Incidence of pheochromocytoma in trauma patients during the management of unrelated illness: A retrospective review

BACKGROUND

Over the last two decades the rate of detection of asymptomatic adrenal masses has increased as a result of the widespread use of abdominal imaging modalities. Incidental pheochromocytoma discovered during the management of an unrelated illness is a rare presentation of these tumors. They can occur in patients treated for multiple trauma with no history of prior arterial hypertension.

METHODS

From January 1995 to December 2005 a total of 45 patients underwent adrenalectomy for incidentaloma. Of these, a pheochromocytoma was detected in 13 patients (29%) seen for an unrelated condition, 3 were in trauma patients. Nine men and 4 women with a mean age 44.5 years (range 21-67) underwent adrenalectomy for incidental pheochromocytoma.

RESULTS

Less than half (6 patients, 46%), and one of the trauma patients had a history of arterial hypertension. Preoperative hormonal studies revealed a pheochromocytoma in 11 patients with incidentalomas. One patient had normal preoperative catecholamines levels. Laparoscopic transabdominal adrenalectomy was attempted in 10 patients with one conversion to open surgery in the case of paraganglioma and one for injury to the left renal vein. Three patients underwent open adrenalectomy. Mean surgery time of trauma patients was 167 (range, 130-235) min. Intraoperative instability (systolic pressure >200 mmHg) requiring nitroprusside and/or labetalol, was observed in 7 patients (54%). There was no postoperative morbidity or mortality. Over the last 10 years, 23% of the pheochromocytomas found incidentally were in trauma patients.

CONCLUSION

Incidentally discovered adrenal masses need to be investigated for pheochromocytoma. This holds specially true for trauma patients who may be put in serious jeopardy should they need surgery for their injuries.

Use of the embedded peritoneal dialysis catheter: Experience and results from a North American Center

Since 2000, the Ottawa Hospital Home Dialysis Program has used a variation on the embedded peritoneal dialysis catheter technique described by Moncrief et al. In this paper, we describe our approach to placement of peritoneal access and report our experience with 304 embedded catheters placed between January 2000 and December 2003. We review the advantages and disadvantages of this technique and describe factors that have been important to the success of our program.

Management of adult splenic injuries in Ontario: a population-based study

OBJECTIVES

To determine the population-based incidence of splenic injuries in the Province of Ontario, the proportion of splenic injuries treated by observation, splenectomy and splenorrhaphy, changes in management over time and the variation in management of splenic injuries among Ontario hospitals.

DESIGN

A retrospective cohort study.

PATIENTS

All adults (older than 16 years) admitted with a diagnosis of splenic injury (clinical modification of the International Classification of Diseases, 9th revision) to acute care hospitals in Ontario between 1991 and 1994, identified from the Ontario Trauma Registry.

RESULTS

The incidence of splenic injury was 1.7 cases per 1000 trauma admissions per year. Patients with splenic injury were young (median age 32 years) and male (71%), and the death rate was 8%. Observation was the commonest method of treatment (69%), followed by splenectomy (28%) and splenorrhaphy (4%). The use of observation increased over the study period from 59% to 75% (p < 0.001). There was significant variation in the use of observation among hospitals (range 11% to 100%, p < 0.0001).

CONCLUSIONS

The majority of splenic injuries are managed by observation with an acceptable hospital death rate. The use of observation has increased over time, confirming the growing adoption of this management approach by most hospitals in the province when feasible. Splenorrhaphy was infrequently performed despite reports to the contrary from many centres in the United States. There was significant variation in splenic injury management, suggesting the need for further refinement and dissemination of practical guidelines for splenic salvage.

Anesthesia for laparoscopic adrenalectomy (pheochromocytoma) in an anemic adult Jehovah's Witness

PURPOSE

To report the anesthetic management of an anemic Jehovah's Witness patient presenting for laparoscopic adrenalectomy for pheochromocytoma.

