Iranian Journal of Surgery
Year:2005 | Volume:13 | Issue:2 (35)|Papers Count:16

Introduction & Objective: Surgical resection is still the most effective treatment of non-small cell lung cancers (NSCLC). Due to its tendency to spread via lymphatics, controversy is still present regarding the management of mediastinal lymph nodes during surgery. Considering TNM staging, lymphatic involvement has a major role in prognosis. The main subject of controversy is whether to perform a mediastinal lymph node dissection concomitant with lung resection in treatment of NSCLC.Those surgeons who support this procedure believe in:1- Precise pathological staging2- Selection of an appropriate adjuvant therapy3- No significant morbidity especially after learning curve4- Increased survivalBut those who just recommend mediastinal lymph node sampling believe on:1- Systemic nature of the disease2- Inability to do a complete lymph node dissection3- The chance of reducing the immunological defense mechanism4- Increased morbidity5- No apparent effect on survivalMaterials & Methods: In this "Review Article", it was tried to answer these questions by a literature review since 1984 till now.Results: The most common type of recurrence is local recurrence in mediastinal lymph nodes, and no incomplete surgical resection could potentially be curative.Conclusions: It is recommended to perform a mediastinal lymph node dissection in concomitant with pulmonary resection for the surgical treatment of NSCLC.

Introduction & Objective: Human Epidermal growth factor Receptor-2 as a new prognostic and predictive factor has been believed as an essential measurement in breast carcinoma.Materials & Methods: Review of recent published articles on HER-2, selecting 280 and referring to 115 articles.Results: Human Epidermal growth factor Receptor-2 is an oncoprotein epidermal growth factor receptor produced by a so called cell surface oncogene. Overexpression results in aggressive behavior; early lymphnode and distant metastasis and poor prognosis in breast carcinoma.Positive HER-2 as a Predictive factor leads to a biologic and less side results treatment (Herceptin).Conclusions: HER-2 is a prognostic and Predictive factor and must be considered in all Breast Carcinoma cases.

Introduction & Objective: Intraperitoneal adhesion bands which usually occur after previous abdominal surgery, is one of the most important causes of bowel obstruction. It can be as a morbid condition for long life. Therefore, any research for its prevention after abdominal surgery can improve length and quality of life of patients.Materials & Methods: In an experimental study, 30 male rats (mean weight: 220±20 gr) were selected and divided in two equal groups (case and control) randomly. After anesthesia with ketamin laparatomy was performed. A segment of left peritoneal wall was removed and longitudinal incisions was performed on right side of abdominal peritoneum.After operation, in cases group Pentoxifylline tablet was added to regimen. Two weeks later, laparatomy was performed with previous technique and severity of adhesions was evaluated.Mann-Whitney test analysis was used for evaluation.Results: Three rats were died from control group. Mean of adhesion scores was 2.5±0.9 in controls and 1.06±0.866 in case group (P<0.05).Conclusions: Pentoxifylline can decrease adhesion band formation after abdominal surgery in rats. For its effects on human, more research should be done.

Introduction & Objective: Epithelioid hemangioendothelioma (EH) is a very rare tumor of vascular origin. It can develop in different tissues such as soft tissue, lung or liver. Hepatic Epithelioid Hemangioendothelioma (HEH) mostly affects females. The malignant potential of HEH often remains unclear in the individual patient. It can range from benign hemangioma to malignant hemangioendotheliosarcoma.Materials & Methods: Here we present our experience with five patients with primary HEH, which were treated with curative intention in our department.Results: All patients in our series with confirmed histological HEH did not show extrahepatic extension and consequently underwent surgical treatment. In 3 patients liver transplantation (LTx) was performed (two cadaveric and one living related). In one patient a right sided hemihepatectomy with partial resection of the diaphragm was performed. One patient died while on the waiting list for LTx due to rapid tumor progression. Postoperative follow-up ranged from 1 to 13-years. No adjuvant chemotherapy was applied. Until now, no recurrence of local tumor, nor distant metastases could be observed during follow up in our series.Conclusions: Early detection and surgical intervention in cases of HEH can potentially offer curative treatment. The treatment of first choice appears to be radical liver resection. In our view, LTx represents a potentially important option for patients with a non-resectable tumor. Despite the long waiting time, its often unclear dignity, and a proven progressive growth pattern, living related LTx also plays a potentially important role. The 5-year overall survival rate of patients with HEH in the literature varies from 43% to 55%. Long term survival of patients with HEH is significantly higher compared to other hepatic malignancies. The role of adjuvant therapy currently remains unclear.

