نشریه جراحی ایران
سال بیست و دوم شماره 4 (زمستان 1393)

Burn is among the most expensive injuries which occurs at all ages. Furthermore, large skin damage can cause mortality. More than 90% of burn deaths occur in low- and middle-income countries, where prevention programs are uncommon and the quality of acute care is inconsistent. While most of the deaths are due to infection and burns shock, still the treatment of burn patients is a serious challenge, particularly about rehydration method and antibiotics administering (topically or systemically). This study was performed with the aim to increase awareness and provide a review on management of burns. In this review study, databases of Pubmed, Medline, Embase and the Cochrane Library were searched with appropriate keywords for relevant English manuscript. In this study, variety of studies including randomized clinical trials, cohort (prospective and retrospective), case-control and case reports that were about burns and their outcome were used. Among 358 articles found from the electronic searches in the beginning of the study, there were 127 related articles that of these articles, 32 cases were in line with the objectives of the study. Given the roles of burn breadth and depth in the rate of morbidity and mortality and prognostic, the measure of them in children and adults, and protocols for the management of burns were reviewed. Although the burn shock and infection are the most common causes of death and complications in burn, rehydration method for prevention and treatment of burn shock, especially in children and the use of systemic or topical antibiotics are discussed. Determine the appropriate protocol based on the patient's condition and clinical studies on this issue are recommended.

Introduction & Chronic anal fissure is one of the most common anorectal diseases. Most patients recovered by conservative treatments. But the disease is chronic if clinical manifestations lasts more than six weeks. Sphincterotomy is known as the treatment of choice for chronic anal fissure, although it is associated with long-term potential complications. Flatus and fecal incontinence, infection, and persistent pain are uncomfortable side effects that may occur in 0.35 of patients undergoing sphincterotomy. In a randomized clinical trial, 86 patients with chronic anal fissure were randomly divided into two groups. Eligible patients were divided into two groups: the first group were treated with 60 unit of Dysport injected into the internal anal sphincter, and the second group underwent lateral internal sphincterotomy. Then the rate of recovery and postoperative complications, such as pain, bleeding and recurrence or other complications were compared during the 3-month follow-up. Two weeks after the treatment, the recovery rate was 100% (86 patients), from which 19 patients (22.09%) had partial improvement and 67 (77.91%) had complete recovery. The complete recovery rate in the two study groups of PLIS and disport injection were (36 cases) 83.72% and (31 cases) 72.09% respectively. The relative recovery rate in the two groups, were 16.28% and 27.91%, respectively (P=0.194). In 3 months follow-up after the treatment, the complete recovery rate in the two groups of PLIS and disport injection groups were (36 cases) 83.72% and (31 cases) 72.09% respectively. The relative recovery rate in the two groups were respectively (4 cases) 9.3% and (3 cases) 6.98%. The recurrence rate between the two groups of PLIS and disport injection groups were respectively (3 cases) 6.98% and (9 cases) 20.93%. The difference between the recovery rate and recurrence rate, 3 months after the treatment in both groups was not significant (P=0.059). The mean duration of pain for the disport injection and PLIS were respectively 6.77±2.02 and 11.98±2.48 days, (P

Introduction & Post-operative surgical site wound infection (SSWI) is one of the most common complications after spine surgeries. To detect the risk factors for such a complication, studies with large numbers of patients and high quality data-gathering and analysis are required. In this study, we prospectively included 987 patients who underwent operation for different pathologies over a three-year period (2010-2013). Among these patients, 27 (2.7%) developed infection in the post-operative period. Multi-variant analysis indicated the factors associated with increased risk of post-operative infection as: trauma as the main etiology of damage in trauma cases, past-history of diabetes and smoking, patients being bed ridden in the peri-operative period, blood sugar levels above 120 mg/dl during the treatment period, increased length of incision, and increased hospital stay. Considering the preventable nature of most of the causes, it seems possible to reduce the chance of infection by controlling these factors.

