Emergency laparotomy and perioperative COVID-19: a single-center retrospective cohort study

Concerning the perioperative outcomes of patients diagnosed with COVID-19 who underwent emergency laparotomy, more data must be collected. Because COVID-19 can affect multiple organs, cause various complications, and act as a risk factor for surgery, in this study, we aimed to compare the outcomes of emergency laparotomy between SARS-CoV-2 infected and uninfected patients. This retrospective cohort study was conducted on patients who underwent emergency laparotomy from December 2021 to December 2022. Postoperative outcomes were compared between patients with and without confirmed perioperative SARS-CoV-2 infection. The primary outcome was 30-day mortality. Secondary outcomes were postoperative intensive care unit admission, hospital length of stay, re-operation, and postoperative complications. Data were analyzed by SPSS statistic version 27. In this study, 50 patients in the COVID-19 group and 91 patients in the non-COVID-19 group were assessed. The 30-day mortality in the COVID-19 group was significantly higher than in the non-COVID-19 group (34% vs. 12.1%, respectively, P = 0.004). Postoperative complications were significantly higher in the COVID-19 group (64% vs. 26.4%, P < 0.001). The frequency of ICU admission and need for re-operation were significantly higher in the COVID-19 group (P = 0.003 and P = 0.039, respectively). Length of hospital stay was significantly lower in the non-COVID-19 group (P = 0.021). In patients with confirmed COVID-19, emergency laparotomy is associated with increased postoperative morbidity and mortality. Additionally, emergency laparotomy is associated with increasing postoperative complications, length of hospital stay, intensive care admission, and additional surgery requirement.

Changes in blood flow vortices inside the left ventricle in COVID-19 patients with intraventricular clot despite a normal coronary and myocardial motion

PURPOSE

Our clinical observations showed clot formations in different regions of the left ventricle of the heart in some COVID-19 patients with normal myocardial motion and coronary artery. The aim of this study was to examine the changes caused by COVID-19 disease on blood flow inside the heart as a possible etiology of intracardiac clot formation.

METHODS

In a synergic convergence of mathematics, computer science, and cardio-vascular medicine, we evaluated patients hospitalized due to COVID-19 without cardiac symptoms who underwent two-dimensional echocardiography. Patients with normal myocardial motions on echocardiography, normal coronary findings on noninvasive cardio-vascular diagnostic tests, and normal cardiac biochemical examinations but who presented with a clot in their left ventricle were included. To display the velocity vectors of the blood in the left ventricle, motion and deformation echocardiographic data were imported into MATLAB software.

RESULTS

Analysis and output of the MATLAB program indicted anomalous blood flow vortices inside the left ventricular cavity, indicating irregular flow and turbulence of the blood inside the left ventricle in COVID-19 patients.

CONCLUSION

Our results suggest that in some COVID-19 patients, cardiac wall motion is not satisfactorily able to circulate the blood fluid in normal directions and that, despite normal myocardium, changes in the directions of blood flow inside the left ventricle might lead to clots in different zones. This phenomenon may be related to changes in blood properties, such as viscosity.

Cecal Perforation Induced by Migrated Biliary Stent as a Rare Complication of ERCP: A Case Report and Literature Review

Introduction and Importance. Endoscopic retrograde cholangiopancreatography (ERCP) is a non-surgical method utilized to manage biliary tract obstruction, but the complication of biliary stent migration occurs in 5-10% of patients. Though migrated stents are commonly passed through the gastrointestinal tract without harm, intestinal perforation is a rare but severe complication, affecting less than 1% of cases. Case Presentation. We report a case of a 65-year-old woman who presented to the emergency department with symptoms of abdominal pain, nausea, and loss of appetite. According to clinical examination and evidence, the patient underwent surgery with high suspicion of appendicitis, which unexpectedly uncovered a perforated cecum with a protruding biliary stent. Clinical Discussion. Our report describes a unique and unexpected finding of cecal perforation caused by a migrated biliary stent in a patient. We also conducted a review of current literature on ERCP complications, including risk factors for stent migration, relevant statistics, and appropriate interventions. Conclusion. Surgeons should be aware of the risk of stent migration and complications in patients with a history of ERCP. Removal of migrated biliary stents is recommended, regardless of the presence of complications. Additional assessments for alternative diagnoses are recommended for older patients with abdominal pain complaints. Flexible plastic stents should be used for patients at risk of stent passage.

