Diabetic ketoacidosis in a postoperative gastric bypass patient.

We report a case of postoperative life threatening metabolic acidosis in a young Type-2 diabetic woman who had no history of diabetic ketoacidosis. The patient underwent a non-complicated laparoscopic Roux-en-Y gastric bypass 6 days earlier. We discuss her clinical features, pathogenesis, management and outcome. We would like to make the surgical field aware of this potentially fatal diabetic complication since bariatric procedures are now indicated for the management of diabetic m'orbid obesity and Type-2 diabetes prevalence is on the rise, particularly in young individuals.

Transaxillary endoscopic thyroidectomy: an alternative to traditional open thyroidectomy.

BACKGROUND: The traditional thyroidectomy technique typically approaches the thyroid through a range of different sized transverse incisions in the neck. Such a scar can result in hypesthesias, paresthesias, and increased patient self-awareness. Furthermore, in some patients of darker-skin ethnicity, the traditional neck incision can result in hyperplastic and keloid scar formation in a highly visible area of the neck. In an effort to lessen this adverse cosmetic outcome, we recently began performing endoscopic thyroidectomy, as described by Ikeda et al, using an axillary approach to conceal the incisions. We recently reviewed our series and studied the feasibility and safety of this approach in patients undergoing thyroidectomy. We herein present our results in the use of this procedure in all patients requiring thyroid resection and highlight the potential advantage in patients having a tendency for hypertrophic cervical scarring. From August 2003 to January 2008 we performed a transaxillary endoscopic thyroidectomy on 53 patients. Forty-one patients were of African descent. All patients underwent successful completion of thyroidectomy using this approach. CONCLUSIONS: Excellent aesthetic results with no visible scarring in the neck region can be safely achieved with this innovative surgical technique. Although the procedure has been shown to be of benefit to all patients, an added advantage may be seen in those patients prone to hypertrophic scarring. Transaxillary endoscopic thyroidectomy is a safe alternative to the traditional open approach in select patients with benign thyroid disease.

Surgical excision of large multinodular goiter using an endoscopic transaxillary approach: a case report.

BACKGROUND: Minimal access surgery for thyroid and parathyroid disease has gained increasing popularity due to excellent endoscopic visualization and overall cosmetic outcome. Most current techniques limit the size of the gland that can be removed to less than 4 cm. Patients with multinodular goiter with gland size greater than 4 cm commonly present for surgical therapy. We evaluated the use of an endoscopic transaxillary approach for the treatment of large multinodular goiters. We herein present a case report of 3 consecutive patients undergoing this technique for benign multinodular goiter disease. METHODS: Three consecutive patients with large multinodular goiter (>6 cm) were treated using a transaxillary endoscopic approach. RESULTS: All patients had successful endoscopic thyroidectomy using a transaxillary endoscopic approach. There were no recurrent nerve injuries. One patient had transient hypoparathyroidism that subsequently resolved after surgery. CONCLUSIONS: Transaxillary endoscopic thyroidectomy may be a viable option to open cervical thyroidectomy in the treatment of patients with large multinodular goiter. We herein present a case report of 3 consecutive patients undergoing this technique for benign multinodular goiter disease.

Endoscopic transaxillary near total thyroidectomy.

BACKGROUND: Since first reported in 1996, endoscopic minimally invasive surgery of the cervical region has been shown to be safe and effective in the treatment of benign thyroid and parathyroid disease. The endoscopic transaxillary technique uses a remote lateral approach to the thyroid gland. Because of the perceived difficulty in accessing the contralateral anatomy of the thyroid gland, this technique has typically been reserved for patients with unilateral disease. OBJECTIVES: The present study examines the safety and feasibility of the transaxillary technique in dissecting and assessment of both thyroid lobes in performing near total thyroidectomy. METHODS: Prior to this study we successfully performed endoscopic transaxillary thyroid lobectomy in 32 patients between August 2003 and August 2005. Technical feasibility in performing total thyroidectomy using this approach was accomplished first utilizing a porcine model followed by three human cadaver models prior to proceeding to human surgery. After IRB approval three female patients with histories of enlarging multinodular goiter were selected to undergo endoscopic near total thyroidectomy. RESULTS: The average operative time for all models was 142 minutes (range 57-327 min). The three patients in this study had clinically enlarging multinodular goiters with an average size of 4 cm. The contralateral recurrent laryngeal nerve and parathyroid glands were identified in all cases. There was no post-operative bleeding, hoarseness or subcutaneous emphysema. CONCLUSION: Endoscopic transaxillary near total thyroidectomy is feasible and can be performed safely in human patients with bilateral thyroid disease.