Introduction & Objective: Insertion of the CVP catheters through internal jugular and subclavian veins has a high incidence of major complications like pneumothorax, arterial puncture and nerve injury. Sometimes we use peripherally inserted central catheters (PICC) which have very few major complications. As, correct placement of the tip of these catheters is difficult, intravascular ECG, is used to determine the position of the tips of these catheters.Materials & Methods: In 105 patients undergoing CABG, 16 gauge, 70 cm length catheters (cavafix) were inserted through basilic and median basilic veins. The patients were randomly divided into two groups of right and left hands. Before the insertion a guide wire (used in urologic endoscopic surgery) was inserted into the catheters, so that the tip of the wire would extend just to the tip of the catheter. The proximal end of the guide wire was attached to a chest lead, and the negative electrode of the lead II (right arm) was joined to this chest lead. While advancing the catheter toward the right atrium, the P wave height of the lead 11was recorded from the wire on the monitoring screen. The tallest P ware was recorded when the tip of the guide wire was close to SA node, which is located at the junction of SVC and RA. The guide wire was removed at this point and the catheter was fixed. The correct position of the catheter tip was confirmed by the surgeon during operation.Results: In 76 patients (72.4%), the tip of the catheter was located exactly at the junction of SVC and RA. In 14 patients (13.3%), it was within 1 cm of the junction. In six patients (5.7%), the tip of the catheter was not palpated by the surgeon although P wave changes were observed. In 9 patients(8.6%)no P wave changes were detected, and the tip of the catheter was not palpated by the surgeon. In this group, the catheters had been misplaced into the internal jugular veins, that was confirmed after the operation by chest x-ray. In 8 patients of this group, the catheter had been inserted through the right hand.Conclusions: Placement of PICC is a safe method. We can place the catheters tip in an optimum position by the use of IVECG. Performing this procedure is very easy and does not need much experience. If the catheter is misplaced during insertion, we will be able to detect this problem and we can insert it through other veins.

Introduction & Objective: Tracheal stenosis is a life-threatening situation. The most commonetiology is incorrect tracheal intubations. The choice of treatment is Resection and Reanastomosis. Materials & Methods: Between 1992-2000, 96 patient with tracheal stenosis had tracheal resection and reanastomosis. Age, etiology, length of stenosis, site of anastomosis, time of intubation, mortality and morbidity were reported.Results: Eighty-six percent of patients had tracheal intubation prior to admission. Complication were 22.7% (infection, 14.5% and recurrent stenosis, 8.2%).Conclusions: Increased complication of this study in comparison with other studies is mainly due to tracheotomy at the time of admission.

Introduction & Objective: To evaluate the impact of preoperative external radiation therapy combined with systemic chemotherapy on sphincter preservation and local control in locally advanced low lying (<5 cm from anal verge) rectal cancer.Materials & Methods: Between 1999 and 2002,32 consecutive patients (22 male, 10 female, mean age 49, range 31-85) with biopsy proven locally advanced low lying rectal cancer were treated with preoperative 5FU (750 mg/m2/day, first and fifth week of radiation) and external beam radiation (45 GY in 25 fractions over5 weeks) followed by radical resection. Surgery was performed 4-6 weeks after the end of chemoradiation.The mean tumor distance from anal verge was 2.1 centimeter (range 0.5-5 cm). A temporary stoma was performed in 7 patients. Mean follow up was 29 months (range 8 - 54).Results: There was no major acute toxicity following chemoradiation and all patients completed their scheduled preoperative therapy. A complete pathologic response to preoperative chemoradiation was confirmed in 3 patients (9%).The pathologic tumor stages in the remaining patients were: T3N0 (n=5, 17%), T3N1 (n=4, 14%), T4N0 (n=12, 41 %), T4N1 (n=8, 28%).Sphincter saving surgical was done on 23 patients had a procedure but sphincter was finally preserved in 21 patients (66%). A perfect continence was achieved in 18 patients (86% of cases). There were 2 (6%) perioperative mortality and 11 (34%) preoperative morbidity. In 4 patients a reoperation was required (anastomotic fistula and perineal abscess n=1, pelvic & abdominal abscess n=1, fecal peritonitis n=1, gastrointestinal bleeding n=1).At a mean follow up of 29 month local recurrence was observed in 2 patient (6.2 %) and distant metastases in 5 patients (16%).Conclusions: Preoperative chemoradiation for locally advanced rectal cancer may provide higher rate of sphincter preservation.

Introduction & Objective: The management of infected femoral artery pseudoaneurysms is controversial. Primary surgical resection with vascular ligation or use of conduit during arterial revascularization is in debate.We present the results of common femoral artery legation with debridement and arterial revascularization for the treatment of infected pseudoaneurysms.Materials & Methods: This study is an observational case series. Forty six consecutive cases of I.V drug abuser with vascular injury over four years were studied. Some of the patients with infected pseudoaneurysms of femoral arteries, treated with resection and ligation, while resection and bypass grafts was performed in others. They were observed from 1 to 30 months by clinical examination or duplex ultrasonography.Results: During the 4 years period, 46 IV drug abusers with vascular injury were admitted. All patients were men with right-sided lesions. The age of the patients was between 17 and 57 years, with a mean of 33.Thirty two patients with femoral pseudoaneurysm underwent arterial ligation and in 9 patients resection and bypass grafts was performed. Four patients has had venous damage. Embolectomy was done in one patient. Limbs of all the patients were saved. A duplex ultrasound scan showed patent blood vessels in all the patients after operation.Conclusions: Arterial ligation and radical debridement is safe and a low risk treatment modality for infected pseudoaneurysm. A reconstruction with autologous material is necessary in the cases of aneurysms who had ischemia in limbs after the first operation.

