CASE_STUDY http://annbsurg.iums.ac.ir/article-1-151-fa.pdf 2015-02-15 100 110 Introduction Hepatic choristomas, defined as completely separated ectopic liver tissue, are rare. They are most commonly found adjacent to the gallbladder. Details of their anatomy, such as blood supply and biliary drainage, remain ill-defined and are inconsistently described in the literature. Case presentation A case of hepatic choristoma was found incidentally in a 77-year-old woman during an elective laparoscopic cholecystectomy. Conclusions We outlined its biliary drainage and blood supply, as well as our surgical approach, which may be a guide to surgeons who encounter hepatic choristomas in their clinical practice. http://annbsurg.iums.ac.ir/article-1-151-en.pdf 2015-02-15 100 110 Choristoma Cholecystectomy Gallbladder Julian Klaus Smyth 1 Faculty of Medicine, The University of Sydney, Camperdown, Australia AUTHOR Kheng Seong Ng 2 Academic Colorectal Unit, Concord Hospital Campus, University of Sydney, Concord, Australia AUTHOR Elizabeth Caroline Sinclair 3 AUTHOR Samuel Kuo 4 AUTHOR

OTHERS_CITABLE http://annbsurg.iums.ac.ir/article-1-155-fa.pdf 2015-02-15 100 110 Background Laparoscopic cholecystectomy (LC) is the gold standard treatment for cholelithiasis. Objectives Our study intended to evaluate whether timing of surgery is of any influence on the course of the laparoscopic cholecystectomy (LC) following Endoscopic Retrograde Cholangio-Pancreatography ERCP/Endoscopic sphincterotomy (ES) and to identify and assess various factors that can affect the outcome in these patients. Patients and Methods Data of 77 patients treated for choledochocystolithiasis with ERCP/ES followed by LC were reviewed. Patients were classified into four groups, group A (n = 29): LC performed within 24 hours after ERCP; group B (n = 20): LC performed after 24 hours to 7 days; group C (n = 12): LC done between 8 to 28 days; group D (n = 16): LC done after 28 days of ERCP. Primary outcome was operating time and secondary outcomes included intra- or post-operative complications, hospital stay and hospital expenses. Results Mean operative time was shortest in group A (57.1 minutes) and longest in group B [63.4 (P = 0.131)]. Mean hospital stay was shortest in group A (2.1 days) and longest in group C (5.7 days) (P = 0.003). Hospital expenses were minimal in group A (P = 0.001). Male sex, serum bilirubin level, White blood cell (WBC) count, duration of ERCP/ES procedure, contracted gall bladder and large calculus size on Ultrasonography (USG) were significantly associated with primary outcome. Conclusions LC can be performed within 24 hours of ERCP/ES with favorable outcome and less expenses. Timing of LC after ERCP/ES is not significantly associated with outcome of the procedure. Male sex, serum bilirubin level, WBC count, ERCP/ES procedure duration, contracted gall bladder and large size of gall bladder calculus on imaging are significantly associated with difficulty in surgery. http://annbsurg.iums.ac.ir/article-1-155-en.pdf 2015-02-15 100 110 Choledocholithiasis Cholelithiasis Laparoscopic Cholecystectomy Diwakar Sahu 1 Registrar, Department of Surgical Gastroenterology and Minimal Access Surgery, Apollo Hospitals, Greams Road, Chennai, Tamil Nadu, India AUTHOR Mittu John Mathew 2 Registrar, Department of Surgical Gastroenterology and Minimal Access Surgery, Apollo Hospitals, Greams Road, Chennai, Tamil Nadu, India AUTHOR Prasanna Kumar Reddy 3 Registrar, Department of Surgical Gastroenterology and Minimal Access Surgery, Apollo Hospitals, Greams Road, Chennai, Tamil Nadu, India AUTHOR

