Iranian Journal of Surgery
Year:2010 | Volume:18 | Issue:2|Papers Count:16

In this article after a short review about colorectal carcinoma, recent advances in surgical as well as radiation, adjuvant and neo-adjuvant treatments has been discussed. The preparative and generative causes of primary cells of colorectal cancer are relatively known, but little is known about what initiates the process. We discuss about all recent techniques of total mesorectomy or mesocolectomy, and we also discuss about those patients who have been affected by metastatic lesions and their treatment. There is also discussion about the significance and extent of safe margin in the surgery, the number of respected lymphatic glands (even lymphatic glands smaller than one centimeter), the collaboration of pathologist with the surgeon, the determination of the extent of the disease advancement, and the use of lymphatic map for maximizing the number of resected glands.

Introduction & Objective: The aim of this study is the assessment of the factors effective in the outcome of surgical treatment of discopathy and or spinal canal stenosis among two groups of patients with and without diabetes mellitus (DM) at Sina Hospital during 2006-2009.Materials & Methods: We conducted a prospective cohort on all the patients with discopathy and/or spinal canal stenosis, who underwent surgical treatment at Sina hospital, Tehran University of Medical Sciences during during 2007-2009. The patients were divided into 2 groups according to being diabetic or nondiabetic. All the varients were included in the validated data sheet. The operations were performed according to the clinical findings, images and the attending surgeons’ preference. They were followed up for 1 and 6 months and annually thereafter. To measure the outcome a modification of the Owestry low back pain disability questionnaire and basic activity daily living (BADL) was used. Data were analyzed using SPSS version 13.Results: There were 152 male and 137 female patients with the age range between 15 to 80 years, mean=52±12 years. Patients with DM reported signs and symptoms of illness for a longer period of time compared to nondiabetic patients. The mean value of the Owestry disability score was 36.1 for diabetic and 20.0 for nondiabetic cases. Walking distance, incontinency and BADL did not show any statistical differences between two groups preoperatively. However, they indicated marked improvement in both groups. Pain relief was not reported by two diabetic patients and 18 non-diabetics (P=0.111). One case of death was reported among diabetic group and two cases of death occurred among non-diabetics. Four cases of reoperation were registered during the follow up period (one diabetic and 3 non-diabetic patient).Conclusions: Due to the prevalence of the combination of disc herniation and lumbar spinal canal stenosis in the population, it may be impossible to distinguish between the two affections in a specific manner, but It can be concluded that 1) spinal canal stenosis appears in more advanced stages among diabetic patients and 2) long term outcome of surgical treatment is not as good for diabetic patients as the case of nondiabetic patients 3) the difference is not statistically significant between the two groups.

Introduction & Objective: Despite different studies on end-to-side nerve repair, the results are controversial. The importance of end-to-side method is that, it is very useful in cases that proximal nerve is not available and also in this method, the donor’s nerves remain intact and without injury. Finally comparison to other classic procedures, end-to-side repair need less time and less dissection. The majority of studies only evaluated nerve recovery by non functional or functional parameters. As it has been proven, the results of functional and non functional studies are not always matched. This study was designed to evaluate this method by both functional (SFI) and non-functional parameters (histochemical study). Materials & Methods: In this study, the 40 rats were randomly classified in to 4 groups of 10 rats: 1- control group (n=10) in which the nerve was exposed and cut and implanted onto adductor muscles, 2- end-toend anastomosis (n=10) in which peroneal nerve cut and two segment were anastomosed end-to-end, 3- endto- side anastomosis with window (n=10) in which peroneal nerve was cut and anastomosed with window to tibial nerve, 4- end-to-side anastomosis without window (n=10) in which that peroneal nerve was cut and anastomosed without window to tibial nerve. After the 1th, 8th, 16th week functional (PFI) and non functional (histological) studies were performed and the results were compared. The axon count was analyzed by the statistical tests any way Anova and paired sample t-test and were checked by post Hoc Tukye’s test. The data from FSI test were checked with data from repeated tests. Danet test was also used for the confirmation of the data.Results: In all experimental groups (group 2,3,4) motor recovery (SFI) at 8th, and 16th week were not statisticaly different (P >0.05). In histological study axon count in end -to-side with window anastomosis were higher than other experimental groups (P<0.05).Conclusions: According to this study, the authors believe that nerve regeneration and functional recovery occur in end-to-side nerve anastomosis and it has a better outcome than classic producer of nd to end. Considering the different size and diameter of nerves and muscles between mouse and human, the results my by different for humans. The authors propose another similar study in a lagere, such as primates, to generalize these findings.

