Iranian Journal of Surgery
Year:2007 | Volume:15 | Issue:1|Papers Count:21

Introduction & Objective: Malignant hepatic epithelioid hemangioendothelioma (HER) is a rare malignant tumor of vascular origin with unknown etiology and a variable natural course. The authors present a comprehensive review of the literature on HER with a focus on clinical outcome after different therapeutic strategies. Materials & Methods: All published series on patients with HEH (n = 434 patients) were: analyzed from the first description in 1984 to the current literature. The reviewed parameters included demographic data clinical manifestations, therapeutic modalities, and clinical outcome.Results: The mean age of patients with HER was 41.7 years and the male-to-female ratio was 2:3. The most common clinical manifestations were right upper quadrant pain, hepatomegaly, and weight loss. Most patients presented with multifocal tumor that involved both lobes of the liver. Lung peritoneum, lymph nodes, and bone were the most common sites of extrahepatic involvement at the time of diagnosis. The most common management has been liver transplantation (LTx) (44.8% of patients), followed by no treatment (24.8% of patients), chemo-therapy or radiotherapy (21% of patients), and liver resection (LRx) (9.4% of patients). The 1-year and 5-year patient survival rates were 96% and 54.5%, respectively, after LTx; 39.3% and 4.5%, respectively; after no treatment, 73.3% and 30%, respectively, after chemotherapy or radiotherapy; and 100% and 75%, respectively, after LRx.Conclusions: LRx has been the treatment of chosen in patients with resectable HER. LTx has been proposed as the treatment of choice because of the hepatic muIticentricity of HEH. In addition, LTx is an acceptable option for patients, who have HEH with extrahepatic manifestation. Highly selected patients may be able to undergo living-donor LTx, preserving the donor pool. The role of different adjuvant therapies for patients with HEH remains to be determined.

Introduction & Objective: To review the articles and data sources published on male breast cancer. Materials & Methods: Searching for male breast cancer in recent half decade results in more than 10000 – links leading to 3472 chosen direct sours for male breast cancer which among 198 articles and web sites from 1982 to 2006 has been mentioned. In this review; screening, diagnostic tools, surgery and adjuvant therapy and also the prognosis has been analyzed.Results: Male breast carcinomas are 1% of male carcinomas, often presented with painless tumor and mean age of 60 worldwide. Screen mammography is advisable only in first degree related breast carcinoma cases and in genetic positive ones. Advised surgical procedure is mastectomy either modified or radical and some case series rare reported conserving method. There are not clinical trials comparing different chemotherapy regimes in male patients and so the adjuvant in males is the same as women. Prognosis is the same as in females but males are diagnosed in later stages due to less informed concepts.Conclusions: Increase in attitude and approach quality in men is indicated.

Introduction & Objective: Many studies were done and designed to determine the pathophysiology and to find a way to reduce the formation of adhesion bands after laparatomy. The purpose of our study was to determine the effect of aminiotic fluid in prevention of post laparatomy adhesion formation in rat models. Materials & Methods: Our study was experimental and laboratory. Thirty adult male rat were used in this study, divided in to two equal groups randomly.We opened the abdominal wall, then 1 * 1 cm peritoneal layer was excised from the left abdominal wall and 10 longitudinal incision of 2 to 3 cm in length were made on the right parietal peritoneum after that we filled the abdomen of the rats of group I (case group) with 5 cc of amniotic fluid and filled the abdominal of the rats group II (control group) with 5 cc normal saline. Second laparatomy carried out 14 day after the first laparatomy and abdominal adhesion were scored in order to Ahmet Canbaz scale and analyzed with Mann – withney test; P< 0.05 was significant.Results: After analysis we saw a significant difference between two group (P=0.008). The average of adhesion score were 1.13 ±1.3 in group I and 2.5 ± 1.18 in group II (P<0.05).Conclusions: Our study showed that Aminiotic fluid is capable to reduce the formation of adhesion bands after laparatomy.

Introduction & Objective: Successful inflation of the expander device and coverage of the face with tissue of similar color and texture is usually limited by the amount of skin generated. Selecting a smaller device and over expanding it produces more flap generation and an overall better reconstructive outcome. Materials & Methods: Described are the experiences encountered from 32 patients in whom a total of 52 expanders were inserted; 29 patients were burn victims with head and neck scars, one case was of a giant hairy nevus and two were post mastectomy patients. In all cases, a smaller device was applied with subsequent overexpansion to 2-4 times its registered volume.Results: In using the above technique, we gained more transferable skin which was used to cover the defects. In comparing our results to previous studies, the rate of major and minor complications was the same. Illustrations of several representative cases are submitted.Conclusions: Meticulous surgical techniques using smaller non-tension bearing incisions are important in minimizing complication rates of the procedure, ensuring its success, and allowing for salvage in case of any mishaps.

