Malignant Schwannoma of Anterior Abdominal Wall: Report of a Case

Malignant schwannoma of the anterior abdominal wall nerves is extremely rare. Malignant peripheral nerve sheath tumors (MPNST) represent approximately 10% of all soft tissue sarcomas and it is found in 4% of patients with neurofibromatosis 1. We present a case of malignant schwannoma in a 28-year-old female patient with neurofibromatosis 1. She presented with a painful mass in the right upper quadrant of her abdomen. The tumor location was in the abdominal wall in explorative laparatomy and malignant schwannoma was diagnosed in pathologic assessment. The tumor recurred in 3 months and computed tomography showed two masses in the right side of abdominopelvic cavity. Thereafter, second complete surgical resection was performed and pathologic finding was the same. In spite of administering chemotherapy after second surgery,the tumor recurred and magnetic resonance imaging finding showed a huge heterogeneously enhancing mass with adhesion to the inner side of the abdominal wall. The patient died because of acute respiratory failure due to multiple bilateral pulmonary metastases. Tumor location and rapid recurrence was unique in our patient

Comparison of Complete Sinus Excision and Reconstruction with Sinus Excision and Umbilical Preservation for Treatment of Umbilical Pilonidal Sinus

Background: Umbilical pilonidal sinus is a granulomatous reaction to hair shaft penetrating the epidermis of umbilicus from the external surface. In this study, the outcome of complete excision of the umbilical sinus with umbilical reconstruction and sinus excision with umbilical preservation is considered.Methods: This study was a clinical trial. In this study, 60 subjects with umbilical pilonidal sinus were enrolled  into two groups (Group I, complete excision of the umbilical sinus with umbilical reconstruction, n = 30, Group II, sinus excision with umbilical preservation n = 30). Discharge, bulging, pain, bleeding, and itching of umbilicus and existence of hair were registered in the base visit and then 1 and 2 weeks, and 1, 3, and 6 monthslater. Patients with umbilical pilonidal sinus, who had not undergone any previous surgeries, were operated on using a technique that involves complete excision of the umbilical sinus followed by reconstruction of the umbilicus or sinus excision with umbilical preservation. Patients were then followed and wound complications,and recurrence were evaluated at post-operative visits (1 week, 2 weeks, 1 month, 3 months, and 6 months later). Remission and relapse of each symptom were compared. Data were analyzed by SPSS version 16.Results: A total of 60 patients underwent the operation; 55 (91.7%) were male, and 5 (8.3%) were female. The mean age in Group I, complete excision of the umbilical sinus with umbilical reconstruction was 29.9 years (18-45 years) and mean age of Group II, sinus excision with umbilical preservation was 28 years (19-42). Themean follow-up period was ٦ months. Only one patient in Group I, complete excision of the umbilical sinus with umbilical reconstruction had seroma and hyperemia of the skin after the operation, and treated  conservatively at an outpatient clinic. No recurrence was observed during the follow-up period, and the most patients were satisfied with the appearance of their umbilicus. The two groups were not different by the meansof age, sex and symptoms at baseline (P > 0.050). Remission of symptoms were not significantly different inthe two groups (P > 0.050). The probability of relapse of other symptoms were not different in two groups (P > 0.050).Conclusions: Umbilical sinus excision with umbilical reconstruction is a relatively simple and effectivesurgical option for treating umbilical pilonidal disease with acceptable patient satisfaction and no serious complications. It may also be associated with a low risk of recurrence

Using 360-degree multi-source feedback to evaluate professionalism in surgery departments: an Iranian perspective

Background: Medical professionalism helps physicians adopt a proper and good healing action for the patients based on their particular circumstance. This study was conducted to assess professionalism in surgical residents, using a 360-degree evaluation technique in several teaching hospitals in Tehran, Iran. Methods: This study was conducted on all the second and third year surgery residents from three university teaching hospitals in Tehran. Multi-source feedback questionnaire contained 10 questions on the residents’ professional behavior and was completed by the faculty and staff members (nurses, operation room staff, and medical assistants) as well as other surgery residents, interns and patients to evaluate each resident. Response rates were used to determine feasibility for each of the respondent groups and the mean and standard deviation score for each question was computed to determine the viability of the items. Reliability was assessed using alpha Cronbach coefficient for each respondent group. The correlation between these scores and the residents’ final and OSCE grade was also assessed. Results: The internal consistency reliability for 360-degree rating was 0.889. There was no significant difference in the residents’ score in different hospitals. While male residents obtained higher total score, there was no significant difference between them. The residents, however, obtained lower scores compared to the staff. The highest score was recorded for question 6, suggesting that the residents treated the patients regardless of their socioeconomic status. Conclusion: This study revealed a strong agreement between the results gathered from different respondents, confirming the reliability of the questionnaire and the respondents’ unbiased response. It also revealed that the residents did well in the whole test, showing they were conscientious and learning to become medical professionals

