دکتر قدرت الله مداح

Emphysematous cholecystitis is a rare variant of acute cholecystitis with high mortality and morbidity rate. Emphysematous cholecystitis most often occurs in older men and Emphysematous cholecystitis often occurs in patients with chronic diseases such as diabetes and vascular disease. The combination of emphysematous cholecystitis and pneumoperitoneum is even rarer. In this study, we reported a rare case of pneumoperitoneum on plain abdominal X-ray with emphysematous cholecystitis in an 83-year-old woman.

The patient was 83 years old, lady who had been referred to the emergency department of Ghaem Hospital, Mashhad University of Medical Sciences in April 2019, due to diffuse abdominal pain that had started suddenly 3 days earlier. Pneumoperitoneum, the air in the gallbladder wall and the air encircling the gallbladder were reported in standing and supine abdominal x-rays and standing chest X-rays. At first, the patient was resuscitated and treated with broad-spectrum antibiotics. After initial treatment, the patient underwent open cholecystectomy with a subcostal incision on the right and a diagnosis of emphysematous cholecystitis. After surgery, the patientchr('39')s general condition improved and she was discharged without mortality and morbidity with oral third-generation Cephalosporin antibiotics. The general condition of the patient after discharge was good in the examinations performed in the clinic of Ghaem Hospital, 1 and 3 months after discharge.

Emphysematous cholecystitis is a rare and severe form of acute cholecystitis that occurs due to the process of arterial ischemia caused by contamination with anaerobic bacteria and the formation of gas in the wall and lumen of the gallbladder. Emphysematous cholecystitis is more severe than other types of acute cholecystitis and has higher mortality and morbidity and is life-threatening. Due to the acute and progressive course of emphysematous cholecystitis, correct and timely diagnosis and treatment are important.

Anaplastic variant of juvenile granulosa cell tumor is one of the rarest ovarian malignancies. The aim of this study is to describe a case of anaplastic variant ovarian granulosa cell tumor in a 14-year-old girl with presentation of abnormal uterine bleeding and gradual abdominal enlargement.

The patient at the time of diagnosis with an inhibin A and B more than 500 Pg/ml and ovarian mass of about 30×20×15 cm underwent unilateral salpingo-oophorectomy and juvenile granulosa cell tumor was diagnosed with no follow-up. She has referred with ascites, recurrent mass and distance metastasis of liver after 10 months. The patient underwent four courses of BEP (Bleomycin, Etoposide, Cisplatin)and five courses of paclitaxel and carboplatin. Then, she underwent laparotomy for metastasectomy, which was not successful due to the extent of involvement. Eventually, she died six months after the second surgery.

This case report confirms the need for accurate follow-up of patients with juvenile granulosa cell tumor and appropriate justification for the patient and their caregiver to prescribe needed adjuvant therapies to prevent recurrence.

Granular cell tumor (GCT), formerly known as granular cell myoblastoma, is an uncommon soft tissue neoplasm that may be of neural or neuroectodermal origin. For a long time, this neoplastic lesion was considered to be of striated muscle origin. This type of tumor can be found anywhere in the body, but rarely in the abdominal wall. In this study, we report a granular cell tumor in abdominal wall.

We report a 54-year-old woman with relatively painful and rigid abdominal wall lesion in the suprapubic area from 20 days before admission. Ultrasound and CT scan were performed and the patient underwent abdominal wall mass excision surgery in the suprapubic region. Surgical resection was performed extensively with the removal of adjacent muscles and fascia. Preoperative histopathologic diagnosis is important because one of the therapeutic targets of GCT is extensive excision to obtain tumor-free margins, as in the case of margin involvement, the chance of recurrence is high. Then, the sample was sent to the pathology department for further examination, and immunohistochemistry study with CK, chromogranin, S100, and CD68 markers was done for final diagnosis. Since abdominal wall GCT is a very rare clinically and radiologically finding and can mimic malignant symptoms, it is important to correctly diagnose it.

Due to the numerous reported cases of this lesion in women and the possibility of more encountering of gynecologists with this case, the need for accurate knowledge of this lesion in the gynecological surgery group is of greater importance to prevent the consequences of improper treatment.

Sometimes in reconstruction of abdominal wall after resection of its tumors, the defect is too large and therefore there is no chance to cover it with skin. The aim of this report was presentation of 5 cases that had undergone successful reconstruction of abdominal wall defect with mesh. In five patients who had undergone resection of abdominal wall due to its tumors, artificial mesh was used as a replacement for the abdominal wall. The mesh ((mersilene or prolene)) was sutured to the margins of fascia and after growing of granulation tissue over the mesh, split thickness graft was placed over it.None of the patients had local or systemic recurrence in 11& 56 months follow up. Our report showed that after extensive removal of abdominal wall tumors, if it was impossible to cover the defect with natural tissue, artificial mesh could be used as its replacement. Acknowledgment: This is no conflict of interest

