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.

Primary Leiomyosarcoma of the Pancreas: a Comprehensive Analytical Review.

PURPOSE: Primary leiomyosarcoma of the pancreas (PLMSP) is rare. The clinical features and outcomes are still unclear. The present study aims to identify the clinical features, outcomes, and racial differences of PLMSP. METHODS: PLMSP cases reported in Chinese, English, French, and Japanese journals were collected and reviewed. Data from these reports were summarized and analyzed statistically. RESULTS: In addition to a female patient presented to our department with PLMS, a total of 87 cases reported in the literature were included in the present study. An equal incidence in gender was observed. The mean age was 53.8 years. Common symptoms were abdominal pain and abdominal mass. At the time of diagnosis or after a period of follow-up, 37.5% of patients had distant metastasis and 31.8% of patients had regional organs/vessels invasion. The 5-year mortality rate was 77.8%. The presence of distant metastasis and the absence of radical surgery are significantly associated with poor outcomes. Regional invasion was significantly more common in East Asians. CONCLUSION: PLMSP is an aggressive tumor with a poor prognosis. Radical resection can decrease the mortality of the patients. Early detection of such tumor is recommended.

Endovascular Management of an Acquired Carotid-Jugular Fistula in a Child.

BACKGROUND There is a paucity of published literature on carotid-jugular fistulae in children. These injuries are uncommon in the pediatric age group and most of the current practice in managing such injuries is extrapolated from similar injuries in the adult population. CASE REPORT We report a case of an acquired carotid-jugular fistula (CJF) following penetrating neck trauma in a 12-year-old male, treated by minimally invasive endovascular covered stent. Successful endovascular management was achieved in this case with anatomical and symptomatic resolution at 6 weeks and normal duplex ultrasound at 18 months. CONCLUSIONS The rarity of carotid-jugular fistulae in children means there is a lack of consensus for the appropriate management in the available literature. This case report adds to the evidence for endovascular management of this condition in a pediatric population.

Predictors of major lower limb amputation in type 2 diabetic patients referred for hospital care with diabetic foot syndrome.

PURPOSE: This study was conducted to determine the risk factors of major lower extremity amputations in type 2 diabetic patients referred for hospital care with diabetic foot syndrome. PATIENTS AND METHODS: This retrospective study involved 225 type 2 diabetic patients referred for management of diabetic foot syndrome at King Abdullah University Hospital in the period between January 2014 and December 2015. A structured customized diabetic foot data collection form with diabetic foot characteristics chart was used for documentation of relevant information, which checks for age, sex, body mass index, smoking, duration of diabetes, diabetic control therapy, associated hypertension, cardiac diseases, stroke, chronic renal impairment, renal replacement therapy (hem-dialysis), and history of diabetes-related complication in both feet prior to the study period. The predictors for major lower limb amputations were compared between groups using chi-square test, and binary logistic regression was used to determine the factors associated with major amputation. RESULTS: Twenty-seven limbs underwent major amputations with an overall rate of major amputation of 11.6%. The following predictors were found to be associated with the higher incidence of major lower limb amputations: duration of diabetes ≥15 years, HbA1c ≥8%, patients on insulin, with hypertension, cardiac diseases, chronic renal impairment, stroke, having gangrene, higher number of components, higher Wagner classification, and ischemia. However, the rate did not differ significantly between men and women. CONCLUSION: Presentation with gangrenous tissue and poor glycemic control are the important risks and significant predictive factors for type 2 diabetes-related major lower limb amputations.

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.

Iatrogenic gastric dilatation: a rare and transient cause of hepatic-portal venous gas.

Gas in the portal veins is rare and in most cases is associated with serious diseases and poor clinical outcome. A case of gas in the hepatic-portal veins with gastric dilatation, as shown by CT-scanning for abdominal trauma, is reported. The condition was clinically benign and resolved spontaneously. An abdominal CT scan documented the findings.

Postcatheterization femoral artery pseudoaneurysms: therapeutic options. A case-controlled study.

