نشریه جراحی ایران
سال شانزدهم شماره 4 (زمستان 1387)

Introduction & Today, regardless of significant progresses, diabetic foot and its complications are major cause of morbidity in diabetic patients. So, we decided to have a systematic review of valuable papers and prepare a valuable a collection to guide the management of these patients. From electronic journals and papers, 877 papers were extracted and among them, those were chosen that were published in the last five years and their full texts were available. Neuropathy and vasculopathy are still taken to be the roots of diabetic foot ulcers. Determination of depth of involvement of tissues and existence of infection are two most important factors which must be cleared at the beginning of treatment. Anti biotic therapy and surgery are complement of each other and then, soft tissue coverage and new dressing techniques are considered. Prevention of the ulcer and exact control of blood sugar are more convenient and more economical than treatment of diabetic foot ulcer. If ulcer appears, the priority is to prevent infection and if infection happens, on time treatment of if is necessary if limb salvage is desired.

Introduction & The replacement of segments of esophagus damaged by a tumor or other diseases is usually difficult requiring complex surgical procedures such as replacement of the involved area with stomach, colon, small bowel or composite tissue flaps. In esophageal lesions, this problem is more complicated; whereas, the resection of the segments of trachea and anastomosis of the two ends is a simple and practical procedure with low complications. In this experimental study we resected a piece of cervical esophagus and replaced it with a segment of trachea to find a simple solution for patients suffering from esophageal lesions. In 20-30 kg mature adult dogs, 5 cm of trachea was resected while preserving its attachments to the surrounding fibroareolar tissues. Then, 5 cm of esophagus was resected and replaced with the prepared segment of trachea. End to end tracheal anastomosis performed by a combination of interrupted and running vicryle sutures and anastomosis of esophageal ends to the tracheal segment was performed by running nylon sutures. No complication occurred during surgery. Both swallowing function and voice were normal in all three dogs after the operation. Oral diet started the day after operation. No sign of aspiration was seen in clinical and radiographic examinations. On autopsy examination, anastomoses were patent without being narrowed or having abnormal muscosal changes. The replacement of segment of esophagus with an autogenous tracheal segment is a practical procedure with low complications and can probabely be used for the treatment of esophageal lesions in human begings.

Introduction & Less than 2% of all pregnancies are ectopic. Ruptured ectopic pregnancy (EP) remains the leading cause of pregnancy related maternal death in the first trimester. The greatest danger is related to undiagnosed early stage of tubal rupture. The aim of study is the dertermination of ability of the shock index in identifying ruptured ectopic pregnancy This cross sectional survey was conducted on 99 patients with ectopic pregnancy in Rasht's Alzahra hospital. We calculated shock index for all patients and then we calculated sensitivity, spicifity, positive and negative predictive values for each index. We determined the cut-off point of shock index with Roc curve and evaluated the correlation between shock index and hemoperitoneum. Statistical significans for variables were determined with the x2, Student t test, Pearson coefficient and logistic regression. All statistical calculations were done with Stat.V8, SPSS.15. 38 of the 99 patients had ruptured EP and 61 of 99 patients had unruptured EP. The mean of shock index in ruptured group was 0.99±0.3 and in the unruptured group was 0.82±0.2. There was significant difference between these two groups (P=0.001). The cut off point of shock index was ≥ 0.89.There was a significant correlation between hemoperitoneum and shock index (P≤ 0.001; r =0.54). The shock index ≥ 0.89 is a valuable predictive factor for Ruptured EP and has correlation with Hemoperitoneum.

Introduction & In women under 40 years of age, which are afflicted with palpable breast masses, the surgeon sometimes encounters situations that inspite of physical examination, mammography and fine needle aspiration, cant decide whether to perform open biopsy or not. The purpose of this study was to develop a rapid and accurate diagnostic test for palpable breast masses in women under the age of 40. Breast masses are evaluated utilizing a modified triple test score (MTTS) which assigned scores of 1 for benign, 2 for suspicious, and 3 for malignant masses from physical examination, ultra-sonography, and fine needle aspiration. The MTTS is the sum of three scores and is corrected with biopsy and follow up. Among the 100 evaluated masses, 69 scored 3, 15 scored 4; all were benign. Four scored 5; 1 was malignant. Five scored 6 and three were malignant. Seven scored 7, 8, and 9 and all were malignant. The MTTS had 100% diagnostic accuracy in cases other than those with scores 5 and 6 points. Masses scores 4 points are benign. Those having scores seven up to nine points were proceed to definitive therapy. Those having scores five and six points need evaluation. This approach dose not avoids open biopsy in the majority of cases, but while captures all malignant cases.

