Iranian Journal of Surgery
Year:2008 | Volume:15 | Issue:4|Papers Count:20

The report of the US institute of medicine showed that a large proportion of medical errors occurred because of poor knowledge about the best method practice. The use of careful and systematic of research results in evidence-based practice lead to less errors. Evidence-based surgery has been less developed than evidence-based practice in non-surgical disciplines because of many factors. The surgeon's willingness to do operative procedures they are more skilled in, the problematic nature of conducting double blind randomized surgical trials, the scarcity of systematic reviews and finally professional dogmatism of surgeons, all are contributing to poor state of evidence-based practice among the surgeons. An increase in the number of quality clinical trials and synthetic studies in surgery, developing the culture of using best evidence as well as the improvement of the skills and knowledge of evidence-based practice among surgeons, provides the required supportive facilities and practicalities in the surgical settings, higher use of sham surgeries in effectiveness studies and refraining from intense pragmatism in part of surgeons are measures that can facilitate greater evidence-based practice in surgery.

Introduction & Objective: A few number of post-intubation tracheal stenosis recur following resection and anastomosis. Several factors appear to be responsible for recurrence but there is insufficient dat available in this regard. In this study we assessed the factors responsible for the recurrence of post-intubation tracheal stenosis after resection and anastomosis in a large group of patients who were operated in our center by one surgical team.Materials & Methods: All patients who underwent tracheal and/or subglottic resection and anastomosis due to post intubation tracheal stenosis, at our center during 1995-2006 were divided into two groups (case and control). The study group consisted of patients who had developed recurrence while the controls had no recurrence. The diagnosis of the recurrence was made based on the presence of clinical signs or symptoms and bronchoscopic confirmation. The following variables were compared in both groups: Age, sex, duration of intubation, the reason for intubation, period of time between intubation and surgical operation, history of previous tracheotomy, previous therapeutic interventions such as laser therapy, subglottic involvement, length of resection, presence of tension at the site of anastomosis and the development of surgical site infection. This was a case – control study and statistical analyses were performed using SPSS 15.Results: Four hundred ninety-four patients underwent resection and anastomosis (365 women and 129 men) with a mean age of 25-34 years (in the range of 4 months to 83 yrs.). Fifty-two patients (10.5%) developed recurrence. Length of resection (mean 42.8 mm in the case group versus 37.8 mm in the control group; P=0.012), the presence of tension at the site of anastomosis (32.7% versus 19.3%; P=0.03), the development of infection at the site of operation (18.2% versus 5%, P=0.006) and subglottic involvement (36.5% versus 19.2%, P=0.005) were higher in the case group and it seems that these factors are responsible for the recurrence.Conclusions: In this study, the factors responsible for increasing the recurrence rate of post- intubation tracheal stenoses were long lengths of resection, presence of too much tension at the site of anastomosis, wound infection and subglottic involvement. We believe that the surgeon can play an important role by decreasing tension, preventing infection, and preserving subglottic structures.

Introduction & Objective: One of the basic rules that all physician know is the danger of epinephrine injection in end organs. This article investigates the necroses of end organs following epinephrine injection in various concentrations.Materials & Methods: This double blind pure experimental study has been done on 54 simulated samples of 9 rabbits’ ears. Under general anesthesia, the surgeons divided rabbits’ ears into 3 lobs, each lobe being nourished only by one end artery. Pure lidocaine of 1% and lidocaine of 1% concentrations with epinephrine in 3 concentrations (1:200000, 1:100000, 1:50000) was injected, and necrosis or viability of end organs was evaluated by physical examination after 48 hours.Results: In the first and second group for which epinephrine concentration were 1:200000 and 1:100000, necrosis was not seen. In third group for which epinephrine concentration was 1:50000, 4 necrosis were seen among 9 cases (36%- P=0.08).Conclusions: Epinephrine injection with 1:100000 and 1:200000 concentrations in end organs are absolutely safe, but with 1:50000 concentrations is clinically unsafe. Xylocain-epinephrine solution lower than 1:50000 can be used safely as a chemical tourniquet.