Bariatric Surgery and Femoral Vein Diameter in Morbidly Obese Patients: a Cohort Study in Iran

INTRODUCTION

Considering the importance of health, the effect of obesity on the quality of life, the person's self-image, and the effect of obesity on various organs, especially the vessels, and the absence or presence of a study in Iran that investigated the effect of gastric bariatric surgery on the diameter of the femoral vein, in the present study, we investigated the effect of bariatric surgery on femoral vein diameter in morbidly obese patients referred to Imam Hossein hospital.

MATERIALS AND METHODS

The present study was a prospective cohort study on morbidly obese patients referred to the center in 2022-2023. In this study, 31 morbidly obese patients with BMI above 30 kg/m2 who were candidates for bariatric surgery were examined. Demographic data were collected using a demographic profile checklist. BMI, the diameter of common femoral veins, and the great saphenous vein were measured and recorded before and 6 months after surgery. Ultimately, the data was collected and analyzed using SPSS V.24 software.

RESULTS

In the current study, 31 patients (62 extremities) were examined. The mean age of the patients was 34.45, with a standard deviation of 8.86. Fourteen patients (45.2%) were male, and 17 (54.8%) were female. The mean diameter of the common femoral vein in the 6 months after surgery was significantly less than before surgery (11.58 (1.64) compared to 12.95 (1.84), P = 0.0001). The mean diameter of the great saphenous vein in the 6 months after surgery was significantly less than before surgery (7.30 (1.45) compared to 7.75 (1.45), P = 0.0001).

CONCLUSION

It seems that bariatric surgery causes a significant decrease in the diameter of lower limb veins (common femoral vein and great saphenous vein) compared to before surgery. However, further studies in this field are recommended.

Sugar-sweetened beverages intake and the risk of obesity in children: An updated systematic review and dose-response meta-analysis

BACKGROUND

The prevalence of childhood obesity has increased worldwide and has reached alarming proportions. Contradictive results from studies and reviews have fuelled an endless debate on the role of SSBs in the development of childhood obesity.

OBJECTIVE

This study aimed to assess the impact of sugar-sweetened beverages (SSBs) intake on body mass index (BMI), body fat percentage (BFP), and waist circumference (WC) among children.

METHODS

Databases including PubMed/MEDLINE, Scopus, Cochrane Library, EMBASE, and Web of Science were searched up to August 2021. Observational studies reporting the relation between SSBs intake and BMI, BFP, and WC were included. STATA version 15 was used to analyse the data.

RESULTS

In this meta-analysis, 33 studies with 121 282 subjects were included. Excessive SSBs intake was associated with 0.75 kg/m² increase in BMI in children and adolescents (WMD: 0.75; CI 0.35-1.15; p < 0.001). In addition, high SSBs intake was significantly associated with higher WC (WMD: 2.35 cm; 95% CI, 1.34, 3.37; p = 0.016) and BFP (WMD: 2.81; CI 2.21-3.41; p < 0.001). No departure from linearity was detected in dose-response meta-analysis between SSBs consumption and changes in BMI, WC, and BFP.

CONCLUSION

High SSBs consumption was associated with increased BMI, WC, and BFP among children and adolescents. Further large prospective long-term interventions are recommended to confirm the observed relationships.

Modulation of astrocyte activity and improvement of oxidative stress through blockage of NO/NMDAR pathway improve posttraumatic stress disorder (PTSD)-like behavior induced by social isolation stress

BACKGROUND

It has been well documented that social isolation stress (SIS) can induce posttraumatic stress disorder (PTSD)-like behavior in rodents, however, the underlying mechanism is remained misunderstood. In the current study, we aimed to elucidate the role of NO/NMDAR pathway in PTSD-like behavior through modulating of astrocyte activity and improvement of oxidative stress.

