Habib Rahman

Serotonin syndrome following methylene blue infusion during parathyroidectomy : a case report and literature review

Purpose: To report a case of autonomic, neurological and neuromuscular instability following methylene blue infusion for parathyroidectomy; to advance the argument for a diagnosis of serotonin syndrome; and to consider this diagnosis in previous, unexplained reports of adverse reactions amongst patients undergoing parathyroidectomy using methylene blue.Clinical features: Methylene blue was administered to a 58-yr-old woman undergoing a parathyroidectomy under general anesthesia. The patient had a background of obsessive compulsive disorder treated with paroxetine. Postoperatively, she demonstrated symptoms and signs of serotonin syndrome; specifically tachycardia, agitation, dystonia and abnormal eye movements. These clinical findings spontaneously resolved themselves over the subsequent 48 hr.Conclusion: An interaction between methylene blue and serotonergic agents may give rise to the serotonin syndrome. Consideration should be given to avoiding methylene blue in patients taking serotonergic agents. The diagnosis should be considered in patients with autonomic, neuromuscular or neurological changes and should be managed accordingly.RésuméObjectif: Présenter un cas d’instabilité autonome, neurologique et neuromusculaire suivant une perfusion de bleu de méthylène pendant une parathyroïdectomie ; développer les assises du diagnostic de syndrome sérotoninergique ; reconsidérer, à la lumière de ce diagnostic, des cas précédents de réactions indésirables inexpliquées chez des patients ayant subi des parathyroïdectomies et traités avec du bleu de méthylène.Éléments cliniques : Du bleu de méthylène a été administré à une femme de 58 ans subissant une parathyroïdectomie sous anesthésie générale. La patiente présentait des antécédents de troubles obsessionnels compulsifs traités avec de la paroxétine. Après l’opération, elle a présenté des symptômes et signes d’un syndrome sérotoninergique, spécifiquement: tachycardie, agitation, dystonie et mouvements oculaires anormaux. Ces observations cliniques se sont résolues spontanément durant les 48 h suivantes.Conclusion : Une interaction entre le bleu de méthylène et les agents sérotoninergiques pourrait provoquer un syndrome sérotoninergique. Il faudrait considérer l’option d’éviter le bleu de méthy-lène chez les patients traités avec des agents sérotoninergiques. Ce diagnostic devrait être envisagé chez les patients présentant des modifications autonomes, neuromusculaires ou neurologiques et ils devraient être pris en charge en conséquence.

Single-stage laparoscopic sleeve gastrectomy: safety and efficacy in the super-obese

BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is increasingly used as a single-stage bariatric procedure. However, its safety and efficacy in super-obese patients (body mass index [BMI] > 50 kg/m(2)) is less well defined. This series reports on 400 consecutive patients who underwent LSG at our institution, to evaluate safety and efficacy in the super-obese. MATERIALS AND METHODS We performed a retrospective review of prospectively collected data on 400 consecutive patients who underwent LSG at our institution. We analyzed baseline demographic data, median length of hospital stay, complications, length of follow-up, weight loss, and comorbidity resolution. We graded complications according to the Clavien-Dindo classification system. We classified patients as super-obese and non-super-obese and compared outcomes between groups. We used the two-tailed t-test and Fishers exact test as necessary. RESULTS There were 400 patients, 291 of whom were female (73%). The mean age was 44 y (standard deviation [SD] ± 9 y). The mean preoperative weight and BMI were 140 kg (SD ± 31 kg) and 49 kg/m(2) (SD ± 9 kg/m(2)), respectively. There were 67 complications (16%) in total. The major complication rate was 7.2%, with one recorded death. The median length of hospital stay was 3 d, and the mean follow-up period was 1 y. A total of 170 patients (43%) were super-obese, with a mean preoperative BMI of 56 kg/m(2) (SD ± 5 kg/m(2)). The mean absolute weight loss (59 versus 36.7 kg; P < 0.01) and percentage excess weight loss (58.9% versus 45.9%; P < 0.01) was significantly higher in the super-obese. The mean postoperative BMI for super-obese patients was 38.9 kg/m(2). There was no difference between groups in the incidence of major complications (8.2% versus 6.5%; P = 0.56). CONCLUSION Laparoscopic sleeve gastrectomy is safe and effective in the super-obese, with acceptable weight loss and no increase in the major complication rate.

