Comparison of Optic Nerve Sheath Diameter (ONSD) in Low-Pressure Versus Normal Pressure Pneumoperitoneum in Laparoscopic Cholecystectomy: A Randomized Clinical Study.

Background: Low pressure laparoscopic cholecystectomy has been advocated due to reduction in postoperative pain, ventilation problems, hemodynamic complications, and potential for reduction in surgical events. No reported data have been found focusing on the effects of low-pressure laparoscopic cholecystectomy on intracranial pressure (ICP). The aim of this study was to investigate the effect of low-pressure laparoscopic cholecystectomy on intracranial pressure measured by optic nerve sheath diameter (ONSD) in Imam Hossein Medical Center, Tehran, Iran. Methods: The patients classified as American Society of Anesthesiologists physical status I or II undergoing elective laparoscopic cholecystectomy due to benign gallbladder disease were randomly assigned to low-pressure laparoscopy (LPL) group or normal pressure laparoscopy group (NPL). ONSD was measured at 3 different times: (1) before induction of anesthesia; (2) after initiation of gas insufflation; and (3) after the termination of gas insufflation. The collected data were entered into SPSS software (V 24). Data were demonstrated with frequency (percentage) or mean ± standard deviation. We used the Mann-Whitney test to compare the means of continuous variables. The Friedman test was used to compare the mean of variables over time in each of the 2 groups. The significance level in all analyses was considered at ˂0.05. Results: ONSD after the termination of gas insufflation was significantly lower in the LPL group with the mean of 4.97±0.83 mm than the NPL group with the mean of 5.62±1.32 mm (p=0.018). ONSD before induction of anesthesia or immediately after gas insufflation did not differ significantly between LPL and NPL groups. Duration of anesthesia and surgery, mean arterial pressure, the total dose of propofol (p=0.600), and fentanyl (p=0.201) did not show significant differences between the 2 groups. Conclusion: ONSD was lower with low-pressure laparoscopic cholecystectomy after the termination of gas insufflation, which emphasized the neural protective effect of low intraperitoneal pressure. Further studies are needed to evaluate this diagnostic tool in different populations, especially in patients with increased ICP undergoing laparoscopic interventions.

A new decision making model for diagnosing acute appendicitis among non-pregnant women and its comparison with alvarado scoring system.

Background: Although acute appendicitis is a common problem, it remains a difficult diagnosis to establish, particularly among females of reproductive age. The present study was conducted to devise a new decision making model for diagnosing acute appendicitis in non-pregnant women. Methods: The present study was a retrospective study consisting of women who had undergone an appendectomy between 2007 and 2015 at the emergency department of Imam Hossein Medical Center, Tehran, Iran. The inclusion criteria were being a female, presenting with abdominal pain, being a suspected case of acute appendicitis, and undergoing an emergency appendectomy. A classification and regression tree (CART) analysis was performed to partition exam and laboratory data obtained from these patients into homogeneous groups in order to develop a prediction rule for appendicitis diagnosis. Results: The study population included 433 non pregnant women who underwent emergency operations with a preliminary diagnosis of acute appendicis. Out of these patients, 295 patients (68.1%) were appendicitis positive based on the pathology exam results, while 138 patients had a normal appendix, indicating a negative appendectomy rate of 31.8%. The final devised CART model included hemoglobin level, PMN count, age, and history of abdominal incision and yielded a sensitivity of 82.7% and specificity of 55.8%, which were better than Alvarado prediction results for the Asian population. Conclusion: We have devised a simple and cost effective prediction model for predicting the outcome among non-pregnant women undergoing emergency appendectomy operation with good sensitivity and specificity compared to the Alvarado model.

Abdominal Surgery in Patients With COVID-19: Detection of SARS-CoV-2 in Abdominal and Adipose Tissues.

