Iranian Journal of Surgery
Year:2010 | Volume:17 | Issue:4|Papers Count:26

Introduction & Objective: Esophageal cancer is one of the most fetal and poor-prognosis cancers and is very common in Iran. The main treatment for this cancer is surgery which may be performed with either trans-thoracic (TTE) or trans-hiatal esophagectomy (THE). Each of these methods has specific morbidities and mortalities. So, the choice between their has been controversial. In this study, the outcomes of these two approaches were compared for the case of Iranian patients.Materials & Methods: In this descriptive cross-sectional survey, we studied 100 patients with esophageal cancer who had undergone operation with either TTE or THE in Shohada-E-Tajrish Hospital, Tehran, during 2000-2008. Patients in the two groups were matched for age, sex, duration of dysphagia, surgical grading, pathologic type, tumor location, and background diseases. Analysis was performed by Mann-Whitney, Independent-Sample T, Chi-Square, and Fisher tests.Results: The mean age of the patients was 61 years. Mortality and morbidity rates were the same across the groups (P > 0.05); except for anastomosis leak that was more frequent in the trans-hiatal approach (six versus three cases) with odds ratio of 1.4 (95% Confidence Interval, 1.3-1.6), and also the duration of operation was longer in the trans-thoracic surgeries with odds ratio of 1.3 (95% Confidence Interval, 1.2-1.4) for a duration of longer than five hours (P < 0.05).Conclusions: According to these findings, trans-hiatal and trans-thoracic approaches for esophagectomy have not statistically significant difference in the outcomes. So, each procedure may be chosen, considering physician's opinion and patient's condition.

Introduction & Objective: Surgery in the elderly is an important part of surgery. In the last two decades, the number of surgeries in persons >65 years old has increased from 19% to 37% of all of surgeries. It is expected that the population of over 65 years old will increase from 12.7% to 20% by 2030. If we evaluate the risk factors and relationships between them and post operative morbidity and mortality, then we can decrease post operative complications by controlling the most common and the most important risk factors.Materials & Methods: From 1996 to 2006, 1000 patients with the age of >65 years old were operated (only laparatomy) under general anesthesia at Loghman Medical Center. The randomly selected patients were separated into three groups: 65 to 75, 75 to 85 and >85 years old. The duration of hospitalization and post operative complications and mortality of these patients were recorded and their relations with risk factors were evaluated.Results: This study included 624 men and 376 women. They were divided into three age groups among which 60.1% of the patients had no history of comorbidity and 39.9% had this history. Mortality in patients that had IHD was much more than those that did not have risk factors significantly. In three groups the mortality rate consisted of: 4.5% vs 1.5%, 6% vs 1% and 8.5% vs 2%. Duration of hospitalization in three groups was: 14 days vs 7, 20 days vs 11 and 28 days vs 18. Conclusions: In this study various kinds of comorbidity in patients were evaluated. Among these, IHD was the most common comorbidity that was associated with morbidity and mortality. This relationship was increased from >65 to >85 years old patients. On the other hand, we can decrease morbidity and mortality in the elderly through controls and aggressive treatment of cardiovascular system diseases and evaluations and controls of risk factors.

