نشریه جراحی ایران
سال شانزدهم شماره 3 (پاییز 1387)

Introduction & Gastrointestinal stromal tumors are the most common mesenchymal tumors of gastro intestinal tract. These tumors have lower prevalence compared to tumor arising from mucosa. So there is less evidence about them. This article tries to summarize present studies in this area. Among 2257 articles found in medline, 158 articles were selected because of their more relevance. After more evaluation, 58 papers were used for our summary. The incidence of gastrointestinal stromal tumors is mostly in the fifth and sixth decades if life. These tumors originate from mesenteric ganglion cells. Most of these tumors express C-kit and CD34 antigens, which enable differentiation of these tumors from other mesenchymal tumors. Clinical manifestation of these tumors is not specific and the most common manifestation is long-lasting gastrointestinal bleeding. Endoscopic and endosonographic evaluations are helpful in diagnosis of these lesions. Complete surgical resection of these tumors is the basis of treatment. Imatinib which inhibits intracellular tyrosine kinase, is an effective medical treatment, and is used in patients with unresectable or metastatic tumors, both as neoadjuvant and as adjuvant treatment.

Introduction & One of the most noteworthy achievements in our contemporary epoch is lung transplantation which is a very difficult kind of transplantation because of complexity of the operation and the need for the coordination of diverse therapeutic teams to prevent infection, to control immune system to avoid recurrent rejections, and to treat complications of the surgery. In Iran lung transplantation has been implemented since April 2000, but a general report of the outcome has not been published yet. This study explains the surgical methods, difficulties, and results of lung transplantations in Iran. The data were collected from patients’ files, clinical visits, and telephone interviews. Studied variables were method of the surgery, morbidity and mortality due to the surgery, final morbidity and mortality, and final outcome. Final outcomes were categorized into good, acceptable, and bad. The good result refers to a patient who suffered no major complication after the surgery and were completely satisfied. The acceptable results refer to patients who were satisfacted with the transplantation in spite of some remarkable complications after the surgery and the bad results refers to those patients who were not satisfied with their lung transplantation. 21 patients underwent lung transplantation. There were 13 males and 8 females with, the mean age of 40.1 years (ranging from 18 to 64 years). 18 patients underwent transplantation of one lung via posterolateral thoracotomy, while 3 patients underwent transplantation of 2 lungs via bilateral transverse thoracotomy incisions (Clamshell). From the 11 patients who did not survive after transplantation, 6 individuals died because of technical problems like prolonged ischemic time and inappropriate preservation of the graft, while after 2004, only one death occurred due to technical problems. Two patients passed away after 9 and 10 months mostly due to poor socioeconomic condition which led to ineffective therapy. From 10 survived cases, 9 patients had a good result and in one case an acceptable result was obtained. 13 complications were seen in 11 patients (52.3%) as follows: arterial anastomotic stenosis (2 cases, 15.4%), bronchial anastomotic stenosis (1 case, 7.7%), suture site hematoma (1 case, 7.7%), bleeding of surgical site (2 cases, 15.4%), extensive cervical and thoracic emphysema (3 cases, 23%), and pneumothorax (4 cases, 30.8%). The outcomes of lung transplantation in Iran have improved during 2000 to 2008. Results of the surgery have been good in most cases of the survived patients. Surgical techniques of lung transplantation in Iran have been attained and the implementation of this surgery is feasible in our country.

Introduction & Deviated nose correction is difficult and constitutes a very different issue from septal deviation. When correcting this deformity, traces of asymmetry can be detected. The authors demonstrate facial asymmetry accompanying deviated noses, and such asymmetry is usually ignored by surgeons, who typically concentrate only on nose deformities. A total of 5822 pre- and post-rhinoplasty photographs related to 547women and 124 men were reviewed. Three separate groups were selected out of the total population: Group A: Gross Nose and face asymmetry Group B: Nose asymmetry with no facial deformity Group C: Facial asymmetry with straight nose Different measurements were applied to the selected photos. These included measurement from the lateral canthi to the lateral mouth corners (D1) and from the mid-face to each most lateral part of the zygomatic arch (D2). Measurements from one side were compared to those from the contralateral side to identify true anatomic differences (Figure 1). There was a significant difference in the nose and face deformity group, as evidenced by a meaningful difference in both the D1 and D2 measurements We report a significant growth retardation of the mid-face and orbit on the concave side of the nose. This impediment may serve as the etiology for many asymmetries of the face and nose.

