Iranian Journal of Surgery
Year:2006 | Volume:14 | Issue:1 (36)|Papers Count:18

Introduction & Objective: Frostbite may be defined as the freezing of tissues when exposed to temperatures below the freezing point of intact skin. With frostbite the skin and subcutaneous tissue of exposed body parts, especially the hands, feet, nose and ears are most often affected. The severity of the injury is enhanced by wet clothing, air movement, peripheral vascular disease and decreased level of consciousness. Once seen as a military phenomenon, the frequency in the civilian population has risen over the past two decades. Effective treatment of this condition has therefore become an issue, not only for the rural physician in polar climates, but also for many urban hospitals.Materials & Methods: In this article we present a 22 year old man with frostbite of lower exteremity and elavuate management and treatment of this patient. In addition, we searched the litreatures for frostbite, the literature refrenced in this review was obtained from a computer search of frostbite in little of English language article in pub Med database from 1980 through January 2006. Results: Research into the pathophysiology has revealed marked similarities in inflammatory processes to those seen in thermal burns and ischemia/reperfusion injury. Evidence of the role of thromboxanes and prostaglandins has resulted in more active approaches to the medical treatment of frostbite wounds. Although the surgical management of frostbite involves delayed debridement after demarcation, recent improvements in radiologic assessment of tissue viability have led to the possibility of earlier surgical intervention.Conclusions: Several adjunctive therapies, including dexteran, antithrombotic, vitamin C, pentoxifylline, defibrotide, vasodilators, thrombolysis, hyperbaric oxygen, and sympathectomy, are discussed and finally we proposed a therapeutic protocol for the best management and follow-up of frostbite.

Introduction & Objective: Trauma is the most common cause of death for individuals between age of 1 to 44 years and the third most common cause of death of all ages. Abdominal trauma is accounting for approximately 25% of all trauma and delayed diagnosis and treatment is the principal cause of death. In this case, CT scan as a diagnostic modality with physical exam and other procedures is used. The aim of this study is to survey CT accuracy in Abdominal trauma in Alzahra and Kashani hospitals so that evaluate the rate of CT influence in operation results and if there was probable difference between CT sensitivity and specificity in this and other studies, will be eliminated by radiologist and surgeon more attention.Materials & Methods: This study had been descriptive - analytic trial for collecting data, 120 patients with kidney, liver and spleen trauma who had CT and laparatomy report sheets in their files, were selected and their advantages were recorded in a from. The information were classified and listed in tables then analysis with chi square test was done. The time of this study had been in March 2004 and data collection was before then.Results: The results of this research are: Splenic trauma prevalence in CT is 50.8%, in laparatomy 65%, CT Sensitivity 73.1%, Specificity 90.5%, P.P.V 93.4%, N.P.V 64.4% and Accuracy 79.2%. Hepatic trauma prevalence in CT is 29.2%, in laparatomy 28.3%, CT Sensitivity 64.7%, Specificity 84.9%, P.P.V 62.9%, N.P.V 85.9% and accuracy 79.2%. Renal trauma prevalence in CT is 23.3%, in laparatomy 26.7%, CT Specificity 97.8%, P.P.V 92.9%, N.P.V 93.5% and accuracy 93.3%. Injury prevalence in CT is 79.2%, in laparatomy 89.2% CT Sensitivity 86.9% Specificity 84.6%, P.P.V 97.9%, N.P.V 44% and Accuracy 86.7%. Conclusions: According to a comparison between results of this and other trials, was found that CT accuracy was less than mentioned trials. The causes could be related to delayed rupture of spleen not diagnosed with conventional CT, inavailability of Spiral CT in 24 hour time, different opinions between radiologists in CT reporting and undoing suitable standard protocol in CT Scan for trauma patients.

Introduction & Objective: Patients suffering from a major trauma such as burn, have a high risk of infection that is attributed to decline of their immune response. Nonspecific immune stimulators have been used experimentally to improve the patients' immune status. Immune-stimulatory effects of levamisole have been cited in literatures.Materials & Methods: This study is conducted to assess the efficacy of levamisole on improvement and duration of hospitalization of burn patients in university-affiliated burn center in Yasuj, southwest Iran. Sixty-one thermal burned patients were randomly allocated into two groups. The case group (29 patients) received levamisole 3mg/kg weekly (one mg/kg) every other day, and the control group received vitamin C every other day as a placebo.Both groups had received routine burn treatments.Results: The eschar peeling time was 19.14 days in group A and 23.13 Days in group B. Complete wound healing in group A was on 27.72 days, while was on 32.87 days in group B. Statistical analysis of the data using T test showed that the differences are significant (p<0.0001).Conclusions: Levamisole as a non-specific immune stimulator can be used to enhance the immune status of burn patients which in turn improves the patients recovery time.

