نشریه جراحی ایران
سال هجدهم شماره 1 (بهار 1389)

Deep venous thrombophelebitis (DVT) and pulmonary embuli (PE), as a relatively common complication of major operative procedures, may result in life long post phelebitic syndrome or sudden death. The high and intermediate risk patients could be identified and treated in order to prevent DVT and PE. Prophylactic measures, both mechanical and chemical have proved to be quite effective and recommended in majority of the surgical patient population.

Introduction & Corticosteroids and Antihistamines have been effective in reducing adhesion formation. This study was performed to examine the effect of clemastin - methyl prednisolone combination in the prevention of intra-abdominal adhesions after lapartomy in rats. The samples included 40 healthy, male rats that were randomly assigned to the case and control groups. The rats, used in the experiment, were from the same generation and the same age, weighting about 230±20g. Each rat was anesthetized with ketamine-hydrochloride (5mg/kg). Using sterile technique, the abdominal cavity was entered via a 4cm vertical midline incision. Ten longitudinal incision, each of them 1cm in length, were incised in the internal port of their right abdominal wall and a 2×2 (cm)2 piece of peritoneum was excised from the left side. Concurrently, clemastin (50 µg/kg) and methyl-prednisolone (40 mg/kg) was injected intra peritonealy in case group. Then, 20 days later, they had a second laparatomy for assessing the grade of adhesions. At last, the findings were analyzed by Mann-Whitney and fisher exact tests (P

Introduction & Lung transplantation is the ultimate treatment in many patients with advanced stages of pulmonary disease. Complexity, lack of donors, lack of specialized centers and the cost of the procedure are main barriers for its expansion. Although more than 30 lung transplantation have been done in our country, there is no report about the survival of these patients. We report here the survival rate of the patients who underwent lung transplantation at the research center of Masih Daneshvari Hospital. We used the database of lung transplantation research center of Masih Daneshvari Hospital, Tehran, Iran and extracted all cases of lung transplantation during 2000-2009 periods. Masih Daneshvari Hospital is a university based hospital and is the referral center for lung transplantation. We analyzed the survival of the patients using life table and Kaplan-Meier method. 33 patients underwent lung transplantation during this period. 25 (76%) of them were male and the mean age of patients was 38 ± 15 yr. The causes of transplantation were: pulmonary fibrosis (22, 67%), COPD (5, 15%), bronchiectasis (4, 12%) and cystic fibrosis (2, 6%). Lung transplantation was single-sided in 22 (67%) patients and double-sided 11 (33%) in others. One- and five-year survival of the all patients was 33% and 24%, and the mean and median of patient's survival were 32 and 17 months, respectively. In patients who were alive after two weeks of transplantation, one- and five-year survival were 51% and 36% and the mean and median of patient's survival were 45.8 and 20.8 months, respectively. The patients’ survival was lower at our center than what was reported from other centers. However, when interpreting these results, one should notice that lung transplantation is very young in our center. Most of our transplantations were performed while the center was in learning curve. Also, bad clinical condition and more advance disease-status of the transplanted patients along with patients’ poor education and their low socioeconomic status that made them stop their medications and follow-up, could be the other reasons.

Introduction & Based on the other studies that had shown preoperative coagulation tests and fibrinolysis factors have correlated with different malignancies and degree of extension of these tumors, we have checked preoperative plasma levels of D-dimer, fibrinogen, PT, PTT, Hb, WBC count and the formation of platelets in the gastric cancer patients and control group to assess the relationship between preoperative plasma levels of these factors and gastric cancer and the different pathological stages of this tumor that is high prevalent in Iran. 114 patients with gastric cancer and 114 patients with benign gastric disease were assessed in our case-control study and we evaluated plasma levels of these factors in their plasma samples, 24 hours before their operations or upper GI endoscopies. The pathological stages of gastric tumors were assessed according to AJCC (American Joint Committee of Cancer) protocol and manual. The plasma D-dimer level, plasma fibrinogen level, platelet count, platelet abnormal formation, Hb and PTT levels were significantly correlated with gastric adenocarcinoma. Based on the logistic regression analysis, this correlation was stronger for plasma D-dimer level, plasma fibrinogen level and abnormal platelet formation in PBS. Plasma D-dimer level was significantly correlate with resectability of tumor, distant metastasis and the clinical stages of this tumor, but there was no significant correlation between this factor and lymph node metastasis, tumor site and the type of gastric adenocarcinoma. We also found no significant correlation of PT level and WBC count with gastric cancer in this study. In this study the cut off points of plasma D-dimer level and plasma fibrinogen level were 0.15 mg/lit and 400 mg/dl respectively.The sensitivity and specificity of D-dimer in diagnosis of gastric cancer was 54% and 84%, and the sensitivity and specificity of fibrinogen was 79% and 63% respectively. Preoperative levels of plasma D-dimer and fibrinogen and the abnormal platelet formation in PBS can be diagnostic factors in the presence of gastric cancer. Also, preoperative plasma D-dimer level can be a predictor of the extension of this tumor.