Introduction & Objective: Pain control after surgery is one of the important issues in postoperative care. Pain alleviation leads to patient satisfaction, faster recovery, and improvement in the function of cardiovascular, respiratory, and gastrointestinal systems. Pain control with anesthetic substances administration in the wound through catheter, is one of the methods which is under study. In this study we assessed Bupivacaine administration in the wound through catheter between and over rectus fascia after midline laparotomy.Materials & Methods: In this study, after informed consent, the patients were divided into three groups. In one group, a catheter was placed between fascias of each rectus muscle. In other groups two catheters ware placed over fascia, after fascia repair .In first two groups, 5cc Bupivacaine 0.25% was administered through each catheter. In third group, normal saline was used and when patients suffered server pain, 50mg pethidine was administered. Pain score was assessed by visual analogue score and narcotic use and post-operative recovery were compared in the three groups. For statistical analysis, the proportions were compared using chi square test. The continuous variables were compared with ANOVA test followed by Dunnett post-test for significance.Results: All 90 patients under study were similar according to age, gender, incision length, literacy level, and cooperativeness. Pain scores in three groups were different (P < 0.0001) and pain was less in patients with catheter in their wounds. Dose of pethedine administration in patients with catheters between rectus fascias, over fascias, and the control group were 250±97.3, 293.2±135.7, and 357±116.6 milligrams respectively (P=0.01). Time of return of bowel sound and gas passage, and hospital stay after surgery were longer in the central group than the other two groups significantly. No wound complication was seen in patients with catheter. There was no significant difference between the two groups with catheters.Conclusions: Bupivacaine administration with catheter in surgical wound after midline laparotomy can reduce pain. This method can reduce period of ileus and hospital stay without major complications. Inserting Bupivacaine catheter between rectus muscle fascias was not significantly beneficial and needs more studies.

Introduction & Objective: Avascular necrosis of femoral is one of the complexities in orthopedic surgery. In advanced cases, the treatment is straighter forward but in early stages the goal is the preservation of head of femur. However there is no agreement with regard to the method. Decompression and drilling with one of bone grafting methods is used with variable results. In this study, decompression and drilling with bone marrow injection, aspirated from iliac crest is investigated. Materials & Methods: Finally 18 patients (23 hips) were included in study. Inclusion criteria were: stage 1 or 2 of avascular necrosis of femoral head, no previous operation on the involved hip and the age under 50. Drilling to subchondral bone and injection of bone marrow from iliac crest was done. Then in 3 and 6 and 12 weeks and 6 and 12 months after operation radiography from hip joint was done and evaluated for signs of collapse and destruction of joint. Results were evaluated with fisher test. Results: A large number of patients who had stage 2 at the beginning of study (18 hips) showed collapse in about 6 months after operation (16 hips 88%). But patients at stage 1 had better results and showed destruction after 12 months of follow up (1 hips 20%).Conclusions: It seems (after evaluation of the results with fisher test) that drilling and bone marrow injection can not prevent progression of disease even in primary stages of the disease.

