Cohort analysis of 50% lethal area (LA50) and associating factors in burn patients based on quality improvements and health policies.

Burn injuries are among the common traumatic injuries, which can be accompanied with lifelong morbidity and mortality. The Lethal Area Fifty Percent (LA50) index is another reliable outcome measurement tool that assesses the standard of medical care at burn centers. It is widely used as a benchmark for assessing the quality of burn care and is considered the percentage at which 50% of burn patients are expected to die because of burn-related injuries. We aimed to determine and compare the LA50 in burn patients admitted to Shiraz Burn Referral Centers in 2018-2021 and 2011-2018 with regard to improving the quality of special care and infection control in the new hospital. We conducted a retrospective cohort analysis on patients admitted to Amir al-Momenin Burn Injury Hospital in Shiraz, Fars, Southern Iran. Data were retrospectively gathered from March 2011 to January 2022, and subsequently analyzed with standard statistical analysis, and also multivariate and probability analysis. A total of 7382 patients with acute burns injuries were identified. Among them, 4852 (65.7%) patients were men, and the median age was 27 years [Q1-Q3 7-40; range 1-98]. Most of the patients were in the pediatric and early adulthood age range, with 76.2% being younger than 40 years old. The median TBSA was 24% [IQR 14, 43], and the median duration of hospitalization was 11 [IQR 11] days. Most injuries were secondary to flame and fire (33.5%; n = 2472). The mortality rate in our study was 19.0% (n = 1403). We evaluated our patients based on two main time intervals: March 2011 till February 2018 (n = 3409; 46.2%), and March 2018 to January 2022 (n = 3973; 53.8%). Based on multivariate analysis, the second interval of our study was significantly correlated with a more female patients, higher age, lower TBSA, less burn injuries due to scald, contact, but more frequent fire and flame injuries, and also lower mortality rate. Factors correlated with higher mortality included male gender, older age, shorter hospitalization duration, higher TBSA, etiology of fire and flame, and accidental burn injuries. A Baux score of 76.5 had a sensitivity of 81.1%, specificity of 87.3%, accuracy of 86.1% in predicting mortality among our patients. The mortality probability for the study intervals were 20.67% (SD 33.0%) for 2011-2018, and 17.02% (SD 29.9%) for 2018-2022 (P < 0.001). The LA50 was 52.15 ± 2 for all patients. This ammount was 50 ± 2% in 2011-2018, and 54 ± 2 in 2018-2022 (P < 0.001). The mean LA50 values showed significant improvements following significant modifications in our critical care for burn victims, including augmented intensive care unit capacity, prompt relocation of inhalation burn cases to the intensive care unit, establishing a well-trained multidisciplinary team, and improved infection control. To improve outcomes for burn patients in developing countries, major changes should be made in the management of burn patients and LA50 is a reliable assessment tool for evaluating the how these changes affect patient's outcomes.

Outcome of early versus late ileostomy closure in patients with rectal cancers undergoing low anterior resection: A prospective cohort study.

BACKGROUND: Protective loop ileostomy is performed following low anterior resection (LAR) in patients with rectal cancer to reduce the complications of primary anastomosis. The optimal timing for ileostomy closure remains controversial. The aim of the current study was to compare the effects of early (<2 weeks) versus late (≥2 months) closure of the stoma in patients with rectal cancer undergoing LAR on surgical outcome and complications rates. METHODS: This prospective cohort study was conducted in two referral centers in Shiraz, Iran, during a 2-year period. We have consecutively and prospectively included adult patients with rectal adenocarcinoma who underwent LAR followed by protective loop ileostomy in our center during the study period. The baseline, tumor characteristics and complication as well as outcome was recorded in a 1-year follow-up and was compared between early and late ileostomy closure. RESULTS: Overall, 69 patients (32 in early and 37 in late group) were included. The mean age of the patients was 59.40 ± 9.30 years and there were 46 (66.7%) men and 23 (33.3%) women. Patients undergoing early closure of the ileostomy had significantly shorter operation duration (p<0.001) and lower intraoperative bleeding (p<0.001) compared to late ileostomy closure. There was no significant difference between two study groups regarding the complications. Early closure was also not found to be a predictive factor of post-ileostomy closure complications. CONCLUSION: Early closure (<2 weeks) of ileostomy after LAR in patients with rectal adenocarcinoma is a safe and feasible technique which is associated with favorable outcome.

Spontaneous rupture of a large splenic artery aneurysm in a 59-year-old male patient with pemphigus vulgaris: a case report.

