Enterocolic fistula in GI lymphoma: a case report

The following case describes a young patient with failure to thrive and new-onset diarrhea who underwent upper GI series. The findings on upper GI series revealed an enterocolic fistula. Laparatomy was performed and the persistent pathology was lymphoma

Necessity of bilateral chest tube insertion, after transhiatal esophagectomy in esophageal cancer

Esophageal dysfunction occurs due to various disorders such as benign or malignant tumors, perforations, and motility disorders. Esophagectomy is considered as the final option for treatment of the diseases. Except malignant cases, in which lymphatic dissection is considered, transhiatal esophagectomy is the appropriate procedure for the esophageal cancer. Avoidance of thoracotomy and thoracic anastomosis are of advantages which reduces morbidity and mortality rate in transhiatal esophagectomy. In the procedure, pleural drainage through bilateral tube thoracostomy is routinely recommended. The aim of the study was to evaluate application of routine thoracostomy and to find specific criteria concerning chest tube insertion. This descriptive study was performed from 2001 to 2005 in General Surgery Department of Imam Reza Hospital, Participants included 123 patients who underwent transhiatal esophagectomy. Blood sampling, Chest radiography, abdominal ultrasonography, barium swallow, cardiopulmonary function tests, and upper GI endoscopy was carried out for all patients. Individual, radiography and laboratory findings, post operation complications and mortality were collected in a questionnaire and analyzed by the descriptive statistics and frequency distribution tables. Patients, 84 male [68.3%] and 39 female [31.7%], with mean age of 57.7 years underwent transhiatal esophagectomy. Clinical diagnosis of 94% of cases was squamous cell carcinoma [S.C.C.]. Surgical complications included rupture of azygous vein in 1 case, chylothorax in 2 cases, right main bronchial injury in 1 case, anastomosis fistula in 2 cases, and wound infection in 4 cases. Chest tube insertion was performed in 41 cases [33.3%] at the end of operation, and in 19 cases [15.4%] postoperatively. Volume drainage >/= 400cc was reported in 29% of patients and tube duration >/= 4 days in 51% of patients. Transhiatal esophagectomy which was inaugurated in 1933 is a less morbid procedure among various approaches of esophagectomy. Bilateral chest tube insertion can cause less movement of the patient and respiratory distress, and rise surgical complications including thromboemboli, empyema, atelectasis, and lung infection. According to the results of this study, tube thoracostomy is indicated for following reasons: a. high volume of intraoperative mediastinal bleeding, b. pleural effusion irrelevant to the operation, c. postoperative respiratory distress along with pleural effusion, and d. asymptomatic high volume of pleural fluid

study on the survival of allograft in patients with major burn injuries at Imam Reza Burn Center

In the treatment of patients with severe burns, it is a matter of urgency to achieve definitive and total wound closure in order to avoid the metabolic abnormalities and septic complications of an open wound. In the absence of autologous skin, allograft skin is the best alternative for wound coverage. The purpose of this study was to evaluate survival of allograft in major burn injuries. This cross- sectional descriptive study, carried out from 2004 to 2006 on seventeen female patients with severe burns, ranged from 60% to 90% total body surface area in Imam Reza Burn Center. Allograft was used for wound coverage from first degree relatives, and patients were followed up for six months. Data were recorded in a questionnaire and analyzed by descriptive statistics and frequency distribution tables. Twenty two allografts were used in the course of treatment of 17 severely burned patients. Five patients [29%] had two allografts and 12 patients [71%] had one allograft. In 9 patients [53%] rejection of transplanted skin was observed. In 3 cases [18%], rejection in one of the allografts was observed, while in 5 patients [29%] the total transplanted skin was rejected. Allograft is an effective alternative treatment to resurface major burns in case of limited auto skin graft donor site, and the percent age of rejection was much lower than the other studies

[Comparison between finger bougie of the pylorus and pyloroplasty or pyloromyotomy in gastric pull-up esophageal surgery]