Introduction & Objective: Revolutionary concept in the strategy of diagnosis and treatment of breast cancer in the last 30 years has significantly increased the accuracy of diagnosis and the quality of treatment while decreasing invasion to the patient.Multidisciplinary team work approach in the Specialized Breast Units is the key point in this new approach. Intimate collaboration of the breast surgeon with the interventional breast radiologist is the base of this multidisciplinary team work. In this new approach the surgeon is in a real sense the one who treats the patient. The surgery is neither acceptable for diagnosis nor for staging purpose. Rather it is done only to treat the cancer mostly as a single stage and to remove symptomatic benign breast lesions. In this study multidisciplinary team work based on this new concept and its role in increasing the accuracy of diagnosis and the quality of care while decreasing unnecessary surgery, is evaluated for the case of Iranian patients. Materials & Methods: Between March 2006 to Feb 2009, trucut biopsy was done for 505 patients with clinical suspicion and/or BIRADS III-V classification in imaging. If pathologic result and clinical suspicion were in concordance, surgery was replaced by short term follow up. Otherwise, and in the presence of moderate and severe hyperplasia, with or without atypia, lobular or papillary lesions guide wire open biopsy was done.Results: Cancer was found in 30% of the cases (24% in stereotactic and 46% in sono-guided biopsies). Moderate and severe hyperplasia with or without atypia, lobular or papillary lesions were found in 5%. There was 2% discordance between clinical/image suspicion and pathologic result.Conclusions: Multidisciplinary team work approach, especially by intimate collaboration between breast surgeon and interventional breast radiologist, can eliminate the need for surgery in 63% of the cases while increasing the accuracy of diagnosis. Pre-operative tissue diagnosis will decrease the expenses of diagnosis of breast disease and breast cancer significantly by omitting unnecessary surgeries, intra-operative pathologic evaluation by frozen section and one stage cancer treatment. This approach which is especially suitable for countries with limited health budget, improves the quality of diagnosis and treatment for breast disease and especially breast cancer.

Introduction & Objective: The rupture of an abdominal aortic aneurysm (AAA) is often life threatening and inappropriate treatment can be catastrophic. The outcome and survival after the operative repair of ruptured abdominal aortic aneurysm depends on a quick, reliable proximal aortic control. This study has been designed to evaluate the result of using a NO20- 24 Foley catheter as proximal aortic control above renal arteries in patients with ruptured abdominal aortic aneurysm.Materials & Methods: This study is a descriptive and Case-Series study for reporting of the results of endoluminal proximal control in aorta. In this surgical method, NO20- 24 Foley catheter is used throughout aneurismal sack on the proximal of the renal arteries. In reporting on quantitative variables, use is made of the average, standard deviation and amplitude, and in reporting on qualitative variables, abundance and ratio is used.Results: Of fifty-seven patients with ruptured abdominal aortic aneurysm 35 patients underwent repair of a ruptured AAA and 22 patients (38.5%) died in emergency room of shohadaye Tajrish Hospital (between 1996 to 2007), where they were operated upon. Mortality rate of patients whom underwent repair was 26 out of 35 and 68.7% of them was in the first 24 hours. The type and rate of complications after surgery were dialysis in 8 (22.9%), gastrointestinal ischemia in 3 (8.6%), myocardial infarction in 2 (5.7%), stroke in 1 (2.9%) and deep vein thrombosis in 1 (2.9%) patients.Conclusions: Using a Foley catheter as proximal control of aorta leads to less mortality and morbidity. Improved outcome can be expected with this new technique.

