Laparoscopic gastric plication: A long-term follow-up and comparison of outcomes in severe vs. non-severe obesity.

BACKGROUND: LGGCP is a non-gastrectomy, restrictive bariatric technique. This study aims to assess its long-term efficacy. METHODS: This is a retrospective cohort study on LGGCP patients (2010-2019) from a single tertiary center, followed for up to 60 months. RESULTS: Ninety-four patients with obesity were included in the study. The mean five-year postoperative BMI was 32.00. Excess weight loss (EWL): 30%-50% and EWL<30% occurred in 16 and 9 cases, respectively. The mean EWL was higher at 3-, 6-, and 12- months post-operation in patients with a BMI<40. Weight regain was 46.3% at the five-year follow-up. Eighty-seven patients had associated comorbidity, and 76 had improved in at least one of their comorbidities. Sixteen patients (17.0%) experienced complications. CONCLUSION: LGGCP is safe and effective, with benefits in patients with BMI<40. Thus, we suggest the usage of LGGCP, especially in this group of patients, due to its less-invasive nature and acceptable cost-benefit. Further studies with larger sample sizes are required for validation.

One anastomosis gastric bypass surgery in Type2 diabetes patients with body mass index < 35 kg/m2: A multi-center retrospective cohort study.

Introduction: Bariatric surgeries have shown efficacy in weight reduction, glycemic control and improvement of type-2 diabetes (T2DM) in patients with obesity. We aimed to assess the efficacy of one anastomosis gastric bypass surgery (OAGB) in T2DM patients with body mass index (BMI) < 35 kg/m2 within a year after surgery. Methods: In this multicenter retrospective cohort study, 14 T2DM patients with BMI <35 kg/m2 (females, %: 71.4% (10 of 14), and age, mean (standard deviation): 51.2 (12.3) years) who had underwent OAGB surgery by the same surgeon, were followed at intervals of one, three, six, and 12 months after surgery. The remission rates of T2DM were calculated and the metabolic indices were compared using paired t-test and Wilcoxon rank test. Results: No adverse outcomes were detected 12 months after surgery. Within six months, seven (50%) patients underwent remission (one (7.1%) within one, three (21.4%) within three, and three (21.4%) within six months). Post-operative weight (p < 0.001) and fasting blood glucose (p < 0.01) in all time periods were significantly lower compared to pre-operative values. Hemoglobin A1C (HbA1C) was significantly lower at three- and six-month intervals (p < 0.05) but not at twelve months (p = 0.2). Thyroid-stimulating hormone and triglyceride levels were lower at six months compared to pre-surgical levels (p < 0.05) but cholesterol levels were not different in any of time points (p > 0.05). Conclusion: OAGB surgery is associated with weight reduction, glycemic control and a 50% remission rate within six months in patients with diabetes and BMI <35 kg/m2.

Laparoscopic sleeve gastrectomy in a patient with Situs Inversus Totalis: A case report and literature review.

Introduction: & Importance: Laparoscopic sleeve gastrectomy (LSG) is a widely accepted and effective bariatric surgery for achieving weight loss in patients with extreme obesity. Performing this surgical procedure in patients with congenital anatomical changes including situs inversus (SI) is a challenge for the surgical team. In this condition, the orientation of intra-abdominal organs is the mirror image of those in normal populations. Case presentation: Herein, we present a 29-year-old female with situs inversus totalis who successfully underwent an LSG surgery with proper weight loss post-operatively and no early and late complications. Clinical discussion: By reviewing the literature for patients with SI undergoing the same procedure, all patients achieved significant weight loss. Three out of nineteen cases experienced complications which were controlled without significant morbidity or mortality.Conclusion: we concluded that LSG will be a safe and effective surgery for the treatment of extreme obesity in SI patients, if the condition is diagnosed preoperatively.

Short-Term Changes on Body Composition After Sleeve Gastrectomy and One Anastomosis Gastric Bypass.

