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Background: Anastomotic leakage (AL) is the main complication of colorectal surgeries. Recent studies have assessed the effects of the ghost ileostomy on preventing complications related to a defunctioning stoma (DS) in high-risk anastomoses. In this study, we aimed to review patients who underwent ghost ileostomy and assess their colon leakage score (CLS) and Dutch leakage score (DULK) to evaluate their preoperative AL risk and post-operative AL diagnostic score, respectively. We examined whether the suggested cut-off points of these scores (>11 for CLS and >4 for DULK) could be appropriate criteria for determining when to insert ghost ileostomy and when to convert it to a DS. Methods: All patients from three referral hospitals in Shiraz, Iran who underwent colorectal surgery with ghost ileostomy during 2019-2020 were enrolled in this retrospective case series. We calculated preoperative CLS and post-operative DULK scores for all patients and assessed what diagnostic and therapeutic measures were performed for them based on their scores. Results: AL was diagnosed in two of 34 patients. Eight patients had a total CLS score of 11 and above, but only one of them experienced AL. The other case of AL had a CLS score of 10. The DULK score of these two patients increased during hospitalization. Conclusion: Because of the importance of accurately identifying high-risk patients for ghost ileostomy, it is imperative to undertake additional research aimed at determining the optimal cut-off value for CLS or devising alternative valid scoring systems. DULK score could be an appropriate post-operative monitoring tool to reduce morbidity. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: Patients with chronic functional constipation have some problems such as weakness of pelvic floor muscles, and a lack of coordination of pelvic floor and abdominal muscles has been seen. The goal of this study was to investigate the lumbar proprioception and the core muscle recruitment pattern. Methods: The study type is a cross-sectional case–control study. There were 30 participants (case, n = 15, and control, n = 15). Electromyography of the core muscles was recorded while the subjects were getting up from the chair accompanied by lifting a weight, to check the pattern of muscle recruitment. Moreover, the lumbar proprioception was evaluated by an isokinetic device in both groups. The study was analyzed using independent t test and Mann–Whitney U test, and a nonparametric Friedman test was performed followed by Bonferroni pairwise comparison. Results: The comparison of muscle activity delay between the two groups showed that there was a significant difference between the two groups regarding the abdominal muscles, anal sphincter, and erector spinae (p < 0.05). However, there was no significant difference in the rectus femoris and gluteal muscles between the two groups (p > 0.05). Moreover, the proprioception of the lumbar region showed a significant difference (p < 0.05) between the two groups. Conclusions: The results of this study demonstrated that the lumbar proprioception sense was reduced in the case group. This result can be justified, based on the problems in constipation (lack of coordination of muscles, weakness of pelvic floor muscles). The coordination of core muscles changed in patients with chronic functional constipation during a functional task. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Abdominal cocoon syndrome and Chilaiditi syndrome are rare etiologies of bowel obstruction which have to be considered in patients with obstructive symptoms. Patients can profit from surgical management rather than non‐surgical approach. Encapsulating peritoneal sclerosis or abdominal cocoon syndrome (ACS) is an uncommon cause of intestinal obstructions associated with encapsulation of the small bowel by a fibro collagenous sac. Clinical presentations of ACS are unspecific and most patients are diagnosed intraoperatively. Moreover, Chilaiditi syndrome is another rare cause of bowel obstruction defined by interposition of colon and liver. There is no reported relation between these two conditions and surgical intervention is the suggested approach for severe bowel obstruction following them individually. We present a case with both conditions and describe our approach. A 47‐year‐old male presented with complaints of colic abdominal pain and distention, nausea and several attacks of bilious and nonbilious vomiting, anorexia, and constipation in the last 10 days before his admission. Laboratory data were normal and abdominal X‐ray showed large dilation at the distal part of the bowel without air fluid level. The patient underwent explorative laparotomy and a mass‐like lesion containing necrotic bowel and a whitish spleen accompanied by a complete anterior‐rotated liver was found. The encapsulated bowel and the spleen were resected followed by the complete resolution of symptoms in the patient. The intestinal obstruction caused by ACS is mostly approached by surgery to prevent the fatal sequela of this condition. [ABSTRACT FROM AUTHOR]

Objective: Human amniotic membrane (HAM) used as a wound coverage for more than a century. The aim of this study is to evaluate the efficacy of amniotic membrane on wound healing and reduce post-operative complication. Study design: Randomized clinical trial study. Place and duration of study: Surgery Department, Shahid Faghihi Hospital, Shiraz, in the period of between Sep. 2014 and Nov. 2015. Methodology: 73 patients with anal fistula were divided into two groups. The patients suffered from simple perianal fistula (low type) without any past medical history. Fistulotomy were performed for all of them and in interventional group HAM were applied as biologic dressing. Their wound healing improvement was evaluated post-operative in two groups. Results: From 73 patients participated in the study, 36 patients were in control group and 37 patients were in intervention group. According to the analysis of images taken from the wound, the rate of wound healing was 67.39% in intervention group and 54.51% in control group (p

