نشریه جراحی ایران
سال بیست و یکم شماره 3 (پاییز 1392)

Primary chronic constipation is a common problem, but is less likely lead to a malignant condition. The act of defecation is involuntary at the beginning but it needs voluntary muscles to work synergistically to take place satisfactorily. Some metabolic diseases and drugs can cause constipation, which can be cured by the cessation of the drug or the treatment of the underlying disease. Acute or sudden onset of constipation or change of bowel hobbit should be thoroughly worked up. Secondary constipation is due to spinal cord injury or nerve damage, but it is not discussed here. Ordinary person have their own definition of constipation, so in handling a patient with this problem it should be known precisely what does he or she means by constipation.In the last decade new drugs are used for the treatment of constipation. Surgical treatment of constipation is also common in some cases, after careful work ups, and is defined as total colectomy and ileorectal anastomosis and it is described here. Since this kind of surgery is becoming common in certain cases, it is necessary that our colleagues become familiar with it.

Introduction & With the introduction of endoscope in the field of neurosurgery since 1980, the approaches to the sellar region has been modified remarkably, and Endoscopic Transsphenoidal surgery for pituitary tumors is now a good alternative to the traditional Microscopic Transseptal approach with comparable results. All patients who were operated for pituitary adenoma using either endoscopic or microscopic transsphenoidal approaches from 2008 until 2012, were followed up on a regular basis by neuroimaging, pituitary hormonal study and neuro-ophtalmologic examination. Short-term and long-term complications, the rate of hormonal remission, visual improvement in long-term, and recurrence rate were compared between the two groups. Forty one patients were included in this study. Thirty two cases were operated upon using the endoscopic approach, and 9 were operated upon by the microscopic approach. Null cell adenoma was the most common pituitary tumor in the series. The rate of short-term and long-term complications including DI, CSF leak, and sinusitis, were more common in the group who underwent endoscopic resection of pituitary adenoma, although this approach was associated with lower recurrence rate, less hospital stay, and more success in the rate of hormonal normalization (P > 0.005 for all variables). The present study suggests that endoscopic approaches to the sellar region can be done safely with comparable results with microscopic approaches in the experienced and well equipped hands, although prospective randomized studies are needed to address better results.

Introduction & Due to esophageal cancer, over two thousand people lose their lives in Iran annually. Obviously, esophageal cancer can be curable, if an appropriate treatment is chosen. Although this disease is not one of the 10 common cancers in the world, esophageal cancer is very common in regions like the 5 northern provinces of Iran. In these areas its considered the biggest problem in the health care system, However, cancer behavior and response to the treatment is different in every geographical region. This study compares one to three-year survival rate of patients with esophageal cancer with chemoradiation therapy (CRT) alone versus surgery with chemoradiation therapy (CRT-S) during eight years in Gilan province. In this historical cohort study, all esophageal cancer patients’ records had been studied since the launching of radiotherapy clinic of Razi hospital in Rasht, during eight years (2004-2012). Finally, 266 patients in the stages II and III of esophageal cancer were entered in our study and were followed up till 2012. The patients were divided into two groups. The two groups treated by chemo-radiation therapy (CRT) alone and surgery plus chemo-radiation (S- CRT), were compared in terms of survival duration. The results were analysed by SPSS software using descriptive analytical statistic and statistical test Log Tarone-ware. In addition in order to stimate the rate of survival Kaplan-Meier and to estimate the chance of survival with the control of underline and interventive factors Cox Regression was used. Out of 266 patients in the stages II and III of esophageal cancer, 222 patients were treated by CRT (these patients were unwilling to undergo surgery) and 44 patients were treated by S-CRT. The mean age of the patients was 65 ±11. Most patients were men (57%). The most common site of tumor involvement was in the lower third of the esophagus (46%). The pathology of tumors was SCC in 80% of the cases. The mean age of overall survival was 17 ± 1.1 months with median survival of 12 months. The overall one year survival was 49% and the three year survival was 11.8%. The survival mean of patients with CRT was 17±1.2 months with median survival of 13 months and those with CRT-S was 18 ± 2.3 months with median survival of 14 months. There was no significant relationship in the rate of survival in two groups with the intervention, anatomic location, histologic type and gender were concerned. The rate of survival in SCC group and adenocarcinoma were compared and following results were obtained: survival of SCC patients, in both groups of CRT and CRT-S had no significant difference (P<0.32). Survival was higher in the adenocarcinoma group (P<0.0001). Patients with the non-metastatic esophagus cancer of SCC responded positively to chemo-radiation therapy alone, and adding surgery to patients’ treatment not only didn’t have any effect on the survival duration, but also caused big stress, high cost treatment for the patients and long hospitalization for health care system. Hence, chemo-radiation therapy alone is recommended for the treatment of non-metastatic esophagus cancer of SCC in high-risk areas.