Introduction & Brain trauma is a threat to the health of communities and 9% of all deaths throughout the world are caused by this type of injury. The purpose of this study was to determine the frequency of traumatic brain hemorrhage and factors influencing the consequences of the treatment of these patients. In a retrospective study, 640 patients’ records referred to Besat Hospital in Hamedan during 2012-2013, who had the evidence of hemorrhage during the first 6 hours after trauma in their CT scan, was investigated by census sampling method. In the case of patients who had died in the hospital, hemorrhage was specified, but to determine the result of 6 months of hemorrhage in patients who were alive at the time of discharge from the hospital, telephone interviews were done with patients or their families and GOS (Glasgow Outcome Score) were specified. Data were entered into the SPSS software, version 18, and they were analyzed using descriptive statistics and chi-square test. The significant level of tests was less than 0.05. The average age of men and women was 20.88 ± 38.42 and 24.27 ± 43.59 years, respectively. 100 persons (71.41%) of the patients were male. In 413 patients (64.53%) there was isolated hemorrhage. Subarachnoid hemorrhage formed most cases of hemorrhage with 261 cases (40.78%). The frequency of all traumatic brain hemorrhage, either isolated or combined, was more in men than women (P ≥ 0.01). The frequency of all traumatic brain hemorrhages for the age group of 16 to 30 years were more likely than other age groups (207 to 32/34%) (P ≥ 0.001). GCS on the admission of 287 cases of patients (44.8%) were 14 or 15 and in 223 cases of patients (34.8%) were 3 to 8. Consequences of cerebral hemorrhage in 228 patients (35.6%) of patients was death or stable vegetative state (GOS: 1-2). In 86 patients (13.4%), there was severe disability (GOS: 3). Among the isolated hemorrhages, 125 patients (88.65%) had epidural hemorrhage, 47 patients (38.84%) had subdural hematoma, 52 patients (54.74%) had subarachnoid hemorrhage, and 38 patients (67.86%) had intraventricular hemorrhage. Intracranial hemorrhage were improved or had a moderate disability (GOS: 4-5). Glasgow outcome scale in 64 patients (28.19%) who had a combination hemorrhage was, 4 or 5 (P ≥ 0.001). According to the obtained results, traumatic brain hemorrhage is more common in young and subarachnoid hemorrhage is the most common type of traumatic brain hemorrhage which is observed alone or in combination with other hemorrhages and epidural hematoma is the most common among isolated hemorrhages. The type of traumatic brain hemorrhage has correlation with age, gender, type of trauma and initial GCS and the type of trauma is related to age and gender. Age, GCS on admission, type of trauma and hemorrhage type are effective on the consequences of traumatic brain hemorrhage, but the consequences are not related to gender.

Introduction & Gestational diabetes is a common disease, it is but asymptomatic with high morbidity. Hypertension is more common in women suffering from gestational diabetes. The purpose of this study was to evaluate the frequency of hypertensive disorders in patients with gestational diabetes (class A2) and its risk factors in women with gestational diabetes, who were admitted to Al-zahra hospital in Rasht. This descriptive-analytical cross-sectional study was conducted on 421 patients with gestational diabetes (class A2) who were admitted to Al-Zahra hospital in Rasht, Iran, from April 2011 to March 2013. Data including age, gestational age, parity, number of births, number of abortions, previous medical history (heart disease, hypertension, dyslipidemia, etc.), family history of diabetes or hypertension, and hypertension (primary hypertension, pregnancy induced hypertension and pre-eclampsia) were collected. The data were analyzed by SPSS, version 16. Chi squire test and logistic regression were used. P-value less than 0.05 were considered as significant. Hypertension was diagnosed in 175 (41.6%) of patents. Frequency distribution of age groups (P < 0.001) gestational age (P < 0.001), history of previous diseases (P = 0.001), family history of diabetes (P = 0.038), and family history of hypertension (P < 0.001), between two groups of patients with and without hypertension were statistically significant. Logistic regression revealed that having age more than 35 years, 2.3 times (95% confidence interval (CI): 1.5-3.8), history of previous diseases 4.3 fold (95% CI: 1.5-12.8), and family history of hypertension 6 fold (95% CI: 2.9-12.6), odds of incidence of hypertension will be increased. But other surveyed variables were not effective in increasing or decreasing the odds of hypertension incidence. Considering high prevalence of pregnancy hypertension in women with gestational diabetes and its determined risk factors, it is necessary that high risk pregnant women with gestational diabetes receive appropriate care for the prevention of hypertension incidence and its complications.

