Primary Spontaneous Pneumothorax: Open Thoracotomy vs. Video-assisted Thoracoscopic Surgery: A Single-center Retrospective Cohort Study.

Background: Primary spontaneous pneumothorax (PSP) is a spontaneous pneumothorax without underlying lung disease. The main goals of this study were to compare the outcomes of video-assisted thoracoscopic surgery (VATS) and open thoracotomy in patients with PSP. Methods: The current study is a retrospective cohort study of patients who were admitted to the emergency department or general surgery ward at Dr. Masih Daneshvari Hospital (Tehran, Iran) with the diagnosis of PSP and underwent surgery by open or VATS approach from 2006 to 2012. The groups were compared in terms of the length of operation, the length of hospitalization, recurrence, and postoperative complications. Data were analyzed using SPSS version 18.0, and Student's t test, analysis of variance (ANOVA), Chi square, and Fisher's exact test were employed. P values less than 0.05 were considered statistically significant. Results: PSP was diagnosed in 90 patients who underwent surgery. Open thoracotomy and VATS procedures were performed in 65 (72.2%) and 25 (27.8%) patients, respectively. VATS was converted to open in seven cases (7.7%). Recurrent pneumothorax was the most common surgical indication for PSP. There was no significant difference between the two groups in terms of mean age, sex, smoking, side of the involved lung, previous pneumothorax history, mean length of hospitalization for recurrence, post-operation bleeding, and failure of lung expansion. However, the length of surgery (P=0.011) and air leakage (P=0.048) significantly differed between the two groups. Conclusion: When compared to open thoracotomy, VATS could be the primary treatment option in the surgical treatment of PSP due to the shorter length of surgery and decreased complications such as air leakage.

Evaluation of the quality and accuracy of breast cancer knowledge among persian language websites.

INTRODUCTION: The internet has become a powerful worldwide information source that revolutionized access to knowledge, especially in the fields of health and medicine (health knowledge). Therefore, providing high-quality, accurate, reliable, and relevant information on dependable websites is a possible way of providing the patient with needed information and, thus, achieving the benefits of informed patients regarding outcomes. This study aimed to evaluate the quality and accuracy of breast cancer knowledge among Persian language websites. METHODS: Two search engines were searched in the Persian language about breast cancer. The first 30 websites were selected for further evaluation based on the completeness, correctness, transparency, and accessibility of health knowledge. The DISCERN instrument was used to assess the quality of the Persian language websites on this issue. RESULTS: Among the 30 websites, about 23% of websites provide completely correct information and about 30% provide mostly correct information. Sixty percent of the websites provided author information, and 46% of them had a healthcare professional or expert as the author. Sixty percent of the websites stated the creation date on the pages, while 40% of them did not provide any health knowledge. Scores on accessibility were always easy for most of the websites. Based on the quality rating system of DISCERN, about 60% of the websites were presented as very poor. CONCLUSION: Website rankings enable healthcare professionals to identify and signpost patients to reliable up-to-date websites to ensure that patients receive high-quality knowledge. This review has provided evidence of inadequate and inaccurate health knowledge about breast cancer on the Persian language websites. This issue requires further investigation to understand the barriers and solutions available to provide reliable information about breast cancer and how this information affects the patient's outcomes. TRIAL REGISTRATION: The project was found to be in accordance with the ethical principles and the national norms and standards for conducting research in Iran with the approval ID and date of IR.TUMS.IKHC.REC.1399.379 and 2021-01-01 respectively, and is registered with research project number 49890 in the Vice Chancellor for Research and Technology Development of Tehran University of Medical Sciences, Tehran, Iran. URL: https://ethics. RESEARCH: ac.ir/EthicsProposalViewEn.php?id=170978 .

Isolated comminuted fracture of the cricoid cartilage and narrowing of the airway after a traumatic blunt injury of the neck: a case report.