In gastric pull-up esophageal surgery, functional obstruction of the pylorus is seen in almost 20% of patients. The purpose of this study was launching finger bougie of pylorus instead of traditional pyloroplasty or pyloromyotomy. This descriptive study carried out from 2002 to 2004 on patients, admitted to the Department of General Surgery of Imam Reza Hospital, Mashhad. Of 58 patients with esophageal cancer, who underwent gastric pull-up esophageal surgery, pyloroplasty or pyloromyotomy was randomly performed on 31 cases [group A], and finger bougie of pylorus [group B] on 24 patients. On the 9[th] day postoperatively static function of pylorus was evaluated with gastric emptying study. Based on emptying time of the stomach, patients were divided into normal, delayed drainage and complete obstruction groups. Using a questionnaire, individual characteristics, surgical outcome and results of gastric emptying scan were recorded and analyzed by descriptive statistics, frequency distribution tables, Chi-2 and Chi- Square tests. Of patients, 58 with average age of 58 years old were evaluated from these. 40 cases [69%] were male and 18 cases [31%] were female. Pyloric operations were finger bougie in 31 cases [53/4%], pyloromyotomy in 24 cases [42/4%], and pyloroplasty in 2 cases [3/4%]. In 1 case [1/7%] pylorus was intact.Complications were, wound infections in 8 patients [13/8%], cervical fistula in 2 [3.4%] thoracic fistula in 1 [1.7%], chylothorax in 3 patients and tracheal injury in 1 patient. Gastric emptying time was measured in 53 patients with TC99 scanning. The result was normal in 44 cases [75/9%], delayed in 8 cases [13/8%], and gastric outlet obstruction in 1 [1/7%]. Although transhiatal esophagectomy is considered as a palliative procedure, some surgeons prescribe it for all stages of the disease. Most of tracheal injuries are in membranous portion. In small tearing, conservative management with bypassing the site of injury by endotracheal or tracheostomy tube was recommended. Surgery is suggested in large tear or failure of conservative therapy. The first recommendation for fistula in cervical anastomosis is conservative. Early surgery is suggested in complete disruption, non responsive patient after 3 weeks, and intra thoracic fistula. In the present study the results of gastric emptying test in group A [finger bougie of pylorus] and group B [pyloromyotomy or pyloroplasty] were compared. Finger bougie of pylorus in gastric pull-up surgery is preferred and suggested

[ comparison between results of topical nitroglycerin ointment and sphincterotomy in chronic idiopathic anal fissure]

Chronic anal fissure is a common problem, and there are different ways for treatment. The goal of this study was to compare the effectiveness and complications of topical nitroglycerin with internal sphicterotomy in the treatment of chronic anal fissure. This randomized clinical trial study was performed from 2002 to 2005 at Imam Reza Hospital, Mashhad, Iran on 200 patients with symptomatic anal fissure, who randomly categorized into two groups of case [n=100] and control [n=100]. The case group [A] treated with nitroglycerin ointment%0.2 twice a day for 6 weeks and the control group [B] recieved sphincterotomy. Individual, surgical and medical results data were recorded in the questionnaire. Data analyzed using descriptive statistics, frequency distribution tables, and Fisher test. after 6 weeks of treatment, results showed that healing was not significantly different between the two groups, but after 6 months, difference was significant [p=0/11]. Surgical group healed 100%. Headache in medical group was more noticable than the other group [p<0/001]. But hypotension attack, palpitation, dizziness, and vomiting were not considerably different between the two groups. Internal sphincterotomy is superior to topical nitroglycerin in treatment of chronic anal fissure, with a high rate of healing, few side effects, and low risk of early incontinence

[Polypoid lesions of the gallbladder in Emam Reza hospital in Mashhad]

