Nelaton catheter assisted versus standard nasogastric tube insertion: a randomized, clinical trial

It is sometimes difficult to insert a nasogastric tube in an anaesthetized patient. We evaluated the benefit of reinforcing the distal portion of the nasogastric tube with a Nelaton catheter: 8 and 10 French Nelaton catheters were inserted into 16 and 18 French nasogastric tubes respectively through the first proximal holes of tubes up to their tips. The patients anaesthetized were randomly allocated into either the control or the Nelaton groups, and nasogastric tube was inserted as deeply as the catheter length, then the catheter was withdrawn and the tube was inserted farther to reach the stomach. Eighty patients [40 in each group] were included in this study. The success rate of nasogastric tube insertion was 90% in the Nelaton group and 57% in the control group [P = 0.001]. The mean insertion time was 80 [SD 43] and 92 [SD 35] seconds in the Nelaton and the control groups respectively

case report of newborn with thrombocytosis born to an opioid-addict mother

Neonatal thrombocytosis is a very rare phenomenon in infants born to addict mothers. It can be due to opioids withdrawal and occurs a few days after delivery. The etiology is unknown and it is eradicated gradually without any complication. The reported neonate was born to a heroin addict mother who has used methadone during pregnancy. The neonate was admitted in 14th day of life in neonatal intensive care unit [NICU] with the diagnosis of withdrawal syndrome and supportive care was administered for him. Thrombocytosis was detected in routine lab tests. There was not any reason for it except his mother's addiction. The platelet count was 1,168,000 in the first day and decreased gradually during 28 days to 739,000. There was not any complication and no special treatment was administered. This case indicates that thrombocytosis may happen as a part of neonatal abstinence syndrome and is eradicated without any complication

[ effect of obesity on spinal anesthesia for cesarean section]

Obesity is a global health problem with an increasing prevalence which affects different medical and health care domains including anesthesia. The present study was carried out to answer the question of which anesthesia technique is proper in obese parturients. The aim of this study was to evaluate the effect of obesity on blood pressure reduction, amount and dose of ephedrine, and sensory level duration of spinal technique for cesarean section. In this cohort study the treatment group consisted of 40 expectant women with body mass index [BMI] of over 30, and the control group comprised of 40 expectant women with BMI of under 30, who were all candidate for elective cesarean section: In both groups 70 mg of Lidocaine was injected into spinal cord from L4-L5 space. Then the mean blood pressure, the amount and dose of ephedrine, sensory level of block and duration of spinal technique were measured. The collected data was compared by statistical tests. There was no statistical different in mean blood pressure reduction and sensory level of block between the two groups. Duration of spinal tap, amount and number of ephedrine injection were higher in obese cases. Relative risk of receiving two or more times of ephedrine was 1.63 times higher in obese expectant women than in normal women. Spinal anesthesia is an appropriate method for cesarean section in obese expectant women and blood pressure reduction can easily be controlled by ephedrine

[ 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

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

[Comparison of the sensory-motor block effects of low dose hyperbaric bupivacaine and lidocaine in anorectal surgery with spinal anesthesia]

Outpatient surgery can be performed by general or spinal anesthesia. Spinal anesthetic drugs have side effects. Many anesthesiologists choose general anesthesia, because of its relative predictability and to avoid undesirable side effects associated with spinal anesthesia. For example; lidocaine is frequently associated with Transient Neuroligic Symptoms [TNS]. Bupivacaine may cause urinary retention, prolonged discharge time and unpredictable level of anesthesia dependent on dose. Reducing bupivacaine dose will shorten the duration of action and its anesthesia level will be predictable in saddle block technique. This study was designed to assess the effects of hyperbaric, low dose bupivacaine in level of sensory block, duration of anesthesia and selective sensory block in an rectal surgery and its comparison with lidocaine. In a clinical trial study, 64 patients who were the candidates for anorectal surgery were divided in two groups randomly. In one group, hyperbaric bupivacaine 0.5% was injected in sitting position. The other group received hyperbaric lidocaine 5% in the same position. The patients were laid in lithotomy position after 5 minute. Blood pressure, pulse rate, severity of sensory and motor block, duration of anesthesia and tonicity of anal sphincter were recorded in two groups. The results were analyzed through T-test, chi square and variance analysis. Sensory level and anesthesia duration in bupivacaine group were higher than lidocaine group. Motor block degree and anal sphincter tonicity loss in lidocaine group were greater than the other one. Blood pressure decreasing in lidocaine group was significantly higher to bupivacaine group. The proper sensory level and short anesthetic duration of low-dose hyperbaric bupivacaine are comparable with lidocaine in saddle block position; and selective sensory block may be useful for anorectal surgery in lithotomy position

[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

Value and accuracy of fine needle aspiration cytolbgy [FNAC] in thediagnosis of breast masses