Introduction & Objective: Complete drainage of fluid and blood from pericardial and pleural cavity after cardiac surgery is very important because the residual blood, directly or indirectly, increases morbidity or mortality. The main goal of this study was to find the best method of pericardial and pleural drainage after cardiac surgery.Materials & Methods: This study was performed in 415 patients undergoing open heart surgery in Shariati Hospital between April 1998 and March 1999. Radiological findings and pericardial and pleural effusion in terms of the drain sites and in terms of posterior pericardiotomy (groups A, B, C and D) were analyzed and evaluated in these patients.Results: In 21.7% of the patients on the 3rd postoperative day, and in 17.9% of the patients on the 7th postoperative day, pleural effusion was seen. The lateral drain with or without posterior pericardiotomy significantly reduced pleural effusion on the 3rd (p-value = 0.02) and 7th (p-value=0.0001) postoperative days in comparison with the median drain. Pericardial effusion in this study was 32.2%, whereas the drain site did not affect pericardial effusion, posterior pericardiotomy affected and reduced pericardial effusion. There was significant difference (P-value = 0.0001) in terms of pericardial effusion between groups A, B, C and D.Conclusions: This study shows the better outcome of posterior pericardiotomy and lateral (direct) drainage of pleural cavity. In patients undergoing open heart surgery, if either of the pleural spaces is opened, we recommend that a drain be directly inserted into that space laterally and that posterior pericardiotomy be also performed for them.

Introduction & Objective: Trauma is one of the leading causes of children death after 1 year old. Providing that, pre-hospital emergency care for children is still a health problem. Current study was conducted with the aim of assessment of causes, and early outcomes of pediatric ambulance runs in Tehran. Materials & Methods: Current study was a cross, sectional study. All ambulance runs for patients under 16 years between 4 months during 2005 and 2006 was assessed for demographic data, cause of call and very early outcomes. Results: In 335 calls, the cause of EMS call was pediatrics trauma. From these, 211 (63%) was for males. Mean (+ SD) age was 11.35 ± 3.65. Traffic accidents was the cause in 197 (58.5%), 9 subjects (5.1%) died before ambulance arrival, but no one died in the way to the hospital. Mean response time was 14.75 ± 6.29. Response time was significantly shorter in those who survived to hospital (18.4 ± 3.8 vs. 14.6 ± 6.6, p=0.05). Conclusions: In Tehran, one from 3 of ambulance runs for pediatric patients is due to trauma. This highlights the need for planning of health care providers in order to improve health care services in this field. Although the time intervals for ambulance arrival are somewhat accepted in comparison to some countries, but it is still far from the standards and recommended levels. According to this study shortening the response time can improve prehospital survival.

Introduction & Objective: Varicose veins are a common disorder which apart from heaviness and discomfort may have more serious consequences. This has been done in past by surgery which has some limitations and for this reason different methods to replace vein stripping have been tried. The aim of this article is to evaluate the use of endovascular laser.Materials & Methods: This study was a clinical trail. Patients with varicose veins due to saphenous incompetence were treated with endovascular 980 nm diode laser as a treatment of venous reflux. Clinical and duplex assessment of all patients was performed prior to operation and 10-14 days after operation.Results: The numbers of 76 saphenous veins in 69 patients were treated by Endovenous laser, receiving on average 2487 joules in 103 pulses in 154 seconds. The preoperative diameter of the saphenofemoral junction was 10.58 mm and this compares with post laser diameter at 10-14 days of 7.42 mm. This difference is statistically significant (students t test; P<0.001). Post laser examination showed that of the 76 saphenous veins 73 were completely occluded up to the junction and in three veins only the upper 2-4 cm was patent but the rest of the vein was occluded. 98% of patients were satisfied with the result of the treatment of the varicose veins.Conclusions: This study demonstrates that endovascular 980 nm diode laser is 96% effective in ablating incompetent saphenous vein with 98% satisfaction with the treatment. This method may help undecided varicose vein sufferers to seek effective treatment.