METHODS

Male NMRI mice were used to evaluate the memory function by using Morris water maze (MWM) and fear memory extinction by using freezing response. We used MK-801 (NMDAR-antagonist), L-NNA (NOS-inhibitor), NMDA (NMDAR-agonist), and L-arginine (NO-agent) to find a proper treatment. Also, immunohistochemistry, RT-PCR, and oxidative stress assays were used to evaluate the levels of astrocytes and oxidative stress. We used five mice in each experimental task.

RESULTS

Our results revealed that SIS could induce learning and memory dysfunction as well as impairment of fear memory extinction in MWM and freezing response tests, respectively. Also, we observed that combined treatment including blockage of NOS (by L-NNA, 0.5 mg/kg) and NMDAR (by MK-801, 0.001 mg/kg) at subeffective doses could result in improvement of both memory and fear memory. In addition, we observed that SIS significantly increases the GFAP expression and astrocyte activity, which results in significant imbalance in oxidative stress. Coadministration of MK-801 and L-NNA at subeffective doses not only decreases the expression of GFAP, but also regulates the oxidative stress imbalance CONCLUSION: Based on these results, it could be hypothesized that blockage of NO/NMDAR pathway might be a novel treatment for PTSD-like behavior in animals by inhibiting the astrocyte and regulating oxidative stress level.

Foreign bodies in the rectum: Three case reports of sexual violence

Background

Sexual violence is one of the worst forms of violence with long-term physical and psychological effects on victims. It has been stated that sexual stimulation was responsible for 78% of clinically relevant foreign rectal bodies. About 10% of the cases were due to sexual assault. A problem commonly encountered in patients with RFB is the delay in presentation. While patients may be reluctant to disclose the cause of their presentation.

Cases presentations

All the patients were males with a mean age of 41.1 years old. On average, they presented 2 days after the rape, Diagnosis was made in all 3 patients with a history and abdominal x-ray.The cause of the foreign body in each patient was violence and retaliatory behavior. Foreign objects included bottles, lamps, and water pipes. In 2 patients the foreign bodies were removed through Trans-anal procedure and in one patient laparotomy and colostomy need to be done for removing the Foreign object.

Conclusion

Despite the urgency in the treatment of these patients, which involves the removal of a foreign body, special attention should be paid to psychological trauma and its long-term effects on patients' wellbeing. In stable, non-perforated patients, tans-anal approach under sedation is a good approach. If it fails, the patient needs to go to operating room for further anesthetic and surgical interventions.

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In stable, non-perforated patients, tans-anal approach under sedation is a good approach.

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Special attention to psychological trauma and its long-term effects on patients requires long-term follow-up.

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Rigid proctoscopy or flexible sigmoidoscopy is recommend after the rectal FB removal.

Comparing the standard surgical dressing with dehydrated amnion and platelet-derived growth factor dressings in the healing rate of diabetic foot ulcer: A randomized clinical trial

AIMS

The management of diabetic foot ulcers is a challenging issue due to the pathophysiological background, delay in healing, and prevalence of diabetes. The purpose of this study was to compare the therapeutic effects of the three methods of diabetic wound care: surgical debridement and dressing, dressing with dehydrated amnion powder, and dressing with platelet-derived growth factor gel.

METHODS

In this multi-arm parallel-group randomized trial, 243 patients with a minimum 4-week medical history of diabetic foot ulcers with Wagner's grades 1 and 2, no infection, and adequate tissue blood flow were randomly assigned to one of three 81-person groups: surgical debridement (the standard method), dehydrated amnion dressing, or platelet-derived growth factor dressing. The follow-up period lasted 12 weeks. The percentage area reduction (PAR) was measured as the final target. SPSS version 25 was used to perform statistical analysis on the data.

RESULTS

All three study groups were comparable in terms of the type of ulcer, the area of ulcer, Wagner's grade, the period, and the ulcer's size. The PAR in the surgical debridement, platelet-derived growth factor, and dehydrated amnion groups were 7.4%, 14.8%, and 49.3% in week 4; 20.1%, 35.8%, and 79% in week 6; 43.7%, 56.8%, 86.4% in week 8; and 50%, 61.7%, and 87.6% in weeks 10 and 12, respectively. The observed differences were statistically significant (p < 0.05) over the entire period.

