Birth of the Beta-knife Thyroidectomy: The Radiance of Saul Hertz.

This is the story of how one man's life's work allowed for Iodine-131 (I-131) to become a therapy for hyperthyroidism and thyroid cancer. What is now a standard in our times arose from Saul Hertz's rather challenging and humble beginnings. Thyroid lobectomy and total thyroidectomy were therapeutic mainstays for thyroid disease until Hertz treated his first patient with radioactive iodine (RAI) ablation therapy at Massachusetts General Hospital (MGH) on March 31, 1941. His concepts for using beta particle emission from RAI to ablate thyroid tissue were revolutionary. Hertz's RAI therapy translated to research with thyroid cancer by the mid-1940s. The high-energy beta particles produced cytolethal effects on remnant thyroid tissue left behind by total thyroidectomy, thereby accomplishing completion thyroidectomy in some patients. Progressive surgeons from the Hertz era incorporated RAI into their practice. MGH surgery resident Francis Moore took sabbatical from clinical training to do translational research with RAI and other radioisotopes. Irving Ariel of New York became known as a nuclear surgeon in the wake of Hertz's work. George Crile Jr of Cleveland became an RAI advocate for the surgical community, implementing several paradigm-changing concepts in thyroid disease along the way. Hertz was a visionary who sparked this movement, predicting many of the molecular dilemmas with RAI-tumor avidity that clinical researchers continue to navigate today. This timely history for surgical oncologists and endocrine surgeons traces the development of RAI therapy through the life of Saul Hertz, a biographical window influenced by social stigma, political controversy, and mainstream media.

Traumatic abdominal wall hernia caused by a low fall.

BACKGROUND: Traumatic abdominal wall hernias (TAWH) are uncommon injuries classically associated with high-energy blunt traumatic mechanisms. Motor vehicle collisions cause the highest proportion of all TAWH. Literature is currently limited, with some debate existing over surgical management strategies. CASE PRESENTATION: A 67-year-old man presented after falling from a short step stool while landscaping his yard. On exam, an exquisitely tender lateral flank mass was present with peristaltic movement. CT imaging revealed a TAWH with incarcerated large and small bowel. He was taken to the OR for exploratory laparotomy and mesh hernia repair. The patient was discharged on the third postoperative day with no untoward complications. DISCUSSION: This patient's mechanism and injury pattern are together a rare combination. Exam findings and radiologic technologies are used to hone the clinical index of suspicion for TAWH. Traumatic abdominal wall defects can have unusual anatomic borders, not always obeying well-known hernia patterns. In this case, the potential space for visceral herniation was created by an 11th rib fracture with associated avulsion of the oblique musculature. Operative approach can be open or laparoscopic, however concomitant injuries directly influence surgical management. Evidence for mesh versus primary repair for TAWH is conflicted by the current literature. CONCLUSIONS: Nearly any amount of blunt abdominal force can cause TAWH. For wall defects with bowel herniation caused directly by trauma, the safest approach may involve exploratory laparotomy. Future multi-center studies may be able to distinguish TAWH repair strategies based on herniation through old defects versus newly-created abdominal wall injuries.

Evaluation and Management of Watercraft-Related Injuries for Acute Care Surgeons: Towards Improving Care and Implementing Effective Public Health Prevention Policies.

Boating has exposed humans to elemental hazards for centuries. What was once a lifelong craft and time-honored skillset is now, with modern technology, a popular recreational activity. Boating safety has inherent limitations and has been historically challenging to enforce. These circumstances have given way to a rising number of watercraft-associated injuries and fatalities. This review aims to investigate the diagnosis, work-up, and management of watercraft-related injuries, including blunt mechanisms, propeller wounds, water-force trauma, associated marine infections, and submersion injuries, as well as outline gaps in current public health policy on watercraft injuries, potential interventions, and available solutions. Motorboats and personal watercraft differ in size, power modality, and differential risk for injury. Accidents aboard watercraft often share commonalities with motor vehicles and motorcycles, namely: rapid deceleration, ejection, and collision with humans. The complexity of care is added by the austere environment in which many watercraft accidents occur, as well as the added morbidity of drowning and hypothermia. Wounds can also become infected by marine organisms, which require wound care and antimicrobial therapy specific to the aquatic environment in which the injury occurred. The treatment of these patients can be further exacerbated by the prolonged transportation times due to complicated water rescue. There are many measures that can prevent or abate watercraft injuries, but inconsistent regulations and enforcement may impair the success of these interventions. Further research is needed to identify possible solutions to common causes of watercraft injuries, such as inconsistent lifejacket use and bow riding.

