نشریه جراحی ایران
سال بیست و ششم شماره 4 (زمستان 1397)

BI-ALCL is an uncommon T-cell lymphoma. In 2011 FDA suggested that breast implants are possibly associated with development of BI-ALCL, since then more cases of BI-ALCL were reported. It is estimated that to this date more than 500 cases have been diagnosed as BI-ALCL around the world. In most of these cases implant surface was textured rather than smooth. Both silicone and saline filled implants have been reported to develop this problem.
BIA-ALCL has two different presentations. Two-thirds of the cases present as periprosthetic fluid collection one year or later after implant insertion, and the remaining one-third as a capsular mass around breast implant.
These presentations seem to be different stages of one disease. Although the best imaging-based screening is not identified, sonography, PET and CT are appropriate methods. Mammography has low sensitivity for screening of BI-ALCL. Every suspicious case should be confirmed with fine-needle aspiration and pathological examination for IHC (CD30) with insistence to rule out BI-ALCL before surgery. Operative treatment of confirmed cases should include removal of bilateral implants, total capsulectomy, and complete excision of any suspicious lymph node. The role of adjuvant treatments is under investigation.
Although BIA-ALCL is rare lymphoma of breast, early diagnosis and appropriate treatment is necessary in the patients. Death has been reported in 9 patients in the U.S.

Along with the advancement of medical knowledge and increasing life expectancy, the number of complicated surgical operations in people with underlying diseases has also increased a lot. It seems that providing a practical guideline for improving the quality of surgical operation will lead to reduce of complications of surgery and quickly return of patient to community, in which this program presented by a group of academic surgeons in the name of Enhanced Recovery After Surgery (ERAS) in 2001 and in London.
ERAS, is a multimodal and multidisciplinary approach for caring the patients who has underwented surgery. There are some evidences that in case of successful implementation of ERAS protocols, not only the quality of treatment and surgery improved but also it caused to reducing the length of stay of patient at hospital and its cost accordingly.
So we decided to introduce this program by reviewing its background, existential philosophy, teams, implementation and achievements of running ERAS.

Cleft Palate is the most common congenital craniofacial disorder with prevalence about one in every 2000 births. In most of these patients, local and regional tissues in the mouth are used to repair it. However, in cases of wide cleft palate or large and recurrent fistula, these methods are not efficient and require the transfer of free flaps. In this retrospective study, records of 17 patients with cleft palate or palatal fistula that treated with free flaps were studied. The information includes age, sex, cause of surgery, type of transferred flap, recipient artery and vein, size of skin paddle, pre-laminate or graft coverage of nasal side, early flap survival, long-term results, effects on nasal regurgitation and velopharyngeal insufficiency were collected. Data were analyzed by SPSS software version 19 and using descriptive statistics. The mean age of patients was 13.540 ± 15.705 (3-54 years). 10 (60%) were male and 7 (40%) were female. 8 (47%) patients were operated due to wide cleft palate (WCP), 7 (41%) patients due to recurrent palatal fistula (PF), one (6%) patient due to extensive tumor resection and one (6%) patient due to extensive defect followed by Mucormycosis fungal infection in a diabetic patient. All the flaps survived, and complete or partial necrosis were not observed. Nasal Regurgitation was cured in all but three patients and Velopharyngeal insufficiency (VFI) was improved in all patients. Radial Forearm Free Flap is one of the best choices to cover the defect in patients with a wide cleft palate or a recurrent or large palatal fistula. In our study, the success rate was 100%, however, in about 18% of patients, there was complications that needed another operation. The most important disadvantage of this flap is the unaesthetic scar of forearm, which should be placed against its great benefits.

