No abstract

Bouveret's syndrome is a rare cause of gastric outlet obstruction. Its diagnosis is often delayed or overlooked. It is characterized by the passage of a large gall bladder stone through a bilio-duodenal fistula, which becomes lodged in the duodenum causing duodenal obstruction. We report the case of a 70-year-old male with a history suggestive of gall bladder disease over a 1-year period. The diagnosis was confirmed by ultrasound, which showed a single large gall bladder stone and the patient was planned for elective laparoscopic cholecystectomy. One week prior to the elective surgery he presented with upper gastrointestinal bleeding for which he was admitted, diagnosed by a gastroenterologist as bleeding duodenal ulcer and treated by local epinephrine injection and blood transfusion. One week later he presented with a picture of acute gastric outlet obstruction, which proved by endoscopy to be due to a large stone impacted in the duodenum. Endoscopic management failed and the stone was managed by open surgery. The patient made a good postoperative recovery and for the last year he has remained free of symptoms.

has profoundly modified the way healthcare is delivered. Jordan imposed lockdown and restrictive policies between March 17 and May 20, 2020. We aimed to assess the impact of such measures on thyroid cancer treatment plans. In the specified period, 12 patients were scheduled for surgery. Since papillary carcinoma was the preoperative diagnosis in all cases, radioactive iodine ablation (RIA) therapy was also planned 3-4 weeks following surgery after withdrawing thyroxine and achieving a thyroid stimulating hormone (TSH) level > 30 mU/L. Thyroxine withdrawal is the routine method applied for RIA in Jordan as it is less costly compared to the rapid method of exogenous stimulation using recombinant TSH. All surgical procedures were performed without delay since all patients were asymptomatic per flu-like illness and came from a region of low COVID-19 prevalence. These included total thyroidectomy (n = 11), bilateral therapeutic central compartment neck dissection (n = 7), lateral compartment neck dissection (n = 5). However, the RIA treatment plan was altered considerably according to the period in which they were operated. 6 out of the 7 patients operated in March changed to the stimulated method of RIA at a considerable additional extra cost. The seventh patient and the April patient opt to delay RIA until after lockdown. The remaining cases (operated in May) followed the usual withdrawal method as restrictions were due to an end. The restrictive measures applied during COVID-19 did not affect the safe and timely delivery of surgical care. However, it added a financial and psychological burden to the entire cancer management plan.

The routine addition of total thyroidectomy to Sistrunk's procedure seems to be appropriate for comprehensive loco-regional control especially that selecting a subset of patients in which it could be omitted is a difficult task.

The surgical management of papillary thyroid carcinoma remains contentious and the optimal surgical strategy has not been yet established. The extent of thyroid resection has been the nub of this debate. Literature lacks prospective randomized controlled trials that could help put this debate to rest, and these have been labeled as being impractical. Consequently, large retrospective studies and expert opinion have constituted the basis of clinical practice guidelines. Recent American Thyroid Association and National Comprehensive Cancer Network guidelines consider a conservative approach in the form of a thyroid lobectomy sufficient for low-risk disease and that total thyroidectomy remains the standard of care in the presence of high-risk features. Nevertheless, many authorities still advocate more aggressive therapy for low-risk disease. The challenge in standardizing the surgical strategy to papillary thyroid carcinoma is mainly related to a major tumor characteristic: the high frequency of occult cancerous foci whether within the thyroid gland itself or within loco-regional lymph nodes as this tumor characteristic has been incriminated for a higher risk of recurrent disease and its adverse sequelae. The purpose of this article is to provide an overview of the surgical management of papillary thyroid carcinoma and the main arguments surrounding this hotly debated topic. All evidences for this review article were drawn from PubMed articles in English language mostly cross-referenced with international guideline statements.

Pediatric patients are likely to benefit from a tailored surgical strategy. Uniformly offering patients total thyroidectomy seems to be an overly radical approach.

Patients strongly motivated to undergo a novel surgical procedure tailored to their needs and desires should be properly counselled particularly regarding unconventional procedure-related complications.

The 2019 novel corona virus and the disease it causes (COVID-19) is a public health crisis that has profoundly modified the way medical and surgical care is delivered. Countries around the globe had a variable initial response to the COVID-19 pandemic from imposing massive lock downs and quarantine to surrendering to herd immunity. However, healthcare bodies worldwide recognized early on that a triumph against COVID-19 could only be achieved by maintaining the infrastructure of healthcare systems and their capacity to accommodate a potentially overwhelming increase in critical patient care needs. Therefore, they reacted by restricting medical care to emergency cases and postponing elective surgical procedures in all disciplines. The priority was made for treatment of COVID-19 patients and emergency cases. Nevertheless, the battle against the COVID-19 pandemic is still ongoing. In the absence of vaccines or effective drug treatments, its timeline remains uncertain and it cannot be forecast how long healthcare systems will need to cope with it in managing inpatient and outpatient services. Accordingly, extreme measures and restriction may become a recipe for a disaster in the context of the potential adverse health implications imposed by delaying timely medical and surgical care. Therefore, restrictive measures should be substituted with a comprehensive surgical and medical care strategy. One that provides a safe balance between the prevention of COVID-19 and the delivery of essential surgical care. This article provides an overview on how to safely deliver essential surgical care in the time of