Role of Emergent Nephrectomy for Grade V Blunt Renal Injuries.

BACKGROUND Blunt renal injuries constitute a small proportion of solid organ trauma cases. Many American Association for the Surgery of Trauma grade IV and V lacerations are manageable with volume resuscitation and angioembolization. In select cases, emergent nephrectomy can be beneficial to patients, with little associated morbidity. CASE REPORT In 2 separate cases, an 18-year-old man and a 21-year-old woman were brought to our center after sustaining blunt trauma to the left flank. They were both found to have isolated grade V renal lacerations with vascular compromise. Both initially had normal vital signs but became unstable. Active extravasation was visible on contrast-enhanced computed tomography scans, and the patients ultimately underwent exploratory laparotomy and nephrectomy on hospital day 1. Both of them recovered quickly, had no acute complications, and were discharged in <1 week. Follow-up over the course of 1 year showed no untoward sequelae. CONCLUSIONS These cases highlight the role of nephrectomy to mitigate life-threatening hemorrhage in unstable patients. While observation or angioembolization is the preferred approach for many renal injuries, emergent nephrectomy remains important for patients who do not respond to blood products and have rapidly deteriorating shock. In these patients, results of an initial trauma evaluation can be unclear because of concomitant splenic injury, as well as renal injuries with hemoperitoneum that are visible on focused abdominal ultrasonography for trauma. When forgoing immediate laparotomy, surgeons can use continuous noninvasive hemoglobin monitoring along with serial hemoglobin measurements and abdominal examinations. Laparotomy with nephrectomy results in limited morbidity when it is done expeditiously with ongoing volume resuscitation.

Multidisciplinary management of a traumatic posterior meningeal artery pseudoaneurysm: A case report and review of the literature.

BACKGROUND: Meningeal arterial injuries represent <1% of all blunt traumatic brain injuries (TBIs). Middle meningeal artery (MMA) lesions comprise the majority. However, there is little clinical data on posterior meningeal artery (PMA) injuries. CASE REPORT: A 69-year-old man was brought to our trauma center after sustaining a fall inside a warehouse. He was GCS (Glasgow Coma Scale) 3 on arrival. Non-contrast CT (computed tomography) brain showed subarachnoid hemorrhage with diffuse cerebral edema and a basilar skull fracture. The patient subsequently underwent emergency ventriculostomy. Immediately after the procedure, further imaging with CTA (computed tomography angiography) head identified a hyperintense posterior cranial fossa lesion, prompting cerebral angiography with identification and embolization of a traumatic PMA pseudoaneurysm. The patient improved and was discharged to a long-term acute care facility. At 3 months post-discharge, the patient was eating, talking with family, and working aggressively with physical therapy. DISCUSSION: This case represents a functional neurologic outcome from a rare subset of TBI. Early CTA head imaging is not supported by limited literature, but allowed for expedient identification and definitive management of this PMA pseudoaneurysm. In the critical care setting, hyperosmolar therapy, CSF (cerebrospinal fluid) drainage, prompt enteral nutritional support, and early tracheostomy all represent evolving evidence-based strategies to optimize care for severe TBI. CONCLUSIONS: The initial evaluation and management of severe TBI can be nuanced. Future research may refine indications for CTA head to the diagnostic evaluation of patients with both severe TBI and skull fractures.

Historical Observations on Clamshell Thoracotomy.