Polypoid lesions of the gallbladder encompass a wide variety of pathology. Although most of these lesions are benign, some early carcinoma of the gallbladder do present as polypoid lesions. Problems remain in selecting patients with polypoid lesions of the gallbladder for surgery. 411 patients underwent cholecystectomy for gallbladder disease in the department of surgery, Imam Reza hospital between 1995 and 2000. Benign polyps were present in 32 gallbladders and malignant polyps in 8 patients. Clinical data, age and sex distribution, symptoms and evaluation of preoperative diagnosis were correlated with the pathology of polyps were reviewed. In 411 patients undergoing cholecystectomy benign polyps were present in 32 gallbladder and malignant polyps in 8. Cholesterol polyps account for most of benign lesions and all malignant lesions were adenocarcinoma. Gallstone coexisted in 50% of malignant lesions. 69% of patients with benign lesions were under 60 years, whereas 75% of malignant lesions were over 60 years. 94% of benign lesions were less than 10 mm in diameter, while 88% of malignant lesions exceeded this size. Most small polypoid lesions of the gallbladder are benign and remain static for years. Age more than 60 years and polyp size more than 10 mm are the most important factors predicting malignancy in polypoid lesions of the gallbladder. Other risk factors include concurrent gallstone, solitary polyps and symptomatic polyps. Cholecystectomy is the treatment of choice

[Treatment of penetrating lung parenchyma injuries]

Reports of military injuries have advocated early thoracotomy and aggressive management of pulmonary injuries with resection; which opposed to the more conservative and traditional treatment with chest tube thoracostomy in civilian trauma. This study is done in order to study the result of urban lung injury treatment. A retrospective descriptive study was performed in the General Surgery Department of Imam Reza Hospital during the years 1382 - 1383, to determine the incidence of thoracotomy and lung resection in civilian injuries and to evaluate the effective treatment of these injuries in 1168 patients. Indications of thoracotomy were: 1- Air leakage after 2 weeks, 2- drainage of more than 1500 cc blood after tube thoracostomy, 3- Bleeding speed more than 200cc/hour, 4-Massive air leakage with collapsed lung. All patients with mediastinal or heart trauma were excluded from this study. Personal, laboratory and treatment data were recorded in the quastionare. Data was Analyzed using qualitive statistics and frequency distribution tabels. Between 1368-1382 in a series of 1168 patients, there were 384-gunshot wound and 784-stab wound to the thorax. 283 patients with gunshot wound [74%] and 602 with stab wound [77%] were treated with chest tubes alone. 68 patients [9%] of the total required operative thoracotomy. Pulmonary resection was done in 18 patients [9 wedge resection, 6 lobectomy and 3 pneumonectomy]. Mortality rate for all injuries was 2/3%, 0.7% for those treated with chest tube alone, 30% for pulmonaryhilar injuries which led to pneumonectomy, 8.6% for sewed parenchymal injuries and 28% for lung resection. Most civilian lung injuries can be treated by tube thoracostomy alone. Only 15-30% will require thoracotomy, among those most injuries can be handled by simple over - sewing of the lung. Some patients may require pulmonary resection because of sever tissue destruction, in these injuries lobectomy may be performed

Transthoracic versus transhiatal esophagectomy

Due to our geographical area of living, esophageal cancer is one of the most common cancers in gastrointestinal system. Treatment of choice in these diseases is surgery. Because of various kinds of surgical techniques, in this study we tried to compare common techniques in these groups of patients. In a retrospective study between 1990 and 2005 all patients with esophageal cancer in middle and distal third of esophagus whom underwent transhiatal or transthoracic esophagectomy, have been studied about age, sex, pathology of tumor and tumor staging. Then in other study, with considering special parameters of two groups [transhiatal or transthoracic] are studied separately about factors such as intraoperative bleeding, operation time, post-operation morbidity, time of hospitalization, mortality 30 days after surgery, incidence of anastomosis leak and stenosis and survival have been evaluated. 156 patients entered our study with M/F=110/46 ratio. 116 patients with S.C.C and 40 patients with adenocarcinoma. The comparing study between transhiatal groups with Ivor Lewis groups [with similarization] showed intraoperate bleeding, cardiac and pulmonary complications after surgery, mean time of hospitalization, mortality in 30 days after surgery and incidence of late stenosis and survival are similar but the incidence of anastomosis leakage was higher in transhiatal group and mean operation time was longer in Ivor Lewis group. Since the leakage was more common in transhiatal group but mortality rates were the same, it indicates that leaking in neck has a better outcome. According to the results of this study, both of these techniques are similar and choosing one of them depends on surgeon's choice and patient's conditions