Prolonged Hypercupremia after Laparoscopic Vertical Sleeve Gastrectomy Successfully Treated with Oral Zinc.

A 30-year-old female underwent vertical sleeve gastrectomy. Postoperatively, hypercupremia and elevated ceruloplasmin were identified. Further testing revealed normal blood levels of transaminases, alkaline phosphatase, and albumin. She stopped ingestion of multivitamins, began a copper-free multivitamin, and then began a low copper diet, but with no improvement in hypercupremia. Protein electrophoresis was normal with no M-spike. Urinary copper excretion was normal at 0.24 micromol/24 hours (normal: < 0.55), and there were no Kayser-Fleischer rings on slit lamp examination. Two years postoperatively, she lost 44% of excess preoperative weight and she began zinc sulfate before meals twice daily (115 mg elemental Zinc/day). At 2 months and 8 months later, plasma copper and ceruloplasmin had essentially normalized. Increased production of ceruloplasmin could have been a response to significant weight loss or the presence of nonalcoholic steatohepatitis. The mechanism of zinc's beneficial effect is uncertain but may be related to suppressing hepatic synthesis of or secretion of ceruloplasmin.

Extremity Vascular Injury Management: Good Outcomes Using Selective Referral to Vascular Surgeons.

Revascularization after extremity vascular injury has long been considered an important skill among trauma surgeons. Increasingly, some trauma surgeons defer vascular repair in response to training or practice patterns. This study was designed to document results of extremity revascularization surgery to evaluate trauma surgeon outcomes and judicious referral of more complex injuries to vascular surgeons (VAS). The trauma registry of an urban level I trauma center was used to identify all patients from 2003 to 2013 who underwent an early (<24 hours) procedure for urgent management of acute injury to extremity vessels. Patients were managed by trauma (TRA) versus VAS based on the practice pattern of the on-call trauma surgeon. Injury and outcome variables were recorded. Of 115 patients, 84 patients were revascularized by trauma and 31 vascular surgeries. There was no difference in complication rates or frequency of any type of complication associated with repairs performed by VAS or TRA. There were similar rates between the two groups for patients with multiple injuries, such as venous, bone or tendon, and nerve injury to the affected extremity. One VAS patient and two TRA patients developed compartment syndrome. In appropriately selected patients, trauma surgeons achieve good outcomes after revascularization of injured extremities.