Iranian Journal of Surgery
Year:2008 | Volume:16 | Issue:1|Papers Count:21

Introduction & Objective: Nipple discharge is a bothering experience in half of the women, the 3th complain of the breast, and is among the signs of breast cancer. Updating the information on nipple discharge is the main purpose of this review.Materials & Methods: For this review, we chose 126 articles among 1134 articles recently published. Results: Intraductul papilloma is the main cause of nipple discharge. Diagnostic procedures have their positive and negative values.Conclusions: There is little link between nipple discharge and breast cancer. There is no definitive diagnostic procedure, but ductoscopy is promising.

Introduction & Objective: Despite extensive research concerning the more beneficial management of patients suffering from 'chronic subdural hematoma' (CSDH), controversy still exists about 'which is the most appropriate treatment?'. The objective of this study is to review the literature on the various aspects of different surgical techniques used and their effect upon the outcome of patients suffering from CSDH. Materials & Methods: The search was done at Cochrane Central Registery of Controlled Trials, MEDLINE and EMBASE search engines up to the August 2007 with no language restrictions. Manual search and data banks of Web of Science and Scopus were also used for finding references included in the studies and in the literature reviews. Two independent observers performed study selection, methodological quality assessment (Maximum score 11) and data extraction in a blind and objective manner. Data on recurrence of CSDH were analyzed as pooled analysis by Poisson's regression method and the relative risk of each variant of surgical procedures (type of craniostomy, using irrigation, using drainage) were calculated within a 95% confidence interval. For the analysis of variants of surgery that might increase the risk of morbidity and mortality, logistic regression method was used and the odd's ratios with 95% confidence interval were calculated. STATA v 9.1 software was used for the statistical analysis.Results: Nine randomized controlled trials (RCTs) could be allocated in the systematic review, comparing different surgical methods. All the included RCTs had poor qualities with a mean score of 4.1±1.7. The relative risk (RR) of recurrence of hematoma using camiostomy with drainage and camiostomy with irrigation were 2.3 and 5.9 respectively which were statistically significant. 'Drainage' and 'irrigation' had no statistically significant relationship with morbidity and mortality. The type of craniostomy had no effect upon recurrence.Conclusions: It looks quite probable that surgery is not a main factor affecting upon the outcome of treatment of CSDH but may act as a confounding factor. Accordingly, it is necessary to conduct properly designed prospective and randomized trials with adequate number of patients to evaluate the effective factors.

Introduction & Objective: Although the presence of lung metastases of cancer indicates the an advanced and often incurable disease, nevertheless, there have been many efforts for the treatment of these patients by surgical resection of metastases. Results of these efforts have been variable in different reports and different histological types of tumors. In this study we report about our experience of lung metastatectomy and its survival benefits in our patients.Materials & Methods: In a retrospective study, we reviewed hospital files of 99 patients who had referred to us for the treatment of lung metastases during 1995-2007.Among them, 48 patients were selected for metastatectomy. The criteria for the selection were: complete resectability, absence of any extra-thoracic metastasis and suitable general condition of the patient for operation and controlled primary disease. The following data were extracted: site of primary lesion, histology, duration of the primary disease to the appearance of lung metastasis, surgical morbidity and mortality, type of surgical procedure, incision, number of metastases and survival of patients after metastatectomy. The patients were followed by out - patient visits and when necessary more information was collected through telephone calls. The data were analyzed by SPSS software and Kaplan-Mayer test was used to evaluate the survival results.Results: Sixty seven surgical procedures were performed on 48 patients. There were 31 men and 17 women, with mean age of 40 years (16-86) years. Twenty Five patients had unilateral and 23 patients had bilateral lung metastases. In the case of bilateral metastases, single stage bilateral metastatectomy was done on 7 patients and in 16 patients metastatectomy was done in 2 or more stages. Types of incisions were: 60 posterolateral thoracotomy, 4 median sternotomy, and 3 clamshell bilateral thoracotomy with sterna transection. Sixty one metaetases removed by the wedge resection, 14 were removed by lobectomy and one removed by pneumonectomy. The mean number of removed lesions in each patient was 6.7 (1-59). There were 10(15%) surgical complications including: 9 pnemothorax and one chylothorax. There was no major or life threatening complication in any patient. The mean time of survival after metastatectomy was 22 month (1-128 month) and probability of 5 years survival was 24.5%. Five patients survived 5 years or more.Conclusions: Although the patients did not have the same histological types of cancers, it seems that metastatectomy has a defmite beneficial effect on survival and sometimes results in the cure of cancer, morbidity and mortality of this procedure is also unremarkable.

