نشریه جراحی ایران
سال نوزدهم شماره 2 (تابستان 1390)

Weight loss surgery (WLS) initiated five decades ago with questionable weight loss, unacceptable high risk and unknown long term results, is becoming one of the most successful and popular operations in the field of general surgery. Soon it may not be unreasonable to consider WLS as the first line treatment for obesity and weight-related comorbidties like diabetes and sleep area. Between 1998 and 2004, the number of WLS performed in USA shows 800% increase. Indeed WLS offers much more than significant and sustained weight loss. Recent studies demonstrates its ability to cure diabetes and improve outcome for cardiovascular disease in large matched cohort studies and to reduce risk of death by approximately 35% over time. With explosive increase in number of cases, the young surgeons must be familiar with different techniques and possible complication and appropriate care of obese individuals.

Introduction & Management of complex fistula has two important long term closure of the tract and preservation of sphincter complex function. This study introduces a novel sphincter sparing technique called LIFT (ligation of intersphincteric fistula tract) with encourage results in controlling the perianal sepsis. All patients with complex fistula were treated with LIFT and they were prospectively followed. Demographic data, previous repair attempts, the type of treatment and score of fecal continence were collected. The procedure was performed by trained colorectal surgeons. The patients were followed for 12 to 50 weeks. A total of 23 patients underwent LIFT during 12 months. The median age of the patients was 35 years and 50 % had two previous attempts at surgery. A total of 18 patients (78%) had high transsphincteric fistula. Median follow up was 32 weeks. Successful fistula closure was achieved in 74% of the patients (17 of 23).Median time of recurrence was 4.5 weeks. One (4.3%) patient reported for gas incontinence (score: 3) after the procedure. LIFT is a novel treatment method for complicated fistula- in ano. It’s success rate is comparable with other sphincter sparing procedures. Furthermore LIFT is easy to learn and has very low cost. More importantly, it appears to be a safe procedure. Durability and efficacy of the procedure must be confirmed by long-term follow up and randomized control clinical trials.

Introduction & Cryptorchidism is the most frequent birth abnormaly in boys with the prevalence of 2-5% in full term infants. This abnormaly is associated with an increased risk of testicular cancer and infertility as well as hernia, testicular torsion, and psychological distress. Surgery is the main treatment method for this abnormaly. This study was aimesd to evaluate the therapeutic efficacy of laparoscopic orchiopexy in the treatment of non-palpable undescended testis. In this descriptive cross-sectional study, 40 patients with a non-palpable testis underwent by laparoscopic orchiopexy in Ekbatan hospital located in Hamedan from the winter of 2006 to the autumn of 2009. The patients were followed up after the surgery and 3 month later than that, regarding their response to the treatment and the testicular atrophy. The average age of patients was 19±12.16. Thirteen patients did not have a testis in the laparoscopic investigation and 6 patients had testes located in the inguinal canal. So these people were excluded from the analysis. 17 patients were treated by 1-stage laparoscopic orchiopexy while 4 patients were treated by a 2-stage Fowler-Stephens laparoscopic orchiopexy. The success rate for the treatment turned out to be 100%. Laparoscopic orchiopexy is a safe and effective method for the treatment of non-palpable undescended testes.

