Delayed Presentation of Traumatic Diaphragmatic Hernia: The Evaluation of Surgical Treatment Results

Introduction: Diaphragmatic hernia could be caused by congenital disorders, blunt trauma or penetrating injuries. The diagnosis of traumatic diaphragmatic hernia is normally neglected during the first presentation leading to late complications and considerably increased mortality and morbidity among the patients. Materials and Methods: In this retrospective, descriptive study, we reviewed the medical records of patients presented with traumatic diaphragmatic hernia who had undergone surgical operations between 1982-2015 in Ghaem Hospital and Omid Hospital affiliated to Mashhad University of Medical Sciences, Iran. The studied variables included age, gender, clinical symptoms, location of hernia, involved organs, type of imaging modalities, surgical techniques, length of hospital stay, mortality rate and surgical complications. Results: In this study, 38 patients were diagnosed with traumatic diaphragmatic hernia consisting of 28 men and 10 women. In total, 79% and 21% of the patients suffered from penetrating trauma and blunt trauma, respectively. In addition, left-sided, right-sided and bilateral hernias were present in 33%, 4% and 1% of the patients, respectively. The most frequently herniated organ was the stomach, and the most common clinical symptoms were abdominal pain (84%) and dyspnea (53%). Initially, chest radiographs were performed on all the patients, and thoracotomy was performed to repair diaphragmatic tears in all the cases (100%). In this study, 3 patients had previously undergone Hartmann’s operation for gangrenous herniated colon, and devolvulation of gastric volvulus had also been performed on 3 patients. The main post-operative complications were reported to be pneumonia and respiratory insufficiency (2 cases), and the mean length of hospital stay was 6 days (5-8 days) which was longer (1-2 months) in patients with gangrenous bowel (3 patients). Furthermore, no mortality was reported during the course of hospitalization in these patients. Conclusion: According to the results of this study, patients presented with blunt or penetrating traumas to the upper abdomen or lower chest require urgent attention as to immediately rule out diaphragmatic hernia in order to prevent later complications and mortality and morbidity among these patients

Effect of Folic Acid therapy on Homocysteine Level in patients with Atherosclerosis or Buerger’s Disease and in Healthy individuals: A clinical trial

Background: Hyperhomocysteinemia is considered a risk factor for atherosclerosis and some other vascular diseases such as Buerger’s disease. Objective: The aim of this study was to measure the Homocysteine levels in 3 different groups of participants (Buerger’s disease, atherosclerosis patients, and healthy cases) and determine the therapeutic effect of folic acid therapy on homocysteine levels for these three groups. Methods: This nonrandomized clinical trial study was conducted in the vascular and endovascular surgery research center of Mashhad University of Medical Sciences in Mashhad, Iran. This interventional study consisted of 44 participants of which 22 patients had Buerger’s disease and a control group of 22 healthy individuals, all of which were enrolled in this study. All of the study’s participants had their serum homocysteine levels measured both before and after 12 weeks of folic acid (5mg/day) therapy. The data analysis used fo data analysis was a Chi square and t-test or their non-parametrical equivalents for data analysis by means of Statistical Package for the Social Sciences (SPSS) version 16. Results: The homocysteine levels were found to be significantly higher in patients with Buerger’s disease as compared to other groups before treatment with folic acid (Buerger = 21.8 ± 8.5 Mm/L, atherosclerosis = 17.3 ± 6.9, healthy = 13.8 ± 3.1; p < 0.001). After treatment with folic acid at 5 mg/daily for 12 weeks, the new plasma homocysteine levels did not show any significant difference (p = 0.38) between the Buerger’s disease group (14.6 ± 4.5 Mm/L) and atherosclerosis group (13.9 ± 4.7), but it was found to besignificantly higher in both groups when compared to the healthy group (10.7 ± 3.9, p<0.05). The plasma homocysteine level was reduced significantly when compared to its initial level in all 3 groups. The comparison of differences among three groups was found not to be significant (p=0.41). Conclusions: It seems that supplementary therapy with folic acid at a dose of 5 mg daily may reduce the serum homocysteine levels significantly and may have a role in the development of vascular diseases such as Buerger’s disease. We suggest that folic acid should be considered as a routine agent in the Buerger’s disease therapeutic regime. Clinical trial registration: The trial was registered at the Thai Clinical Trials Registry (http://www.clinicaltrials.in.th) with the ID: TCTR20160601003. Funding: This study was not funded by any organization

Therapeutic Outcomes of Pectoralis Major Muscle Turnover Flap in Mediastinitis

Background: This study aimed to evaluate the therapeutic results and safety of pectoralis major muscle turnover flaps in the treatment of mediastinitis after coronary artery bypass grafting (CABG) procedures. Methods: Data regarding 33 patients with post-CABG deep sternal wound infections (DSWIs) who underwent pectoralis major muscle turnover flap procedures in the Emam Reza and Ghaem Hospitals of Mashhad, Iran were reviewed in this study. For each patient, age, sex, hospital stay duration, remission, recurrence, and associated morbidity and mortality were evaluated. Results: Of the 2,447 CABG procedures that were carried out during the time period encompassed by our study, DSWIs occurred in 61 patients (2.5%). Of these 61 patients, 33 patients (nine females [27.3%] and 24 males [72.7%]) with an average age of 63±4.54 years underwent pectoralis major muscle turnover flap placement. Symptoms of infection mainly occurred within the first 10 days after surgery (mean, 10.24±13.62 days). The most common risk factor for DSWIs was obesity (n=16, 48.4%) followed by diabetes mellitus (n=13, 39.4%). Bilateral and unilateral pectoralis major muscle turnover flaps were performed in 20 patients (60.6%) and 13 patients (39.4%), respectively. Complete remission was achieved in 25 patients (75.7%), with no recurrence in the follow-up period. Four patients (12.1%) needed reoperation. The mean hospitalization time was 11.69±6.516 days. Four patients (12.1%) died during the course of the study: three due to the postoperative complication of respiratory failure and one due to pulmonary thromboembolism. Conclusion: Pectoralis major muscle turnover flaps are an optimal technique in the treatment of post-CABG mediastinitis. In addition to leading to favorable therapeutic results, this flap is associated with minimal morbidity and mortality, as well as a short hospitalization time