Iranian Journal of Surgery
Year:2010 | Volume:18 | Issue:3|Papers Count:12

Discovery of antibiotics has been one of the third great advances in the field of surgery in the past 150 years. On the other hand antibiotics are one of the most prescribed drugs in surgical practice. Therefore, surgeons should keep themselves up to date in this field. Because of so much use of antibiotics, the infection has become much more complicated and severe due to bacterial resistance. The disappearance of non-resistant bacteria has been replaced with the most virulent form which is able to induce organ failure and shock and sometimes an irreversible situation.Surgery in geriatric patients which most often have comorbid conditions makes them more liable to infection. The application of implants, metallic devices, meshes and immunosuppressive drug which are routinely used in organ transplant, have made the patients more susceptible to bacterial infection. So it is clear that for use of the antibiotics in any patient it should be approached individually. Nevertheless infection is the second cause of death after cardiac events in surgery.

Introduction & Objective: Tissue ischemia and necrosis of flap is a challenging problem in reconstructive surgery. Pharmacological agents and modifications of procedures have been examined for halting or reversing these processes and maximizing the length to width ratio with different results. In this study, the effects of clexan, plavix and their combination on skin random flap survival were examined in rat.Materials & Methods: Forty male rats of a specific race were randomly assigned to four equal groups. In all of these rats surgery were done as follow: Surgery was done under general anesthesia a rectangular 3×11 cm modified distally based Mc-Farlan type flap. Then the flap sutured back into its primary site over a sterile surgical drape. In the first group only anesthetic agent and prophylactic antibiotic was given. In the 2th group after surgery clexan with a dose single of 3.2 mg/kg was injected subcutaneously after surgery. In 3rd group, plavix tablet, 25 mg/kg via OGT (OroGasteric tube) was given after surgery and this drug was continued for 7 days. In the 4th group we combined the methods used in groups 2 and 3 (Each rats received both clexan and plavix.). After 7 days all rats were scarified and then the photo of flaps was taken with Digital camera. The total surface of flap and also the area of necrosis were calculated with Image J software. Mean standard deviation and variance analysis were used to compare the groups.Results: Plavix alone significantly improved flap survival in comparison to control group (P<0.05), but effect of clexan alone and combined clexan and plavix was not statistically significant.Conclusions: It seems that plavix may have an important role in clinical setting of ischemic flap but clexan may have not.

Introduction & Objective: Chronic subdural hematoma (CSDH) is a common disease and consists of bleeding in the intracranial space. Trauma is the most common cause of CSDH. The present study is designed to determine factors associated with the outcomes of patients suffering from CSDH after surgery by Burr hole-drainage method.Materials & Methods: Through a prospective cross sectional study, all 59 patients with CSDH, who had been hospitalized in the Neurosurgery Department of Besat Hospital, in Sanandaj, Iran between 2008- 2009, were recruited. A check list was prepared and data was gathered by interview and referring to patients’ hospital records. Patients were divided into four groups according to Odom and Finney outcome scale and then were further divided into two groups for easier analysis. T test, Chi square, Fisher exact test, and Logistic Regression via SPSS version 17 was used for analyses.Results: Of 59 patients recruited, 51 (86.4%) were male. The mean age (±standard deviations) of patient's was 62.0±19.9 years. No statistical correlation was found between the time interval of the previous trauma to surgery, preoperative hospitalization, hematoma bloody content, drain anatomic site, recurrence signs in CT scan, recurrence treatment and patient’s outcomes (P>0.05). However, patient's age (elderly), sex (female), anticoagulatory drugs consumption, duration in which drain was kept within the hematoma cavity, presence of postoperative medical and surgical complications, GCS at hospitalization and at discharge and one month after discharge, risk factors and underlying medical conditions had significant relationships with the patient's outcomes (P<0.05 for all). A multiple logistic regression analysis showed that only two demographic factors including elderly (Adjusted OR; 4.2, 95% CI, 2.5-6.4) and female gender (AOR; 7.2, 95% CI, 2.5-6.4) were remained statistically significant.Conclusions: The present study found a gender-based as well as an age-based association for unfavorable outcomes in patients suffering from chronic subdural hematoma.

