Lightning strike injuries are a relatively common natural phenomenon, but documented cases of lightning causing hollow visceral perforation are extremely rare. In our case, male patient a 50-year-old, suffered acute abdominal pain and burns on the abdominal skin after being struck by lightning. Subsequent tests confirmed a bowel injury, leading to the need for surgery to repair the perforation in the small bowel and evacuate a hematoma in the omentum. This highlights the importance of understanding and addressing the potential medical consequences of lightning strikes.
Abdullah Almunifi Department of Surgery, College of Medicine, Majmaah University, Al Majma’ah, 11952, Saudi ArabiaCorrespondence: Abdullah Almunifi, Email a.almunifi@mu.edu.saBackground: Artificial intelligence (AI) is emerging as a transformative force in healthcare, particularly in metabolic bariatric surgery (MBS) and minimally invasive surgery (MIS). This literature review explores AI’s applications, advantages, challenges, and future potential in these fields.Methods: A narrative review of 30 studies, including randomized controlled trials, observational studies, literature reviews, and meta-analyses, was conducted. Critical findings on AI’s impact on surgical precision, workflow efficiency, complications, and patient outcomes were synthesized.Results: AI-enabled techniques significantly improved surgical precision, reduced complication rates, and optimized workflows. AI applications in preoperative planning, intraoperative assistance, and postoperative monitoring demonstrated consistent advantages. However, ethical concerns, data privacy, and standardization issues persist.Conclusion: AI integration in MBS and MIS has the potential to revolutionize surgical outcomes, enhance precision, and improve efficiency. Addressing interoperability, data security, and regulatory barriers will be crucial for widespread adoption.Keywords: metabolic bariatric surgery, minimally invasive surgery, artificial intelligence, robotic surgery, precision medicine, surgical efficiency
Sintayehu Asrat Beyene,1 Nahom Tadesse Bogale,1 Binyam Mohammedbirhan Berhe,2 Demis Degu Teshome3 1General Surgery Unit, Department of Surgery, Jigjiga University Sheik Hassen Yabare Comprehensive Specialized Hospital, Jigjiga, Ethiopia; 2Department of Pathology, Jigjiga University Sheik Hassen Yabare Comprehensive Specialized Hospital, Jigjiga, Ethiopia; 3Department of Obstetrics and Gynecology, Jigjiga University Sheik Hassen Yabare Comprehensive Specialized Hospital, Jigjiga, EthiopiaCorrespondence: Sintayehu Asrat Beyene; Nahom Tadesse Bogale, Email sintayehubeyene54@gmail.com; Tadnahi2@gmail.comIntroduction: Endometriosis is a disease condition characterized by the presence of endometrial glands and stroma outside the uterine cavity and musculature. It affects 7– 10% of women of reproductive age and usually involves pelvic organs. The common symptoms include dysmenorrhea, menorrhagia, pelvic pain, dyspareunia, and infertility. Umbilical endometriosis is the rarest form of extra-pelvic endometriosis.Case Presentation: A 32-year-old Para II mother presented with umbilical swelling and pain that worsened during the menses of 2 months. She had two caesarean scars, both transverse Pfannenstein incisions. There was a dark blue, firm to hard 2× 3 cm umbilical mass on physical examination. Laboratory results are normal. Ultrasound of the abdomen showed umbilical mass with homogeneous echotexture measuring 2 cm × 3 cm with an irregular border and hypoechoic texture. An excisional biopsy was performed and a biopsy showed umbilical endometriosis.Discussion: Primary umbilical endometriosis is a disorder first described by Villar in 1886, and among all cases of extra-genital involvement of endometriosis, primary umbilical endometriosis accounts for 0.5– 1%. The usual presentation of primary umbilical endometriosis is typically the presence of a discrete bluish-purple mass in the umbilicus, which becomes swollen, painful, and bleeds concomitantly with the menstrual cycle. Ultrasound and other imaging techniques help in making diagnoses, and the diagnosis is confirmed by cytological examination. The management of umbilical endometriosis involves surgical excision and reconstruction of the umbilicus.Conclusion: Umbilical endometriosis is an uncommon form of extra-pelvic endometriosis. There is a wide differential diagnosis for swellings of the abdominal wall; however, it should be suspected in any female patient of reproductive age with an umbilical lesion that becomes more painful and swollen during her menstrual period. Appropriate clinical examination and workup are helpful to make a diagnosis and do a surgical excision.Keywords: endometriosis, umbilical nodules, umbilical hernia, abdominal wall scar, caesareans section