CLINICAL FEATURES

A 49-yr-old woman presented with hemodynamic instability progressing to cardiogenic shock and subsequent acute renal failure. Her course was complicated by anemia. An adrenal pheochromocytoma was diagnosed. Preoperatively, alpha- and beta-adrenergic blockade was instituted with phenoxybenzamine and metoprolol therapy and her anemia was treated with erythropoietin. She underwent laparoscopic resection of the adrenal tumour. A cell saver device was employed and attached to the laparoscopic suction-irrigation apparatus to provide salvage capability in the event of a major hemorrhage. The surgical intervention was uneventful and well tolerated. The patient was discharged home and well on follow-up.

CONCLUSIONS

Cell salvage is the only mechanism currently acceptable to Jehovah's Witnesses which will allow for perioperative salvage and replacement of blood loss. Its use is encouraged in all situations in which surgical hemorrhage is anticipated.

Use of abdominal computed tomography in blunt trauma: do we scan too much?

OBJECTIVES

To determine what proportion of abdominal computed tomography (CT) scans ordered after blunt trauma are positive and the applicability and accuracy of existing clinical prediction rules for obtaining a CT scan of the abdomen in this setting.

SETTING

A leading trauma hospital, affiliated with the University of Ottawa.

DESIGN

A retrospective cohort study.

PATIENTS AND METHODS

All patients with blunt trauma admitted to hospital over a 1-year period having an Injury Severity Score (ISS) greater than 12 who underwent CT of the abdomen during the initial assessment. Recorded data included age, sex, Glasgow Coma Scale (GCS) score, ISS, type of injuries, number of abdominal CT scans ordered, and scan results. Two clinical prediction rules were found in the literature that identify patients likely to have intra-abdominal injuries. These rules were applied retrospectively to the cohort. The predicted proportion of positive CT scans was compared with the observed proportion, and the sensitivity, specificity, and accuracy were estimated.

RESULTS

Of the 297 patients entered in the study, 109 underwent abdominal CT. The median age was 32 years, 71% were male and the median ISS was 24. In only 36.7% (40 of 109) of scans were findings suggestive of intra-abdominal injuries. Application of one of the clinical prediction rules gave a sensitivity of 93.8% and specificity of 25.5% but excluded 23% of patients because of a GCS score less than 11. The second prediction rule tested could be applied to all patients and was highly sensitive (92.5%) and specific (100.0%).

CONCLUSIONS

The assessment of the abdomen in blunt trauma remains a challenge. Accuracy in predicting positive scans in equivocal cases is poor. Retrospective application of an existing clinical prediction rule was found to be highly accurate in identifying patients with positive CT findings. Prospective use of such a rule could reduce the number of CT scans ordered without missing significant injuries.

Management of choledocholithiasis in the time of laparoscopic cholecystectomy

BACKGROUND

The best way to detect and manage common duct stones in conjunction with laparoscopic cholecystectomy is not agreed upon at the present time.

PATIENTS AND METHODS

Our experience with choledocholithiasis in a consecutive series of 1,123 cholecystectomies (94% by laparoscopy) has been reviewed. Suspected duct stones were investigated preoperatively or postoperatively by endoscopic retrograde cholangiography (ERC), and if necessary, duct clearance was attempted by endoscopic sphincterotomy (ES). No attempt was made to identify choledocholithiasis intraoperatively.

RESULTS

Endoscopic retrograde cholangiography was performed in 11% of patients, and 32% of these required ES. The complication rate of ERC and ES was 8%, without mortality. Two patients required a second operation for missed choledocholithiasis, for a reoperation rate of 0.2%.

CONCLUSION

We believe that primary or secondary open surgery is only occasionally necessary for the management of choledocholithiasis. Preoperative ERC and ES for suspected duct stones, with the same strategy employed as a salvage for stones presenting after cholecystectomy, was safe and efficient.

Differential performance of TRISS-like in early and late blunt trauma deaths

OBJECTIVES

(1) To independently validate the Trauma and Injury Severity Score-Like (TRISS-Like) model derived by Offner et al. (Revision of TRISS for intubated patients. J Trauma. 1992;32:32-35) in a population of Canadian blunt trauma victims, and (2) to compare the ability of this model to predict mortality in early and late trauma deaths.

STUDY POPULATION

Prospective cohort of blunt trauma cases with Injury Severity Score > 12 identified from the Ontario Trauma Registry over a 5-year period.