OBJECTIVES: Postcatheterization femoral artery pseudoaneurysm is a troublesome complication following percutaneous canulations of the femoral artery. Both diagnostic and therapeutic options in the management of these pseudoaneurysms have changed dramatically, with surgery being required only rarely. We aimed to perform a comprehensive review of our experience, techniques and results in treating postcatheterization femoral artery pseudoaneurysms. METHODS: A retrospective study of all patients presenting with local complications following invasive percutaneous femoral artery canulations over a five-year period was performed. Physical examination with color Doppler ultrasound analysis identified 29 femoral artery pseudoaneurysms. Surgery, duplex-guided compression, and thrombin injection were the main therapeutic options. RESULTS: Fourteen cases of femoral artery pseudoaneurysms were treated by duplex-guided compression obliteration with a 78.5% success rate. Four patients had spontaneous thrombosis of their pseudoaneurysms. Five patients underwent percutaneous thrombin injection. Six patients had conventional surgery. Three cases failed duplex-guided compression: one closed with thrombin injection, and two were repaired surgically. Follow-up US showed no recurrent pseudoaneurysms for patients who underwent successful duplex-guided compression. CONCLUSION: Despite the voluminous data in the literature of treating postcatheterization femoral artery pseudoaneurysms by thrombin guided injection, as a quick and effective method of therapy, with infrequent failures and complications, our study confirms the clinical usefulness of duplex-guided compression in the management of these pseudoaneurysms. The possibility of spontaneous thrombosis of small pseudoaneurysms is emphasized.

Herniation of part of the breast through a congenital defect of the superficial fascia of the anterior thoracic wall.

This report describes the management of a 28-year-old female patient who had herniation of part of her left breast through a defect in the superficial fascia of the anterior thoracic wall. Closure of the defect was associated with correction of the deformity. To the best of our knowledge, this is the first report describing such a lesion.

Sigmoid volvulus in the Middle East.

Little is known about sigmoid volvulus in the Middle East despite textbooks referring to the region as part of the "volvulus belt." Our objectives were to assess the prevalence, clinical presentations, radiological findings, operative treatments, and postoperative outcomes of patients managed for sigmoid volvulus in Jordan as a model for the region. The medical records of patients with large bowel obstruction who were managed at King Abdullah University Hospital and its affiliated institutes, northern Jordan, over a 6-year period between January 2001 and January 2007 were retrospectively reviewed to identify patients with a confirmed diagnosis of sigmoid volvulus. Sigmoid volvulus was responsible for 9.2% of all cases of large bowel obstruction seen during the study period. There were 32 patients with sigmoid volvulus, 24 (75%) of whom were men. The median age of the patients was 59 years (range 21-83 years). Abdominal pain and distention were the main presentations. Colonoscopic detorsion was applied in 25 patients, which was achieved in 17 (68%) of them after the first attempt. Six patients had a gangrenous sigmoid colon, four of which required resection and a Hartmann procedure. Sigmoid resection with primary anastomosis was performed in 28 patients, including 2 with a gangrenous colon. Postoperative complications were observed in five patients, including one patient with viable colon who develop an anastomotic leak. Two patients died, making the mortality rate 6%. Sigmoid volvulus is uncommon in Jordan. Resection of the sigmoid colon with primary anastomosis appears to be the preferred procedure.

The clinical and epidemiological features of hydatid disease in Northern Jordan.

OBJECTIVE: To elaborate on the epidemiology of hydatid disease in Jordan as a model for the Middle East, and highlight the obstacles that face disease control in the region. METHODS: The clinical and epidemiological data for 65 patients with the diagnosis of hydatid cyst (who were treated in the Department of Surgery, Jordan University of Science and Technology, Irbid and its affiliated hospitals, between January 1994 through to September 2003) were analyzed. Fifty-five patients were interviewed for details of life style. RESULTS: Forty-six percent of patients were below 40- years of age. Fifty-seven percent were females. All interviewed patients gave history of contact with dogs and history of ingestion of raw vegetable food. The latter in addition to a high zoonotic infection rate and uncontrolled animal movement were factors contributing to the high prevalence. CONCLUSION: Optimization of control programs in the Middle East requires the establishment of a regional center. Wide traveling has made it essential for physicians practicing in non-endemic areas to be aware of the diverse presentations of this disease when dealing with immigrants from endemic areas.

Gastric malignancies in Northern Jordan with special emphasis on descriptive epidemiology.