Introduction & Objective: The aim of bum scar management is to prevent scars from interfering with normal function and to make them cosmetically acceptable.Silicone gel treatment has been shown to make scars more flexible and smoother. We therefore conducted a randomized, double-blind, placebo-controlled trial to study the efficacy of silicone gel on burn-induced hypertrophic scars.Materials & Methods: Thirty-eight patients with burn hypertrophic scars were selected. Each scar was divided into two segments and silicone gel was applied randomly to one of the two. Patients were followed after starting the treatment and visited again after one and four months. The patients' data and wound characteristics (pigmentation, vascularity, pliability, pain and itchiness) were collected according to the Vancouver scar scale (the height of the scars was not included due to a lack of precise measuring equipment). Four patients (10.5%) failed to appear for their follow-up. The median age of all patients was 22 years (1.5 to 60 years). Sixteen patients (47.1 %) were male.Results: There were no significant differences in baseline characteristics. Although after the first month of follow-up, all scar scales measures were more diminished in the silicone gel treated areas than the control areas, but only the vascularity scale was significantly different between the two samples (P<0.05). In the second follow-up period (four months post-therapy), all scales were significantly lower in the silicone gel group than in the control group except for the pain score.Conclusions: According to our study, silicone gel is an effective treatment for hypertrophic burn scars.

Introduction & Objective: Tibia fracture is the most common long bone fracture in adults and is specifically in motorcycle accidents; it is an open fracture which treated primarily with the external fixator. But, there is controversy about the continuation of this treatment until complete union of fracture site as far as costs, efficacy and complications are concerned.Materials & Methods: 43 patients were studied. If after 4 months from application of external fixator, healing process was not satisfactory, bone graft from iliac crest was applied for stimulating the healing process and if necessary, at the same time the alignment and opposition of fragments were corrected and they were followed for 6 months.Results: In 38 cases fracture union were seen after 6 months of follow up and without any complication, but in 2 cases we needed second bone graft procedure and in 3 cases there was of infection in the fracture site and we needed aggressive debridement and used another method for the treatment.Conclusions: It seems that because of good results and low costs and complications, insitu bone grafting is a suitable method for bone healing after the application of external fixators in tibia fracture. 

Introduction & Objective: Breast cancer is the most common cancer among women and can be cured if detected at early stages. Our aim was to determine the knowledge, attitude and behavior of female teachers in Tehran towards breast cancer screening methods.Materials & Methods: A structured self-administered questionnaire was designed and teachers from schools located in different parts of Tehran were asked to fill them. The questionnaire included items about demographic characteristics, baseline knowledge about breast cancer, breast self-examination (BSB), clinical breast examination (CBB), and mammography. Their attitude about screening methods was assessed using a Likert scale. Behavior towards screening methods was also assessed by asking questions about number of times they had undergone breast cancer screening and its frequency.Results: From 125 teachers that were asked to fill the questionnaire, 77 teachers (61.6%) returned them. Their age ranged from 24-54 years without, with the mean 39.8±8.0 (SD). Their level of education ranged from 12-18 years with the mean of 15.4±1.8 (SD). Only 3 cases knew the correct age for starting BSE and 39% knew that it should be performed each month. 57.1% knew how to perform BSB correctly. Only 4 cases (5.2%) knew the correct age to start CBB and 9 cases (11.7%) knew its frequency. The appropriate age for starting mammography and its frequency were correctly answered by 20.8% and 35.1% of the participants, respectively. The attitudes regarding the implementation of screening methods were favorable. BSB was not performed in the past 2 years by 50.6% and 27.3% did it 2-3 times in a year. Fifty-five cases (71.5%) had never referred for a CBB and those who had referred, did it with a mean period of 16.5 months. Twenty-five cases were aged over 40 and 15 of them had no history of mammography.Conclusions: Our results show a moderate level of knowledge about screening methods and a positive attitude towards them. However, most of the women do not practice screening methods.