The postoperative radiological features of laparoscopic sleeve gastrectomy

Obesity is rapidly becoming one of the major challenges for health care systems. Surgery has proved to be one of the most effective methods of helping patients to achieve sustainable weight loss.

Insulinoma and Tuberous Sclerosis: A Possible Mechanistic Target of Rapamycin (mTOR) Pathway Abnormality?

A 23-year-old New Zealand Māori male with tuberous sclerosis (TSC) and associated neurocognitive abnormalities presented with altered behavior and increasing seizure frequency. Endogenous hyperinsulinemia from an underlying insulinoma was confirmed and this was managed surgically. This case represents only the sixth description of insulinoma in TSC to date. The role of the hamartin–tuberin complex in regulation of the mechanistic target of rapamycin pathway provides a plausible pathogenetic mechanism between insulinoma and TSC. This rare disease association should be considered in TSC patients who present with otherwise unexplained worsening neurocognitive symptoms.

Pancreatic neuroendocrine tumour occurring with Guillian‐Barré syndrome

Pancreatic neuroendocrine tumours are rare tumours (<10%) arising from the islet cells. Non-functioning tumours in this category make up 15–50% of the total. While cancer has been noted to occur more frequently in patients with Guillian-Barré syndrome (GBS), this association is extremely rare. We report a case of a patient simultaneously diagnosed with a pancreatic neuroendocrine tumour and GBS. A 63-year-old woman presented with a 4-day history of acute on chronic back pain associated with 4 weeks of progressive numbness and tingling of lips, tongue, fingers, and toes. Computed tomography (CT) scan showed a 6-cm mass in the pancreatic tail (Fig. 1). Staging CT and magnetic resonance imaging showed no metastatic disease. She was formally reviewed by neurologist and diagnosed with GBS. She underwent distal pancreatectomy and splenectomy with no complications. No metastatic disease was seen intra-operatively. Histology showed a well-differentiated pancreatic neuroendocrine tumour, encapsulated by fibrous capsule, with tumour cells staining positive for synaptophysin and chromogranin. Microscopic invasion of the capsular lymphovascular spaces was noted but no extension beyond the capsule. No metastases were found in the 16 lymph nodes resected. Pancreatic islet cell tumours without specific clinical features were first described by Warren in 1926 and the term ‘nonfunctioning endocrine pancreatic tumour’ was first used by Zanetti in 1927. The difference between functioning and non-functioning tumours is that non-functioning are neoplasms with endocrine differentiation but are not associated with a clinical syndrome of hormone hyperfunction. Therefore, they often present late as large tumours. Presenting symptoms include abdominal pain, weight loss, pancreatitis, obstructive jaundice and distant metastases. In one series of 184 patients with non-functioning pancreatic endocrine tumours, 120 cases (65.2%) presented with symptoms while the remaining 64 cases (34.8%) had the tumour discovered incidentally. In general, patients with a cystic pancreatic tumour who are surgical candidates should have resection of the tumour. Surgery has therapeutic value as well as a diagnostic role. For patients who are borderline or clearly unfit for surgery, radiological-guided fine needle aspirate for fluid analysis and cytology may provide diagnostic and prognostic value. Prognosis in cases of pancreatic neuroendocrine tumour is good when associated with asymptomatic tumours, successful surgical resection, absence of metastases and small tumour size ( 3cm). This case is an example of how non-functioning pancreatic neuroendocrine tumours can be incidentally found in patients presenting with rare and unrelated disorders. Surgical exploration and resection remains the principle diagnostic and interventional modality for these tumours.

TS20P LAPAROSCOPIC REPAIR OF TRAUMATIC DIAPHRAGMATIC HERNIAE: A CASE PRESENTATION AND SYNTHESIS OF THE LITERATURE EXPERIENCE

Purpose  Traumatic diaphragmatic herniae are an uncommon sequelae of abdominal trauma which present a significant diagnostic challenge, especially when unaccompanied by other intraabdominal injuries necessitating exploratory laparotomy. Laparoscopic repair is a relatively new and uncommon procedure, with the literature consisting almost entirely of isolated case reports and small case series. We present one of our own cases, and perform a quantitative analysis of the combined literature experience to date.