Bilateral transverse thoracosternotomy, known colloquially as "clamshell thoracotomy," provides quick and extensive exposure to the thoracic organs. The origins of the radical incision are unclear, and its influence on historical developments in surgery has not been elaborated. Transsternal extension to bilateral thoracotomy likely occurred during World War I and was designated as Tuffier's method by 1922. Théodore Tuffier had already solidified his reputation as a trailblazing thoracic surgeon in Paris when the French army summoned him to design triage systems for trauma patients during the Great War. Following World War II, cardiac surgery grew tremendously during the 1950s, and many pioneering open-heart procedures utilized the bilateral incision for safe exposures with satisfactory results. Median sternotomy became the incision of choice for open-heart surgery by the early 1960s; however, thoracotomy remained important to the trauma surgeon's repertoire. Transsternal conversion was only briefly mentioned in trauma literature through the 1980s, although up to one-half of reported emergency thoracotomies at busy trauma centers were clamshells. The moniker clamshell thoracotomy came in 1994 when thoracic surgical oncology and lung transplantation flourished with complex operations requiring larger incisions. The twenty-first century has brought two iterations of evidence-based guidelines for emergency thoracotomy, but incision choice has not been formally discussed. Renewed conversation in recent years has advocated for the clamshell as arguably the best approach for patients in extremis. Given these trends, the tortuous history of this controversial incision deserves attention.

Innominate Artery Ligation: A History From Mott to Matas.

Innominate artery ligation emerged in the 19th century as an early operation for right subclavian aneurysm. Clinical outcomes were often dire, but undeterred surgeons believed that ligation represented an opportunity that outweighed the risks of nonoperative aneurysm management. Valentine Mott of New York performed the procedure in 1818; his patient died 26 days later. Variations on Mott's approach were undertaken 13 more times from 1822 to 1861 by surgeons in the United States and abroad, all of which proved fatal. Andrew Woods Smyth of New Orleans was the first to successfully control a subclavian artery aneurysm with innominate ligation in 1864. The Charity Hospital house surgeon used a series of ligations on the innominate, common carotid, vertebral, and internal mammary arteries to prevent collateral and recurrent blood flow to the aneurysmal sac. These physiologically-oriented operations kept Smyth's patient alive and functional for ten years. New Orleans became an internationally-recognized hub for advancements in aneurysm surgery. One of Smyth's students, Rudolph Matas, went on to revolutionize vascular surgery. Along his path to becoming the Father of modern vascular surgery, Matas documented his own performance of Smyth's operation at Charity 4 times over the course of his career. Although later supplanted by primary vascular anastomosis and grafting, the first successful innominate ligation was a collaborative effort between New York and New Orleans that served as a foundation for the development of modern aneurysm repair.

Prophylactic Inferior Vena Cava Filters : Outcomes in Severely Injured Trauma Patients.

BACKGROUND: Patients with major trauma and contraindications to anticoagulation are often considered candidates for a prophylactic inferior vena cava filter (IVCF). Prophylactic IVCFs are controversial in trauma and backed by varying levels of evidence. This study aims to analyze outcomes in severely injured patients who receive IVCFs. METHODS: A retrospective review of trauma patients aged ≥ 16 years with ISS ≥ 15 admitted to our level 1 trauma center from years 2013 through 2018. Patients were divided into 2 groups: prophylactic IVCF versus VTE chemoprophylaxis. The analysis evaluated demographics, stratified by ISS (15-24, 25-34, ≥35), and subgrouped those with AIS-Head ≥3. Adjusted outcome measures included DVT, PE, mortality, and ICU length-of-stay (ICU-LOS). RESULTS: The study sample included 413 patients with prophylactic IVCFs and 2487 on VTE chemoprophylaxis. IVCF placement was associated with higher severity injuries: ISS 28 versus 25 and lower GCS 10.0 versus 11.8, TBI prevalence 83% versus 68% (P < .001). Patients with IVCFs had increased ICU-LOS (23.2 days vs 12.2 days), DVT (14.8% vs 4.3%), and PE (5.8% vs 1.6%) for patients with ISS <35 (P < .001). ISS ≥35 was not associated with intergroup DVT or PE rate differences (P = .81 and .43). No intergroup mortality differences were observed, including after ISS stratification. Among patients with AIS-Head ≥3, prophylactic IVCF was associated with lower in-hospital mortality (8.4% vs 15.7%, P = .001). CONCLUSIONS: Prophylactic IVCF placement was associated with higher rates of DVT and nonfatal PE, and prolonged ICU-LOS. Prophylactic IVCF placement was not associated with increased in-hospital mortality for severely injured trauma patients. Among patients with concomitant critical head injuries (AIS-Head ≥3), prophylactic IVCF placement was associated with lower in-hospital mortality than VTE chemoprophylaxis.