Prophylactic Oral Calcium Reduces Symptomatic Hypocalcemia in Patients undergoing Total or Subtotal Thyroidectomy: a Randomized Controlled Trial

Objectives: Prophylactic oral calcium supplement has been proposed in patients undergoing thyroidectomy in order to decrease incidence of postoperative hypocalcemia, and the duration of hospital stay. This study aimed to assess the effects of prophylactic oral calcium in patients undergoing total or subtotal thyroidectomy.Methods: Forty three patients who were scheduled for total and subtotal thyroidectomy, were randomly allocated to the case (n=23) and control (n=20) groups. Oral calcium carbonate (1 gram q 8 hours) was given to the patients in the case group starting 12 hours before surgery till 7 days post thyroidectomy. Clinical symptoms of hypocalcemia and postoperative calcium levels were compared between the two groups.Results: The mean postoperative calcium level 12 hours after surgery was not statistically different between the two groups (8.9±0.5 vs. 8.5±0.7, p=0.092); while after 24 hours, calcium level was significantly lower in the control group (8.9±0.5 vs. 8.4±0.8, p=0.037). The number of patients who had paresthesia was significantly higher in the control group than case group, at both 12 hours (p=0.02) and 24 hours postoperatively (p=0.04). Duration of hospitalization was significantly lower in the case group compared to the control group (p=0.006).Conclusions: Prophylactic oral calcium supplementation decreases the hypocalcemia related paresthesia after thyroidectomy and shortens duration of hospital stay

Comparison of Methoxyisobutylisonitrile Scintigraphy and Ultrasonography in Preoperative Localization of Secondary Hyperparathyroidism

Background: In patients with secondary hyperparathyroidism, the four glands are not uniformly enlarged; therefore, preoperative localization is difficult in comparison with primary hyperparathyroidism. The aim of this study was to compare the usefulness of 99mTc-sestamibi scintigraphy versus ultrasonography in the preoperative assessment of patients with secondary hyperparathyroidism.Methods: Between October 2008 and March 2012, 25 uremic patients with secondary hyperparathyroidism underwent 99mTc-sestamibi scintigraphy and high resolution ultrasonography before total or subtotal parathyroidectomy. We measured plasma concentration of intact parathyroid hormone (PTH), calcium, phosphorus, and alkaline phosphatase (ALP) before parathyroidectomy.Results: Sensitivity and positive predictive value (PPV), respectively, were 47.3% and 97.8% for MIBI scintigraphy, and 69.5% and 96.9% for ultrasonography. The sensitivity of combined techniques was 84.2%. There was a positive correlation between the parathyroid glands’ weight and serum calcium level, and positive MIBI scintigraphy and ultrasonography results. However, there was no correlation between the preoperative serum PTH, phosphorus, alkaline phosphatase (ALP), dialysis duration, and parathyroid glands’ weight.Conclusions: Ultrasonography is a reliable non-invasive localization tool. It has greater sensitivity in localizing parathyroid glands in secondary hyperparathyroidism than scintigraphy

Outcome of Common Bile Duct Exploration without Intraoperative Cholangiography: a Case Series and Review of Literature

Background: Open or laparoscopic surgical exploration of common bile duct (CBD) is performed when endoscopic approaches fail to extract CBD stones. Intraoperative cholangiography (IOC) through T-tube is performed in order to reduce the rate of retained stones. The aim of this study was to evaluate results of CBD exploration without IOC through T-tube and reviewing existing literature.Methods: A retrospective medical chart review of 392 patients who underwent surgical CBD exploration was performed. All patients had proven CBD stones and had previously undergone failed attempts of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES). T-tube insertion or biliary-enteric anastomosis was performed after open CBD exploration with regard to patient’s presentation and CBD diameter. IOC was not performed after T-tube insertion and cholangiography was postponed until 7th postoperative day. Postoperative retained stone and their management were reviewed.Results: Of 392 patients with CBD explorations, T-tube was placed in 215 (54.8%) including 66 (30.7%) emergent biliary drainage and 149 (69.3%) elective operations. A number of 177 of 392 (45.2%) patients underwent biliaryenteric anastomosis. In 6 of 215 patients (2.8%) with T-tube placement, retained CBD stones were detected by T-tube cholangiography during postoperative period. All of them were treated successfully by ERCP.Conclusions: T-tube placement without IOC is accompanied by a low rate of retained stone. Omitting IOC may decrease the operation time which is especially important in emergent cases. Retained stones following CBD exploration and T-tube placement can be treated successfully using ERCP