Introduction: Changes in body composition after different bariatric surgeries have been studied extensively, but most of them have emphasized on Roux-en-Y gastric bypass. Only a few studies have assessed the effects of sleeve gastrectomy (SG). Also, the effect of one anastomosis gastric bypass (OAGB) on body composition is not fully apprehended. Furthermore, there is no agreement on how much fat-free mass (FFM) loss is tolerable in weight loss interventions. Therefore, we decided to assess the reduction in fat mass (FM) and FFM at 1, 3, 6, and 12 months after two types of bariatric surgery in a single center. Methods: In the current retrospective cross-sectional study, the patients' hospital records were analyzed. We included patients who had SG or OAGB and a complete 1-year follow-up record. We recorded demographic data as well as weight, body mass index (BMI), FM, and FFM before and at 1, 3, 6, and 12 months after surgery in a predesigned checklist. Results: We analyzed 311 patients (43 males and 268 females) in the SG (N = 192, 61.7%) and OAGB (N = 119, 38.3%) groups. Both the SG and OAGB groups demonstrated a statistically significant reduction in weight, BMI, FM, and FFM indices at 12 months after the intervention (P < .001). Moreover, no statistically significant difference was observed between the SG and OAGB groups regarding the mean of all body composition indices at 3, 6, and 12 months after the intervention. Conclusion: We found that SG and OAGB effectively decreased weight and body composition indices, comprising FM and FFM, with no significant difference between each other.

The Role of Fundoplication after Laparoscopic Heller Myotomy in Reducing Postoperative Symptoms in Patients with Achalasia: A Controlled Clinical Trial.

Background: Laparoscopic Heller myotomy (LHM) is considered the standard surgical approach in patients newly diagnosed with achalasia worldwide. However, proceeding to fundoplication after LHM remains controversial due to the observed postoperative symptoms, including dysphagia and regurgitation. This study was conducted to compare the postoperatively experienced regurgitation and dysphagia between those undergoing LHM with fundoplication and those with mere LHM. Methods: This four-year controlled clinical trial was performed on adult patients with esophageal type two achalasia, referring to the Shariati Hospital, who gave their written informed consent to enroll. The diagnosis of achalasia was confirmed using manometric assessments. The control group underwent LHM with fundoplication, while the cases received LHM without fundoplication. The validated Achalasia Patients Questionnaire was used for assessing the experienced symptoms pre- and postoperatively. Also, esophagography was used to investigate the alterations of the symptoms pre- and postoperatively. Results: A total of 48 patients were evaluated. 23 were assigned to the case group, while 25 were considered the controls (male to female ratio: 25 to 23). The mean age of the patients was 36.94 years, and the average disease duration was 6.22 years. Cases and controls were matched demographically. There was no statistically significant difference between the cases and controls regarding postoperative active or passive regurgitation or dysphagia to either solids or fluids. Also, the mean score of total clinical symptoms after the surgery was not significantly different between cases and controls. Lastly, esophagography revealed significant improvement regarding all the symptoms postoperatively (P=0.001); however, no statistically significant difference existed in this regard between cases and controls. Conclusion: Our results indicate no significant difference regarding the postoperative achalasia-related symptoms, namely regurgitation and dysphagia, between those patients undergoing LHM with and without fundoplication. However, further studies are required to thoroughly investigate the effects of various fundoplication techniques in relation to all achalasia-related symptoms to confirm these results.

Investigating the Factors Affecting the Development of Biliary Pancreatitis and Their Relationship with the Type and Severity of Complications.