Introduction & Objective: Laparoscopic Cholecystectomy in the superior method for the treatment of symptomatic gall bladder disease. The method which was done initially through four ports has under gone many developments. Studies have shown that although the reduction of the number of ports and their size has not affected the side effects and the duration of the surgery, it has reduced the pain after surgery.Materials & Methods: 70 patients (89.5%) were female, and 8 patients (10.5%) were male. Patients were between 24 and 82 years old, and the average age was 57.6 years.Results: In 8 patients the indication for operation was acute cholecystitis. We convert the three port laparoscopic cholecystectomy to open cholecystectomy in one patient due to difficulties in exploration (1.28%). We convert three port laparoscopic cholecystectomy to four port laparoscopic cholecystectomy in 2 patients (2.56), who were male, and one was previously mentioned patient (patient with acute cholecystitis). We use drain in 21 patients (27%) in the end of operation, which all of them were expelled in the next day. The oral feeding was started averagely in 1.2 days, and patients were discharged averagely after 1.6 days.We used about 25 mg of LV pethidine for pain relief. The average operating time was 43 minute, and we performed intra-operative cholangiography in 8 patients due to it's classic indications. We documented one trocar site infection in one of our patients.Conclusions: Three port laparoscopic cholecystectomy is a safe and effective method in the treatment of symptomatic gallbladder disease, with minimal morbidity, but we advise to perform it after enough experience.

Introduction & Objective: The repair of soft tissue defect in lower leg and heel area with free flap is still a standard in reference books. However, there are disadvantages in the use of free flap like increased operative time, the damage of major vessels and the need for experienced microsurgeon. The use of local fasciocutaneous flap is usually impossible in these areas due to limited soft tissue, especially in moderate and large size defect.Reverse island sural flap is an island flap based on the vascular axis of the sural nerve, which gets reverse blood flow through communication with the perforating branch of the proneal artery in lateral malleolar gutter. This flap can be a good alternative to free flap for the reconstruction of lower leg and heel soft tissue defect.Materials & Methods: Between 1383 and 1386,20 patients (18 male and 2 female), mean age 36 years were treated in 2 plastic and reconstructive centers for soft tissue defect of lower leg and heel area with reverse island sural flap. The mean follow up of patients was 6 months. After debridment and detection of defect size, flap was elevated. The flap was inserted in defect aria and the pedicle passed over skin in 18 patients and passed through subcutalous tunnel in 2 patients. Flap pedicel was removed after 2 months. Results: In all patients, repair was complete, venous congestion was occurred in 16 patients. Superficial partial flap necrosis was present in 2 patients which were treated with conservative management. In 1patient, bleeding from flap border was occurred, but stopped after 12 hours.Conclusions: According to the results of our study, reverse island sural flap is a good alternative to free flap for coverage of lower leg and heel soft tissue defect. Short operative time, easy technique and rapid ambulation of patient are the advantages of this flap.