BACKGROUND: Blunt trauma to the anterior of the neck may compromise the vital structures like major blood vessels, trachea, larynx, pharynx, thyroid, spine, esophagus, and the cricoid. Laryngeal trauma is rare and accounts for 1% of all neck blunt traumas. Cricoid trauma is also very rare and accounts for half of the laryngeal traumas, and the diagnosis is frequently missed. CASE PRESENTATION: A 43-year-old man, with blunt neck trauma after being hardly hit by a crane lifting hook, was referred to the Shahid Beheshti Hospital. The patient complained of dysphonia (hoarseness) and dyspnea. The CT scans showed a comminuted fracture of the left anterior arch of the cricoid cartilage with left-sided mucosal thickening, inflammation, and edema which was extended to the glottis, causing a narrowing of the airway. Direct fiber-optic laryngoscopy revealed swelling and congestion in the epiglottis and swelling at the level of the left vocal cord. CONCLUSION: This case report highlights the conservative treatment of isolated cricoid cartilage fracture in the setting of low-energy blunt trauma. The patient was clinically stable and treated conservatively with oxygen therapy and silence therapy (complete silence).

An asymptomatic huge primary retroperitoneal pseudocyst: a case report and review of the literature.

BACKGROUND: Retroperitoneal non-pancreatic or idiopathic pseudocysts are very rare lesions. This case report aimed to present our patient and to check all the available literature on this kind of rare disease. CASE PRESENTATION: Our patient was a 67-year-old Iranian man admitted with mild abdominal discomfort for three months. Ultrasonography and CT scan revealed a huge cystic structure within the retroperitoneal space. The lesion was excised through midline laparotomy and opening of the retro-peritoneum. The histopathology of the cyst wall revealed a benign cystic lesion with no epithelial lining. A histologic diagnosis of non-neoplastic retroperitoneal pseudocyst was made. CONCLUSION: The primary non-pancreatic retroperitoneal pseudocysts are rare lesions and have to be distinguished from other differential diagnoses of retroperitoneal lesions, and a surgeon should be aware of the possible occurrence of these lesions with unknown origin. Surgical excision is the only way to exclude malignancy and confirm the diagnosis.

Does application of honey improve surgical outcome in pilonidal cyst excision with secondary intention healing? A prospective randomized placebo-controlled clinical trial.

BACKGROUND: Pilonidal sinus disease (PSD) is a common chronic inflammatory debilitating illness caused by ingrowth of hair into the skin. Excision and healing by secondary intention is one of the acceptable managements. The post-operative wound care needs frequent and time-consuming follow-ups. Honey is considered to be a traditional remedy for wound healing. The current study aimed at finding if application of honey could improve surgical outcome in pilonidal cyst excision with secondary intention healing. METHODS: This study was designed as a randomized placebo-controlled parallel assignment interventional (clinical trial) study conducted at the surgical ward of Shahid Beheshti Hospital affiliated to the Yasuj University of Medical sciences, Yasuj, Iran, and was consisted of the 48 patients who underwent surgical resection for PSD with secondary intention healing (24 patients in intervention and placebo-controlled groups). The main element of honey medicinal gel was the unheated natural honey of Dena Biosphere Reserve within the Zagros Mountains. Patients' wounds were visited by a surgeon and a nurse on the days 7, 15, 30, 45, 60, and 90 post-operation. The surgical outcomes including the time to complete wound healing, pain intensity, odor, discharge at the site of surgery, use of analgesics, the time of to return to the daily activities, and occurring of any side effects including infection, erythema, and bleeding were all recorded. RESULTS: In intervention group, there was significantly lower wound healing time, the lower time to return to the daily activities, lower mean wound volume at the days of 30, 45, 60, and 90 of the follow-up, higher mean post-operative pain level at the days of 15, 30, 45, 60, and 90 of the follow-up, and more usage of analgesics at the days of 15, 30, 45, and 60 of the follow-up. There was no significant difference between intervention and placebo-controlled groups according to the foul smell and fluid discharge at the site of the operation. There were no side effects and complications in both groups of the study. CONCLUSIONS: Application of honey after resection surgery with secondary wound healing is associated with a better surgical outcome and could eventually decrease healing time and reduce duration of return to normal activities, but could increase post-operation pain and analgesic consumption, and no effect on foul smell and discharge. TRIAL REGISTRATION: The project was found to be in accordance to the ethical principles and the national norms and standards for conducting research in Iran with the approval ID and date of IR.YUMS.REC.1399.088 and 2020.05.30 respectively, and is the result of a residency dissertation to get the specialty in general surgery, which has been registered with the research project number 960508 in the Vice Chancellor for Research and Technology Development of Yasuj University of Medical Sciences, Yasuj, Iran, URL: https://ethics. RESEARCH: ac.ir/EthicsProposalViewEn.php?id=144742.