Introduction & The combination of oxaliplatin and capecitabine has demonstrated its effect against various gastrointestinal cancers. On the other hand, Epirubicin, Cisplatin plus continuous infusion of 5-FU is widely used as a palliative regimen in patients with gastric cancer. If cisplatin is substituted by oxaliplatin and 5-FU by capecitabine, this regimen can be administered in the out patient setting, therefore we conducted this study to evaluate the effect of this first line combination in patients with metastatic gastric cancer. Twenty three patients with histologic confirmation of gastric cancer were enrolled. All patients had adequate major organ function and their PS was in the range o-2. The Patients received 100mg/m2 Oxaliplatin intravenously on the first day and 850mg/m2 capecitabine in the first days and 60mg/m2 Epirubicin on the first day of every third week, for maximum of 8 cycles. The meximum number of given courses were 6(1-8). The response rate was 60.8% [95% confidence intervals (CI) 38.5 – 80.3%] medium PFS was 7 months and median survival was 10.6 months. The most important toxicities were as follows: anemia 45%, nausea and vomiting 10%, diarrhea 2%. Neurotoxicity grade I was seen in 10%. We concluded that EXE regimen every third week is a convenient and effective regimen that can easily be administrated in the outpatient setting, but this regimen needs further evaluation in large trials.

Introduction & Patient with epidermolysis bullosa face multiple problems during their life. One of the most debilitating and challenging complications is hand contracture which has not had a successful treatment so far. Evaluating the effectiveness of amniotic membrane in the treatment of hand contractures in patients with epidermolysis bullosa has been shown. Ten patients aged between 5-10years entered into this study. Hand contractures were released and covered with amniotic membrane as a biological dressing instead of skin graft. In four patients chorionic membrane was applied for the right hand and in six patients amniotic membrane was used for the left hand, and the outcomes for the two hands were compared. Amniotic membrane facilitated re-epithelialization in our patients. There was a significant improvement in hand function. We did not find any recurrence in our patients. Using plancenta's membranes specially amniotic as a biological dressing is easy to perform and can be an excellent alternative to skin grafts.

Introduction & Traditional treatments sometimes are effective but it seems that in musculoskeletal injuries it leads to many complications so we decide to evaluate the results in this field, on the other hand local bone setters do their intervention without any permission by health organizations and they are not responsible for the complications. This study involves those patients who had been treated by bonesetters via traditional methods such as splinting by wood and referred to the orthopedic clinic of Khorramabad's Shohadaye Ashayer hospital in the time interval 20.01.2005 to 20.08.2005. 104 Patients had been treated by nonscientific methods. The most common injury which was treated by this method was distal radius fracture (21%) and the second most common injury was fracture of metaphysis of distal radius (9.6%). The most common education level of patients or their parents was mid school certificate (30.7%). The most common complication was malunion and the second was restriction of range of motion (ROM) (41% and 17%by order). The most common method was wood splinting (71%). Most of the patients who had been treated with traditional methods had only one musculoskeletal injury. So they didn’t feel that it was necessary to refer to hospital, thereby referred they prefer to bonesetters. The most common complication is malunion so it seems that because patients have no X-rays they have no insight about displacement of bones and don’t exactly feel their problem's depth and on the other hand bone setters cannot reduce fractures correctly because they don’t know positions of fracture parts. Limitation of R.O.M occurs because of malpositioning of extremities by bonesetters and lack of appropriate physiotherapy during and after the treatment.

Introduction & Pilonidal disease is a common inflammatory condition, especially in young population. A wide variety of surgical techniques are used to treat pilonidal sinuses, including open and close techniques. An ideal surgical technique would have minimum risk of recurrence, a short hospital stay and improved patient satisfaction. In this paper we are reporting about our experience in Limberg flap technique, assessing our experience in comparison with studies of other relevant centers in the world. In this observative, descriptive, cross sectional study. 70 patients were followed prospectively at least one year post operation. Data collection method is Census and all information was evaluated with SPSS14. The relevant information has been obtained from patients files and also has been directly approached with them. Results reveal that surgery of pilonidal sinus by Limberg flap causes the patients to return to their daily activities earlier. It can also be effective in reducing the hospitalization period as well as hematoma (0%), infection (2.6%), flap necrosis (0%) and numbness of the operation site (26.31%). The prominent point in this method is the low rate of recurrence rate. In this method, early and delayed complications are less than in other surgery methods. The problem of recurrence is that it causes complication and also cost and time for patients. Thus method can be a suitable one to reduce patient’s expenses and costs of apart from work for patients as well as society.