CONCLUSION

The study concluded that dehydrated amnion dressing, when compared to platelet-derived growth factor dressing and surgical debridement, resulted in better-improved healing in diabetic foot ulcer patients.

Primary versus delayed primary skin closure in operated patients due to perforated peptic ulcer disease: a randomized controlled clinical trial

PURPOSE

Perforated peptic ulcer (PPU) is a life-threatening complication of peptic ulcer disease. This condition is characterized by a dirty abdomen that predisposes to postoperative wound infection. Delayed primary skin closure is occasionally preferred over primary closure to reduce the risk of surgical site infection in dirty abdominal wounds. In primary skin closure, the skin is sutured immediately after surgery. Meanwhile, in delayed primary skin closure, the incision is left open, and sutured after 2-5 days. The current research aimed to compare the risk for surgical site infection, length of hospitalization, and mortality rate between primary versus delayed primary skin closure among patients who underwent surgery for PPU.

METHODS

This single-blind randomized clinical trial included 120 patients who were randomly allocated into the primary and delayed primary closure groups. A research assistant who was blinded to the study examined the wounds for surgical site infection based on the 1992 Center for Disease Control criteria. The outcomes were mortality rate and duration of hospitalization.

RESULTS

The delayed primary and primary closure groups did not significantly differ in terms of postsurgical wound infection occurring on the 3rd, 7th, 14th, and 30th days after surgery, mortality rate, and duration of hospitalization.

CONCLUSION

In patients who underwent surgery for PPU, delayed primary closure is not recommended over primary closure due to the risk of postoperative surgical site infection.

COVID-19 Diagnosis Using Capsule Network and Fuzzy C-Means and Mayfly Optimization Algorithm

The COVID-19 epidemic is spreading day by day. Early diagnosis of this disease is essential to provide effective preventive and therapeutic measures. This process can be used by a computer-aided methodology to improve accuracy. In this study, a new and optimal method has been utilized for the diagnosis of COVID-19. Here, a method based on fuzzy C-ordered means (FCOM) along with an improved version of the enhanced capsule network (ECN) has been proposed for this purpose. The proposed ECN method is improved based on mayfly optimization (MFO) algorithm. The suggested technique is then implemented on the chest X-ray COVID-19 images from publicly available datasets. Simulation results are assessed by considering a comparison with some state-of-the-art methods, including FOMPA, MID, and 4S-DT. The results show that the proposed method with 97.08% accuracy and 97.29% precision provides the highest accuracy and reliability compared with the other studied methods. Moreover, the results show that the proposed method with a 97.1% sensitivity rate has the highest ratio. And finally, the proposed method with a 97.47% F1-score rate gives the uppermost value compared to the others.

Comparing the Success Rate and Side Effects of Endovenous Laser Ablation and Radiofrequency Ablation to Treat Varicose Veins in the Lower Limbs: A Randomized Clinical Trial

Introduction: Varicosis is a condition affecting the superficial venous system of the lower limbs. Endovenous laser ablation (EVLA) is a minimally invasive method that uses different frequencies of laser for treatment. Radiofrequency (RF) has also been effectively used for vein ablation through thermal mechanisms. This study compares the success rate and side effects of EVLA and RF to treat varicose veins in the lower limbs within 12 months. Methods: In this two-arm, parallel-group, randomized controlled, single-blind study, 1090 patients with lower limb varicosis proven by Doppler ultrasonography (DUS) were randomly placed into one of the two groups: EVLA and RF ablation. In the EVLA group, we used a 980-nm diode laser in a pulse mode and in the RF group, a 7-cm ClosureFast (Covidien, USA) catheter with an RF generator. We assessed pain during the operation and 8 and 24 hours after the surgery by the numerical rating scale (NRS). The patients were followed up on day 7, then 3, 6, and 12 months postoperatively. The presence or absence of pain and then the severity of pain (according to NRS), the recurrence rate, complications, and the length of the procedure were compared. Results: There was no significant difference between the two groups in the patients' characteristics, major adverse events and pain severity during the procedure and 8 and 24 hours after the surgery. According to NRS, the mean chronic pain severity in the EVLA group was 3.99± 0.754 versus 4.50± 0.657 in the RF group, and the difference was not significant. The length of operation and the recurrence rate 12 months after the procedure were not significantly different. Conclusion: The results of our study further establish the efficacy of EVLT and RF ablation for lower limb varicosis treatment without any significant difference in the clinical outcomes and complications during a 12-months follow-up.

