Extensive stage small cell lung cancer presenting as an acute perforated appendix: case report and review of the literature.

Malignancies of the appendix are uncommon; a small subset of these lesions are actually metastatic cancers. In some rare cases, these lesions can cause obstruction, appendicitis, and perforation. M.K. is a 54-year-old man who presented to our institution with a 1-day history of right lower quadrant pain and a past medical history significant only for a 75-pack-year smoking history. CT scan revealed a perforated appendix, and the patient was taken to the operating room where a gangrenous appendix was removed uneventfully. Two days post-procedure, the patient was found to have acute mental status changes, requiring intubation and transfer to the surgical intensive care unit. As part of a workup, a CT scan of the head revealed multiple lesions compatible with metastatic disease. At that point, the pathology from the appendix came back as small cell lung cancer. Chest CT revealed hilar adenopathy and a hilar mass. The patient received emergent whole-brain irradiation therapy with improvement in his mental status, allowing him to be extubated and discharged from the hospital within 10 days of admission. Surgeons should remember that an underlying oncologic process may be the etiology of appendicitis in a small but important subgroup of patients.

Use of drotrecogin alfa (activated) in bariatric surgery patients with severe sepsis syndrome: experience in an urban community teaching hospital.

BACKGROUND: Severe sepsis syndrome (SSS) and septic shock have an associated mortality ranging from 31 to 60%. Drotrecogin alfa (activated), activated protein C (APC), has been shown in a recent trial to decrease mortality from 44 to 31% in patients with SSS and a high risk of death. We present 3 patients who developed SSS after bariatric surgery and were treated with APC as part of comprehensive therapy for sepsis. METHODS: At our institution, patients must have SSS plus an APACHE II score >or= 25 in order to receive APC. JL is a 43-year-old man who developed SSS (APACHE II score 26) after Roux-en-Y gastric bypass. ML is a 33-year-old man who developed SSS (APACHE II=28) because of a distal obstruction 2.5 years after gastric bypass surgery. TQ was a 35-year-old man who developed SSS (APACHE II=35) in the setting of laparoscopic banding. RESULTS: After receiving 90% of the 96-hour infusion, JL developed ecchymoses and a decrease in his platelet count; thus, the drug was stopped. ML received a full 96-hour infusion. Both patients made a full recovery from their SSS and were successfully discharged from the hospital. TQ developed septic shock and expired despite all efforts. CONCLUSION: Weight alone should not be considered a contraindication to the use of APC. Close coordination between the intensivist and surgeon is recommended for bariatric surgery patients with SSS, so that a rapid determination can be made as to the patient's risk of death and eligibility to receive APC.