نشریه جراحی ایران
سال بیست و سوم شماره 2 (تابستان 1394)

Gynecomastia is characterized by the enlargement of male breast، due to glandular proliferation and fat deposition. Gynecomastia is a common condition which occurs in three different age groups: adolescents، adults and old people. In this review the pathogenesis، etiology، evaluation and treatment of this condition will be discussed. A hormonal imbalance between estrogen and androgen is the key cause of the gynecomastia occurrence. Physiologic factors، Endocrine dysfunction، endocrine tumors، non endocrine disorders، drug usage and idiopathic causes are among the etiologic factors of gynecomastia. In the clinical evaluation، a thorough etiologic investigation should be considered. Therapeutic options for gynecomastia can be listed as: weight loss، reassurance، medical treatment with Tamoxifen، and surgery. Liposuction and mammary، adenectomy as a combined surgery، gives the best result for long standing gynecomastia.

Introduction & Head injuries are the leading cause of death in motorcycle crashes. In this way، the benefit of head protection devices has been shown in the literature. From the clinical point of view، many investigations have tried to find a standard helmet type but they have had limitations such as، small number of cases have been studied or have been a retrospective data analysis. During a prospective observational study from April 2012 to 2014، victims of motorcycle crash accidents، with head trauma، were included، regardless of their age، sex، severity of trauma and type of helmet used. Details of trauma to each organ were recorded and injury severity score (ISS) calculated. Four groups of patients were analyzed based on four types of helmets available in the Iranian market. This study included 384 patients (371 male، 13 female). The average age of patients was 32±13 and the mean ISS was 8. 45±6. 9. The mortality rate was 1. 6%. The group of patients using “vertex covering” or “open face” helmets had 4 fold higher risk of face injuries of (AIS=1) in comparison to patients with “full face” helmets (P = 0. 002; 95% CI: 1. 7، 10. 5). The risk was 14 fold in cases with more severe AIS=2 face injuries (P = 0. 009; 95% CI: 1. 98، 122. 8). There was no correlation between helmet type and the types of head and neck injuries. In comparison with other types of motorcycle helmets، using full face helmet can provide more protection against mild، moderate and perhaps severe face injuries. In the context of head or neck injuries، there were no significant differences between various types of helmets. Full face helmet may be offered to motorcyclists as a standard helmet.

Introduction & Understanding of the factors that cause the conversion of laparoscopic to open surgery is a good way for helping surgeons to choose the right treatment for each patient. The purpose of this study was to investigate the relationship between the gallbladder wall thickenings for the change of laparoscopic cholecystectomy to open surgery. 619 patients who were candidates for laparoscopic cholecystectomy surgery enrolled in our cross-sectional study. Patients’ information including: age، gender، diagnosis، gallbladder wall thickness، and conversion factors were collected. SPSS version 20، T-test، X2 test and Logistic regression model were used for statistical analysis. 31 cases (%5) were led to conversion، and 588 patients (%95) did not need conversion to open surgery. In this study، 219 patients (%47) had thicknesses less than or equal to 3 mm of which 4 patients (%1. 4) were converted to open surgery and 287 patients (%98. 6) were not. Also، among 328 patients (% 53) who had thicknesses more than 3 mm، 27 patients (%8. 2) were converted to open surgery. There were a significant relationship between gallbladder wall thickness and conversion (P)

Introduction & The quality of life is a good feeling of satisfaction or dissatisfaction with those aspects of life that are important to the person involved. This study was conducted to determine the quality of life in patients with chronic burns. This descriptive cross-sectional study was done on 150 burn patients with a minimum history of 6 months. Data was collected، using a demographic questionnaire and a QOL questionnaire in burn patients (BSHS). Sampling was done with purposive sampling using the available method. The collected data were analyzed using descriptive statistics، statistical tests ANOVA and Pearson correlation coefficient. Quality of life، in the physical status، was significantly different with the history interval of 6 months (P=0. 001)، marital status (P=0. 005)، job (P=0. 001)، the place of living (P=0. 00)، and education level (P=0. 004). Quality of life in emotional status (9. 3% were unfavorable and 42. 7% relatively unfavorable) and overall it was relatively unfavorable. As far as social status was concerned 16% were unfavorable، and 45. 3% were relatively unfavorable، and overall were relatively unfavorable. The quality of life in the study population was relatively unfavorable. This could be due to the effect of burn on the mental image of burn patient. Life skills، effective communication skills، establishing and maintaining interpersonal relationships and coping with emotions and coping skills is recommended for these patients.