Introduction & Objective: Transthoracic needle biopsy (TTNB) is a well established method for obtaining pathologic diagnosis in the lung mass that performed after a previous negative bronchoscopy. The gole of this study is the evaluation of safety and accuracy of ultrasonographic guided TTNB for diagnosis of peripheral lung masses.Materials & Methods: In a cross - sectional study from September 2005, 30 patients with peripheral lung mass, greater than 3cm in diameter and less 5cm distance to the chest wall, underwent ultrasonographic guided TTNB and diagnostic accuracy and complications were analyzed.Results: In this group male to female ratio was 2 to one; with average age at 61.2 years. 60% of lesions located in right side, the adequate biopsy specimens were obtained in all patients, but TTNB and diagnostic in 86.6%. 13.3% of patients underwent thoracotomy for definitive diagnosis. Pathological diagnoses were malignant in 83.3% and benign in 16.6% of cases. Squamous Cell Carcinoma and Adenocarcinoma were the most common malignant diagnoses. In benign lesions, tuberculosis was the most common one. Complications were observed in 13.3% that included pneumothorax (6.6%) and hemoptysis (6.6%), mortality wasn’t observed.Conclusions: TTNB with ultrasonographic guided due to appropriate diagnostic accuracy and low complication rate with low cost and availability was recommended for diagnosis of peripheral lung masses.

Introduction & Objective: Because of too sever pain accompanying a hemorrhoidectomy operation; this double blind clinical trial study was done for comparison of post operative analgesia in patients which used preoperative topical lidocaine jel with those that used preoprative lubricant gel.Materials & Methods: Two group 45 patients were candidated for elective hemorrhoidectomy under general anesthesia, and they were randomly divided into two groups, one group received preoperative topical lidocaine jel and second group received preoperative lubricant gel. Then gathered data was analyzed with Chi-square and Mann-Whitney U and T-Student test by SPSS 13 software. The results were evaluated as the mean ± SD and considered statistically significant for P<0.05.Results: The two groups showed similar results for demographic parameters such as age, weight and sex (P>0.05). In the preoperative lidocaine jel group severity of postoperative pain was lower (P<0.05) similarly, the time of free pain period in the preoperative lidocaine jel group was longer (P<0.05).Conclusions: The use of preoperative lidocaine jel in hemorrhoidectomy operation can decrease the severity of pain and can cause longer postoperative free pain period in patients.

Introduction & Objective: Rubber band ligation is one of outpatient treatments of internal hemorrhoid; it leads to ischemic necrosis of hemorrhoids. This method has been carried out prospectively in Hazrat-e-Rasoul hospital or office in which patients were that treated with rubber band ligation, and it was evaluated and compared with results of other centers.Materials & Methods: Our study populations were 50 patients with hemorrhoids who referred to the colorectal clinic of Hazrat-e-Rasool Hospital or private clinic between October 2003 to March 2005. The study considered the patients with hemorrhoids in grades 1, 2 and 3, for whom the most common symptom was bleeding. They were treated with Rubber Band ligation. We have used both disposable O’Regan and reusable McGiveny instrument.Results: In our study sample, 35 patients were in grade 2, 10 in grade 3 and 5 in grade 1 of internal hemorrhoids. A 6-months follow up considered for post operative evaluation. 36 of 50 patients had no postoperative pain (72%), 13 patients had mild or moderate pain (26%), and 1(2%) had severe pain. The patients were classified in three groups according to their response to the treatment: Group 1 had no change of severity and interval of symptoms, and therefore had no response. Group 2 had relative response to the treatment in view of severity and interval of symptoms. Group 3 had complete response to the treatment and their symptoms were disappeared and no recurrence in the follow-up was detected in patients treated with Rubber Band Ligation, 1 of 50 (2%) 2 of 50 (4%) and 47 of 50 (94%) had no response, relative response and complete response, respectively.Conclusions: Rubber Band ligation considered of outpatient procedure for the treatments of hemorrhoids. This method most use for grade 1, 2 and sometime grade 3 hemorrhoids. According to our study results, with 94% good or excellent response, we conclude that this technique is first choice for grade 1 to 3 internal hemorrhoids and occasionally it can be used for grade 4. In our series aside from some reports about sepsis in rubber band technique, we didn’t observe any cases of sepsis.

