Iatrogenic Thyrotoxicosis: Causal Circumstances, Pathophysiology, and Principles of Treatment—Review of the Literature

Thyrotoxicosis is the clinical syndrome that results when tissues are exposed to high levels of circulating thyroid hormones. In most instances thyrotoxicosis is due to hyperthyroidism, a term reserved for disorders characterized by overproduction of thyroid hormones by the thyroid gland. Nevertheless, thyrotoxicosis may also result from a variety of conditions other than thyroid hyperfunction. The present report focuses on the etiologies, pathophysiology, and treatment of iatrogenic thyrotoxicosis. Iatrogenic thyrotoxicosis may be caused by (1) subacute thyroiditis (a result of lymphocytic infiltration, cellular injury, trauma, irradiation) with release of preformed hormones into circulation; (2) excessive ingestion of thyroid hormones (“thyrotoxicosis factitia”); (3) iodine-induced hyperthyroidism (radiologic contrast agents, topical antiseptics, other medications). Among these causes of iatrogenic thyrotoxicosis, that induced by the iodine overload and cytotoxicity associated with amiodarone represents a significant challenge. Successful management of amiodarone-induced thyrotoxicosis requires close cooperation between endocrinologists and endocrine surgeons. Surgical treatment may have a leading yet often underestimated role in view of the potential life-threatening severity of this disease, whereas others kinds of iatrogenic thyrotoxicosis are usually treated conservatively.     

The Surgical Treatment of Lymphedema: A Systematic Review of the Contemporary Literature (2004–2010)

Purpose  

A systematic review of the literature was performed to examine contemporary peer-reviewed literature (2004–2010) evaluating the surgical treatment of lymphedema.     

Nonsurgical Treatment of Osteomyelitis of the Hallux Sesamoids: A Case Series and Literature Review

The aim of the present study was to determine the effectiveness of nonsurgical treatment for osteomyelitis of the hallucal sesamoids. Osteomyelitis of the hallucal sesamoids in young and healthy patients is rare and might originate from hematogenous spread or after a puncture wound. In diabetic patients with peripheral neuropathy, it often results from direct contiguous seeding from adjacent ulceration. The superiority of surgical versus nonsurgical therapy is still debated. In our institution, all patients presenting with osteomyelitis of the hallucal sesamoids are first treated nonsurgically but eventually usually require a surgical procedure. We reviewed 18 patients with a clinical and radiologic diagnosis of osteomyelitis of the hallucal sesamoids treated in our institution during a 13-year period (from January 2000 to December 2012). The inclusion criteria were a signal alteration on magnetic resonance imaging or bone lesions on computed tomography or conventional radiographs, combined with a deep ulcer with a positive probe-to-bone test. Nonsurgical therapy consisted of frequent wound treatment, immobilization, offloading in a cast or other orthotic device, and oral antibiotics. Of the 18 patients, 11 had diabetes, 16 had peripheral neuropathy, 11 had peripheral arterial disease, and 5 had immunosuppression. After a period of nonsurgical therapy ranging from 4 weeks to 9 months, 15 of 18 patients required surgical excision, internal resection, or amputation. In this patient population, we no longer consider nonsurgical therapy a viable option. Patients should be advised, before starting nonsurgical treatment, that the therapy will be long and demanding and very often results in a surgical procedure.     

Short Bowel Syndrome: An Uncommon Clinical Entity and a Therapeutic Challenge—Our Experience and Review of Literature

Short bowel syndrome (SBS), one of the commonest types of intestinal failure, usually secondary to extensive bowel resection, traditionally has been associated with a high mortality rate and hence a big challenge for the treating surgeons. It requires comprehensive clinical care to minimise the morbidities and mortality associated with the condition. We report a retrospective review of a series of seven patients with SBS, who presented at our surgical emergency within a period of 1 year and their outcome so as to encourage others in managing such a challenge with more positive mindsets. A retrospective analysis of seven patients with SBS admitted from January 2014 to January 2015 with a follow-up of 1 year has been done in terms of their demographic characteristics, underlying pathology and clinical outcome. A rising incidence of SBS in the younger age group (71.4%) has been observed in this analysis. Majority of patients (57.1%) had mesenteric ischemia as the underlying cause followed by each case of small bowel volvulus, internal herniation and blunt trauma abdomen. A discharge rate of 71.4% and mortality rate of 28.5% were observed. With this analysis, we believe that SBS is no more an uncommon condition. A structured clinical approach, timely surgical intervention and multidisciplinary postoperative management are essential for managing such frail patients to achieve best possible results. This will encourage others in managing such a critically challenged condition with a more positive approach and thus beneficial for both the patients and the treating surgeon.     