Introduction & It is believed that the appendix location changes with the growing of uterus during pregnancy. Therefore، it is expected that pregnant patients with acute appendicitis، pain and tenderness shif to the superolateral part of abdominal cavity. This can affect both the diagnostic and surgical approach to the acute appendicitis of these patients. A descriptive study was carried out over 240 pregnant women. During laparotomy and cesarean section anatomical position of the appendix was evaluated with respect to the Mcburney point and incision. The patients were grouped into A (full term with gestational age > 37 weeks) and B (preterm with gestational age 20-37 weeks). Also anatomical location of the appendix evaluated in 50 other men and non pregnant women as control group. Comparison of anatomical location of the appendix and cecum in 240 studied patients in their respect to the 50 patients in the control group revealed no significant statistical difference with chi square test. In 188 (78. 3%) patients the appendix was located in the limit of Mcburney point and incision. In 52 patients (21. 7%) the anatomical location of the appendix had been changed to Subheptic space (28 Case) and right flank (24 cases). In 46 patients، the location of the cecum was at subheptic and right flank. Gross change of the appendix position toward the upper and lateral part of the peritoneal cavity was seen only in 6 patients. No statistical analysis difference was seen on the change of appendix location between 223 full term and 17 preterm pregnant patients relative to the 50 patients of the control group. Usually، the anatomical position of the appendix does not change with the growing of uterus during pregnancy. Therefore، Mcburney point and right lower quadrant is the landmark location in simple acute appendicitis for both clinical diagnosis and surgical approach.

Introduction & Bleck classification is the common method of assessing Metatarsus Adductus (MA) which is associated with some limitations and problems. Foot scan is one of the new methods in the examination of lower extremities. The present study aimed to study the efficiency of a new method based on foot scan in determining the severity of MA and its compliance with Bleck classification. In this cross-sectional descriptive research، 100 subjects were equally divided into each of the four categories of Bleck classification. Their foot were scanned and the ratio of foot transverse distance on the fifth metatarsophalangeal joint (MTP) to the tangent to the outer edge of the foot (a)، and the foot width on the metatarsophalangeal joints (b) were measured from the images obtained. Then، these ratios were compared between the 4 groups by the One-way ANOVA analysis. The mean ratio of a/b in normal group 0. 02، with a standard deviation of 0. 02. This ratio in the mild metatarsus addactus was 0. 1، with standard deviation 0. 01; in the moderate metatarsus addactus was 0. 159 with standard deviation 0. 03 calculated، and the ratio in sever metatarsus addactus was 0. 216، with standard deviation 0. 025 was calculated. In addition، a significant difference was found between the groups (P)