Introduction & Objective: Acute appendicitis is the most common cause of acute abdomen. Appendectomy is only curative treatment for acute appendicitis. The patients, after appendectomy complain from ugly configuration of suture site, scar problem is stitch abscess and wound infection after appendectomy. This is aesthetically important, because appendicitis is prevalent in the second and third decades of life. This study compared wound closure result by two methods; Subcuticular and Mattress suture.Materials & Methods: In this analytic, clinical trial, 207 patients (105 group A and 102 group B) with the initial diagnosis of appendicitis were appendectomised at Shahid Sadooghi, Mortaz and Saidoshohada hospitals, from April 2005 to December 2006. In 4 follow up visit, patients were clinically examed for Maximum of wound scar width, wound infection and stitch abscess to 3 months after appendectomy at the clinics. Collected data were analyzed with ANOVA test using SPSS 11.5 software.Results: The Mean Scar width in Subcuticular group (A) was 0.96 mm and in Mattress group (B) was 7 mm. There was significant difference between two groups (P.Value=0.0001). The Abscess in the Subcuticular group was seen in one case (0.8%) and in the Mattress group no abscess was seen. There was no significant difference between two groups (P.Value = 0.45). There was no case of wound infection in the two groups. In this study, the age and gender factors were confounding and by using co variance analysis, they were taken care of.Conclusions: Considering the results of this study, the Subcuticular method is a better option in closure of an appendectomy wound.

Introduction & Objective: The term «scoliosis» denotes lateral curvature of the spine. The deformity may be structural; implying a permanent change in the bones or soft tissues, or it may be no more than a temporary disturbance produced by reflex or postural activity of the spinal muscles. This skeletal disorderis one of the important health problems in school ages that is much more common in female’s gender. The aim of this study was to investigate the prevalence of scoliosis among 10 years old female students of Khorramabad schools.Materials & Methods: It was a cross – sectional study which evaluated 768 ten-year old female students of Khorramabad School who were selected by the random clustering sampling method. After determination of samples and obtaining medical history through a questionnaire, physical examination was performed by the plumb line and then in the cases that had no signs of deviation, in this portion of examination, the second stage of examination was performed by the adams test. Finally the screened cases were referred to shohada hospital clinic. And thoracolumbar X-ray was obtained and the angle of deviation was measured using cobb's method.Results: The number of screened cases was 97(12.6%) and after radiology was done, 30 were identified as being afflicted with scoliosis. Finally the prevalence of scoliosis in this study was 3.9 percent of which (3.25%) had cobb's angle below ten degree and only five cases (0.65%) had cobb's angle above ten degree. In this study there was statistical significant difference between student that perform regular aerobic exercise against those who did not perform this exercise.Conclusions: According to this study a partly high prevalence of scoliosis existed among our female school children. This shows the necessity of school screening programs, because by early diagnosis of scoliosis and conservative treatment (by using brace), one may be prevent scoliosis's progression and finally the appearance of complication.

Introduction & Objective: Hypertrophic scars (HTS) following surgical incisions develop mainly due to fibroblast dysfunction in wound healing process, and it may cause significant psychological and social consequences in various patient populations. With regard to growing evidence on tamoxifen effects on fibroblast growth patterns at the cellular level, this study was designated to evaluate the clinical utility of tamoxifen in the prevention of hypertrophic scars, which had been carried out in Shohadaye Tajrish and Ayatollah Taleghani Medical Centers in the 2000 2001 time interval.Materials & Methods: In a double-blind randomized clinical trial after obtaining informed consent, of 300 patients with a history of HTS, who had undergone surgical operations with different skin incisions were assigned randomly into two groups. The first group received tamoxifen tablets postoperatively according to a standard protocol while the control group received placebo. After two months the two groups were compared according to the development of HTS and the result was statistically analyzed.Results: The studied population, comprised of 235 men (78.7%) and 65 women (21.7%), developed HTS following surgical incision. Of these 138 patients (92%) were in the study group, while 78 patients (52%) belonged to control group.Conclusions: Regarding the significant difference of HTS development between the study and control groups (92% vs. 52%), tamoxifen seems to be an effective agent in the prevention of Hypertrophic scars following surgery.