Introduction & Objective: In Iran due to accessibility and ease of performance, Doppler Sonography is used frequently to evaluate the etiologies of erectile dysfunction. Since our patient population is younger compared with the developed world and Doppler Sonography is relatively invasive, there is a need for some screening tool before referral of the patients for sonography. The purpose of the current study is to evaluate the sensitivity, specificity and accuracy of Farsi International Index of Erectile Function questionnaire as compared with the results of Doppler Sonography.Materials & Methods: Doppler Sonography evaluated 103 impotent patients. Before the procedure, and after obtaining patients' consent, they filled in the Farsi questionnaire. Doppler Sonography was performed in the sonography unit and papaverine 40 mg intra-cavernous injection was utilized. After the calculation of the questionnaire's scores, the best sensitivity and specificity cut-off levels for the detection of probable vascular etiologies was determined using the Receiver Operating Characteristic (ROC) analysis. Results: Mean age (SD) was 40 years (+/- 10). Fifty-nine (57%) were 40 years old or less. Doppler Sonography was normal in 61 (59%) of the cases. Diagnosis of arterial insufficiency is possible when the questionnaire scores are 40 or less with 88% sensitivity, 82% specificity and 82% positive predictive value (ROC=0.90). Scores of the erectile maintenance can predict a diagnosis of venous leak with a 99% sensitivity, 77% specificity and 76% positive predictive value (ROC=0.97).Conclusions: Farsi International Index of Erectile Function questionnaire is a reliable tooL If scores sum 40 or less, chances are high that Doppler Sonography will detect a vascular problem to explain the patient's sexual dysfunction. In such a circumstance, the physician should refer the patient to a specialist or order a Doppler Sonography by himself.

Introduction & Objective: Covering of the surgical wound with a sterile dressing is usually considered a routine conclusion to an aseptic operation.Atleast the wound is usually left dressed for 3 to 5 days. The main purpose is keeping the site of surgery, safe from any risks bound to contamination with microorganisms. If the contamination happens then a wide spectrum of complications may occur ranging from local redness to copious infective discharge, dehiscence or even eviscration.The goal of this study was to compare complications when clean and clean- contaminated surgical wounds left undressed ordinary managed, verfus dressed routinely.Materials & Methods: One hundred one patients with clean and clean-contaminated surgical wounds were randomized prospectively to receive dressing (N=45) or have their wounds left exposed without any dressing (N=56).Results: In the group that received wound dressing, happened no complications. But infection developed in one case (0.99%) in other group and also there were 2 cases of hematoma and seroma (1.98%). There was no significant difference in terms of wound infection after applying dressing or leaving the clean and clean contaminated wounds exposed without any dressing (P<0.05).Conclusions: Dressing of clean or clean-contaminated wounds may be unnecessary.

Introduction & Objective: Vasectomy is the most effective permanent contraceptive method in men. It is a simple operation that infiltrates the men with extelling the sperms from ejaculated semen from penis during intercourse. This surgery can perform with different techniques and like other surgeries can be complicated with some side effects. Each of vasectomy techniques have got advantages and disadvantages. Our purpose in this study are comparing of two different surgical techniques for vasectomy and determining of its disadvantages. Two performed techniques were: 1. ligation of vas ends 2. Cauterization of vas ends.Materials & Methods: This study was prospective and descriptive (case-series). The samples were the men referring for outpatient surgical vasectomy at outpatient operating room in Baghiatallah hospital. One hundred patients underwent vasectomy surgery were selected for one of mentioned methods (at two group of 50) and after studying of sheets and ask them, we assessed the duration of operation, intensity of pain during surgery, intensity of pain after surgery, outcome on number of coitus and outcome on libido, haematoma, infection, granuloma, epididimits, chronic pain after surgery.Results: The results, point that the group underwent cauterization in comparison to the group underwent ligation had got less duration of operation (mean 7.56 min versus 9.88 min), less intensity of pain after operation (3 cases versus 10 cases), less cases affected with epididimitis (2 cases versus 8 cases) and less cases affected with epididimits (zero cases versus 5 cases), in other aspects there were no significant differences between two groups.Conclusions: By regarding the less time of surgery, and less pain after surgery, less granuloma formation and epididimtis and also because in cauterization the surgeon doesn't use of string so the evidences suggest that the electrocautery seems to be superior than ligation technique.

Introduction & Objective: Demography of peptic ulcer perforation has changed considerably since first reported case, especially according to age and gender. The incidence in stomach and duodenum has also changed.Material & Methods: This descriptive study has been performed on patients who presented with perforated peptic ulcer to Loghman Medical Center between 1999 and 2004.Results: In these study 88 patients with perforated peptic ulcer were included. The mean age was 41 year. Eithgty five patients were male and only 3 were female. History of smoking was positive in 56 patients (63%) and 39 patients (44%) were opium addicts. Eleven patients (12%) had a history of occasional alcohol consumption. Comorbidites were present in 8 cases (10%) consisting of diabetes, hypertension, heart disease, pulmonary disease and strokes.Discussion: Some important changes appeared in the demography of perforated peptic ulcer, such as, increasing age, changes in gender distribution (male dominance) and a predisposing factor such as opium addiction.  