Pregnant women are at higher risk of getting severe Covid-19 disease and consequences on the health status of them and their fetuses. Despite vaccination, all preventive behaviors are emphasized. This study aimed to identify the determinants of Covid-19 preventive health behaviors in pregnant women using Extended Parallel Process Model. This cross-sectional study, was conducted on 175pregnant women. The model fit indices were acceptable. Knowledge had indirect effect on adherence to Covid-19 preventive behaviors trough mediating role of self-efficacy and response efficacy. So, it is suggested that, educational interventions should focus on increasing knowledge. There were statistically significant correlations between all constructs of the EPPM model except knowledge, with adherence to Covid-19 preventive behaviors. Self-efficacy and response efficacy were the strongest predictors of Covid-19 prevention behaviors Perceived susceptibility and severity were the other significant predictors of Covid-19 preventive behaviors. Knowledge indirectly through the mediating role of response efficiency and self-efficacy effected on preventive behaviors [ABSTRACT FROM AUTHOR]

Objectives. This study examined the validity and reliability of the Family Health Climate Scale (FHC-Scale) among Iranian families. Second, can it be attributed to other family members by measuring the health climate in one person? Method. In total, 261 female students and 196 mothers completed the FHC-Scale. The study instrument was a Persian version of the FHC-Scale prepared through a translation and back-translation process. Results. The results showed that the Persian version of the FHC-Scale is acceptable. Cronbach's alpha coefficient for FHC-PA in female students and their mothers, respectively, was 0.88 and 0.86 for the whole scale. Cronbach's alpha coefficient for FHC-NU in female students and their mothers, respectively, was 0.83 and 0.92 for the whole scale. The CVI values for all the items were equal to or above 0.8, and the CVR value for the total scale was 0.90. Conclusion. The Persian version of the FHC-Scale is therefore an effective tool for evaluating the different dimensions of family health climate in the Iranian population. [ABSTRACT FROM AUTHOR]

The cover image is based on the Case Report Primary abdominal cocoon syndrome manifesting with Chilaiditi syndrome and intestinal obstruction: A case report by Ali Tajaddini et al., https://doi.org/10.1002/ccr3.8363.By Ali Tajaddini; Mohammadmehdi Fallahi; Hoda Haghshenas; Soheila‐sadat Nourmohammadi; Leila Ghahramani and Reza ShahriariradReported by Author; Author; Author; Author; Author; Author [Extracted from the article]

CD4CD25FoxP3 cells are a newly recognized subset of T cells which was first reported in autoimmune diseases. In our previous study, this subset was detected in tumor-draining lymph nodes (TDLNs) of patients with breast cancer. As little is known about their function in TDLNs of cancer patients, in this study, their frequency as well as their ability to produce interleukin (IL)-2, IL-10, or interferon (IFN)-γ were investigated in TDLNs of colorectal cancer (CRC) patients. Mononuclear cells were isolated from lymph nodes of 13 patients with CRC using Ficoll-Hypaque gradient centrifugation. Cells were stimulated in vitro and stained with CD25, CD4, FoxP3, IFN-γ, IL-10, and IL-2 or isotype matched antibodies and subjected to flow cytometry. The frequency of CD4CD25FoxP3CD127 cells was significantly lower than CD4CD25FoxP3CD127 population in TDLNs of CRC patients. The percentage of CD127 cells and also the MFI of FoxP3 expression was significantly lower in CD4CD25FoxP3 in comparison with CD4CD25FoxP3 population. Moreover, CD4CD25FoxP3 cells contained higher percentages of IL-2- and IFN-γ-producing cells than CD4CD25FoxP3 subpopulation. But, no difference was seen between two subsets in terms of IL-10 production. CD4CD25FoxP3 cells in TDLNs of CRC patients had lower suppressive and higher effector properties in comparison with CD4CD25FoxP3 conventional regulatory T cells. [ABSTRACT FROM AUTHOR]

