A Rare Case of Hamartoma Chest Wall Following Trauma in a 42-year-old Man.

BACKGROUND: Chest wall mesenchymal hamartoma (CWH) is a distinct and extremely rare tumor-like lesion of the thorax. It usually presents in the neonatal period or in infancy. The common presentation is in the form of a visible chest wall mass with or without respiratory distress. CASE PRESENTATION: A 42-year-old man with a history of chest wall trauma since 5 years ago was admitted with a swelling of the anterior of the chest wall and during this period has grown slowly. Physical examination showed a left anterior chest wall deformity. Chest radiographs and chest CT showed a left anterolateral chest wall mass involving the fourth and fifth ribs. Thoracotomy was performed. The tumor and involved ribs were resected with a 5cm safe margin. The histopathologic examination showed hamartoma. The patient has been fallowed up since 60 month ago, and has not had any complaints in this time. RESULT: Despite the rarity of chest wall hematoma, this side effect must always be taken into consideration while studying the chest wall injuries especially in the case of trauma history due to other differential diagnosis and her side effects such as respiratory problems. CONCLUSION: Although rare, this condition ought to be kept in mind while dealing with hamartoma Chest wall following trauma in order to avoid its complications such as respiratory problems. Surgical excision is usually curative in combination with conservative therapy if possible.

Honey in the treatment of Fournier's gangrene as an adjuvant: a cross sectional study.

Fournier's gangrene is a progressive polymicrobial necrotising infection. The purpose of this study was to assess the outcome of Fournier's gangrene infection in patients who received topical honey with their therapeutic regimens. The cross-sectional study included 17 patients with Fournier's gangrene. Under spinal anaesthesia, the necrotic areas were debrided. In the first week, every day, the wounds were cleansed with Betadine, normal saline, and 2% oxygenated water, then 30-50cc of honey was used after the wounds were dried. The wounds were then dressed. This method of dressing was taught to the patients' attendants. The granulation tissues, generally bright pink, were observed on the 10th day. Four (23.5%) patients underwent colostomy and 1 (5.9%) died. All the patients were discharged two weeks after the initial debridement. Compared with other studies, honey reduced the healing and hospitalisation time as well as additional costs.

Post-traumatic pseudoaneurysm of the descending aorta.

High-energy deceleration injuries of the thoracic aorta are associated with high mortality. But among long term survivors, just 2 %-5 % of traumatic aortic injuries fail initial detection and are discovered later (Pozek et al., 2012 [1]). We present a rare case of pseudoaneurysm of the descending aorta in a female with a history of chest blunt trauma 45 days before who presented with chronic severe cough and vocal hoarseness that was treated with endovascular intervention in our center.

Inguinal hernia: Lichtenstein VS Shouldice technique repair: A randomized controlled trial.

Background: Inguinal hernia repair is the most frequent operation in general surgery. The chance of a person having to undergo an inguinal hernia operation during his/her life is quite high, 27 % in men and 3 % in women. European Hernia Society guidelines state that the Lichtenstein technique (mesh-based repair) is the standard treatment of elective inguinal hernia in adults. Some authors consider the Shouldice technique (tissue-based repair) the best conventional method for open hernia repair. In this study, we compared these two methods. Methods: In This randomized study, 452 patients were randomly allocated into 2 groups. 51 patients were lost during follow-up period and were excluded from further analysis in the study. Finally, the analyzed patients were 183 patients in Shouldice technique group and 218 patients in Lichtenstein technique group. All patients were examined after 1 week, 1, 3 months, 1, 2, and 3 years after the operation date. Results: After 3 years follow up Recurrence of hernia in Shouldice technique group was 7.1 % and in Lichtenstein technique group was 3 % with significant differences (p-value 0.006). No statistically significant differences were found between the groups in wound infection, Seroma, hematoma, Hydrocele, Bladder damage, chronic pain in the inguinal region, and Patient Satisfaction level after surgery. Conclusion: It seems that inguinal hernia treatment by the Lichtenstein technique is better than the Shouldice technique in elective patients.

Evaluation of Clinical Characteristics and Outcomes of Chest Trauma Patients with COVID-19 Infection Undergoing Emergency Surgeries.