Introduction & Objective: In a prospective multicentric phase II trial, we evaluated the efficacy and toxicity of combination of docetaxel, cisplatin and 5fu/lv (DCF) in a group of untreated patients with unresectable advanced and metastatic Gastric Cancer.Materials & Methods: Fifty six patients with locally advanced and metastatic Gastric cancer were enrolled in this study. Docetaxel, 75mg/m2 in day 1, Cisplatin 75mg/m2 in day 1, 5-fu 750mg/m2/ for day 1 – 3 with continuous infusion with folinic acid support were administered. The above regimen was given every 3 weeks for total of 6 cycles. The primary end points were time to progression (TTP) and overall survival (OS).Results: In 56 assigned patients (Male = 36, Female = 20) with median age of 56 year, 40% had already undergone unsuccessful laparatomy, a total of 274 cycles of above regimen were given. The average of received cycles was 5 cycles. In 16 months of follow up 75% of patients showed progression, in evaluation after 19 months 65% of patients died and overall survival was 10 months. Until this report 19 out of 56 (35%) were alive for more than a year. Time to progression with DCF was almost two times compared to prior chemotherapy regimen. The most important toxicity of this regimen were neutropenic fever in 12% of patients, gastrointestinal toxicity and neuropathy.Conclusions: Adding Docetaxel to CF significantly improved RR, TTP, and OS. The above results have associated with brief increase in toxicity, the overall quality of life was better, therefore, DCF regimen could be one of the standard options for patients with untreated advanced gastric cancers.

Introduction & Objective: Laryngopharyngeal Reflux (LPR) of gastric content, causes a spectrum of disease including Chronic Rhinosinusitis (CRS). Chronic infection due to H. Pylori is one of the suspected pathophysiology of CRS. Accordingly, this study was planned to determine the role of H. Pylori in CRS and LPR. Materials & Methods: This is a clinical cohort study. In this study a group of 18 patients with CRS is compared with a group of 18 controls with regards to H. Pylori role in CRS and LPR. PCR, a highly sensitive and specific diagnostic test is used to detect H.Pylori.Results: H. Pylori was positive only in 2 of 18 CRS patients. This number was 6 for control group. Unexpectedly, there was a reverse correlation between H. Pylori and CRS. Besides, there was no significant relation between positive cases of sinus and gastric samples in each group and between two groups.Conclusions: H. Pylori has no role in CRS and sinus is just a reservoir of H. Pylori without being afflicted.

Introduction & Objective: Tranexamic acid is a synthetic antifibrinolytic drug that reduces bleeding and transfusion requirements in cardiac surgery and total knee arthroplasty. In this study, we evaluated the efficacy of the prophylactic tranexamic acid to reduce intraoperative bleeding and improving visual field of the surgeon in patients undergoing lumbar hernial disc resection, anesthetize with two different methods of inhalation or total intravenous anesthesia.Materials & Methods: Eighty percent patients in ASA class I-II were randomized into 4 groups. In group 1, anesthesia was achieved by total intravenous anesthesia and tranexamic acid was administered too. Other groups were: group 2, anesthesia by total intravenous anesthesia without tranexamic acid, group 3, anesthesia by halothane and tranexamic acid was administered and in group 4, anesthesia by halothane without tranexamic acid was achieved. Blood loss and surgeon's satisfaction were registered.Results: The amount of blood loss in each group was as follow: Group 1: 267.1 ± 177.3 ml; group 2: 656 ± 411.6 mlGroup 3: 357 ± 307.2 ml; group 4: 550 ± 406.7 mlThe least bleeding was recorded in group 1 which had a significant difference with group 2 (p=0.007) and group 4 (p=0.04) that tranexamic acid was not administered. Blood loss in group 2 and 4 was identical and had no significant difference (p= 0.3). Surgeon's highest satisfaction was with group 1. No complications were registered in 4 groups. Conclusions: We concluded that administration of prophylactic tranexamic acid in patients undergoing hernial disc resection has the potential to reduce intraoperative bleeding and improving visualization of the surgical field especially when administered with total intravenous anesthesia. The method of anesthetic management had no effect.

Introduction & Objective: Acupressure can be used as a adaptation strategy for stress control. The aim of this research is the assessment of acupressure effects on anxity in patients before amputation. Materials & Methods: The sample of this clinical trial study was 42 patients, the number of 21 patients in control group and 21 patients in case group. Data collection instrument had 3 parts. Part 1 was related to demographic characteristic; part 2 was eshpilburger anxity questionnaire and part 3 was vital signs checklist.Results: Results showed that acupressure affected on anxity in samples, it has controlled the Blood Pressure and Pulse Rate before operation. The changes in vital signs changes related to anxity.Conclusions: Results of comparison between 2 groups shows that acupressure affected on anxity before amputation, so we suggest the usages of this method for patients’ preparation before operation.