Introduction & In most anatomic references, the shape of the lower lateral cartilage (LLC) is described as a two-dimensional structure. However, the authors have found different forms of LLC in at least 40% of their open rhinoplasty cases in the last 20 years. We found this cartilage to have a three-dimensional hemispheric appearance that was connected to the upper lateral cartilage (ULC) at scroll area by an inward limb of this hemisphere. This inward limb may have an important role in producing asymmetry and flare of the nostril. The LLC of 286 patients was evaluated during open rhinoplasty over a two-year period, with the main focus on the shape of this structure, especially at the LLC-ULC junction (scroll area). A dome-shaped appearance of the LLC was noted in 40.9% of cases, and 11.5% of cases had bilateral LLC variation. This different anatomic form was seen mostly in patients with a strong bulbous tip, although it was observed less frequently in narrow nasal tips as well. At least one-third of the LLCs that were analyzed had a medial wall in addition to the lateral wall, which significantly increased the flare and recoil force of this structure. This makes this cartilage more redundant to reshaping procedures (straightening); thus, special attention must sometimes be paid to this common anatomic variation in order to produce symmetric nostrils and obtain a more aesthetically acceptable alar tip.

Introduction & Traumatic nerve damage is quiet a frequent event in the upper extremity. Microscopic reconstructive nerve repair is usually used to restore the continuity of the injured nerve. Restoration of the sensory ability of the nerve is of great importance in normalization of the hand function. Since we could not find an individual study comparing the sensory out come between median and ulnar repair, we designed this study to better understand the results of sensational out comes between these two nerves. During 3 Months period, 65 patients who had median, ulnar or both nerves injuries at the wrist level, and who had been operated upon in Hazrat Fatemeh Hospital were assessed with regard sensibility improvement were compared with each other. The criterias for inclusion were negative history of medical illness and adequate follow-up (at last 9 months) after surgery. The sensory evaluation was performed by monofilament test, static and moving two point discrimination, and the results were compared. Of the 65 patients included in this study, the mean age was 27.2 years. The cause of trauma was predominantly laceration with glass. Ulnar nerve was the most commonly injured nerve (46.2%) and sole median nerve injury was observed in 36.9% of patients. In 16.9% of the patients both ulnar and median nerve were damaged. The mean time for patient evaluation was 24.5 months after surgery. Middle finger was the mostly impaired one in the test after median nerve injuries and the little finger was the mostly impaired one in the tests after ulnar injuries. The results show that the sensory return is better and higher in median nerve repairs in comparison to ulnar nerve repairs at the wrist level. In upper limb nerve injuries, radial nerve has the best prognosis and the ulnar nerve has the worst one. In our study, however it is shown that in the same condition of age, cause of trauma, time elapsed before surgery and surgical method, sensory return in median nerve is better that ulnar nerve at wrist level. This can be due to less complexity of the median nerve in terms of anatomy and topography, smaller motor component and easier exposure during surgery. Also, the best area for evaluation of sensory impairment and return after median nerve injury is the volar side of middle finger.

Introduction & The anatomical study of the compression site of median nerve in patients with carpal tunnel syndrome can result in to better understanding of carpal tunnel anatomy and the narrowest location of carpal tunnel. This study was performed to have a better understanding of the carpal tunnel anatomy. Forty patients with severe idiopathic carpal tunnel syndrome, who had undergone carpal tunnel release, were entered in this study. The length of compression area in median nerve, the distance between the middle of compression area and distal wrist crease were determined. From these 40 patients 38 were women and 2 were men. The mean age of these patients was 54± 6.5(37-76) years. The mean length of compression area was 6±1 (3-10) millimeter and the mean distance between the middle of compression area and distal wrist crease was 23±3.5 (18-26) millimeter. This area was adjacent to the hook of the hamate. According to the results of present study on the anatomy of median nerve in carpal tunnel, the location of the narrowest area and the site with most compression correspond to the location of the hook of the hamate bone.