Bariatric Surgery Outcomes in Patients with Chronic Liver Disease - Nationwide Study

BACKGROUND: Chronic liver disease (CLD) is a risk factor for surgical complications and a relative contraindication to bariatric surgery. This study evaluates early outcomes after bariatric surgery in patients with CLD with and without liver cirrhosis (LC). METHODS: In a retrospective analysis of 2012–2016 Healthcare Cost and Utilization Project-National Inpatient Sample, adult patients with obesity undergoing laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) were studied. CLD and LC were identified along with patient comorbidities. Outcomes were Long Hospital Stay (LHS) defined as ≥5 days (as a proxy of complicated course), blood product transfusion, total hospital charges, and in-hospital mortality. Binary logistic regression was used for multivariate analysis (MVA). RESULTS: 139,952 patients were analyzed (RYGB 36.6%, female 78.6%, age 44.7±12 years). CLD was listed in 17,423 (12.4%) patients, including 818 (0.6%) with LC. Non-alcoholic fatty liver disease was the most common cause of CLD. Patients with LC were more likely to be older, male, and have diabetes mellitus and hyperlipidemia. 37.7% of LC and 42.1% of non-cirrhotic CLD patients underwent RYGB. Transfusion, LHS, and total charges were higher in the LC group (Table). In-hospital mortality was higher in CLD (0.1%) and LC (<0.3%). In MVA, LC was an independent predictor of LHS (Odds Ratio (OR): 1.82, 95% CI: 1.25-2.67) but non-cirrhotic CLD was not a predictor of LHS. Subgroup MVA in CLD showed RYGB was independently associated with LHS (OR: 1.85, 95% CI: 1.53-2.25). CONCLUSION: Bariatric surgery can be performed safely in appropriately selected patients with non-cirrhotic CLD and LC. Further studies are needed to assess long-term outcomes of bariatric surgery in CLD.N

Single Incision Laparoscopic Surgery: Review of Pros and Cons

Despite huge advances in minimally invasive surgeries, efforts still continue for finding less invasive methods of surgery. Patients desire less postoperative pain as well as better cosmetic outcomes. This may be achieved by decreasing the number of laparoscopic ports in which all the surgical maneuvers are performed through a single incision. However, surgeons should be also equipped to act well while avoiding adverse events of the new practicing approach. Along with increasing trends in performing of single incision laparoscopic surgery (SILS) in routine practice, the number of assessing the pros and cons of this new modality is also on the rise.&nbsp;Although it has been claimed that SILS is able to make the dream of invisible laparoscopy true for patients and surgeons, consecutive studies regarding postoperative outcomes questioned the benefits of the new evolved technique. Subsequent meta-analysis also revealed equal outcomes for SILS in comparison to the standard laparoscopy. Our review aimed to outline the pros and cons of SILS

Is Endogenous Prolactin, Not Endocrine Prolactin, Responsible for Hyperparathyroidism in Breast Cancer Patients?

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Vagus Nerve Shwannoma Presented With Long-Term Cachexia: Report of a Case and Review of Literature

Intraabdominal schwannomas are rare tumors that may arise from viscera or abdominal wall.The rarity accompanied by occurrence in odds places may make their diagnosis difficult and delayed.We present a case of distal paraesophageal schwannoma with long-term cachexia.A34-year-old man presented with long-lasting vomiting, dysphagia, and progressive cachexia for four years.Multiple paraclinical assessments were normal;subsequently he was referred to psychiatric department and treated for anorexia nervosa for three year without any improvement.Further evaluations showed a mass in diaphragm hiatus in paraesophageal region. Explorative laparotomy revealed a cylindric shaped encapsulated tumor parallel to distal esophagus risen from vagus nerve, which was resected completely. Pathological and immunohistochemical examinations of the tumor revealed a benign plexiform schwannoma.After surgery,the patient was relieved from symptoms and gained weight significantly.It is important to consider physical causes in patients with cachexia who are treated for psychiatric problems and it is necessary to reevaluate these patients specially when there is no response to psychiatric treatments.