Multiple tissue samples were obtained during emergent abdominal surgery in 4 patients with coronavirus disease 2019 (COVID-19) to examine for tissue involvement by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The first patient underwent a laparoscopic cholecystectomy for gallbladder empyema and died from severe respiratory failure. The second patient with Crohn disease underwent emergent laparotomy for a perforation in the terminal ileum and recovered. The third patient underwent an open appendectomy and recovered. The fourth patient underwent emergent laparotomy for a perforated peptic ulcer and died from sepsis. Although the SARS-CoV-2 RNA was found in the feces of 3 patients and in the duodenal wall of the patient with perforated peptic ulcer, real time reverse transcriptase polymerase chain reaction (RT-PCR) examination of abdominal fluid was negative for the virus. The RT-PCR did not detect viral RNA in the wall of small intestine, appendix, gallbladder, bile, liver, and urine. Visceral fat (omentum) and abdominal subcutaneous fat of 4 patients were also not infected with the SARS-CoV-2. Although this limited experience did not show direct involvement of abdominal fluid and omentum, assessment in large series is suggested to provide answers about the safety of abdominal surgery in patients with COVID-19.

Reconstruction of the plantar toe with a distal reverse instep sensory island flap.

BACKGROUND: Plantar toe ulcers are a challenging surgical problem. There are several methods for reconstruction, but no attention has been given to the preservation of sensation. This report proposes a method to provide protective sensation for the reconstructed area. PATIENTS AND METHODS: The ulcers of seven patients ranged from 2 × 3 to 7 × 3 cm with defects of the plantar first toe and distal metatarsus, including four burns, a trauma, a diabetic ulcer, and a neuropathy injury reconstructed with a distal reverse instep sensory island (DRISI) flap. The patients were 21-38 years old. The second metatarsus medial nerve was co-opted using the end-to-side method to the adjacent lateral nerve, then its proximal stump provided the donor nerve for the sensation of the flap. Patients were assessed in terms of protective sensory functions, including touch, pain, dermatomeric somatosensory-evoked potentials (SEP), thermal sensation and Semmes-Weinstein monofilament (SWM) light touch. RESULTS: The flaps ranged from 2 × 3 to 7 × 3 cm. All transferred flaps to the plantar first toe survived. No complications were observed at the donor and flap sites. Patients were followed-up 8-24 months. Except for two cases, all nerves of the donor and flap sites exhibited protective sensation, including positive SEP responses between 44 and 50 ms and positive SWM responses ≤ 3.84. CONCLUSION: The DRISI flap can be used for the reconstruction of various plantar first toe defects with acceptable protective sensation. End-to-side neurorrhaphy provides a sensory nerve end to subsequent end to end co-optation to the flap nerve for protective sensation.

Age - specific incidence rate change at breast Cancer and its different histopathologic subtypes in Iran and Western countries.

OBJECTIVE: The aim of the present study was to determine the frequency and age-specific incidence rate of different histopathologic subtypes of breast cancer in Iran, and compare it to neighboring and Western countries and to discuss the probable effective main factors. METHODS: National data from cancer registry for 6265 female breast cancer patients were studied in 10 histopathologic groups. RESULTS: The most common tumor was ductal carcinoma (89%). The peak age - specific incidence rate of breast cancer in total, and for epithelial, non-epithelial and ductal carcinomas were all 50-59 years, and it decreased in older age. It is in contrast to US SEER report which shows the incidence increases in higher age. CONCLUSION: Three main factors including younger age of Iranian patients, probable more ERN tumors and different histopathological profile of breast cancer in Iran might be considered and studied to explain different slope of breast cancer after menopause compared to other countries.

The Clinical Efficacy of Infrared Photocoagulation Versus Closed Hemorrhoidectomy in Treatment of Hemorrhoid.

