Iranian Journal of Surgery
Year:2006 | Volume:14 | Issue:3|Papers Count:17

Introduction & Objective: Controversy still exists about the optimal surgical approach for degenerative cervical disc disease. Several factors may be considered by the attending surgeon to choose either of techniques; posterior interlaminar approach, anterior cervical discectomy without interbody fusion graft (ACD), or anterior cervical discectomy with interbody fusion graft (ACDF). This survey was designed to compare techniques of ACD with ACDF approach.Materials & Methods: This study is a prospective non-randomized clinical trial. All patients suffering from degenerative cervical disc disease who were admitted in the Department of Neurosurgery, Sina Hospital, during 2003-2005 were included. Demographic data, clinical findings, surgical complications and patients’ outcomes in the two groups were compared immediately after the operation and through a 1-year follow-up period.Results: Men were more affected than women (n=46), summing up to 65 patients. The mean age of cases was 44.7(±12) years. The most common level of involvement was C5/6 interspace (50.8%), In 36 cases (55%) the disc protrusion was lateral, while in 29 cases (45%), there was only a central or paracentral disc bulging. There was no statistically significant difference between the two non-randomized groups in the clinical and radiological presentation. The extent of pain relief, the duration of operation, post-operative hospital stay, and the time elapsed for the patients to return to the previous job was significantly different between the two surgical groups, favoring ACD, (P value <0.01). The rate of muscle force retrieval was better in the group with ACDF. No serious surgical complication occurred in the ACD group, and most of the complications were encountered in the ACDF group.Conclusions: This survey goes in favor of ACD technique versus ACDF in patients suffering from single level degenerative cervical disc disease. Another well designed study incorporating larger numbers of patients with more protracted follow-up interval is strongly recommended.

Introduction & Objective: During axillary burn scar release, using transposition flaps such as Z-plasty technique, problems such as tip necrosis and hair bearing skin transfer to visible areas of axilla were noticed. This led the authors to introduce a new technique; Multiple V-Y Advancement flaps (M-plasty).Materials & Methods: 12 patients underwent M-plasty and followed for 5 to 18 months. The results were evaluated by comparative measurements of the active range of shoulder abduction before and after operation.Results: Range of shoulder abduction before operation was 45º -90º and post operatively increased to 110o -180o. The mean percent of improvement was 48%. The amount of scar lengthening was satisfactory and no recurrence of the contracture was noted. Two patients developed hypertrophic scars on the incision line.Conclusions: The results of this study show that multiple V-Y advancement flaps (M-plasty) procedure, promises to be a good alternate technique in the treatment of axillary contracture bands in terms of rate of elongation, prevention of flap tip necrosis and inhibition of hair bearing skin transfer to visible areas of axilla.

Introduction & Objective: Transsphenoidal adenomectomy has been the accepted surgical management for treatment of growth hormone (GH)-secreting pituitary adenomas. Although the goal of treatment might be to keep the GH level in the reference range, the actual definition of success in control of acromegaly is not yet clear.Materials & Methods: The aim of this study was to analyze prospectively the result of transsphenoidal adenoctomy performed over 23-year period by a single neurosurgeon in one center. The analysis has been performed to determine which preoperative factor could significantly influence the long term outcome. This series consisted of 151 patients. The preoperative hormonal studies documenting the high GH and/or insulinlike growth factor were available in all the cases. At least 1 laboratory report documenting the postoperative level of hormones was also available for all of them. Transsphenoidal microsurgical adenomectomy was performed in all the cases.Results: There were 90 patients with pure GH-secreting adenoma (59.6%) with the highest GH level of 235 mU/L. A second group of 12 patients had normal GH level but elevated serum level of insulin-like growth factor 1 (8%). The group with mixed secretion of GH and prolactin included 49 cases (32.4%). There was no postoperative mortality. Cerebrospinal fluid leakage occurred in 12 patients. Transient diabetes insipidus was encountered in 19 cases (12.6%) and long lasting diabetes insipidus in 2 patients (1.3%). Early and minor hypopituitarism was encountered in 14 patients, whereas a persistent condition occurred mainly after irradiation in 14 other cases. Normal postoperative serum GH level could be achieved in 98 patients (94.2%) of 104 cases with full follow-up.Conclusions: In the developing countries, early diagnosis and proper surgical extirpation of the GH - secreting adenoma by an experienced and dedicated pituitary surgeon is mandatory to reduce the mortality and increase the chance of cure of this rather mortal endocrionopathy.

