The impact of the acute respiratory distress syndrome on outcome after oesophagectomy.

BACKGROUND: The Acute Respiratory Distress Syndrome (ARDS) is a serious complication of major surgery and consumes substantial healthcare resources. Oesophagectomy is associated with high rates of ARDS. The aim of this study was to characterize patients and identify risk factors for developing ARDS after oesophagectomy. METHODS: A secondary analysis of data from 331 patients gathered during the Beta Agonists Lung Injury Prevention Trial was undertaken. Characteristics and outcomes of patients with early (first 72 h postoperatively) and late (after 72 h) ARDS were determined. Linear and multivariate regression analysis was used to study the differences between early and late ARDS and identify risk factors. RESULTS: ARDS was associated with more non-respiratory organ failure (early 44.1%, late 75.0%, no ARDS 27.6% P<0.001), longer ICU stay (mean early 12.1, late 20.2, no ARDS 7.3 days P<0.001) and longer hospital stay (mean early 18.1, late 24.5, no ARDS 14.2 days P<0.001) but no difference in mortality or quality of life. Older patients (OR 1.06 (1.00 to 1.13), P=0.045) and those with mid-oesophageal tumours (OR 7.48 (1.62-34.5), P=0.010) had a higher risk for ARDS. CONCLUSIONS: Early and late ARDS after oesophagectomy increases intensive care and hospital length of stay. Given the high incidence of ARDS, cohorts of patients undergoing oesophagectomy may be useful as models for studies investigating ARDS prevention and treatment. Further investigations aimed at reducing perioperative ARDS are warranted.

An investigation of the radiation doses to the lower legs and feet of staff undertaking interventional procedures.

OBJECTIVE: Occupational radiation doses from fluoroscopic procedures are some of the highest doses of exposure amongst medical staff using radiography. Protective equipment and dose monitoring are used to minimize and control the risk from these occupational doses. Other studies have considered the effectiveness of this protection, but this study further considers whether protection is adequate for the lower leg and foot and the extent to which these doses can be reduced. METHODS: Scatter air kerma profiles at toe level were measured with an ionization chamber. Thermoluminescent dosemeters and lower extremity phantoms were used to estimate the dose variation with the height of patient couch. A 7-week period of in situ toe dose monitoring of four radiologists was also undertaken. RESULTS: The use of protective curtains effectively reduced the exposure to most of the lower extremities. Toe doses were found to be high and increased with increase in couch height. In situ monitoring indicated annual toe doses of 110 mSv for two of the four radiologists monitored. CONCLUSION: Protective curtains should be used, but they might have limitations with respect to toe doses. Annual toe doses approaching the classification threshold of 150 mSv were measured for two radiologists. Caution should be exercised when there is a gap below curtains and, when possible, staff should step back from the couch. Lower legs and toes should be included in local radiation protection programmes. ADVANCES IN KNOWLEDGE: Toe doses in interventional radiology may be higher than expected and may have to be included in radiation protection programmes.

Risk of radiation exposure during endovascular aortic repair.

OBJECTIVE: Exposure to radiation doses above 2 Gray (Gy) can cause skin burns. There is also a lifetime cancer risk of ≈5.5% for every Sievert (Sv) of radiation. We assessed the radiation burden associated with endovascular treatment of the aorta. METHOD: Thoracic (TEVAR), Infra-renal (IEVAR) and branched/fenestrated (BEVAR/FEVAR) endovascular aortic repairs were studied. The prospectively recorded dosimetric parameters included: fluoroscopy time and dose area product (DAP). Exposure films, placed underneath 10 patients intra-operatively, recorded skin dose and were used to calculate skin (Gy) and tissue (Sv) doses. RESULTS: The TEVAR cohort (n = 232) were younger (p < 0.0001) than BEVAR/FEVAR (n = 53) and IEVAR (n = 630). The median DAP was higher (p = 0.004) in the BEVAR/FEVAR group compared with IEVAR and TEVAR: 32,060 cGy cm(2) (17,207-213,322) vs 17,300 cGy cm(2) (10,940-33,4340) vs 19,440 cGy cm2 (11,284-35,101), respectively. The equivalent skin doses were BEVAR/FEVAR: 1.3 Gy (0.71-8.75); IEVR: 0.71 Gy (0.44-13.7); TEVAR: 0.8 Gy (0.46-1.44). The whole body effective doses were BEVAR/FEVAR: 0.096 Sv (0.052-0.64); IEVR: 0.053 Sv (0.033-1.00); TEVAR: 0.058 Sv (0.034-0.11). CONCLUSIONS: The radiation exposure during endovascular aortic surgery is relatively low for the majority but some patients are exposed to very high doses. Efforts to minimise intra-operative exposure and graft surveillance methods that do not use radiation may reduce the cumulative lifetime malignancy risk.