Introduction & Objective: Pain control is one of the main issues in laparoscopic surgeries. Although opioid and non-steroidal anti-inflammatory drugs (NSAIDS) are used for pain control but there are severe side effects, but it is thought that, new generation of NSAIDS are able to control pain without any significant side effects of narcotics. We compared postoperative pain, analgesic administration, duration of hospital stay, and side effect of surgeries such as vomiting.Materials & Methods: From September 2008 to March 2009, we enrolled 75 laparoscopic cholecystectomy patients in a randomized clinical trial study. The patients were randomly divided into two groups. In intervention group, 200 mg for celecoxib administered one hour before surgery and then 200 mg each 12 hours, for two days after surgery. Placebo was administered in the control group. Then severity of pain was measured by visual analogue score (VAS) every six hours during 48 hours. Opioid consumption, duration of hospital stay, antiemetic usage, and other complications of surgery (such as nausea and vomiting) were recorded. Statistical analysis was performed with SPSS version 16.0. Data were reported as means and SD. Data with normal distribution was tested with independent t-test. Qualitative data was analyzed with chisquare. Means of pain intensity were analyzed with repeated measures anova. P<0.05 was considered statistically significant.Results: From the 75 patients, who enrolled in our study, 37 patients took celecoxib and 38 patients took placebo. The two groups were identical in; age, gender, and type of gallbladder disease. The amounts of pethidine administered in celecoxib and placebo groups were 36.1±15.2 mg and 63.2±18.7 mg respectively (P-Value<0.001). Pain scores according to VAS were lower significantly in celecoxib group (P<0,001). Postoperative hospital stay in celecoxib group was 1.5±1.2 day in compare to 2.2±1.3 days in placebo group (P-Value<0.001). These results were significant for the case of post-operating, vomiting, duration of hospitalization and intestinal function.Conclusions: Perioperative oral celecoxib can reduce postoperative pain after LC. It can also decrease the usage of analgesic and antiemetic drugs and their complications. This practice lead to faster recovery and lower hospital stay after LC and probably after other minor laparoscopic surgeries.

Introduction & Objective: Fractals are complex geometric structures, which was introduced in 1975, and gained special place in medicine. Fractals are used in diagnosis of bone disease and structural of bone malignancies and heart arrhythmia diseases and it seems that fractals can be brought in any structural anarshaes, like cancers, for diagnosis and prognosis evaluation by quantifying it and expressing it in terms of fractal geometry. In this study we evaluate pathologic grades or breast carcinomas by fractal analysis.Materials & Methods: In this cross-sectional study 60 women with breast ductal carcinoma, of pathology grades 2 and 3, were recruited. They were randomly selected among 1000 women in Booali Hospital, Tehran, Iran, during the years 2008 to 2010. From all the patients some photographs from the smears with pathological standard and with Digital Sony Camera (700 Mega-pixel) were taken to analyze them by MATLAB software (version 7.0.1.246 [R14] Service Pack 3, Tehran, Iran) via Box-Counting method. The used analytical methods were ANOVA and T tests.Results: The mean age of the women were 52.48±10.83 of these, 38 (63.3%) had grade 2 and 22 (36.7%) had grade 3. The average size of tumor was 2.8±1.48. The mean fractal count was 1.95±0.03. There was a significant association between fractal count and pathological grade and the mean fractal count was 1.94±0.03 in grade 2 and 1.98±0.004 in grade 3 patients (P<0.001).Conclusions: According to our results, it may be concluded that fractal count is a prognostic indicator in breast cancer patients. However, it is recommended to perform further studies with higher sample volume and also in other caners to obtain more definitive results.

Introduction & Objective: Hemodynamic Changes in open heart surgery, especially during transfer to intensive care unit (ICU) and in the early hours of stay in ICU is very common. The most common cause of hypotension in the intensive care unit after surgery is the reduction of intravascular volume, so that appropriate compensation and adequate intravascular volume after separation from cardio pulmonary bypass is very important. The aim of this study is to compare the effects of gelatin 4%, voluven 6% and Ringer solution to maintain hemodynamic status after cardiopulmonary bypass in patients undergoing coronary artery bypass surgery.Materials & Methods: In this randomized double blind clinical trial, 92 patients who were candidate for on-pump Coronary Artery Bypass Graft were put randomly in three groups. The first group received Ringer solution, the second group Gelatin 4%, and third group Hydroxy Ethyl Starch 6% (Voluven). Hemodynamic parameters like heart rate, mean arterial pressure, systolic blood pressure, diastolic blood pressure, central venous pressure, cardiac output, urine output and the presence of arrhythmias all were documented for the first 24 hours after operation. One-way ANOVA or its non-parametric equivalent, chi square and Fisher’s exact test, were used for statistical analysis.Results: The volume of solutions that was needed for keeping normal pressure and keeping central venues pressure in the range of 7 to 14mmHg and adequate blood pressure, at the time of surgery during the first 24 hours of stay in ICU was significantly less in the group using voluven 6% than Gelatin and Ringer groups (P-Value = 0.001), but there was no significant difference between Ringer and Gelatin group. Urine volume in the first 4 hours as well as 24 hours stay in Intensive Care Units in group Voluven was more than Gelatin and Ringer groups (P-Value=0.03). The mean serum creatinine level were significantly lower from other groups (P-value=0.004).Conclusions: Hydroxyl Ethyl Starch 6% has better volume expanding effect than Gelatin 4% and ringer and its short-term effects on renal function is also better than other solutions.