Introduction & Due to Iranian Thoracic surgery fellows’ exaggerated belief in textbooks on the one hand and their unfamiliarity with scientific search and reading articles and article appraisal on the other hand, only a few fellows employ articles to promote their scientific work and practice. Furthermore as a result of fellows’ incapability to prepare informative power point presentations and give speech properly, fellows are unable to present new information to their colleagues. Participation in journal clubs and presenting articles could help fellows to become skillful in mentioned issues. This study aimed to evaluate the effect of journal clubs on different aspects of reading, presenting and practices of thoracic surgery fellows. After 4 years of conducting journal clubs every month, evaluation survey via e mail from thoracic surgery fellows (who had participated in 22 journal clubs in their 2 years training) was carried out to assess the effect of journal clubs on scientific search, study appraisal, power point preparation, study habit, presentation skill, and practice promotion. More than 80% of the fellows stated that journal clubs had been very good or excellent for achieving the mentioned educational goals. Additionally considerable percentage of fellows evaluated the effectiveness of this educational method on separated asked items to be very good or excellent. Conducting journal club sessions not only improves fellows approach in reading articles, better understanding of the text books, and preparing power point presentations, but also provides an opportunity for them to update their information in one of the selected thoracic surgery subjects every month. Bedsides, a valuable archive from selected and updated articles have been gathered for Iranian thoracic surgeons every month. As the running of journal clubs is simple and clear, it is quite possible for other departments in our medical schools to employ our method and carry out similar journal clubs.

Introduction & Wound complication is one of the most common problems after surgical incisions. The aim of this study was the evaluation of wound complications with subcutaneous tissue closure versus non closure after hip surgery. 100 patients who were candidates for hip surgery, from 2011 to 2013, were entered in this study. The patients randomly divided into two groups: Group 1, patients with subcutaneous closure (n=48) and group 2, patients without subcutaneous closure (n=52). Wound complications such as hematoma, necrosis, dehiscence, infection and scar were evaluated. Patients were seen in first, second, fourth and eighth weeks after operation. Statistical analysis was done with SPSS 16 by chi-squared and independent sample t-test. In 100 patients, the mean age (55±18.009) year and mean weight (75.41±10.007) kg were not significantly different between the two groups. 56 patients were men and 44 of patients were women. Sex was not significantly different between two groups (P=0.652).One person had diabet mellitus and one had psoriasis. Of 100 surgical operations two were urgent. Of 100 patients 48 were operated with DHS fixatin, 16 hemi and total hip arthroplasty and 4 with osseous resection. 20 had femoral IM and 12 had fracture of acetabulum. Surgical technique was not significantly different between the two groups (P=0.958). We found hematoma in 2 patients and inflammation in 3 patients. Dehiscence was not detected in anybody. Wound infection was found in 3 persons. As a whole no complication was significantly different between the two groups. The mean operation time in the first group was 113±15 minute and in second group was 105 ±14 minute. The first group’s operation time was significantly more than second group (P=0.012). The mean incisional length in first group (11.88±3cm) was significantly more than second group (9.88±3cm), (P=0.004). Our study showed that subcutaneous closure, not only has no significant role on wound complication reduction, but also makes patients to tolerate longer surgical operation.

Introduction & During child’s motion development and growth, sagittal parameters of spine and spinopelvic, such as thoracic kyphosis, lumbar lordosis, pelvic tilt, change in order to preserve the global sagittal balance. Correct concept of normal spinopelvic parameters of children would effectively help spinal surgeons assessing spinal deformities and proper planning for treatment. There was no study about this subject in Iran. We aimed to determine spinopelvic parameters in 8-19 years old Iranians for the first time, in order to demonstrate pelvic and spinal sagittal parameters change during growth. Subjects of our study were 98 healthy students (50 boys and 48 girls), aged 8-19 years, who live in Tehran. Each subject was examined by an orthopedic surgeon. Spinal radiographs in lateral view were obtained at Shafa Yahyaian radiology center. Eight spinopelvic parameters (thoracic kyphosis, lumbar lordosis, thoracic, lumbar and pelvic tilt, pelvic incidence, sacral slope and sagittal balance) were measured by 2 orthopedic surgeons on each standing lateral total spine radiograph. Data were described with mean standard deviation, frequency and percentage. Then different group were compared with “ANOVA” and “Duncan” test. Level of significance was considered to be 0.05 in all tests. Nighty eight subjects 48 girls (49%) and 50 boys (51%) with the mean age of 13.6±2.9 years (range: 8-19) were examined. Maximum TK was in the 14-16 year age group (mean 40.8) that was significantly different with that of 8-10 year age group. Age had significant and positive correlation with thoracic kyphosis but had no correlation with the other sagittal parameters. This means that TK increases during growth. Thus, we should note these changes in decision making in the treatment of spinal deformity, and in the reconstruction of normal curve during spinal surgery.