Sarah K Lee,1 Kaushik Mukherjee2 1Department of Plastic Surgery, University of California Irvine Health, Irvine, CA, USA; 2Division of Acute Care Surgery, Loma Linda University Health, Loma Linda, CA, USACorrespondence: Kaushik Mukherjee, Division of Acute Care Surgery, Loma Linda University Health, 11175 Campus Street, CP, 21111, Loma Linda, CA, 92350, USA, Tel +001 909-558-4286, Fax +001 909-558-236, Email kmukherjee@llu.eduAbstract: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has emerged as a promising intervention for hemorrhagic shock and traumatic injury management, offering a minimally invasive means of aortic occlusion compared to resuscitative thoracotomy. While REBOA’s origin dates back to the 1950s, recent advancements have made it more accessible and applicable in various clinical scenarios. REBOA has become increasingly utilized in not only the exsanguinating trauma patient but also in non-traumatic hemorrhage as a bridge to definitive hemostatic control. This article reviews the procedure and mechanism, clinical applications, and challenges associated with the REBOA. There are several challenges to consider when implementing the REBOA, particularly in procedural execution and patient selection. Determining the ideal candidates for REBOA remains inconclusive, with varying outcomes reported in different patient populations. Additionally, the potential for ischemic complications, such as visceral organ injury, end organ damage, and lower extremity ischemia, underscores the critical importance of procedural planning and ongoing monitoring. Partial and intermittent REBOA techniques have been introduced to mitigate ischemic complications associated with complete occlusion, but their efficacy and safety warrant further investigation. Beyond technical considerations, logistical and institutional factors pose as potential barriers to the effective utilization of REBOA, highlighting the importance of standardized training and a multidisciplinary approach when establishing a REBOA program. REBOA offers promising advancements in hemorrhage control, and the technology continues to evolve to address potential challenges and complications. Further research is imperative to delineate its optimal use and potential impact on patient outcomes.Keywords: traumatic hemorrhagic shock, REBOA, postpartum hemorrhage, partial REBOA, aortic occlusion, endovascular
Background: Rectovaginal fistulas (RVFs) present a significant surgical challenge, particularly those resulting from gynecologic procedures, which are often complex and associated with higher recurrence rates. The Martius Flap technique, which involves the use of a vascularized adipose tissue graft, is an established method for enhancing fistula repair, especially in cases involving large, recurrent, or radiation-induced fistulas. Materials and Methods: We conducted a prospective evaluation of 46 female patients with RVFs treated using the Martius Flap technique between December 2008 and December 2019. The study focused on patients with RVFs caused predominantly by gynecologic procedures, including surgeries for benign and malignant conditions, as well as those with a history of radiation therapy. Results: The average age of the patients was 38.7 years (range 18-75 years). Of the 46 RVFs treated, 65.2% were due to gynecologic surgery, 26.1% were associated with iatrogenic injury or radiation therapy, and 8.7% were post-coital. Successful fistula closure was achieved in 95.6% of cases, with a recurrence rate of 4.4%. The Martius Flap demonstrated high efficacy, particularly in large and complex fistulas, with most patients reporting significant satisfaction and improved continence post-operatively. Conclusion: The Martius Flap technique is a highly effective option for the surgical management of RVFs, particularly those secondary to gynecologic procedures. The technique's ability to introduce well-vascularized tissue into the repair site significantly reduces recurrence rates and enhances healing, making it a preferred method for treating complex and recurrent RVFs.