BACKGROUND: This study aims to examine the clinical characteristics and prognosis of patients with chest trauma who were infected with COVID-19 and underwent emergency surgery. OBJECTIVE: In light of the COVID-19 pandemic, this research investigates the impact of COVID-19 on patients with chest trauma who underwent emergency surgery. METHODS: This retrospective cohort study was conducted on 56 patients with chest trauma in two groups with COVID-19, and no covid who underwent surgery in Shahid Madani Hospital. RESULTS: Among the trauma patients, 21 were infected with COVID-19, and 35 were not. The predominant causes of trauma were car and motorcycle accidents. Among COVID-19 patients, 3.3% exhibited symptoms of fever, chills, cough, shortness of breath, and gastrointestinal symptoms, while 5.9% had severe lung involvement confirmed by CT scan. Following surgery, 1.57% (12 individuals) of COVID-19 patients were transferred to the ICU, with an average hospitalization duration of 1.11 days. In contrast, the average hospitalization duration for non-COVID-19 chest trauma patients was 1.9 days (p =0.015). CONCLUSION: Patients with chest trauma who underwent surgery and were infected with COVID-19 demonstrated significant differences in average length of stay, ICU admissions, and pneumonia incidence. However, there was no significant distinction in the mortality rate between the two groups.

A rare case of carotid artery injury during maggot debridement therapy for locally advanced parotid gland carcinoma.

INTRODUCTION AND IMPORTANCE: Maggot debridement therapy (MDT) is a treatment for chronic ulcers that involves using live larvae to debride the wound. CASE PRESENTATION: We report a case of serious arterial bleeding in the cervical region in a 52-year-old woman who was hospitalized in Iran for a malignant ulcer of the retro-auricular area. The patient was brought to the hospital by Emergency medical service due to severe hemorrhagic shock. CLINICAL DISCUSSION: Debridement is a commonly used method for wound management, aimed at reducing the risk of infection and removing ulcer debridement. Several techniques are available for debridement of chronic wounds, including mechanical, surgical, autolytic, and enzymatic methods, each with its own advantages and disadvantages. CONCLUSION: Maggot debridement therapy (MDT) is one of these methods that seem to be relatively safer. In this method, some larvae are used for debriding wounds in patients. It is usually used as a last resort treatment but in this case, it was used as a third line after surgery and chemoradiotherapy.

Sigmoid volvulus secondary to undescended testicle: Report of first case in the literatures.

Sigmoid volvulus accounts for 20%-50% of colonic obstructions in Eastern countries. This occurs mostly in patients with a lack of mobility and a history of chronic constipation. There are some very known complications of a undescended intra-abdominal testicle such as cancer, ischemia, and infertility; But the rotation of the colon around the spermatic cord of one UDT is a very rare phenomenon that there is no similar report. A 67-year-old man came to the emergency department with a complaint of abdominal pain and obstipation. On examination, patient was febrile (T: 38.5) and had mild general tenderness. According to the appearance of coffee beans in the X-ray, the diagnosis of sigmoid volvulus was made. In the requested tests, leukocytosis was observed. Rectosigmoidoscopy was unsuccessful. The patient underwent laparotomy. After manual untwisting, a tubular structure at the base of the meso-sigmoid was noticed. With further exploration, the testis was observed intra-abdominally. Orchidectomy and sigmoidectomy were performed by Hartmann's method. Sigmoid volvulus is one of the common cases that surgeons frequently encounter. The case scenarios are often the same, and from experience, most cases result from a long meso and an elongated sigmoid secondary to prolonged constipation. Therefore, it is clear that a scrotal examination would not be part of the routine examination of a patient with sigmoid volvulus. In this article, by reporting a very rare etiology for a very common pathology, we tried to point out the importance of head-to-toe examination in all patients.

Evaluating Diagnostic Efficiency of Thyroid Imaging Reporting and Data Systems proposed by the American College of Radiology in Surgically Resected Thyroid Nodules.

