Endovenous laser ablation of the great saphenous vein versus high ligation: long-term results.

Endovenous laser therapy (EVLT) for greater saphenous vein (GSV) insufficiency is a relatively new method of treatment only recently made available in Iran. This is the first long-term randomized trial comparing EVLT with high ligation of saphenous vein (HLS) in the Iranian population. Sixty-five patients met the inclusion criteria and were divided into homogenous treatment groups of EVLT (n = 30) or HLS (n = 35). Clinical severity, etiology, anatomy, pathophysiology (CEAP) classification and Aberdeen Varicose Vein Symptom Severity Scores (AVSS) were used to determine disease severity and symptoms before and after the procedure in both groups. Outcome was measured by the rate of recurrence as shown in Doppler ultrasonography evaluation. Follow-up was conducted 1 week and 3, 6, 12, and 18 months after the intervention. The occlusion rate of GSV was similar in both groups (93.6% for EVLT, 88.3 for HLS) at 18 months of follow-up. The median CEAP score showed a dramatic decrease in both groups after 1 week which was sustained for the rest of the study. The Aberdeen Varicose Vein Symptom Severity score was significantly lower in the EVLT group at 12 and 18 months of follow-up. There was no significant difference in patient satisfaction in both groups. Our findings show that EVLT may offer a better long-term relief of symptoms. This, alongside its better cosmetic outcome, and less invasive anesthesia requirements may make it the favorable choice for treatment of GSV insufficiency.

Dumble cystic lymphangioma as an underlying cause of vague abdominal complaints in a 2-year-old girl: case report.

Lymphatic malformations (LM) refer to very rare hamartomatous benign lymphatic ectasias with an incidence of 1:250 000. They almost involve children more than adults, and among them, infants under one age are mostly affected. Macrocytic LM is found to be more than 2 cm in diameter or 2×2 cm2 in volume. The proper treatment for mesenteric LM is complete surgical excision unless there is vital structure involvement. Case presentation: The authors report a mesenteric macrocytic LM in a 2-year-old girl complaining of vague abdominal discomfort and persistent vomiting in which ultrasonography revealed a cystic masse with seromucous components. She then underwent exploratory laparotomy. The operation and the follow-up duration were uneventful. Discussion: LMs are rare benign lesions of vascular origin with lymphatic differentiation, according to the latest International Society for the Study of Vascular Anomalies (ISSVA 2018). Under light microscopy, these malformations are characterized by their thin-walled endothelium and lymphatic tissue.These mobile lesions are incidentally found or appear with intestinal obstruction or acute abdomen scenarios. Conclusion: Although benign, the LMs have the potential for invasion and recurrence. Thus, the examiner physician must keep such intra-abdominal lesions in mind.

A life-threatening encounter: an uncommon case of ruptured hydatid cyst presenting as anaphylactic shock and respiratory distress in a 12-year-old boy.

Introduction and importance: Although rare, the spontaneous rupture of a lung hydatid cyst or its perforation into the pleural cavity can give rise to an abrupt onset of symptoms, including cough, fever, hemoptysis (coughing up blood), and hypersensitivity reactions, and can ultimately lead to respiratory failure. Case presentation: A 12-year-old boy was brought to the emergency room with a loss of consciousness. Symptoms included tachypnea, fever, low blood pressure, and overall respiratory distress. After resuscitation, a chest X-ray revealed a distinct, well-defined round opacity located in the lower region of the right lung, leading to mediastinal displacement. After confirmation of the disease, the child was hospitalized in the ICU care and consequently underwent surgery. Treatment was successful and there was no recurrence on the follow-up. Clinical discussion: Studies have demonstrated that the right lower lobe of the lung is the most frequently affected area of the lung by hydatid cysts. Symptomatic and complicated hydatid cysts are a rare concept in children, and only a small percentage, are diagnosed in patients younger than 16 years. Surgery remains the preferred treatment for the majority of patients with pulmonary hydatid disease. It is important to note that combined surgery and chemotherapy represents the current gold standard in managing pulmonary hydatid cyst. Conclusion: Although anaphylactic shock caused by a ruptured lung hydatid cyst is rare, it should be taken into consideration by physicians as a differential diagnosis in patients who also have respiratory symptoms, particularly in endemic areas.