AIM: To study the epidemiology of gastric malignancies in Jordan as a model for Middle East countries where such data is scarce. METHODS: Pertinent epidemiological and clinicopathological data for 201 patients with gastric malignancy in north of Jordan between 1991 and 2001 were analyzed. RESULTS: Male: female ratio was 1.8:1. The mean age was 61.2 years, and 8.5% of the patients were younger than 40 years of age. The overall age-adjusted incidence was 5.82/100 000 population/year. The age specific incidence for males raised from 1.48 in those aged 30-39 years to 72.4 in those aged 70-79 years. Adenocarcinomas, gastric lymphomas, malignant stromal tumors, and carcinoids were found in 87.5%, 8%, 2.5%, and 2% respectively. There was an average of 10.1-month delay between the initial symptoms and the diagnosis. Only 82 patients underwent curative gastrectomy. Among adenocarcinoma groups, Lauren intestinal type was the commonest (72.2%) and the distal third was the most common localization (48.9%). The mean follow up for patients with gastric adenocarcinoma was 25.1 mo (range 1-132 mo). The 5-year survival rates for stages I (n=15), II (n=41), III (n=59), and IV (n=53) were 67.3%, 41.3%, 5.7%, and 0% respectively (P=0.0001). The overall 5 year survival was 21.1%. CONCLUSION: Despite low incidence, some epidemiological features of gastric cancer in Jordan mimic those of high-risk areas. Patients are detected and treated after a relatively long delay. No justification in favor of a possible gastric cancer screening effort in Jordan is supported by our study; rather, the need of an earlier diagnosis and subsequent better care.

Is fear of anaphylactic shock discouraging surgeons from more widely adopting percutaneous and laparoscopic techniques in the treatment of liver hydatid cyst?

BACKGROUND: Sources of reports about laparoscopic and percutaneous treatment of liver hydatid cysts are limited to just a few countries. To address the reason behind this, we carried out a survey of 30 surgeons in northern Jordan. METHODS: A questionnaire was distributed to collect data regarding the surgical technique preferred by each surgeon. Further information was collected from those not adopting minimal-access techniques to determine their reasons for not doing so. RESULTS: Only 3 surgeons (10%) considered laparoscopy as the first line of treatment. Of the 27 surgeons who did not consider percutaneous or laparoscopic treatment, fear of anaphylaxis and/or dissemination was the main reason given by 21 surgeons (78%) for not using minimal access techniques. CONCLUSIONS: The seemingly exaggerated traditional fear of anaphylaxis seems to discourage surgeons from more widely adopting minimal access techniques for the treatment of hydatid cyst.

Carotid body tumors.

We present our approach to the management of patients with carotid body tumors, emphasizing the role of magnetic resonance angiography for the identification of these tumors. Medical records of all patients with carotid body tumors who were managed between 1991 and 2001 were retrospectively reviewed. Nine patients with carotid body tumors were identified. There were four males and five females, ranging in age from 28 to 74 years. Duplux scanning, computed tomography (CT) scanning, and angiography were performed for seven patients, whereas Duplux and magnetic resonance angiography were performed for the remaining two patients. Eight patients underwent successful excision of the tumor. Neither postoperative deaths nor strokes occurred. Temporary cranial nerve injury occurred in two patients. One patient developed local recurrence 5 years later. Early diagnosis of carotid body tumors with Duplex and magnetic resonance angiography is possible. Early surgery for carotid body tumors minimizes the risk of complications associated with large tumors.

Effort thrombosis of the subclavian-axillary vein.

OBJECTIVE: The aim of this study is to outline the clinical patterns, diagnosis and the outcome of patients with 'effort' subclavian-axillary vein thrombosis. METHODS: The medical records of 7 patients diagnosed with 'effort' subclavian-axillary vein thrombosis between 1992 and 2000 at the Princess Basma Teaching Hospital, Irbid, Jordan were reviewed. Patients with secondary subclavian-axillary vein thrombosis (catheter related or secondary to thoracic outlet compression) were excluded. RESULTS: The clinical presentations of this condition were swelling, pain, and cyanosis of the upper limbs. The presence of dilated superficial vein is a late sign. All patients were treated by non-fractionated heparin continued with warfarin with a favorable outcome. CONCLUSION: Effort thrombosis of subclavian-axillary vein (Paget-Von Schroetter syndrome) is less reported in the literature contrary to secondary subclavian-axillary vein thrombosis. Early and effective anticoagulation constitutes the base of curative treatment. Prevention of recurrence is mandatory.