Introduction & Multiple factors can lead to increase in acute abdominal pressure and Abdominal Compartment Syndrome (ACS), such as increase in retroperitoneal volume due to pancreatitis, bleeding and edema due to pelvic fracture. It is observed that sometimes pelvic ring fracture or an open book fracture of pelvic can cause a huge pelvic hematoma in retroperitoneal space that causes abdominal compartment syndrome. Primary ACS problem is often observed during the first 24 hours after sever abdominal and pelvic trauma and surgery. Clinicians, especially nurses, should remember the risk factors for intra abdomen hypertension and should be vigilant to avoid the progression to abdominal compartment syndrome. By measuring the Intra-abdominal pressure through the bladder, we can provide a quick and accurate assessment of abdominal pressure changes and this can be performed by emergency or critical care nurses without a specific medical order or sophisticated invasive monitoring equipment. Regarding this matter that ACS is a very lethal condition. This study’s survey had the intention of finding the relationship between pelvic fracture and abdominal compartment syndrome in trauma patients who refer to Nemazee hospital in Shiraz. This research was a descriptive- analytical study that was performed to survey the relationship between pelvic fracture and abdominal compartment syndrome in patients with severe abdominal trauma and pelvic fracture in Nemazee hospital in 2008. Tools for data collection included check list consisting of demographic information and other data required for this research and also intra abdominal pressure (IAP) measurement instruments. The IAP was measured in patients with abdominal trauma who referred to emergency ward via folley catheter indwelling in bladder and pelvic fracture confirmed with pelvic X-ray. Collected data was analyzed by using SPSS software. Of 100 patients with abdominal trauma referred whose abdominal pressure was measured, 28 patients had abdominal compartment syndrome. According to associated injury with abdominal trauma 19% of all patient (19 persons) and 46.42% of the patient with abdominal compartment syndrome (13 persons) had pelvic fracture. Using of qi-sqare test revealed that the relationship between pelvic fracture and incidence rate of abdominal compartment syndrome was significant (P < 0.001). According to our collected data pelvic fracture due to trauma can one of the important causes of increase intra abdominal pressure and abdominal compartment syndrome. In this lethal condition prevention is better than cure. By serial measuring, the Intra abdominal pressure through the bladder in patients at risk, such as pelvic fracture by trauma, nurses can recognize this condition and decrease incidence of mortality.

Introduction & Vascular access complications are the most important cause of hospitalization, morbidity and mortality in dialysis patients. The most frequent complication of central catheters is dysfunction due to thrombosis. Aspirin as an antiplatelet drug may increase central catheter’s patency. Nevertheles there are limited data available regarding the effect of antiplatelet drugs on central catheter’s patency. 180 patients were included in this clinical trial. Patients were equally divided between intervention (with 80 mg/day aspirin) and control (placebo) group. The average time in which the permcath was functional was noted. Patient’s demographics (including comorbidities and past history) were also utilized to address probable effect on permacth patency.T test was used to analyze quantitative variables and chi-square and Fisher’s exact tests were used to analyze qualitative variables. The mean survival time of catheter in aspirin group was significantly higher than the control group (5.3±4.7 month vs3.9±2.7 month, P = 0.012). No significant difference in major complications of aspirin use (GI bleeding) was noted between the two groups (P = 0.52). Female gender and history of diabetes was found to significantly influence the median survival rate of the catheters (P

Introduction & Thymoma is not a common tumor, but is one of the most common mediastinal neoplasms. Treatment strategies for different kinds of thymomas are controversial. In Iran few studies have been reported on this matter. Demography, clinical course, histopathology and progression free survivals (PFS) of 53 patients with thymoma were investigated retrospectively. Data analysis was done with Kaplan - Meyer method. Survival rate has been described according to PFS (survival between diagnosis and recurrence or death). Using log-Rank test, the difference between two groups of patients with invasive tumor and non-invasive tumor was studied. Patients were 32 male and 21 female with mean age of 43 years (17-75 years). The most common symptoms were: cough (43.4%), dyspnea (39.6%), myastnenia (20.8%), weight loss (18.9%), and chest pain (17%). Most of tumors were in advanced stages. Treatment modalities were: surgery in 20.8%, surgery and chemoradiation in 66.8% and chemotherapy alone in 7.5% cases PFS results were 5.75 + 2.45 years. PFS between patients with invasive tumor and patients with non-invasive tumor did not show meaningful difference (P=0.616). In Iran, no definite protocol for therapy of thymoma has been recommended. Different modalities are used in our country. Although the principle method of treatment is surgery, other treatment modalities are used as well. Considering the slow growing pattern of this tumor, evaluation of different treatment modalities, need a prolonged follow up.