Introduction & Breast cancer is the most common cancer among women with an increasing rate among developing countries. In Iran, breast cancer affects, women at least one decade earlier than their counterparts in developed countries. Moreover there’s not still any comprehensive published mass data about benign breast masses among Iranian women. In this study we present epidemiological data about benign and malignant breast masses among women in Esfahan, Iran. A total of 1542 females older than 20 referring to the mammography center of said alshohada Hospital of Esfahan between 2003 to 2007 were studied. After a comprehensive breast exam by trained physicians, information including age, physical exam results and patient’s complaints were collected for each patient. Mammography was obtained from patients and tissue sample was prepared if become necessary and related data were recorded. Among these 1542 patients 222(14.4%) had breast masses in physical exam or mammography, including 190(12.3%) patients with benign and 32(2.1%) patients with malignant masses. Among patients with benign masses the most prevalent age group was 40-49(38.3%) and so was the case with patients having malignant masses (38.4%). The most common presented symptom was dull pain (59.4% of complaints).The most prevalent malignancy was invasive ductal carcinoma (90.2%) and other types were medullary carcinoma and colloid tubular carcinoma, with frequencies of 7.3% and 2.5% respectively. According to our study breast masses are prevalent among Iranian females from 40 to 49 years old. Dull pain is the most common complaint of patients and invasive ductal carcinoma is the most common type of breast malignancy in Iranian females.

Introduction & Laparoscopic cholecystectomy (LC) is one of the most common elective surgeries and is accepted as a primary therapy in symptomatic gall bladder disease. This procedure like other operations has same advantages but it can lead to complications which can threat the patient’s life. The aim of this study was to evaluate the complications frequency in Laparoscopic cholecystectomies which were done at Hamadan hospitals during 1997 to 2005. This retrospective study was comprised of 426 patients with cholecystitis who had been admitted at One of Hamadan hospitals (Ekbatan, Tamin Ejtamaiee, Mobasher, Boali and Artesh) and had undergone laparoscopic cholecystectomy from 1997 to September 2005. Among 426 patients who underwent LC, 53(12.44%) were male and 373 (87.56%) were female. The most common complication was retained stone (1.64%), followed by biliary tract injury (1.4%), bile leakage (1.4%) and bleeding, (1.17%). Although, the laparoscopic cholecystectomy has been recognized as the gold standard therapy for gallstone disease, but serious attention must be paid to bile duct injury.

Introduction & Anatomy of median nerve may be different in patients with carpal tunnel syndrome compared to normal persons. This study was performed to help to avoid injuring the median nerve during carpal tunnel release surgery. Forty patients with severe idiopathic carpal tunnel syndrome who had undergone carpal tunnel release, were included in this study. The distance between distal wrist crease and the origin of recurrent branch of median nerve was determined. The anatomy of recurrent branch of median nerve was investigated to determine its status regarding extraligamentous, subligamentous or transligamentous patterns. The location of the origin of recurrent branch (ulnar, radial or palmar side) was also studied. From these 40 patients, 38 were women and 2 were men. Their mean age was 54(37-76) years. The anatomic pattern of recurrent branch was extraligamentous in 38 cases, subligamentous in one case and transligamentous in a single case. In all cases the origin of recurrent branch was from the radial side and we did not have any case of ulnar side or palmar side origin. The mean distance between distal wrist crease and the origin of recurrent branch was 31(29-35) millimeter. According to these results there are differences in the anatomy of median nerve in patients with carpal tunnel syndrome with that of normal persons, and surgeons should pay attention to these findings during carpal tunnel release surgery.

Non-missile low velocity penetrating brain injuries are unusual among civilian population. Penetrating brain injuries are even rare among this group. It is intended to report 2 rare cases of penetrating brain injuries due to grinder tool. The cases were both male patients which werestruck in their heads by detached blades of the grinder tool. Depressed fractures and penetrated bone fragments and dural lacerations were all treated by surgery. Paranasal sinus damage and further cerebrospinal fluid (CSF) leakage was also treated conservatively. In this report, it is intended to: 1. The reported cases are unexpected variants of injuries that neurosurgeons may come across and their management is still beyond the scope of textbooks. Skill and experience of the neurosurgeons can handle the cases properly. 2. Prevention of such happenings, by using safer and guarded tools, should be stressed to the manufacturers.

Schwannoma is a benign tumor of nerve sheath origin. It is commonly found in the head and neck, mediastan, retroperitoan and flexor surfaces of the extremities. Schwannoma's occurrence in the breast is rare with only a few cases being reported in women and is even less frequent in men. This case study introduces a 57 years old male breast schwannoma and reviews other reported cases and compare with them.