Background: Birth defects of the digestive system are a phenotypically and etiologically different category common birth defects caused by various causes during fetal development. Objective: The study's goal was to evaluate patient demographics, related abnormalities, atresia location, operational management, postoperative care, and results of patients with gastrointestinal atresia and compare them with other research. Methods: A 5-year retrospective study in cases with gastrointestinal atresia at a tertiary hospital in Mogadishu, Somalia, was carried out by the pediatric surgery department from January 2017 to January 2022. Results: A165 cases were operated due to gastrointestinal atresia in five-year period., 105 were male (63.6%) and 60 were female (36.4%), giving the male to female ratio of 1.75:1. According to the age group of the study population, the majority of cases (48.5%) were aged less than 1 month. The esophageal atresia, duodenal atresia, high jejunal atresia, jejunoileal atresia, and colon atresia, anorectal malformations were 9.7%, 9.1%, 0.6%, 7.3%, 73.3%, respectively; the anorectal malformations has resulted in the majority of cases (73.3%). 20 % of cases had no follow-up, while 80% arrived as planned. 52.1% got well and had no complications and some developed different complications like peristomal skin irritation (14%), rectal and urethral fistula (4.8%), rectal prolapse (1.8%), rectal stenosis (2.4%), rectal adhesions (1.2%), esophageal stricture (1.2%), wound infection (3.6%), anastomosis dehiscence (0.6%), abdominal distension (0.6%), recto-perineal fistula (1.2%), urethral damage and urinary retention (0.6%). Mortality for this study was 24.8% (41 patients). Conclusion: Children with gastrointestinal atresia present late in the course of their illness, with substantial morbidity and death due to poor economic conditions, poor nutrition, surgical problems, and likely related anomalies, rather than surgical morbidity alone.
Objective: As a positive features in C-TIRADS (Chinese Thyroid Imaging Reporting and Data System) guidelines, solid features represent the latest positive indicator, which differs from those in other guidelines. This study was to explore the diagnostic value of the solid features for thyroid nodules of different sizes. Methods: Between January 2022 and October 2023, a total of 1561 patients with 1790 thyroid nodules confirmed by surgical pathology were prospectively included in this study. These nodules were divided into three groups based on their maximum diameter: Group A(1) (<= 10mm), Group A(2) (>10mm, <20mm), and Group A3 3 (>= 20mm). The component characteristics of thyroid nodules in each group were analyzed. Based on the surgical pathology results, Receiver Operating Characteristic (ROC) curves were constructed to evaluate the diagnostic efficiency of C-TIRADS solid features for thyroid nodules of different sizes. Results: As the size of thyroid nodules increased, the incidence of cystic changes in both benign and malignant nodules showed a linear increasing trend (Z-values of 46.251 and 156.586, respectively; P values <0.001 for both). The occurrence rate of solid malignant nodules was higher than that of benign nodules in all groups, with Area Under Curve (AUC) values of 0.620, 0.723, and 0.767, respectively. Conclusion: With the increase in the size of thyroid nodules, the diagnostic value of solid features for thyroid cancer progressively increases. The specificity of thyroid nodule diagnosis also increases progressively. Which may have certain value in the evaluation process using C-TIRADS, particularly in the management of thyroid nodules in clinical settings.
Objective: This study aimed to determine the demography, incidence of surgical complications, and visual outcomes of cataract surgeries at a rural eye care facility in Tarlac, Philippines. Methods: This is a 1-year retrospective case study of the visual outcomes of cataract surgeries in a rural eye care facility in Tarlac, Philippines. Comparative statistics such as t-test for means and Z-test for proportions were used to determine differences between bivariate groups. Results: During the 1-year period, 340 eyes underwent cataract surgery. Fifty-nine patients were <60 years of age, whereas 235 patients were >60 years old. There were 142 males and 152 females. Preoperative visual acuity (VA) appears to be skewed towards poor vision (<20/200). Two hundred sixteen eyes had VA <20/200, while the number of eyes with fair (<20/60- 20/200) and good (20/ 20- 20/60) vision were 95 and 29, respectively. Preoperative and postoperative VA were categorized as good, fair and poor based on the definition stated by the WHO. There are significant differences (p < 0.0001) between the preoperative and postoperative VA in all categories. The number of eyes with good VA increased from 29 to 320, whereas the frequency of fair and poor VA decreased from 95 and 216 to 8 and 12, respectively. Conclusion: The eye care facility achieved the WHO recommendation for adequate visual outcomes of >80% of good visual outcome. Contrary to other studies, old age does not necessarily equate to poor outcomes in this study. However, pre-existing ocular illnesses and surgical complications do contribute to poor outcomes. It is still possible to gain a good outcome if the pre-existing ocular comorbidity is still on the early stages. In cases of posterior capsular rupture, good outcomes are also achievable if the surgeon is skilled enough to handle such situations.