Introduction & Breast cancer is the most common malignancy in women in many countries. Axillary dissection has an important role in prognosis, staging and probably treatment of breast cancer. Some experts believe that the number of lymph nodes involved is one of the most important factors in the prognosis of breast cancer. In this study we have reported data about tumor size, axillary dissection in patients referred for chemotherapy in 3 medical oncology centers in Iran. In this study we evaluated available data from 149 patients who had referred to the three centers. Data about patients’ demography, tumor size and axillary dissections were collected from their medical records. 128 out of 149 patients had complete data. The average age was 41.1±6.3 years, mean tumor size was 3.5±2.5 cm and the total numbers of dissected nodes were 9.7±5.2. Incidence of axillary metastasis was 63.3% and the total number of dissected node was 10.1± 5 in patients with node metastasis and 9.1±1.3 without node metastasis. The mean of tumor size in our patients was 3.5 cm which is larger than the case of western countries (1.8 cm). A relation between tumor size and the number of total dissected nodes is reported but in our study there was no relation between these two factors. Only 38% of our patients had more than 10 dissected nodes but in Australia and the USA it was 82% and 72.1% respectively. Therefore the number of patients with more than l0 dissected lymph nodes is much less than the case of western countries. So we think axillary dissection in Iran is less aggressive than the case of developed countries, but is the same as that of developing countries.

Introduction & Breast cancer is the most common malignancy in women in many countries. Axillary dissection has an important role in prognosis, staging and probably treatment of breast cancer. Some experts believe that the number of lymph nodes involved is one of the most important factors in the prognosis of breast cancer. In this study we have reported data about tumor size, axillary dissection in patients referred for chemotherapy in 3 medical oncology centers in Iran. In this study we evaluated available data from 149 patients who had referred to the three centers. Data about patients’ demography, tumor size and axillary dissections were collected from their medical records. 128 out of 149 patients had complete data. The average age was 41.1±6.3 years, mean tumor size was 3.5±2.5 cm and the total numbers of dissected nodes were 9.7±5.2. Incidence of axillary metastasis was 63.3% and the total number of dissected node was 10.1± 5 in patients with node metastasis and 9.1±1.3 without node metastasis. The mean of tumor size in our patients was 3.5 cm which is larger than the case of western countries (1.8 cm). A relation between tumor size and the number of total dissected nodes is reported but in our study there was no relation between these two factors. Only 38% of our patients had more than 10 dissected nodes but in Australia and the USA it was 82% and 72.1% respectively. Therefore the number of patients with more than l0 dissected lymph nodes is much less than the case of western countries. So we think axillary dissection in Iran is less aggressive than the case of developed countries, but is the same as that of developing countries.

Introduction & Acid assault is one of the most brutal crimes. This crime is not meant to kill but to punish the victim or to destroy the victim’s social life. This violent act usually occurs in developing countries. The aim of our study was to assess the place and intensity of burns and their abundance from viewpoint of age, sex, material status and the relation between the injured and the assailant. From May 2004 to October 2010 the charts of victims of acid violence, who were referred to the Motahari Burn Center, were reviewed. Over this 6-year period, 59 patients were included in this retrospective study. The reviewed cases were 51% male and 49% female. The face and hands were the most commonly injured areas, and the most common assailant was a close family member. 1. Acid assault is still a major social problem in our country. 2. The abundance of this problem is the same for men and women. 3. It is very abundant among family members. 4. Perhaps the limitation of access to dangerous materials can reduce the rate of this terrific crime.

As a retroperitoneal organ, duodenal injuries following blunt abdominal trauma is rare and constitutes only 22% of all duodenal injuries (3%-5%). It often occurs after severe and suddenly blows to the upper abdomen or abdominal compression from high-riding seat belts. It is difficult to have a primary and proper diagnosis despite advances in the laboratory and imaging techniques. Here, we present a case of isolated rupture of the third part of the duodenum due to blunt abdominal trauma, resulting from motorcycle accident. The rupture was diagnosed and repaired while the patient underwent laparotomy surgery only according to physical examination (guarding, tenderness, rebound tenderness), whereas all of the laboratory and imaging findings were normal. After seven days and patient’s ability to eat meal, the patient was discharged without any complication.