Introduction & Objective: A robot is an electro-mechanical device made to accomplish a defined physical action skillfully and with high precision. Modern advanced robots are capable of doing a wide range of complex predefined functions precisely and repeatedly, without getting tired. Therefore, they are a good alternative when humans are expected to perform such tasks. In this paper the technical and functional features of a new camera holder robot for laparoscopic surgery are described and the results of its preliminary clinical tests are presented.Materials & Methods: After reviewing the previous experiments, a portable robot capable of gripping the laparoscopic camera, moving at all directions(up, down, left, right, in, and out), and holding the camera steadily at any desired position was designed and developed. It could be controlled by foot pedals or voice commands, alternatively. Preliminary clinical test was conducted on the prototype in different laparoscopic surgeries including cholecystectomy, appendectomy, splenectomy, and inguinal hernia repair, at Imam Khomeini Teaching hospital (Tehran University of Medical Science). During these tests the robot fully replaced the human camera holder, and its functional efficacy was evaluated.Results: Variables, including robot setup time, ease of use, robot’s response to the surgeon’s command(s), precision of movements, provision of optimal view, stability of image, absence of tiredness in long time surgeries, absence of unwanted movement, and absence of incorrect movement were measured that indicated safety, efficacy, and satisfactory function of the robot, which speeded up the course of surgery while facilitating the flow of procedure. Although the setup of the robot takes time and needs some additional work at the start, findings revealed a significant decrease in surgery time in most of operations.Conclusions: Stability of the image, absence of unwanted fine movements and smoothness in changing the view are advantages exclusive to robot. Regarding so, laparoscopic camera holding robot can be a good alternative to its human counterpart. The next step is to simplify the operation of robot through upgrading its software, and conducting a larger randomized clinical study for comparative evaluation of its efficacy.

Introduction & Objective: Colorectal carcinoma is the second most common cause of cancer death in United States. In Islamic Republic of Iran, the incidence rate of colorectal carcinoma is third among men and fourth among women. Based on performed studies, the epidemiology of colorectal carcinoma differs in various regions. Present study has been performed during a 10 years period for assessing epidemiologic features of colorectal carcinoma at Ekbatan and Besat hospitals of Hamedan Iran.Materials & Methods: In this retrograde descriptive study, the dossiers of 167 patients with colorectal carcinoma, who had referred to Ekbatan and Beasat hospitals during years 1998 to 2008, were assessed. Acquired data were analyzed statistically with the SPSS 17, and T-test and Chi-square test were used whenever was necessary.Results: The mean age of patients was 58.67±14.31 years (14-87 years). 12% of patients belonged to the group younger than 40 years. The majority of patients under our study were male (52.1%). There was no significant age difference between the two sexes (P = 0.939) .The most common locations of tumor were rectum, sigmoid colon and ascending colon with the frequency of 31.1%, 20.4% and 18.6% respectively. The most common reported pathology was adenocarcinoma (96.4%). Most of the patients were in the second stage of disease (39.5%). 30.5% of patients were consuming cigarette. Rectal bleeding was the most common the symptom presented by patients (22%). The mean duration between the appearance of symptoms and diagnosis of the disease was 4.13±3.54 months. This duration was significantly shorter in women than men (P=0.008).Conclusions: The most common symptom presented by patients with colorectal carcinoma was rectal bleeding and the most common carcinoma was adenocarcinoma. Performing prospective studies with attention to risk factors of the disease can help decreasing the incidence of this disease.

Introduction & Objective: Fronto-orbital remodeling is the procedure of choice for the treatment of craniosynostosis, affecting the anterior area of the skull and orbital regions. The resorbable plating systems provide rigid fixation while potentially minimizing the long term drawbacks of permanent plating systems. However, plate palpability, visibility, skin breakdown over the plate, encapsulated foreign body and osteolytic changes have been reported. The absorbable fixation systems are composed of either a plate or a mesh and screws. In this clinical trial, we have used plates prepared by cutting a row of mesh for fixation, reducing the palpability and visibility of the implant.Materials & Methods: In this Q experimental study from May 2006 to May 2009, 20 patients (14 males, 6 female) aged 4 to 19 months (mean 6±3 months) underwent operation. Indications for operation were Metopic suture in 8 patients, unicoronal suture in 5 patients, Bicoronal suture in 3 patients, Sagittal suture in 1 patients, Multiple suture suture in 3 patients.All patients underwent fronto-orbital remodeling with cranial reshaping .Through bicoronal approach, once the supra orbital bar is remodeled, a new forehead is created by remodeling the rest of it. Symmetrical repositioning and fixation of supraorbital bar was done, and frontal bone segments were fixed in to position by handmade resorbable mesh plates and screws. The temporal muscle was then advanced to lateral orbital rim and temporal crest, and the priosteum was advanced for the coverage of reconstructed forehead region. The results of treatment, at aminimal follow-up of 6 months were assessed, based on preoperative and postoperative photographs and direct patient examination.Results: The follow-up of the patients ranged from 6 to 36 months (mean 15±6 months). All patients were studied, using photography, radiography, and 3-D CTscans preoperatively and were visited in the clinic 1, 2, 3, 6 week and up to36 months after their operations.During the observation period of up to 36 months, no infection, visibility, exposure, instability or dislocation was observed. The results aesthetically were satisfactory in 90% and good in 10% of patients, according to Bartlett categorization.Conclusions: Absorbable fixation devices in the fronto-orbital remodeling surgery of patients affected by craniosynostosis provides secure fixation while avoiding the potential and well-documented problems with rigid metal fixation. Using a row of absorbable mesh, instead of conventional plate, could effectively reduce visibility and even the palpability of the normal fixation device.