Fecal incontinence is a challenging condition in that it exerts various psychosocial impacts on daily life. Different treatment modalities have been suggested for fecal incontinence. The present study aimed to evaluate the efficacy of biofeedback therapy in combination with surgery in the management of fecal incontinence. The present randomized controlled trial was performed on 27 women with a complaint of fecal incontinence because of delivery trauma. The patients underwent sphincteroplasty and levatorplasty via the same method by 2 colorectal surgeons. In Group I, biofeedback therapy was performed 3 months before and 6 months after the surgery; in Group II, biofeedback therapy was applied only 6 months after the surgery; and in Group III, only surgical management was performed. The results revealed a significant difference between the preoperative and postoperative Wexner scores of incontinence in all the 3 groups. Additionally, the difference between the preoperative and postoperative scores was significant only in Group I and Group III, but not in Group II. The reduction in the Wexner score was significantly less in Group III. However, no significant difference was observed between the 3 groups concerning the mean difference of preoperative and postoperative manometry. The present study revealed no significant role for biofeedback therapy alone in the improvement of manometric evaluation. However, the Wexner score, which is an indicator of patient satisfaction, increased with biofeedback therapy following sphincteroplasty. In general, surgical treatment is now reserved for selected patients with fecal incontinence and has recently been developed with biofeedback therapy. Trial Registration Number: IRCT201206039936N1 [ABSTRACT FROM AUTHOR]

Extramedullary hematopoiesis (EMH) is defi ned as the production of the myeloid and erythroid elements outside the bone marrow. It is usually a compensatory mechanism of the myeloid and erythroid production due to increased breakdown or diminished production of erythrocytes. Presacral EMH is an extremely rare condition, and there is a limited number of case reports published in the literature. A 39-year-old female patient as a known case of thalassemia intermedia presented with lower abdominal pain. A computerized tomography scan showed a large presacral mass, associated with bone destruction. The patient was admitted for exploratory laparotomy with suspicion to malignant lesions, but the fi nal pathological diagnosis was EMH. It should be considered in differential diagnosis of mass-like lesions in the presacral area in patients with predisposing factors such as thalassemia, although there were malignant features such as bone destruction in imaging studies. Preoperative diagnostic tools such as fi ne needle aspiration and biopsy could help us to render the defi nite diagnosis and prevent unnecessary operation. [ABSTRACT FROM AUTHOR]

Although the development of modern medicine has helped us detect and treat diseases better than in the past, especially in the field of surgery; the history of medicine may be a trigger that can help us use neglected aspects of prior knowledge for the advancement of modern-day science. Since historical papers that have specifically focused on anorectal diseases are rare, but those that exist contain brief discussions in this field, the current study aims to present a detailed review of Avicenna’s approach to anorectal diseases. Therefore, we reviewed On the Diseases of the Anus, the 17th chapter of the third volume of the Canon of Medicine written by Avicenna, and compared his views on the classification and diagnosis of, and the approach to anorectal diseases with that of modern proctology. Avicenna discussed in detail about anorectal diseases such as hemorrhoid, fissure, perianal abscess and fistula, rectal prolapse, fecal incontinence, and pruritus ani. In addition, we introduce herbs which Avicenna used to treat these diseases. Our findings show that Avicenna’s views on the classification and diagnosis of, and the approach to anorectal diseases have few fundamental differences with modern medicine. In addition, the pharmacological effects of some of the herbs that were recommended by Avicenna, and are used in current medicine are proven. Thus the Medieval knowledge can be further scientifically investigated to develop new therapeutic options for anorectal diseases. [ABSTRACT FROM AUTHOR]

Colon transit time study with radio opaque markers is a simple method for assessment of colon motility disorder in patients with chronic idiopathic constipation. Appendicitis caused by metallic objects has been reported repeatedly and is very important because of its complications. We report a case of acute appendicitis that was induced by impaction of radio opaque markers after colon transit time study. We think that this case report is first significant complication of colon transit time study until now. [ABSTRACT FROM AUTHOR]

Background: On an average 30-50% of patients who undergo incision and drainage (I and D) of anal abscess will develop recurrence or fistula formation. It is claimed that finding the internal orifice of anal abscess to distract the corresponding anal gland duct; will decline the rate of future anal fistula. Surgeons supporting I and D alone claim that finding the internal opening is hazardous. This study is conducted to assess short-term results of optional method to manage patients with anal abscess and fitula-in-ano at the same time. Materials and Methods: In this cross-sectional descriptive study 49 from 77 patients with anal abscess whose internal orifice was not identified by pressing on the abscess, diluted hydrogen peroxide (2%) and methylene blue was injected into the abscess cavity and the anal canal was inspected to find out the internal opening. Once the opening was distinguished, an incision was given from the anal verge to the internal opening. Results: The internal orifice was identified in 44 out of 49 patients (90%) who underwent this new technique. Up to 18 months during follow-up, only 2.5% of patients with primary fistulotomy developed fistula on the site of a previous abscess. Conclusion: Conventional method to seek the internal orifice of anal abscesses is successful in about one-third of cases. By applying this new technique, surgeons would properly find the internal opening in >90% of patients. Needless to say, safe identification of the anal gland orifice in anal abscess disease best helps surgeons to do primary fistulotomy and in turn it would significantly decrease the rate of recurrence in anal abscess and fistula formation. [ABSTRACT FROM AUTHOR]

