Novel jejunoduodenostomy technique for prevention of duodenal stump blowout following gastrectomy.

INTRODUCTION: Many patients undergo gastrectomy every year with a risk of duodenal stump blowout. We compared the conventional surgical techniques with a new and simple method of reconstruction to prevent this complication. METHODS: We reviewed the medical records of all the patients who underwent gastrectomy from 2002 to 2013 (total or partial distal gastrectomies with Billroth II, Roux-en-Y, and our new technique of reconstruction) in Shohada Tajrish University hospital, Tehran, Iran. RESULTS: A total of 179 patients were eligible for the study: 101 had undergone the new technique (study group) and 78 had undergone the conventional methods (control group). There were three cases of duodenal stump blowout, all in the control group (4 %, P<0.05). One was fatal (1 %). The post-operative hospital stay was significantly shorter in the study group (8.93 vs. 11.51 days, P<0.05). DISCUSSION: Our results show that this new technique can effectively prevent duodenal stump blowout. Other advantages of this technique include the maintenance of physiological passage of food and a safe route for future diagnostic and therapeutic endoscopic interventions. CONCLUSIONS: We present a simple technique that eliminates the risk of duodenal stump blowout. Randomized controlled trials are necessary to confirm our findings.

Effects of negative T wave in electrocardiography on prognosis of post-myocardial infarction patients.

BACKGROUND: Negative T (NT) wave in electrocardiography (ECG) is one of the important factors in determining short- and long-term outcomes in patients with acute myocardial infarction (MI). In this study, we compared clinical and paraclinical findings in post-MI patients according to presence or absence of NT wave. METHODS: A cross-sectional study was conducted on patients with acute ST elevation MI who presented to Shahid Modares Hospital (Tehran, Iran) during 2009-10. After undergoing streptokinase therapy, demographic characteristics and ECG and exercise test findings of the subjects were compared based on the presence or absence of NT wave. RESULTS: Overall, 116 patients including 69 cases with NT wave (NT group) and 47 cases without NT wave (PT group) were enrolled (mean age: 53.7 ± 7.1 vs. 54.1 ± 6.8 years old). Mortality rate during the first five days was 13% in the NT group and 29% in the PT group (P < 0.05). Ejection fraction values of the NT group were significantly higher than the PT group (P = 0.005). However, left ventricular end-diastolic diameter of the NT group was significantly less than the PT group (P = 0.005). Moreover, ST segment depression was significantly less frequent in the NT group compared to the PT group. CONCLUSION: Patients with ST elevation MI accompanying with NT wave in ECG versus have better prognosis and myocardial function than similar patients without NT wave. Therefore, invasive procedures should be recommended for patients without NT wave.

Iatrogenic left main artery dissection: A catastrophic complication.

Iatrogenic left main artery (LM) dissection is a catastrophic complication of coronary angiography and angioplasty that requires prompt management using stenting. Although LM dissection can be prevented, it cannot always be avoided and has a reported incidence rate of 0.02%. In the present report, a case of iatrogenic LM dissection that was successfully treated with multiple stents is presented and followed by a brief review of the literature.

Ligature versus transvenous endovenorrhaphy for closure of side-to-side arteriovenous fistula created for hemodialysis.

PURPOSE: To report a novel technique for arteriovenous fistula (AVF) closure in side-to-side fistulas. MATERIALS AND METHODS: One hundred and sixty-two patients with side-to-side AVFs, who were candidates for AVF closure, were randomly divided into two groups: group A (84 patients) who underwent AVF ligature and group B (78 patients) who underwent AVF closure using transvenous endovenorrhaphy technique. Both procedures were conducted by the same surgical team. The patients were followed up for 6 months. RESULTS: Of 124 patients with proximal AVFs, 65 (52%) subjects underwent ligation and 59 (42%) transvenous endovenorrhaphy. Of 38 patients with distal AVFs, half underwent ligation and for the remainder, transvenous endovenorrhaphy was done. Failure of AVF closure was detected in 28 (17%) patients; 25 (89.28%) were in group A and 3 (10.71%) were in group B. All of these recurrences were successfully treated by transvenous endovenorrhaphy technique. CONCLUSION: We claim that significant lower failure rate of transvenous endovenorrhaphy makes it the technique of choice, especially for side-to-side AVFs.

L-carnitine treatment in patients with mild diastolic heart failure is associated with improvement in diastolic function and symptoms.