Purpose: Enhanced recovery after surgery (ERAS) programs are evidence-based protocols designed to standardize medical care, improve outcomes, and lower costs. Research shows that ERAS in colorectal surgery is associated with reduced length of stay (LOS) and morbidity, faster recovery and comparable or reduced readmission rates versus traditional models. Very little evidence exists assessing ERAS outcomes in inflammatory bowel disease (IBD) surgery. We hypothesized that ERAS protocols following IBD surgery is associated with a reasonable LOS and morbidity. Secondary aims were to identify factors affecting patient selection for ERAS programs in IBD surgery. Patients and methods: A retrospective review of 119 patients undergoing abdominal surgery in a high volume IBD tertiary referral centre with a well-established ERAS protocol. Results: During the study period, 119 patients with IBD underwent surgery. Of these, 78 patients were allocated to an ERAS protocol; compliance was 72%. The ERAS cohort were more likely to have laparoscopic surgery (53.8%), compared to the non-ERAS cohort (N-ERAS) (46.3%). Median hospital stay was significantly shorter in the ERAS cohort compared to the N-ERAS cohort (7 vs 9 days; p < 0.05). Operative time was significantly longer in the N-ERAS cohort (233 +/- 73.0 vs 266 +/- 96; p = 0.040). Complication rates were higher in the N-ERAS cohort (48.8% vs 37.1%; p = 0.33). Conclusion: Patients undergoing surgery with an ERAS protocol have improved outcomes compared with patients deemed not suitable for ERAS. Factors affecting suitability are longer operations, a requirement for stoma, malnourished patients, patients with a higher ASA and the commencement of a new fellow to the unit.
Background: This study investigated perioperative clinical information, surgical findings, and postoperative courses of patients who underwent reoperation due to bleeding after the surgery for pulmonary malignancies. Methods: We identified patients who underwent reoperation due to postoperative bleeding from 6989 patients who had had operations for pulmonary malignancies between January 2007 and July 2019. Data were retrospectively collected from medical charts. Results: Twenty-two patients (0.3%) underwent reoperation for hemostasis. The reason for reoperation was a shock state with minimum systolic blood pressure < 90 mm Hg in 12 patients (55%), persistent bloody drainage of 100 mL/h or more in 15 patients (68%), and intrathoracic hematoma on a chest X-ray image in 14 patients (64%). All those three findings were observed in five patients (23%), two in nine patients (41%), and one in eight patients (36%). The source of bleeding could not be identified during reoperation in four patients (18%). In the regression analysis, the coefficient of determination between the amount of drainage from a chest drain and the volume of intrathoracic hematoma found during reoperation was 0.31, indicating poor correlation. Postoperative complications and death occurred in two (9%) and zero patients, respectively. Conclusion: Reoperation due to bleeding is required in certain cases. The amount of drainage from a chest drain does not necessarily reflect the volume of intrathoracic hematoma and it is hard to estimate the total amount of bleeding. The decision to perform reoperation for hemostasis should be comprehensively made on the basis of clinical signs and chest X-ray findings.
Introduction: Sacral nerve stimulation (SNS) has emerged as a viable option in patients with fecal incontinence who do not respond to conservative care. Technology has significantly progressed over the years. The current InterStimTM device is compatible with MRI, lasts for many years, and is performed using a minimally invasive technique, using mild sedation and local anesthesia. The precise mechanism of action remains unknown, and there is increasing interest in expanding the indications for the management of digestive diseases. There is now an increasing interest in brain neuromodulator devices, which may enable physicians to visit a larger number of patients simultaneously. Case Presentation: We present a case report of a patient with fecal incontinence (FI) who failed to respond to conservative management. The patient also had an occipital device for cluster headaches. The FI symptoms improved significantly with InterStimTM and there was no interaction with another device. Discussion: InterStimTM may be safely integrated with other neuromodulators. Additional research is required to determine the safety and benefit of InterStimTM implantation with other neuromodulators devices.