Background: The gold standard of the management of rectal cancer in the middle and lower parts is low anterior resection with coloanal anastomosis. About 50% of the patients undergoing this procedure might experience some complications because of the low capacity of the neorectum. The aim of this study was to evaluate ileal J-pouch interposition as a neorectum between the anal canal and the remaining colon in comparison to coloanal anastomosis and transverse coloplasty. Methods: Twelve dogs, weighing 23-27 kg, were divided into three groups. After laparotomy, the volume of the primary rectum was measured so that it could be compared with that of the neorectum at the end of the study. After rectal resection in Group A, the colon was directly anastomosed to the anus. In Group B, a 5-cm longitudinal incision was made 2 cm proximal to the anastomosis and was sutured transversely (coloplasty). In Group C, a 5-cm ileal J-pouch was interposed between the colon and anus. After 8 weeks, the neorectum was evaluated for volume, radiology, and pathology. Results: All the samples were alive until the end of the study. The healing of the anastomotic lines was acceptable (pathologically) in all. The mean volume expansion was 20.9% in Group A, 21.7% in Group B, and 118.2% in Group C, with the latter being significantly higher than that of the other groups (P=0.03). Colon J-pouch and coloplasty after proctectomy in some situations have not been performable. This study evaluated the performance of ileal J-pouch interposition. Conclusion: This study showed that ileal J-pouch interposition might produce an acceptable reservoir function and that it seems feasible and safe in selected cases. [ABSTRACT FROM AUTHOR]

Neurofibromatosis type 1, also known as von Recklinghausen disease, is an autosomal dominant disorder with an incidence of 1 per 4000. Neurofibromas are benign, heterogeneous tumors arising from the connective tissue of peripheral nerve sheaths, especially the endoneurium. Visceral involvement in disseminated neurofibromatosis is rare. Neurofibroma occurs most frequently in the stomach and jejunum, but the colon and anorectal canal may also be involved. Gastrointestinal neurofibromas may lead to bleeding, obstruction, intussusception, protein-losing enteropathy and bowel perforation. We present a case of diffuse involvement of the anorectal area by a huge neurofibroma, with pelvic pain, watery diarrhea and urgency. [ABSTRACT FROM AUTHOR]

Neurofibromatosis type-1 (NF1), also known as Von Recklinghausen disease, is an autosomal dominant disorder with incidence of one per 4000. Neurofibromas are benign, heterogeneous, peripheral nerve sheath tumors coming up from the connective tissue of peripheral nerve sheaths, particularly the endoneurium. Visceral involvement in disseminated neurofibromatosis is considered rare. Neurofibroma occurs most frequently in the stomach and jejunum, but colon and anorectal canal may also be involved. Gastrointestinal neurofibromas may lead to bleeding, obstruction, intussusception, protein-losing enteropathy and bowel perforation. We encountered a case of diffusely involving the anorectal area by huge neurofibroma, which resulted in pelvic pain with watery diarrhea and urgency. [ABSTRACT FROM AUTHOR]

Anal fissure which is an ischemic ulcer in the lining of the anus, is a common challenging problem in current medicine. This study was designed to evaluate the benefits of a Persian Medicine cerate containing wallflower (Erysimum cheiri) and damask rose (Rosa × damascena) oil (WDC) on anal fissure. This randomized, controlled clinical trial was conducted on 64 acute anal fissure patients. In each group, patients were given either 0.5 g of WDC or 2.5 cm of Diltiazem 2% gel twice daily for 2 weeks. Anal pain, itching and inflammation were primary outcomes. The recurrence rate and statistical analyses were performed on a per protocol and intention-to-treat basis. Fifty-three patients completed the study. The symptoms decreased significantly (p < 0.05) in all patients after 2 weeks. Comparison of responses between groups reveals no significant differences (p > 0.05) in pain, itching, and inflammation. There was no significant difference (p > 0.05) in recurrence rate of the disease, but the trend of healing in WDC group was better than Diltiazem 2% gel after six weeks. No serious adverse events were observed. The results suggest that topical application of the cerate containing wallflower and damask rose oil can be considered as a potential herbal medicine for the treatment of anal fissure. It exerts comparable clinical effects to current routine treatment. Further studies with long-term follow-ups and larger sample sizes are necessary to have a comprehensive overview of the safety and efficacy of this natural preparation. [ABSTRACT FROM AUTHOR]