Introduction & Diagnostic difficulties in decision making for patients with acute abdomen always have made surgeons to utilize Paraclinical instruments for making better diagnosis. Ultrasonography with high diagnostic ability, is cheap, non invasive and one of the powerful instruments. The purpose of this study is to consider its diagnostic value by comparison of ultrasonigraphic and post-operational Finings. This is a cross-sectional study. 220 patients with acute abdomen underwent ultrasonography. Patients were chosen from two hospitals Fatemi and Sabalan. To collect information, question sheets were used. 122 cases (55.4%) were female. The majority of cases were in the range of 30-39 years of age (46.3%). More cases were married (51.8%) and most of them were complaining of periumblical pain. Laboratory finings for most of patients were normal laboratory Findings. Finally, most of reported cases with cholecystitis and appendicitis (87.5%) were led to correct diagnosis during the operation. It seems that most of sonographic diagnoses reports were consistent with operational findings. Thus, it is suggested that in patients with acute abdomen which face with diagnostic problem, ultrasonography can be used as a useful tool.

Introduction & Post operative nausea and vomiting (PONV) is regarded as important post operative complications that leads to reducing patients satisfaction and other complications such as aspirations pneumonia, wound dehiscence and delay in discharge the patient. Several drugs have been examinated for diminishing this complication during the past few years. In this study we compared the efficacy of oral clonidine in the prevention of PONV in two groups. This was a double blind randomized clinical trial performed on 160 patients who were candidate for elective limb orthopedic surgery at Khatam al-Anbia' (sal) hospital Zahedan, Iran at 2007. The patients were randomly grouped into two 80 member groups. The 1st groups was given 0.1 mg oral clonidine and the 2nd groups was given placebo 45 min before surgery. Then they underwent similar standard anesthetic methods and the follow up was done in recovery room and then in the orthopedic department for maximum of 24 h after surgery. The prevalence of PONV in the two groups was compared through statistical tests. The results of this study in the two groups demonstrated a statistically meaning full difference between the prevalence of PONV in the two groups (P<0.0001). Side effects in both groups were equally rare. Using a low dose of oral clonidine can significantly increase the change of PONV free orthopedic surgeries.

Introduction & Urinary incontinence is a very common problem affecting the quality of life of millions of individuals all over the world. Stress Urinary Incontinence (SUI) is the most common form of urinary incontinence which affects women more than men. Intravaginal Slingoplasty (IVS) is a treatment for urinary incontinence which has attracted attention in various parts of the world in recent years. This study includes, stress urinary incontinence patients treated by IVS at the Mojibian hospital of Yazd, Iran. This study includes 17 SUI women patients who referred to the urinary incontinence clinic of Mojibian hospital during the years 2006-2007 and had a positive Marshal's test and candidates for IVS surgery were studied. Results were analyzed using SPSS 11.5 and wilcoxon test. The mean age of the patients was 43.41+5.86 years (age ranges between 34 and 55 years). The mean number of previous child births was 4.82+1.5 (range 3-7 parturitions). 3 of the patients (17.64%) had symptoms of urinary frequency and urgency. 12 patients (70.58%) had history of previous abdominal or pelvic surgeries. Complications included intra operational urinary bladder tear in 3 cases (17.64%), post surgical urinary retention in 2 cases (11.76%), which was relieved by catheterization and only one case of infection (5.88%) was observed. The mean duration of hospital stay was 4+1.15 days (range 3-7 days). After 6 weeks of follow up, all of the patients had a negative stress test, but one patient complained of urinary incontinence which was of an obsessive psychiatric nature and the patient was treated by a psychiatrist (P-value=0.000). After one year of follow up, 82.35% of the patients were treated both objectively and subjectively. Even though general conclusion is not possible due to the small number of cases, it seems that the treatment response is comparable with other existing and customary modes of treatment, but the intra operational complications rate in the study was more than those in other similar IVS studies.

Introduction & Anal fissure is a common problem that causes significant morbidity in a young and otherwise healthy population. In this study we aimed at comparing the two surgical treatments: Closed lateral internal subcutaneous sphincterotomy, and Open lateral internal subcutaneous sphincterotomy. 60 patients with signs and symptoms of chronic anal fissure who had referred to Ekbatan Hospital of Hamadan for surgical treatment, were included in this study. They were randomly divided into two groups of 30 patients, One group underwent Open Lateral internal subcutaneous sphincterotomy (group A), and the other group underwent close Lateral internal subcutaneous sphincterotomy (group B). Afterwards the questionnaires were filled in concerning the patients` demographic characteristics and the duration of their problem and their post surgical conditions such as: healing and back to work time and days with pain, using patients’ words and the physical exam performed by the physician during the patient’s stay in hospital and later on by interviewing the patients six month after the operation. The data were analyzed by SPSS 10 software and were compared by T-test and chi square tests. Average healing time in the two groups was 21.53±3.55 days in group A and 7.7±2.1 days in group B, which are statistically different (P<0.001).Patients went back to work 4.39±0.8 days after operation in group A, and 3.27±1 days after operation in group B (P<0.001). Also average days with pain after surgical treatment was significantly different in the two groups (P=0.02). Hematoma was not discovered and bleeding did not take place in the first 48 hours post surgery in any of the patients. We suggest that open lateral internal sphincterotmy is associated with less post operative discomfort and healing times.