Demographic, Chemical, and Helicobacter pylori Positivity Assessment in Different Types of Gallstones and the Bile in a Random Sample of Cholecystectomied Iranian Patients with Cholelithiasis.

Background: The occurrence of stones in the gallbladder or common bile duct and the symptoms and complications they cause is called gallstone disease. The symptoms of gallstone disease range from mild, nonspecific symptoms to a severe right quadrant abdominal pain. Characteristics of gallstone types in an Iranian population have not been well studied before and there are very limited studies on the demographic pattern of stone types in our country, so this study is one of the first studies on its kind on the epidemiology of gallstone types in Iran. As information on chemical components of the stone will help in the management and prevention of gallstones, in this study, we aimed to do chemical component analysis of gallstones including cholesterol, bilirubin, and calcium. Given the conflicting reports about the relationship between H. pylori infections and gallstone formation, this study aimed to investigate the relationship between H. pylori positivity in the bile specimen of Iranian patients with cholelithiasis and formation and type of stone. Methods: This prospective study reviewed a total of 196 patients who underwent cholecystectomy for symptomatic cholelithiasis at Shahid Beheshti Training and Research Hospital affiliated to the Yasuj University of Medical Sciences between September 2015 and May 2018. Chemical analysis of gallstone components performed using the colorimetry method. Microbiological analysis for H. pylori was done using the OnSite H. pylori Ag Rapid Test on the bile sample. For the validation test of bile, the H. pylori Rapid Stool Ag Test on stool was used, and Cohen's Kappa statistical analysis was done next. Results: There were significant associations between the stone types and age, chemical composition of the stones such as calcium, cholesterol, and bilirubin levels, and also H. pylori positivity and cholesterol and bilirubin levels; however, no significant association was found between the stone types and sex, H. pylori positivity and age, sex, stone types, and calcium level. The main bile and validity tests were matched to the substantial agreement according to Cohen's Kappa analysis. The most common drugs used were proton pump inhibitors, nonsteroidal anti-inflammatory drugs, antihypertensive drugs, and oral contraceptives. Conclusions: This study suggested that the chemical composition of the stones could predict the presence of bacteria, there is no correlation between H. pylori and gallstone formation, and some of the drugs could be predisposing factors for gallstones. This work provides an objective basis for further research into gallbladder stone formation; meanwhile, it has great significance in the treatment and prevention of gallbladder stones. Trial registration. The project was found to be in accordance to the ethical principles and the national norms and standards for conducting research in Iran with the approval ID IR.YUMS.REC.1399.147 and date 2020.09.23, and this project is the result of a residency dissertation to obtain the specialty in general surgery, which has been registered with the research project number 960159 in the Vice Chancellor for Research and Technology Development of the Yasuj University of Medical Sciences, Yasuj, Iran, URL: https://ethics.research.ac.ir/EthicsProposalViewEn.php?id=160634.

Hybrid Percutaneous Brachiofemoral Shunt and Open Abdominal Aortic Aneurysm Repair in a Kidney Transplant Recipient.

Abdominal aortic aneurysm (AAA) repair in kidney transplant recipients may cause ischemia in the transplanted kidney. As a result, various techniques have been described for protection of the renal allograft during AAA repair including temporary shunt, extracorporeal bypass, cold renal perfusion, endovascular aortic aneurysm repair (EVAR), and operation without renal allograft protection. We successfully treated a 56-year-old man, a case of kidney transplantation with AAA, using a temporary hybrid percutaneous brachiofemoral shunt using vascular prosthesis with a long 7-French (Fr) catheter sheath introducer (CSI) in the aortic arch via the right brachial artery and 8 Fr CSI in the right femoral artery that were connected together with a 7 Fr guiding catheter, before aortic cross-clamping and repair of AAA using a Dacron tube graft. The patient recovered well from the surgery without any complication and was discharged on the 6th postoperative day. To our knowledge, this is the first report of using a temporary hybrid percutaneous brachiofemoral shunt for renal allograft protection in AAA repair surgery in a patient with kidney transplantation, and we think that this temporary shunt is an easy, safe, and rapid method for renal allograft protection from ischemia.

