Routine Upper Gastrointestinal Series Post-bariatric Surgery: Predictors, Usage, and Utility.

OBJECTIVE: To investigate usage and utility of routine upper gastrointestinal (UGI) series in the immediate post-operative period to evaluate for leak and other complications. METHODS: Single institution IRB-approved retrospective review of patients who underwent bariatric procedure between 01/08 and 12/12 with at least 6-month follow-up. RESULTS: Out of 135 patients (23%) who underwent routine UGI imaging, 32% of patients were post-gastric bypass (127) versus 4% of sleeve gastrectomy (8). In patients post-gastric bypass, 22 were found with delayed contrast passage, 3 possible obstruction, 4 possible leak, and only 1 definite leak. In patients post-sleeve gastrectomy, 2 had delayed passage of contrast without evidence of a leak. No leak was identified in 443 patients (77%) who did not undergo imaging. The sensitivity and specificity of UGI series for the detection of leak in gastric bypass patients were 100% and 97%, respectively, and the positive and negative predictive values were 20% and 100%, respectively. On univariate and multivariate analysis, sleeve gastrectomy patients (OR 0.4 sleeve vs bypass; P < 0.01) and male patients (OR 0.4 M vs F; P 0.02) were less likely to undergo routine UGI series (OR 0.4 M vs F; P 0.02). CONCLUSION: Routine UGI series may be of limited value for the detection of anastomotic leaks after gastric bypass or sleeve gastrectomy and patients should undergo routine imaging based on clinical parameters. Gastric bypass procedure and female gender were factors increasing the likelihood of routine post-operative UGI. Further larger scale analysis of this important topic is warranted.

Left Atrial Myxoma Embolization Presenting as Acute Limb Ischemia: An Unusual Presentation.

Cardiac myxomas are rare with reported incidences of less than 0.03%. Cardiac myxomas are most commonly observed in the left atrium. Their clinical manifestations vary and most are non-specific to the diagnosis. The most common extra-cardiac manifestations are thrombo-embolic infarcts from tumor embolization. A previously healthy 55-year-old man presented with findings suggestive of acute arterial limb ischemia. Following surgical treatment of his acute presentation, a left atrial mass was found on echocardiography suggesting that the embolization was secondary to a cardiac myxoma. The patient was discharged without complication. Embolic myxoma should be included in the differential in younger, previously healthy patients presenting with acute arterial limb ischemia without obvious cause. Our patient's dramatic presentation with a single acute event, however, prompted immediate treatment and resulted in a functional recovery with minimal complications.

Hidden Obligatory Fluid Intake in Critical Care Patients.

INTRODUCTION: In addition to the fluid intake in the form of intravenous maintenance or boluses in intensive care unit (ICU) patients, there are sources of fluids that may remain unrecognized but contribute significantly to the overall fluid balance. We hypothesized that fluids not ordered as boluses or maintenance infusions-"hidden obligatory fluids"-may contribute more than a liter to the fluid intake of a patient during any random 24 hours of critical care admission. METHODS: Patients admitted to the Harlem Hospital ICU for at least 24 hours were included in this study (N = 98). Medical records and nursing charts were reviewed to determine the sources and volumes of various fluids for the study patients. RESULTS: The mean hidden obligatory volume for an ICU patient was calculated to be 978 mL (standard deviation [SD]: 904, median: 645) and 1571 mL (SD: 1023, median: 1505), with enteral feeds compared to the discretionary volume of 2821 mL (SD: 2367, median: 2595); this obligatory fluid volume was affected by a patient's need for pressor support and renal replacement therapy. CONCLUSION: Hidden obligatory fluids constitute a major source of the fluid intake among patients in a critical care unit. Up to 1.5 L should be taken into account during daily decision making to effectively regulate their volumes.