BACKGROUND: There is currently no information on the anatomical risk factors for splenic artery aneurysm rupture, specifically the location or size of the lesion; therefore, reporting this entity to obtain data and ultimately reduce morbidity and mortality is essential. Here we report a case of a male patient with spontaneous rupture of a large splenic artery aneurysm presenting with abdominal pain. CASE PRESENTATION: A 59-year middle-eastern male, with known pemphigus vulgaris presented with a chief complaint of headache and syncope, followed by abdominal pain along with severe metabolic acidosis. A contrast-enhanced computed tomography scan of the abdomen and pelvic showed a splenic artery aneurysm of 33 × 30 mm with a 150 × 90 mm hematoma formation around the aneurysm site. The patient underwent an operation and splenectomy, with confirmation of the diagnosis of ruptured splenic artery aneurysm. CONCLUSION: It is essential to consider splenic aneurysm rupture as a second-line differential diagnosis, especially among patients with comorbid diseases, as this can lead to timely and appropriate lifesaving intervention.

Report of 13-year survival of patients with colon and rectal cancers; lessons from Shiraz colorectal cancer surgery registry system of a level three medical center.

BACKGROUND: Colorectal cancer (CRC) is the second most common cancer in women and the third most common cancer in men worldwide, with an increasing trend in its incidence in Asian countries. In the present study, we aimed to describe the 13-year results of patients with CRC based on the Shiraz Colorectal Cancer Surgery (SCORCS) registry system in patients with a pathologically confirmed diagnosis of colon cancer (CC) and rectal cancer (RC) undergoing surgery. METHODS: Between 2007 and 2020, 811 patients, including 280 patients with CC and 531 patients with RC, registered in SCORCS, were included in the present study. The information collected for this study included demographic characteristics of the patients, primary clinical presentations, laboratory findings before surgery, radiologic and colonoscopy results, and surgical procedures. Death was confirmed by the physician as "CRC-related". The data were analyzed by SPSS software version 21; life table and Kaplan-Meier curve were used for evaluating the overall survival, recurrence, and metastasis rates and Log-Rank test or Breslow test to check significant differences between the subgroups. The Cox proportional regression model was fitted to evaluate the prognostic factors of survival recurrence and metastasis. RESULTS: Laparoscopy was performed in 60% of patients (66% in RC and 51% in CC), laparotomy in 32% (27% in RC and 41% in CC), and 7% required conversion. The median time of follow-up was 29 months in all patients; 28 months in patients with RC, and 33 months in patients with CC; 1, 3, and 5 years' survival rate was 90, 70, and 63% for all the patients, 89%, 67%, and 58% for RC and 90%, 74%, and 71% for CC, respectively (P = 0.009). The Cox regression analysis revealed tumor stages II, (P = 0.003, HR:2.45, 95% CI;1.34-4.49), III, (P ≤ 0.001, HR:3.46, 95% CI;1.88-6.36) and IV, (P ≤ 0.001, HR:6.28, 95% CI;2.73-14.42) in RC and stage IV, (P = 0.03, HR:9.33, 95% CI;1.1-76.37) in CC were the significant survival prognostic factors. The metastasis and recurrence of the tumors occurred earlier in patients with RC than CC (P = 0.001 and 0.03, respectively). CONCLUSIONS: Long-term follow-up of patients with CRC in an Iranian population indicated the significance of screening for diagnosis of early stages and improved survival of the patients.

Prognostic Factors of Recurrence and Survival in Operated Patients with Colorectal Cancer.

BACKGROUND: The recurrence of colorectal cancers is considered to be one of the greatest post-surgical complications that is affected by various factors. This study was designed to investigate the prognostic factors that affect the recurrence and survival of patients with colon and rectal cancers. METHODS: A retrospective study was performed on 380 patients with colorectal cancers who underwent surgery were enrolled in the study (152 patients with colon cancer and 228 patients with rectal cancer). Preoperative serum albumin level, type of surgery, tumor size, differentiation grade, proximal, distal and radial, and marginal involvement, the total number of excised lymph nodes, the number of involved lymph nodes, and tumor stage were recorded. Also, the incidences of recurrence and metastasis were recorded during the study. RESULTS: 380 patients with a mean age of 57.11 years were enrolled in the study. 152 patients with an average age of 57.57 years were diagnosed as having colon cancer. Recurrence and metastasis occurred in two patients (1.3%) and five patients (3.3%), respectively. 18 patients (11.8%) died because of colon cancer. 228 patients with a mean age of 56.81 had rectal cancer. Recurrence was seen in 19 patients (8.3%) and metastasis in 33 patients (14.5%). 38 patients (16.7%) died because of rectal cancer. Tumor size and involved lymph nodes were independent prognostic factors for the recurrence and metastases of colon cancer. Only involved lymph nodes were associated with death due to colon cancer. Independent prognostic factors for rectal cancer metastasis include serum albumin level and age. The total number of excised lymph nodes was the only predictor of tumor recurrence and death in rectal cancer. The median survival times of colon and rectal cancers were 90 and 110 months, respectively. CONCLUSION: The size of the tumor and the number of involved lymph nodes were independent prognostic factors for recurrence and metastasis of colon cancer. Also, the number of involved lymph nodes was associated with colon cancer-related deaths. In the case of rectal cancer, serum albumin levels and age predicted metastases. Only the total number of excised lymph nodes had a reverse relationship with recurrence and rectal cancer-related death.