Introduction & Objective: Intestinal damage in gastroschisis is due to contact of intestinal wall with amniotic fluid. In this study effects of fluid dilution on histological changes of intestine in rabbit fetus were evaluated.Materials & Methods: In an experimental clinical trial, 10 rabbit fetuses as shams 7 an fetuses as controls and 7 fetuses as cases were studied. In shams, after delivery abdomen of fetus was opened and fetus was placed in formalin. In controls, with fetal surgery, we produce gastroschisis. In cases, before closure of hystrotomy, a 14 central vein catheter was placed in uterus and 6 hours later, amniotic fluid was diluted by injection of 1-2 cc of warm normal saline every four hours. Forty-eight hours later, fetuses were delivered by Cesarean section and analyzed histologically.Results: There were no differences between, mucosa, submucosa, muscularis thickness and ganglion cell in groups. Serosal thickness was 4.5±3.6 mm in shams 64.2±28.7 mm in controls and 6±4.1 mm in cases group.In control group, serosal thickness was higher than shams (P=0.001) and case group (P=0.002). In histological evaluation, fibroblast infiltration and collagen deposition with fibrin were seen in serosal layer.Conclusions: With intermittently dilution of amniotic fluid, we can prevent the effects of this fluid on in fetal intestine histology.

Introduction & Objective: Botulinum toxin is a presynaptic blocker of acetylcholine in neuromuscular junction and autonomic nerve endings. In recent years, in a few studies, transperineal injection of botulinum toxin into the prostate has been used for treatment of urinary symptoms in men with benign prostatic hyperplasia. We investigated the efficacy and safety of transurethral injection of botulinum toxin into the prostate gland for the management of lower urinary tract symptom associated with benign prostatic hyperplasia.Materials & Methods: After urethrocystoscopy under local anesthesia, botulinum toxin, 100 units for each lobe were injected with a 3 centimeter 22 gauge needle. Prostate volume, post voiding residue, maximum flow rate, AUA Symptom scores, AUA Quality of life scores and serum PSA were measured before and after intervention at 1, 6 and 9 months follow up.Results: Fifteen patients with median age of 65 years were included in this study. After the primary intervention, all patients experienced partial improvement at 1-month follow up,; as demonstrated by 20% decrease in AUA Symptom Score and 25% decrease in QOL Score. Maximum flow rate increased 32%. Prostate volume and post voiding residue decreased 13% and 46% respectively. Serum PSA decreased 30%. Patients’ symptom scores remained at the same level after 6- and 9- month follow up, although maximum flow rate decreased 1.5 mL/ s at 9- month as compared with 6- month follow up.Conclusions: Transurethral injection of botulinum toxin under local anesthesia is a safe, easy, and effective treatment for the management of symptoms of benign prostatic hyperplasia.