Background and Objective: Prolonged hospitalization lead to considerable financial burden for patients as well as health care system. This study aimed to identifying important factors resulting in excess hospitalization days in patients undergoing abdominal surgeries using the multilevel zeroinflated Poisson regression model. Methods: In this descriptive - analytic study, 485 patients from five teaching and private hospitals in Shiraz (southern Iran) were selected based on convince sampling method. Multilevel zero-inflated Poisson regression model was used to determine the risk factors of excess hospitalization day. Maximum likelihood method was used to estimate parameters of the model. Moreover, Akaike Information Criterion (AIC) and Bayes Information Criterion (BIC) indices were applied to assess the goodness of fit of the model. Results: The primary analysis of data showed that 81.2% of the patients did not undergo excess hospitalization days. Based on findings, age, respiration rate, blood infusion, fever, smoking and drug abuse did not affect excess hospitalization days. In contrast, gender, renal diseases, operation history, laparoscopic gallbladder removal, prostate surgery and ileus significantly led to excess hospitalization days (P<0.05). Laparoscopic gallbladder removal, prostate surgery increased the chance of excess of hospitalization days to 4.64 and 9 times, respectively (P<0.05). Conclusion: Geder, renal diseases, operation history, laparoscopic gallbladder removal, prostate surgery and ileus significantly led to excess hospitalization days. [ABSTRACT FROM AUTHOR]

Background: Understanding the prognostic factors affecting the recurrence-free survival (RFS) of patients with rectal cancer (RC) is the mainstay of care. The present study aimed to identify factors affecting both short- and long-term RFS of patients with RC using semiparametric mixture cure models. Methods: The data were obtained from the database of the Colorectal Research Center of Shiraz University of Medical Sciences, Shiraz, Iran, which was collected during 2007-2017. To determine the factors affecting recurrence, cure models were applied to short-term and long-term RFS of patients with RC separately. The cure rate was calculated using the smcure package in R 3.5.1 (2018-07-02) software. P<0.05 was considered statistically significant. Results: Out of the 376 eligible patients with RC, 75.8% of men and 74.5% of women were long-term survivors. The mean age of the patients was 57.0±13.8 years. Lymph node ratio (LNR)≤0.2 increased the probability of short-term RFS. The prominent factors affecting long-term RFS were body mass index (BMI)<25 kg/m² (OR=1.98, P=0.047), tumor-nodemetastasis (TNM) stage (OR=6.48, P<0.001), abdominal pain (OR=2.15, P=0.007), and computed tomography (CT) scan detected pelvic lymph nodes (OR=3.40, P=0.01). Over a 9-year follow-up period, the empirical and estimated values of cure rates were 75.3% and 83.9%, respectively. Conclusion: The results showed that factors affecting shortterm RFS might be different from long-term RFS. A lower BMI was related to a poorer prognosis in patients with RC. Early diagnosis leads to a lower TNM stage and could increase the probability of long-term RFS. [ABSTRACT FROM AUTHOR]

Background: Radiotherapy is one of the most important factors which results in negative effects on wound healing and increases anastomosis leakage. Diverting loop ileostomy has been usually performed after colorectal anastomosis in cases of colorectal cancer with a history of neoadjuvant radiotherapy to decrease the chance of leakage. Considering the side effects of diverting loop ileostomy, the objective of the present study is to investigate the effect of human amniotic membrane (HAM) on colorectal anastomosis leakage after neo-adjuvant radiotherapy. Methods: In this experimental animal study, 20 crossbreed rabbits were randomly divided into two groups (case group: 13 rabbits, control group: 7 rabbits) after receiving an equal dose of external beam radiation. Four weeks after irradiation, resection of 4 cm of colorectal segment and end-to-end single layer anastomosis were conducted. In the case group, a 2x2 cm wrap of HAM applied around the site of anastomosis. Eight weeks later, all the survived rabbits were sacrificed. A segment of anastomotic sites was resected in all expired and survived rabbits and sent for pathological evaluation. Mann-Whitney U Test (SPSS for Windows, Ver. 16, Chicago, IL) was applied to analyze healing scores between the two groups. Results: Due to anastomosis dehiscence, 5 rabbits expired in the control group, but all the 13 rabbits (case group) survived after 8 weeks and showed no leakage. In addition, pathological evaluation revealed significant epithelialization and neovascularization in the case group. Statistically, healing score was higher in the case group rather than the control group (P<0.001). Conclusion: To prevent post irradiation colorectal anastomosis leakage, the use of HAM might play a significant role and a feasible technical approach. [ABSTRACT FROM AUTHOR]

