Maim, death cases following the installation of vascular access devices filed with specialized forensic medicine commissions of Tehran, Iran, 2013-2018, (A descriptive study).

Background: Implantation of vascular access devices is of great importance in critically ill patients or those vulnerable to clinical worsening. The aim of this study was to identify the complications of implantation of vascular access leading to complaints from patients, in the forensic medicine commissions of Tehran. Methods: The present descriptive-cross sectional study was performed on all cases that died from implantation of vascular access devices and complaints about permanent local complications caused by this procedure, filed with the forensic medicine commissions of Tehran in period of 2013-2018, based on selected variables, and the results were statistically analyzed using the chi-square and Fisher exact tests in SPSS Version 18. A p-value of <0.01 was considered statistically significant. Results: All alleged deaths were due to implantation of central venous port placed in a large vein in the neck, and most organ failure cases were attributed to anterior forearm deformity. The most common cause of death was acute cardiac death; internal bleeding was observed in 14% of them. Most complaints of death were filed against general surgery and anesthesia assistants, and most complaints about peripheral venipuncture were against trainee nurses. The present study findings were significantly different in terms of cannulation site, age, cause of death, type of local complication (p<0.01). Conclusion: This study shows, as patients become more aware, complaints from physicians about implantation of vascular access, in the judicial authority are also on the rise. Therefore, in choosing these patients, Venice should be treated more carefully.

Jump Technique versus Seton Method for Anal Fistula Repair: A Randomized Controlled Trial.

BACKGROUND: The treatment of anal fistula has been a conundrum for surgeons over the years. Various methods such as fistulotomy, fistulectomy, seton, ligation of the intersphincteric fistula tract (LIFT), advancement flaps, fibrin glue, and plugs are well-known techniques. Yet, they may be followed by several considerable complications, including incontinency and recurrence. METHODS: In this study, the outcomes of the "Jump" and "Seton" techniques are compared. A randomized controlled trial consisting of 130 cases with cryptoglandular anal fistula randomly sorted into two groups was conducted. Group A underwent the "Jump technique" while group B underwent the "Seton technique." Outcomes, incontinency and recurrences in particular, were evaluated after a year of treatment. Data were analyzed by Fisher Exact, Chi-Square and Mann Whitney Tests. RESULTS: Group A with 65 cases underwent the "Jump technique" while group B with 65 cases underwent the "Seton Method." Recurrence was reported in 12 (20%) cases in group A and 10 (15.6%) cases in group B (p=0.687). Overall incontinence was reported in 3 (4.6%) cases in group A and 18 (27.7%) cases in group B (P=0.001). The total St. Mark's scores for incontinency of group A (0.092±0.52) and group B (1.8±02.47) significantly differed (p<0.001). CONCLUSIONS: The "Jump technique", named after a runner who jumped over hurdles, has obviated these complications. The "Jump technique" had satisfactory results and can be utilized as a first-line approach for all types of fistulas. Moreover, it can be redone for cases with recurrences without affecting the continence, paving the way to change the technique during operations.

Factors Related to Mortality in Patients with Fournier's Gangrene or Necrotising Fasciitis; a 10-year Cross-Sectional Study.

INTRODUCTION: Fournier's gangrene (FG) is a life-threatening disease, even with early diagnosis and administration of vigorous treatment, its mortality rate is high. This study aimed to evaluate the factors relate to mortality in patients with FG or necrotising fasciitis managed in a referral center. METHODS: This retrospective cross-sectional study was conducted on patients managed in a tertiary referral center, Tehran, Iran, from March 2009 to March 2019, with diagnosis of FG or necrotising fasciitis. The correlation between different demographic and clinical parameters with mortality was analysed and reported. RESULTS: 73 cases with the mean age of 59.1 ± 15.8 (range: 25 - 88) years were studied (87.7% male). 21 (28.8%) patients died. Escherichia coli (26 cases, 35.6%) was the most frequent microorganism in cultures. Non-survived cases had higher mean age (p = 0.01), higher frequency of hyperlipidaemia (p = 0.02), immunosuppression (p < 0.001), longer hospital stay (p=0.02), lower blood pressure (p=0.01), and lower platelet count (p=<0.001). Based on multivariate analysis, age (p = 0.015; Odds: 0.88 (0.79-0.97)), haematocrit level (p = 0.01; Odds: 1.27 (1.04-1.55)), platelet count (p = 0.03; Odds: 10.11 (1.14-89.35)), and immunosuppression (p = 0.01; Odds: 0.01 (0.0-0.54)) were independent related factors of mortality. CONCLUSIONS: The rate of mortality due to FG and necrotizing fasciitis was 28.8%. Based on multivariate analysis, the independent related factors of mortality were older age, lower haematocrit level and platelet count, and presence of immunosuppression.

Comparing open conventional carpal tunnel release with mini-incision technique in the treatment of carpal tunnel syndrome: A non-randomized clinical trial.