Introduction & Objective: In growing of the nail of the hallux has been described to an abnormality of the shape of the nail; in stage III of diseases surgical treatment indicated. This study evaluated two methods of treatment: (a) a surgical matricectomy and (b) chemical matrisectomy.Materials & Methods: In this randomized clinical trial study, 260 patients were seen in a special general surgery clinic, were assessed for severity and duration of symptoms. 130 patients were treated with chemical matrisectomy and 130 patients were treated with surgical matricectomy those with no history of immunocompremised diseases and diabetes mellitus and with only minor infection were treated by the surgical matricectomy. The nail was nicked and torn down to expose the infected nail fold. The patients were then taught to clean the area, spray it with povidone-iodine dry powder, and pack the nail fold with a twist of cotton wool. Patient; with recurrent or severe in growing toenails were treated by chemical matrisectomy.Results: The rate of infection in surgical matricectomy in men was less than woman. The recurrence rate in surgical matricectomy was 3.98% and in chemical matrisectomy was %11.8. The operative time was 13.8 and 8.6 minute in chemical matrisectomy. The operative cost was less in chemical matrisectomy.Conclusions: On the whole surgical matrisectomy is a better procedure than chemical matrisectomy.

Introduction & Objective: Bronchial carcinoids are rare, slow growing neoplasms with nonspecific clinical signs which can mimic many respiratory syndromes. To evaluate clinical presentations, diagnosis and modes of treatment of these tumors in long term, a clinical research was performed in our center. The aim of this presentation is to report our experience.Materials & Methods: By completing the prepared computerized data sheets for these patients and use of SPSS and Access software’s and Fisher exact and Mc Nemar tests, information’s about age, sex, clinical signs, Hx of smoking, diagnosis and the results were evaluated. The evaluation took eleven years (1996-2007) therapies, with a complete follow up in 86.4% of the patients.Results: 73 patients (38 women, 35 men) with mean age 41.4 years-old (range 11-70) were treated, with diagnosis of bronchial carcinoids. Surgical resections (from wedge resection to pneumonectomy) with or without mediastinal lymph node dissection (MLND) were performed. Other therapies such as bronchoscopic resections or ND YAG laser ablation were done before surgery in some patients. There were two recurrences both in lymphatics (2.7%). During this period 6 patient's (8.2%) have been died, 4 from operated patients (%6 of total operated ones) and one due to surgical complication and 2 were among non-operated ones (28.6% of non-operated cases).Conclusions: Bronchial carcinoids with slow progression are often treated as other diagnoses before definite diagnosis. Fiberoptic bronchoscopy is more accurate in their findings than rigid broncoscopy (P= 0.04), were as considering that rigid bronchoscope should be available during biopsy time due to the high risk of hemorrhage. Their treatment is surgical resection (maintaining as much paranchyma as possible) with mediastinal lymph node dissection especially in atypical ones. Local recurrence was in lymphatics in our patients. When possible, re-resection is the treatment of choice for recurrences. The use of endoscopic resection or laser ablation in finding tumoral origin or in treating obstruction and infection distal to it might be helpful. Role of chemotherapy and radiation aren't clearly obvious.

Epithelioid sarcoma is one of the malignant soft tissue tumors of uncertain type has been applied to a morphologically distinctive neoplasm which characteristically affects the distal parts of the extremities of young adults. In fact epithelioid sarcoma is the most common soft tissue sarcoma in the hand and wrist. This article is a case report of the tumor followed by operation of inguinal hernia in 32 years old male. At first with uncommon manifestation and site of tumor another differential diagnosis was suggested such as abscess, GI malignacies. In supplementary evaluation and biopsy of ulcer the diagnosis focused on undifferentiated high grade epithelial tumor highly suggestive Epithelioid sarcoma. In Immunohisochemical finding, CD34 and, cytokeratin, this diagnosis was confirmed. The most important point was the role of surgical trauma in disease flare up. The best strategy in management of Ephithelioid Sarcoma is extensive resection amputation for relative long survival.

The pubic symphysis is a rare site for osteomyelitis. We reported a case of osteomylitis pubic about 9 months after inguinal hernia repair. The causative organism is staphylococcus aureus resistant to all antibiotics except vancomycin. The patient was treated with antibiotics for six months without any surgical debridement. This is a report of a pubic osteomylitis following inguinal hernia repair.