Esophageal leiomyoma and simultaneous overlying squamous cell carcinoma: a case report and review of the literature.

BACKGROUND: Squamous cell carcinoma is the most common epithelial tumor of the esophagus. Upper endoscopy with multiple minimally invasive biopsies should be performed to confirm the diagnosis. Leiomyoma of esophagus is rare, but it's the most common benign submucosal mesenchymal tumor of the esophagus. The simultaneous occurrence of an overlying epithelial lesion and a mesenchymal lesion is very rare. This study aims to show a case operated due to squamous cell carcinoma of esophagus that was postoperatively diagnosed with coexistent esophageal leiomyoma and give a clear overview of the existing literature on it. CASE PRESENTATION: The patient was a 41-year-old woman who underwent three field esophagectomy (McKeown). Pathological evaluation was done, and the patient had poorly differentiated squamous cell carcinoma and multiple leiomyomas. A leiomyoma was found with an invading overlying squamous cell carcinoma. CONCLUSION: It is concluded that esophageal carcinomas may coexist with leiomyomas; preexisting benign tumors may have played an important role in the development of the carcinoma by inducing constant stimulation of the overlying mucosa; endoscopic ultrasonography is recommended to avoid overestimating the extent of tumor invasion and the resultant aggressive radical surgery. As the developing countries had limited equipment, esophageal resection could be the modality of choice in the treatment.

Non-penetrating traumatic psoas muscle hematoma presenting with gross hematuria: a case report.

Psoas muscle hematoma is defined as a spontaneous or traumatic retroperitoneal collection of blood involving the psoas muscle. Early symptoms of an iliopsoas hematoma include lower abdominal or severe groin pain. Although psoas hematoma is a known complication of coagulopathy, psoas hematoma caused by non-penetrating trauma is the subject of only scattered reports and its significance has not been well described in the literature, so the aim of this study was to report a case of blunt traumatic psoas hematoma with the fracture of vertebral transverse process with the presentation of gross hematuria. A 65-year-old Iranian man slipped backward to the ground, and the patient complaint of gross hematuria and difficulty in walking. There was severe left costo-vertebral angle (CVA) tenderness, and mild groin tenderness, and the lower back area was painful, and he had some pain with the flexion of the vertebral column, and there was tenderness on lumbar spine, but there was no tingling, paresthesia, and weakness in left lower extremity. Hip flexion was 3/5 in the left lower. We used some diagnostic modalities as x-ray radiography, ultrasonography, computed tomography (CT) scan with intravenous (IV) contrast, CT cystography, and intravenous pyelogram (IVP) IVP to differentiate the diagnoses and also find skeletal and other organ injuries associated with this kind of injury. We can conclude that post-traumatic psoas hematoma is a rare condition. The diagnostic modality of choice is CT scan which allows rapid identification and measurement of the hematoma. The lesion usually treated with non-operative conservative management.

Cutaneous Metastasis vs. Isolated Skin Recurrence of Invasive Breast Carcinoma after Modified Radical Mastectomy.

BACKGROUND: Five to ten percent of the patients with operable breast cancer develop a chest wall recurrence within 10 years following the mastectomy. One of the most distressing presentations of locally recurrent breast cancer is the appearance of cutaneous metastases. To the best of authors' knowledge, there is no study distinguishing skin metastasis from local recurrence, so the main aim of this report was to elucidate if these two features are important in the prognosis and management of the disease. Case Presentation. A 51-year-old woman referred to the breast clinic due to a painful mass in the left breast. The patient underwent the modified radical mastectomy (MRM) and left axillary lymph node dissection followed by 30 sessions of radiotherapy and 8 sessions of chemotherapy (T3N1M0, ER-, and HER2+). About 15 months after the surgery, she presented with redness and eruptive lesions over the mastectomy scar that increased in size within a three-month follow-up. CONCLUSION: Mastectomy is not an absolute cure in the treatment of an invasive breast cancer because almost always, there is a recurrence risk and possibility of metastasis. It is vital to differentiate between local recurrence and skin metastasis because it would alter the overall treatment decision, prognosis, and patient outcomes.