Timing of Prophylactic Inferior Vena Cava Filter Placement and Trauma Outcomes : Does Early Placement Matter?

BACKGROUND: Prophylactic inferior vena cava filters (IVCFs) are often placed in trauma patients who cannot receive prophylactic anticoagulation. IVCFs are utilized in an effort to reduce the risk of acute pulmonary embolism (PE) and mortality. This study aims to investigate whether time-to-filter placement is associated with differences in trauma outcomes. METHODS: We conducted a single-center retrospective review of adult trauma patients who underwent prophylactic IVCF placement. Patients were divided into 2 groups based on time-to-filter: 0-48 hours and >48 hours. Outcome measures included post-filter deep vein thrombosis (DVT), post-filter PE, in-hospital mortality, and ICU length of stay (ICU-LOS). Significance was defined as P < .05. RESULTS: During the 6-year study period, 513 patients underwent prophylactic IVCF placement. Both groups were similar with respect to injury severity score (ISS) (P = .540), percent of patients on home anticoagulation (38% and 39%, P = .845), abbreviated injury scale (AIS) by anatomic region (P = .899), and traumatic brain injury (TBI) prevalence (P = .182). Time-to-filter was not associated with significant differences in DVT, PE, or in-hospital mortality (P > .05 for all). Filter placement in the first 48 hours was associated with shorter ICU-LOS and hospital-LOS. CONCLUSIONS: Currently, there are no investigations in the trauma literature looking at the impact of time-to-filter on complications related to venous thromboembolism and potential survival benefit. Results of this investigation showed that IVCF placement within the first 48 hours was significantly associated with shorter ICU- and hospital- LOS.

Antithrombin Deficiency in Trauma and Surgical Critical Care.

Antithrombin deficiency (ATD) was described in 1965 by Olav Egeberg as the first known inherited form of thrombophilia. Today, it is understood that ATDs can be congenital or acquired, leading to qualitative, quantitative, or mixed abnormalities in antithrombin (AT). All ATDs ultimately hinder AT's ability to serve as an endogenous anticoagulant and antiinflammatory agent. As a result, ATD patients possess higher risk for thromboembolism and can develop recurrent venous and arterial thromboses. Because heparin relies on AT to augment its physiologic function, patients with ATD often exhibit profound heparin resistance. Although rare as a genetic disorder, acquired forms of ATD are seen with surprising frequency in critically ill patients. This review discusses ATD in the context of surgical critical care with specific relevance to trauma, thermal burns, cardiothoracic surgery, and sepsis.

Carbolic Acid before Joseph Lister: Rail Ties, Sewage, Manure, and the Great Stink.

