Background Patients with thyroid disease frequently complain of dysphagia. To date, there have been no prospective studies evaluating swallowing function before and after thyroid surgery. We used the swallowing quality of life (SWAL-QOL) validated outcomes assessment tool to measure changes in swallowing-related quality-of-life in patients undergoing thyroid surgery. Methods Patients undergoing thyroid surgery from May 2002 to December 2004 completed the SWAL-QOL questionnaire before and one year after surgery. Data were collected on demographic and clinicopathologic variables, and comparisons were made to determine the effect of surgery on patients’ perceptions of swallowing function. Results Of 146 eligible patients, 116 (79%) completed the study. The mean patient age was 49 years, and 81% were female. Sixty-four patients (55%) underwent total thyroidectomy and the remainder received thyroid lobectomy. Thirty patients (26%) had thyroid cancer. The most frequent benign thyroid conditions were multinodular goiter (28%) and Hashimoto’s thyroiditis (27%). Mean pre-operative SWAL-QOL scores were below 90 for nine of the eleven domains, indicating the perception of impaired swallowing and imperfect quality of life. After surgery, significant improvements were seen in eight SWAL-QOL domains. Recurrent laryngeal nerve injury was associated with dramatic score decreases in multiple domains. Conclusions In patients with thyroid disease, uncomplicated thyroidectomy leads to significant improvements in many aspects of patient-reported swallowing-related quality-of-life measured by the SWAL-QOL instrument.

Reverse-alignment surgical skills can be improved with experience, but may require a volume of cases exceeding that encountered in residency training. Reverse image skills are not derivative from surgical skills developed in a video trainer with forward orientation.

IgG4-related disease is a recently recognized entity linked initially to autoimmune pancreatitis and has been subsequently described in nearly every organ system. Men over the age of 50 represent the most affected demographic group and a comprehensive set of diagnostic criteria has been developed to aid treating clinicians. Though elevated levels of IgG4 in the serum are suggestive of the disease, definitive diagnosis is made on histopathology. Treatment is tailored to the clinical presentation with corticosteroid therapy known to have proven efficacy. Gastric manifestations of the IgG4-related disease primarily come in two varieties, notably chronic ulceration or pseudotumor formation. Autoimmune pancreatitis conveys increased risk for IgG4-related disease of the stomach, which is independent of Helicobacter pylori status. In this case report, we present an acute gastric-pericardial fistula secondary to IgG4-related disease that required urgent operative management. To our knowledge, this is the first report in the medical literature describing this complication of IgG4-related disease.

IntroductionIntussusception is rarely encountered in adults, accounting for just 5% of all occurrences and 1% of bowel obstructions. In up to 90% of episodes of adult intussusceptions, operative intervention is required secondary to pathological lead points. Prior to the current report, only three cases of total ileocolic intussusception with rectal prolapse in adults have been described in the world literature, making it an important contribution to surgical knowledge. In addition to a discussion of disease etiology, this review outlines sound diagnostic and therapeutic principles in the successful management of this rare emergent surgical condition.Case presentation and literature reviewIn this case report, we will present a rare case of total ileocolic intussusception with rectal prolapse in a 22 year-old female without antecedent history. She had both a lead point in the cecum, as well as a highly mobile, intraperitoneal colon. Lead points have been found in only half of the reported cases, including this one. In addition, colonic laxity may enable this phenomenon, being attributed to the loss of zygosis during the embryological period, in which there is persistence of the ascending and descending mesocolons and lack of apposition to the retroperitoneum. The diagnostic work-up, operative strategy and pathological findings are discussed. The three previous cases reported in the English-language medical literature were reviewed.ConclusionsAdult intussusception, while uncommon, may be encountered in an acute surgical setting and optimal outcomes depend on a high index of suspicion and expeditious management. Embryological divergence may contribute to the even rarer variant of total ileocolic intussusception with rectal prolapse.

IntroductionObscure gastrointestinal bleeding from the small intestine may present the Acute Care Surgeon with a formidable diagnostic and therapeutic challenge. Despite the current array of diagnostic studies, localization of the causative pathology may be elusive, especially when the bleeding is intermittent. When a small intestinal arteriovenous malformation is the responsible lesion, a technique combining super-selective angiography with intra-operative methylene blue injection and focused enterectomy has been described in a number of case series. The current case report utilizes this same approach with emphasis on computed tomography angiography representing a key first step in the diagnostic algorithm.Case reportIn this case report, we describe the diagnosis and treatment of obscure gastrointestinal bleeding emanating from an arteriovenous malformation in the small intestine of a 52 year old male. After an extensive work-up including upper and lower endoscopy, double balloon enteroscopy and capsule endoscopy, he was referred for computed tomography angiography. Though he was not actively bleeding, a jejunal arteriovenous malformation was localized on imaging. This prompted directed transfemoral angiography, placement of a super-selective microcatheter in the 4th jejunal arterial branch, intra-operative methylene blue injection and focused enterectomy with pathological confirmation. The patient was found to be free of gastrointestinal bleeding on 6 month follow-up.ConclusionsA step-wise, rational diagnostic approach should be utilized in the evaluation of obscure gastrointestinal bleeding. In the non-actively bleeding patient, computed tomography angiogram may facilitate the diagnosis of a small intestinal arteriovenous malformation. Methylene blue injection via a super-selective angiographic microcatheter may then allow for focused enterectomy.