Introduction & Objective: Feeding patients following GI operations especially in GI track anastomosis is a matter of consideration. For years, surgeons did not used to feed their patients for couple of days. Gradually, this delay was argued and early feeding, immediately after disappearance of ilues applied. This article represents the results of a research about safety of early oral feeding after resection of gasteroesophageal malignancies and its potential benefits.Materials & Methods: The protocol of this study has been carried out in TUMS cancer Institute in patients with esophageal or gastric cancers since 1997. The patients were divided in two groups. In case group, the liquid regime started in 24 to 48 hours after surgery. The regime was one glass (50 to 100 cc) of tea with sugar every 8 hours, while the patient still has the NG Tube. In control group, early oral feeding was not initiated and the patients were NPO for at least 4 days. The information about the demographic characteristics of the patients, post operative feeding pattern, post operative oral feeding tolerance and post operative complications were collected and analyzed.Results: In this study, data of 132 patients were collected. The patients were matched by age, sex and surgical techniques. The number of 71 patients had esophageal cancer and 61 patients had gastric malignancy. On the whole 61 patients were early fed and 71 patients lately fed. The early fed group was fed orally 1.8 days on the average after the surgery, and the lately fed one was fed 6.2 days after the operation. In the case group, the NG Tube was removed 2 days earlier (P value=<0.0001) and the beginning of the soft diet was 3 days earlier (P value=<0.0001). The serum therapy was paused 2 days earlier in the case group (P value=0.031). Also the overall inpatient period and the post operative inpatient period come out to be 4 and 2.5 days shorter respectively in case group which show a significant statistical difference with the control group. There were also no significant differences in the mortality rate in the two groups.Conclusions: The result of this research showed that early oral feeding in the first or second postoperative days in patients with surgery on their upper GI tract does not cause complications such as leakage, and lowers the rate of morbidities and mortalities. Also this procedure will decrease the excesses by shortening the inpatient period and incidence of complications.

Acute hemorrhagic pancreatitis is a rare disease in children. Its usual etiologies are trauma, infections and drugs. Nearly all of the reported cases of this disease are older than four years old. Here we present a case of 16 months boy with acute hemorrhagic pancreatitis which we didn't find any etiology for his disease in our investigations.

Introduction & Objective: Postoperative pain control is among the most important deals of thoracic surgeons for which several methods were proposed. In this study postoperative pain of thoracotomy was compared in intracostals and intercostals sutures.Materials & Methods: In this study, 92 consecutive patients underwent elective thoracotomy were studied. Patients with a history of chronic chest pain, analgesic use, addiction, psychiatric illness, refusal to enter the trial, history of previous ipsilateral thoracotomy and chest wall resection operation were excluded. In case group, ribs were closed by intracostal sutures but in controls, conventional intercostals sutures were used. Postoperative pain was objectified by a numeric pain score at one 2, 3 weeks and 1, 2 and 3 months postoperatively.Results: Two groups were matched for age, gender, number of chest tubes and length of hospital stay. The mean pain score for intracostal group at 1, 2, 3 weeks and 1, 2 and 3 months post operatively was 4.82, 3.91, 2.91, 2.78, 1.82 and 0.5 respectively. For intercostal group it was 5.04, 3.91, 2.95, 2.86, 2.08 and 0.82 respectively. There was no significant difference.Conclusions: Chest wall closure by intracostal suture has no benefit to conventional intercostal suture closure.

Introduction & Objective: Eusthachian tube injury during adenoidectomy may cause complications of middle ear. Adenoidectomy with inappropriate and larger curette size may cause these injuries. A simple anatomic correlation that can predict the optimal curette choice for adenoidectomy is beneficial.Materials & Methods: This prospective study evaluates correlation between upper central incisor width and intertubarius width (ITW) as a predictor of adenoidectomy curette size. Between June 2005 and January 2006, one hundred patients were evaluated whom underwent adenoidectomy, tonsillectomy, or adenotonsillectomy at ENT ward of Emam Reza hospital. Mean age of patients was 12.18 (SD: 2.91), ranged from 2 to 32 years old. During operations, the distance between the upper central incisors and inter tubarius width was measured in millimeters.Results: There was no significant satistical difference between mean of ITW and upper central incisors width (P=0.01). This relation was more prominent in 1-5 year old patients regarding time constraint for dental and maxilla changes resulting from large adenoid.Conclusions: Therefore a curette that the outer diameter does not overlap the lateral aspects of upper central incisors can be used safely specially in 1-5 year old group.