Introduction & Objective: Postoperative adequate analgesia decreases complications, hospital staying and cost. Postoperative pain management is very difficult and important. There are different techniques for it. One of these methods is patient controlled analgesia (PCA). The aim of this study is the comparison of analgesic and side effects of Morphine, Sufentanil and Placebo in PCA method.Materials & Methods: In this prospective randomized double-blind placebo controlled clinical trial 120 patients who had undergone CABG were divided in to three groups randomly. All of them were anesthetized with the same standard method and were extubated in post cardiac surgery intensive care. A basal infusion rate of 4cc/h was started intraoperativly before closing the sternum by Morphine0.3mg/kg/100cc for group M, Sufentanil 0.015mic/kg/100cc for group S, 0.2 mg /kg Morphine/15minute for group C. After tracheal extubation at ICU, PCA was started by Morphine0.3mg/kg/100cc for M group, Sufentanil 0.015mic/kg/100cc for S group an d normal saline at the same volume for C grouped with PCA bolus dose one milliliter, 15 minute lockout interval and basal infusion rate of 4cc/h, with auto infusion PCA pump (GMbH-WZ-6523C-8). The pain was evaluated (0-10) by visual analogue scale (VAS). Statistical analysis was done by Tukey-HSD test and means of analysis variance ANOVA was at 1 hour, 6h, 12h, 18h and 24 hours after tracheal extubation. Results: VAS was significantly different between the control group and the other two groups at all times (P< 0.0001), but there were no significant statistical difference between Morphine and Sufentanil group. Conclusions: Although PCA is very successful and safe in control of post CABG surgery pain, but either Morphine or Sufentanil could sufficiently decrease post operative pain with no significant difference.

Introduction & Objective: Previous studies have indicated a correlation between variations of the Circle of Willis and some cerebrovascular diseases but the frequency of such variants has not been compared in different races. The aim of this study is to compare variation of the Circle of Willis in a limited population of Iranian people with other studies.Materials & Methods: Samples were obtained from 200 medicolegal autopsy subjects of varying ages. The circle of Willis was examined at the base of the brain. The cerebral vessels were observed for caliber and typical configuration. Variations were noted and grouped into different categories.Results: Out of the 200 specimens examined, 69 (34.5 %) conformed to the typical pattern. In the rest of the specimens (65.5 %) there were variations in the Circle of Willis. Hypoplasia of posterior communicating arteries was the most common variation in our study. One of the autopsies showed the presence of an aneurysm (0.5%).Conclusions: The anatomical variations found in our study of the circle of willis were not significantly different from those reported in the literature. Based on the available studies, there is no evidence that the distribution of the variations of the circle of willis is different in various societies.

Introduction & Objective: Esophageal cancer is one of the most fetal and poor-prognosis cancers and is very common in Iran. The main treatment for this cancer is surgery which may be performed with either trans-thoracic (TTE) or trans-hiatal esophagectomy (THE). Each of these methods has specific morbidities and mortalities. So, the choice between their has been controversial. In this study, the outcomes of these two approaches were compared for the case of Iranian patients.Materials & Methods: In this descriptive cross-sectional survey, we studied 100 patients with esophageal cancer who had undergone operation with either TTE or THE in Shohada-E-Tajrish Hospital, Tehran, during 2000-2008. Patients in the two groups were matched for age, sex, duration of dysphagia, surgical grading, pathologic type, tumor location, and background diseases. Analysis was performed by Mann-Whitney, Independent-Sample T, Chi-Square, and Fisher tests.Results: The mean age of the patients was 61 years. Mortality and morbidity rates were the same across the groups (P > 0.05); except for anastomosis leak that was more frequent in the trans-hiatal approach (six versus three cases) with odds ratio of 1.4 (95% Confidence Interval, 1.3-1.6), and also the duration of operation was longer in the trans-thoracic surgeries with odds ratio of 1.3 (95% Confidence Interval, 1.2-1.4) for a duration of longer than five hours (P < 0.05).Conclusions: According to these findings, trans-hiatal and trans-thoracic approaches for esophagectomy have not statistically significant difference in the outcomes. So, each procedure may be chosen, considering physician's opinion and patient's condition.

Bladder Bladder extrophy is a complex defect in the formation of anterior wall of abdomen and bladder and uretra. It is necessary that the defect be repaired in first days of life. Reports of repair in advanced ages are rare.A 2 years old male with external rotation deformity of both lower limbs and wide perineum in addition to the bladder extrophy and epispadias and bilateral undescended testis, without any history of operation, underwent bilateral iliac osteotomy and closure of symphysis diastasis.

