Total thyroidectomy for amiodarone-associated thyrotoxicosis: should surgery always be delayed for pre-operative medical preparation?

OBJECTIVE: Amiodarone can induce severe hyperthyroidism that justifies its withdrawal and the introduction of antithyroid drugs. Continuing amiodarone use, failure to control hyperthyroidism and poor clinical progress may require thyroidectomy. This study aimed to evaluate patients' post-operative development and mid-term outcome after thyroidectomy for amiodarone-associated thyrotoxicosis. STUDY DESIGN: Prospective case series. SETTING: Tertiary care centre. SUBJECTS AND METHODS: We prospectively collected cases of amiodarone-associated thyrotoxicosis requiring thyroidectomy due to failure of antithyroid treatment, despite amiodarone discontinuation. Post-thyroidectomy complications were compared immediately, 30 days and one year post-operatively, and also for scheduled versus emergency surgery cases. RESULTS: Of 11 total cases, nine scheduled thyroidectomy cases had no morbidity after elective surgery. Two cases required emergency surgery for multiple organ failure and cardiac problems. Immediate post-operative complications (mostly haemodynamic) occurred in both cases (emergency vs routine surgery, p = 0.018). CONCLUSION: In such cases, pre-operative medical treatment is vital to limit peri- and post-operative complications, but surgery should not be delayed if the haemodynamic status deteriorates. Surgery, with careful anaesthesia, is the cornerstone of the treatment.

Lessons learned from the experience of visceral military surgeons in the French role 3 Medical Treatment Facility of Kabul (Afghanistan): an extended skill mix required.

OBJECTIVE: To evaluate the activity of visceral surgeons assigned to the Medical Treatment Facility (MTF) (role 3) in Kabul International Airport (KAIA) and identify the skills and qualifications required by these specialists. PATIENTS AND METHODS: Between July 2009 and December 2010, all the patients operated by the visceral surgeons were eligible for inclusion in this study. They were International Security and Assistance Force (ISAF), Afghan National Security Forces (ANSF) soldiers, non-afghan civilians personnel and local nationals (LNs). They sustained war-related injuries, non-war related trauma emergencies, non-trauma related emergencies or had elective surgical care. The mechanisms and types of injuries, the affected organs and the surgical procedures were collected. RESULTS: Over the period of study, the visceral surgeons treated 261 over 971 patients (26.9%) achieving a total of 438 surgical procedures. Thirty one percent of these procedures were war-related, 26% non-war related, 24.2% non-trauma related emergencies and 18.1% elective surgery. Non-trauma related emergencies and elective surgery required the same skills as in civilian practice. War-related injuries and non-war related trauma emergencies were more challenging. Combined injuries represented 56% of the cases requiring damage control resuscitation procedures and/or treatment of severe burns. Life-threatening thoracic or vascular injuries (30%) required life-saving emergency surgical procedures. CONCLUSION: A visceral surgeon in a role 3 MTF should master a wide range of skills and expertise to be able to deal with many complex situations, in particular life-threatening situations such as thoracic and vascular wounds. A comprehensive surgical training programme for surgeons in abroad deployment (Advance Course for Deployment Surgery - CACHIRMEX) has been designed and settled up in 2007 to provide these necessary skills. The feedback obtained from each previous deployment demonstrates that the advanced course for deployment surgery provides visceral surgeons the necessary skills required to deliver surgical healthcare in a role 3 MTF. However, a regular assessment of this programme is mandatory to ensure that this training stays appropriate and contributes to better outcomes and a decreased mortality rate.

Double Sigmoid colon perforation due to migration of a biliary stent.

Migration of pancreatico-biliary stents is a rare event, usually benign, but which can lead to severe complications such as digestive tube perforation. We report the case of a patient with double sigmoid perforation due to distal migration of a biliary stent placed to decompress a pancreatic head carcinoma.

[Cavernous hemangioma: rare incidentaloma of the adrenal gland]. / L'hémangiome caverneux : un incidentalome rare de la surrénale.

The hemangioma of the adrenal gland is an adrenal gland lesion rare, benign and usually asymptomatic. Discovered incidentally during an abdominal imaging study, it is part of incidentalomas. Imagery is the best to characterise these silent adrenal masses (computed tomography [CT], Magnetic Resonance Imaging [MRI]± Positron Emission Tomography [PET scan] with 18F-FDG). The main risks of the hemangioma are ignorance of malignancy, bleeding and abdominal mass syndrome. The analysis of the literature shows the importance of laparoscopy. A multidisciplinary discussion on this type of lesion appears indispensable both diagnostic and therapeutic.

[Chronic compartmental syndrome. a review of 234 patients]. / Le syndrome chronique des loges. À propos d'une série de 234 patients opérés.

