Academic Journal of Surgery (AJS - Tehran University of Medical Sciences)
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Conservative management of hematoma of the rectus sheath, unusual cause of acute abdomen: A case report
Get PDFRectus sheath hematoma (RSH) is an accumulation of blood within the rectus sheath, secondary to rupture of the epigastric arteries. It is a rare condition, accounting for 1.6-1.8% of abdominal pain cases. It is more frequentlyo bserved in women, over the age of 50. Predisposing factors include the long-term use of anticoagulants, antiplatelets, steroids or immunosuppressants, prolonged INR, pregnancy, cardiovascular disease, hematologicaldis ease, hypertension, and diabetes. The symptoms are typically described as persistent and non-radiating acuteabdominal pain that classically worsens with movements involving the abdominal wall (Carnett’s sign). Cullen’ssigns (periumbilical ecchymosis) and Gray Turner’s signs (flank ecchymosis) may also be present. In stablepatients, the management is conservative
Dermatofibrosarcoma protuberans of the face: A case report
Get PDFIntroduction: Dermatofibrosarcoma protuberans (DFSP) is a rare locally aggressive tumor with high rate of local recurrence but low metastatic potential. Its occurrence in the head and neck is a rare finding but it is associated with increased morbidity and mortality.Case report: A 53-year-old Iranian man referred to a complaint about an increase in the size of the subcutaneous mass on the right cheek that had been present since he was 17 years old. On clinical examination, the lesion was not painful and had no erythema. In examining the patient's CT scan without contrast, a mass-like area with soft tissue density was seen. During the surgery, the flap was lifted after a lateral rhinotomy incision. The biopsy sample was sent for frozen section, and the pathology result was a Spindle cell tumor. In immunohistochemistry (IHC), two factors, including CD34 and VIMENTIN, were positive and Dermatofibrosarcoma protuberans (DFSP) was reported.Conclusion: The most important prognostic factor for surgery of Dermatofibrosarcoma protuberans is obtaining tumor free surgical margins. As a result, accurate diagnosis and correct management of this uncommon and locally invasive malignancy is very important, especially in head and neck surgery
Surgical Never Events: A retrospective study in Iranian Hospitals
Get PDFBackground: Never event is an unintentional injury or complication that increases the length of hospital stay, disability at the time of discharge or death due to improper health care management. Adverse events are potentially preventable in terms of patient injury, increasing the length of hospital stay, and increasing health care costs. Due to the importance of the subject, the present study was conducted to investigate the factors related to adverse surgical events in Iranian hospitals in 2020.Methods: This cross-sectional study (descriptive-analytical) was conducted to determine the factors associated with adverse events related to surgery in Iranian hospitals. All reports entered in the unwanted events registration system related to codes 1, 2, 3 and 4 of unwanted surgical events from March 2018 to March 2021 were included in the study.Results: The results showed that the rate of surgical Never events in Iranian hospitals is about 0.006%. The highest incidence of unwanted surgical events in error code 4 (leaving any device including gas, scissors, pliers, etc. in the patient's body) with 63.7% and the lowest incidence of adverse surgical events in error code 2 (performing surgery incorrectly on another patient) was 4%.Conclusions: The findings of the present study show that the rate of unwanted surgical events in Iranian hospitals is lower than the global average. Lack of a precise framework for job descriptions and responsibilities, failure to use instructions, and lack of decision support systems are all factors in the occurrence of adverse surgical events. 