OTHERS_CITABLE http://annbsurg.iums.ac.ir/article-1-153-fa.pdf 2015-02-15 100 110 Diabetes Mellitus has been one of the most prevalent diseases in human beings from the very beginning. Its prevalence is estimated at about 8% in different societies and with increasing body mass index of people all over the world the rate of type 2 diabetes is increasing (1). It is estimated that about 90% of diabetic patients are of type 2 (2). Weight loss, and the change in life style remains the cornerstone of its treatment. Different oral and injectable drugs have been used to treat this debilitating disease, but so far even in the most developed countries like US the rate of uncontrolled diabetes mellitus is more than 20 % (3). This rate is even higher in some countries. Since 1955 the role of gastric surgery to improve diabetes was reported and in 1991 NIH consensus recommended bariatric surgery for diabetic patients with BMI to be more than 35 (4). Resolution of hyperglycemia in morbid obese patients a few days after some bariatric surgeries -even before enough weight loss- showed there are other mechanisms that are responsible for such dramatic results. Many investigations showed different hormonal roles in that effect. Glucagon as one of the most important gut hormones which has a major role for insulin resistance is decreased promptly after gastric bypass surgery. This finding resulted in the production of Foregut theory and at present the changing direction of food away from duodenum is essential in all diabetic surgeries. In gastric bypass, biliopancreatic diversion, and biliopancreatic diversion–duodenal switch which have been postulated to be the most effective bariatric surgeries on resolution of diabetes mellitus type 2, this deviation of food direction is seen. It seems that restrictive bariatric surgeries, like sleeve gastrectomy and gastric banding and vertical gastric plication have less effect on diabetes mellitus type 2 resolutions. It may be because they mostly act by weight reduction mechanism, although hormonal effect of sleeve gastrectomy on ghrelin and reduction of gastric emptying time may have some hormonal effect. Another major theory for resolution of diabetes mellitus type 2 after bariatric surgery is hindgut theory, which is mainly described by hormonal release from L cells by reaching undigested food to distal ileum. These hormones are mainly GLP1, and Peptide YY. These magical results -which resolved diabetes mellitus type 2 even in about 98% of patients- gave a new vision to scientists about bariatric surgery (5). In this regard Metabolic and Diabetic surgery nomination was done. http://annbsurg.iums.ac.ir/article-1-153-en.pdf 2015-02-15 100 110 Diabetes Mellitus Obesity surgery Metabolic Surgery Diabetic Surgery Abdolreza Pazouki 1 Center of Excellence for Minimally Invasive Surgery Education, Iran University of Medical Sciences, Tehran, IR Iran AUTHOR Gholamreza Mohammadi Farsani 2 Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, IR Iran AUTHOR

OTHERS_CITABLE http://annbsurg.iums.ac.ir/article-1-156-fa.pdf 2015-02-15 100 110 Background Laparoscopic surgery provides tremendous benefits to patients, including faster recovery, shorter hospital stay, and earlier return to normal activities and less immunologic impairments. Objectives In this study we aimed to study the effect of different intraperitoneal instillations on leukocyte count to evaluate patients&#x2019; immunologic response. Patients and Methods We studied 125 patients in a double-blind, randomized clinical trial. The patients received either instillation of 250 mL of normal saline (n = 31) or 100 mg bupivacaine diluted in 250 mL of normal saline (n = 31) or 100 mg hydrocortisone diluted in 250 mL of normal saline (n = 31) or 100 mg hydrocortisone plus 100 mg bupivacaine diluted in 250 mL normal saline (n = 32) before insufflation of Carbon Dioxide into the peritoneum randomly. Leukocyte counts were recorded before and after the operation. We recorded abdominal pain using visual analogue scale (VAS), postoperative analgesics needed and recovery variables in the recovery room and 6, 12 and 24 hours after the operation. Results The study was completed by 120 patients. Patients who received intraperitoneal hydrocortisone and hydrocortisone plus bupivacaine had higher white blood cell (WBC) count (P < 0.0001). The patients were similar with respect to demographic information, operational characteristics and recovery variables. The abdominal pain scores were significantly lower in patients receiving instilled intraperitoneal hydrocortisone plus bupivacaine and less analgesic was require by them (P < 0.0001). Conclusions We conclude that intraperitoneal hydrocortisone instillation caused leukocytosis and is thus suggested not to be used in immune-compromised patients. http://annbsurg.iums.ac.ir/article-1-156-en.pdf 2015-02-15 100 110 Hydrocortisone Injections Intraperitoneal Leukocytosis Amene Sabzi Sarvestani 1 Department of Surgery, Imam-Ali Educational Hospital, Zahedan University of Medical Sciences, Zahedan, IR Iran AUTHOR Mehdi Zamiri 2 Department of Surgery, Imam-Ali Educational Hospital, Zahedan University of Medical Sciences, Zahedan, IR Iran AUTHOR