AIM: Thyroid nodules are one of the most common clinical findings, with a prevalence of 68% in adults. Thyroid cancer is the fifth most common cancer in women. INTRODUCTION: The purpose of this study is to evaluate the diagnostic efficacy of Thyroid Imaging Reporting and Data Systems proposed by the American College of Radiology (ACR-TIRADS) for the diagnosis of malignancy in surgically resected thyroid nodules. METHODS: In this retrospective study, patients who underwent thyroid nodules resected surgically from 2018-2020 were included. Before resection, an ultrasound was performed for TIRADS scores, and after resection histopathology, thyroid mass was obtained. The outcomes of the two systems were statistically compared. RESULTS: The mean age of the 146 included patients was 47.6 ± 14.08 years, of which 109 (74.7%) were female. Based on TIRADS, 47 patients (32.2%) were in TI-RADS TR3, 36 patients (24.7%) were in TIRADS TR2, 34 (23.3%) in TIRADS 4, 24 (16.4%) in TIRADS TR5 and 5 patients (3.4%) were in TIRADS TR1. The overall sensitivity was 79.9% when ACR-TIRADS TR4 was set as a diagnostic cutoff value. Considering the total of TIRADS TR4 and TIRADS TR5 as predictors of thyroid malignancy, the sensitivity was 74.5% and the specificity was 76.8%. The positive and negative predictive value was 60.3% and 76.8%. CONCLUSION: ACR-TIRADS 4 and 5 can be considered good predictors of malignancy in thyroid nodules. More studies, including larger samples, are required to obtain a better conclusion.

Touch imprint and crash preparation intra operative cytology versus frozen section in thyroid nodule.

BACKGROUND: Intra operative cytology (IC), including touch imprint (TI) and crash preparations (CP), in general has been demonstrated to be a diagnostic tool for many organs but its validity and reliability for diagnosis of thyroid nodules remain controversial. We evaluate the diagnostic value of frozen section, touch imprint, crash preparation and the combination of touch imprint and crash preparation and the combination of frozen section, touch imprint and crash preparation. MATERIALS AND METHODS: [corrected] 55 intra operative specimens from patients with thyroid nodules who underwent thyroidectomy were evaluated at Alzahra and vali-Asr hospital laboratories. For all of the patients frozen section (FS), touch imprint (TI) and crash preparation (CP) was obtained and reviewed by two pathologists at the same time. Serial TI and CP, and FS, TI and CP were reviewed by the same pathologists. Sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio and accuracy were calculated according to the permanent section as the gold standard test. RESULTS: In our study sensitivity, specificity and accuracy for FS was 100%, 97.6% and 98.1% respectively; for TI they were 78.6%, 95% and 92.4%; for CP they were 78.6%, 92.7% and 89.9%; for serial TI and CP they were 85.7%, 92.7% and 90.9%; and for the combination of FS and TI and CP they were 100%, 97.6% and 98.18% respectively. CONCLUSIONS: Intra operative cytology (including TI and CP) seems to be a useful, valuable and inexpensive method in clinics, which do not have equipment for frozen sections. Intra operative cytology combined with FS increased the overall accuracy of diagnosis. Further studies are needed to validate the obtained results of this study.

A Comparative Study between the Postoperative Complications of Stripping Esophagectomy and Classic (Orringer's Technique) Esophagectomy.

Recent studies have suggested that morbidity and mortality rate of transhiatal esophagectomy is comparable to that of thoracotomy, calling the need for the modifications in the surgical procedures. Our methodology includes stripping of esophagus by nasogastric tube to reduce the manipulation of thoracic cavity and associated complications. We also present the comparison between the stripping and classic (Orringer's technique) esophagectomy. Patients presenting esophageal carcinoma from 2015 to 2017 were the target of this study. Patients undergoing esophagectomy were randomized to have classic or stripping esophagectomy. Operating time, manipulation time, blood losses during the surgery, duration of hospitalization, volume intake, hypotension time, arrhythmia, and transfusion were the recorded parameters. Complications, such as anastomotic leak, cardiac effects, and morbidity, were also studied. Seventy patients were referred for transhiatal esophagectomy for esophageal carcinoma at the Al Zahra Hospital. Mean ages of patients in the stripping and Orringer group were 64.00 ± 10.57 and 57.42 ± 12.20 years, respectively. Manipulation time, operating time, blood loss during the surgery, and transfusion were statistically significant variables between the two groups. Although volume intake and duration of hospitalization were not significantly different parameters, however, betterment in the outcomes was evident. Substantial decrease in overall complications via stripping method was obtained, hence can be suggested as an effective alternative, to remove the need of thoracotomy, for transhiatal esophagectomy.