Purpose: This prospective study aimed to investigate the early outcomes of colorectal surgery in patients with colorectal cancer and determine their relationships with specific risk factors and comorbidities. Patients and Methods: This study was conducted at AL-Thawra Modern General Hospital and Kuwait University Hospital in Sana'a, Yemen, from January 2021 to December 2022. All consecutive patients who underwent surgical intervention for colorectal cancer were included. Data on patient demographics, comorbidities, tumor characteristics, surgical procedures, and postoperative outcomes were collected. Results: A total of 73 patients, with a mean age of 52.5 years (SD = 14.3), were included in the study. Among the patients, 44 (60.3%) were male, and 29 (39.7%) were female. The most frequent complication observed was surgical site infection, which occurred in 13 (17.8%) patients, primarily as superficial infections in 11 (15.1%) patients. Other local complications included wound dehiscence, anastomotic leakage, paralytic ileus, and abdominal sepsis. Systemic complications, such as pneumonia, deep vein thrombosis, acute myocardial infarction, and urinary tract infection, were observed in 9 patients. Significant associations were found between the development of early postoperative complications and various factors. Patients aged 65 years and above had a greater rate of complications than did those aged younger than 65 years (55% vs 22.6%, p value = 0.008). Furthermore, the presence of diabetes mellitus and low serum ALB levels (<35 g/L) were associated with increased complication rates (60% vs 24.1%, p value = 0.01 and 42.9% vs 8.3%, p value = 0.02, respectively). Conclusion: Our study demonstrated favorable outcomes with no mortality and a comparable complication rate to other studies, despite the smaller sample size. The significant associations between postoperative complications, advanced age, diabetes mellitus, and low serum ALB levels highlight the importance of a multidisciplinary approach to enhancing overall patient outcomes.
Background: Thymectomy is an option for the treatment of myasthenia gravis (MG). While the open technique was most frequently performed in the past, nowadays the endoscopic approach has gained wide acceptance. Here we assessed our early experience in thoracoscopic thymectomy (TT). Methods: This case series was retrospectively conducted at Al-Thawra Modern General Hospital and included all patients diagnosed with MG who underwent TT from January 2018 to January 2024. Results: Our case series consisted of 13 predominantly female patients (61.5%), with a median age of 39.5 years. Surgeries typically lasted 50 +/- 10.41 minutes, with the majority performed using a left-sided thoracoscopic approach (n=10, 77%). Immediate extubation was achieved in 10 patients (76%). Four patients experienced early postoperative complications (31%), including dyspnoea, prolonged intubation, chest infection, confusion, tracheostomy, and re-tracheostomy. There were 2 recorded deaths due to complications. Eleven patients were followed up for an average of 16.5 months, revealing that 54.5% achieved complete stable remission, 18% showed improvement with reduced symptoms and medications, and 27% remained unchanged. Conclusion: Thoracoscopic thymectomy is feasible and effective procedure for the management of MG in Yemeni patients. The observed remission and improvement rates are promising and align with global experiences. It is recommended that with proper resources and expertise, similar minimally invasive surgical approaches can be implemented in resource-limited regions. Plain language summary: This study was conducted to evaluate the use of thoracoscopic thymectomy (TT) for the treatment of myasthenia gravis (MG) at Al-Thawra Modern General Hospital. In this study, we included 13 predominantly female patients with a median age of 39.5 years. The most common symptoms experienced by the patients were generalized weakness and ptosis (drooping of the eyelids). During the surgeries, which typically lasted around 50 minutes, we primarily used a left-sided thoracoscopic approach. We were successful in immediately removing the breathing tube in 10 out of 13 patients. However, four patients experienced early postoperative complications, including difficulties in breathing, longer intubation, chest infection, confusion, and the need for tracheostomy. Out of the 13 patients, two unfortunately passed away due to complications. We followed up with 11 patients for an average of 16.5 months and observed that 54.5% of them achieved complete stable remission, meaning they had no MG symptoms and did not require any treatment for at least one year. Additionally, 18% of the patients showed improvement with reduced symptoms and medication usage, while 27% remained unchanged. Based on our findings, we conclude that thoracoscopic thymectomy is a safe and effective procedure for managing MG in Yemeni patients. The remission and improvement rates we observed align with experiences from around the world. We believe that with appropriate resources and expertise, similar minimally invasive surgical approaches can be implemented in resource-limited regions.