OBJECTIVES: L-Carnitine is a crucial component of activated fatty acid transport. The aim of this study was to evaluate the effect of L-carnitine on patients with a history of mild heart failure and diastolic dysfunction. METHODS: Twenty-nine patients with a history of NYHA functional class II symptoms and ejection fraction >45% with documented grade 1 diastolic dysfunction on echocardiogram were randomized in blinded fashion to receive 1,500 mg of L-carnitine daily for 3 months in comparison to a no treatment group (31 patients). Baseline echocardiographic and follow-up measurements of diastolic parameters were assessed after 3 months. RESULTS: Important parameters of diastolic function improved in the L-carnitine group only: left atrial size (3.6 +/- 0.4 cm before treatment vs. 3.4 +/- 0.5 cm after treatment, p = 0.01); isovolemic relaxation time (127 +/- 26 ms before vs. 113 +/- 24 ms after treatment, p = 0.007); septal mitral E' velocity (0.064 +/- 0.01 m/s before vs. 0.074 +/- 0.01 m/s after treatment, p = 0.01), and lateral mitral E velocity (0.082 +/- 0.01 m/s before vs. 0.091 +/- 0.02 m/s after treatment, p = 0.006). Dyspnea also significantly improved in L-carnitine-treated patients. CONCLUSION: In patients with a history of diastolic heart failure, important indices of diastolic function and symptoms appear to improve with L-carnitine treatment.

Changes of left ventricular mass index among end-stage renal disease patients after renal transplantation.

PURPOSE: The aim of this study was to determine left ventricular (LV) mass index via echocardiography in end-stage renal disease patients (ESRD) before and after renal transplantation, and its association with one-year survival. MATERIALS AND METHODS: Forty-seven patients with ESRD who were candidate for renal transplantation were evaluated with echocardiography before and 4 months after the operation. Left ventricular ejection fraction (EF), LV mass, and LV mass index were determined. All of the patients were followed up for 1 year. RESULTS: Mean LVEF was 51.6% which increased to 53.7% after renal transplantation (P = .001). Mean LV mass was 209 gr before the operation which decreased to 189 gr after the operation (P = .001). Mean LV mass index before the operation was 120 gr/m2 which decreased to 110 gr/m2 following the operation (P = .002). All of the patients survived during 1-year follow-up, and no death was reported. CONCLUSION: Renal transplantation had beneficial effects in terms of LV function in young patients with ESRD.

Efficacy of folic acid therapy for prevention of in-stent restenosis: a randomized clinical trial.

BACKGROUND: It is known that there is an association between elevated total plasma homocysteine level and restenosis after percutaneous coronary angioplasty. OBJECTIVE: To evaluate the effect of lowering plasma homocysteine levels on the rate of restenosis after stent-percutaneous coronary angioplasty. METHODS: Folic acid (1 mg) or placebo was administered to 200 patients (mean +/- SD age of 54 +/- 9 years) for 3 months, after successful coronary angioplasty in a double-blind randomized clinical trial. The primary end point was restenosis within six months, as assessed by quantitative coronary angiography after positive exercise tolerance test. The secondary end point was a composite of major cardiac events. RESULTS: Base line characteristics and initial angiographic results after stent-percutaneous coronary angioplasty were similar in the two study groups. The rate of restenosis showed no significant difference in the two groups (5% in placebo vs. 10% in folic acid groups; P = 0.141), as there was the need for revascularization of the target lesion (4% in both groups; P = 0.766). CONCLUSION: Treatment with folic acid does not decrease the rate of restenosis and need for revascularization of the target lesion after stent-percutaneous coronary angioplasty.

Pulse tissue Doppler analysis of tricuspid annular motion in Iranian children.

BACKGROUND: Quantitative assessment of right ventricular (RV) function has been difficult to assess non-invasively secondary to its non-geometric shape and respiratory-variable filling. With recent improvements in ultrasound equipment we are now able to study myocardial velocity changes, which is known as tissue Doppler imaging. OBJECTIVES: To define normal indices of tricuspid pulse tissue Doppler echocardiography imaging in children and infants. METHODS: We enrolled 100 healthy children with the age of 1 month-15 year old who were referred for echocardiography and had no cardiac lesion in primary echocardiography evaluations. Pulse tissue Doppler images of the lateral tricuspid annular motion were recorded using 4-chamber apical view. Simultaneous electrocardiography was used to correct annular motion time with electrical events. RESULTS: Among our patients 9 were under 1 year, 46 between 10 and 15, 36 between 5 and 10, and 9 between 10 and 15. Infants had decreased peak early diastolic annular velocities and early diastolic annular velocity-to-diastolic annular velocity at atrial contraction ratios compared with the older group. Isovolumic relaxation time difference was not significant between two different groups. In this group of patients, deceleration time and isovolumic contraction time were lower too. CONCLUSION: In this study we found out normal values for systolic and diastolic indices of pulse TDI imaging of tricuspid valve in Iranian healthy children. This can be a basis for RV function studies in different congenital cardiac disease.