Introduction & Objective: One of the main functions of general hospitals is surgical care which allocates numerous admissions. About 11 percent of diseases are treated by surgery, and the volume of surgery in rich countries is much higher than in the poor ones. Also cost- benefits for essential surgical care in low and middle income countries aren’t suitable. In this regard, the World Health Organization (WHO) has done a study to identify surgical care situations in various countries. This study was done, according to WHO Program, to investigate situational analysis of surgical services at the district hospitals in Iran.Materials & Methods: This Research is a descriptive and applied one. The research population consisted of 53 general hospitals in Iran of which researcher couldn’t get data from 13 general hospitals. Data from 40 hospitals was gathered using standard WHO questionnaire with 130 questions, and it was subsequently analyzed.Results: The study indicated that in relation to surgical infrastructure services, all hospitals had emergency rooms but only 50 percent of them had central oxygen cylinder supply. As for human resources involved in the surgical services, on the average 2.12% fulltime surgeons 0.97 anesthesiologist and 0.68 obstetrician/gynecologist were on duty. The most frequent services rendered in all of these hospitals were: suturing, wound debridement, regional and spinal anesthesia, general anesthesia inhalation and male circumcision(100 percent); most referral cases were related to acute burn management (62.5%), cleft lip repair and neonatal surgery (60%), clubfoot repair (57.5%), skin grafting and urethral stricture dilatation (55%). The mean needed equipment for resuscitation supplies in studied hospitals was 42.2, while for capital outlay the averages 97.43, and for renewable items and Supplementary equipment it was 12.8.Conclusions: Iran’s general hospitals are capable of delivering general surgical care and have a capacity and potentials for providing professional and advanced surgical care. Therefore based on the results of this research and in the direction of WHO activities in integrating management, for elevating quality of emergency services and essential surgical care, documented and organized information in the surgical care domain could be gathered and supplied to WHO in order to complete the global atlas regarding to Iran. Finally, with WHO cooperation, desired strategies for elevating the quality of surgical services can be presented to health system officials and providers.

Introduction & Objective: It is often advised to have repair of subcutaneous soft tissue using absorbable suture at the end of surgery before skin closure. We decided to compare the complication of subcutaneous suturing with those without subcutaneous suturing in the clean orthopedic wounds.Materials & Methods: We conducted a single blind randomized clinical trial on all admitted orthopedic patients who were candidate for primary wound clousure, during 1382-88 in Sina hospital. After categorizing patients based on upper/lower limb and fascia repair, the patients were divided into two groups with or without subcutaneous repair, by using computerized random numbers chart. The patients were assessed for probable complications (wound dehiscence, infection, fluid collection, inflammation, and skin necrosis) for 3 months postoperatively. Exclusion criteria were; the patients who need any kind of skin or muscle flaps, those who needed subcutaneous drainage, those who need secondary repair and those with loss to follow up.Results: After applying exclusion criteria, 14953 patients (1662 female, 13291 male, mean age 40.6±4.9 years) were enrolled into our study. Of these, 4153 were allocated to upper limb and the others to lower limb group. These groups were further divided based on fascia and subcutaneous repair. Totally, 6120 (41% of patients) had subcutaneous repair. The observed complications were more in patients without subcutaneous suture in comparison to those having with subcutaneous suture. Other parameters (upper or lower extremity and fascia repair) were not statistically significant regarding wound inflammation, infection, fluid collection, necrosis and dehiscence.Conclusions: It seems that omitting subcutaneous soft tissue repair will not lead to major complications in several cases of orthopedic surgery. It shortens the time of surgery and it may also reduce the costs, because of avoiding the use of suture materials.

Introduction & Objective: Direct access to blood circulating system especially superficial veins in some emergency situation such as severe burning, severe edema, thrombosis in superficial veins, severe obesity and shock due to severe bleeding is difficult and in some cases impossible. So, in such situations other routes of injection should be used for fluid and drug infusion. In this study, the two routes of intravenous and intraosseous injection were evaluated in the case of adult rabbits with mature bones.Materials & Methods: This study was carried out, as an experimental study, on 20 adult white New Zealand rabbits with 4-6 month age. Methylen-blue was used to compare the two ways of intravenous and intraosseous injection, 10 rabbits received 5cc Methylen-blue intravenously and 10 rabbits received 5cc Methylen-blue intraosseously. Data were collected and analyzed by using appropriate frequency tables for the available data.Results: The average time of Methylen-blue appearance in the Aortic cannulation was 9.781±2.336 second for intraosseous injection and 10.052±2.336 seconds for intravenous injection. The difference was not statistically (Man Whitney) significant (P=0.800).Conclusions: It is seems that intraosseous injection has the same efficacy as the intravenous injection and we can use intraosseous injection route in adults when the vein is inaccessible.

Omental infarction is a rare cause of acute abdomen which can be secondary to torsion around its vascular pedicle, thrombosis, vasculitis of omental vessels or omental venous outflow obstruction. The symptoms may mimic acute appendicitis, cholecyctitis, diverticulitis or ovarian cyst rupture. In this report we will present a patient who was admitted with right side abdominal pain after taking oral contraceptive pills and was diagnosed to have high hematocrit level, portal vein thrombosis and omental infarction. She underwent surgery and the gangrenous part of the omentum was resected. The patient’s postoperative recovery was uneventful and she was discharged with anticoagulant.