Infantile hypertrophic pyloric stenosis, the cause of non-bilious vomiting of a 3-day-old male infant with situs inversus totalis: A case report.

The synchronicity of situs inversus totalis (SIT) and infantile hypertrophic pyloric stenosis (IHPS) is rare. We have reported a case of this concurrency in a 3-day-old newborn with classic symptoms.

The Ileoileal intussusception due to a tubular duplication in a child: A case report.

Intussusception is a surgical emergency that may result in the perforation of the intestinal wall if not immediately treated. Pathologic lead points, such as intestinal duplication, are present in 2.2%-15% of the cases.We describe a 4-year-old girl with a necrotic ileoileal intussusception diagnosed with a rare tubular ileal duplication.

A rare case of necrotizing fasciitis after early infant male circumcision.

Even though circumcision is low-risk, complications may occur, necessitating careful management. Here, we describe a 5-month-and-28-day-old infant who developed necrotizing fasciitis following Plastibell circumcision. This report emphasizes that clinicians should use standard equipment and appropriate-sized rings to prevent these unusual complications following circumcision.

The effects of botulinum toxin injection on urodynamic changes in pediatric population with neurospastic bladder: First trial in Iran.

BACKGROUND: Neurogenic bladder is one of the serious, disturbing problems referred to pediatric urologic clinics. The increase in bladder pressure may damage the upper urinary tract. Anticholinergic medications have been used as the first line of complementary treatment. Regardless can be omitted, botulinum toxin (BT) was introduced as an alternative method for increasing bladder compliance. BT is a neurotoxic poison that can interfere with acetylcholine release, leading to reduced external sphincter pressure and detrusor activity. This study was established to assess urodynamic changes following BT injection among Iranian pediatric population, for the first time. METHODS: This clinical trial was conducted at Shahid Beheshti University of Medical Sciences (SBUM), Tehran, Iran, from November 2018 to January 2019 as a medical graduation dissertation. Twenty patients, previously as followings with a neurogenic bladder who met the eligibility criteria, underwent BT injection with general anesthesia using a rigid cystoscope and an endoscopic needle. Demographic data, history of anticholinergic consumption, side effects or intolerance, and the dosage of the injected BT were all recorded. The urodynamic variables during our study included: flow rate in second two, the flow time of diuresis, time of peak flow, average flow, discharged volume, maximum detrusor muscle filling pressure, maximum flow, acceleration, post-void residual volume, compliance, and cystometric bladder capacity. SPSS software version 22 was used to analyze data. The significance level was considered less than 0.05. RESULTS: Twenty patients who did not respond to anticholinergic medications or could not tolerate the side effects were entered the study. The mean age was 7.7 ±â€¯2.02 years (range 5-13), and 13 (65%) of them were male. All patients received anticholinergic medications before BT injection. Discharge volume and maximum detrusor muscle filling pressure showed the most significant changes after injection (p < 0.005). However, there was no significant effect of the baseline characteristics on post-injection improvement in urodynamic results (p > 0.05). CONCLUSION: In this study, maximum detrusor filling pressure and discharge volume were both significantly improved. These findings motivate additional studies towards selecting better indexes for defining the clinical improvement and its relation with specific urodynamic results. LEVEL OF EVIDENCE: Treatment study, level III.

Early pyeloplasty versus conservative management of severe ureteropelvic junction obstruction in asymptomatic infants.

BACKGROUND: Ureteric-pelvic junction obstruction (UPJO) is the most common cause of antenatal and neonatal hydronephrosis and its management remains controversial. While conservative management is advocated for all, this strategy puts a quarter of these patients at risk for possibly irreversible renal damage. AIM: In this study, we compare functional and anatomic outcomes in newborns and infants less than 1 year of age with high-grade unilateral UPJO, following early surgical pyeloplasty (ESP) versus conservative management (CM). MATERIALS AND METHODS: This was a single center prospective interventional study. Infants referred to our tertiary care pediatric surgery clinic between September 2016 and September 2018 with UPJO were considered. To be included patients must have been less than 1 year old, lack of clinical symptoms, suffer from severe hydronephrosis as defined by Society for Fetal Urology (SFU) grades 3 or 4, and have affected kidney Split Renal Function (SRF) above 40%. Patients with bilateral disease, structural anomalies, or an abnormal voiding cystourethrogram (VCUG) were excluded. Anatomical and functional outcomes were measured and compared at 6 and 12 months. RESULTS: Fifty-six patients were assigned to receive either ESP (n = 28) or CM (n = 28). At 6 months Cortical thickness, polar length, and SFU indices were significantly lower in the ESP group, while none of the outcomes were significantly different between the two groups at 12 months. Despite the two groups not being different at 12 months regarding differential renal function (DRF), there was a significant decrease of function in the CM group compared to baseline. CONCLUSION: When considering treatment options for infants with high-grade UPJO, it appears that ESP hastens improvement of anatomic and functional indices, while CM may lead to a significant deterioration in renal function.