BACKGROUND Pancreatitis is an inflammation of the pancreatic tissue. Gallstones are known to be the most common cause of acute pancreatitis, especially in eastern countries, including Iran. Pancreatitis, in its course, can cause complications for the patient. Different systems have been identified as predictors of the severity of acute pancreatitis. As a result, we decided to examine the factors influencing the severity of biliary pancreatitis and their relationship with the complications in Iranian society. METHODS The present study is a cross-sectional, analytical study that was performed retrospectively on 160 patients with biliary pancreatitis. The main and dependent variable in this study is the severity of pancreatitis, which is divided into two groups of complications (local complications and systemic complications) and without complications. The necessary information was extracted from the patients' files and evaluated with SPSS software version 22. RESULTS Based on the results of single-variable analysis, there was a significant relationship between the patient's age, sex, Ranson and CRP criteria, and complication of the disease. In the univariate analysis, no significant statistical relationship was found between patients' BMI(Body Mass Index), CBD (common bile duct) size, serum alkaline phosphatase level, gallstone size, and FBS(Fasting blood sugar), and the complications of the disease, based on the multivariate analysis results. CONCLUSION The results of this study showed that four variables of the female sex, stone size, CRP, and high score of Ranson criteria act as independent risk factors in the development of complicating biliary pancreatitis.

The Comparison of Postoperative Pain, Nausea, and Vomiting between Veress Needle Entry and Direct Trocar Entry Methods in Patients Undergoing Laparoscopic Cholecystectomy.

BACKGROUND Postoperative pain, nausea, and vomiting are the most common side effects of laparoscopic cholecystectomy (LC). In the present study, we investigated the differences in postoperative pain, nausea, and vomiting between Veress needle and direct trocar entry methods among patients undergoing LC. METHODS 96 patients with gallstones were studied. They were randomly divided into two groups: the patients in the first group (n = 48) were insufflated 8.1 liters per minute CO2 gas by direct trocar port, and the patients in another group (n = 48) were insufflated 2.1 liters per minute CO2 gas by Veress needle. Pain intensity, nausea, and vomiting were assessed at 20 minutes, 4 hours, and 12 hours after the operations. RESULTS The duration of CO2 gas insufflation in Veress needle was 88.7 ± 10.7 seconds and indirect trocar was 16.6 ± 1.6 seconds. Visual analog scale (VAS) score significantly reduced in Veress needle compared with direct trocar (0.39 ± 0.98 vs. 1.68 ± 1.48) at 20 min after the operation, while there was no difference at 4 hours and 12 hours after the operation. The requirement and dose of pethidine injection were significantly lower in Veress needle than direct trocar. In addition, nausea and vomiting occurred in Veress needle less than direct trocar at 20 min, 4 hours, and 12 hours after LC. CONCLUSION Pain intensity just in the short term after LC in the group with CO2 gas insufflation in Veress needle was significantly less than the other group, while nausea and vomiting were significantly less during the whole follow-up periods in the group with CO2 gas insufflation in Veress needle.

Effect of Laparoscopic Sleeve Gastrectomy vs. OAGB on Thyroid Function Tests in Patients with Morbid Obesity and Subclinical or Clinical Hypothyroidism.

PURPOSE: As one of the major problems for the health sector, morbid obesity is associated with many hormonal dysfunctions, including thyroid hormone disorders. Few studies have been performed on improving subclinical and clinical hypothyroidism following bariatric surgery. Therefore, we designed and conducted this study to evaluate the effect of various types of bariatric surgery on thyroid hormone levels and to assess the change of levothyroxine requirement in these patients. METHODS: The data of all patients who underwent either sleeve gastrectomy (SG) or one-anastomosis gastric bypass (OAGB) surgery in the 5 years from 2016 to 2020 at our hospital were analyzed retrospectively. RESULTS: From 1486 patients (792 cases of SG and 694 cases of OAGB), 281 patients had preoperative abnormal thyroid function tests: subclinical hypothyroidism (102 patients) and clinical hypothyroidism (179 patients). The T4 level did not change significantly in any of the groups and subgroups. However, the TSH level at the end of the sixth month after SG and OAGB in both groups significantly lowered. Nevertheless, there is no significant difference between the effect of SG and OAGB surgical procedures on the rate of TSH and T4 alterations in both subclinical and clinical hypothyroid patients. In the sixth month after surgery, 49% of clinically hypothyroid patients in the SG group (n = 179) reduced or stopped taking the medication. CONCLUSION: Whereas bariatric surgery reduces TSH levels, it does not significantly alter T4 levels. Furthermore, there is no apparent difference between subclinical and clinical hypothyroidism and different types of bariatric surgery.