Introduction & Acute appendicitis is one of the most common problems requiring emergency surgery. Although more than 20 years has elapsed since the introduction of laparoscopic appendectomy, there is no consensus on its advantages and disadvantages compared to the conventional technique. Recent studies have shown significant advantages of laparoscopic appendectomy with respect to the length of hospital stay, postoperative pain and infectious complications. These findings have been challenged by other authors who observed no significant differences in the outcome between the two procedures. In the present study, we aimed to compare the laparoscopic approach and the open technique in the treatment of acute appendicitis. 70 patients with diagnosis of acute appendicitis, who referred to Besat Hospital of Hamadan, were included in this study. They were randomly divided into two groups of 35 patients, One group underwent Open appendectomy (group A), and the other group, had laparoscopic appendectomy (group B). The parameters examined in this study included patient’s characteristics (age, sex), operation time (from skin incision to wound closure), postoperative pain, length of hospital stay, return to work and postoperative complications. The data were analyzed by the SPSS 17 software. There were no significant differences between two groups with respect to gender and age. The mean operation time was significantly different in the two groups (it was 55.71 ± 16.09 min in the open group vs 64.42 ± 17.14 min in the laparoscopic group; P = 0.032). Also the length of hospital stay time was significantly different in the two groups (54.77 ± 27.02 hours in the open group vs 30.25 ± 11.85 hours in the laparoscopic group; P < 0.001). Open appendectomy was associated with a significantly higher incidence of wound infection compared with the laparoscopic group (14.3% vs 0%; P = 0.027).Patients went back to work 7.8 days after their operation in open group, and 5.22 days after their operation in the laparoscopic group (P < 0.001). Also, the average dose of patient’s requirements for analgesia, with pain after surgical treatment, was significantly different in the two groups (P = 0.027). In the present study, we were able to demonstrate the superiority of the laparoscopic approach in terms of hospital stay, postoperative pain, return to work and wound infection.

Introduction & Femoral neck fracture is one of the most complicated fractures in orthopedic diseases, and its common complication is nonunion. If the head of femur is alive, one of treatments of nonunion is to alter the fracture line angle and the conversion of displacing force to pressure force at the site of fracture, and this leads to union. On the other hand, it changes the biomechanic of hip and disposes it early destruction that will affect patient’s life adverse. Our aim in this study was to achieve an angle that accelerates union and on the other hand does not lead to Arthrosis and joint destruction. With biomechanical analysis and using computational simulation, we assessed the displacing force of femur neck fracture and the pressure force on the head of femur at different angles of valgus. Considering individual geometrical and biological factores and producing graphs to be able to determine the proper angle for valgus osteotomy. It must be able to produce proper pressure force for union at the fracture site, not leading at the destruction of femur head, and not exceeding the physiological limits. To produce fracture in femur and Blade modeling we used solid work software, and then located the blade at the proper place for osteotomy. Geometry was used in the software to perform simulation. We offered values of stress intensity for fracture angles 30 to 70 and correction angles 0 to 40, and obtained from simulations suitable angles for osteotomy, based on the minimum of shear stress. Furthermore, at the angles 50 and 55 there was no significant change in the shear stress. According to the results of this study, we offered stress intensity suggested through simulations and recommended angles for osteotomy, based on the minimum of shear stress. Changing the fracture line between 0 to 40 degree had no obvious effect on the force on the head of the femur.

Pulmonary hydatid cyst (cystic echinococcosis) is a parasitic infection caused by Echinococcus species and is a major health threat in endemic areas such as Iran. In most cases, there is a single cysts in one lung, but in 4% of cases lung cysts are bilateral. Treatment of bilateral lung cysts is controversial and is associated with some problems. We operated on a ten years old girl with two large cyst in both lungs in one stage through two anterolateral thoracotomies and present the treatment results.Key Words:

In recent years a new method, called minimal invasive surgery (MIS), has been welcomed. In addition to creating enormous development in the field of surgery, it has corrected defects and aggressive face of this field. MIS usually uses endoscopes and is done through small holes on the skin or through the body cavities, such as airways, digestive and etc. and has less injury and side effects for patients. The main problem of MIS in comparison to open surgeries is the lost of surgeon’s vision in finding the endoscope's position or other surgical instruments inside the body that needs more experience and increase probability of injury to critical tissues. To solve this problem, in recent years surgical navigation systems have been developed, and a kind of these systems was invented and used in Iran in 2011. The main task of a surgical navigation system is to estimate the position of the surgical instrument and how to move it inside the body, and showing this data on the pre-operative images, which were taken from the patients. Experiments show that surgical navigation systems improve endoscopic surgery’s quality and reduce its complications in patients. Therefore these systems will be one of the important requirements of all operating rooms in future. So, due to the rapid advancement of this technology and medical community’s need and especially surgeon’s need to be familiar with surgical navigation system, we have carefully discussed. In this article various parts of these systems, their performance and some of their advantages in an endoscopic surgery has been carefully discussed and reviewed.