CASE_STUDY http://annbsurg.iums.ac.ir/article-1-154-fa.pdf 2015-02-15 100 110 Introduction Acute appendicitis (AA) is one of the most common differential diagnoses in a pregnant lady presented with right iliac fossa (RIF) pain. Traditional concept of early exploration has been questioned, as far as recent evidences showed much higher morbidity rates than expected. Mandatory pre-operative imaging (ultrasound or Computer Tomography scan) has been advocated and proven able to significantly reduce its related avoidable morbidity. Case Presentation Three cases are presented: Case 1 was a 41-year-old lady who had acute appendicitis which was successfully managed conservatively. Case 2 was a 29-year-old lady at 25 weeks of gestation, presented with 2 weeks history of RIF pain. Open appendectomy was offered for her, as far as obstetric review and ultrasound were inconclusive. Even though, she had a negative appendectomy, and her postoperative period was complicated by recurrent premature uterine contractions. The third case was an unfortunate lady at 30 weeks of gestation. Laparotomy was done for her, as her RIF pain persisted, which was diagnosed by significant fluids at both iliac fossae with other unremarkable obstetric review. Her postoperative period was complicated by paralytic ileus and intra-uterine death. Conclusions Our review demonstrated that a pregnant lady suspected of AA poses a great clinical challenge to surgeons, as far as scoring systems are almost unreliable. Positive imaging prior to surgery is warranted, in order to avoid a nontherapeutic surgery which is always associated with high morbidity rates. http://annbsurg.iums.ac.ir/article-1-154-en.pdf 2015-02-15 100 110 Appendicitis Pregnancy Complications Asri Che Jusoh 1 Department of General Surgery, Kuala Krai Hospital, Kelantan, Malaysia AUTHOR Ahmad Faiz Najmuddin Mohd Ghazi 2 Department of General Surgery, Kuala Krai Hospital, Kelantan, Malaysia AUTHOR Muhammad Syahmi Abdul Ghani 3 Department of General Surgery, Kuala Krai Hospital, Kelantan, Malaysia AUTHOR

CASE_STUDY http://annbsurg.iums.ac.ir/article-1-152-fa.pdf 2015-02-15 100 110 Introduction Although thymoma is the most common anterior mediastinal tumor, only 5% of thymoma cases develop pure red cell aplasia (PRCA). Case Presentation In this article we have reported a 59-year-old man with a large anterior mediastinal mass (diameter of 10 cm) and severe anemia, that thymoma and pure red cell aplasia have been demonstrated by histopathologic and hematological examination. Despite the large mass, a complete video-assisted thoracoscopic surgery (VATS) thymectomy and combinational medical therapy were performed for him successfully. Aplasia remission occurred 6 months after thymectomy and his hemoglobin level reached to 13 g/dL. Conclusions We believe that a complete resection in combination with medical therapy is necessary to achieve total remission of PRCA symptoms and conclude that VATS thymectomy is an effective and technically feasible procedure for surgery without any contraindications about the size of the thymoma in these patients. http://annbsurg.iums.ac.ir/article-1-152-en.pdf 2015-02-15 100 110 Pure Red Cell Aplasia Thymectomy Thoracoscopy Gholamreza Mohajeri 1 Department of Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, IR Iran AUTHOR Masoud Sayadi Shahraki 2 Department of Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, IR Iran AUTHOR Mohsen Mahmoudieh 3 Department of Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, IR Iran AUTHOR Behrouz Keleidary 4 Department of Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, IR Iran AUTHOR Noushin Afshar Moghaddam 5 Department of Pathology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, IR Iran AUTHOR Ebrahim Nourian 6 Department of Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, IR Iran AUTHOR