Comparison of an ephedrine infusion with lidocaine %5 for prevention of hypotension during spinal anesthesia in cesarean section.

BACKGROUND: Spinal anesthesia is the method of choice for cesarean section and in most cases causes hypotension. OBJECTIVE: The aim of this study was to treat hypotension by ephedrine in order to prevent maternal and fetal complications, and also to determine the effective amount of ephedrine for reducing arterial hypertension in order to prevent its complications, including cardiac arrhythmias. METHOD: This cross-sectional descriptive study was conducted on 131 patients. Mean arterial blood pressure (MAP) of the candidates for cesarean section in the supine position was measured and recorded as mean baseline blood pressure. 75 mg of lidocaine (5%) was used as spinal anesthesia, following which the average blood pressure was measured every 1 min. In the event of a decrease in the mean arterial blood pressure of at least 20% of the mean baseline blood pressure, ephedrine 0.1/mg/kg was injected intravenously and after 1 min of MAP was measured. RESULT: The prevalence of hypotension was 89.30%. 25.60% of patients with hypotension had 30-34.99% reduction in MAP compared to baseline MAP. 12% patients had 40% drop in their MAP. 4 min following spinal anesthesia, the incidence of hypotension reduced by 20%. The average dose of ephedrine required to reduce the incidence of hypotension was 20.5 mg. CONCLUSION: Reduction in MAP following spinal anesthesia using lidocaine is common. Ephedrine at the dose of 20 mg is effective to reduce the incidence of perioperative hypotension.

A rare case of abdominal foreign bodies; laparoscopic removal of a sewing needle.

Background: Foreign body (FB) ingestion is a common condition. Mostly FBs are found ingested accidently or intentionally in children and adults with mental status alterations. Depending on the type of object, different complications can occur. There exist numerous methods for removing each specific FB. Fortunately, most FBs tend to move uneventfully through the gastrointestinal tract without any intervention; but managing some foreign objects can be difficult and lead to severe complications. Endoscopy helps with the diagnosis and treatment of these cases, but the time of the management plays an important role. Case presentation: A 26-year-old female who intentionally swallowed two sewing needles, presented to our emergency department with abdominal pain two months after the FB ingestion. One of the sewing needles was spontaneously excreted through the bowel, and the other was present in her body for two months. The FB had penetrated the stomach and migrated to the peritoneal cavity. The patient's condition was managed by laparoscopic removal of the FB and repair of the damaged tissue. According to the traumatic nature of the needle to abdominal viscera, and standing outside the GI tract on the pancreas surface, laparoscopic removal of the foreign metallic body was chosen to be performed. No complication was seen during the postoperative period. Conclusion: This report emphasizes the importance of prompt evaluation of FB patients and finding the appropriate method of managing its complications. Preventing complications requires focusing on symptoms and instant management of the ingested FBs.

A case report of largest rectal prolapse in the literature successfully treated with Altemeier's procedure.

Background: The rectal prolapse is defined as the concentric protrusion of full or partial thickness of the rectum or rectosigmoid via the anus. This is an increasing clinical concern that is usually found in old female patients. Cases presentation: A 39-year-old male patient was referred due to an un-reduceable rectal projection from a week ago. The primary endeavor for reduction of the projection under sedation and after local mannitol treatment at the operation room was unsuccessful, so surgical resection and reduction were planned for the patient. Conclusion: Management of rectal prolapse has always been one of the challenges of colorectal surgery. For patients with incarcerated prolapse manual reduction under sedation is used. If the reduction is unsuccessful, surgical procedures are used.

Bronchoalveolar lavage of ventilator-associated pneumonia patients for antibiotic resistance and susceptibility test.