Introduction & Colorectal carcinoma is one of the most prevalent cancers. Early diagnosis and diagnosis in primary stages are important in patient’s prognosis. In this study we evaluated factors such as age, sex, stage and tumor location in colorectal patients in five year peroid. From the cancer database of a single referral institution, Shariati Hospital 109 patients who had resection of colorectal cancer from 1999 to 2002 were identified. Cases with recurrent colon cancer or previous history of neoadjuvant chemotherapy were excluded. Survival curves were constructed using the kaplan-meier method. The factors that were used included: age, sex, TNM stage, T-status, nodal status, distant metastasis, grade, lymphatic and vascular invasion, tumor location, preoperative CEA level and liver function tests. Multivariate analysis of factors was conducted using cox-regression analysis. The mean survival time for all patients was 42.8±2.8) months. The overall 1, 3, 5 year survival rates were 72%, 54%, 47% respectively. The single variable analysis, patients age (P

Introduction & Laprascopy is the selected procedure in cholecystectomy and because of reducing complications, like pain, infection, and the duration of hospital staying, it is a favorite procedure for most surgeons. Drain insertion in laparoscopic cholecystectomy can increase post operative hospital staying. In this study we compared post operative hospital staying of our patients with (group A) and without (group B) drain. In this study we compared post operative hospital staying of patients, who had recently undergone laparoscopic cholecystectomy in Logman Hakim Hospita and had drain insertion, with those who did not have it. The effect of drain in post operative management was also assessed. This study included 75 patients. Drain was inserted for 49 patients (group A) and was not inserted for the remaining 26 patients (group B). The average post operative hospital staying was about 3.22 days in group A and 1.92 days for group B. In one of the group a patients, drain altered post operative management, but it had no significant effect on others. According to the results of this study, the routine use of drain can increase post operative hospital staying in uncomplicated laparoscopic cholecystectomy and it has no significant effect on post operative management of the patients. Thus, it is not recommended routinely.

Introduction & About 7.7% of all born neonates through at the world have low birth weight. Also 56% of pregnant women in under developed countries, 18% of pregnant women in developed countries and 80% of pregnant women in South Asia are anemic. The result of studies, which have been already done, about the relationship between mother's hemoglobin concentration and birth weight of her neonate are contravertial and also in reference books of obstetrics and genycology nothing is specifically mentioned about this issue. Our aim in this study is to evaluate the relationship between mother's hemoglobin concentration and BMI in the first trimester of pregnancy and birth weight of her neonate. This was a cross sectional study in which the files of 555 nulipar women, which related during August 2004 - August 2007 to 5 health center in Rasht city, during August 2004-August 2007, were selected randomly and referred to the data needed for this study, such as age, height, weight, mother's hemoglobin and birth weight of her neonate were collected. Other confounding factor such as prematurity, genetic disorders, placental insufficiency, chronic disease and administration of some special drugs were eliminated. The data were analyzed by pearson and linear regression Analysis. There was not significant relationship between mother's hemoglobin concentration during the first terimestr of pregnancy and her neonate's birth weight. Also the relationship between mother's hemoglobin concentration and her neonate's birth weight with interfering factor of age, was not significant, but the relationship with the interfering factor of BMI, in BMI higher than 30 kg/m2 was found to be significant (P=0.041). The ratio of LBW in our study was 4% and the ratio of macrosomy was 5%. Also ratio of anemic pregnant women in our study was 21.3%. According to our study there is no significant relationship between mother's hemoglobin concentration during the first terimestr of pregnancy and her neonate's birth weight. The ratio of LBW in our study was lower than world-wide average. Also the ratio of anemic pregnant women in our study was lower than under developed countries and a little higher than developed countries.

A Case of plastic deformity of forearm due to trauma and engagement of upper extremity in an industrial machine in a skeletally mature adult, with ipsilateral humerus fracture, is reported in this article. Clinical findings were pain in the forearm, deformity, and limitation of rotation (supination and pronation). Neurovascular examination was normal. Superficial abrasions were seen throughout upper extremity. In the radiography, the radius and ulna had an apex dorsal bow.

:Primary intrathoracic goiter, especially of posterior mediastinum were rare and were less than 1%. Primary intrathoracic goiters supplied by intrathoracic blood vessels. We introduce a patient who referred with a huge mass in the posterior mediastinum extended to the anterior superior mediastinum with a sign of dyspnea and chronic cough. This mass was easily removed through standard postrolateral thoracotomy and all the symptoms of the patient were resolved. The blood supply of mass arises from intrathoracic vessels.