Small Bowel Volvulus in a Quadriplegic: A Rare Complication of the Simon Nitinol Inferior Vena Cava Filter.

The advent and use of inferior vena cava (IVC) filters have reduced the overall incidence of pulmonary embolism in hospitalized patients, but are not without potential complications. With the exponential increase in the utilization of IVC filters over the past two decades, it is important to consider the use of retrievable filters, where indicated, in order to potentially reduce long-term IVC filter-related complications. We report a rare case of small bowel volvulus due to IVC perforation by a Simon Nitinol filter strut in a quadriplegic patient 4 years after IVC filter insertion.

Outcomes of Roux-en-Y gastric bypass stratified by a body mass index of 70 kg/m2: a comparative analysis of 825 procedures.

We compared the safety, excess weight loss (EWL), and improvement in comorbidities after Roux-en-Y gastric bypass (RYGB) in morbidly obese and superobese patients (body mass index, <70 kg/m2 or >or=70 kg/m2). Of 825 patients who underwent RYGB by our group between 1995 and 2003, 79 (9.6%) were superobese (group A) and 746 were morbidly obese (group B). There were significant differences in age (A, 40.8 years; B, 43.2 years; P=0.01), gender (males: A, 40.5%; B, 17.6%; P<0.0001), and type of access (laparoscopic RYGB: A, 4.1%; B, 34.2%; P<0.0001). Sleep apnea (A, 57%; B, 31.4%; P<0.0001) and venous insufficiency (A, 16.5%; B, 2.4%; P<0.0001) were more common in superobese patients. Hospital stay was similar (A, 6.3 days; B, 5.3 days) with adjustment for differences in type of access. Although morbidity was comparable, mortality was higher in the superobese group (A, 2.5%; B, 0.5%; P<0.05). At a comparable follow-up (A, 17.7 months; B, 18.25 months), percent EWL at 1 year was lower in the superobese group (A, 54.6%; B, 64.3%; P<0.0001), but it became similar at 3 years (A, 66.5%; B, 60.7%). Postoperative improvement of comorbidities was equally dramatic in both groups with the exception of venous insufficiency. In conclusion, complications are not increased in the superobese, but they are more often fatal. Superobese patients achieve their maximum weight loss in a longer period of time and reach their nadir at year 3.

TRISS unexpected survivors: an outdated standard?

BACKGROUND: Performance improvement is an essential component of the trauma center. TRISS methodology has been applied as a national standard against which trauma centers can compare their outcomes. Earlier reviews of TRISS unexpected survivors sustained the classification of unexpected survivor in the vast majority of cases. Our hypothesis was that the level of care that is currently expected has made the TRISS unexpected survivors a statistical phenomenon only. METHODS: Two hundred seventy TRISS unexpected survivors at a Level I trauma center from 1991 to 1995 were reviewed. Each case was reviewed as a blinded abstract by six reviewers (three of whom are directors at other facilities) and classified as clinically unexpected survivor (confirmed TRISS classification) or clinically expected survivor (did not sustain TRISS classification as unexpected survivor). Data are expressed as mean +/- SD. Statistical significance was achieved at p < 0.05. RESULTS: Among the 270 patients categorized by TRISS as unexpected survivors, only 10.7% were corroborated as clinically unexpected survivors by this peer review process and 89.3% were reclassified as clinically expected survivors. Confirmed clinically unexpected survivors were more likely to go directly from the emergency department to the operating room (82 vs. 46%; p < 0.05). Age (32 +/- 12 years vs. 40 +/- 19 years; p < 0.05), Injury Severity Score (46 +/- 20 vs. 32 +/- 14; p < 0.05), Revised Trauma Score (2.46 +/- 1.89 vs. 3.11 +/- 1.21; p < 0.05), probability of survival (0.13 +/- 0.13 vs. 0.24 +/- 0.15; p < 0.05), systolic blood pressure in the emergency department (60 +/- 51 mm Hg vs. 109 +/- 33 mm Hg; p < 0.05), hospital length of stay (39.6 +/- 30.3 days vs. 24.0 +/- 23.0 days; p < 0.05), and intensive care unit length of stay (19.5 +/- 20.6 days vs. 9.6 +/- 10.1 days; p < 0.05) were significantly different comparing confirmed versus unsustained classification as unexpected survivors. CONCLUSION: Only 10.7% of survivors classified as unexpected by TRISS were corroborated as unexpected by a blinded, peer-review process. TRISS needs to be updated for meaningful interpretation; modifications need to be made and coefficients need to be revised.