OBJECTIVE: Diagnosis of chronic compartment syndrome of the lower leg, which occurs in a young and athletic population, is often delayed. We studied postoperative outcomes after fasciotomy in patients with compartment syndrome in order to identify specific postoperative complications. Long-term functional outcomes were also evaluated. METHODS: All patients with a diagnosis of chronic exercise-related compartment syndrome of the lower leg who underwent surgery from January 1985 to August 2009 were studied prospectively. The type of compartment and whether surgery was uni or bilateral was recorded. One year after surgery, patients completed a questionnaire to evaluate their functional outcome. RESULTS: Two hundred and thirty-six compartment procedures were performed in 234 patients. Only one compartment (constantly the superficial posterior compartment) was treated in 56/236 (23.7%) procedures. Two compartments (anterior and lateral) were involved in 90/236 procedures (38.1%). Three compartments (anterolateral and superficial posterior) were noted in 74/236 procedures (31.4%) and four compartments (anterolateral and superficial and deep posterior) were described in 6.8%. Involvement of the deep posterior compartment was always associated with another compartment. Surgery was bilateral in 70% of patients. The questionnaire response rate was 65%. The success rate of fasciotomy was 68.4% and a significant improvement was reported by 23.9% of responders; outcome was unsatisfactory for 7.7%. CONCLUSIONS: The diagnostic criteria used to confirm chronic exercise-related compartment syndrome of the lower leg were based on the compartment pressure measurement after exercise. In this study, all patients underwent fasciotomy. The surgical technique was standardized. Outcomes have been satisfactory with few surgical complications.

[Giant retroperitoneal hydatid cyst in a traveller]. / Kyste hydatique rétropéritonéal géant chez un voyageur.

INTRODUCTION: Giant hydatid cyst located in the retroperitoneal space is rare. The purpose of this report is to present a case cured by surgery in an adult traveller. CASE REPORT: In August 2009, a 67-year-old female who traveled frequently to Lebanon was admitted for assessment of a giant retroperitoneal hydatid cyst discovered coincidentally following palpation of an abdominal mass in 1997. From 1966 to 1975, the patient had undergone several surgical procedures for pulmonary and hepatic hydatidosis, complicated by vomica and anaphylactic shock. In 1997, computed tomography showed that the retroperitoneal cyst measured 100 mm at the widest point. At that time, the patient refused to undergo further surgery and was treated medically using albendazole initially in association with praziquantel. In 2009, the cyst had expanded to 180 mm at the widest point and the patient finally consented to perikystectomy. Excision was total and recovery was uneventful. Histology examination confirmed the viability of the cyst. Follow-up examination at 12 months indicated no relapse. COMMENTS: The retroperitoneal space is a rare location for hydatidosis. Occurrence in this location is generally primary. In case of discovery of a liquid-filled retroperitoneal mass, a history of travel to an endemic area for hydatid disease should be elicited. Diagnosis relies on radiological findings and positive serology. Since retroperitoneal cysts are often giant, they respond poorly to medical treatment. Similarly radiological treatment is difficult due to retroperitoneal location. Surgery, preferably perikystectomy, is the treatment of choice.

[Role of self-expanding stent in the treatment of obstructing colorectal cancer]. / L'endoprothèse dans l'occlusion colique tumorale.

BACKGROUND: Obstruction due to colorectal cancer is a common occurrence. It often arises in patients in poor general condition with malnutrition and advanced tumor stage. Prognosis can be improved by prompt resolution of obstruction through a mininimally invasive approach. GOAL: To analyze the management of cases of acute colorectal obstruction and evaluate the efficacity and morbidity/mortality associated with the use of endocolic stent prostheses. MATERIAL AND METHODS: This retrospective study at a single center evaluated patients presenting with acute colorectal obstruction between January 2003 and May 2008, assessing the patient sample, cancer characteristics, treatment, and morbidity/mortality. RESULTS: The mean age of the 26 patients was 75 years; ASA Class was greater than III in 63% of cases, The colorectal cancer was located in the sigmoid in 65% of cases and was a Stage IV tumor in 73% of cases. Placement of an endocolic stent was the primary intervention in 94% of patients. Morbidity was 12% and mortality was 4%. CONCLUSION: Colonic stenting is an effective therapeutic option in the elderly with painful symptoms of obstruction and should be the initial approach.

[Seizure and Bourneville tuberous sclerosis: think about insulinoma]. / Crise comitiale et sclérose tubéreuse de Bourneville: penser à l'insulinome.

Bourneville tuberous sclerosis is a phacomatosis characterized by skin, neurological and ophthalmological lesions. At first, seizure can reveal cerebral lesions, but other causes may be suspected. We report a case of a Bourneville tuberous sclerosis in a 41-year-old-man with hypoglycemia leading to seizures, resulting from an insulinoma.

[Desmoid tumors]. / Les tumeurs desmoïdes.

Desmoid tumors are a rare form of malignancy with a great propensity for local extension and recurrence. They typically occur in the abdominal wall or within the abdomen but also may occur extra-abdominally. Most cases are sporadic but traumatic, hormonal, and genetic etiologies have been implicated. The only curative treatment is wide surgical excision, but the risk of local recurrence is high. Several adjuvant or complementary treatments have been proposed and the results show promise; the authors review all these therapies.