Introduction & Objective: There are a variety of methods for limb lengthening; with their known advantages and disadvantages. We intended to re-introduce an easy and economic device for lengthening. Here the results of 12 cases of unilateral tibial lengthening with REZAIAN external fixator are represented.Materials & Methods: Twelve cases of unilateral tibial shortening (4-7 cm, average 5.5), including 7 females and 5 males between 11-27 years old (average 16.5 y/o) , with no accompanying limb deviation, angulation, joint contracture/subluxation, soft tissue compromise or underlying bone disease were selected. Patients underwent unilateral lengthening of 1 mm/day with REZAIAN external fixator, and subsequent PTB cast and FWB after appearance of proper callus. PTB cast was discarded after radiologic union.Results: Correction of 4-5 cm (mean 43 mm) in 12-20 month period (mean 15 month) was obtained. The mean time for every centimeter of lengthening was 74 days. There were no neurovascular, joint or substantial angulatory complication. There was 4 pin track infections which were managed with oral antibiotics, and 2 patients needed bone grafts following delayed union, 8 month after surgery. All cases were followed for at least 12 months, and no major problem was encountered.Conclusions: Although the mean time for lengthening is higher than conventional lengthening devices, the introduced device has advantage of easy application and low price and few complications.

Introduction & Objective: The differential diagnosis for a dorsal midlinmass presenting in a newborn encompasses a wide range of pathological conditions, including spinal dysraphisms, tumoral overgrowths including teratoma and hamartoma, disturbances in regression of fetal tail, and pseudotail formation.Materials & Methods: To present (a) three rare cases of human tails and one case of tethered cord due to a midline anomaly resembling part of a human limb, (b) to discuss different kinds of clinical and pathological conditions which may be encountered in such newborns, (c) to hypothesize a theory about genesis of these congenital lesions, and (d) to remind drawbacks in preoperative evaluations and surgical management of these newborns.Results: Four new borns with dorsal midline malformations initially diagnosed as heterotopias are presented. Appropriate preoperative investigations and proper surgical interventions leading to resection of the lesions were performed. All four were skin-covered lesions containing well differentiated cellular elements of fat, vascular, muscular, bony, and cartilaginous origin. Midline spinal dysraphism was detectable both preand intraoperatively only in one case in which cord untethering was also performed along with the first surgical intervention. In the other three "tailed cases," midline bone defect could not be etected in the available X -ray films; consequently, simple excision of the tail-like lesions was done. The first patient had to be explored for repeat untethering of the cord after 4 years, but the others have not yet developed any sign of tethering during an average period of 12 years follow-up.Conclusions: Morphological diagnosis of these lesions is not easy, and the attending pediatrician and neurosurgeon should be familiar with the differential diagnosis of such lesions and be prepared for possible time-consuming operation mandatory to achieve total resection of the lesion in a newborn under general anesthesia. Reviewing the possible theories regarding the genesis of such anomalies, it is hypothesized and suggested that all similar cases could have been of hamartomatous origin rather than defects of embryogenesis.

Introduction & Objective: Osteoporosis is a worldwide public health problem and has an increasing prevalence. In women rapid bone mass loss at beginning of menopause due to estrogen deficiency is established. This is a pilot study to estimate the prevalence of osteopenia and osteoporosis in postmenopausal women.Materials & Methods: In this observational and cross-sectional study, we studied 502 post menopausal women that admitted consecutively to only bone densitometry center of Yazd between 2002 and 2003. We excluded whom with diagnosis of osteoporosis, chrollic, metabolic and bone disease, previous oopherectomy/hysterectomy and consumption of bone metabolism affected drugs. A questionnaire containing of demographic data was completed. lumbar spine and femoral region bone density was measured using dual x-ray absorptiometry (DXA) at the Doctor Mojibian Hospital, YAZO, by only one educated technician.  Statistical analysis was performed by SPSS 11.5 and wit Chi Square, Anova and Kappa tests.Results: We studied 502 post menopausal women between 50 to 85 years old and with mean age of 60.78± 7.05 year. The results of the bone mineral density (BMD) in gm/cm2 were compared to the peak bone density (P6D) in healthy young women (T-score). Based on the definition of World Health Organization (WHO), the T-score value was considered for analysis. Accordingly, 138 (27.5%) subjects showed normal result, while 261 (52%) subjects showed osteopenia, 103 (20.5%) subject showed osteoporosis due to L2-L4 spine BMD. On the other hand, 70 (13.94%) subjects showed normal result, while 216 (43.03%) subjects showed osteopenia, 216 (43.03%) subject showed osteoporosis due to femoral region BMD. Only 261 (52%) of cases showed one diagnosis in both regions and others (241 cases, 48%) had different diagnosis based on measured region.Conclusions: Osteopenia and osteoporosis are common among postmenopausal women in YAZD and in extent, similar to Saudi Arabia and should be considered as a matter of public hearth. Bone densitometry should be used to assess the severity of bone loss, identify those who need therapy and for follow up and early diagnosis of those with osteopenla in order to institute proper therapy and avoid future osteoporosis.