At present, based on reference books, at the end of the more thoracic surgeries, two chest tubes are inserted in the anterior and the poster for drainage of air and fluid. Considering the development of thoracic surgery and the advances made, the need to insert two chest tubes and compare it with the embedding of just one tube and also compare the removal of the chest tube in a deep inspiration with deep exhalation will be considered. A total of 43 patients referred to the Army Hospitals during the years 95 to 97 who were referred to thoracotomy were randomly assigned a chest tube or two chest tubes. The duration of hospitalization, the amount of pain and re-effusion of fluid after discharge were evaluated. Chest tube removal was done in 22 patients with deep inspiration and 21 patients were in deep expiration. 43 patients aged between 14 and 72 years old, including 27 males and 16 females, were enrolled in the study. Surgery included 21 cases of decortication, 14 cases of hydatid cyst, 3 cases of lobectomy and 5 cases of spontaneous pneumothorax. The amount of pain and duration of hospitalization and patient satisfaction in the group of one chest tube were significantly lower (P < 0.005). The amount of fluid re-accumulation in the group with one chest tube was little more (7 to 4), but not significant
(P = 0.05). Taking off chest tube in deep inspiration or expiration if the Valsalva maneuver is done well, there is no difference in the air's lick. The insertion of only one chest tube leads to a reduction in the cost and duration of hospitalization and improves the patient's postoperative activity, but it is necessary for this study to be evaluated in the larger matched group.

Asymmetry of body and face is possessed in common between vertebrates especially in human. After years of plastic surgery practice and examining many patients, we noticed that there is a considerable occurrence of asymmetry among them. Most patients show the bigger left side of the face comparing to the right side. These findings lead us to do a more accurate study on natural human skulls. On thirty-four natural human skulls we marked cephalometric points, and took pictures from the anterior, both laterals and superior views, and did standard digital photography. We did exact measurements of 19 different distances between points, with the Image j software (National institute of health). After comparing between left and right side measurements, we found out that the left orbit is longer and wider and also the left orbital area is bigger than right side. Measuring the lateral sides of the twenty completed skulls (including mandibles) showed that mandibular body is longer on the right side view but wider on the left side in the anterior view. Asymmetry and laterality of the face and body is a common rule between animals and humans. The correlation of this asymmetry between left and right sides in human skulls is our new finding. With this concept, both patients and surgeon will be aware of the natural anatomical variations and will have a better prediction of surgical outcome.

In cancer studies, sometimes events are semi-competing. In this case, each patient experiences more than one event, and only one of those is a terminal event (for example, death), and others are non-terminal events (for example, relapse of the disease after treatment) where the risk of death competes with the risk of a non-terminal event of relapse but not vice versa. The aim of this study was to determine the effect of risk factors on relapse time, death time without relapse, and death time after relapse in gastric cancer patients using an illness-death model.
Materials & In this historical cohort study, 200 patients with gastric cancer were studied. These patients had referred to Imam Khomeini hospital 2003 - 2007 and were followed up to October 2009. The data was analyzed by illness-death model, with and without frailty by considering semi-Markov assumption in R 3.4.3 software. Of the patients, 61 (30.5%) had relapses, 71 (35.5%) deaths, 27 (13%) relapsed and death, 34 (17%) relapsed without death and 44 (22%) was died without relapsed. In multivariate analysis, based on confidence intervals, the lymph nodes had a significant effect on the relapse time; metastasis had a significant effect on the time of death without relapse and stage of disease had a significant effect on the death time after relapse. Estimates of the effect of variables were different at the stages in the model. In other words, the effect of risk factors on the time of death was different before and after of relapse occurrence. Therefore, the relapse event as an intermediate event is very important and should be considered by therapists.

Due to the growth of scientific production in recent years, this question has always been raised in scientific circles and society, how much scientific production has led to the elimination of the problems of society and how many of them led to the production of goods and services and jobs in a country. In this regard, the present study has investigated the scope of surgical field patents at the global level and Iran's position in this field in order to determine the extent of the invention from the point of view of scientific production. The method of this study is scientometric, using Scopus citation database and embedded engine on it. Also, Excel software was used to draw tables and charts. The results of this study showed that the United States, Japan, the United Kingdom, Germany, Italy, China, France, Canada, India and Turkey ranked first to tenth in terms of patents for surgery, respectively. Iran is ranked 23rd. Other findings, according to data from this site, indicate that the patent process has been slightly decreased in recent years. With 757 in 2014, 729 in 2015, 2016 in 716, 2017 in 692 cases, and 2018 in 660 cases. The growth of scientific production in the field of surgery in the world and Iran has grown relatively well. Perhaps one of the reasons for this is limiting patents to surgeons, since surgery may has an inventive, cooperative, and involved role, but for some reasons its name has not been documented or many of these inventions have been documented in general. In this regard, the status of surgeons in the patent has declined. Understanding the surgical community with patent practices can be another cause. Because surgical procedures are subject to the laws of most countries, including exceptions from patents. But many surgeons do not care and do not record it, which is why one of the reasons is that there is a lack of patent growth in this area.

