Obesity and incidence of colorectal polyps: a case-controlled study.

Previous essays have presented possible concordance between obesity and colorectal polyp development. However, neither for the hypothesis nor for the details general consensus exists. This study aimed to evaluate the association between higher BMI rather than the normal and colorectal polyp presentation and characteristics if any. Methods: Eligible patients based on study criteria who were candidates for total colonoscopy examination enrolled in this case-controlled trial. Controls had normal colonoscopy reports. A positive colonoscopy for any kind of polyp was followed by a histopathological study. Demographic data also was registered, and patients were categorized according to the calculated BMI. Groups were matched by both gender and status of tobacco abuse. Finally, the outcomes of colonoscopy and histopathological studies were compared between groups. Results: A total of 141 and 125 persons investigated, respectively, as patients and controls. Possible effects of gender, tobacco abuse, and cigarette smoking were declined by participants matching. Hence, we found no significant difference between groups regarding the latter variables (P>0.05). Colorectal polyps were found absolutely more in BMI>25 kg/m-2 rather than in lesser values (P<0.001). However, there was no obvious difference in the incidence of colorectal polyps between groups categorized as overweight and obese (P>0.05). Namely, even weighing over could be the risk for colorectal polyp development. Additionally, it was more expected to find neoplastic adenomatous polyp(s) with high-graded dysplasia in BMI>25 kg/m-2 (P<0.001). Conclusion: Even little changes in BMI further than the normal values can independently increase the risk of developing dysplastic adenomatous colorectal polyp(s) significantly.

Effects of oral N-acetyl cysteine on pain and plasma biochemical parameters in fibrocystic breast disorder: A randomized controlled trial.

Background: Fibrocystic change is the most common benign lesion in breasts of a woman in her reproductive age. It is an outcome of estrogen excess due to sex hormone imbalance. Cyclical pain as the most common symptom worsens life quality, compels patient to seek health care support continuously, and imposes large amounts of expense to both patient and health system. Current study aims to evaluate effects of N-acetyl cysteine on decreasing pain and changes in plasma biochemistry. Method: A total of 64 eligible women participated in this double-blinded randomized controlled trial. They were between 18 and 40 years. Participants were randomly allocated into oral N-acetyl cysteine and placebo receivers. Intervention and follow-up lasted for, respectively, a 12-week drugs-on and 12-month drugs-off period. Visual analog scaling was applied to measure severity of pain. Peripheral venous plasma was extracted and compared for inflammatory parameters including high-sensitivity C-reactive protein, total antioxidant capacity, malondialdehyde, total plasma glutathione, lipid profile, and fasting blood sugar. Results: Oral N-acetyl cysteine significantly decreased feeling of cyclical mastalgia (P < .01) after 12 weeks of consumption. In addition to lowering of plasma level of high-sensitivity C-reactive protein (P = .008), total plasma glutathione significantly increased (P = .02) among N-acetyl cysteine receivers. No change in lipid profile and insulin sensitivity was seen. Conclusion: N-Acetyl cysteine could mitigate cyclical mastalgia. Inflammation as a considered reason for cyclical mastalgia also was halted by N-acetyl cysteine consumption.

Evaluation of applying topical tranexamic acid to control septorhinoplasy - induced hemorrhage.

OBJECTIVES: Hemorrhagic events related to surgical field is a common disturbing complication which could worsen the outcomes of operation. This study aimed to evaluate how applying of topical tranexamic acid (TXA) could affect bleeding related to septorhinoplasty operation. MATERIAL AND METHODS: This double-blind controlled trial study finally evaluated 198 candidates for septorhinoplasty repair who were randomly allocated to two groups: TXA receivers (5 mg/kg) and control group (received 5 mg/kg of saline 0.9 %). Then cumulative volume of hemorrhage was calculated by adding total volume of suctioned blood and numbers of fully blood-filled surgical gauzes (15 mL in each). Additionally postoperative 24 h volume of hemorrhage was measured by counting number of bloody surgical gauzes. RESULTS: Of all participants, 90 % were female. The mean age was 26 ± 7 years. Total cumulative volume of hemorrhage during surgery was significantly diminished when topical TXA was applied (p < 0.0001). Additionally drier field of operation was illustrated postoperatively in patients received topical TXA (2 % & 28 % in TXA and saline 0.9 % receivers, respectively) (p < 0.001). CONCLUSION: Using topical TXA could decrease bleeding volume and make surgical field of septorhinoplasty drier either during surgery or postoperatively.