This study aims to evaluate the outcomes and late complications of open Roux-en-Y gastric bypass surgery in the treatment of morbid obesity. Over a 15 year-period between May 1997 and May 2012، we reviewed our experiments with 39 patients who underwent open gastric bypass for morbid obesity. The weight of the patient and surgical complications were recorded. Ideal weight، body mass index، weight loss and excess weight loss were calculated. The follow up period ranged from 6 to 180 months with a mean of 100 months after operation. Average weight loss was 3. 9 and 0. 28 kg per month during the first and second years after operation weight loss was slower from the third year on-wards. Weight loss generally was stabilized between 12 and 18 months after operation. Only one patient (2. 6%) had a weight loss failure criterion. Concomitant condition ex-isted in 14 patients (48. 2%) of our series. These included hypertension in 3 cases (10. 3%) that was resolved in 100%، diabetes mellitus in 4 (13. 7%) that was resolved in 75%، cholelithiasis in 7 cases (24. 1%) that was resolved by cholecystectomy during the operation. There was no early postoperative death. Early complications occurred in 2 patients (5. 1%)، including pulmonary embolism (2. 6%) and gastrointestinal bleeding (2. 6%). The late complications occurred in 7 patients (17. 9%) involved 2 patients with anastomotic stricture at the gastrojejunostomy (5. 1%)، One patient with symptomatic cholelithiasis (2. 6%)، three patient with anemia (7. 7%)، and one patient had Wernicke ’s disease who died of this complication (2. 6%). The results of the study showed that the open Roux-en-Y gastric bypass surgery is an effective procedure in the treatment of morbid obesity with minimal late complications.

Gastric adenocarcinoma is one of the most common cancers worldwide. Most epidemiological studies have indicated the role of H. pylori infection on increased risk of gastric adenocarcinoma. The aim of the present study was to investigate the presence of this microorganism in gastric cancer in different regions of the stomach and to compare it with non malignant lesions. Samples were obtained from 50 confirmed cases of gastric adenocarcinoma who underwent gastrectomy during the years of 2007- 2008 at Ghaem and Omid hospitals of Mashhad. Gastric tissue of 50 patients who underwent endoscopy without gastric cancer was obtained as control samples. All patients were matched with regard to age and sex. The urease test and histology were used for the diagnosis of H. pylori infection. The prevalence of H. pylori was compared between the two groups. The data analysis was performed using SPSS version 16. through t student، Chi-square test، and Fisher exact tests. The prevalence of H. pylori infection in gastric adenocarcinoma group was 92% and in the control group was 60%. The prevalence of H. pylori infection in gastric adenocarcinoma patients was 100% in the antropyloric region and 95% in the body of the stomach. There is a significant correlation between Helicobacter pylori infection and risk of gastric adenocarcinoma.

Hydatid disease or echinococcosis is a common parasitic disease of human and bovine، caused by infection with larva of the cestode echinococcus. Liver is the most common organ that is involved in this disease. Pelvic involvement and neurological symptoms، due to mass effect of pelvic involvement، in lower extremities are very uncommon manifestations of the disease. A forty six year old man was referred to clinic of surgery at Ghaem Hospital، Medical University of Mashhad، Iran. The patient complained about weakness and motor impairment in right lower extremity accompanied by numbness and radicular pain over past two months. Physical examination demonstrated muscular atrophy and reduced muscular strength in right lower extremity. Computed tomography and ultrasonographic studies showed a cystic mass in right side of the pelvic cavity with extention to the sciatic notch and another cystic mass in right gluteal region. Surgical operation revealed a cystic mass deep in pelvic cavity with the extention to the right sciatic notch with compression of nerve roots. The cystic mass was contained of daughter cysts which confirmed the diagnosis of hydatid cyst disease. This diagnosis was confirmed by pathologic assessment. Although uncommon، but hydatid disease can involve the pelvic cavity and make a pelvic، usually cystic، mass; that can make compression on nerve roots and so making neurologic symptoms in lower extremities. So in endemic areas for hydatid disease، such as Iran، pelvic hydatid cysts should be considered as a possible differential diagnosis in patients presenting with the sciatic pain and neurological manifestations in whom a pelvic mass has been found too.

Eating the egg of Echinococcus granulosus tapeworm in vegetables contaminated with dog''s fecal material is the main cause of hydatid cyst. The most common involved organ is liver and the second are lungs. Spinal involvement especially primary involvement of paravertebral soft tissue without vertebral and extradural involvement is very rare. We report a case with paravertebral hydatid cyst without vertebral involvement. A 61 years old man patient resident of Torbatjam، Khorasan Razavi provience، was admitted to our department complaining a mass in back from six years ago. In physical examination he had several right paravertebral masses. MRI reveals a huge multilocular mass in the right paraspinal from T1 to L5 that is accompanied by ribs erosion without destruction. Operation was performed and the cyst was completely removed while contained several liquid-filled cysts، the hydatid-like cysts. Pathological findings were confirmed the diagnosis. Albendazole (10mg/kg) was prescribed post-operatively for six months. Recurrence has not occurred after two years follow up. Hydatid disease is a major infectious disease that is a main problem in many countries. In some articles paravertebral involvement without vertebral and extradural involvement is reported but primary paravertebral involvement with hydatid cyst is very rare. In this case we report paravertebral without vertebral involvement and the patient did not show any sign of spinal and vertebral pressure. In spite of the fact that hydatid cyst involves liver and lungs more than other organs، it can involve any organ and this point should be taken into consideration especially in the endemic areas.