A prospective, randomized trial of Acticoat versus silver sulfadiazine in the treatment of partial-thickness burns: which method is less painful?

Despite recent improvements in analgesia, pain control during dressing changes continues to be a major challenge in patients with burns. We investigated two different dressing modalities to compare how much pain the patient experienced during and after the dressing change. Patients with partial-thickness burns that required only topical wound care were assigned randomly to treatment with Acticoat (Smith and Nephew USA, Largo, FL) or silver sulfadiazine (AgSD). The outcome variable was pain during wound care, which was measured using visual analog pain scores. The mean visual analog pain scores for the wounds treated with Acticoat or AgSD wounds were 3.2 and 7.9, respectively (P < .0001; paired Student's t-test). In 41 of the 47 paired pain score observations, the pain in the wound treated with AgSD was perceived as greater than in the wound treated with Acticoat. Burn wound care with Acticoat is less painful than burn wound care with AgSD in patients with selected partial-thickness burns.

Early injection of high-dose recombinant factor VIIa decreases blood loss and prolongs time from injury to death in experimental liver injury.

BACKGROUND: Recombinant factor VIIa (rFVIIa) is used for treatment of bleeding episodes in hemophilia patients who develop inhibitors to factors VIII and IX. We tested the hypothesis that administration of rFVIIa early after injury would decrease bleeding and prolong the time from injury to death after experimental hepatic trauma. METHODS: Anesthetized swine were cannulated for blood sampling and hemodynamic monitoring. Avulsion of the left median lobe of the liver induced uncontrolled hemorrhage. After a 10% reduction in mean arterial pressure, animals (n = 8 per group) were blindly randomized to receive intravenous rFVIIa 180 microg/kg, rFVIIa 720 microg/kg, or placebo. Pathologic examination of brain, lung, kidney, heart, and small bowel was performed to assess intravascular thrombosis. RESULTS Mortality during the first hour was 50% (four of eight) in controls versus 0% with rFVIIa 720 microg/kg (p = 0.02, chi2). Blood loss was decreased in the rFVIIa 720 microg/kg group versus the placebo group (13.2 +/- 5.5 mL/kg vs. 21.9 +/- 7.7 mL/kg;p = 0.0223). Time from injury to death was significantly prolonged in the rFVIIa 720 microg/kg group compared with placebo (116 minutes vs. 8.5 +/- 3.5 minutes; p= 0.02). No macro- or microthrombi in vital organs were identified on pathologic examination. CONCLUSION: Intravenous administration of high-dose rFVIIa early after induction of hemorrhage decreased bleeding and prolonged survival. No evidence of thrombosis in vital organs was observed.

Early use of recombinant factor VIIa improves mean arterial pressure and may potentially decrease mortality in experimental hemorrhagic shock: a pilot study.

BACKGROUND: Recombinant factor VIIa (rFVIIa) is used for treatment of bleeding episodes in hemophilia patients who develop inhibitors to factors VIII and IX. We tested the hypothesis that administration of rFVIIa early after injury would decrease bleeding and improve survival after experimental hepatic trauma. METHODS: Anesthetized swine were cannulated for blood sampling and hemodynamic monitoring. Avulsion of left median lobe of the liver induced uncontrolled hemorrhage. After a 10% reduction of mean arterial pressure, animals were blindly randomized to receive intravenous rFVIIa (180 microg/kg) (n = 6) or placebo (n = 7). RESULTS: Mortality was 43% (three of seven) in controls versus 0% with rFVIIa (p = 0.08, chi2). Significantly shorter prothrombin time and higher mean arterial pressures were observed in the rFVIIa group. CONCLUSION: Intravenous administration of rFVIIa early after induction of hemorrhage shortens prothrombin time and improves mean arterial pressure. A trend toward improved survival was observed.