Implications of a background of Hashimoto's thyroiditis on the current conservative surgical trend towards papillary thyroid carcinoma.

The purpose is to delineate the clinico-pathologic features of papillary thyroid carcinoma (PTC) occurring in a background of Hashimoto's thyroiditis (HT). A retrospective analysis of consecutive PTC patients who underwent surgery at an academic center between Jan. 2010 and Jan. 2020 was performed. The primary end point was to assess whether a background of HT implied a higher likelihood for postoperatively determined high-risk histopathologic features. Accordingly, its implication on initial surgical planning. Tumor high-risk features included aggressive histologic variants, lymphovascular invasion, extrathyroidal extension, multifocality, and positive nodal metastasis. To achieve the primary outcome of interest, a two group-designation was followed: group A (none-HT-group) and group B (HT-group). The two groups were also compared regarding postoperative complications as a secondary outcome of interest. In the specified period, 331 patients were found to have a histologically proven diagnosis of PTC. Group A accounted for 80% (265/331) of the study cohort, while group B accounted for the remainder 20%. PTC was significantly more prevalent in the absence of HT (p < 0.0001). Both groups were comparable in mean-patient-age. However, Group B demonstrated a considerably higher male:female ratio (1:10 vs. 1:3; p = 0.01). All postoperatively determined high-risk histopathologic features were comparable in both groups (p > 0.05). Nevertheless, transient hypoparathyroidism was considerably higher in group B (12% vs. 23%; p = 0.02). A background of HT does not seem to reflect a more aggressive cancerous biologic behavior. Therefore, it should not preclude the conservative surgical strategy adopted by the most recent clinical practice guidelines.

Cutaneous Myiasis Around Gastrostomy (PEG) Tube Insertion Site: The Second Case Report.

BACKGROUND: Myiasis refers to the infestation of live human with 2-winged larvae (maggots). Cutaneous myiasis is the most commonly encountered clinical form. It is divided into 3 main forms: furuncular, creeping (migratory), and wound (traumatic) myiasis. CASE REPORT: In this article, we report an extremely rare case of myiasis around percutaneous endoscopic gastrostomy (PEG) tube in a 71-year-old female patient. She had the tube placed for feeding purposes, 8 months prior to her presentation. Family noticed alive worms emerging from skin at the gastrostomy tube insertion site. Patient was treated conservatively with daily dressing with no debridement or use of systemic agents. CONCLUSIONS: PEG tube cutaneous myiasis is an extremely rare disease. Conservative management with petroleum-based and sterilizing agents is shown to be efficient to clear the disease in a short period of time.

Portomesenteric Venous Thrombosis Post-Laparoscopic Sleeve Gastrectomy: Do Energy Systems Pose as Instigating Factor to This Infrequent Complication?

BACKGROUND: Portomesenteric venous thrombosis (PMVT), a rare complication after laparoscopic sleeve gastrectomy (LSG). Severe consequences are owed to a high risk of bowel ischemia. Our aim is to present a series of patients who developed PMVT after LSG, highlighting the potential role of the vessel sealer and divider as a risk factor. METHODS: Medical records of seven patients who underwent LSG and developed PMVT from April 2010 to January 2019, at King Abdullah University Hospital and Jordan University Hospital, Jordan were reviewed. Our findings were studied, audited, and compared with published data. RESULTS: A sum of 4900 patients underwent LSG, 7 (0.14%) developed PMVT. The mean age and body mass index (BMI) were 36.8 years and 45 kg/m2, respectively. Four were women. Epigastric pain radiating to the back was the presenting symptom at a median time of 9 days after surgery. Computed tomography (CT) of the abdomen confirmed the diagnosis. Five patients presented with a total portal vein thrombosis (PVT), one with splenic vein thrombosis and one with dual portal and mesenteric vein thrombosis. CONCLUSION: Portomesenteric venous thrombosis is a relatively uncommon complication following LSG. Early recognition is required to avoid catastrophic outcomes. The role of energy systems in the development of PMVT remains unknown and requires further elaboration.