Introduction & Objective: Duodenal obstruction and atresia is an emergency in pediatric surgery. The prevalence of congenital duodenal obstruction is 1 in 20000 births to 1 in 40000 births. The aim of this study is detection of etiologic finding of this obstruction, clinical findings, operation and mortality rate.Material & Methods: This study was done on 51 children operated on with the diagnosis of duodenal obstruction and atresia. We gathered our data from the patients with using their hospital records from March 1986 till September 2002 at Taleghani hospital.Results: A total of 51 patients (22 females and 29 males, male to female ratio: 1.3/1) presented to Taleghani Medical Center. 43 infants were neonate and the other 8 cases had more than 28 days of age. (The most common etiology was atresia in 32 cases, annular pancreas in 11 cases and Ladd bands due to malrotation in 8 cases were seen in the others. There were 20 cases of mortality after operation. The most common associated anomaly was Down's syndrome in 11 children). Conclusions: Despite other studies, we found difference between the sex ratio in our study in comparison with the others. In our study male to female ratio was not the same as the other studies. It maybe the result of cultural differences or paying much more attention to the boys in Iran. The most common etiology was duodenal atresia in all ages as in the other studies. The most common clinical presentation was vomiting (88.2% of cases) as the same of the other studies. We therefore recommend appropriate diagnostic study and timely referral of patients with complete or incomplete duodenal obstruction.

Introduction & Objective: The aggressive biological behavior of invasive and metastatic cancer is considered to be the most insidious and life threatening aspect for breast cancer patients. It is mostly the result of changes in many molecular characteristics of tumor cell, including alterations in the mechanisms controlling cell growth and proliferation. Many key decisions in therapeutic management of patients depend upon prognostic and predictive factors. Many of these factors were identified and the value of some of them has been proved and they are in general acceptance but the others are controversial.The aim of this retrospective study was to identify predictors of aggressive biological behavior and metastatic potential in breast carcinoma among a number of intrinsic biomarkers of tumor cells such as hormonal receptors and oncogene and tumor suppressor gene products.Materials & Methods: Routine formalin - fixed, paraffin - embedded tumor samples were used and sections were stained immunohistochemically to determine the expression of ER, PR, HER-2, Ki67, PS3 and cathepsin D in 66 breast cancer patients with prolonged follow up. The results of the quantitative Immunohistochemical assays were correlated with clinical and histological data such as age, tumor size, axillary lymph node status, tumor grade and overall and disease free survival. In this research which used a historical cohort study with statistical analysis methods such as Kaplan -Meier, Chi - Square, Log - Rank, Fischer and regression multivariate analysis.Results: After analysis only a significant statistical' relationship between tumor size and P53 overexpression (P-value = 0.045) and between increasing tumor grade and overexpression of PS3 (p-value= 0.008), overexpression of Ki67 (P-value = 0.001) and loss of PR expression (P-value = 0.042) were achieved which in the later instance, after multivariate regression analysis, just Ki67 (p-value = 0.007) and PR (p-value = 0.0048) are independent biological markers in prediction of tumor grade.Conclusions: Identified P-value did not show any significant statistical relationship between any studied biological markers and events such as metastasis, local recurrence or survival rates (disease free and overall) but there is a remarkable apparent difference between various groups in survival periods and it means that, this failure in gaining access to significant statistical relationship is due to low number of patient group.

Introduction & Objective: Minimally invasive techniques in surgery have been increasingly popular in recent years among physicians and patients. In Department of General Surgery of Ahwaz University of Medical Sciences, laparoscopic procedures have been established since Sep. 2003. The aim of this study is to evaluate outcomes of the first group of patients that underwent this operation over three different hospitals in Ahwaz.Materials & Methods: All patients were treated by laparoscopic cholecystectomy from Sep. 2003 to Oct.2004 were included in this study, retrospectively. Differences of the categorical variables were evaluated by x2 statistical test.Results: One hundred thirty seven cases with age ranged from 21 to 75 years old were included in the study. The mean operation time was 35 min (20-70 min). There was no report of mortality while morbidity rate was 6.5%.The most common complication during operation were spillage of stones from ruptured gall bladder to peritoneal cavity (3 cases) and cystic artery injury which occurred in three patients (2.2%). Other complications were liver parenchyma injuries (2 cases) and abdominal wall arteries injury in one patient. There was no case of conversion to open cholecystectomy. The mean duration of hospitalization was 15 hours (12-48 hrs).Conclusions: In our experience, all of the complications were managed during laparoscopy without any need to conversion to open cholecystectomy (formal laparotomy). Although in these cases mean operation time were significantly higher in comparison with uncomplicated cases (p-Value=0.003).These data support further research on more effective ways for managing these complications.

This is a case report of an 18-year-old girl with Hereditary Multiple Exostosis (HME) who develops a rare but recognized complication of Pseudoaneurysm formation as a result of laceration of the popliteal artery by an exostosis. The unique feature of this case report is that the patient has an identical twin sister who has a milder form of the bone disease but has not developed vascular complication.