Background Empowering adolescents in the field of puberty health is one of the important goals of public health programs. The present study was carried out with the aim of determining the effect of peer-led training on puberty-related behavior and its determinants using social cognitive theory., Methods: A total of 245 teenage girls were randomly divided into two groups: the intervention group and the comparison group. The questionnaire measuring puberty-related behavior and its determinants was self-administered and completed before and 2 months after training in the two groups. One session for parents, four sessions for peer educators, and four sessions for participants were conducted for 1 month., Results: In the intervention group, unlike the comparison group, the mean scores of knowledge, outcome expectations, self-efficacy, self-control, social support, and behavior increased significantly after training (p <0.05). Based on regression analysis, outcome expectations and social support were the main determinants of puberty-related behavior (adjusted R 2 = 0.464)., Conclusion: The findings of this study support the effectiveness of the peer-led educational intervention based on social cognitive theory in the improvement of puberty-related behavior and its determinants, which can be used in the design of puberty-related health promotion programs. Further research to assess the longer-term outcomes and to examine other theories of behavior change are suggested., Competing Interests: Conflicts of Interest The authors declare no conflict of interest., (Copyright © 2024. Published by Elsevier Masson SAS.)

Background and objective Tracheostomy in coronavirus disease 2019 (COVID-19) patients can be performed in cases of prolonged intubation or in patients with a known difficult airway. Tracheostomy is usually performed by two main approaches: open surgery or percutaneous endoscopic insertion. However, few studies have compared these two techniques in severe COVID-19 patients. The objective of the present study was to compare the efficacy of the two main methods of tracheostomy among patients with severe COVID-19 infection. We also aimed to investigate the impact of various lab data and medications on patient outcomes. Materials and methods We included all symptomatic severe COVID-19 patients in need of prolonged mechanical ventilation. We examined the patients' past medical history, arterial blood gas (ABG) analysis, laboratory workups, and medication history. We calculated the PaO 2 /FiO 2  ratio as an index to evaluate the severity of acute respiratory distress syndrome (ARDS). Results During the study period, 72 patients with severe COVID-19 underwent tracheostomy tube insertion. The average age of participants was 58.93 ±15.27 years; 44 (61.1%) were male and 28 (38.9%) were female. Of note, 54 (75.0%) patients passed away and only 18 (25.0%) survived. Among the survivors, 13 (29.5%) were men and five (17.9%) were women. The study showed a significantly higher mortality rate (23, 92.0%) among patients who underwent open surgery compared to those who received percutaneous surgery (31, 65.9%) (p=0.01). Conclusion Based on our findings, percutaneous endoscopic tracheostomy seems to be the superior approach compared to open tracheostomy. Other predictive factors associated with patient outcomes included levels of HCO 3 , FiO 2 , PaCO 2 , and PaO 2 /FiO 2 ratio., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Akbari et al.)

CD4 + CD25 - FoxP3 + cells are a newly recognized subset of T cells which was first reported in autoimmune diseases. In our previous study, this subset was detected in tumor-draining lymph nodes (TDLNs) of patients with breast cancer. As little is known about their function in TDLNs of cancer patients, in this study, their frequency as well as their ability to produce interleukin (IL)-2, IL-10, or interferon (IFN)-γ were investigated in TDLNs of colorectal cancer (CRC) patients. Mononuclear cells were isolated from lymph nodes of 13 patients with CRC using Ficoll-Hypaque gradient centrifugation. Cells were stimulated in vitro and stained with CD25, CD4, FoxP3, IFN-γ, IL-10, and IL-2 or isotype matched antibodies and subjected to flow cytometry. The frequency of CD4 + CD25 - FoxP3 + CD127 dim/- cells was significantly lower than CD4 + CD25 + FoxP3 + CD127 dim/- population in TDLNs of CRC patients. The percentage of CD127 dim/- cells and also the MFI of FoxP3 expression was significantly lower in CD4 + CD25 - FoxP3 + in comparison with CD4 + CD25 + FoxP3 + population. Moreover, CD4 + CD25 - FoxP3 + cells contained higher percentages of IL-2- and IFN-γ-producing cells than CD4 + CD25 + FoxP3 + subpopulation. But, no difference was seen between two subsets in terms of IL-10 production. CD4 + CD25 - FoxP3 + cells in TDLNs of CRC patients had lower suppressive and higher effector properties in comparison with CD4 + CD25 + FoxP3 + conventional regulatory T cells.