Introduction & Objective: In certain cases of endoscopic forehead lift with no muscle resection, it has been found that, although the muscles remained intact, patients lost or developed weakness in their frowning ability after the operation. This finding persuaded the authors to try to eliminate or decrease the sensory problems of open or endoscopic frowning muscle resection by dis-inserting these muscles. We also sought to determine the efficacy of a brow/forehead lift that did not involve muscle resection. Materials & Methods: In a case series of 18 patients, small scalp incisions were used to elevate the brows/forehead and perform glabellar and forehead muscle dis-insertion. Results: The majority of patients achieved an aesthetically pleasing eyebrow and forehead lift, with reduced power in the frowning muscles. In these patients, we observed a significant decrease in the depth of vertical and horizontal glabellar creases in 14 of 18 patients. [success ratio=0.871, with 95% confidence interval (0.753, 0.989)].Conclusions: Dis-insertion, but not resection, of corrugator supercilli, procerus, or orbicularis occuli muscles can decrease the power of contraction, with a smaller chance of damaging the forehead sensory nerves intermingled in these muscles.

Introduction & Objective: The epidermal growth factor receptor gene (HER-2) plays an important role in cell transformation and tumorgenesis. The presence of HER-2 gene generally predicts a good response to anthracycline-based agents and therapies that specifically target HER-2 (Herceptin).Materials & Methods: Comparison between IHC and CISH methods for assessment of HER-2 status was performed on 38 women suffering from invasive ductal carcinoma. Data analysis was performed by pair wise grouped statistical method.Results: There was a good correlation between IHC and CISH methods for assessment of HER-2 status in 92.1% of cases (Kappa=0.938, P<0.001).Conclusions: CISH method is recommended as a complementary method in the assessment of HER-2 status in invasive ductal carcinoma of breast of those having weakly positive HER-2.

Introduction & Objective: Dermatofibrosarcoma protuberans (DFSP) is a dermal and subdermal sarcoma which involves different parts of body surface. DFSP is a locally invasive tumor and distant metastasis are rare .Wide local resection and coverage of the defects with flaps or grafts is the conclusive treatment of choice. Radiotherapy is recommended when the surgical margins are involved or the tumor is unresectable. In some special cases, imatinib is advised.Materials & Methods: From 1994 till 2005, 11 cases of dermatofibrosarcom protuberans of different parts of body surface were operated on in Shohada Hospital. Most of our patients had experienced one or more operations before. All the tumors were resected with 3cm of safe margin; Deep margin included deep fascia, and in some cases parts of the underling muscle. In cases of scalp DFSP with involvement of external table, full bony layer of the scalp was resected with the tumor and in cases with no involved external table, only soft tissue with periostium was resected. In all scalp involvements, rotation flaps were performed to cover defects. The patients had follow up for 3-14 years. Results: With 3-14 years follow-up, we had neither local recurrence nor distant metastasis. Conclusions: DFSP is a malignant dermal and subdermal lesion which grows slowly and is locally invasive. It can be best treated with wide surgical excision with a macroscopic margin of 3cm and deep margin including deep fascia and/or underling muscles. Radiotherapy is recommended when a residual microscopic tumoral effect is reported.

Introduction & Objective: The aim of this study is to define the relative prevalence of, clinical and demographic state of Burger’s patients admitted to Alzahra hospital, in order to achieve a new attitude on clinical and epidemiological future of the disease.Materials & Methods: This is a descriptive analytic study based on 80 Burger’s patient profiles admitted to Alzahra hospital from 2003 to 2005. The patient information was analyzed on the bases of age, sex, involving limb, smoking, opium addiction, symptoms and duration of the disease and interventions (either medical or surgical) used. Finally the data was analyzed by X2 and Fisher’s exact test in SPSS 13 software.Results: The study demonstrated that there was a significant correlation between addiction and ulcer in patients but no significant correlation was established between the age, sex, smoking and clinical sign and symptoms of the disease.Among all patients evaluated in this study, amputation of the limb was done on 60.1%, sympathectomy on 97.6%, dural catheter on 3.8% and revascularization on 2.6%. Drugs used subsequently as medical therapy were pentoxifyelin, Aspirin, iloprost on 61.2%, 18.8% and 2.5% respectively. Conclusions: There was a significant correlation between opium addiction and ulcer and also amputation. Other studies were on accordance with our study. With early diagnosis based on history and clinical examination, we can prevent disease.