Introduction & Regarding low incidence of retro peritoneal masses and related surgeries, we studied the results of surgical approaches for these masses (except prostate) in recent years to justify success of early surgery, in low stage retroperitoneal masses. We studied 17 patients with retroperitoneal masses who had undergone extensive surgery in Hasheminejad Kidney Center, since ten years ago. Six of seventeen patients had pelvic soft tissue sarcoma, three cases had tumors with neural origin, two cases with seminal vesicol carcinoma, two cases with retroperitoneal fibrosis, one case with endomethriosis, one case with grem-cell tumor, following UDT, and one case with pelvic abcess following G-U- manipulation. In most of the patients, disease free survival was more than five years. 12 of 17 patients have had tumor without invasion to vital pelvic organ and bladder, which 92% of them (11 patients), had five years survival. In parallel 29% of patients (5 of 17 patients) had a tumor with invasion to pelvic vital organ or peritoneum. None of them had a five year survival. We have seen three local invasions in five patients (30%) that tumor resection was performed for three of them. The pathologic stage and negative surgical margin of tumor were the main prognostic factors for patient survival rate. Wide resection of tumoral mass, the whole soft tissue and lymphnodes surrounding the tumors that lead to negative surgical margin, is the principle management in the non metastatic pelvic masses, that lead to negative surgical margin.

Introduction & The aim of this study was detection of incidence of arrhythmia and hypotension during mediastinal manipulation due to transhiatal esophagectomy and evaluation of related factors. In this prospective study we selected 61 patients undergone transhiatal esophagectomy during 2years (2006-2007) in the Al-Zahra hospital. The demographic information, site of tumor, cardiopulmonary function, nutrition, per operation and post operation complications (i.e. arrhythmia and hypotension), histopathology, duration of surgery, duration of mediastinal manipulation, amount of hemorrhage, need of reoperation, need to transfusion, and death rate were evaluated by chi-square, exact fisher, logistic regression, and T tests methods. 8.2% of patients before, 50. 8% during, and 11.2% after mediastinal manipulation showed arrhythmia. Need to transfusion, pathology of tumor, pre-existing arrhythmia, amount of hydration, and FEV1< 2 liter were significantly correlated with arrhythmia. 8.2% of patients before and 55.7% during mediastinal manipulation showed hypotension. Duration of manipulation, amount of hemorrhage, systolic and diastolic pressure before manipulation, and FEV1< liter were significantly increased risk of hypotension during operation. Our data showed the amount of hydration, transfusion, premanipulation arrhythmia, and pulmonary function should be controlled to decrease the risk of arrhythmias. Minor mediastinal manipulation, less intraoperative hemorrhage, improvement of pulmonary function, and careful blood pressure monitoring can reduce the risk of hypotension.

Reconstruction of complex facial defects has always been a challenge for plastic surgeons. The reconstruction can be done by use of local, regional, distant and free flaps; each of these has its own advantages and disadvantages. In this article a technique is presented about how to reconstruct complex facial defects simultaneously. This presented technique has been used for a 45-year-old woman with severe destruction of nose, upper lip and right side of cheek due to progressive ulcerating lesion that had begun since about 20 years ago. By expansion of normal neck skin and suitable design and taking surgical steps in sequence, the nose, upper lip and left side of cheek were reconstructed by a cylindrical cervical flap. The result was satisfactory and donor site morbidity was minimal. The use of this flap can be feasible in selected cases in which the extent of facial injury is great but the neck is not damaged.

Posterior mediastinal goiters are very rare and occur mostly due to the descent of a posterior lateraly enlarging inferior pole of the thyroid gland. Most patients refer with a cervical mass and symptoms due to compression or distortion of the trachea, esophagus, or superior vena cava. The diagnosis is done by Chest. X. Ray, cervical and thoracic computed tomography scan, and Barium esophagogram. Progrresive enlargement, risk of sudden hemorrhage within the thyroid gland causing respiratory impairment and the possibility of associated malignancy, make excision of the goiter mandatory. The routine approach to intrathoracic goiters is through cervical or cervicothoracic approach. Our patient was a 56 years old man who referred with dysphagia, dyspnea and pleatoric head and neck. Cervical and thoracic CT scan revealed a mass in the posterior mediastinum with the origin in right thyroid lobe. After routine investigation the patient was operated upon through cervical incision in which subtotal thyroidectomy with unblock resection of posterior mediastinal extension of thyroid was done.

Hernias is a well-known disease which has attracted the attention of human beings since the ancient period. some of its manifestations, symptoms and treatment approaches were also considered in ancient literature. Throughout the time of transmission from the ancient times to the barber-surgeon era, no major progress was made in diagnosing and treatment of hernia. However, following the emergence of renaissence in Europe and the getting opportunities of disection and autopsy afterwards, the anatomical knowledge of humans on hernia was expanded and by promoting sterilizing methods using lister and also stabilizing the position and advances of anesthesia in surgery, a major revolution took place in the area of hernia treatment. At the same time of developing different tissue repair methods, using metallic or non-metallic prosthesis in hernioplasty have progressed since the Bassini, about a century ago. Considering technological progresses and the optimization of various mesh types, different surgical methods have been developed and depending on the expertise of the surgeons have been used, so recurrence and post-operative complications have reduced, as well.