Introduction & Chronic Kidney Disease (CKD) is a complicated kidney defect causing permanent failure in renal function in progressive stages. Hemodialysis (HD) is the most accepted treatment to maintain body’s fluid/mineral homeostasis at the terminal stages of the disease. Arterio Venus Fistula (AVF), is the most practical way of providing proper access to the blood circulatory system. However, maturation of the fistula is a challenge for both patient and his surgeon, since there are number of variables interfering with the whole process. By using cross-sectional and prospective method, the medical history of 87 patients before and during the AVF creation surgery and risk factors such as history of blood pressure abnormalities, diabetes and congestive heart failure, as well as the successive development of AVF was studied and finally processed, logistic regression. The ‘decision tree’ indicated the significant impact of the systolic blood pressure (SBP) in the delay of the patient’s AVF maturation. The prediction of AVF maturation was made with a 70.59% precision, in regard to their BP condition. Also the risk factors of HD patients - Ischemic Heart Disease (IHD), Diabetes Mellitus (DM) and their Blood pressure - delay Maturation time; IHD and then DM have the greatest negative impacts. This study demonstrated that monitoring of patients SBP is one of the important steps in the management of the cardiovascular variables interfering with the development of the AVF and therefore, produces some delay in the process of the patient’s HD. Also the logistic regression can assist in revealing the hidden relationship between patient’s medical histories with his general condition, and this helps in the prediction of the potential disorders.

Introduction & In recent years high ranking officials of Iran have emphasized more and more on scientometric studies and scientific productivity in journals inside and outside of the country. In this regard, promotion of science production in the article format ISI journals’ level is recommended among faculty members and researchers. Therefore, showing the status of scientific productivity and the publishing of papers in journals of ISI database can give a better picture in this regard to research officials of Iran, so that they can allocate research budget and human resources in a better way. The study tries to give a prefect and reliable view on scientific productivity of Iranian surgery community in the format of articles. The data of this study has been collected from three sub databases of the ISI database. Duration of the study was from 1992 to 2014. Entering the keyword of SERGERY in topic search of ISI database and limiting it to Iran, the retrieved items were analyzed by the analysis engine of the database, and then the data were further analyzed by the EXCEL software. Our findings shows that from 1992 until 2014 totally 2909 articles have been published by Iranian surgery researchers in journals indexed in ISI journals. This data also revealed that more than 60% of all productions have been made in the five recent years and that the scientific productivity of researchers in this field in these 5 years is more than the previous 30 years. From the viewpoint of the most active higher education institute in Iran, it was found out that Tehran University of Medical Sciences with publishing 725 articles (24.92%) of all scientific productivity in this area, stands at the top level first. From the viewpoint of international collaboration, our findings show that up to 2009 only 150 articles were published with international collaboration while during the last 5 years 545 articles have been published with international collaborators. All the articles with international collaborations in the years under study were 695, while out of these 695 articles 311 articles were published with American researchers. It is obvious that the fast growth of scientific productivity of Iranian surgery community could be clearly observed and the fast growth in this area of research could be taken into consideration for other areas of medical research. It was found out that international scientific collaboration in the last 5 years have tremendously increased in this research area and this international collaboration can bring new ideas and experiences to the country, and therefore cause professional and scientific growth of researchers in Iran.