Trends of Gallbladder Cancer in Jordan Over 2 Decades: Where Are We?

BACKGROUND AND STUDY AIMS: The prevalence of gallbladder cancer (GBC) varies between different parts of the world. This study is a review of literature and an update of a previously published study conducted in our university and aims to reassess the incidence of GBC over the past 2 decades. PATIENTS AND METHODS: We conducted a retrospective study between 2002 and 2016. Data regarding demographics, clinical presentation, risk factors, histopathology, investigations, and treatments were obtained. A diagnosis of GBC established during surgery or primarily detected in the surgical specimen was classified as incidental. RESULTS: Of 11 391 cholecystectomies performed, 31 cases (0.27%) of GBC were found. The mean age of patients with GBC was 68 years (43-103 years), 74% were women. The annual incidence of GBC was 0.2/100 000 (men: 0.1/100 000; women: 0.3/100 000). Biliary colic and acute cholecystitis were the main presentations. Diagnosis of GBC was "incidental" in 67% of cases. About 75% of patients with GBC had gallstones, 13% had polyps, and 3% had porcelain gallbladder. Adenocarcinoma was the dominant (87%) histologic type. CONCLUSIONS: The GBC rate in our region, similar to others parts of the world, is still low and has not changed over the past 2 decades. This study consolidates the previously published recommendations regarding the high index of suspicion of GBC in elderly with cholelithiasis.

Passage of Gallstones Into Common Bile Duct During Laparoscopic Cholecystectomy: Is It the Surgeon's Responsibility?

PURPOSE: Gallstones patients without preoperative history of jaundice, deranged liver function tests, or dilated bile ducts (BD) are unlikely to have BD stones. However, some of these patients in our series underwent endoscopic stone(s) removal after laparoscopic cholecystectomy (LC). We aim to find the incidence, possible intraoperative risk factors, and if the Surgeon can be blamed for this event. MATERIALS AND METHODS: We studied LC cases over 12-year period at our university hospital and identified patients who did not have preoperative risk factors for BD stones but developed postoperative jaundice and/or persistent abdominal pain. RESULTS: Only 16 (0.7%) of 2390 LC met the inclusion criteria. In 5/16 patients, cystic duct (CD) stones were felt Intraoperatively and likely passed into BD during surgery. After surgery, 14/16 patients underwent endoscopic stone(s) removal. CONCLUSIONS: If CD stone(s) are encountered during LC, we suggest that careful attention should be paid to make sure that patient does not develop complications from possible BD stone(s). Technical precautions during LC (ie, early CD clipping, avoiding excessive manipulation, and crushing the stones) are recommended.

Reproducibility of gallbladder ejection fraction measured by Fatty meal cholescintigraphy.

PURPOSE: There are conflicting data in the literature regarding the reproducibility of the gallbladder ejection fraction (GBEF) measured by fatty meal cholescintigraphy (CS). We aimed to test the reproducibility of GBEF measured by fatty meal CS. METHODS: Thirty-five subjects (25 healthy volunteers and 10 patients with chronic abdominal pain) underwent fatty meal CS twice in order to measure GBEF1 and GBEF2. The healthy volunteers underwent a repeat scan within 1-13 months from the first scan. The patients underwent a repeat scan within 1-4 years from the first scan and were not found to have chronic acalculous cholecystitis (CAC). Our standard fatty meal was composed of a 60-g Snickers chocolate bar and 200 ml full-fat yogurt. RESULTS: The mean ± SD values for GBEF1 and GBEF2 were 52 ± 17% and 52 ± 16%, respectively. There was a direct linear correlation between the values of GBEF1 and GBEF2 for the subjects, with a correlation coefficient of 0.509 (p = 0.002). Subgroup data analysis of the volunteer group showed that there was significant linear correlation between volunteer values of GBEF1 and GBEF2, with a correlation coefficient of 0.473 (p = 0.017). Subgroup data analysis of the non-CAC patient group showed no significant correlation between patient values of GBEF1 and GBEF2, likely due to limited sample size. CONCLUSIONS: This study showed that fatty meal CS is a reliable test in gallbladder motility evaluation and that GBEF measured by fatty meal CS is reproducible.