Hydatid cyst disease may involve all organs of human body, but, the most common sites are liver and lung, and the less common are brain, heart, spleen, bone and parotid. Herein, we report a case of this cyst in the parotid of a two-year-old girl, who was treated medicaly, before surgical intervention in our center.

Introduction & Objective: To determine the relationship between serum phosphate, serum calcium, and serum parathyroid hormone levels with parathyroid adenoma weight and postoperative serum calcium in primary hyperparathyroidism.Materials & Methods: In a prospective study from 2005 to 2007, eighty patients with single parathyroid adenoma entered the study. Preoperative serum calcium, phosphate, parathyroid hormone, alkaline phosphatase and weight of adenomas were recorded. Postoperative serum calcium was measured 24 hours after adenoma resection. Analysis was performed with student T-test and Bivariate correlation. The level of significance was set at P<0.05.Results: With respect to the adenoma weight, there was a significant correlation with serum calcium and parathyroid hormone (P = 0.003 and, P =0.0001 respectively).There was no correlation between postoperative serum calcium and serum alkaline phosphatase (P=0.3), serum parathyroid hormone (P=0.3) and adenoma weight (P= 0.1). But there was correlation between serum calcium decline after adenoma resection and preoperative serum calcium (r=0.92, P<0.001), parathyroid hormone level (r=0.54, P<0.001), alkaline phosphatase level (r=0.3, P=0.006) and adenoma weight (r=0.036, P=0.001).Conclusions: Adenoma weight has a positive impact on preoperative serum calcium, parathyroid hormone and alkaline phosphatase. Preoperative serum markers and adenoma weight are unreliable for predicting serum calcium level postoperatively, but we can estimate calcium decline postoperatively with preoperative serum calcium, PTH, alkaline phosphatase level and adenoma weight.

Introduction & Objective: The use of different techniques that reduce post operative pain after laparoscopic surgeries, especially laparoscopic cholecystectomy, as a one of the most prevalent laparoscopic surgeries, has been controversial. The aim of this project has been to compare the procedures of intraperitonal bupivacaine and intravenous petidine as far as pain after Laparoscopic Cholecystectomy is concenrned. Materials & Methods: In a randomized controlled trial at Modarres hospital's general surgery ward, 48 patients, who had enrolled for laparoscopic cholecystectomy, were divided in two groups. In 24 patients traditional method of intravenous petidine, was used at the end of laparoscopic cholecystectomy surgery, for reducing of post operative surgery pain and in 24 another patients, intraperitoneal injection of Bupivacaine was used at the end of surgery. The two groups were compared as far as the need for excessive analgesic, respiratory effort and some complications such as nausea and vomiting, hypotention, and respiratory depression was concerned. The data were analyzed by SPSS 13 and statistical t-test, Fisher's exact test and multiple measure test, and were expressed as mean standard deviation P<0.05 was considered significant.Results: In none of the two groups, hypotetion or respiratory depressions were seen. The amount of need for oral excessive analgesic were significantly fewer in Bupivacaine group than the other group (P<0.05). Likewise, nausea and vomiting in primary hour’s after surgery were fewer in Bupivacaine group than pethidine group (P<0.05). Respiratory effort in Bupivacaine group was significantly higher than petidine group.Conclusions: The routine use of intraperitoneal Bupivacaine at the end of laparoscopic cholecystectomy is recommended, because it is more effective in reducing pain, nausea and vomiting and more comfortable respiration.