Serial envenomation in a snake handler with severe coaguloapathy.

We present a rare case study of a 37-year-old man with a history of multiple prior snake bites who presented to the emergency department for treatment of a rattlesnake bite to his right hand. Upon examination, he was found to be mildly hypertensive and exhibited significant coagulation abnormalities. Initial treatment included six vials of Crotalidae polyvalent immune fab; however, his coagulopathy was so severe that he required an additional eight vials. Continuous monitoring and calculations of Snakebite Severity Score demonstrated resolution of coagulopathy within 36 hours of admission. We believe the patient's unusual recovery was likely due to an innate immune response, specifically an activated memory B-cell cascade. This case should lead researchers to consider that the resolution of severe coagulopathy might result from a memory-driven immune response in instances of multiple envenomations.

Two surgeons' collaboration to close an extreme open abdomen with loss of domain utilizing the abdominal dynamic tissue system and porcine urinary bladder matrix.

Acute open abdomen with loss of domain is an extremely difficult surgical scenario, and secondary complications are common. This case describes a 33-year-old woman who initially underwent an elective, laparoscopic endometrioma resection during which a complete iatrogenic transection of the left ureter and part of the sigmoid mesentery occurred. After discharge 5 days later, she was immediately readmitted for worsening abdominal pain. During the emergency abdominal reexploration, an ischemic, perforated sigmoid colon was removed and large volume paracentesis was performed due to fecal contamination. Nine additional reexplorations over 2 months resulted in an extreme acute open abdomen with loss of domain. Viscera was protected with negative pressure wound therapy, but primary myofascial closure was not feasible. Through surgical collaboration between two institutions, an abdominal dynamic tissue system was installed, which achieved primary myofascial closure 31 days after installation. Nine days later, complete wound closure utilizing porcine urinary bladder matrix was accomplished. This case highlights the successful achievement of primary myofascial closure and complete wound healing without a surgical site infection or hernia development in this heavily contaminated abdomen using dynamic tissue system biomechanics with porcine urinary bladder matrix biologics.

Autologous Skin Cell Suspension Application for Toxic Epidermal Necrolysis: A Case Report.

Toxic epidermal necrolysis (TEN) is a drug-mediated disease process that mimics a partial-thickness thermal injury. It has long been treated with frequent wound dressing changes and supportive care. There has been minimal efficacious systemic therapy. The pathophysiology is poorly understood but causes necrosis of keratinocytes at the dermal-epidermal junction leading to sloughing of the epidermis. The disease is rare with high mortality rates associated with long hospital stays. This case report describes the application of autologous skin cell suspension to a patient with TEN after antihypertensive and hyperglycemic therapy. This was associated with minimal wound care and efficacious arrest of patient disease process and timely closure of wound.

Laparoscopic colectomies associated with decreased retrieval of 12 or more lymph nodes compared to open in elective colon cancer surgery.

BACKGROUND: Colorectal cancer is the third most commonly diagnosed cancer worldwide. Lymph node (LN) retrieval is a key factor for pathologic staging and prognosis of colorectal cancer. Increase in number of LNs removal suggests improvement in tumour clearance and decrease in metastatic spread. Studies have suggested that excising 12 or more LNs during colectomy in patients with colon cancer is associated with improved survival. To date, there have been no studies to determine whether minimally invasive surgery affects the ability to retrieve 12+ LNs in elective colon cancer surgery. Therefore, we elected to determine whether a difference exists on the ability to retrieve 12+ nodes in elective colon cancer colectomies performed open versus laparoscopic. METHODS: The National Surgical Quality Improvement Program (NSQIP) Procedure Specific Colectomy database was analysed for the year 2014-2015. Inclusion criteria were colon cancer (ICD-9 Code 153.9), age greater than 18 years. Exclusion criteria were missing data. Data abstracted included patient demographics, type of operation performed and number of LNs retrieved. The patients were categorised based on their elective colon cancer colectomies such as laparoscopic or open. Binary logistic regression was used to identify confounding variables in the retrieval of 12+ LNs. RESULTS: After accounting for missing cases, a total of 18,792 patients with a diagnosis of colon cancer were analysed. Twelve or more LNs were retrieved in 88% (16,538) of patients, Among them, 2,516 patients underwent laparoscopic colectomy and 5,284 patients underwent open colectomy. The difference was not statistically significant for the average number of LNs retrieved among both the groups. Open operative approach compared to the laparoscopic approach was associated with 15% greater odds of retrieval of >12 LNs (OR 1.148; 95% CI (1.035-1.272); p = 0.008). CONCLUSION: The majority of colectomies such as open or laparoscopic are able to retrieve 12 or more LNs. However, there are greater odds of retrieving more than 12 LNs with the open approach compared to the laparoscopic approach. By allowing for more LN retrieval, open colectomies suggest improvement in tumour clearance and decrease metastatic spread. Additional research is needed to further investigate the specific factors influencing the ability to retrieve an adequate number of LNs, such as viewing angles provided with an open approach versus laparoscopic approach.

Porcine Urinary Bladder Matrix for Management of Infected Radiation Mastectomy Wound.

We present a case report on the successful healing of a Pseudomonas infection wound in a 52-year-old female with morbid obesity, noninsulin dependent diabetes mellitus and a history of tobacco use, who presented with Stage IIIA (T3, N2, Mo) infiltrating ductal carcinoma. The patient received neoadjuvant chemotherapy prior to her bilateral skin-sparing total mastectomies with right axillary sentinel lymphadenectomy. She also had staged reconstruction with temporary breast implants and plans for deep inferior epigastric perforator flaps. Two months after chest wall and regional nodal radiation therapy, she developed a marked soft tissue reaction to radiation. She underwent over 10 right chest wall open wound radical debridements resulting in a tissue defect of 25 cm in length, by 20 cm in width, by 10 cm in depth. Despite surgical debridement, intravenous antibiotics, hyperbaric oxygen therapy, colistin spray therapy, and heat lamp therapy, the infection failed to resolve and the wound failed to heal. She was left with an open wound that was extremely painful and required chronic pain management with opioids. The patient later was found to have developed a multidrug-resistant Pseudomonas infection in her wound. However, the experimental placement of a porcine bladder matrix (ACell©, Inc., Columbia, MD) on the wound resulted in the complete relief of pain just three days after the application of the product. After two weekly applications of ACell