Laparoscopic splenectomy: consensus and debatable points.

INTRODUCTION: The emergence of minimally invasive techniques has broadened interest in splenectomy for a variety of haematological illnesses. Laparoscopic splenectomy (LS) is currently considered the gold standard for the treatment of various haematological disorders. PURPOSE: The literature was reviewed to highlight points of consensus and debatable points regarding best practice in LS, looking at issues such as bleeding and conversion, splenomegaly, splenic retrieval techniques, types of instruments used, hand-assisted LS (HALS), complications, approaches, accessory spleen and splenosis. Our goal was to share our experience with LS and compare it with other reports. BACKGROUND: LS has emerged as the standard of care for elective splenectomy for benign haematological diseases. However, doubts have been raised regarding the suitability of patients with splenomegaly for LS. There is also uncertainty about its efficacy in major trauma. HALS has emerged as an option for safe manipulation and splenic dissection. METHOD: We performed 25 consecutive LSs at King Abdullah University Hospital (KAUH), Jordan, from 2001 to 2008. Patient demographics, operative time, intra- and postoperative complications, conversion rate, additional procedures and length of hospital stay were retrospectively reviewed. RESULTS: The mean age of the patients was 38.8 years (range 11-77 years), mean operative time was 132 minutes (90- 170 minutes), and length of hospital stay was 2.9 (standard deviation 2.7) days. One case was converted to open surgery (5%). There was 1 case of superficial wound infection in the series (5%), and no deaths. CONCLUSION: LS is a well- accepted minimally invasive procedure, but knowledge and skill are required to perform it with minimal morbidity and mortality.

Usefulness of fatty meal-stimulated cholescintigraphy in the diagnosis and treatment of chronic acalculous cholecystitis.

OBJECTIVE: Fatty meal cholescintigraphy (fatty meal CS) is a potential physiologic alternative for cholecystokinin (CCK) CS in the diagnosis and treatment of chronic acalculous cholecystitis (CAC). However, there are limited data in the literature to support this assumption. Our objective was to determine the usefulness of fatty meal CS in the diagnosis and treatment of CAC. METHODS: We retrospectively reviewed the medical records of 198 patients who had undergone fatty meal CS for presumed CAC. Data retrieved focused on symptom improvement following management. Gallbladder ejection fraction (GBEF) of 50% or less was considered abnormal. Patients were divided into groups on the basis of test results and management. RESULTS: In group 1a, patients with low GBEF and cholecystectomy, 88% (54 of 61) reported symptom improvement, whereas the remaining 12% (7 of 61) retained their symptoms. Group 1b consisted of patients with low GBEF and who were managed medically. Persistence of symptoms was noted in 76% (32 of 42) of patients, whereas the remaining 24% (10 of 42) had symptom improvement. Group 2 consisted of patients with normal GBEF. Follow-up showed that 60% (47 of 78) of patients had symptom improvement either spontaneously or on medical treatment, whereas the remaining 40% (31 of 78) retained their symptoms. CONCLUSIONS: Fatty meal CS is a very useful technique in the diagnosis of CAC. It predicts a good surgical outcome once GBEF is low in patients with high pre-test probability for CAC. Moreover, fatty meal CS may be a good alternative to CCK CS.

Safety of endoscopic retrograde cholangiopancreatography during pregnancy.