Evaluation of plasma level of fibrinogen as a diagnostic criterion in acute appendicitis; cohort study.

BACKGROUND: Acute appendicitis (AA) is the most common etiology of abdominal operation worldwide. Despite advances in diagnostic guidelines there are still missed patients. This study evaluates assumption of plasma fibrinogen as a diagnostic criterion in AA. METHOD: All patients over 12 years who were referred to emergency department and underwent index open appendectomy were enrolled in this cohort study. Histopathologically confirmed positive reports for presence of AA were allocated in a group. Controls experienced open appendectomy although pathological study was negative for AA. In addition to registering demographic data, plasma sample was examined for fibrinogen, quantitative C-reactive protein (CRP), and complete blood count preoperatively. Variables were compared. The ROC curve was customized and correlation coefficient for study markers was measured. RESULTS: Total 168 patients were enrolled. From all, 96 (57.1%) had confirmed AA, histopathologically. Gender, age, race, and body mass index had no difference between study groups (p > 0.05). In almost all patients increasing in white cell counts and left cellular shift was observed (p > 0.05). However, plasma level of fibrinogen and CRP reached to 389.2 ± 229.99 mg/dL (p = 0.001) and 33.06 ± 16.29 mg/L (p = 0.03) respectively, which both were significantly elevated in positive AA. Analysis showed area under the curve of serum fibrinogen was 0.892 (p < 0.001) with a cut-off point of 272 mg/dL had about 66.7% (95% CI:58.2-73.3) sensitivity, 92.8% (95% CI: 89.5-96.1) specificity, and 0.698 (p = 0.04) correlation coefficient for diagnosis of AA. CONCLUSION: Amounts of elevated serum fibrinogen could imply on the diagnosis of AA specifically when concordance of clinical findings except for increasing CRP is unremarkable.

Duodenal dislodgement of an ingested sharp foreign body by mucosal unfolding "Gilan maneuver"; A novel surgical approach.

INTRODUCTION AND IMPORTANCE: Foreign body (FB) ingestion is a common challenge for pediatric health care providers globally. Although endoscopic approach for FB extraction is recommended, surgery remains life giving specifically in developing countries. We presented a novel surgical approach called 'Gilan maneuver' for removal of FB which lodged in duodenal loop. CASE PRESENTATION: An eighteen months old male infant referred to emergency department while he lied on his mother's arm. Parents stated their son has ingested a sharp metallic pointy thick needle which applies for cattle injection. On examination mid epigastric tenderness was remarkable. Laboratory finding was normal. Plain thoracoabdominal radiologic study confirmed the diagnosis. Patient underwent explorative laparotomy and the needle was removed through 'Gilan maneuver' in which mucosal unfolding of duodenal loop facilitated dislodgement of the FB and it was extracted on the jujenal side. CLINICAL DISCUSSION: Duodenal lodge of sharp FB is rare and could be masked by gastric deposition diagnosis. Mucosal folding, narrow luminal diameter, retroperitoneal adherence, and hard surgical anatomy of the duodenal loop make both sharp and large FBs spontaneous dislodgement and favorable surgical outcome relatively unanticipated. CONCLUSION: Despite rarity of duodenal deposition of FB it is possible and could be harmful due to adjacent unforgiving organs. Although endoscopic extraction of FB is generally recommended in guidelines, surgical approach is safe and could be considered.

A Case Series of Life-Threatening Hemorrhagic Events in Patients with COVID-19.

Since venous microthrombotic and thromboembolic events in end organs have been pathophysiologically confirmed as a component of thrombo-inflammatory cascade in COVID-19 syndrome, anticoagulant prescription with prophylactic or therapeutic goal is recommended. Different guidelines for the above are introduced; however, there is no general consensus on any neither the type of anticoagulant nor for the dosage and duration of prescription. In our medical center, adopted internal guideline was considered for patients COVID-19. We consulted patients with COVID-19 who suffered from concurrent hematoma. Appropriate surgical approach was considered. Finally autopsy study was performed for patients. In this article, we presented a series of seven SARS-CoV-2 confirmed cases faced with bleeding complication following initiation of anticoagulation protocol. The rectus sheath hematoma with extension to pelvic and/or retroperitoneal space, even involving bowel mesentery was seen most commonly. Despite receiving appropriate surgical care, all seven cases died. Finally, in all cases, autopsy studies revealed no evidence for confirmation of DIC/SIC or organ failure as the reason of death although pulmonary involvement with SARS-CoV-2 and bleeding phenomena were approved. The nature of the COVID-19 syndrome makes patients vulnerable to hemorrhagic events following anticoagulant administration which relatively causes or accelerates patient's expiration.