Before Joseph Lister's landmark Lancet publications on the use of carbolic acid wound dressings in 1867, surgeons Jules Lemaire in France and Enrico Bottini in Italy had already used carbolic acid on hundreds of patients to control suppurative wounds. After Friedlieb Runge isolated it from coal tar in 1834, a number of scientists recognized the efficacy of carbolic acid in preventing decay and neutralizing the stench of dead animals and human cadavers. Frederick Calvert, Alexander McDougall, and Angus Smith in Manchester promoted a powdered form of carbolic acid as a deodorizing agent to treat municipal sewage across the United Kingdom, most notably during London's famous "Great Stink" of 1858. Edmond Corne in France introduced his formulation, which Alfred-Armand-Louis-Marie Velpeau, Ferdinand LeBeuf, and Lemaire adapted for clinical use in 1859. Lemaire wrote extensively on carbolic acid and its surgical application in three publications from 1860 to 1862. In 1866, Bottini published his experience of 600 cases where it was used. In 1865, Lister began to use carbolic acid in open fractures after Thomas Anderson, his colleague in agricultural chemistry at the University of Glasgow, told him about its use in Carlisle sewage works. This article traces the rich history of carbolic acid from an unknown compound in coal to the cornerstone of Listerism in late-19th-century operating rooms.

Superficial Stab Wound to Zone I of the Neck Resulting in Thyrocervical Trunk Pseudoaneurysm Presented as Recurrent Hemothorax and Successfully Managed by Coil Embolization.

BACKGROUND Thyrocervical trunk pseudoaneurysms are rare complications that have been documented after internal jugular or subclavian venous cannulation. Even less common, these pseudoaneurysms can arise after blunt or penetrating trauma. Clinical hallmarks include an expanding supraclavicular mass with local compressive symptoms such as paresthesias, arterial steal syndrome, and Horner's syndrome. Patients may be asymptomatic, however, or present with overlying ecchymosis or the presence of a new bruit or thrill. With the risk of rupture, thyrocervical trunk pseudoaneurysm is associated with significant morbidity and mortality. CASE REPORT We report the case of a 27-year-old man who presented after sustaining a self-inflicted stab wound to zone I of his neck. Initial examination revealed only a superficial small laceration, but a chest x-ray revealed a pneumothorax, and tube thoracostomy returned 300 mL of bloody output. After resolution of the hemothorax and removal of the thoracostomy tube, the patient reaccumulated blood, requiring a repeat tube thoracostomy. Angiography at that time revealed a pseudoaneurysm of the thyrocervical trunk, and coil embolization was performed to obliterate the pseudoaneurysm. CONCLUSIONS Thyrocervical trunk pseudoaneurysms can be asymptomatic, often have a delayed presentation, and can be life-threatening due to the risk of rupture and subsequent hemodynamic decline or airway compromise. While these pseudoaneurysms are well-known complications of deep penetrating injuries, they can also present following superficial penetrating injury to zone I of the neck. Selective angiography is the imaging modality of choice. Open surgical repair was traditionally the criterion standard for treatment; however, endovascular approaches are minimally invasive, feasible, and safer alternatives with reduced complications and are becoming more common.

Aggressive Crystalloid Resuscitation Outcomes in Low-Severity Pediatric Trauma.

BACKGROUND: Trauma is the leading cause of death among children. Studies have found that insufficient intravenous (IV) fluid resuscitation contributes significantly to morbidity and mortality in pediatric trauma. While large-volume resuscitation represents a potential solution, overly aggressive fluid management may complicate hospitalizations and recovery. Through this study, we aim to evaluate the impact of aggressive fluid resuscitation on outcomes in pediatric trauma. MATERIALS AND METHODS: This is a retrospective review utilizing our level I trauma center registry for pediatric patients aged <16 y admitted from 2014 to 2017. Patients transferred from our center within 24 h and those who arrived from outside hospitals were excluded. Patients who received blood product transfusions were excluded. Included patients were divided into two crystalloid groups: <60 mL/kg/24 h and ≥60 mL/kg/24 h. Outcome measures included ICU length-of-stay, length-of-hospitalization, complications, and mortality rate. RESULTS: Study sample included 320 patients (<60 mL/kg/24 h = 219; ≥60 mL/kg/24 h = 101). The ≥60 mL/kg/24 h group was younger (9.95 versus 5.27, P = 0.0001). There were no significant differences in GCS on arrival, injury severity score, Abbreviated Injury Scale, Revised Trauma Scores, traumatic brain injury, and operative intervention between groups. Outcome measures showed there was no significant difference in 30-day readmission rate, complications, or mortality. Large-volume crystalloid resuscitation was associated with longer mean ICU length-of-stay (1.5 d versus 0.8 d, P = 0.004). CONCLUSIONS: In this single-institution retrospective database analysis, large-volume crystalloid resuscitation (≥60 mL/kg) was associated with a significant increase in ICU length-of-stay without survival benefit. More research in the form of randomized trials will help determine the optimal rate for fluid resuscitation in pediatric trauma patients while weighing potential critical care complications.