Background: Common bile duct stone (CBDS) as a result of gallstone is one of the gastrointestinal disorders. In this study, the incidence of CBDS and symptomatic gallstone in Shiraz were investigated, and their management suggested., Materials and Methods: This is a retrospective study that enrolled among 560 patients. The incidence of gallstone together with CBDS was evaluated using an ultrasonography studyand clinical data in the period between March 2014 and 2014 in Shiraz. Comparison between data was done using Student's t-test or Chi-square test., Results: Of these patients, 18.6% were male, and 81.4% were female with a mean age of 47.67 ± 0.74 years. The concomitant rate of gallstone and CBDS was 8.6%. 6.8% of patients with concomitant of gallstone and CBDS showed symptoms while 1.8% had not been diagnosed before the operation. The mean of serum alkaline phosphatase level in patients with the only gallstone was 255.80 IU/L and patients with concomitant gallstone, and CBDS was 580.88 IU/L with a significant difference between two groups (P < 0.001). Furthermore, liver function tests (aspartate aminotransferase, alanine transaminase) showed a significant difference between two groups of patients (P < 0.01, P < 0.001)., Conclusions: Clinical variables such as tenderness, fever, and Morphy sign were more severein patients with concomitant gallstone and CBDS. The concomitant rate of gallstone and CBDS in our society is less that Western countries and asymptomatic patients showed fewer ratios than other countries. We think the approach for asymptomatic CBDS patients with gallstone can be affected by our results.

Background: Seton-based techniques are among popular methods for treating high type anal fistula. These techniques are categorized to cutting and noncutting regarding their mechanism of action. In this report we are about to describe a new technique, which is a combination of both mechanisms; we call it Pulling Seton., Materials and Methods: In this technique after determining internal and external orifice of fistula, fistulectomy is done from both ends to the level of external sphincteric muscle. Finally, a remnant of fistula, which remains beneath external sphincteric muscle is excised, and Seton is passed instead of it and tied externally. After the wound heals, patient is asked to pull down the Seton for 3-4 min, 4 times a day. We prospectively enrolled 201 patients with high type anal fistula in this study., Results: Seton gradually passes through external sphincteric muscle till it is displaced outwards or removed by a surgeon via a small incision. 94% of patients treated by this method accomplished their treatment completely without recurrence. None of the patients developed permanent fecal or gas incontinence. Only 5% of patients developed with recurrence of fistula. Since Seton traction is not permanent in this technique, Seton cuts external sphincter slowly, and minimal rate of incontinence is reported., Conclusion: Pulling Seton seems to be an efficient way in treating high type anal fistula with minimal rate of recurrence and complications such as incontinence and authors suggest further randomized studies to compare its efficacy with other Seton-based techniques.

Purpose: Despite advances in rectal cancer treatment over the last decade, local control and risk of late side effects due to external beam radiation therapy (EBRT) remain as concerns. The present study aimed to investigate the efficacy and the safety of low-dose-rate endorectal brachytherapy (LDRBT) as a boost to neoadjuvant chemoradiation for use in treating locally advanced distal rectal adenocarcinomas., Methods: This phase-II clinical trial included 34 patients (as the study arm) with newly diagnosed, locally advanced (clinical T3-T4 and/or N1/N2, M0) lower rectal cancer. For comparative analysis, 102 matched patients (as the historical control arm) with rectal cancer were also selected. All the patients were treated with LDRBT (15 Gy in 3 fractions) and concurrent chemoradiation (45-50.4 Gy). Concurrent chemotherapy consisted of oxaliplatin 130 mg/m(2) intravenously on day 1 plus oral capecitabine 825 mg/m(2) twice daily during LDRBT and EBRT., Results: The study results revealed a significant differences between the study arm and the control arm in terms in the pathologic tumor size (2.1 cm vs. 3.6 cm, P = 0.001), the pathologic tumor stage (35% T3-4 vs. 65% T3-4, P = 0.003), and the pathologic complete response (29.4% vs. 11.7%, P < 0.028). Moreover, a significantly higher dose of EBRT (P = 0.041) was found in the control arm, and a longer time to surgery was observed in the study arm (P < 0.001). The higher rate of treatment-related toxicities, such as mild proctitis and anemia, in the study arm was tolerable and easily manageable., Conclusion: A boost of LDRBT can optimize the pathologic complete response, with acceptable toxicities, in patients with distal rectal cancer.