Spontaneous perforation as a fatal presentation of esophageal tuberculosis: A case report

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Esophageal perforation due to tuberculosis should be considered in countries with high prevalence of Tuberculosis.

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Antibiosis for tuberculosis coverage should be initiated in appropriate group of patients with esophageal perforation with no response to conventional antibiotics and adequate surgical source control.

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In patient with perforation and sepsis due to acute mediastinitis, surgical intervention should be considered.

Introduction

Tuberculosis is a multisystematic disease and is the most common cause of infectious disease–related mortality worldwide. Gastrointestinal tract is an uncommon site for extrapulmonary tuberculosis (TB). Esophageal TB is exceedingly rare.

Presentation of case

We report a 22-years-old male with esophageal TB that presented in septic shock from esophageal perforation. Despite all measures including surgical intervention and aggressive support in the intensive care unit, patient passed away.

Discussion

The most common mechanism for esophageal involvement is secondary to direct spread from mediastinal structures and/or spreading the inoculation of swallowed sputum, or hematogenous or lymphatic spread. Once the diagnosis of TB is established, antibiosis is the cornerstone of treatment. Surgery is reserved only for complications of TB such as fistula, abscess, strictures or perforation. Less than 50% of cases are diagnosed within 24 h, and delay in diagnosis lead to significant increases in the mortality.

Conclusion

In countries with high prevalence of TB, this diagnosis should be considered in those with esophageal perforation with no underlying etiology and medical treatment for TB should be initiated in addition to conventional treatment in appropriate group of patients.

Comparing suture with N-Hexyl Cyanoacrylate glue for mesh fixation in inguinal hernia repair, a randomised clinical trial

PURPOSE

Inguinal hernia is a common surgical problem and different methods are currently used to repair it. In The Lichtenstein technique, the inguinal floor defect is buttressed with a prosthetic mesh and commonly, sutures are used for mesh fixation. N-Hexyl Cyanoacrylate is a gluelike product that can be used for mesh fixation as a substitute with fewer complications. This study was done for comparing therapeutic outcomes of mesh fixation with suture and N-Hexyl cyanoacrylate glue in inguinal hernia repair with the Lichtenstein method.

METHODS

In a two-arm parallel-group randomised controlled trial with blinded patients, 58 hernia cases who were candidates for hernia repair with the Lichtenstein method entered the study and randomly divided into two groups. In the control group, the mesh that was used for inguinal floor reinforcement was fixed with sutures and in the intervention group with N-Hexyl Cyanoacrylate glue. The results including acute and chronic pain, hospital stay, complications, and recurrence rate after one year were compared.

RESULTS

There was no recurrence. According to the numeric rating scale (NRS), mean postoperative pain (acute pain) was 6.5 and 5.7 points in the suture and N-Hexyl Cyanoacrylate glue groups respectively, with significant difference (P = 0.006). Mean duration of surgery was 73.3 and 64.5 min in the suture and N-Hexyl cyanoacrylate glue groups respectively, with significant difference (P = 0.014). Complications, hospital stay days, and chronic pain did not differ across the groups (P > 0.05).

CONCLUSION

Mesh fixation with N-Hexyl cyanoacrylate glue in hernia repair with the Lichtenstein method can lower postoperative pain and duration of surgery and this product might be used as a substitute for suture.