Partial Upper Lip Reconstruction Using Fujimori Flap: A Case Report
Get PDFThe Fujimori gate flap is known and used for the reconstruction of defects resulting from oncologic surgery. This case report describes the use of this flap to reconstruct the upper lip of a patient who had a defect following lip carcinoma, resulting in a loss of 2/3 of the upper lip tissue. The case involves a 34-year-old woman presenting a partial lip defect after upper lip carcinoma. She underwent a unilateral gate flap procedure, which allowed the authors to reconstruct the three levels of skin, muscle, and mucosa. Following surgery, no complications were observed. The patient was followed up at three months and a year later. She was able to speak and chew without any trouble after the flap restored oral competency. The patient’s treatment objectives, which included regaining oral competency and achieving an acceptable aesthetic result, were met thanks to the use of the Fujimori gate flap in this case. Compared to the use of other local, regional, or remote flaps, the flap also provides good color matching. The Fujimori flap ensures the restoration of the oral sphincter, in contrast to the typical flaps used to reconstruct the upper and lower lip, thereby promoting oral competence
A rare case of pneumothorax caused by ruptured pulmonary hydatid cysts accompanied by deep vein thrombosis: A Case Report
Get PDFHydatid disease is mostly found in endemic areas such as middle east, particularly in patients with certain history of exposure. Signs and symptoms depend on the organ infected by the cysts, as hepatic cysts may cause abdominal pain and jaundice. Pulmonary hydatid cysts on the other hand, usually occur in the lower lobe of the right lung, and present with chest pain, cough, or shortness of breath. Rupture occurs in about one third of patients, releasing a highly antigenic fluid, which can result in anaphylaxis when ruptured into the bronchus. Alternatively, although not common, pulmonary hydatid cyst rupture may result in pleural effusion or rarely, pneumothorax. Our patient was a young man presented with pneumothorax resulted from a ruptured pulmonary hydatid cyst and concurrent extensive DVT. The cysts were completely resected, and underlying parenchyma was repaired through a posterolateral thoracotomy, while DVT was managed by anti-thrombotic therapy.
 
Comparing the outcomes of total thyroidectomy using a harmonic scalpel versus the conventional ligation techniques in Iran
Get PDFBackground: Maintaining hemostasis is considered a remarkable challenge during total thyroidectomy. Theuse of thermal ultrasonic electrocoagulation (harmonic scalpel) for total thyroidectomy was recently introducedto substitute the conventional ligation methods. However, controversies exist on the efficacy of this techniquecompared to the classic method.Methods: The data regarding this prospective cohort study was gathered between March 2019 to March 2020.Ninety participants were enrolled in the study. Forty-five subjects received harmonic scalpel ligation and theother forty-five participants underwent conventional total thyroidectomy. Afterward, these two groups werestatistically compared regarding surgical time, postoperative hypocalcemia, drainage volume, postoperativepain, hospital stay, and recurrent nerve damage.Results: No significant difference was detected in the group undergoing harmonic ligation concerningpostoperative pain, postoperative hospital stay, drainage volume, and postoperative hypocalcemia in the first 48hours post-operation. However, using a harmonic scalpel significantly reduced the surgical time (56 ± 2 minutesin the harmonic scalpel group versus 67 ± 9 in the conventional technique group, p < 0.001). Also, no recurrentnerve damage was detected in the study.Conclusions: Utilizing a harmonic scalpel has a remarkably higher time efficacy in total thyroidectomy.However, the study suggests no further advantage for this method compared to the conventional techniques intotal thyroidectomy
Comparison of the efficacy Talc solution injection through Chest Tube and Talcum Powder through Pleuroscopy for the Treatment of Malignant Pleural Effusion: a randomized clinical trial
Get PDFBackground: The aim of the present study was to compare the different outcomes and response rates of talcpowder injection via chest tube and talc spray through thoracoscopy in the treatment of malignant pleural effusion in patients.Methods: In this randomized controlled trial, patients with malignant pleural effusion, who were hospitalizedin the surgery and hematology-oncology departments of Shariati and Imam Khomeini Hospitals, were enrolled.The patients were randomly divided into two groups: chest tube and pleuroscopy, using simple randomization.The mean and standard deviation, frequency and percentage, independent sample t-tests, chi-square, and Fisher’sexact tests were used for data analysis. A p-value of less than 0.05 was considered statistically significant.Results: No significant difference was observed between the two groups in the incidences of chest pain, fever,and both symptoms (p > 0.05). The treatment success rates among the chest tube and pleuroscopy cases were83.3% and 100%, respectively, and there was no significant difference between the two groups (p = 0.05). Among the five patients who had a recurrence, four (80%) had lung cancer, and one (20%) had liver cancer, and this difference was significant (P = 0.003). Regarding the rate of response to the treatment according to the side witheffusion, among the people who had a relapse, two people (40%) had right-sided effusion, and three others (60%) had left-sided effusion (P = 0.623).Conclusions: Both techniques were safe, had minor side effects, were transient, and easy to manage. However,the recurrence of the disease in the thoracoscopic pleurodesis method was significantly less than in the chest tube