Despite vast improvements in training of colorectal surgeons and the care of patients undergoing colorectal resections, contemporary series still show an anastomotic leak rate of 1-19%, which continues to contribute to the morbidity and mortality to these patients. New technologies and more recent studies investigating factors affecting the integrity of colorectal anastomosis have been published. Understanding the factors that increase the risk of anastomotic leak allows surgeons to take steps to prevent and ameliorate these risks. We aim to present an evidence-based narrative review relating anastomotic failure and an algorithm for early detection.
Introduction: Perioperative blood transfusions are necessary during orthopaedic surgery since it is linked with significant bleeding. Remember that receiving blood transfusions containing various blood components might lead to a number of problems. In order to draw conclusions on perioperative blood transfusion methods in orthopaedic surgery, including adjuvants, this literature analysis looks at the most recent data that are currently available. Methods: Databases and other sources were searched for pertinent literature. The following databases were searched for recent evidence: MEDLINE, EMBASE, SCOPUS, PubMed, Google Scholar, the Cochrane Library, and Science Direct. Medical heading subjects (MeSH) were merged with Boolean operators such as OR, AND, and NOT, which restrict or broaden the scope of possible supporting evidence. The weight of the evidence supporting each conclusion was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Results: The included literatures cover a wide range of topics, including fracture type, perioperative bleeding management techniques like adjuvant therapies used to reduce problems from blood transfusions, and hemoglobin thresholds for blood transfusion. Conclusion and Recommendations: Patients who are at danger of bleeding during surgery or who are anemic should be handled with medication, allogenic blood transfusions (restrictive type), adjuvants, and non -pharmacological methods such tourniquets and cell savers. Instead of relying just on one transfusion technique, healthcare personnel should consider the patient's situation in depth and use a variety of transfusion tactics.
Historically, postoperative mortality rates were high after pancreaticoduodenectomy (PD), but in recent times those rates have improved, and Whipple procedures are safely performed. Multiple factors have contributed to the improvement of postoperative mortality rates after PD over time. Known risk factors leading to postoperative mortality after PD are based on patient factors, surgeon/ hospital factors, and postoperative factors. These factors can be attributed to improvements in patient selection and optimization, operative techniques and regionalization to high volume centers, and better understanding and standardization of postoperative care and management of common complications. Further studies should investigate preoperative optimization using prehabilitation and explore early diagnosis of postoperative complications and interventions to prevent mortality after PD.
Purpose: This study aimed to assess and compare the in-hospital recovery times between two groups: those exposed to early intervention and those with late intervention in a cohort of Traumatic Brain Injury (TBI) patients requiring urgent neurosurgical intervention in ALERT Trauma Center in Addis Ababa, Ethiopia.Methods: The study was conducted over seven consecutive months, from March 14, 2020, to October 13, 2020.Patients were consecutively recruited from the emergency department until the final sample size was fulfilled.The recovery time between the early and late surgery groups was compared using the Log rank test.The Cox proportional hazard model was used to analyze the event data, with the assumption of proportional hazards being checked.The measure of effect was reported using the adjusted hazard ratio, and a stepwise approach was used to build the final model.Results: A total of 117 TBI patients undergoing urgent neurosurgical intervention were observed and the median survival time for the early surgery group was 4.1 days, and for the late surgery group, it was 6.4 days, with no statistically significant difference (CHR: 0.73; 95% CI; 0.47-1.11).On the other hand, severe TBI grade emerged as a significant independent predictor, indicating an 86% lower rate of recovery compared to mild TBI cases.Additionally, higher diastolic blood pressure within the range of 50 to 100 was associated with a 24% increased rate of recovery. Conclusion:This study identified factors influencing recovery outcomes and predictors of prolonged recovery, specifically severe TBI grade and lower diastolic blood pressure.The results emphasize the importance of timely intervention and provide specific considerations for optimizing patient outcomes in TBI cases and guiding further research in the area.