Thoracotomy versus Video-Assisted Thoracoscopy in Pediatric Empyema.

BACKGROUND: To compare the outcomes of video-assisted thoracoscopic surgery (VATS) in comparison to open thoracic surgery in pediatric patients suffering from empyema. METHODS: A prospective study was carried out in 80 patients referred to the Department of Pediatric Surgery between 2015 and 2018. The patients were randomly divided into thoracotomy and VATS groups (groups I and II, respectively). Forty patients were in the thoracotomy group (16 males [40%], 24 females [60%]; average age, 5.77±4.08 years) and 40 patients were in the VATS group (18 males [45%], 22 females [55%]; average age, 6.27±3.67 years). There were no significant differences in age (p=0.61) or sex (p=0.26). Routine preliminary workups for all patients were ordered, and the patients were followed up for 90 days at regular intervals. RESULTS: The average length of hospital stay (16.28±7.83 days vs. 15.83±9.44 days, p=0.04) and the duration of treatment needed for pain relief (10 days vs. 5 days, p=0.004) were longer in the thoracotomy group than in the VATS group. Thoracotomy patients had surgical wound infections in 27.3% of cases, whereas no cases of infection were reported in the VATS group (p=0.04). CONCLUSION: Our results indicate that VATS was not only less invasive than thoracotomy, but also showed promising results, such as an earlier discharge from the hospital and fewer postoperative complications.

Undifferentiated Pleomorphic Sarcoma Presenting as Abdominal Pain with a Pulsatile Mass.

Malignant fibrous histiocytoma (MFH) is a rare tumor that mostly involves adults aged 50 to 70. The most common anatomic location is the lower extremities. MFH of the retroperitoneum usually manifests late in its course and may be initially mistaken with other more common diagnosis. Here, the authors describe a 60-year-old man that was brought to the emergency department with a chief complaint of periumbilical abdominal pain. Our patient presented with symptoms consistent with a symptomatic aortic aneurysm, but a mass was encountered during surgery. In such circumstances the diagnosis of malignant sarcoma must be kept in mind and attempts at full resection with tumor-free margins are necessary.

Rare presentation of retroperitoneal schwannoma: a case report.

The deadly Schwannomas, as uncommon subtype of soft tissue tumors originate from peripheral nerve sheaths. Retro peritoneum is an uncommon site for these tumors. Here we present the clinical feature and therapeutic implication of a 38-year-old man affected by recurrent retroperitoneal schwannoma who admitted to emergency ward following abdominal pain. Computed Tomorgraphic Scan showed a solid well-differentiated heterogeneous mass, 8.5x6 cm size in portahepatis beneath liver and right periumbilical .On laboratory tests Cancer Antigen 19-9 and Cancer Embryonic Antigen were in normal range. In surgery, a 7x8cm round mass was discovered at juxta renal juxta duodenal retro peritoneum, It was completely adhered to second part of duodenum with no signs of infiltration of the liver and right kidney, unable to simply being enucleated, curative resection was performed by classical whipple procedure. The patient`s hospitalization course was uneventful and on the second week he was discharged from the hospital with complete recovery. Due to the high recurrent rate of retroperitoneal Schwannomas even in benign circumstances, radical resection would be the treatment of choice.

Familial adenomatous polyposis: ileo-anal pouch versus ileo-rectal anastomosis.