Modulation of the Gut Microbiota and Serum Biomarkers After Laparoscopic Sleeve Gastrectomy: a 1-Year Follow-Up Study.

PURPOSE: Bariatric surgery is a treatment option for those affected by severe obesity. This study investigated changes in gut microbiota and serum biomarkers after laparoscopic sleeve gastrectomy (LSG). MATERIALS AND METHODS: A total of 126 patients with morbid obesity who underwent LSG were enrolled in this study. Routine biochemical tests, hormonal (insulin and glucagon), and cytokine levels (IL-6, IL-1ß, TNF-α, IL-10, and TGF-ß 1) were measured, in addition, real-time PCR (quantitative PCR, qPCR) quantitated gut microbiota. All the parameters were measured pre-operatively, 3, and 12 months post-surgery (F0, F3, and F12, respectively). RESULTS: At F3, the level of FBS, HbA1c, HOMA-IR, triglyceride, cholesterol, LDL, BUN, creatinine, urea, SGOT, SGPT, IL-1ß, IL-6, IFNγ, insulin, glucagon, the abundance of Prevotella and Bacteroides fragilis group, as well as the concentration of Firmicutes spp. showed significant decrease (P < 0.01), and HDL level, Akkermansia muciniphila and Roseburia spp. abundance, and Bacteroidetes and Bifidobacterium spp. concentration showed significant increase (P < 0.0001). The observed pattern continued or remained stable at F12 for all of these variables. IL-10 and TGF-ß1 remained unchanged until F3 and showed a significant drop at F12. At F3, Clostridium cluster IV increased significantly and remained at that level afterward. Moreover, concentration of Phylum Actinobacteria showed an initial drop at F3 and a later increase at F12 (P < 0.0001). CONCLUSION: LSG is associated with a significant improvement in serum biomarkers, as well as significant changes in fecal microbiota. Future systems biology analyses would shed more light on the underlying interactions of these parameters, and could help in developing novel diagnostic and therapeutic strategies for obesity management.

Postoperative Outcomes and Advantages of Hand-Sewn Laparoscopic One-Anastomosis Gastric Bypass: Experience on 805 Patients.

PURPOSE: One-anastomosis gastric bypass (OAGB) is a novel laparoscopic approach. The anastomosis of OAGB can be sewn either with a stapler or manually. The aim of this study is to determine the outcome of hand-sewn OAGB. MATERIALS AND METHODS: A total of 805 consecutive patients were retrospectively enrolled in this study. Data collection included change in weight, body mass index (BMI), symptoms, and complications before surgery and continued during annual follow-up visits up to 5 years. Inclusion criteria were patients with a BMI of higher than 40 kg/m2 or higher than 35 kg/m2 with one severe comorbidity. Patients with BMI > 50 kg/m2 were referred to dieticians. RESULTS: The follow-up rate ranged from 93 to 50% at the 1-year and 5-year visits after surgery, respectively. Mean weight and BMI of patients before surgery were 121.93 kg (± 22.92) and 44.79 kg/m2 (± 6.07), respectively. Mean of annual BMI in 5 years of follow-up were 27.83, 27.26, 28.90, 29.45, and 29.56 kg/m2. Excess weight loss (EWL) in 5 years of follow-up were 85.7%, 89.5%, 78.9%, 77.7%, and 76.0%. Reflux was present in 202 patients (25.1%) before surgery and resolved in 153 cases (75.7%) 1 year after surgery. Procedure-specific early complication was an anastomosis leak in one patient, which led to death. Two cases of malnutrition necessitating reversal and two severe reflux disorders leading to Roux-en-Y bypass surgery were remarkable late complications. CONCLUSION: Hand-sewn anastomosis could represent an efficient and safe technique in the management of patients undergoing OAGB surgery with acceptable outcomes and rare adverse complications.

The Effect of Laparoscopic Sleeve Gastrectomy and Gastric Bypass Surgery on Non-Alcoholic Steatohepatitis in Iranian Patients with Obesity.