Biliary infection; distribution of species and antibiogram study.

BACKGROUND: Biliary infections like cholecystitis and cholangitis are common and could be life threatening if treated inappropriate. Prescribing antibiotics is the key to control such infections. Occurrence of bacterial resistance to antibiotics is highly probable and should be continuously monitored. This study aimed to re-evaluate bacterial species distribution and their interaction to antibiotics in biliary infections. METHOD: Total 2288 patients who were diagnosed as whether acute or chronic cholecystitis with/without concurrent cholangitis enrolled in this cohort study. All were candidate for cholecystectomy operation. In the theatre a sterile bile sample was aspirated from the gallbladder as early as the organ was exposed. Analysis was performed on culture and antibiogram results. RESULTS: Finally 492 (21.5%) microorganism growth was seen in all culture environments. Bacterial colonization was most common in cholangitis (63.8%) which followed by acute (26%) and chronic (10.9%) cholecystitis respectively (p = 0.001). Escherichia coli (58%) and Klebsiella species (12.2%) were mostly isolated pathogens. Antibiogram study illustrated bacterial sensitivity of gram-negative pathogens to imipenem (100%), amikacin (98.1%), and gentamicin (90.4%) which in gram-positive bacterial species was 100% to imipenem, vancomycin, rifampcin, and clindamycin. CONCLUSION: Cephalosporins as an empirical treatment for biliary infections is not suitable. Aminoglycosides including amikacin and gentamycin are costly beneficial as the first line for empirical antibiotic therapy in selected patients because of their good bacterial sensitivity and low expenses. Imipenem should remain for multidrug resistance species.

Lipoabdominoplasty and the leptin hormone.

BACKGROUND: Obesity contributes to a chronic disease with lethal complications. Leptin as an adiponectin interacts with fat metabolism. Surgical extra fat resection is an interventional approach to control obesity. We aimed to evaluate how body contouring surgery would influence on leptin plasma level. METHODS: Females candidate for body contouring surgery were allocated in to two groups included abdominal wall liposuction alone and in combination with abdominoplasty from 2018 to 2020. Demographic data was registered. Serum plasma level of leptin with the ELISA method was measured on the day before the operation and also after 3, 6, and 12 months after surgery with 8 h fasting prior to blood sampling. Finally the amounts of resected fat, type of surgical approach, and plasma level of leptin were analyzed. RESULTS: Total 124 females with mean age of 37 ± 10.1 years underwent abdominal wall liposuction (58%) and liposuction + abdominoplasty (42%) respectively. Mean weight and BMI significantly decreased postoperatively for both groups (p < 0.01). Although in both groups leptin concentration was higher in all triple blood sampling following operation in compared to preoperative measurement, changes were not significantly considerable (p = 0.6). Coefficient of correlation between amounts of resected fat and plasma level of leptin was directly positive and calculated 0.4 (p = 0.03). CONCLUSION: Leptin interacts independently from abdominal wall contouring surgery. However it could be a marker for amounts of resected fat after operation.

Predicting factors and incidence of preventable trauma induced mortality.