Rhinoplasty can be called the most commonly used cosmetic surgery in Iran, which is increasing. Studies have shown that mental health and self-esteem are among the factors that can affect people's tendency to rhinoplasty. People's perceptions of their appearance can also affect mental health, self-esteem and tendency to rhinoplasty. Therefore, the aim of this study was to determine the relationship between meta-cognitive assessment of body shape with mental health and self-esteem of applicant women for rhinoplasty who referred to Kermanshah cosmetic surgery centers in 2017-2018. The present study is a descriptive-analytical-cross-sectional study that was carried out in Kermanshah cosmetic Surgery Centers in 2017-2018, including a private clinic and Taleghani State Hospital on a sample of 150 applicant women for rhinoplasty. Data were collected through questionnaires of meta-cognitive assessment of body deformity (BDMCQ), Rosenberg Self-Esteem Questionnaire (SES), and General Health Questionnaire (GHQ-28). Then, the findings were analyzed using SPSS16 software, descriptive and inferential statistics and Pearson correlation and Linear regression. This study was performed 0n 150 women with an average age 24.04 ± 4.24. In terms of marital status, 80% of subjects were single. The results of the data analysis showed that there was a significant positive correlation between mental health (P < 0.001, r = 0.52), depression (P < 0.001r = 0.48), anxiety (P < 0.001, r = 0.47), social function (P < 0.001, r = 0.32), physical symptoms (P < 0.001, r = 0.41) and meta-cognitive assessment of body deformity. And self-esteem had a negative correlation with meta-cognitive assessment of body shape (r = -0.39, P < 0.001). Also, analysis of the data showed that there was a significant positive correlation between mental health sub-scales (physical symptoms, anxiety, social function, depression) and sub meta-cognitive assessment of body deformity (metacognitive control strategies, thought-action coalitions, positive And negative meta-cognitive beliefs and safety behaviors) (P < 0.05). There was a significant negative correlation between self-esteem and sub-scale meta-cognitive assessment of body malformation syndrome questionnaire (P > 0.001). Also Self-esteem and mental health explained 30% of the meta-cognitive assessment of body deformity
(R2adj = 0.30). According to the results of this study, increase of self-esteem and mental health lead to a better meta-cognitive assessment of the body shape, which can be helpful in reducing the cosmetic surgeries. On the other hand, improving the assessment of body can improve mental health and self-esteem, which these factors are the causes of people tendency to the cosmetic surgery.