Ultrasound-guided Placement of Permanent Hemodialysis Catheters Compared to the Traditional Blind Method

Background: Central venous hemodialysis catheters are one of the most common vascular accesses for patients suffering from end-stage kidney disease. The application of ultrasound-guided placement of permanent hemodialysis catheters is highly recommended by the new guidelines because of its advantages over the traditional blind methods.Methods: In this prospective study, the samples comprised patients (N=80) referred to a vascular surgery clinic by their nephrologist or elective vascular surgery consultations and asking for the placement of permanent hemodialysis catheters in Imam Hossain Hospital (A referral hospital complex center in, Tehran, Iran) during 2014 to 2015. The patients were randomly divided into two groups (n=40); one of the groups underwent the placement of catheters with the guidance of Doppler ultrasound and the other with the traditional blind method. Then, the data were analyzed by SPSS V. 21 software.Results: There was statistically significant fewer attempts for successful placement (Z= -2.725, P=0.006), less insertion failure (Chi-Square=9.600, P=0.002), fewer failures with the first attempt (Chi-square=9.600, P=0.002), and less total placement time (t=1.379, df=69.549, P=0.172) in the sonography-guided group compared to the blind method. Furthermore, there was no significant difference in venous cannulation time and complications such as pneumothorax, neck hematoma, and carotid puncture between the two groups. Moreover, the patients had significantly greater satisfaction with the sonography-guided method (Z=-4.306, P=0.0001).Conclusion: According to this study, it might be beneficial to use ultrasound as the first method of permanent hemodialysis catheters insertion and patients would be more satisfied with this approach as well. In addition, learning the blind method is recommended to the practitioners because of the possibility of lacking ultrasound in an emergency.

Effects of N-acetylcysteine on arterial neo-intimal hyperplasia in rat model of arteriovenous fistula

INTRODUCTION:

Arteriovenous fistula is the best choice for vascular access in hemodialysis patients. However, arteriovenous fistula dysfunction is a major clinical issue. The most common cause of arteriovenous fistula failure is intimal hyperplasia. In this study, we have investigated the effect of N-acetylcysteine on neo-intimal hyperplasia after arteriovenous fistula creation in rats.

METHODS:

This study was conducted in 24 rats which were randomly divided into two groups: control and N-acetylcysteine groups. An end-to-side anastomosis was made between the femoral artery and vein. The control group received distilled water intraperitoneally while the animals in N-acetylcysteine group received 300 mg/kg/day of N-acetylcysteine via the same route. After 28 days, the thickness of intima and media was measured using hematoxylin and eosin.

RESULTS:

There was no significant difference between the two groups regarding age ( p = 0.6) and weight ( p = 0.1). The mean intima thickness in N-acetylcysteine group was significantly less than control group (17 ± 20 and 119 ± 46 µm, respectively; p < 0.001). The mean intima/media thickness in the N-acetylcysteine group was significantly less than control group (0.5 ± 0.63 vs 2.05 ± 1.17 µm; p < 0.001).

CONCLUSION:

N-acetylcysteine is effective in inhibiting neo-intimal hyperplasia in a rat model of arteriovenous fistula.

Comparing the efficacy of preoperative magnetic resonance cholangiopancreatography with intra-operative cholangiography in patients suspicious to biliary stones

AIM

This study was performed to compare the efficacy of preoperative magnetic resonance cholangiopancreatography (MRCP) and intra-operative cholangiography (IOC) methods in patients suspicious to gall stones.

BACKGROUND

According to previous studies, it is recommended that common bile duct investigation should be done in order to rule out choledocholithiasis in all patients with symptomatic cholelithiasis. IOC is an invasive procedure with probable complications, it would seem that MRCP could replace the direct cholangiography.

PATIENTS AND METHODS

In a diagnostic clinical trial, Fifty-nine patients with symptomatic biliary stones or cholecystitis were recruited in this study. The included patients had normal size biliary ducts in sonography but high serum alkaline phosphatase level. Preoperative MRCP and IOC were performed for the patients and the obtained results were analyzed and compared.

RESULTS

The positive predictive value for IOC was 88% and for MRCP was 43%. The diagnostic accuracy of IOC and MRCP were 98% and 85% respectively, suggesting that IOC is much more diagnostically accurate. There were no significant difference in specificity and sensitivity of these two methods.

CONCLUSION

According to the results, we can conclude that MRCP may not obviate the need for IOC. The suggestion for routine use of MRCP instead of IOC and as a substitution of that procedure needs further investigations on more patients.