Although craniofacial clefts (CFC) are rare congenital malformations, their numerous anatomic variety and relatively difficult and longstanding management gives specific importance to them.Proboscis is a rare anomaly in which half of the nose is separated from the face and is connected to the medial canthal area as a tubular structure. A 3 months old infant with left – sided proboscis and left lower eyelid coloboma is presented.The proboscis was managed with local flaps and coloboma was repaired at 10 months of age.

Introduction & Objective: Different techniques are used for surgical treatment of lung hydatid cysts, including: "Cystectomy, repair of bronchial openings and leaving open pericyst cavity", "Cystectomy and capitonage", "Wedge resection", "Lobectomy" and even "Pneumonectomy". Regarding diversity of surgical techniques and different incidences of disease in different areas of the world, it is not yet clear which technique is better than others.We present our results of a single surgical technique in a remarkable number of patients.Materials & Methods: During an eight year period (August 1997 to July 2005) 125 patients with lung hydatid cysts underwent operation in our department (60 female, 65 males, and mean age of 33.12 years, ranging 7-80 years). The surgical technique was "Thoracotomy, opening of the cyst and removing its contents, repairing bronchial openings and leaving the pericyst cavity open in to the pleural cavity". Normal tissues around the cysts were protected with towels dunked in 0.5 percent silver nitrate solution before incising on the cyst, and then only after evacuation of cysts and closure of the bronchial openings, the cavity was irrigated by this scolicidal solution. Radical lung resections were undertaken only in situations that due to destruction of lung parenchyma it was inevitable. Wedge resections were used only for small and peripherally located cysts. The patients were followed and investigated post operatively for surgical complications especially prolonged air leak from chest tubes, pneumonia, pneumothorax and recurrence of the disease.Results: There were 181 cysts in 125 patients. Average number of cysts which were resected was 1.44/patient. One hundred and fifty six cysts (86.19%) were operated with above mentioned technique and in 25 cysts (13.81%) conservative or radical resections was done. One hundred and nine cysts were intact and 72 were ruptured. Location of cysts was: right lung in 65 patients, left lung in 50 patients and both lungs in 10 patients.Early postoperative complications were: Prolonged air leak (more than 7 days) in 9, pleural effusion in one and pulmonary emboli in one patient. These complications were successfully treated in all patients. Late complications included: one prolonged air fluid level at the site of cyst, 5 recurrences. One death occurred due to post-pneumonic empyema.Conclusions: "Cystectomy with closure of bronchial openings and leaving open the pericyst cavity" is a suitable surgical technique for treatment of lung hydatid cysts. This technique could be applied in most patients. Radical lung resections are indicated rarely.

When thinking about medical team responsibilities in surgical procedures, one question comes to mind: «In the event that during a surgical procedure a patient is harmed or looses his/her life. Who will be held responsible?» Would it be the head surgeon who is in charge of the medical team? Or is one or more member of the team responsible? Is the medical team not responsible because they were just following orders from the head surgeon? Or they are responsible?There are many theories regarding this issue. Some of these theories are such as: charitable responsibility, employer responsibility, co-operative responsibility, ship caption responsibility, Legal responsibility and … The view point of this article with respect to the mention of theories is to pay attention to medical team responsibilities in surgical procedures and fair legal procedures regarding doctors and patients.

Introduction & Objective: Posterioinferior cerebellar artery (PICA) aneurysms are rare. We report our series of 7 patients with PICA aneurysms (from 170 patients with cerebellar aneurysms). Materials & Methods: Six patients with PICA aneurysms who were surgically treated with endovascular procedure. All of the patients were treated between 1998-2005. Data relating to clinical, radiological and intraoperative findings and post operative findings were analyzed.Results: In our series, PICA aneurysms reached an incidence of 4.11% of all intracranial aneurysms. All of them were ruptured. We have various clinical and radiological manifestation. Surgical outcome was favorable for all of our patients.Conclusions: This review summarized the presentation and outcome of a series of 7 patients with PICA aneurysms. These aneurysms are rare and have various presentations. Sometimes difficult for diagnosis and management.