Portal Vein Thrombosis following Total Colectomy due to Colonic Inertia: A Case Report and Evaluation of Risk Factors.

The portal vein could be occluded by blood clots partially or completely causing portal vein thrombosis (PVT). The acute episode may be asymptomatic or manifested by abdominal pain, increasing body temperature, and unspecific dyspeptic symptoms. The main causes of PVT are categorized into local, acquired, and genetic thrombophilic factors. To our knowledge, this is the 2nd recognized case of PVT following colectomy for colonic inertia successfully treated with an effective anticoagulation therapy. The patient received unfractionated heparin as soon the diagnosis was implemented. The patient was a 34-year-old lady with chief complaint of severe abdominal pain, nausea, vomiting, and anorexia 10 days after the first hospital admission for subtotal colectomy due to colonic inertia. Spiral abdominal CT scan with intravenous (IV) contrast showed thrombosis in main portal vein with its extension to right and left intrahepatic branches. Our case showed that we should keep in mind PVT in patients who present with upper gastrointestinal symptoms several days after a major surgery (open colectomy) as a risk factor and oral contraceptive pills (OCP) usage, postpregnancy, and immobility as other risk factors, that the protein C, S, and FVL deficiencies were secondary, and that the PVT can be managed by low molecular weight heparin plus oral warfarin therapy in the continue.

Cholecystomegaly: A Case Report and Review of the Literature.

Chronic cholecystitis or symptomatic gallbladder is a prolonged mechanical or functional disorder of abnormal gallbladder emptying. Most of the patients have recurrent pain attacks (acute biliary colic), but when pain lasts more than 24 hours, it requires urgent surgical intervention (acute cholecystitis). The length of a fully distended gallbladder is about 7 to 10 cm. We report a case of a huge and severely inflamed gallbladder, as we have just found only a few previous case reports of the huge gallbladder in the literature. This case report and review may help to find a mechanism for the development of a giant gallbladder. The patient was a 36-year-old woman, who had been known to have a symptomatic gallstone for at least three years. The patient underwent laparotomy, and a giant 22 cm roundish severely inflamed and overdistended gallbladder with wall thickening and tight adhesion to adjacent organs was found under the right liver lobe. Femininity and diabetes seem to be risk factors for developing a huge gallbladder, and several hypotheses are encountered: (1) a long-lasting obstructed cystic duct or biliary tree, and accumulation of mucosal secretion from the gallbladder epithelium, (2) an obstructed hepatic/cystic duct junction with a stone acting like a check valve and bile trapping mechanism, and (3) gallbladder dysfunction and cholecystoparesis affecting through reduced cholecystokinin and celiac parasympathetic nerve disturbance in diabetes and diabetic autonomic neuropathy. Open cholecystectomy is the technique of choice in surgical excision of a huge gallbladder; however, laparoscopy could be performed by expert hands.

Duodenal obstruction due to accidental swallowing of a dental prosthesis: a case report and review of the literature.

BACKGROUND: Artificial dentures are the most common object ingested by elderly patients and account for 4-18% of all foreign body ingestions. Denture impaction in the small bowel is a rare phenomenon. Surgery of the duodenum is difficult, so endoscopy should be the first choice in these patients. There are very rare case reports on denture ingestion-induced duodenal obstruction or perforation, so the aim of this publication was to show a rare case of accidental ingestion of a dental prosthesis with duodenal obstruction and also perforation that could not be treated with endoscopic management and was managed with duodenal kocherization and gastrostomy. CASE PRESENTATION: A 47-year-old Iranian woman presented to our hospital with epigastric abdominal pain of 2 hours' duration after the accidental ingestion of a dental prosthesis 2 days before admission. The patient had severe epigastric tenderness. Radiographic examination revealed nothing. Upper gastrointestinal endoscopy showed a swallowed lodged denture in the second to third parts of the duodenum, and the attempt to extract the denture failed. The patient underwent laparotomy and duodenal kocherization, pushing the denture to the stomach, and gastrostomy, and the denture was brought out without any complications. CONCLUSIONS: Patients with old and worn dentures should have their prosthesis reconstructed and redesigned periodically in order to prevent denture ingestion and its complications. Early surgical intervention is recommended in patients with failed endoscopic extraction of foreign bodies and in those with duodenal perforation.