Introduction & Objective: This is a prospective, randomized trial comparing two treatment methods for thoracolumbar burst fractures: Short-Segment instrumentaion with correction of thoracolumbar curve based on normal sagital index and the traditional treatment method of pedicular screw fixation.The objectives of this study was: evaluate the efficacy of each of the treatment methods normal thoracolumbar curve (based on sagital index).We would like to suggest that correction with aid of sagital index has better outcome and may prevent the early failure.Materials & Methods: Forthy patients with thoracolumbar burst fractures were included in the study. The inclusion criterion was the presence of fractures through the T12-L2 vertebrae without neurologic comproilllse.The patients were randomly selected by a simple method in two groups. In Group 1, Patients were treated using short segment instrumentation with traditional procedure (n=20). In Group 2, Patients were treated using short-segment fixation with correction according to normal thoracolumbar curve regarding to normal sagital index (n=20). Clinical (Likert's questionnair) and radiologic (Sagital index, percentage of anterior body height compression) Outcomes were analyzed.Results: The two groups were similar in age, follow-up period, and severity of deformity and fracture. The postoperative and follow-up sagital index, percentage of anterior body height compression, except the average correction loss in both groups were significantly different.But the failure rate defined as an increase of 10° or more in sagital index and/or hard ware failure was significantly different (Group 1,40%; Groups 2, 20%).Conclusions: Short-Segment transpedicular instrumentation of thoracolumbar burst fractures is associated with a high rate of early failure that can be decreased by correction regarding to normal sagital index.

Introduction & Objective: During the last decades, many changes have been taken place in forehead lifting procedures. These modifications were toward less invasiveness and producing fewer trauma to the muscles and nerves of forehead, to reduce the complications of this operation. Materials & Methods: Using the endoscope made the main changes, by doing key hole surgery through 4-5 small incisions. Extensive studies performed on forehead and upper lip muscle by different authors which lead to a new surgical method. Excising the eyebrow depressor muscles through blephroplasty incision, published by Guyoron combining these two operation, invented a new method, called "Minimal incision, none endoscopic, forehead lift" which introduced by Knize.Results: The authors of this article used endoscopic method for 2 years, but switched to the above technique recently. Thirty two patients were operated by this procedure.Conclusions: We present our experiences in using this new method and our modifications, for refinement of the procedure and to share it with other colleagues for further discussions.

Although tuberculosis of appendix is rare, but the prevalence in some areas, due to socioeconomic problems, in people who have unhealthy sanitary habits, is 0.1- 0.3%.We report a case of Granulomatose Appendicitis, who was operated on for acute Appendicitis, with no detectable disorders elsewhere in the body, in January 2004.She had been healthy and satisfied for seven months. But she was admitted to Toos Hospital in August 2004, after she was experiencing weight loss, anorexia, anemia, fatigue, ascites and constipation from the previous month. She was very ill and depressed. Examination of respiratory and cardiovascular systems was normal. Apart from a CA 125 which was 1800, and slight anemia, laboratory studies were normal. Report of abdominaland pelvis CT Scan showed cystadenocarcinoma of the ovary. Examination of ascites fluid, which was clear, showed inflammatory cells, and negative for malignancy.With provisional diagnosis of carcinoma, the patient was taken up for surgery. We aspirated 5000 ml of fluid, and found seeding all over the peritoneal cavity, but no pus or any tumoral lesions in the cavity. We took some biopsies which was sent for cytopatology. We performed a closed drainage with a Foley catheter No: 14 (closed drainage), and then closed the abdomen. Anti tuberculous treatment was started with four drugsin conventional doses. Post-operative course was uneventful, we removed the drain which was clamped, most of the times, on the 7th post-operative day. She was discharged on the 10th post-operative day, with very good recovery, no remarkable ascites or discharge. She has been satisfied, and symptom free so far (December 2005).

The extensor tendons of the hand have numerous anatomic variations. Knowledge of these variations is essential during hand surgery, especially in tendon transfer operation. In this article, we have reviewed the anatomy of the extensor tendons and the probable variations. We have also reported a rare case of double extensor indicis proprious tendon which had two slips and two muscle bellies which were joint proximally at the origin.