Introduction & Varicocele is the loosening of testicular veins and the pump form venous channel within the spermatic cord. There are different treatments for varicocele, as open surgery, microsurgery, laparoscopy, sclerotherapy and other techniques. The purpose of this study was to compare between the outcomes of laparoscopic and open techniques in the surgical treatment of varicocele. In a randomized interventional study, 96 patients referring to Alvand and Besat hospitals of Hamedan were diagnosed to have Varicocele, and after filling the informed consent they were included in the study. Patients with a confirmed diagnosis of varicocele, were studied after filling the testimonial. Testicles size was measured by using vernie calipers in width and height and the patients underwent the analyzing of their semen fluid. The patients were randomly assigned into 2 groups (n = 48 per group). Following-up the patients in order to assess any effects related to the treatment, such as wound infection, hydrocele, hematoma, and etc. lasted up to 1 month. Examining with regard to the recurrence or lack of examination of the form obvious clinical varicocele was conducted, despite the treatment and related examines with infertility factors after 6 months. The assessment of the size of the testis and analysis of semen was done after 3 and 6 months. At the end of 6 months, the results were compared between the two groups. Data collected were analyzed, using the indicators of frequency, mean, SD and in necessary cases were analyzed using t-test and paired t-test, and in cases of comparing qualitative data it was analyzed by using Chi-square test. The significance of the results were considered P ≤ 0.05. The semen analysis after 6 months, in all patients, indicated a significant difference in favor of the improvement of these factors after the surgery, in comparison with to the state before the surgery. These evaluations were performed separately in each group and in both laparoscopic and open groups a statistically significant difference was observed in favor of improving semen analysis factors. Changes in these factors before and after the surgery were compared in both groups and no significant statistical difference was observed. This means that both groups had no differences regarding the effect on fertility factors. No varicocele recurrence was reported within 6 months. Hospital stay was had no significant differences between the two groups. Also, no significant difference was observed between the two groups, regarding the effects associated with surgery. Open varicocelectomy surgery and laparoscopic varicocelectomy surgery have approximately equal post-surgery consequences, regarding improved parameters of semen liquid and post-surgery effects. However, further research with larger sample size and longer follow-up period is required so that we could judge about the advantages and disadvantages of the two methods with greater certainty.

Ileosigmoid knotting occurs when the ileum wraps around the base of an elongated sigmoid colon, thus producing two closed-loop obstructions, with the possibility of ischemia and necrosis of either the ileum or sigmoid colon. Because of low incidence of the disease and its rapid progression to bowel gangrene, the diagnosis of the disease occurs late for most patients. ISK is more common in adults, with peak of its occurrence in 4th decade of life. A 32 years male patient with sudden onset abdominal pain which lasted for 12 hours, was operated by provisional diagnosis of acute of abdomen. Exploratory laparatomy revealed torsion of ileum around the sigmoid colon along with the gangrene of both of them. Resection of small bowel, with primary anastomosis, sigmoidectomy with end colostomy plus Hartman pouch was performed. Finally colostomy closed after 6 months.

Diaphragm is a skeletal-muscle dome-shaped structure which separates abdominal cavity from thoracic cavity. Diaphragmatic rupture may occur in blunt trauma, penetrating trauma or iatrogenic interventions. This rupture generally remains hidden and out of diagnosis. The prevalence of diaphragmatic rupture is 0/16-5 percent. It's delayed diagnose only is proved when herniation of abdominal viscera into thoracic cavity is occurred and the symptoms following visceral herniation get’s hyalited. In this study we report the case of a 35 years-old man who has been operated with diaphragmatic rupture. This patient had a blunt trauma history in a car accident, one year ago. As the diagnose of this rupture following abdominal blunt trauma in the first patient’s examination is problematic, especially when the rupture of the diaphragm is by without herniaition into hemithorax, a good clinical suspicion, considering clinical symptoms and radiographic finding, confirms the diagnosis.

The history of disasters dates back to the formation of the earth. Usually, after each disaster, hospitals and health centers deal with surge of causalities. Therefore, they must not only treat inpatients but also the patients who attend the system as a result of the disasters. This may create insufficiency or lack of drugs, instruments, and human resources. One solution to solve the problem is to plan for preparations for such events. This includes three types of planning. A comprehensive plan helps the health system to put into action the command system, and is applicable to all types of disasters. Contingency plan is scenario-based and is designed for the most probable internal or external disasters, and the risk analysis helps to decide appropriate scenarios. Finally business continuity plan helps to serve the routine patients in hospitals or health centers. These plans help the system to respond, with safe and high quality services, to the patients during disasters. This paper illustrates and clarifies the three above-mentioned types of plans.