Isoflurane Induced Malignant Hyperthermia in a Patient with Glucose 6-Phosphate Dehydrogenase Deficiency and Growth Hormone Abuse.

Malignant hyperthermia is a pharmacogenetic disorder in the regulation of calcium in skeletal muscles which is related to an uninhibited muscle hypermetabolic reaction to potent inhalation agents, the depolarizing muscle relaxant succinylcholine, and to stressors such as vigorous exercise and heat. MH is diagnosed by the clinical presentation of the disease and laboratory testing. There are a few previous studies working on if there is an association between the occurrence of malignant hyperthermia and the existence of glucose 6-phosphate dehydrogenase (G6PD) deficiency, and there was no report on growth hormone doping in the literature. So, our main goal was to show this rare case of malignant hyperthermia seen in a G6PD patient with growth hormone abuse who underwent surgery and to find if there is an association between G6PD deficiency, growth hormone abuse, and malignant hyperthermia. Our patient was a 17-year-old boy with right lower quadrant abdominal pain and tenderness who underwent appendectomy. At the end of the operation, the patient developed with an increased heart rate (sinus tachycardia), increased body temperature and end-tidal carbon dioxide (ETCO2) level, masseter muscle rigidity, and then, generalized body rigidity, so the malignant hyperthermia susceptibility was considered. The patient was managed by cooling down the patient and the administration of dantrolene. We could hypothesize that malignant hyperthermia might be associated with G6PD deficiency as a triggering factor, but has no association with recombinant human growth hormone (rhGH) abuse. Another main lesson which this study tells us is to make a careful and proper history taking before going on an operation for preoperative evaluation and identification of patients with any form of suspicious drug abuse in order not to receive volatile inhalational agents and, also, performing some preventive measures including avoidance of heat extremes and restricting athletic activity in a patient with a history of malignant hyperthermia, and if the malignant hyperthermia susceptibility is suspected, urgent management should be carried out. As the association between G6PD deficiency, human growth hormone abuse, and malignant hyperthermia has remained unclear up-to-date, further potent studies are seriously needed in the future.

Renal pelvis and ureteropelvic junction incarceration in a Grynfeltt-Lesshaft hernia: a case report and review of the literature.

BACKGROUND: Grynfeltt-Lesshaft hernia is a kind of lumbar abdominal wall hernia in which clinical presentations may vary from an asymptomatic bulge in the lumbar area to a symptomatic lumbar mass with back pain. It has been accepted to be a rare entity, and incarceration of the kidney through this hernia is shown to be very rare, and very few previous cases have been reported in this regard. We present a case of renal pelvic and ureteropelvic junction incarceration in a Grynfeltt-Lesshaft hernia and provide an overview of the existing literature on it. CASE PRESENTATION: A 76-year-old lady presented to the outpatient clinic with the chief complaint of right flank pain and swelling. Computed tomography (CT) scan of the abdomen was revealed a large herniated sac (60*30 mm) in the upper lumbar triangle with protrusion of retroperitoneal and omental fat, right renal pelvis, ureteropelvic junction and proximal ureter with consecutive hydronephrosis. Herniated retroperitoneal and omental fat was reduced, and closure of the abdominal wall defect was done using retro-muscular Mesh and was fixed to the fascia. The patient was discharged 24 h after the surgery without any complications. CONCLUSION: Kidney herniation through the lumbar triangle is extremely rare, and the diagnosis requires careful clinical evaluation. CT scan is the modality of choice for the assessment. Management through surgery should be done in symptomatic patients.