[Acute superior mesenteric vein thrombosis. A retrospective study of 9 patients]. / Thrombose aiguë de la veine mésentérique supérieure. Etude rétrospective de neuf cas.

AIM OF THE STUDY: To determine diagnostic modalities and both immediate and long-term treatment of superior mesenteric venous thrombosis. PATIENTS AND METHODS: Retrospective study from 1997 to 2004 in two institutions concerning patients with superior mesenteric vein thrombosis. RESULTS: Nine patients (all males, mean age=55 years), were included. Abdominal pain (100%), vomiting (44%), and bowel activity disorders (44%) were the most common symptoms. A personal or familial thrombosis history was present in 67% of patients. A genetic predisposing factor of thrombosis was present in 78% of patients. The diagnosis was established with CT-scan in 8 cases with a mean delay of 8 days. Treatment was exclusively medical in 33% of patients and included surgery in 67%. All operated patients underwent resection for bowel infarction and only one had immediate anastomosis. All enterostomies were subsequently closed. No patient died. CONCLUSION: Diagnosis of superior mesenteric vein thrombosis is frequently delayed and relies on CT-scan with intravenous contrast. Prognosis is globally favourable but depends on early application of anticoagulation therapy. In case of surgery, bowel-sparing resection is indicated and enterostomies are often needed. Genetic disorders predisposing to thrombosis are very frequent, that may indicate prolonged even definitive anticoagulation therapy.

The anticancer drug mithramycin A sensitises tumour cells to apoptosis induced by tumour necrosis factor (TNF).

In this report we show that mithramycin considerably increases the direct cytotoxic effect of tumour necrosis factor (TNF) on tumour cells in vitro. Sensitisation to TNF-induced apoptosis was prevented by the broad caspase inhibitor zVAD-fmk, whereas overexpression of Bcl-2 had no effect. Mithramycin also potentiated cell death induced by Fas agonistic antibodies. In contrast, mithramycin reduced the percentage of cells undergoing apoptosis due to factor withdrawal. TNF-induced activation of NF-kappaB (NF-kappaB)-dependent gene expression was not modulated by mithramycin treatment. Concomitantly with the increased sensitivity, the protein level of the short-spliced cFLIP variant was downregulated. These results indicate that mithramycin enhances TNF-induced cell death in an NF-kappaB-independent manner, and suggest that the Fas-associated death domain protein plays a crucial role in the TNF-sensitising effect of mithramycin.

[Blunt force rupture of the thoracic aorta and diaphragm: an unusual association]. / Rupture de l'isthme aortique et de la coupole diaphragmatique droite: une association inhabituelle.

The aim of this study was to report two cases of rupture of the right hemidiaphragm with intra-thoracic liver hernia, associated with a traumatic aortic disruption. These two lesions followed traffic accidents, and were both treated separately. Both patients had a long-term favourable progression. Association of these two lesions is particularly rare: fewer than 50 cases have been previously described in an extensive review of the literature. CT-scan seems to be particularly efficient in diagnosis, even if less efficient than other more specific explorations. The order of surgical management is guided by the physical examination, and especially by abdominal emergency.

[Black esophagus associated with hypothermia]. / Oesophage noir associé à une hypothermie.

The authors report a clinical case concerning a necrotizing esophagitis following severe hypothermic shock. They recall the usual aetiology of the "black esophagus", emphasize the importance of ischemia and the multispeciality management of this very unfrequent disease.

Regulation of MVM NS1 by protein kinase C: impact of mutagenesis at consensus phosphorylation sites on replicative functions and cytopathic effects.

Minute virus of mice NS1, an 83-kDa mainly nuclear phosphoprotein, is the only viral nonstructural protein required in all cell types and it is involved in multiple processes necessary for virus propagation. The diversity of functions assigned to NS1, together with the variation of its complex phosphorylation pattern during infection, suggested that the various activities of NS1 could be regulated by distinct phosphorylation events. So far, it has been demonstrated that NS1 replicative functions, in particular, DNA-unwinding activities, are regulated by protein kinase C (PKC), as exemplified by the modulation of NS1 helicase activity by PKClambda phosphorylation. In order to determine further impact of phosphorylation on NS1 functions, including the induction of cytopathic effects, a mutational approach was pursued in order to produce NS1 variants harboring amino acid substitutions at candidate PKC target residues. Besides the determination of two additional in vivo phosphorylation sites in NS1, this mutagenesis allowed the segregation of distinct NS1 functions from one another, generating NS1 variants with a distinct activity profile. Thus, we obtained NS1 mutants that were fully proficient for trans activation of the viral P38 promoter, while being impaired in their replicative functions. Moreover, the alterations of specific PKC phosphorylation sites gave rise to NS1 polypeptides that exerted reduced cytotoxicity, leading to sustained gene expression, while keeping functions necessary for progeny virus production, i.e., viral DNA replication and activation of the capsid gene promoter. These data suggested that in the course of a viral infection, NS1 may undergo a shift from productive to cytotoxic functions as a result of a phosphorylation-dependent regulation.