Introduction & Objective: Transhiatal esophagectomy is one of the most popular surgical approaches to esophageal carcinoma which has been reintroduced and advocated by Orringer during the past two decades. Despite avoidance of thoracotomy which is considered as its main advantage, pulmonary complications are recognized as the most common cause of morbidity and mortality following this operation.Considering the high prevalence of esophageal carcinoma and frequent use of the Orringer technique in Iran and lack of comprehensive reports focusing on postoperative complications, the undertaking of an assessment in this regard was useful and necessary.Materials & Methods: In this descriptive study, 122 patients with esophageal cancer who were treated by Orringer transhiatal esophagectomy during a six - year period, in Al-Zahra Hospital, Isfahan, were assessed. Data were analyzed using SPSS v. 11.05 software and descriptive statistics indices.Results: Postoperative pulmonary complications included: respiratory failure in 38%, pleural effusion in 35%, pneumothorax in 24%, hemothorax in 17%, Pneumonia in 10% and empyema in 2%.Conclusions: These results indicate a high prevalence of pulmonary complication, following transhiatal esophagectomy and are comparable roughly to other surgical centers through out the world and can be used as a useful guide for choosing the appropriate surgical approach and the avoidance of postoperative complications in esophageal carcinoma.

Introduction & Objective: Pneumoperitoneum and especially subdiaphragmatic air, is a very important and noteworthy for the diagnosis and treatment of patients with acute abdominal pain. On the other hand, if a recent abdominal operation has been performed, it is acceptable in 60-80% of cases and will be absorbed gradually. In cases who refer with acute abdominal pain, following a recent abdominal operation,it is or great importance to distinguish between postoperative pneumoperitioneum and the new onsets. On had study, we are decided to clarify the differentiating criteria.Materials & Methods: During a prospective descriptive survey, 172 patients, in whom abdominal operations with different incisions were performed, underwent chest posteroanterior X-ray imaging in several consecutive postoperative days. So, the incidence of post operative pneumoperitoneum, the duration of complete absorption and the intervening factors were all studied.Results: After assessing 172 patients, a postoperative pneumoperitoneum was found in 95 cases (55-2%). The most frequent incision, in which a P.O.P was detected, was the midline laparotomy incision (81.81%). In the decreasing order of frequency, the were lower midline incision (71.42%), upper midline (45%), kocher (41.66%) and Mc Burney (35.7%). The difference between these incision groups has been statistically significant (P < 0.05).In patients with BMI ³25, the incidence rate was 31.9%, in patients with normal BMI, it was 58% and in the underweight group (MBI < 18.5), it was 78.7% and the difference between these different categories was obviously significant (P<0.05). The mean height of air column in the right subdiaphragmatic area was 9.07mm on the first postoperative day.Conclusions: The incidence rate of postoperative pneumoperitoneum, depends on the type of incision and patient's BMI; regardless of the patient's age, sex, operation type and the duration of operation. The interval between the incidence of P.O.P and complete resorption dependents on the patient's age, BMI and the Volume of initial P.O.P.

Introduction & Objective: In previous studies it has been shown that gum chewing after elective GI tract operation may stimulate bowel motility and decrease duration of postoperative ileus. The aim of the present study was to assess the effects of sugar free gum chewing after upper GI tract on operation postoperative ileus.Materials & Methods: In a randomized clinical trial, 50 patients, who were scheduled for elective upper GI surgeries were randomly allocated to 2 groups of gum-chewing group (n=26) and control group (n=24) postoperatively. The patients in the gum-chewing group chewed postoperatively sugar free gum 3 times daily for 1 hour each time until discharge. Patients' demographic characteristics, surgery duration, time to first flatus, time to first bowel movement, and complications were compared.Results: All gum-chewing patients tolerated the gum. The first passage of flatus (72.23±25.52vs. 92.79±27.35 hours) and time to first bowel movement (95.58±25.88 vs. 110.83±26.18 hours) were significantly lower in the gum-chewing group compared with control group.Conclusions: Gum chewing speeds recovery after the upper GI tract operation. Gum chewing is an inexpensive and helpful care in the upper GI tract postoperative period.