Parsonage–Turner Syndrome—Case Report and Literature Review

Parsonage–Turner syndrome is the term used to describe a neuritis involving the brachial plexus. It may present with symptoms of an isolated peripheral nerve lesion, although the pathology is thought to lie more proximally. A case describing an isolated anterior interosseus nerve palsy due to an acute brachial neuritis is presented where the electromyographic findings confirmed the diagnosis, but also demonstrated the coexistence of a dual pathology in the form of a cervical radiculopathy. The literature is reviewed regarding etiology, treatment, and prognosis.     

Open Surgical Simulation—A Review

BackgroundSurgical simulation has benefited from a surge in interest over the last decade as a result of the increasing need for a change in the traditional apprentice model of teaching surgery. However, despite the recent interest in surgical simulation as an adjunct to surgical training, most of the literature focuses on laparoscopic, endovascular, and endoscopic surgical simulation with very few studies scrutinizing open surgical simulation and its benefit to surgical trainees. The aim of this review is to summarize the current standard of available open surgical simulators and to review the literature on the benefits of open surgical simulation.Current State of Open Surgical SimulationOpen surgical simulators currently used include live animals, cadavers, bench models, virtual reality, and software-based computer simulators. In the current literature, there are 18 different studies (including 6 randomized controlled trials and 12 cohort studies) investigating the efficacy of open surgical simulation using live animal, bench, and cadaveric models in many surgical specialties including general, cardiac, trauma, vascular, urologic, and gynecologic surgery. The current open surgical simulation studies show, in general, a significant benefit of open surgical simulation in developing the surgical skills of surgical trainees. However, these studies have their limitations including a low number of participants, variable assessment standards, and a focus on short-term results often with no follow-up assessment.Future of Open Surgical SimulationThe skills needed for open surgical procedures are the essential basis that a surgical trainee needs to grasp before attempting more technical procedures such as laparoscopic procedures. In this current climate of medical practice with reduced hours of surgical exposure for trainees and where the patient’s safety and outcome is key, open surgical simulation is a promising adjunct to modern surgical training, filling the void between surgeons being trained in a technique and a surgeon achieving fluency in that open surgical procedure. Better quality research is needed into the benefits of open surgical simulation, and this would hopefully stimulate further development of simulators with more accurate and objective assessment tools.     

Immunosuppression Protocols in Intestinal and Multivisceral Transplantation—A Literature Review

BackgroundIntestinal transplantation (IT) and multivisceral transplantation (MVT) are curative therapies for patients with intestinal failure and severe complications associated with total parenteral nutrition. High levels of immunosuppression are required to prevent acute cellular rejection (ACR) from the bowel. Studies regarding pre-treatment, induction, and post-transplant therapy have improved graft acceptance, reducing immunosuppression doses and infectious complications. However, the low rate of IT and MVT and the small number of specialized centers have resulted in a limited number of evidence-based immunosuppression protocols. We reviewed immunosuppression in IT and MVT to draw useful conclusions regarding the best protocol strategies for the induction, maintenance, and management of ACR.MethodsA review was performed using the PubMed database. Articles on immunosuppression protocols in IT and MVT that addressed graft rejection, infection, or survival, published between 2006 and 2022, were selected.ResultsA total of 690 articles were selected. Two researchers applied the inclusion and exclusion criteria and selected 14 articles independently. For induction, thymoglobulin, alemtuzumab, and basiliximab are the most frequently used immunosuppressants for induction. Classic maintenance therapy consists of a combination of corticosteroids and tacrolimus. Methylprednisolone with an increased tacrolimus dose is used most frequently to manage ACR. Depending on the receptor response, such as thymoglobulin, infliximab, adalimumab, or bortezomib, other immunosuppressants should be considered.ConclusionsThere have been great advances in IT and TMV immunosuppression. We conclude that the gold standard immunosuppressive protocol is triple therapy, comprising induction with thymoglobulin, maintenance with steroids for a few months, and tacrolimus and mycophenolate therapy. Innovative approaches for treating intestinal rejection episodes with more appropriate drugs, such as infliximab, adalimumab, or bortezomib, are necessary.     