INTRODUCTION: Trauma is one of the most common causes of morbidity and mortality worldwide. Since the definition of preventable death has been described many studies like current one were conducted to evaluate this issue. METHODS: This cohort retrospective study investigated archived medical files of trauma victims from 2017 to 2020 in a referral single-center trauma hospital. Registered demographic data, vital signs, Glasgow coma scale (GCS), timing of trauma and death, executed interventions, type and mechanism of trauma in addition to time errors, clinical mismanagements, and missed injuries were extracted. Injury severity score, revised trauma score, and probability of survival based on TRISS method for each case were calculated. Eventually preventable and non-preventable death were defined and compared. RESULTS: Finally from the all 413 trauma deaths 246(54.9 %) files were enrolled. Dead persons were from 18 to 95 years. Of all 189(76.8 %) were males. Analysis manifested 135(54.9 %) of all deaths were potentially preventable and the rest 49.1 % was non-preventable for expiration(p = 0.001). Data showed that from all variables systolic blood pressure ≥80 mmHg, respiratory rate >19 per minute, GCS>8, higher RTS, road traffic accidents and control of external bleeding were contributed to prediction of preventable trauma related mortality. CONCLUSION: This study implied on that frequency of trauma related preventable death was regionally high and associating factors that could influence the number of these mortalities included systolic blood pressure, respiratory rate, GCS, revised trauma score, mechanism of trauma, and external bleeding of trauma patients.

Presentation of the hypothenar hammer syndrome as a low incidence aneurysmal disorder of the ulnar artery.

INTRODUCTION AND IMPORTANCE: The hypothenar hammer syndrome (HHS) is either rare or underdiagnosed condition that arises from vascular insufficiency of the ulnar artery in the hand. The most common accused mechanism is repetitive blunt trauma to hypothenar region while activating the latter as a hammer to do the job. CASE PRESENTATION: A 48 year old woman worked as a master of university claimed from pain and numbness in her left hand concurrent with a pulsatile mass. The second case was a 48 year old man who was a mechanic engineer in automotive industry that claimed of a pain and pulsatile mass in his non-dominant left hand. CLINICAL DISCUSSION: Ulnar artery enters the hand from Guyon's canal where fixes to adjacent structure and is susceptible for injury. Aneurysmal formation is an outcome of arterial trauma which could result in distal necrosis if remains untreated. CONCLUSION: This study has revealed that even whether a single blunt trauma or writing with pen could lead to aneurysmal formation. It has also showed primary aneurysmal resection with no further surgical procedure is both safe and reliable if digital ischemia is not concurrently present.

Cruroplasty added to laparoscopic sleeve gastrectomy; does it decrease postoperative incidence of de-novo acid reflux?: A randomised controlled trial.

BACKGROUND: Laparoscopic sleeve gastrectomy(LSG) is the most popular bariatric surgery worldwide. Postoperative de-novo acid reflux is one of the major common complications of the procedure. Different additive anti-reflux surgical techniques have been tried to decrease the complication although no favorable outcome is obtained. This study was conducted to evaluate effects of concurrent cruroplasty during LSG on postoperative de-novo acid reflux incidence rate. METHODS: In current participant-blinded randomised controlled trial total of 80 subjects who were candidate for LSG were enrolled from the September 2018 to the December 2019. Following matching patients by gender and age, simple randomization method was held to allocate participants to LSG alone and LSG + cruroplasty groups with equal 40 members in each. Demographic data, length of hospital stay, and operation time was registered. Presence of acid reflux was looked by using gastroesophageal reflux disease-health related quality of life(GERD-HRQL) questionnaire prior and 6 months after surgery in follow-up visit. RESULTS: Finally 12/28 and 14/26 male/females with 38.5 ± 10.7 and 39.7 ± 8.2 years of age were recruited in LSG alone and LSG + cruroplasty, respectively.(p > 0.05) The length of operative time was significantly shorter in LSG alone(p < 0.01) although no obvious difference was existed in length of hospital stay between groups.(p = 0.7) Postoperative de-novo acid reflux also was not considerably lesser after cruroplasty compared with controls.(p = 0.1) The GERD-HRQL scores were not remarkable between subjects of study groups.(p > 0.05). CONCLUSION: Equipping LSG with concurrent cruroplasty to diminish postoperative de-novo gastroesophageal acid reflux is not effective and not recommended in absence of other indications.

Bile reflux after one anastomosis gastric bypass surgery: A review study.