BACKGROUND: The risk of choledocholithiasis is expected to be higher during pregnancy. This is attributed to alteration in bile composition as well as biliary stasis that take place during gestation. There is significant concern regarding application of endoscopic procedures especially the more invasive ones for treatment of choledocholithiasis during pregnancy. Our aim was to provide an additional support to the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in the management of biliary diseases during pregnancy. METHODS: The medical records of 10 pregnant patients who underwent ERCP at King Abdullah University Hospital, during the period from 2002 to 2007 were reviewed. Pregnancy course and outcomes were followed up in all cases. Results were analysed and compared with published data on safety and efficacy of this procedure. RESULTS: The mean age for mothers was 24.3 years. The mean duration of gestation was 18.4 weeks. Two patients were in the first trimester, five were in their second trimester and another three in the third trimester. The main indication for ERCP was obstructive choledocholithiasis on ultrasound and liver function tests. Fetal radiation exposure was not routinely measured. During, or after, the procedure there was no need for tocolytic agents. Also there was no intrauterine fetal distress. Screening for congenital anomalies was negative in all cases. CONCLUSION: Major complications of biliary obstruction have been prevented through this procedure. Short-term follow up for all neonates whom mothers underwent ERCP during pregnancy supports its safety. However, specific long-term fetal complications of radiation exposure have not been investigated yet.

Jejunal disorders: potentially lethal causes of acute abdomen are still overlooked.

OBJECTIVE: To highlight the importance of considering jejunal disorders in the differential diagnosis of acute abdomen. Although these conditions are relatively uncommon, we should keep in mind that jejunum still occurs, and deserves consideration. METHOD: This study was carried out at King Abdullah University Hospital, Jordan. Medical records of 7 patients with uncommon jejunal disorders that were encountered between 2001 and 2007 were retrospectively evaluated. We had 1 patient with jejunal diverticulitis, 1 with jejunal intussusception, 2 with jejuno-ileal tuberculosis complicated by intestinal obstruction, and 3 with acute mesenteric ischemia. All of these patients presented with acute abdominal pain of nonspecific features. Radiologic workup, along with surgical intervention, was necessary to reach a final diagnosis. RESULTS: Only 1 patient matched preoperative diagnosis, in which computed tomography scan revealed the presence of intussusception. The remaining patients were diagnosed intraoperatively. Laparoscopy and/or laparotomy with resection were performed. Morbidity was within acceptable range. There was no mortality. CONCLUSIONS: Jejunal disorders are potentially serious, and are underestimated. They are considered important causes of acute abdomen. Although they should not be at the top of a differential diagnostic list, they should always be ruled out when there is no apparent cause.

Laparoscopic surgery for symptomatic cholelithiasis during pregnancy.

INTRODUCTION: We are introducing here additional evidence regarding efficacy and safety of laparoscopic cholecystectomy during pregnancy. This is achieved by analysis of 10 successful cases of symptomatic cholelithiasis operated laparoscopically during pregnancy. PURPOSE: To prove the fact that laparoscopic cholecystectomy is safe and effective during pregnancy, especially in the first trimester. BACKGROUND: Cholecystectomy represents the second most common nonobstetric operation during pregnancy. The laparoscopic management of symptomatic cholelithiasis during pregnancy is becoming the standard of care at our center king Abdullah university hospital (KAUH). Old restrictions on this treatment modality are changing; open surgery is not considered to be the only choice any more. METHODS: Ten laparoscopic cholecystectomies during pregnancy at variable gestational ages performed between February 2002 and June 2006 are reported here, all at KAUH. Their medical records were reviewed, deliveries were followed up, outcomes were analyzed, and results were compared with literature. RESULTS: Five patients were in their first trimester; 3 were in their second trimester and 2 in their third trimester in my series. Open cholecystectomy was not used at all in these patients. Intraoperative cholangiography was not performed. No tocolytic agents were given. No maternal or fetal mortality have been reported. None of fetuses had anomalies. One patient who refused any surgical intervention presented with repeated attacks of biliary colic at gestational age of 26 weeks; this pregnancy ended up with stillbirth at 33 weeks. CONCLUSIONS: In my series, laparoscopic cholecystectomy was safe through out all stages of pregnancy. When undertaken by skilled laparoscopic surgeon, it carries low mortality and morbidity. We highlight the fact that first trimester symptomatic cholelithiasis can be managed safely by laparoscope. We add to the evidence that laparoscopic cholecystectomy may not interfere with organogenesis. Early uterine contractions were not reported, though, we think that prophylactic tocolytics are not indicated unless uterine contractions are confirmed. Certain positioning styles, and cannulation techniques, are part of major guidelines that we recommend to be followed during this surgery.