Giant Inguinoscrotal Hernia—Report of a Rare Case With Literature Review

Massive inguinoscrotal hernias extending below the midpoint of the inner thigh, in the standing position constitute giant inguinoscrotal hernias. We report a patient who presented with giant right inguinal hernia with bilateral hydrocele for 25 years. He had no cardiorespiratory illnesses. He was taken up for surgery under general anesthesia after preoperative respiratory exercises. Sliding hernia with entire greater omentum, small bowel, and appendix as contents was identified. Meshplasty after omentectomy with bilateral subtotal excision of sac, right orchidectomy, and scrotoplasty were done. Giant inguinoscrotal hernias pose significant problems while replacing bowel contents because of the increase in intraabdominal and intrathoracic pressures. Recurrence is another complication seen after successful surgical management. Various techniques such as preoperative pneumoperitoneum, debulking abdominal contents with extensive bowel resections, or omentectomy and phrenectomy have been tried. Postoperative elective ventilation is also needed in many cases. We describe simple reduction with omentectomy as a viable technique in this patient. He did not need elective ventilation due to preoperative respiratory exercises and preparation and review of the literature.Key words: Debulking, Giant inguinoscrotal hernia, Massive inguinoscrotal hernia, Phrenectomy, VentilationGiant inguinoscrotal hernias are defined as those extending below the midpoint of the inner thigh, in the standing position.¹ These hernias are rare and usually the result of neglect or fear of surgical procedures and are prevalent in the rural population.² These massive hernias pose significant problems resulting from cardiorespiratory compromise following sudden increase in intra-abdominal pressure during replacement of herniated viscera.³ In order to circumvent these complications, techniques such as debulking, phrenectomy, and progressive pneumoperitoneum have been described.³ Here, we present a patient with giant inguinoscrotal hernia where simple reduction with omentectomy was successful, and we review the literature.     

ASO Visual Abstract: Brenner Borderline Ovarian Tumor—A Case Series and Literature Review

Annals of Surgical Oncology -     

Achalasia—If Surgical Treatment Fails: Analysis of Remedial Surgery

Introduction

Heller myotomy leads to good–excellent long-term results in 90% of patients with achalasia and thereby has evolved to the “first-line” therapy. Failure of surgical treatment, however, remains an urgent problem which has been discussed controversially recently.

Materials and Methods

A systematic review of the literature was performed to analyze the long-term results of failures after Heller’s operation with emphasis on treatment by remedial myotomy.

Discussion

Other reinterventions and their causes after failure of surgical treatment in patients with achalasia are discussed.

     

Isolated Acute Traumatic Subtalar Dislocations: Review of 13 Cases at a Mean Follow-Up of 6 Years and Literature Review

Isolated acute traumatic subtalar dislocations are quite rare. They correspond to talotarsal dislocation, including the talonavicular and talocalcaneal joints. The purpose of the present study was to evaluate the functional and radiologic outcomes of the treatment of acute traumatic isolated subtalar dislocations. The present retrospective study included 13 patients who had sustained isolated subtalar dislocations during a 10-year period. Of the 13 cases, 10 (76.9%) were medial dislocations and 3 (23.1%) were lateral dislocations. All the patients underwent immediate closed reduction under anesthesia followed by immobilization. No open reduction was required. The mean follow-up period was 72.6 (range 24.4 to 124.8) months. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score was 80.1 of 100 (range 66 to 90). The score result was good in 69% of cases and poor in 31% of cases. The subtalar mobility was reduced for 8 (61.5%) patients and significantly affected the American Orthopaedic Foot and Ankle Society score (p = .002). Subtalar osteoarthritis was present in 6 (46.1%) cases with talonavicular osteoarthritis in 3 (23.1%) cases. No cases of avascular necrosis of the talus were noted. In accordance with the published data, the prognosis of isolated acute traumatic subtalar dislocations is favorable. Medial dislocations are more frequent than lateral dislocations. Emergent closed reduction makes it possible to remove soft tissue injuries. The risk of post-traumatic subtalar osteoarthritis is significant, even without an initial subtalar lesion. A postreduction computed tomography scan will enable the diagnosis of osteochondral lesions.     

Barbed Sutures and Tendon Repair—a Review

Introduction

Traumatic tendon lacerations are a common problem encountered by hand surgeons worldwide. Although the use of barbed suture to repair tendon lacerations has gained theoretical popularity in recent years, there is little information available regarding the safety, efficacy, longevity, or complications encountered when used in tenorraphy. In this study, we review the available literature on the use of barbed suture in tendon repair.

Methods

Studies conducted between 1980 and 2014 were identified using several databases, including EMBASE, SCOPUS, MEDLINE, and Web of Science. Keywords used to search for appropriate studies included the following: barbed, v loc, quill, tendon, tendon injuries, suture, tenorraphy, injury, and laceration, in various combinations.

Results

Our initial literature search identified 47 articles, and 8 were deemed appropriate for review after applying our exclusion criteria. The data from each of the articles is reviewed for the following major categories:

1. Maximum load to failure
2. Mode of failure
3. Load to 2-mm gap
4. Change in cross-sectional area
5. Type of repair

Conclusions

Barbed suture tenorraphy has a myriad of theoretical advantages, supported by varying ex vivo studies, as compared to traditional techniques. However, due to the non-uniformity in current studies and the lack of available data in a live model, we are unable to argue for or against barbed suture tenorraphy. We believe our review provides the most in-depth analysis of barbed suture tenorraphy to date, illuminates the potential advantages of using barbed sutures, and highlights the need for further investigation into this technique.