrations of serum estradiol are associated with a higher mortality rate. Our objective was to determine the predictive ability and test characteristics of the serum estradiol concentration at 48 h in critically ill patients.

METHODS

A prospective cohort study of surgical and trauma adult intensive care unit patients at two academic tertiary-care centers. Sex hormones (estradiol, progesterone, testosterone, prolactin, and dehydroepiandrosterone) and cytokines were assayed at 48 h, and the 28-day all-cause mortality rate was assessed.

RESULTS

There was no difference in mortality rates between the sexes (survivors being male in 75.2% of cases vs. 76.0% in non-survivors; p = 0.43). The serum estradiol concentration was significantly elevated in non-survivors regardless of sex (median 18.7 pg/mL [interquartile range {IRQ} 9.99-43.6] in survivors and 40.7 pg/mL [IQR 9.99-94.8] in non-survivors; p < 0.001). The area under the receiver-operating characteristic (ROC) curve for serum estradiol was 0.64 (95% confidence interval [CI] 0.55, 0.72). The parameter with the largest ROC curve was the Acute Physiology and Chronic Health Evaluation (APACHE) II score (0.75; 95% CI 0.68, 0.82). A serum estradiol cut-point of 50 pg/mL was 48% sensitive and 80% specific in predicting death and classified the outcome of 76% of patients correctly.

CONCLUSIONS

Serum estradiol concentration is a valuable prognostic tool and potential contributor to adverse outcomes of critically ill or injured surgical patients.

Gastroduodenal artery pseudoaneurysm associated with hemosuccus pancreaticus and obstructive jaundice

A 42-year-old male was admitted with recurrent gastrointestinal bleeding and new-onset jaundice. Computed tomography showed a persistent gastroduodenal artery pseudoaneurysm and dilated intrahepatic and extrahepatic ducts consistent with obstructive jaundice. This patient had two previous coil embolizations, which failed to prevent recurrent bleeding. The patient underwent pancreaticoduodenectomy for definitive treatment of his pseudoaneurysm. We report this case and review the literature.

Small Bowel Adenocarcinoma Complicating Crohn's Disease: Case Series and Review of the Literature

Colonic adenocarcinoma frequently complicates inflammatory bowel disease of the colon, but small bowel adenocarcinoma (SBA) is a rare complication of Crohn's disease (CD). We present two patients with SBA in CD and review the literature with regards to CD-related SBA. A 45-year-old male with a 17-year history of ileal CD presented with obstructive symptoms but no radiographic evidence of a mass. After laparoscopic ileocolectomy and repair of incidental ileosigmoid fistula, pathology showed a T3N0 adenocarcinoma within the ileal CD. Two years after his resection he was without evidence of disease. A 59-year-old male with a 15-year history of CD presented with an acute exacerbation. Small bowel follow through demonstrated a long ileal stricture for which he underwent an ileocolic resection. Postoperative pathology confirmed a T3N1 CD-related SBA. He died from metastatic cancer 3 months later. Review of the literature identified 154 cases of SBA complicating CD with several distinguishing features from de novo SBA. Patients with SBA and CD are, as a group, younger and more likely to be male. SBA is rarely diagnosed preoperatively in these patients, and has a poor prognosis due to its advanced stage at diagnosis.

Small bowel adenocarcinoma complicating Crohn's disease: case series and review of the literature

Colonic adenocarcinoma frequently complicates inflammatory bowel disease of the colon, but small bowel adenocarcinoma (SBA) is a rare complication of Crohn's disease (CD). We present two patients with SBA in CD and review the literature with regards to CD-related SBA. A 45-year-old male with a 17-year history of ileal CD presented with obstructive symptoms but no radiographic evidence of a mass. After laparoscopic ileocolectomy and repair of incidental ileosigmoid fistula, pathology showed a T3N0 adenocarcinoma within the ileal CD. Two years after his resection he was without evidence of disease. A 59-year-old male with a 15-year history of CD presented with an acute exacerbation. Small bowel follow through demonstrated a long ileal stricture for which he underwent an ileocolic resection. Postoperative pathology confirmed a T3N1 CD-related SBA. He died from metastatic cancer 3 months later. Review of the literature identified 154 cases of SBA complicating CD with several distinguishing features from de novo SBA. Patients with SBA and CD are, as a group, younger and more likely to be male. SBA is rarely diagnosed preoperatively in these patients, and has a poor prognosis due to its advanced stage at diagnosis.

Malignant pheochromocytoma of the organ of Zuckerkandl requiring aortic and vena caval reconstruction

OBJECTIVE

To describe a case of a malignant pheochromocytoma located in the organ of Zuckerkandl that required aortic and vena caval resection and reconstruction.

METHODS

We present a case report that includes clinical, laboratory, and radiographic data as well as photographs, results from pathology, and a brief review of the literature.

RESULTS

A 46-year-old man was referred for evaluation of a 1.4-cm left adrenal mass incidentally discovered on an abdominopelvic computed tomography (CT) scan. Subsequent laboratory evaluation revealed the following values: urine norepinephrine, 252 microg/24 h; urine normetanephrine, 1122 microg/24 h; urine metanephrine, 162 microg/24 h; urine epinephrine, 7 microg/24 h; urine vanillylmandelic acid, 8 mg/24 h; and plasma metanephrine, 98 pg/ mL. Imaging characteristics of the left adrenal mass were consistent with a benign adenoma, but CT also demonstrated a hypervascular para-aortic mass. 123I-metaiodo-benzylguanidine scanning with fusion CT imaging demonstrated increased radiopharmaceutical uptake within the para-aortic mass consistent with a paraganglioma in the organ of Zuckerkandl. Findings from CT angiography of the abdomen and pelvis suggested aortic involvement and vena caval thrombus. The mass was excised en bloc, including portions of the aorta, inferior vena cava, and right ureter. The aorta and vena cava were reconstructed using Dacron grafts. The remaining right ureter and kidney were removed to avoid the possibility of a urine leak from an ureteroureterostomy. Final pathologic and operative findings confirmed a malignant pheochromocytoma of the organ of Zuckerkandl with invasion into the wall of the inferior vena cava and tumor thrombus extending into the lumen.

CONCLUSION

Malignant pheochromocytoma of the organ of Zuckerkandl involving the aorta and inferior vena cava is exceedingly rare, and although surgical resection and reconstruction can be radical and aggressive, this treatment offers the only chance for cure.