Introduction & Previously it was thought that spleen is not an important organ with special function. Therefore the elected treatment of spleen diseases has been full splenectomy. By greater recognition of the spleen function and its important role in the body physiology، it was found that full splenectomy causes immunocompromised increasing in the individuals and made them prone to certain infections and the risk of tromboemboli. The present study was conducted for precise analysis of the immune system changes، including immunoglobulin levels with regard to the study of tissue changes and the regeneration of the transplanted spleen، in order to achieve proper performance with the hope of reducing the complications of inevitable splenectomy especially due to post-traumatic ones. In an interventional and cross-sectional study، 19 patients over 12 years old with blunt trauma، who، were suffering from severe splenic blunt trauma in 2013/14، based on the treating physician’s diagnosis were full splenectomy candidates، came under our study. Patients with census and giving written consent were included in study. After the approval of the patient Candidacy for of splenectomy، necessary explanations were provided to the patients and lack of exclusion criteria، patients were evaluated and eventually graft surgery was performed on them. Finally، all the patients’ informations were entered into SPSS version 16 and were analyzed. Measures of central tendency and dispersion (mean and standard deviation) of charts and graphs were used for data analysis in descriptive statistics. In inferential statistics، repeated measures test were used and in case of abnormal data its equivalent Friedman test were used. In the present study، a total of 19 patients with an average age of 42. 58±18. 78 years old of which 14 (%73. 7) were male، were studied. The results of the univariate analysis showed a statistically significant difference (P=0. 024) in the rate of lymphocyte over time (before the surgery، 3 months after the surgery and 6 months after the surgery). However the variables hemoglobin (P=0. 192)، red blood cells (P=0. 177)، hematocrit (P=0. 192)، platelets (P=0. 221)، and leukocytes (P=0. 071) revealed no significant difference. The presence or absence of Howell bodies indicated a significant difference (P=0. 042)، over time so that the Howell bodies in the 6 months before surgery were less than 3 months after surgery. The difference between average spleen phagocytic at 3 months after surgery and 6 months after surgery was significant (P=0. 044). In fact، the average spleen phagocytic at 6 months after the surgery was higher than that of 3 months after the surgery. Based on the results of this study، by increasing the time as well as transplanted chips، the difference between the individuals with auto transplanted spleen and those with healthy spleen can be reduced to the lowest possible rate. Auto transplantation of Spleen has been proved to be a very appropriate alternative therapy to splenectomy.

Introduction & Citation means to document something، to lean something، or to document an utterance and referring to it. Citation expresses a kind of using previous knowledge، which means that scientific writings do not merely lean on themselves، but benefit from various previous references. Therefore، the more a study receives citations، the more it shows to be fundamental and of quality. With this in mind، the current research has investigated different elements concerning Iranian surgery scientific productions’ citations. This research uses Scientometric method to investigate، the rate of citations of Iranian researchers in the field of surgery by using data from ISI database. We first retrieved the needed data about Iranian researchers in the field of surgery from this database، and then we manually got the elements regarding this research، like the number of domestic and foreign authors، sexuality of authors، types of scientific productions، the number of pages، the number of references، etc. Then our data were entered into the SPSS Software، version 20، and for analyzing data we used scales of descriptive statistics and statistical tests such as Pearson – Moment Correlation، for testing second hypotheses، independent group T- test and for testing third and fourth hypotheses، one way ANOVA. With regard to the sample of 2931 researchers، the findings showed that with an increase in the number of authors of each article، the rate of citations to them increases and there is a positive correlation and significance equal to 0. 056، so that at the level of (P)

Although the treatment of patients referred to medical centers due to foreign body ingestion is a common problem، but surgical intervention is required in less than 1% of cases. This can be attributed to the development of endoscopic techniques. The patient was a 32 years old man who come to the emergency ward with complaint about repeated vomiting and nausea. The patient is a smoker with psychological disorders، and a history of addiction in the past few years. The patient''s vomiting had started on the morning of referral، and his defecation and gas passage had been reduced from two days before the referral. He noted ingestion of two connected safety pins، four days before presentation. Abdominal radiography revealed two safety pins in the terminal ileum and distension of small intestinal loops. The patient was hospitalized for four days with the diagnosis of partial obstruction of small intestine، and finally underwent laparotomy due to the worsening of his general condition. After McBurney incision in abdominal wall، impacted foreign bodies were drawn from terminal ileum to jejunum، and then enterotomy was done. The aim of this report is to attract especial attention to the case of patients with psychological disorders who refer to a hospital due to gastrointestinal tract obstruction.

The Achilles tendon rupture occurs more often than any other tendon، and if the diagnosis is delayed for more than four weeks، it is called chronic rupture. In this case، due to gastrocnemius muscle contractile effect، a distance is created between the two ends of the rupture. As the result، chronic rupture''s healing method is different and more difficult than that of acute rupture. Most cases of chronic Achilles tendon rupture have been reported، previously، in adults. Only one case has been reported in children with chronic ruptured، and that was healed by plantaris gracilis tendon augmentation treatment. The authors of the present study report a case of successful treatment of the traumatic rupture of the Achilles tendon، with 7 cm distance between the two ends of the rupture، in a 9-year-old boy، six weeks after the injury، using end to end treatment method.