Background: There is a growing tendency toward application of human amniotic membrane (HAM) as a biologic substitute in various tissue injuries where a significant tissue loss is a matter of concern. In gastrointestinal injuries especially duodenal ones, some potential limitations in current surgical techniques contribute to not fully acceptable healing outcomes. Thus, this study was carried out to assess repair with HAM patch for duodenal defect in comparison with simple duodenoraphy in an animal model (dog)., Materials and Methods: A total of 15 male German shepherd dogs weighing 23-27 kg were randomly divided into two groups. Group A with 10 dogs, which were a candidate for duodenal repair by amniotic membrane patch and Group B consisted of 5 dogs perform simple duodenorraphy. A precise control was made to match all conditions except surgical technique. Macroscopic and microscopic features of the healed duodenal lumen in both groups were recorded., Results: Gross evaluation revealed no difference in luminal diameter in both groups. Statistical analysis of duodenal diameter between both groups after operation also showed no significant difference (P v = 0.789). Histological assessment indicated less inflammation with better wound healing in Group A., Conclusion: It seems that repairing duodenal wall defect with HAM would result in better histological outcomes compared with what is seen in simple duodenoraphy in animal models. However, there is no significant difference regarding surgical findings.

Background: Recto-vaginal fistula is primarily one of the co-morbidities of vaginal delivery. These patients suffer from persistent malodor vaginal discharge. Various surgical techniques have been employed by surgeons in the course of time. This is the first trial of applying Human Amniotic Membrane (HAM) as a bio-prosthesis in repairing recto-vaginal fistula., Materials and Methods: In a prospective animal study, 8 mixed-breed female dogs weighing 23-27 kg with the age of 12-18 months were selected. They were randomly divided into two groups for standard recto-vaginal fistula repair and fistula repair with human amniotic membrane. The Kruskal-Wallis and Mann Whitney tests were performed to indicate statistical differences., Results: After 6 weeks, fistulas were evaluated both grossly and microscopically. In gross examination, there were no difference between the two groups and healing of fistula seemed to have been occurred in all dogs expect for one which had a persistent patent fistulous tract. Microscopic healing was scored according to epithelialization, collagenization inflammation, ulcer and necrosis of samples. Healing score was significantly higher in the HAM group than the standard group (P = 0.029)., Conclusion: Our findings revealed that using HAM as a bio-prosthesis to repair recto-vaginal fistula would result in better surgical and histological outcomes comparing to simple repair.

Objective: To determine the effects of intravenous Acetaminophen (Apotel®)  on pain severity and clinical findings of peritonitis in patients with acute appendicitis., Methods: This randomized  cross-over clinical trial was carried out duringa 6-month  period from August 2012 to February 2013 and comprised 107 patients diagnosed with acute appendicitis. Patients were randomly assigned to received placebo (n=54) or Apotel® (n=53). Patients were evaluated before, 30 minutes, 1 hour and 4 hours after administration  of Apotel®  or placebo,and were told to fill in two forms. The first form required patientsto measure their painintensityaccording to visual analogue scale (VAS). The second form was filled by a surgeon who examined the patients and recorded his or her findings using Alvarado score criteria for diagnosis of acute appendicitis at foregoing time points., Results: Of 72 patients, 37 (51.4%) were men and 35 (48.6%) were women. The mean age of the patients was 34.1±13.5 years. The mean pain score in 107 patients included in this study was 7.96±2.3. Those who received Apotel®  had significantly lower pain scores when compared to placebo at 30 minutes (p<0.001), 1 hour (p<0.001) and 4 hours of administration. There was no significant difference between two study groups regarding the frequency of Alvarado score; however the frequency of fever was significantly lower in those who received Apotel® (p<0.001). We found that Apotel® was not associated with resolved physical findings of acute appendicitis in different time intervals., Conclusion: Apotel® does not affect the clinical findings of acute appendicitis and dos not interfere with the accurate diagnosis. Therefore, it could safely be used as a reliable pain relieving agent, in patients with acute appendicitis.

Objective: To evaluate the role of physical examination in decision making for exploring patients with penetrating zone II neck injury., Methods: This was a cross-sectional study being performed in a level I trauma center between 2006 and 2010. The present study reviewed the records of 150 patients with penetrating neck injuries. Of 46 cases with zone II deep platysma neck injuries, 3 patients died before taking any significant medical measure., Results: Thirty of 43 patients (70%) presented with hard sings while 13 (30%) did not show these sings. All patients underwent neck exploration. Two patients (4.6%) without hard sings exhibited positive findings, whereas 29 cases (67%) with hard sings reported positive on exploration., Conclusion: Briefly, we hold the view that it seems reasonable to follow an algorithmic approach by using physical examination of the patients with zone II penetrating neck injuries. This prevents unnecessary exploration for management of such patients.