The thumb is regarded as the most important digit of the hand, accounting for approximately 40% of the entire function of the hand, loss of a functional thumb leads to loss of key functions and patient autonomy. When the nature of the injury and the amputated part allow it, replantation is the standard of care. However, in cases of tip injury, where the amputated tissue is destroyed or otherwise rendered unusable, other reconstructive methods are used. It is imperative to maintain as much function and sensation as possible while restoring as much lost function and sensation as possible. This includes preservation of the interphalangeal (IP) joint, achieving good soft tissue coverage and restoring motor and sensory functions. With a variety of techniques described in the literature, thumb reconstruction proves to be a formidable task. Moreover, the technique selected must minimized complications associated with reconstruction such as hypersensitivity, contracture deformities, poor aesthetics, limited range of motion and insufficient coverage. We review and summarize the techniques of revision amputation, Moberg advancement flap, FDMA flaps, free tissue transfer from the great toe and non-operative management. We include case reports that highlight the benefits and limitations of some of these techniques.
Introduction: The incidence of thyroid cancer has increased in the last few decades, and follicular thyroid cancer (FTC) is the second most common differentiated thyroid cancer. Metastases outside the neck occur in 10% to 20% of patients with differentiated thyroid cancer and the most frequent locations are the lungs and bones. Case presentation: A 35 years old female patient presented with anterior neck swelling of 3 years duration and anterior chest swelling of 2 years duration. Objectively, there is a multilobulated 10 * 8 cm anterior neck mass, which is hard and moves with deglutition. She has 7*9 cm midline anterior chest mass, which is hard and also 3*3 cm hard mass on the medial end of the right clavicle. FNAC from the thyroid gland shows follicular carcinoma with the anterior chest mass of secondary deposits of similar malignant cells. Neck and chest CT scans were taken that showed enlargement of bilateral thyroid lobes showing internal flecks of calcifications with heterogeneously enhancing malignant sternal mass with lytic destruction of sternal cortex measuring 9*7*6 cm in widest dimensions and right medial clavicular mass, which is 2*3*2 cm with lytic destruction of the cortex. The patient was managed with total thyroidectomy + proximal clavicle resection + sternectomy + chest wall reconstruction. Postoperatively the patient stayed in the ward for 12 days and the course was uneventful, and both serum calcium and thyroid function tests were normal and discharged with levothyroxine. Conclusion: Patients with follicular thyroid carcinoma can present with multiple metastasis to flat bone at initial presentation. Individuals who present with resectable bony metastatic follicular thyroid cancer best be treated aggressively with thyroidectomy, resection of the bony metastasis and levothyroxine in a resource-limited setting were radio iodine ablation therapy is not available.
Aim: To establish if the NELA risk calculator underestimates mortality risk in older adults undergoing laparotomy for mesenteric or colonic ischaemia. Methods: A retrospective search of the operative database was performed for all patients over age 65 years who underwent laparotomy across two tertiary centres over a 3-year period. Cases of mesenteric or colonic ischaemia were identified from the operative records. Cases where ischaemia occurred secondarily to a primary obstructive or other pathology were excluded. Cases where a NELA score was not documented preoperatively were excluded. We then compared the NELA scores to the observed 30-day mortality rate. Secondary outcomes were hospital length of stay and intensive care unit length of stay. Results: Sixty cases were included in our analysis. There were 27 cases of colonic ischaemia and 33 cases of mesenteric ischaemia (mesenteric ischaemia group included five cases of distal small-bowel and colonic ischaemia). The overall mean NELA score was 21.9%, while the actual 30-day mortality was 43.3% (p=0.0094). Mean NELA score for mesenteric ischaemia cases only was 20.6% with an actual mortality rate of 45.5%. Mean NELA score for the colonic ischaemia cases was 23.5% with an actual mortality rate of 40.7%. The median time from operation to mortality was 8 days. Mean age was 77 years. Length of stay for survivors was a mean 27 days with intensive care unit length of stay of 9.3 days. Conclusion: The NELA risk score for mortality post-emergency laparotomy underestimates mortality risk by a factor of two in older adults where the primary pathology is mesenteric or colonic ischaemia.