Successful utilization of angioembolization and delayed laparoscopy in the management of grade 5 hepatic laceration: Case report and literature review.

INTRODUCTION: The liver is the most commonly injured solid organ in blunt abdominal trauma. Although the incidence of hepatic lacerations continues to rise, non-operative management with angioembolization is currently the standard of care. While active arterial hemorrhage is commonly embolized in grade 3 or 4 injuries, patients with grade 5 injuries frequently require operative intervention. PRESENTATION OF CASE: A 30-year-old man presented to our level I trauma center following a motor scooter accident. CT abdominal imaging revealed a grade 5 right lobar hepatic laceration. He underwent successful angioembolization without further hemorrhage. The patient later developed abdominal discomfort that worsened to peritonitis and he was taken for laparoscopic drainage of massive hemoperitoneum with bile peritonitis. Postoperatively, the patient's abdominal pain abated and he tolerated oral dietary advancement. DISCUSSION: Surgical management of blunt hepatic trauma continues to evolve in tandem with minimally invasive interventional techniques. Patients with high-grade lacerations are at higher risk for developing biliary peritonitis, hemobilia, persistent hemoperitoneum, and venous hemorrhage after angioembolization. Accordingly, the primary role of surgery has shifted in select patients from laparotomy to delayed laparoscopy to address the aforementioned complications. CONCLUSION: While laparotomy remains crucial for hemodynamically unstable patients, angioembolization is the primary treatment option for stable patients with hemorrhage from liver trauma. The combination of angioembolization and delayed laparoscopy may be considered in stable patients with even the highest liver injury grades.

Surgical management for an infected urachal cyst in an adult: Case report and literature review.

INTRODUCTION: Incomplete urachal obliteration during fetal development gives rise to distinct malformations of the median umbilical ligament. Most anomalies are asymptomatic and resolve during early infancy, but some go unrecognized until adulthood. These rare cases can present with acute abdominal symptomatology secondary to infected urachal remnants. PRESENTATION OF CASE: A 20-year-old man presented with periumbilical pain. Physical exam showed a warm, erythematous infra-umbilical mass that was tender to palpation. CT revealed an infected urachal cyst. The patient underwent urachal abscess incision and drainage with cyst excision. The patient returned home on postoperative day two. Two-week outpatient follow-up confirmed an uncomplicated recovery. DISCUSSION: Surgical excision of urachal anomalies in adults is curative and preventive against recurrent infection and malignancy, but preoperative management is currently unstandardized. Current literature recommends a two-stage approach characterized by preoperative antibiotics and cyst incision and drainage followed later by complete surgical excision. Our patient underwent a single therapeutic approach with preoperative antibiotics and definitive operative excision. Our patient had a comparable outcome with no complications and a short hospitalization. CONCLUSION: Preoperative antibiotics with excision of urachal remnants was effective in our case. Staged approaches are appropriate in complicated cases as a means to reduce post-operative infection rates and hospital stays. Urachal remnant excision is recommended in adults to prevent future malignancy.

Management of blunt intraperitoneal bladder rupture: Case report and literature review.