Introduction & Objective: Breast cancer is the most common malignancy in adult female population. Great variations exist in incidence and mortality rate of this cancer in different populations. One of the most important and central factors that can greatly affect mortality of a cancer in a population is the stage of cancer which comes under medical attention. In this study, we describe characteristics of 1500 cases of breast cancer at the time of diagnosis and evaluate probable association between some factors and stage of cancer in which cancer comes under medical attention.Materials & Methods: This retrospective study reviewed files of 1500 cases of female breast cancer. These cases had been referred to a breast cancer private clinic and diagnosis of breast cancer was confirmed by pathologic study. Data about following factors were extracted from files: age of patients, educational level, profession, interval between seeking medical attention and diagnosis confirmation, family history of breast cancer in first-degree relatives, method of diagnosis, results of mammography, tumor size, number of involved lymph nodes, total number of resected lymph nodes, and pathologic stage of tumor. All data of been obtained at the time of diagnosis.Results: Mean age of patients was 49.38±10.46 years. From patients with known size of tumor, 74.5% had a size of more than 2 cm in our population and in patients with known stage of disease, 78.3% of patients were stage 2 or more which means that they had at least one involved lymph node. On an average, an interval of 2.73 ±1.15 years existed between the time of suspicion and time of definite diagnosis. Conclusions: Finally we conclude that stage of breast cancer at presentation is higher in our country when compared with western countries. This difference is both the result of lower compliance of patients and defects in public services.

Thermal burn, which is the most common cause of burns, leads to the destruction of tissues via heat conduction. The heat leads to cellular damage. The depth and severity of burn is determined by the temperature and the duration of contact.In chemical burns with acid, the depth of injury is more than what can be seen initially and the exact evaluation of the depth of the wound needs complete debridement. Here we report about the cases of two pastry workers who had mixed Burns: thermal and chemical (acid). The termal burn was due to the ignition of gasoline and chemical burn was due to the contact with acid that was used for cleaning of the floor.We report on the type of the wound and the follow up and the final results of the treatments of these two patients.

Solitary fibrous tumors of the pleura (SFTP) are rare and often benign tumors, originating from mesenchymal (not mesothelial) cells of pleura. Depending on tumor size and its location it may present with compression effects on adjacent structures or pareneoplastic features such as hypoglycemia and clubbing of the fingers.In this presentation, we reported a 70 years old man who referred to our outpatient's clinic, showing with neurological symptoms such as dizziness, weakness, fatigue and significant weight loss. Laboratory findings showed hypoglycemia, and chest x-ray detected the first indication of the existence of a mass in the left hemi thorax, elevating the ipsilateral diaphragm. He underwent left thoracotomy and a well-encapsulated mass weighing 3 Kg was resected from the thorax. Histopathologically, it was a benign connective tissue without any evidence of malignancy as was shown by immunohistochemistry. Postoperative period was uneventful and patient was discharged from hospital with normal blood sugar.