Breast cancer is the most common malignancy of the women and causes death inmany patients every year. About 70% of breast surgeries and biopsy taking are not necessarybecause they yield benign diagnosis. For diagnosing breast masses accurately and speciallydifferentiating benign from malignant tumors without surgery, Triple Test has been introduced.This project tried to evaluate the diagnostic value and accuracy of fine needle aspiration cytologyof the breast as the most significant element of this test. During a 3 years period, 120 females with the chief complaint of abreast mass being admitted in Mashhad Imam Reza Hospital were subjected to all components ofthe triple test followed by confirmatory open biopsy. In 100 patients all paraclinical procedureswere obtained and the results were available. FNA cytologic results were classified in three groups as benign, malignant andsuspicious for malignancy. Fifty-five patients had benign and 40 had malignant cytology whichwere confirmed by routine histopathology. From 5 patients with suspicious cytology, 2 yieldedmalignancy and 3 benignancy by tissue confirmation. FNA cytology of the breast is a well tolerated, simple, safe, accurate, cost effective,noninvasive, less complicated procedure and operable in office practice for diagnosing breastlesions, with an accuracy of about 100%, specially when it is employed in association withphysical exam and mammography in the triple test.Based on these results we strongly recommend application of this method as an ideal procedurefor breast diagnosis and elimination of open biopsy in our country, which certainly will result inexpenses reduction

[Factors influencing wound dehiscence in abdominal operation]

The purpose of this study was to review our clinical experience with abdominal wound dehiscence. During the 5-year period from [1997-2001], there were 2.761 major abdominal operations performed at the Department of Surgery Imam Reza Hospital. Mashhad, Iran. Twenty-one specific local and systemic risk factors were analyzed and compared with the control group. 31 [1%] abdominal wound dehiscence's occurred in 2.76 1 patients undergoing major abdominal surgery. Significant risk factors were found to include age over 65 year, wound infection, pulmonary disease, helnodynamic instability and ostomies through incision. Risk factors not found to be important included, sex, type of incision, type of closure, anemia-jaundice and diabetes. When dehiscence and control groups were combined 30% of patients with at least five significant risk factor developed dehiscence, and all the patients with more than eight risk factors developed a wound dehiscence.There was an overall mortality of 29% which was directly related to the number of significant risk factors. The coexistence of 9 risk factors portended death in one third of the patients, and all the patients with more than 10 risk factor died. Wound dehiscence carries a very high mortality rate and major morbidity. It is a dreaded complication that increases hospital stay and cost. We believe that serious consideration should be given to placing retention sutures in high risk patients to try to prevent evisceration and dehiscence. Serous drainage from a wound after surgery should alert the physician to possible wound dehiscence

Management of nipple discharge by clinical finding

Management of nipple discharge by clinical finding. All of the data on patients referred for nipple discharge in period from 1990-2000 at the Department of Surgery IMAM REZA Hospital were reviewed. The breast nodularity and duct ectasia was seen in 73% of patients. The age of the patient in this group was 30-40 years. Only 10 of 249 patients [5%] who presented with nipple discharge were proved to have carcinoma of the breast. Breast nodularity and duct ectasia is the most cause of nipple discharge [73%]. Nipple discharge was not commonly associated with carcinoma and when it was the carcinoma was almost always palpable

study of 73 patients with liver trauma

Introduction: liver is one of the most injured organs in trauma. We evaluated and grouped the degree of liver trauma and management of each group

Material and Methods: 73 patients with liver trauma admitted in sugery departement from 1992-2002. The patients' informations were written in special forms

Results: 58 male and 15 female, mean age of 30 years. [6-68 years] presenting from 1992-2002 were reviewed. There were 29 cases of penetrating injury and 44 cases of blunt trauma. 7 patient were successfully managed without operation [5 with blunt injury] and were discharged after a mean hospital stay of 7 days. 51 cases were classified as group A [grade 1 and 2] and were managed by suture [with or without drainage], with 3 deaths. 15 cases were classified as group B [grade 3 and 4] and underwent one or more of the following: peri hepatic packing, resectional debridement and hepatotomy with direct suture ligature. 6 of these died from uncontrolled hemorrhage

Conclusion: Judicious clinical assessment and radiological monitoring may reduce the number of unnecessary laparatomies

Pregnancy and abdominal surgery review of 90 cases

Objective: intraabdominal surgical disease during pregnancy can present a challenge in diagnosis and management for the obstetricians and surgeons

Material and Method: we retrospectively studied all pregnants patient over a 15-year period who had undergone abdominal surgery

Results: a total of 92 abdominal operations were performed on 90 patients. Thirty-seven patients were operated on for acute appendicitis; 20 were operated on for ovarian abnormalities. There were two maternal deaths. The most common postoperative complication was premature labor [21%]. There were five fetal deaths

Conclusion: intraobdominal surgery during pregnancy carries an acceptable risk to the mother and fetus. Complications are related to severity of the disease and operative delay rather than to the operative procedure itself

study of possible relationship between vitamin A and some hematopoietic factors

In a survey of 148 subjects [72 females and 76 males] in 3 villages and one city in Isfahan province, plasma vitamin A, hemoglobin concentration and hematocrit were determined in all subjects, and serum iron was measured in 19 persons, in order to investigate the possible relationship between vitamin A and hematopoietic factors. A positive correlation existed between plasma vitamin A and hemoglobin concentration. People with acceptable hemoglobin values had significantly higher plasma vitamin A levels compared to those with less-than-acceptable hemoglobin values. A direct correlation between plasma vitamin A and serum iron was also observed. The evidence gathered in this study supports the hypothesis that there is a direct relationship between anemia and vitamin A status of the subjects