BACKGROUND AND AIMS: Ventilator-associated pneumonia is highly prevalent nosocomial infection among patients under mechanical ventilation. Bronchoalveolar lavage (BAL) is effective in identifying the type of pathogen involved and determine the course of antibiotic. The aim of this study was to evaluate the prevalence of different pathogens involved in ventilator-associated pneumonia (VAP) and associated antibiotic resistance and sensitivity pattern. METHODS: In this descriptive cross-sectional study, patients admitted to the intensive care unit under mechanical ventilation at Shahid Madani Educational and Medical Center in Karaj during 2018 and 2020 were included. BAL samples were obtained from the patients. Demographic data, duration of hospitalization, duration of mechanical ventilation, and antibiotic susceptibility and resistance tests were recorded for all the patients. RESULTS: Among 335 patients included in the study, 215 (64.2%) were males. The mean age of the patients was 55.06 ± 14.90 years. The most common pathogens reported were Acinetobacter baumannii (40%), Pseudomonas aeruginosa (21.2%), and Staphylococcus aureus (13.4%). The mean age of the patients, gender, duration of mechanical ventilation, and duration of hospitalization were not associated with the type of pathogen, P > .05, respectively. CONCLUSION: BAL of these patients indicated that various pathogens are responsible for VAP, and can vary from patient to patient. Antibiotic resistance and susceptibility pattern of these pathogens vary and therefore is important in determining the course of the treatment.

Bowel obstruction secondary to gallstone ileus within a strangulated inguinal hernia: Report of a rare diagnosis.

INTRODUCTION: Gallstone ileus is rare and inguinal hernias are common causes of intestinal obstruction but combination of them is a very rare cause of intestinal obstruction. It is accepted that in patients with severe comorbidities surgeons can manage inguinal hernias and gallstone conservatively. In this article we report a patient with gallstone and inguinal hernia that managed with conservatively management because of heart failure but admitted with complication of gallstone and hernia and treated successfully. CASE PRESENTATION: An 80-year-old woman with a history of heart failure and two bouts of acute cholecystitis, who presented with pain and swelling in the inguinal region and obstructive symptoms. And due to the urgent nature of the condition, she underwent surgery. CONCLUSION: One of the rare complications of gallstones is cholecystoduodenal fistulas, especially in patients whose episodes of cholecystitis are treated medically. Early diagnosis and appropriate surgical management in these circumstances reduce the mortality and morbidity.

Accessory spleen presenting with an episode of acute appendicitis; a case report of a very rare case.

INTRODUCTION: The accessory spleen (AS) is a condition that results from improper placement of spleen cells. About 95 % of ASs are located in the splenic hilum proximal to the tail of the pancreas. Here we present a 23-year-old male diagnosed with AS in the appendix, following an episode of acute appendicitis. CASE PRESENTATION: A 23-year-old male patient who presented with typical symptoms of appendicitis and the examination and paraclinical findings were in favor of appendicitis. Intraoperative findings showed an inflamed appendix and a 2 cm solid mass in the mesoappendix. The pathology report showed acute appendicitis and normal spleen tissue. CONCLUSION: The current study indicated an abnormal location of AS placed in the mesoappendix, which was presented with an episode of acute appendicitis.

Comparison of Wound Infection in Uncomplicated Acute Appendicitis by Subcuticular Suture and Interrupted Suture.

BACKGROUND: Postoperative complications such as wound infection and scarring are some of the major concerns regarding suturing techniques. This study is designed to evaluate postoperative outcomes of adhering subcuticular sutures in comparison to the interrupted suturing method in patients who underwent appendectomy for uncomplicated acute appendicitis. METHODS: 240 patients were randomly assigned into two groups; 120 with interrupted and 120 subcuticular sutures after an appendectomy, at Shohada Ashayer hospital, Khorramabad, Iran. The prevalence of wound infection, three days after the surgery in the hospital and a week after discharge was determined and evaluated statistically. RESULTS: No wound infection was seen within three days of hospitalization in the subcuticular group whereas, 1 patient reported infection in the interrupted group, however, the difference was not statistically significant. A week after discharge, a patient was reported to have wound infection in the subcuticular group and 2 in the interrupted group. No significant difference was seen in this regard either. 55 females and 66 males received subcuticular sutures whereas, 74 males and 46 females were given interrupted sutures for wound closing. One male in interrupted and 1 male and female in the subcuticular group were referred for wound infection, after discharge, respectively. Among these groups, no significant differences were seen. In catarrhal appendicitis, the infection was reported in the interrupted group only which was not statistically significant. CONCLUSION: Subcuticular sutures provide better cosmetic outcomes without any additional complications in comparison to interrupted sutures.