Introduction: Infrared photocoagulation (IRC) was introduced as a mainstay procedure for treatment of hemorrhoids. The present study aimed to compare the clinical efficacy of IRC compared to closed hemorrhoidectomy. Methods: Forty patients suffering grade-3 hemorrhoid that referred to the surgery clinic at Imam Hossein hospital in Tehran in 2013 were randomly assigned to groups treated with the IRC modality or Ferguson's closed hemorrhoidectomy method. The patients in the 2 groups were followed-up for the first 24 hours after surgery and 8 weeks later. Postoperative pain was assessed using visual analogue scale (VAS) at three time points of 24 hours, 2 weeks and 8 weeks after operation. Results: Regarding bleeding, its overall prevalence was 5.0% in the IRC group and 30.0% in the hemorrhoidectomy group, which was significantly less prevalent in the IRC group. Notably, the IRC group had a lower mean postoperative pain score compared to the hemorrhoidectomy group. Time of return to work was significantly shorter in the IRC group; no difference was found in the mean duration of hospital stay, and recurrence rate across 2 groups. Conclusion: IRC procedure is safer than closed hemorrhoidectomy with lower postoperative pain severity, less secondary bleeding, and leads to earlier return to work in patients with hemorrhoid.

Cutaneous Verrucous Carcinoma Superimposed on Chronically Inflamed Ileostomy Site Skin: A Case Report.

Verrucous carcinoma (VC) is a rare variant of well differentiated squamous cell carcinoma (SCC) which is usually found in oral cavity mucosa. Cutaneous verrucous carcinoma is a rare entity and in this paper we report a 43 years old man with VCsuperimposed on chronically inflamed skin of ileostomy site. Previously, he was operated to treat rectal adenocarcinoma and has had ileostomy for six months. The skin lesion was resected totally during surgical operation for ileostomy closure. Histopathologic examination confirmed the diagnosis of cutaneous verrucous carcinoma. Post-operative follow up shows no evidence of recurrence after six months. We suggest patient's training for follow up visits in order to early detection of osteomy site complications including neoplastic changes.

Developing Cervical Hematoma Following Jaw Thrust Maneuver Triggered Diagnosis of Neurofibromatosis: A Case Report and Brief Literature Review.

A 25-year-old man underwent an excision of a thigh mass under general anesthesia without any complication. After the operation, he developed oxygen desaturation requiring a jaw thrust maneuver. A rapidly expanding hematoma on the right side of the neck was formed shortly after the application of the maneuver. The patient was returned to the operation room for a neck exploration. Damage to the facial artery and vein was noted. Further evaluations confirmed the diagnosis of Neurofibromatosis type 1 (NF-1). It is recommended that considering the probable risk of arising hematoma in NF-1 patients, application of jaw thrust maneuver should be performed meticulously.

Liver Hydatid Cyst and Acute Cholangitis: a Case Report.

Amongst the cause of cystic hepatic disease, hydatid cyst is common in the Asia, South America, and Africa. The definitive therapy for hepatic hydatid disease is surgical resection. Rupture of the hydatid cyst into the biliary tree can lead to serious cholangitis. In this report, a 22-year-old man is presented with the signs and symptoms of obstructive jaundice and cholangitis. Ultrasonography reported dilated common bile duct (CBD) with sludge and stones, a hydatid cyst adjacent to the gall bladder and mild thickening of gallbladder wall without a stone. MRCP revealed dilated CBD with a cyst in segment fifth of liver. Due to signs and symptoms of obstructive jaundice in addition to lab data and imaging modalities, the ruptured hydatid cyst into a biliary tree was considered, and surgical intervention was performed to extract daughter vesicles from the CBD. Post intervention, signs and symptoms and cholestasis enzymes were subsided.

Thirteen -weeks ovarian pregnancy following in vitro fertilization for primary infertility treatment: A case report.

BACKGROUND: Ovarian pregnancy constitutes 0.15-3% of all ectopic pregnancies. The incidence of ectopic pregnancy is on the rise owing to evolution in assisted reproductive techniques (ART). The incidence reported following In vitro fertilization (IVF) or embryo transfer (ET) is 0.27% per clinical pregnancy. CASE: We present a case of a 13-weeks ovarian pregnancy following IVF-ET and through a review of the literature, the specific symptomatology, diagnostic criteria, and treatment of this particular pathology will be described. CONCLUSION: Ovarian pregnancy is a rare condition and its diagnosis is difficult and relies on criteria based on intraoperative and histopathological findings. The management is, in spite of medical improvement, based on surgery. But the trend has shifted towards conservative surgeries in majority of cases.