AIM: In this study we describe the presentation, treatment, and complications of 27 FAP patients. BACKGROUND: Treatment of Familial adenomatous polyposis (FAP) is centered on early recognition and curative surgery with either restorative proctocolectomy with ileal-pouch-anal-anastomosis (IPAA) or colectomy with ileo-rectal anastomosis (IRA). PATIENTS AND METHODS: All patients diagnosed with FAP at our center from 2008 to 2012 were included in this case series. Either IPAA or IRA was used for treatment. Complications were recorded for 12 months after the procedure. RESULTS: Overall 27 patients were included, 12 (44.44%) index patients, and 15 (55.55%) relatives diagnosed by screening. Eight Index patients presented with rectal bleeding, two with occult fecal blood and two with abdominal masses found to be desmoid tumors. Nineteen patients were treated by IPAA, 6 with IRA, and 2 were inoperable due to diffuse desmoid tumors. Daytime stool frequency was the most common side effect (70.37%), followed by bowel discomfort episodes (55.56%), requiring dietary restrictions (37.4%), passive incontinence (25.93%), soiling (22.22%), nighttime stool frequency (18.52%), flatus incontinence (16.0%), and anastomosis leakage (3.70%). On average patients treated by IPAA experienced less complication than those treated by IRA. CONCLUSION: compared with previous reports, this series had older age of diagnosis, higher rate of adenocarcinoma at diagnosis, and fewer side effects after IPAA than IRA. The latter may reflect technique improvement with experience, and if supported by future studies, will cement IPAA as the treatment of choice in FAP.

Neo-adjuvant chemoradiotherapy; an opportunity in sphincter preserving procedure for rectal cancer.

AIM: The present study was designed to assess the impact of neo-adjuvant chemoradiotherapy on the possibility of utilizing sphincter preserving techniques in rectal cancer surgery. BACKGROUND: For both patients and surgeons anal sphincter preserving surgery serves as the ideal procedure to treat rectal cancer. PATIENTS AND METHODS: Patients with rectal cancer who were admitted to Shohadaye Tajrish hospital between 2001 and 2011 and underwent sphincter preserving or non-preserving surgery were identified. They were divided into those who had received neo-adjuvant chemo-radiotherapy prior to surgery and those who didn't, and the type of surgical procedure they underwent was compared between the two arms. Data regarding tumor pathology, tumor size and distance from anal verge before and after neo-adjuvant therapy, together with the duration of chemo-radiotherapy were also assessed. RESULTS: 103 patients with documented rectal cancer were included in our analysis. Among 47 patients who had not received neo-adjuvant therapy, 26 (55%) underwent APR while 15(32%) and 6(13%) patients were treated with LAR and VLAR respectively. Of the 56 patients who had gone through chemo-radiotherapy prior to surgery, 30 (53%) underwent APR while 14 (25%) and 10 (18%) patients were treated with LAR and VLAR respectively. 2 patients had unresectable tumor. Tumor staging before and after neo-adjuvant therapy showed a statistically significant difference (p=0.0001). CONCLUSION: Neo-adjuvant chemo-radiotherpy can decrease tumor size, increase the distance between the tumor and anal verge, and downgrade the staging. However, it does not necessarily increase the possibility of performing sphincter preserving surgery on patients suffering from low-lying tumors.

Perforated jejunal diverticula- a rare cause of acute abdominal pain: a case report.

Jejunal diverticula have a prevalence of approximately 1% in the general population. Perforation of jejunal diverticulum is a rare. Clinically this diagnosis may be easily confused with other causes of an acute abdomen. In the article, we discuss a 74-year-old man with a 2-day history of constipation and left-sided abdominal pain. The day before admission he developed an abrupt exacerbation his symptoms with pain localized to periumbilical and left lower quadrant. An abdominal computed tomography scan revealed soft tissue stranding within the left upper quadrant, bilateral plural effusions , larger on the left, an opacity with the right and left pulmonary lobes and polypoid lesion with in stomach. Physical examination revealed left upper quadrant fullness. An emergency laparotomy was carried out. This revealed multiple jejunal diverticula, one of which had perforated 40 centimeters distal to the ligament of Treitz.

Necrolytic migratory erythema as the first manifestation of glucagonoma.

Necrolytic migratory erythma (NME) as a rare skin disorder that can affected Perineum, distal extremities, lower abdomen and face are the most commonly affected sites.It can be as a part of Glucagonoma syndrome that is defined as an association of glucagonoma with NME, hyperglucagonemia, glucose intolerance, anemia and weight loss. Here, Authors describe a woman admitted to the dermatology ward with NME which was later found to be associated with glucagonoma and multiple hepatic lesions.