Laparoscopic management of diseases has now been accepted as a golden standard in international societies. However, there are still many studies on the newest methods of minimally invasive surgery in order to achieve the best surgical procedure with the most favorable perative outcomes of single-port trans-umbilical laparoscopic appendectomy and single-incision two-port laparoscopic appendectomy. In this retrospective study, 77 patients participated who underwent single-port trans-umbilical laparoscopic appendectomy and single-incision two-port laparoscopic appendectomy during one year (May 2017-2018). In single-incision two-port laparoscopic appendectomy group, two 5-mm trocars were implanted in a trans-umbilically, and another hole was used for left-hand instruments. Demographic specifications, operation data, and post-operative results of groups were compared using Chi-squared test or, if necessary, Fisher test. The T-test was used to compare the average of the two target groups that were independent of each other. The significance level of the tests was considered to be 0.05. Statistical analyses were performed using the SAS EG 5.1 server, version 9.3. (SAS Institute Inc., Cary, NC, USA) The total average time of single-incision two-port laparoscopic appendectomy surgery was significantly lower than that of single-port trans-umbilical laparoscopic appendectomy (P = 0.003). The average laparoscopic time was significantly lower in the single-incision two-port laparoscopic appendectomy group (P < 0.001). The average number of postoperative analgesic drugs in the
single-incision two-port laparoscopic appendectomy group was significantly lower than that of single-port trans-umbilical laparoscopic appendectomy (p = 0.002). The average number of hospitalization  post-operative days in the single-incision two-port laparoscopic appendectomy was significantly lower than that of single-port trans-umbilical laparoscopic appendectomy group (P = 0.008). No other statistically significant difference was observed between the two groups. According to the findings of this study, the average number of duration of the single-incision two-port laparoscopic appendectomy was significantly lesser and thus required less pain management; also, in aesthetic point of view, its result was similar to that of single-port trans-umbilical laparoscopic appendectomy.

Pancreatic injury is the fourth most common solid organ injury, following the spleen, liver, and kidneys. For both penetrating and blunt pancreatic injuries, the presence of main pancreatic ductal injury is the major determinant of surgical procedure. The complete pancreaticoduodenectomy is often the choice of treatment on the surgeon confronting for an injured pancreatic head particularly in the presence of concurrent duodenal injury and is the greatest challenge for trauma surgeon. A-10-year old boy refers to emergency department with the complaint of ongoing abdominal pain after hitting of a bike handlebar to his abdomen; He underwent laparotomy and whipple procedure.

A 34-year-old female patient presented to the general surgery clinic of the hospital complaining of a growing tangible swelling in her neck. In physical examination, patient had two palpable soft nodules in the left lobe of the thyroid without invading to surrounding tissues. The function of thyroid gland was normal and Fine needle aspiration (FNA) result reported benign. Patient went through left lobectomy and isthmectomy. The result of Histopathology reported nodular hyperplasia and a hydatid cyst. After surgery, the patient was examined exactly searching for any other organs cyst, but there was no cystic lesion in the cranial, thoracic and abdominal cavities. Accordingly, the case was a primary thyroid hydatid cyst, which is completely scarce even in endemic regions like Iran.

Coronary artery disease is the cause of most disabilities and deaths in the world. It has been more than two decades since stent technology was introduced and has proved to be useful in preventing coronary thrombosis and restenosis compared to balloon angioplasty. When permanent metal implant is used, this medical device would affect internal walls of blood vessels which would result in late healing process of endothelial. Delay in reconstruction of endothelial might lead to stent thrombosis. In recent years, drug eluting stents have played a revolutionary role in treating coronary artery diseases. These stents are invented to reduce risk of artery stenosis in treating coronary artery diseases. Drug delivery stents are important medical options for patients diagnosed with coronary artery disease and have been successful in suppressing uncontrollable neo-intima proliferation in response to successful stenting. Although improvement due to using drug eluting stents have had significant progress in reducing intra-stent restenosis compared to metallic bare stents, long term safety related to using these stents including location selection, high systemic irritant and stent late thrombosis still exists. However this complexity mechanism is still unknown. Therefore in order to solve the above-mentioned problems, bioresorbable scaffolds have been innovated to overcome this limitation. This equipment provides temporary scaffolds and they disappear as time goes by. These scaffolds are made of bioresorbable polymers and metallic alloys. The absorbed stent must carry out duty it is designed for in a specific time, have drug delivery and gradually absorbs in the body and disappears. Magnesium is an essential mineral material required for different physiological functions in human body. Magnesium alloy used in making this scaffold is bioresorbable and its strength to weight is comparable to strong steels. Hence, a magnesium scaffold has required radial strength to destroy atherosclerotic narrowing and is capable of keeping lumen coronary open. Moreover magnesium has antithrombogenic properties in bodies. In this study, their advantages and disadvantages have been investigated and bioresorbable stents and magnesium nano-hybrid stents will be introduced as a new method.