STUDY DESIGN

The TRISS-Like model consisting of age, Injury Severity Score, systolic blood pressure, and best motor response of the Glasgow Coma Scale was evaluated as to its ability to predict mortality by determining the sensitivity, specificity, and the area under the receiver operating characteristic curve. The sample was then divided into early (< or = 7 days) and late mortality subgroups in which model performance was evaluated with respect to time of death.

RESULTS

A total of 7,703 patients were included in this analysis. The overall mortality was 12.3%. The TRISS-Like model allowed for assessment of an additional 23% of patients than would standard TRISS and performed with a sensitivity of 97.1%, specificity of 39.8% and an area under the receiver operating characteristic curve of 0.873. Analysis of mortality with respect to time demonstrated that 75% of deaths occurred by day 7. The specificity and receiver operating characteristic area increased in the early (< or = 7 days) subgroup, 46.5% and 0.935, respectively, compared with 20.8% and 0.778 in the late mortality group.

CONCLUSIONS

TRISS-Like demonstrated similar performance to that reported with the standard TRISS model but with the additional advantage that it is more generalizable because it can be applied to intubated patients. TRISS-Like demonstrated substantially superior performance in early trauma deaths compared with those that occurred late. This differential performance may be because the model does not include risk factors for late mortality.

Management of splenic injuries in a Canadian trauma centre

OBJECTIVES

To document the current practice pattern for the treatment of splenic injuries in one Canadian trauma centre and to identify factors that determined which method was employed.

DESIGN

A cohort study.

SETTING

A Canadian lead trauma centre.

PATIENTS

A cohort of 100 patients with splenic injury treated at one trauma hospital over 5 years was identified from a prospective trauma database.

MAIN OUTCOME MEASURES

The success rate and failure rate for splenic salvage by splenectomy, splenorrhaphy or observation. Volume of blood transfused, injury severity score (ISS) and method of diagnosis.

RESULTS

The median ISS for the cohort was 34 (36 for splenectomy, 38 for splenorrhaphy and 35 for observation). A blunt mechanism of injury was present in 96%. The diagnosis was made by computed tomography (CT) in 55%. Splenic salvage was accomplished in 51 patients; of these, 44 (86%) were in the observation group, and the success rate was 90% (within the range reported in the literature). Only seven patients underwent splenorrhaphy. CT was performed more frequently in the observation group than in the splenectomy group (82% v. 25%, p < 0.0001). The splenectomy group had more blood transfused than the successful observation group (mean units 15 v. 3, p = 0.0001) and had a higher median ISS (36 v. 29, p = 0.02). Multivariate analysis revealed that the method of diagnosis (CT v. diagnostic peritoneal lavage) was the strongest factor associated with how the splenic injury was treated.

CONCLUSIONS

The finding in this report of an increase in observational treatment of splenic injuries represents a shift in practice from a previous Canadian report and is in keeping with recent published trends from the United States. Future studies are needed to assess whether any strong regional practice pattern variations in the management of blunt splenic injuries exists in other trauma centres across Canada.

Hemobilia complicating elective laparoscopic cholecystectomy: a case report

Iatrogenic injury to the hepatic or cystic arteries can occur during laparoscopic cholecystectomy and can be seen in isolation or in association with bile-duct injury. The most common manifestation of arterial injury is intraoperative hemorrhage; also, interruption of the right hepatic artery can occur without hemorrhage, and this can be clinically insignificant or associated with hepatic ischemia. A less common manifestation of arterial injury during laparoscopic cholecystectomy is presented. A 48-year-old woman had a pseudoaneurysm of the major anterior branch of the right hepatic artery in association with an injury to the common hepatic duct. This complication presented as massive hemobilia after she had been discharged from the hospital. Definitive repair of the pseudoaneurysm was carried out at the time of Roux-en-Y hepaticojejunostomy for correction of the associated duct injury. This unusual vascular complication should be considered in patients after laparoscopic cholecystectomy who demonstrate evidence of late occult or obvious hemorrhage.