Choledochal cyst is a congenital disease of hepatobiliary system. Patients with the disease differ in terms of gender and symptoms. In this study, we aimed to evaluate the patients from clinical signs and symptoms, diagnostic methods and treatment perspectives. In this retrospective study, we evaluated the data from the medical records of patients with choledochal cyst admitted in Ghaem and Omid hospitals affiliated to Mashhad University of Medical Sciences in Mashhad, Iran during 1994 to 2011. The medical records of 23 (18 women and 5 men) patients were evaluated. The mean age of the patients was 24.6 years. The most common type of the disease was choledochal cyst type 1. The most common type of surgery performed in the patients, respectively was resection of biliary cyst, cholecystectomy and Roux-en-Y hepaticojejunostomy. No mortality was observed during the hospital stay or follow-up period. Surgical complications were minor and patients recovered by conservative measures. Regarding the favorable results of surgical treatment of choledochal cysts, timely and definite diagnosis of this congenital anomaly and proper planning for its surgery are of special importance.

Gastrointestinal mesenchymal tumors are classified as tumors that originate from smooth muscles. Gastrointestinal stromal tumors (GIST) are the most common types of the proposed tumors and can be seen in the GI tract from the esophagus to the anus, but they are mostly seen in the stomach. Mostly from the stomach and asymptomatic, the majority of patients would benefit from surgery as the best method of treatment. In this retrospective study we evaluated the data of patients with the diagnosis of esophageal or gastric mesenchymal tumors admitted in Ghaem and Omid Hospitals affiliated to Mashhad University of Medical Sciences in Iran, from 1992 to 2010. We analyzed factors such as age, sex, presenting symptoms and signs, diagnostic methods, types of pathology, types of treatment, morbidity, mortality and 3-year survival rates. Twenty four patients (16 male, 8 female) with a mean age of 50 were included in the study. The common site of tumor was gastric fundus. The most common symptom at the time of diagnosis was epigastric fullness which was observed in almost 50% of the patients. The most common type of surgery in the patients was subtotal gastrectomy and no hospital mortality was recorded. Paralytic ileus was the commonest complication seen in five patients (20.5%). Adjuvant therapy had been performed in eight patients (33.1%). Following the patients three years postoperatively, there were only three deaths (12.45%). Regarding to the low mortality and morbidity of the surgeries, surgical treatment, if tolerated, is recommended for all Esophagogastric mesenchymal tumors patients.

Significant perineal injuries and major pelvic fractures resulting from blunt trauma manifest a high-energy injury. Open pelvic fractures (with perineal injury) are associated with higher mortality rates of 40 to 60 %. This study was a review of patients with multiple traumas comprising of major pelvic fracture and severe perineal injuries (Shahid Kamyab hospital in Mashhad from 2002- 2005). A total of 11 patients, with pelvic fracture and perineal injuries (injury to urethra and anal canal) were entered in the study. The data was gathered by a checklist and analyzed with SPSS software. The population under study included 11 patients (9 male, 2 female) with a mean age of 35years. Cause of trauma in all patients was motor vehicle accidents. All of the patients in the first 6 hours of admission received at least 4 liters of serum ringer lactate and 3 units of packed cells. The mean of packed cell received was 8 units and one patient needed 21 units of packed cells. All of patients were taken to the operating room for diverting colostomy, distal rectal washout, cystostomy and radical debridment and irrigation of devitalized tissue. Good results were achieved in 9 patients and there was one case of mortality and one morbidity (ARF). Open pelvic fractures and perineal injuries are associated with higher mortality rates. Prompt diagnosis and proper treatment (reanimation, colostomy, cystostomy, debridment and irrigation) is the key to success.

Chronic pancreatitis is a progressive fibrosis of the pancreas that leads to loss of endocrine and exocrine function of pancreas. The most common symptom is intractable pain. Which adversely effects quality of life, remains the most common indication for surgery in patients with chronic pancreatitis. Three patients underwent operations for chronic pancreatitis at the Ghaem hospital, Mashhad University of Medical Sciences Mashhad, Iran. Indication for operation in all cases were intractable abdominal pain. In all of the three patients complete relief of symptoms was obtained. There was no morbidity and mortality. In one patient exocrine function of pancreas and malabsorpation resolved after surgery.

Stromal tumors of the gastrointestinal tract (GISTs) are uncommon and the cell of origin is actually mesenchymal. Stemming from smooth muscle, 90% of GISTs, or leiomyomas, are found in the lower two thirds of the esophagus. Typically solitary, multiple tumors (leiomyomatosis) are occasionally reported. Remaining intramural during their growth, most of their bulk protrudes toward the esophageal outer wall, with a freely-movable, normal-looking overlying mucosa. In this study, we report a rare case of esophageal leiomyomatosis treated by esophagectomy. A 70-year-old man presented with discomfort upon swallowing, dysphagia, nausea, belching and weight loss. After a barium swallow