Esophageal perforation during laparoscopic sleeve gastrectomy: Complication of bougie insertion.

INTRODUCTION AND IMPORTANCE: Esophageal perforation (EF) is an uncommon complication of bariatric procedures, mostly related to the intraoperative use of bougie that is used for gastric calibration. CASE PRESENTATION: Here, we present a 33-year-old woman who underwent laparoscopy sleeve surgery (LSG). Due to perforation in the cervical site of the esophagus caused by bougie insertion, she developed subcutaneous emphysema on the first post-operative day. She immediately underwent reconstructive esophageal surgery under the probable diagnosis of having a cervical esophagus perforation. The patient's condition was stable in the postoperative period and discharged after 10 days. CLINICAL DISCUSSION: The patients who present symptoms including subcutaneous emphysema, cervical pain, dysphagia, dysphonia, and fever post-surgery have to be considered for probably EF. The early optimal diagnosis works up and therapeutic approach should be performed as soon as possible to prevent mortality. CONCLUSION: EP caused by a bougie insertion is an uncommon complication that is associated with high mortality rates if the diagnosis and treatment were delayed. The risk of using a bougie during surgery should not be underestimated and have to be inserted with extreme caution and careful guide of surgeon.

Outcome of Fecal Incontinence in Patients with Rectal Prolapse Undergoing the Altemeier Procedure with or without Posterior Levatorplasty / Desfecho de incontinência fecal em pacientes com prolapso retal submetidos ao procedimento de Altermeier com ou sem levatorplastia posterior

Abstract Objective To compare the fecal incontinence status of patients submitted to theAltemeier procedure with or without posterior levatorplasty. Materials and Methods Medical records of the patients who underwent the Altemeier procedure at Shahid Faghihi Hospital (in Shiraz, Iran) from 2014 to 2018 were retrospectively studied. Patients older than 17 years of age who underwent the Altemeier procedure due to complete rectal prolapse were considered. In some cases, the operation was performed with posterior levatorplasty. Rectal prolapse due to collagen or connective tissue disorders, anal/sacral anomalies, immunodeficiency, history of rectal surgery, and pelvic radiotherapy were the exclusion criteria of the present study. In addition to the demographics (including age, gender, and body mass index), the fecal incontinence status of each case was determined through theWexner scale preoperatively and 12 months after the surgery. The incontinence scores were then compared against the baseline values of the two groups of patients: those with and those without posterior levatorplasty. The statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS, IBM Corp., Armonk, NY, US), software, version 21. Results In total, 53 patients (17 men and 36 women) with a mean age of 55.23 ± 18.24 years were analyzed. The comparison of the pre- and postoperative scores on theWexner scale between the two groups revealed no statistically significant difference (p >0.05). Conclusion Posterior levatorplasty during the Altemeier procedure did not result in significant improvement of the fecal incontinence outcome of the patients.

Resumo Objetivo Comparar o status de incontinência fecal de pacientes após o procedimento de Altemeier com e sem levatorplastia posterior. Materiais e métodos Os prontuários médicos dos pacientes submetidos ao procedimento de Altemeier no Shahid Faghihi Hospital (em Shiraz, Irã) entre 2014 e 2018 foram avaliados retrospectivamente. Pacientes com idade superior a 17 anos submetidos ao procedimento de Altemeier devido a prolapso retal completo foram considerados. Em alguns casos, a operação foi realizada com levatorplastia posterior. Prolapso retal devido a distúrbios de colágeno ou do tecido conjuntivo, anomalias anais/sacrais, imunodeficiência, histórico de cirurgia retal, e radioterapia pélvica foram os critérios de exclusão deste estudo. Além dos dados demográficos (incluindo idade, sexo, e índice de massa corporal), o status da incontinência fecal de cada caso foi determinado por meio da escala de Wexner antes e doze meses após a cirurgia. Então, as pontuações de incontinência foram comparadas aos valores de referência dos dois grupos de pacientes: com e sem levatorplastia posterior. A análise estatística foi feita usandose o programa Statistical Package for the Social Sciences (SPSS, IBM Corp., Armonk, NY, EUA), versão 21. Resultados No total, 53 pacientes (17 homens e 36 mulheres) com idade média de 55.23 ± 18.24 anos foramavaliados. A comparação entre os grupos das pontuações na escala de Werner no pré e pós-operatório não revelou diferença estatisticamente significativa (p>0.05). Conclusão Levatorplastia superior durante o procedimento de Altemeier não resultou em melhora significativa do desfecho da incontinência fecal dos pacientes.