Validation of trauma and injury severity score in blunt trauma patients by using a Canadian trauma registry

OBJECTIVE

To compare outcomes in blunt trauma by using Trauma and Injury Severity Score (TRISS) models derived from the Major Trauma Outcome Study (MTOS) and the Ontario Trauma Registry (OTR) as well as to evaluate the role of the Revised Trauma Score within the TRISS model.

METHODS

Consecutive blunt trauma cases from 11 Level I trauma centers over a 4-year period were identified from the OTR. Coefficients of the Revised Trauma Score were modified using the Ontario data and this score was tested by using the Hosmer-Lemeshow Goodness of Fit Test. Two Ontario-specific TRISS models were developed with revised coefficients. The first used the standard Revised Trauma Score and the second used the Revised Trauma Score with regenerated coefficients. The accuracy of mortality predictions for all models were compared by using a Hosmer-Lemeshow Goodness of Fit procedure. Additionally, each TRISS models performance characteristics and receiver operating characteristic (ROC) curves were used to evaluate their discriminative capabilities.

RESULTS

A total of 5,436 cases were incorporated in the analysis. Patients with all component TRISS variables had a significantly lower mortality compared to all blunt trauma patients (7.0% vs. 15.5%,p < 0.01). Use of the Revised Trauma Score led to the exclusion of 40% of cases because of absent data necessary to compute the score. The Hosmer-Lemeshow Goodness of Fit statistic for the Revised Trauma Score was 79.45 (p = 0.0001). The Hosmer-Lemeshow Goodness of Fit Statistic ranged from 11.42, p = 0.175 and 13.1, p = 0.125 for the Ontario TRISS models compared to 25.62, p < 0.005 for the MTOS TRISS model. Sensitivity of all three TRISS models ranged from 98% to 99% with specificity ranging from 24% to 35%. ROC curves were identical for all three TRISS models.

CONCLUSIONS

TRISS demonstrated satisfactory performance in a Canadian blunt trauma population. Although revision of coefficients led to a better fit on the Hosmer-Lemeshow statistic, ROC curves demonstrated virtually identical performance of the MTOS and Ontario-based TRISS models. The poor performance of the Revised Trauma Score and the observation that its use led to the exclusion of 40% of cases with a higher mortality raises concerns regarding its use in the TRISS model.

Adult respiratory distress syndrome: a systemic overview of incidence and risk factors

OBJECTIVE

To determine the published incidence of adult respiratory distress syndrome (ARDS) as well as the clinical evidence supporting a casual association between ARDS and its major risk factors.

DATA SOURCES

The National Library of Medicine MEDLINE database and the bibliographies of selected articles.

STUDY SELECTION

Clinical studies were selected from the English literature, if they pertained to either the incidence of ARDS or its association with one or more commonly identified risk factors.

DATA EXTRACTION

All relevant studies identified by the search were evaluated for strength of design, and risk factors were scored according to established criteria for the strength of causation.

DATA SYNTHESIS

A total of 83 articles were considered relevant: six of incidence and 77 on risk factors. Only 49% of the 83 articles provided a definition of ARDS; a definition of risk factors was given in 64%, and 23% had no definition for either ARDS or risk factors. The published, population-based incidence of ARDS ranges from 1.5 to 5.3/10(5) population/yr. The strongest clinical evidence supporting a cause-effect relationship was identified for sepsis, aspiration, trauma, and multiple transfusions. The weakest clinical evidence was identified for disseminated intravascular coagulation. The following study types were represented by the 77 articles on risk factors: observational case-series (56%); cohorts (23%); case-controls (12%); nonrandomized clinical trials (5%); and randomized clinical trials (3%). Only a single study reported an odds ratio.

CONCLUSIONS

The significant variation in the incidence of ARDS is attributed to differences in the type and strength of study designs, as well as definitions or ARDS. While a substantial body of evidence exists concerning a casual role of ARDS risk factors, such as sepsis, aspiration, and trauma, > 60% of clinical studies employed weak designs. The lack of reproducible definitions for ARDS or its potential risk factors in 49% of studies raises concerns about the validity of the conclusions of these studies regarding the association between ARDS and the supposed risk factors.