Endovascular treatment of thoracoabdominal aortic aneurysm: a case report

Introduction

Thoracoabdominal aortic aneurysms usually present in elderly patients with serious renal, pulmonary, cerebral, or cardiac comorbidities that pose a great challenge to the attending surgeon. Endovascular techniques for the treatment of thoracoabdominal aneurysms are not yet widely used due to limitations associated with them, such as spinal and visceral ischemia.

Case presentation

An 87-year-old Caucasian man with a symptomatic Crawford type I thoracoabdominal aortic aneurysm was treated successfully with a long tube stent graft using endovascular techniques and without any complication in follow-up examinations. The stent was placed distal to the left subclavian artery, and proximal to the celiac axis.

Conclusion

The use of endovascular stents for long segment thoracoabdominal aortic aneurysms needs to undergo clinical investigation to determine whether this procedure decreases morbidity and mortality rates.

Current incidence of peripheral arterial embolism and role of echocardiography

We reviewed the incidence and outcome of all cases of upper and lower limb embolism surgically treated in our vascular unit, from January 2001 to June 2006, to assess the role of transthoracic and transesophageal echocardiography in defining the source of the embolus. Transthoracic echocardiography was carried out postoperatively, and patients in whom the embolic source was not found underwent transesophageal echocardiography. There were 85 patients (mean age, 69 years) who underwent embolectomy: 58 for lower and 27 for upper limb ischemia. The source or potential source of thrombus was demonstrated in 17 (20%) patients after transthoracic echocardiography. Fifty-three patients had transesophageal echocardiography, the source of embolism was found in 85%, and the subsequent management was changed in 47% of them. Arterial limb emboli are still prevalent in developing countries. Transthoracic echocardiography is a good screening tool for detecting a potential cardiac source of peripheral embolism, with transesophageal echocardiography being reserved for specific indications.

Rare presentation of pancreatic schwannoma: a case report

Introduction

Schwannoma is a rare tumor among pancreatic neoplasms. Schwannomas vary in size, and most of them are cystic, mimicking pancreatic cystic lesions. Generally, a definitive diagnosis is made at the time of histological analysis. The mainstay treatment is surgical resection.

Case presentation

We report an unusual presentation of pancreatic schwannoma with abdominal pain and several episodes of cholangitis in a 54-year-old Caucasian (Iranian) man. The condition was not diagnosed pre-operatively and Whipple's procedure was performed.

Conclusion

Pancreatic schwannoma is an important clinical entity to include in the differential diagnosis of pancreatic lesions. Pre-operative diagnosis is difficult but computed tomographic findings may be helpful. The tumor may also have atypical and rare presentations, such as cholangitis and weight loss. For benign tumors, simple enucleation is usually adequate, whereas malignant tumors require standard oncological resection.

Use of vein graft as a tendon sheath substitute following tendon repair: An innovative technique in tendon surgery

OBJECTIVES

This is a new technique for managing tendon repair that may improve the results of existing methods.

METHODS

In a prospective randomized clinical trial, 210 patients were divided into two groups of test and control. All patients had flexor tendon injuries, involving zone 2. They were new or old tendon injuries or complications of previous repairs. In the test group (105 patients), a modified Kessler repairing of tendons with 3-0 prolene was used, followed by a core suture of running 6-0 nylon or prolene epitendinous suture. After the tendon repair, a segment of vein through which the tendon had been passed before or a patch of vein, as a tendon sheath substitute, was used to repair the sheath defects. The results in a span of six months of follow-up were compared with those of the control group whereon 105 patients were operated under the conventional technique--the modified Kessler method.

RESULTS

We assessed the results by measuring the range of motion of the MCP joint in the follow-up period and we graded them as excellent, good, fair and poor. In the test group we had 86% excellent, 11% good, 3% fair and 0% poor results, and in the control group, 0% excellent, 12% good, 38% fair and 50% poor results. The differences were significant (p<0.005).

CONCLUSIONS

Our preliminary results appeared encouraging when compared with the outcomes achieved by the conventional tendon repair technique. As this technique reduces the adhesion formation, improves tendon nourishment, and decreases the need of intensive physiotherapy, it may substitute the conventional one and become a standard technique in the future.