An investigation on causes of delayed referral of patients with pleural empyema
Get PDFBackground: In the treatment of pleural empyema, medical therapy is typically sufficient for the 1st or 2ndstage. However, surgical intervention becomes the optimal modality in the 3rd stage. A significant number ofpatients experience delayed diagnosis and treatment, leading to the conversion of non-surgical pleural empyema into complicated surgical empyema.Methods: A cross-sectional study was conducted on patients with pleural empyema who were admitted toNRITLD in Tehran from 2015 to 2016. Initially, 66 patients were selected; however, after the exclusion of 12patients, a total of 54 patients were included in the study.Results: Delays were attributed to the medical system in 62% of cases and to the patient in 29% of cases. Themedian (IQR) of the total delay time attributed to the system was 38 (25) days. No significant difference wasfound in the median of delayed referrals between genders. A significant correlation was observed between theinterval of the first and last visit and the interval between the onset of symptoms and chest x-ray (CXR), as wellas the interval between the performance of CXR and the insertion of chest tube drainage (CTD).Conclusions: The delay in referral and treatment can be attributed to the patient, practitioners, or both. In thisstudy, it was found that the medical system is the primary cause of delay, primarily due to the long waiting times for admission and operation in hospitals. Patients who experience a delay in CXR and CTD insertion will face a significant delay in referral and their course of treatment. It is suggested that delayed referral could be prevented by providing patients with basic medical education, offering specialized training to general practitioners for early referral, and managing waiting lists effectively
Unveiling the Hidden Peril: A Rare Case of Gossypiboma in an Elderly Woman
Get PDFBackground: Revolutionary developments in the surgical field have led to a comparative reduction in surgeryassociatedcomplications than in the past. However, some complications, which directly indicate surgeon’s negligence, should not be underestimated. Gossypibomas, a rare but horrifying complication of surgeries, occur when cotton foreign bodies are retained in the patient and are only discovered after long periods of time.Methods: A 46-year-old diabetic anemic female, with a previous history of operative management for cancer ofthe cervix (stage IA2), presented with features suggesting sub-acute intestinal obstruction.Results: Contrast Enhanced Computed Tomography (CECT) of the abdomen revealed a linear hyper- attenuating string-like structure in the distal bowel loop, suggesting a Retained Foreign Body. The patient was immediately taken up for exploratory laparotomy, and the retained foreign body was removed.Conclusions: Although the diagnosis of Gossypibomas can be challenging at times, it is imperative to managepatients with this rare complication swiftly and precisely to prevent permanent future disabilities. Youngsurgeons should be made aware of the legal consequences of such a dreaded complication and should anticipate the diagnosis in bizarre surgical circumstances
Identifying the discriminative value of leukocytes, CRP and Procalcitonin serum level in detecting the anastomosis leakage after gastrointestinal surgery
Get PDFIntroduction: Anastomosis leakage is a pivotal post colorectal surgery complication that jeopardizes patients’ survival and unspecific clinical presentations elongates the diagnosis process that could exacerbate the efficacy of interventions. This has raised the need for identifying a biomarker that potentiates early prediction of AL. Former studies have indicated the potential utility of WBC, C-reactive protein (CRP), and procalcitonin (PCT) serum levels as biomarkers for early AL detection. Therefore, this study was proceeded aiming to investigate the potential correlation of these markers with the manifestation of AL.
Materials and Methods: patients referring to the hospitals of Tehran University of medical sciences from November 2018 to January 2020 were evaluated for inclusion in the study and after obtaining informed consents, 277 cases were enrolled in the study. WBC, CRP, and PCT serum level were measured preoperatively and up to five days post operation and statistical correlation analysis was conducted using SPSS software (version 24).
Results: Among 277 cases, 14 manifested AL. Accordingly, the highest sensitivity and specificity for AL was for CRP at second and third post-operative days. PCT however indicated higher utility on the fourth post-operative day with 57% sensitivity, 56% specificity (p-value = 0.001 for the second day and 0.002 on the third day), and the negative predictive value was 96%. These numbers altered to 36%, 64%, and 95% respectively on the fifth post-operative day that sustains within the acceptable range (p-value = 0.018).
Conclusion: Both CRP and PCT devise the potential utility as a diagnostic biomarker considering the presence of AL and can remarkably accelerate the diagnosis period. To attain the highest sensitivity and specificity, CRP is to be used at the second and third post-operative days. The optimum utility for PCT however is on the fourth post-operative day