Using new technicque in sigmoid volvulus surgery in patients affected by COVID19.

INTRODUCTION: Coronavirus pandemic-initiated Wuhan city, Hubei Province, China. It mainly involves respiratory system and cause fever, cough. However, it has other manifestations such as GI system, CNS and skin involvement. It is transmitted mostly through respiratory system, but some researchers claim that in can potentially spread by oral, fecal or intestinal gas. During colorectal surgeries such as volvulus sigmoid, surgeons are at risk of exposure to intestinal gas. CASE PRESENTATION: A 57-year-old mentally retarded man came to our emergency department with complain of abdominal pain, constipation, obstipation, nausea, vomiting and abdominal distention. His vital sign was stable and his laboratory data revealed no abnormality. His abdominal x-ray showed intestinal obstruction with suspicious of sigmoid volvulus. His PCR for COVID 19 was positive and his chest CT scan has manifestations of lung involvement. He was proceeded for surgery. CONCLUSION: Owing to odds of spread of coronavirus through intestinal gas, in this case, sigmoid colon was removed without evacuation of intestinal gas.

Complications in Patients with Cardiac Penetrating Trauma.

BACKGROUND: Cardiac penetrating trauma is a medical emergency that mostly affects young people. Based on the type of injury and associated complications, it can present as a surgical challenge and can lead to mortality. OBJECTIVE: The aim of this study is to evaluate the complications of penetrating heart trauma among patients referred to Shahid Madani Hospital. METHODS: In this retrospective descriptive study, the data of penetrating cardiac trauma patients referred to Shahid Madani hospital, Karaj, Tehran, from 2016-2019, were investigated. Information, including age, sex, cause of trauma, traumatized area and complications, was extracted and recorded in a data collection form. The data were evaluated statistically using SPSS v18. RESULTS: A total of 44 patients were included in the study, where the mean age of the patients was 25 years. 73.3% of these patients were men and 26.7% were women. Knife stab wounds were the most prevalent cause of the trauma, present in 93.3% of patients. 73.3% of the patients had cardiac tamponade and 20% had a pneumothorax. The right ventricle was the most common site of the injury in 46.7% of the patients. A mortality rate of 3.4% was reported in this study. CONCLUSION: The results of this study showed that the highest penetrating heart rate trauma occurred among young people, and the most common cause of the trauma was a knife stab. The most common area of the injury was the right ventricular, and cardiac tamponade was the most common complication.

A retrospective study on the cardiac assessment of isolated sternal fracture patients based on radiographic and clinical outcomes.

OBJECTIVE: Sternal fracture may be associated with major and serious injuries. In this study, the complications associated with isolated sternal fracture in trauma patients are evaluated based on radiographic and cardiac findings. METHODS: This retrospective study was performed on patients with isolated sternal fractures admitted to the emergency department of (XXX) Madani Educational-Medical. Data regarding demographic information, mechanism of trauma, length of hospitalization, electrocardiography (ECG), cardiac enzyme, and chest radiography were recorded in the questionnaire for each patient. RESULTS: The mean age of patients 41.2 + 11.04 years and 63.9% were male. The most common cause of the trauma was car accidents in 41% (25 cases). The mean duration of hospitalization was 1.54 ± 0.90 days. The mechanism of trauma was not associated with x-ray and computed tomography findings, p = 0.53 and p = 0.86, respectively. ECG findings were significantly related to x-ray and computed tomography outcomes, p < 0.001, respectively. CONCLUSION: Patients with isolated sternal fracture with displacement >0.5 cm and hematoma are likely to require cardiac consultation.