INTRODUCTION: Urinary bladder ruptures are an uncommon injury, occurring in less than 1% of all blunt abdominal trauma. Extraperitoneal bladder ruptures are generally associated with pelvic fractures and usually managed nonoperatively. Conversely, intraperitoneal injuries are often caused by large compressive and shear forces produced during seatbelt injuries and almost invariably require surgical intervention. PRESENTATION OF CASE: A 29-year-old woman presented as a trauma alert after a motor vehicle collision with abdominal/flank pain and gross hematuria. Free intraperitoneal fluid was found on ultrasound and CT imaging. Exploratory laparotomy located an intraperitoneal rupture across the bladder dome. The patient recovered without complications, was discharged on postoperative day three, and continued bladder catheter care at home for an additional week until outpatient follow up and catheter removal. DISCUSSION: As evidence for surgical management of bladder trauma continues to grow, clinical practice guidelines have been developed for trauma surgeons. Recent recommendations from the Eastern Association for the Surgery of Trauma appraise the evidence for cystography in the perioperative setting. Postoperative care is focused on preventing catheter-associated urinary tract infections in patients recovering from urotrauma in the critical care setting. CONCLUSION: We present a case of intraperitoneal bladder rupture in the setting of a blunt traumatic seatbelt injury. Our patient recovered uneventfully after surgical repair, a three-day hospitalization, and ten days with an indwelling bladder catheter.

Surgical care for ingested cocaine packets: Case report and literature review.

INTRODUCTION: Body packing is the use of intra-corporeal packages of illicit drugs for the purpose of smuggling, usually through customs. Clinical cases and experience with body packers has increased since the first report appeared in 1971. These cases remain an uncommon cause of acute drug toxicity and/or bowel obstruction. PRESENTATION OF CASE: A 23 year-old man was brought to the emergency department with seizures. CT imaging revealed numerous intestinal foreign bodies, suspicious for body packing. The patient was stabilized and taken emergently to the operating room for exploratory laparotomy and removal of 34 cocaine packets. Ongoing treatment for cocaine overdose was also utilized. The patient recovered without complications. DISCUSSION: This case provides insight and awareness for proper diagnosis and management of body packers by physicians and surgeons alike. CONCLUSION: We present a case report of acute cocaine intoxication in a young man who ingested 34 packets of cocaine for means of drug trafficking. Medical approaches are available for cases in which patients remain asymptomatic, but surgical intervention is necessary for those with signs and symptoms of bowel obstruction or drug overdose.

Pheochromocytoma-related cardiomyopathy presenting as broken heart syndrome: Case report and literature review.

INTRODUCTION: Pheochromocytoma are neuroendocrine tumors that arise from sympathetic chromaffin cells within the adrenal medulla. They principally secrete catecholamines, potentially causing life-threatening cardiovascular complications. A myriad of symptomatology and clinical findings are associated with pheochromocytoma, including a catecholamine-induced dilated cardiomyopathy. PRESENTATION OF CASE: A 50-year-old woman presented with retrosternal chest pain and underwent diagnostic evaluation for acute coronary syndrome. Cardiac catheterization demonstrated patent coronary arteries and a pattern of ventricular hypokinesis consistent with takotsubo cardiomyopathy, also known as broken heart syndrome. Further imaging with abdominal CT revealed an adrenal mass. Laboratory markers supported the clinical picture of pheochromocytoma. Right adrenalectomy was performed and our patient was symptom-free at discharge on post-operative day three. DISCUSSION: Alpha and beta adrenergic blockade are used in a critical care setting to prevent perioperative hemodynamic instability as well as catecholamine-induced heart failure in the setting of pheochromocytoma. Patients commonly require vasopressors in the postoperative period due to the rapid reduction in circulating catecholamines following resection. Discharge planning should include recommendations for genetic counseling to screen for syndromic causes of pheochromocytoma that increase the risk for other neoplasms. CONCLUSION: We present a case report of a rare adrenal tumor in a middle-aged woman that manifested as acute coronary syndrome. A presumptive diagnosis of takotsubo cardiomyopathy on cardiac catheterization led to further investigation. Abdominal imaging located an adrenal mass that correlated with laboratory studies positive for high levels of catecholamines and their metabolites. The tumor was excised and the patient recovered without complications.