BACKGROUND: Carpal tunnel syndrome (CTS) is the most common nerve entrapment neuropathy which is the result of the compression of the median nerve in the wrist. Currently, there is no consensus about the best treatment option. The purpose of this clinical trial was to compare the clinical outcomes of patients undergoing open CT release with mini-incision CT release. PATIENTS AND METHODS: This clinical trial included 75 patients with CTS who were divided into two groups of 45 and 30 patients to undergo open-CT release or mini incision CT release respectively. Patients were evaluated pre-operatively, days after the surgery and then five months after the operation to record outcomes. At follow-up, the visual analogue scale (VAS) scores for pain, patients' satisfaction, return to work, length of scar, paresthesia, grip and opposition strength were measured. RESULTS: A total of 75 patients (mean age: 52.13 years, 73.3% female) underwent CTS surgery. Forty-five patients (60%) had open-CT release and 30 patients (40%) had mini-incision CT release. Postoperative pain and scar length were significantly lower in the mini incision group compared to open group (p < 0.001). The mini-incision CT group returned to work earlier than open group with higher satisfaction (p < 0.001). No significant differences were observed between two groups in respect to the improvement of the opposition, grip and paresthesia (p > 0.05). CONCLUSION: Our study demonstrated that mini-incision CT release improves pain more effectively and has better quality of life because of smaller length of scar, immediate return to work and higher overall satisfaction. Neurosensory and motor improvements were also seen in both techniques with the same clinical impact.

Anastomosis of Free Flap Pedicle to Great Vessels.

BACKGROUND: Free Flaps are viable option to cover the tissue defect. Pedicle anastomosis to vessel branches has excellent result. In some situations which there is a possibility of flap failure like shortage of vessel branches, possibility of pedicle kinking or need to vein graft, anastomosis to great vessels is justified. METHODS: Six patients were allocated to study. Five cases for free jejunal flap and one case for free latissimus flap. In free jejunal flap group, pedicle anastomosis was performed as an end-side fashion to common carotid artery and internal jugular vein and in free latissimus flap, pedicle was anastomosed as an end-side fashion to superficial femoral artery and superficial femoral vein. Follow up was regular up to 20 years. RESULTS: In free jejunal flap group, there were three female and two male with age from 30 to 59 years. The sixth case was a thirteen years old male with flexion contracture of right knee who underwent free latissimus flap. Follow up was regular for 20 years. All flaps survived, and good functional result was obtained in all except one. CONCLUSION: Choosing great vessels as one side of anastomosis is safe and can be done as a primary approach due to technical demand or as a final resort when there is shortage of side branches.

How Much Can We do by Reverse Superficial Sural Artery Flap to Potentiate Its Effects: Introducing Spout Sural Flap as a New Modification.

BACKGROUND: Due to shortage of local donor tissue and unreliable blood supply, free flaps were the mainstay of treatment for tissue defects in the lower leg and foot region, but it requires a qualified microvascular surgeon. Recently, attention has been paid to reverse superficial sural artery flap (RSSAF) and its modifications as a good alternative to pave the way to simple and friendly techniques. METHODS: Excluding each patient with septic and severely ischemic foot, every patient with tissue defect in distal leg and proximal foot region were studied. Various methods were applied including spout technique with sufficient follow up. No imaging was used to evaluate the blood supply. RESULTS: Five patients underwent spout technique with excellent results in four cases. Spout technique in one case failed due to narrow base. In five cases, RSSAF was performed with creating skin tunnel and very good results. CONCLUSION: RSSAF is a good alternative for free flap to cover the leg and foot tissue defects. We also advise wide base pedicle (>4 cm) in every patient.

A study of contractility of proximal surgical margin in esophageal cancer.

BACKGROUND: The marginal length from main tumor in esophageal cancer is aconsiderable issue regarding surgical management and adjuvant treatment; so we decided to study the contractility effect on the proximal surgical margin after immersing it in10% buffered formalin as a fixative. METHODS: The proximal marginal length of ten sequential patients with esophageal cancer who underwent transhiatal esophagectomy were studied, on the operating table as fresh specimens, immediately after resection, and next 24, 48 and 72 hours after immersing in 10% buffered formalin. RESULTS: The contraction continued through the day 3, the mean contractility after one day was about 27%, after two days was 33% and after three days was 38%. CONCLUSION: This study shows how the proximal esophageal margin can vary by the time, after immersing in 10% buffered formalin and should be considered in every settings and reporting documents by pathologists.

Simultaneous gastric adenocarcinoma and gastrointestinal stromal tumor of the stomach: a case report.

Simultaneous a collision tumor of stomach consisting of adenocarcinoma and Gastrointestinal Stromal Tumor (GIST) is very rare based on our knowledge. This coexistence has rarely been reported in literatures. We report a case of 64-year-old woman who has diagnosed with prepyloric poorly-differentiated diffuse signet-ring cell type adenocarcinoma and has undergone an elective D2 total gastrectomy. During operation another mass in fundic body region has found. The pathologic examination of the mass has shown GIST. Immunohistochemical staining for CD117 and Desmin was positive whilst that for S100 was negative. This case reports the simultaneous two tumors development of different histotypes and natures in the same organ.

Surgical treatment of hydatid cyst of the liver: drainage versus omentoplasty.

BACKGROUND: Liver is the most common site of infection and several methods of surgery have been described to treat this common disease. In this study we aim to compare the results of two common methods of surgery; simple drainage versus omentoplasty. METHODS: In this prospective study 65 patients with hepatic hydatid cyst underwent surgery from 10 May 1995 to 1 July 2002. 35 patients were treated with omentoplasty(group I) and 30 of them were treated with drainage(group II). The results of surgery including mortality, complications and recurrences were recorded. RESULTS: There was no case of mortality in each group of patients. Postoperative complications were seen in 5.7% of group I, 16.6% of group II patients. The mean duration of hospital stay was 6.5 and 15.6 days in group I and group II patients. During a mean period of 18.6 month follow up there was no recurrence in each group of patients. CONCLUSION: According to the results of this study we suppose that omentoplasty of cyst cavity--if feasible--is preferred to tube drainage.