BACKGROUND Non-alcoholic steatohepatitis (NASH) is a serious comorbidity in patients with obesity and because of the high risk of cirrhosis and the extreme mortality rate of NASH, approaching effective treatment methods, and improvements are crucial. Following few studies comparing the impact of laparoscopic gastric bypass (LGB) and laparoscopic sleeve gastrectomy (LSG) surgery on NASH, our study was conducted to assess the effect of these two surgical methods separately in patients with NASH through ultrasonography, and concurrently, on other factors such as lipid profiles and blood pressure to reduce the complications of complex obesity surgeries on patients and also provide a solution to prevent NASH-related cirrhosis. METHODS This study was performed at Imam Khomeini Hospital Complex; Vali-e-Asr Hospital affiliated to Tehran University of Medical Sciences.All patients with obesity who had undergone bariatric surgery at Vali-e-Asr Hospital during 2017 and 2018 were included in this prospective cohort study. Weight, body mass index (BMI), blood pressure, Alanine transaminase(ALT), Aspartate transaminase(AST),lipid profile and Fasting blood sugar(FBS)were evaluated before and one year after surgery. The patients underwent an ultrasound examination before surgery to determine the fatty liver grade. The type of operation (sleeve or bypass) was governed by the patient him/herself after receiving thorough clarifications about the available methods, their complications, and expected outcomes. In addition, by the separation of fatty liver grading with ultrasound modality, the correlation between ultrasound grading, laboratory results, and the rate of weight loss in patients who undergone both sleeve and bypass surgeries were evaluated and compared during a one-year follow-up. RESULTS In this study, 44 patients were included. 22 patients underwent laparoscopic sleeve gastrectomy (LSG), and 22 patients underwent laparoscopic gastric bypass (LGB) surgery. The mean age of the patients was 40.45 ± 12.01 years. 35 patients (79.5%) were women, and 9 patients (20.5%) were men. Most patients (81.8%) had grade I and II in terms of preoperative liver ultrasonography results. Bariatric surgery (LSG and LGB) greatly enhanced NASH's hepatic status in liver ultrasonography. Since the liver status of patients with preoperative ultrasonography was not significantly different between the two groups, there was no substantial distinction among the two groups in this regard, postoperatively. Weight and BMI, lipid profile, liver enzymes, FBS, and mean arterial blood pressure (MAP) were significantly reduced individually in both groups and all patients one year after surgery. None of the postoperative variables and their modifications had a prominent difference between the two groups except for High-density lipoprotein(HDL)level after surgery. The postoperative HDL was considerably higher in the LGB group (p = 0.014). However, the changes in HDL were not statistically different between both groups. The levels of AST, ALT, total cholesterol, LDL, and FBS were associated with the NASH grade. CONCLUSION Both types of LSG and LGB bariatric surgeries have been shown to significantly reduce BMI and improve lipid profiles, liver enzymes, and blood glucose levels in patients one year after surgery. The NASH status was also ameliorated considerably. The two types of surgery were not remarkably different in these modifications. Besides, there was a significant correlation between AST, ALT, total cholesterol, LDL, and FBS levels with the NASH grade.

Gut Microbiota and Serum Biomarker Analyses in Obese Patients Diagnosed with Diabetes and Hypothyroid Disorder.