BACKGROUND: Recently the performance rate of one anastomosis gastric bypass (OAGB) bariatric surgery has increased. Bile reflux is on of common considered complication of OAGB challenging surgeon. METHODS: We searched English full text with keyword "bile reflux" AND "OAGB" OR "one anastomosis gastric bypass" OR "SAGB" OR "single anastomosis gastric bypass" that published from January 1st, 2000 to December 31st, 2020 in PubMed, EMBASE, Google scholar and Cochrane Library. We included prospective or retrospective systematic review, review, clinical, and meta-analysis human article that its full text was available and focused on bile reflux after OAGB/SAGB as the fundamental performed bariatric surgery. RESULTS: A total of 1259 articles were analyzed, of which 5 were included. Analysis of number articles by year revealed that 2019 and 2020 was the highest number of published articles (n = 232; 68%). Study type analysis revealed that review studies and clinical research (n = 62; 18.2%) were the most frequent study types. Reported data on bile reflux after OAGB had diversity. Implicitly, postoperative incidence of bile reflux differed from 7.8 to 55.5%. General consensus was not existed among authors to consider the OAGB as the first suspect leading to postoperative bile reflux among other bariatric surgery types. CONCLUSION: Although surgeons prefer to conduct OAGB procedure because of its easier surgical approach needing just one anastomosis formation it is not virtually clear that is the procedure costly benefitted regarding bile reflux outcomes.

The intracranial branch; A rare anatomical variation of the recurrent laryngeal nerve; Case report.

INTRODUCTION: The recurrent laryngeal nerve (RLN) originates from the Vagus nerve intrathoracically. It passes through the tracheoesophageal groove (TEG) in the neck and different variations in this section were observed. The RLN is at highest risk for injury during the thyroid surgery. Therefore, it is important to know variations to decrease the injury effectively. PRESENTATION OF CASE: A 50 years-old woman with no thyroid related complaints except for enlargement of the thyroid gland in recent 12-months that annoyed her during neck movement and for aesthetic features. Medical, surgical, drugs, irradiation history, laboratory data, and physical examination was unremarkable except for multi-lobulated enlarged thyroid gland. The CT scanning study revealed intrathoracic extension of the gland. Patient underwent total thyroidectomy with suspicious diagnosis of multinodular goiter which was confirmed later by pathologic study. Intraoperative exploration of the right RLN discovered an intracranial branch originating from the recurrent laryngeal trunk just beneath the inferior thyroid artery (ITA) at the level of the nerve intersection. The branch then passed laterally about 1 cm and penetrated in ipsilateral carotid sheath. DISCUSSION: The RLN has different anatomical variations in either the right or the left side of the neck. However extra-laryngeal nerve branching is the most common variation but other seldom variations including the non-RLN, and intracranial branch should be mentioned by surgeon intraoperatively. CONCLUSION: To decrease iatrogenic injuries to RLN and its associated nerve branches knowledge of the nerve anatomy is mandatory for surgeon to prevent morbid side effects.

Magnesium Sulfate and Clonidine; Effects on Hemodynamic Factors and Depth of General Anesthesia in Cesarean Section.

BACKGROUND: Making stable hemodynamic and also durable unawareness is a daily challenge in the setting of general anesthesia in women who undergo surgical delivery of neonate and have limitations to receive opioids derivatives. OBJECTIVES: We aimed to evaluate the effects of magnesium sulfate and clonidine on hemodynamic changes and depth of anesthesia and in mentioned mothers and also in neonatal APGAR index. METHODS: Current randomized, double-blind controlled trial study was conducted among a total of 360 pregnant females (38 - 41 weeks of gestation) who underwent elective cesarean section. Participants were randomly divided into three drug-receiving groups (equal 120 members): magnesium sulfate (30 mg/kg), clonidine (3 µg/kg), and placebo (0.9% NaCl). Patients' blood pressure, heart rate, cerebral state index (CSI) in specific time zones, and also late 24-hour recall were recorded. The CSI is an electroencephalographic monitoring method helping to assess the depth of anesthesia. Neonatal parameters, including APGAR score and umbilical venous blood sampling, were measured. RESULTS: Mean patients' age was 28 ± 4.5. A significant decreasing and stabilizing effect of magnesium sulfate and clonidine on hemodynamic parameters (blood pressure and heart rate) was revealed (P < 0.001). Evidence implied on deeper anesthesia (lower CSI) among drug receivers comparing to placebo (P < 0.001). None of the participants experienced a late 24-hour recall postoperatively. All neonates were healthy, and no decrease was reported in APGAR score at minutes 1 and 5. Umbilical blood gas analysis showed no signs of acidosis and/or hypoxemia. CONCLUSIONS: Adjuvant administration of either magnesium sulfate or clonidine is associated with hemodynamic stability and favorable unawareness in the setting of elective surgical delivery.