Parastomal Hernia Following Abdominoperineal Resection / Hérnia paraestomal após ressecc¸ão abdominoperineal

ABSTRACT Parastomal Hernia (PSH) is a common complication of patient who undergone ostomy especially end colostomy. Presence of hernia defect is associated with the risk of strangulation and obstruction so understanding the potential risk factor such as patient's factor and technical issues is important. This study is evaluating the incidence of PSH hernia in patients who undergone end colostomy due to Abdominoperineal Resection (APR) in a tertiary colorectal surgery referral center and explore the possible risk factors of this complication. The study was designed as a retrospective cross sectional study on 41 patients who undergone end colostomy due to APR. Three patient lost the follow up and 13 patients died and 25 patients were enrolled in study. Demographic data, history of smoking, steroid administration, Diabetes, obstructive pulmonary disease, transfusion, Neoadjuvant therapy, wound infection and Body mass Index (BMI) were gathered. The mean age of participants was 58.8 and the mean BMI was 25.04 kg/m2. The incidence of PSH was 40% and 68% of operations were done with Laparoscopy. This study could not find statistically significant risk factor for PSH. The 40% incidence of PSH is noticeable and specific strategies should be applied to reduce such complications. Larger studies is essential to investigate the possible etiologies of this complication.

RESUMO A hérnia paraestomal é uma complicação comum em pacientes submetidos a estomia, especialmente a colostomia terminal. A presença de defeito de hérnia está associada ao risco de estrangulamento e obstrução, portanto, é importante compreender o potencial fator de risco, como o fator do paciente e questões técnicas. Este estudo avalia a incidência de hérnia paraestomal em pacientes submetidos à colostomia terminal devido à ressecção abdominoperineal em um centro terciário de referência em cirurgia colorretal e explorar os possíveis fatores de risco dessa complicação. O desenho do estudo foi transversal retrospectivo de 41 pacientes submetidos à colostomia terminal devido à ressecção abdominoperineal. Três pacientes foram perdidos no seguimento, 13 pacientes morreram, e 25 pacientes foram incluídos no estudo. Dados demográficos, história de tabagismo, administração de esteroides, diabetes, doença pulmonar obstrutiva, transfusão, terapia neoadjuvante, infecção de ferida operatória e Índice de Massa Corporal foram coletados. A média de idade dos participantes foi 58,8 e o índice de massa corporal médio foi 25,04 kg/m2. A incidência de hérnia paraestomal foi de 40% e 68% das cirurgias foram realizadas por laparoscopia. Este estudo não encontrou fator de risco estatisticamente significativo para hérnia paraestomal. A incidência de 40% de hérnia paraestomal é perceptível e estratégias específicas devem ser aplicadas para reduzir tais complicações. Estudos maiores são essenciais para investigar as possíveis etiologias dessa complicação.

Do clinicopathologic features of rectal and colon cancer guide us towards distinct malignancies?

BACKGROUND: Unlike developed countries where studies on all aspects of colorectal cancers are widely numerous, Iran as a Middle Eastern country show very few studies especially ones comparing the differences between colon and rectal cancer. In this study, firstly we report demographic, clinical and pathologic characteristics of patients with rectum and colon cancer and secondly compare these findings in order to investigate probable differences. METHODS: In this cross-sectional study, 238 patients were divided into two groups: the rectal cancer group and the colonic cancer group. Demographic, clinical and pathologic information of patients were statistically compared using Stata version 12. RESULTS: There were no statistical differences between the two groups regarding age and gender and BMI. Regarding clinical presentation, the proportion of rectal bleeding was significantly higher in colon cancer group (P<0.001). Moreover, abdominal pain was significantly more frequent in colon cancer group (P<0.001). Tumor stage showed statistically difference between the two groups (P=0.02). CONCLUSIONS: We did not find enough evidences to conclude that rectal cancer and colon cancer should be investigated as two distinct malignancies but findings showed significant differences such as stage at diagnosis encouraged us in order to conduct other appropriate studies for better evaluation of this issue.