Background: Variations of serum biomarkers and bacterial diversity of the gastrointestinal tract in obese patients with diabetes or hypothyroid are poorly understood. The aim of this study was to provide recent findings in this regard. Methods: A total of 119 obese patients [17 with diabetes, 23 with hypothyroid, and 79 patients without either diabetes or hypothyroid (control)] were recruited in this study. Serum biomarkers such as biochemical, hormonal (insulin and glucagon), and cytokine levels [interleukin (IL)-6, IL-1ß, tumor necrosis factor-alpha, IL-10, and transforming growth factor beta-1 (TGF-ß1)] were measured under fasting conditions. Bacterial abundance of gut microbiota was also quantitated by real-time polymerase chain reaction using 16S rRNA gene-based specific primers. Results: Average value of blood sugar (P: 0.0184), hemoglobin A1c, insulin, homeostasis model assessment insulin resistance, TGF-ß 1, IL-6, IL-1ß, interferon gamma (Pfor each < 0.001), and phylum Actinobacteria [odds ratio (OR): 1.5, P: 0.032] was significantly higher in diabetic versus control group. In contrast, the levels of IL-10 (P < 0.001), Firmicutes (OR: 0.6, P: 0.058), and Akkermansia muciniphila (OR: 0.4, P: 0.053) were significantly lower in diabetic versus control group. However, there was no statistically significant difference between the values in hypothyroid versus control group either in crude or adjusted models. Conclusion: While there are some relationships between serum biomarkers or bacterial abundance with diabetes prediction in obese patients, this prognostication is less likely in obese patients with hypothyroid. Further investigation is warranted in the application of identified preclinical biomarkers in the diagnosis of diabetes or hypothyroid in obese patients.

Positional Vertigo and Unilateral Gradual Hearing Loss Following Sleeve Gastrectomy: A Case Report.

Laparoscopic sleeve gastrectomy (LSG) is an effective treatment option in patients with morbid obesity, with rare long-term sideeffects. In this report, we present a 42-year-old woman who reported positional vertigo and unilateral gradual hearing loss plus continuous tinnitus after LSG. The patient had no signs or symptoms of mental health disorders and the results of the haematological and serum biochemical tests were normal. However, audiometric test revealed mild sensorineural hearing loss with magnitude in high-frequency tones. Also, acoustic reflex threshold showed neural pathway damage, particularly at high frequencies, with no reflex. Pure tone audiometry showed signs of nerve damage in the inner ear. One possible justification for these complications might be eustachian tube dysfunction due to muscle relaxation. Muscle relaxation itself may occur as a result of adipose tissue loss around the ear muscles. Further evidence, however, would be required to better determine whether these complications are attributable to LSG, and to illuminate exact underlying reasons for such complications.

Socio-demographic Characteristics, Biochemical and Cytokine Levels in Bulimia Nervosa Candidates for Sleeve Gastrectomy.

BACKGROUND: Eating disorders (EDs) are widely known by abnormal eating behaviors associated with significant medical complications. Bulimia nervosa (BN) is an eating disorder characterized by uncontrolled episodes of overeating typically followed by some form of compensatory behaviors. We aimed to determine the relationships between socio-demographic characteristics, biochemical markers, and cytokine levels in BN candidates for laparoscopic sleeve gastrectomy (LSG). METHODS: A case-control study was designed among 76 BN participants of Iranian descent who were candidates for LSG based on defined criteria for Bulimia by Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The healthy control subjects (n = 42) were selected at random from academic staff in the college. Moreover, levels of biochemical parameters and serum cytokines were measured in serum samples. RESULTS: Routine consumption of caffeine (odds ratio [OR] = 3.1, 95% CI: 1.23-6.41, P = 0.013), tobacco (OR = 1.8, 95% CI: 0.67-3.57, P = 0.03), and alcohol (OR = 3.6, 95% CI: 0.84-7.18, P = 0.048), and depression history (OR = 2.8, 95% CI: 0.76- 5.79, P = 0.037) were substantially more common among patients with bulimia. Also, the serum levels of fasting blood sugar (P < 0.001), HbA1c (P = 0.04), cholesterol (P = 0.03), triglycerides (P = 0.01), blood urea nitrogen (P = 0.03), and pro-inflammatory cytokines including IL-1ß, IL-6, and TNF-α were significantly higher in BN candidates for LSG (P ≤ 0.001). CONCLUSION: Our findings reveal that lifestyle-related risk factors and a depression history were both related with a significantly increased risk of BN among the candidates for LSG. Furthermore, there is a relationship between clinical characteristics as well as levels of various biochemical and cytokines parameters in serum of BN patients.