Introduction & Objective: Post operative wound infection is the most common form of infection in surgical patients, containing about 38% of all surgical infections. In the text books surgical wounds are divided into 4 groups: clean, clean- contaminated, contaminated and dirty.Prophylactic antibiotic therapy is recommended only in clean -contaminated operations and is not routine in clean operations except for some special situations.However, prophylactic antibiotic therapy is used for all clean elective operations in Firoozgar hospital that has some disadvantages, including resistant strains of bacteria, and financial problems (extra cost) for patients.This study was done to determine whether antibiotic prophylaxis is an effective method in preventing wound infection in these operations or not.Materials & Methods: This interventional study (clinical trial) was done from June 2002 to May 2003 on 121 patients in Firoozager hospital. Patients who were candidate for elective clean surgical procedures divided into two groups, according to randomized numbers.Results: 62 patients (51.2%) received prophylactic antibiotic and 89 patients (48.8%) received no prophylaxis. Wound infection occurred in 13 patients (10.7%), 7 patients (5.78%) in Control group and 6 patients (4.95%) in antibiotic treatment group. There was no statistically significant difference between two groups. (P=0.1).Conclusions: According to results of this study, routine use of antibiotic prophylaxis is not recommended in clean elective operations. 

Introduction & Objective: At 5:30 AM of 25th December 2003 a strong earthquake was occurred in Bam that led to 80 thousands death and traumatic patients. St Zahra hospital as a referral center admitted 255 patients in twenty patients because of soft tissue injury in upper and lower extremity fasciatomy were done. The main aim of this study is evaluation of complication and outcome of these patients. Material & Methods: In 20 cases of fasciatomy of 26 extremities were undergone fasciatomy. In 24 months of follow-up, sensation and motor function of limbs and ROM of joints were evaluated.Results: All of patient after 24 months could walk without help and ROM of joints were within normal ranges. In 7 patients (11 extremities) the sensation was as hyposthesia or hyperesthesia. The others had good or normal sensation in extremities. Only in one patient because of radical debridment, sensation was present only in safenous dermatome. The rest patients had good sensation in palmar region. Conclusions: Fasciatomy is not only a safe procedure but also necessary for limb salvages. Fasciatomy also can preserve normal function of limbs. For best results, physical therapy and prosthesis usage is necessary for patients. Even if fasciatomy can not preserve limb function it must do, because of limb salvage.

Introduction & Objective: Ossification of the posterior longitudinal ligament is a rare disease that can cause myelopathy or radiculopathy. This report is performed for presentation of OPLL as a treatable cause of a disabling condition, myelopathy.Materials & Methods: Seven patients with OPLL underwent surgery by neurosurgical team. Six patients had cervical and one patient had thoracic OPLL. All patients underwent clinical assessment and radiological evaluation with plain x-ray, CT scan and MRI preoperatively.Results: After surgery patient who had radiculopathy or short duration of symptoms had better response to operation.Conclusions: Early diagnosis and selection of best surgical approach will result in improvement of neurological function and better quality of life in OPLL patients. In the other hand patients who had prolonged duration of symptoms before surgery, had poor surgical results.

Hyperplastic polyps are very rare and often solitary. Usually they have no symptoms, if they were symptomatic, they would have gastro intestinal (GI) bleeding, abdominal pain, early fullness of stomach, intermittent obstructive pattern. The patient was a 45 year old woman that complained about fatigue, malaise, dizziness and had severe anemia (Hb: 3.9 gr/dl). She didn’t mention abdominal pain, bloating and, other GI disorders. In endoscopy, many grape like polyps were seen in the stomach; also scattered ones in other parts of GI were observed which none of them were malignant. The patient was operated (Billirot II) and discharged with good general condition. She was hospitalized 4 times during 11 years after surgery because of cardiac decompensation and died finally due to Congestive Heart Failure. The case is interesting and considerable because of the large amount of polyps in the stomach, a few polyps in other parts of GI, absence of obvious alimentary signs or symptoms, severe anemia without active GI bleeding (in spite of extensive pathology in the stomach) or malignancy.

Duplication of the vermiform appendix is an extremely rare malformation. In childhood, almost all patients have serious associated intestinal, genito-urinary or vertebral malformation. It is reported only in two cases of 50000 autopsies. A double appendix in a 2 mouths old female with imperforated anus is reported in this article and it’s prevalence, classification and clinical presentation is discussed.