Introduction & Objectives: Pilonidal sinus disease is common, and essential treatment of this disease is surgery. One of main post operative problems is the recurrence of disease. But in spite of its high prevalence, and recurrence disease studies about: prevalence, incidence, causes of recurrence and etc, is scarce. In this study we study relationship between Body Mass Index (BMI) and the recurrence of pilonidal sinus disease.Materials & Methods: Study is an analytic type (case-control) and was performed in patients who refer to two university hospitals: Loghman Hakim and Emam Hossein, in the time interval 1382-1385. Two hundred and thirty-three accessible patients who were operated for pilonidal sinus disease (close and open surgery) divided in two groups patients: these with recurrence were considered as case group and patient without recurrence determined as control group. Patients with BMI < 25 were considered to have normal weight and patients with BMI ³25, were considered obese, and the mean follow-up period was 21 months (range 6-36). Results were analyzed with SPSS software and chi-Square test.Results: Most of patients were 20-29 years old, and men were affected four times more commonly than women. %33 of patients was affected by acne in their life and %20.45 of them had positive family history of pilonidal sinus. Correlation between open and close technique of surgery, was significant between case and control groups. Therefore, open surgery had reduced recurrence rate. (P=0.02). The mean BMI of patients with and without recurrence was 25.5±23 and 24.2±3.1, respectively that difference between two groups was not significant in this study 22 patients had recurrence (0.95%). 8 patients with normal BMI group (137 patients) were recurrence (0.5%) and in obese group (96 patients) 14 patients had recurrence (0.14%). Obesity and recurrence of pilonidal disease statistically was significant Conclusions: Obesity is an important factor in the recurrence of pilonidal sinus disease.

Introduction & Objective: Because the numbers of hip fractures worldwide are projected to increase, osteoporosis will become an increasing burden on the health care system, in addition to causing pain, disability, and reducing quality of life. Mortality rate of hip fracture is 15-20% as compared to 0.9% of other orthopedic problems.The aim of this study is to determine the hip bone mineral density level that is predictive of fracture and whether osteoporosis is more prevalent in patients with hip fracture than in the age-and sex-matched group or not.Materials & Methods: In this prospective study the hip bone mineral density of 100 patients (50 men, 50 women) and 100 control individuals (50 men, 50 women) between 50-90 years old was measured by Dualenergy x-ray absorptiometry. The patients group had hip fracture after minor trauma. The statistical analysis of the two groups was done by t-test.Results: This study showed that bone mineral densitr in the patients group was 0.6333 gr/cm2 versus 0.7589 gr/cm2 in the control group. The mean Z-score in the patients group was -1.218 versus -0.652 in the control group. The mean T-score in the patient group was -2.98 versus -1.98 in the control group. Conclusions: We recommend every person who has been screened by DXA and having bone density below 0.6333 gr/cm2 is prone to hip fracture. Moreover, hip fracture is associated with osteoprosis, which is more prevalent in the patients group than in the age-and sex-matched control group.

Pheochromocytoma is a rare neoplasm with increased production of catecholamines and high blood pressure. These tumors are in chromatin cells group.10% of these tumors are out of Adrenal gland and have negative for chromatin and are named Paraganglioma. Less of 10% of these tumors are malignant and metastasis is the only reliable indicator of malignancy. (Metastasis to lymph node, liver - lung and bone) Our patient was a 34-years-old man with high blood pressure and unilateral nephrectomy that visit us for Lower Back Pain (LBP) with radicular pain in the right foot. After MRI in L4 and L5 one hyposignallesion was considered and in biopsy under CT scan guide from vertebra (pheochromocytoma out of Adrenal gland) Paraganglioma was reported. So in LBP with regional metastatic lesion and high blood pressure we must also consider pheochromocytoma in differential diagnosis.

A case of 9 years old boy who was afflicted with needle aspiration following playing is described. The patient present with sporadic dry cough, but no other symptom. Rigid and fibroptic bronchoscopy, did not show any foein body. Thoracotomy and broncheotomy was performed and Needle was not found. Finally, with C. arm X. ray device, its location in lung paranchyme was found, and it was removed, by lung squeezing.