Reliability and Educational Value of Laparoscopic Sleeve Gastrectomy Surgery Videos on YouTube.

INTRODUCTION: Many surgery videos can be found in different social networks and video sharing websites. Watching surgeries performed by different surgical experts of various institutions can be an invaluable supplement to traditional methods of learning surgery. YouTube is a quite popular video sharing website, and many surgeons and trainees refer to it as a source of surgery videos. However, since its content is not peer-reviewed, there is a concern over reliability and educational value of its surgical videos. In this study, we aimed to investigate the reliability and educational value of laparoscopic sleeve gastrectomy (LSG) videos on YouTube. METHODS: We searched YouTube for videos of "Laparoscopic sleeve gastrectomy" on 20 July 2018. In order to assess videos, we evaluated ten key steps in laparoscopic sleeve gastrectomy. The videos were reviewed by two experienced surgeons in the field of bariatric surgery to determine their reliability. RESULTS: A total of 74 videos were selected. After reviewing videos, 32 (43%) of them were considered as reliable. There was no relationship between reliability and views, likes, dislikes, resolution, and year of upload and affiliation of videos. Only 6 (8% of all) reliable videos showed operation setup and port placement and included voice commentary. CONCLUSION: Importance of online media in the education of surgery cannot be overestimated. However, trainees are advised to search for peer-reviewed contents dedicated to education.

Neutrophil-Lymphocyte Ratio in Different Stages of Breast Cancer.

Despite many advances in the treatment of breast cancer, it is still the second most common cause of death in women in the United States. It has been shown that inflammation plays a major role in the treatment of these cancers and inflammatory factors enhance tumor growth, invasion, metastasis, and vascularization. In this study, we would like to analyze peripheral blood neutrophil-lymphocyte ratio (NLR) in breast cancer patients and its correlation with disease staging. This cross-sectional analytic study was conducted in Imam Hospital, affiliated with Tehran University of Medical Sciences; a total of 195 female patients with breast cancer met the inclusion criteria. All of the patients had a complete blood count with leukocyte differential performed before chemotherapy. Medical records including pathology reports were also available. Data for all patients were collected prior to any surgical intervention. Exclusion criteria included clinical evidence of active infection, presence of hematological disorders, acute as well as chronic inflammatory or autoimmune diseases, or prior steroid therapy. Higher platelet count was significantly associated with the higher stage. The stage was not associated with the hemoglobin level. There was no association between the tumor size and age of patients with NLR. There was a significant relationship between NLR and IDC. There was a significant relationship between IDC and NLRs of less than 8.1 and greater than 3.3. There was a significant relationship between NLR and vascular invasion. There was no association between NLR and estrogen receptor and HER2. There was no significant relationship between the PLR and the cancer stage. In this study, NLR showed a significant relation with the disease staging. As the NLR increases the stage increases as well. Therefore, this ratio may be helpful in the preoperative evaluation of patients with breast cancer.

Hiatal Hernia From Misdiagnosis to Diagnosis.

Complications of hiatal hernia are potentially lethal, and surgical intervention is necessary. This matter is more important in cases that have ambiguous symptoms and are diagnosed with a delay. Such patients may experience life-threatening course and events. Accordingly, in this report, a 23-year-old male patient with unusual findings is presented. A 23-year-old male patient with acute dyspnea and fever was admitted in infectious disease ward with diagnosis of empyema according to chest radiography and CT-scan findings (Figures 1 and 2). On physical examinations the right lung sounds were normal, and the left lung sounds could not be heard. Then a gastrography was performed because of suspicion to hiatal hernia based on physical examination findings showing the presence of stomach in the thorax (Figure 3). In the surgery, the stomach and the transverse colon were released and reputed in the abdomen (Figure 4). The diaphragm was primarily repaired due to small defect, and the patient was discharged after 4-5 days with good general conditions. This case had a learning note that in the case of acute dyspnea with a positive history of stab wound to the chest, hiatal hernia should be considered as an important diagnosis and in these cases performing a gastrography would help physicians to make true and certain diagnosis and therapeutic decision.