About Journal

Basrah Journal of Surgery Editor-in- chief Prof. Thamer A. Hamdan, FRCS Prof. Salam N. Asfar, MSc Information Administrator Dr. Jasim M. Salman, MB,ChB, DA, FICMS Associate Editors Dr. Hashim S. Khayat, FRCS Prof. Mazin H. Al-Hawaz, CABS, FRCS Prof. Zeki A. Al-Faddagh, CABS, FRCS Prof. Issam Merdan CABS, FICMS Assist. Prof. Ali A. Alshawi, FFDRCSI, FDSRCS Assist. Prof. Mazin Abdulsattar, CABS Dr. Zuhair Al-Barazanchi, MSc, PhD National Advisory Board Prof. Ahmad M Al-Abbasi, FRCS Prof. Abdulla M. Jawad, PhD Dr. Hasan K. Muhamed, FRCS Assist. Prof. Tahir A...
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Journal Information

Publisher: Basrah University

Email:  basjsurg95@yahoo.com

Editor-in-chief: Professor Dr. Thamer A. Hamdan, FRCS,FRCP,FACS,FICS

Editor-in-chief: Professor MSc. Salam N. Asfar, MSc

Print ISSN: 1683-3589

Online ISSN: 2409-501X

IS THERE A “FREE SIZE” IN SURGICAL PRACTICE?

Basrah Journal of Surgery, Volume 24, Issue 2, Pages 1-2
DOI: 10.33762/bsurg.2018.160085

Several parameters should seriously be considered in, almost, every pathology before drawing the line of treatment. Patients are not alike even when they are twins. Individual variation is a reality that should be taken in consideration.
On top of this, comes the response to pain. The best example is the delivery of a baby; while one lady shouts loudly, another is very quiet. Some consider the pain stimulus as intense, because of psychogenic factors, while others show a calm response for the same condition.

THE ADVANTAGE OF ACUTE INFLAMMATORY MARKERS IN DIAGNOSIS OF ACUTE APPENDICITIS

Basrah Journal of Surgery, Volume 24, Issue 2, Pages 8-13
DOI: 10.33762/bsurg.2018.160086

Abstract
Acute appendicitis is the most common cause of emergency abdominal surgery with an estimated lifetime prevalence of 7%–8%. Despite advances in diagnosis and treatment, it is still associated with morbidity (10%) and mortality (1%–5%).
This study was designed to investigate the results of WBC count, platelet distribution width and C-reactive protein values based on the pathology results in patients undergoing appendectomy with an early diagnosis of acute appendicitis.
This prospective cross sectional study was carried out in Basrah Teaching Hospital from the period 1st of September 2015 to 1st of June 2017, a total of 154 consecutive patients were enrolled in the study. All patients were admitted to the emergency department with history suggestive of acute appendicitis, blood tests were done for inflammatory markers in form of WBC, CRP and PDW, a period of 24 hours prior to surgery was accepted, histopathological data were used to assess inflammation of the appendix.
The majority of patients were males 61% while females were 39%, with age range between 14-46 years (mean 24.28 years). There was a correlation between WBC count and acute appendicitis(P value=0.004), with sensitivity range (53%-69%) and specificity range (25-89%), while positive predictive value (PPV) and negative predictive value (NPV) were 96% and 8% respectively. A significant correlation found between CRP and acute appendicitis (p value less than 0.0001) with sensitivity range (71%-85%), while specificity was (10%-74%) and PPV, NPV were 95% and 9% respectively. Regarding PDW, no correlation was found with acute appendicitis (p value=0.296) with sensitivity range (6%-16%) while specificity (17%-82%), PPV 78%, NPV 2%. There was significant correlation between inflammatory markers (WBC, CRP, PDW) and complication with a p value=0.0001, ruptured appendix and peri-appendicular abscess were the most common complications recorded, only 8(5.2%) patients had normal appendix after histopathological examination.
In conclusion, acute inflammatory markers play an important role in diagnosis of acute appendicitis along with history and physical examination.

A CHANGING PATTERN OF CANCER–RELATED MORTALITY IN BASRAH

Basrah Journal of Surgery, Volume 24, Issue 2, Pages 24-29
DOI: 10.33762/bsurg.2018.160087

Abstract
Cancer is a growing health problem with substantial mortality. A high mortality reflects high incidence, late detection and inadequate management.
The objective of this study is to examine the time changes of mortality rate of cancer in Basrah. The results presented in this article are all based on officially registered cancer deaths in Basrah Governorate on selected years.
Cancer of lung and bronchus, breast cancer, CNS tumors, all types of leukemia, secondaries of unknown primary site, urinary bladder cancer, stomach cancer, cancer of pancreas and cancer of liver and biliary system were the leading causes of cancer related death and accounted for 68.7%. The time trend showed some tendency for mortality rates to increase over years for most cancers except a noticeable decline in recent years.
In conclusion, cancer is a major cause of death in Basrah accounting for nearly 10% of all officially registered deaths. An initial modest increase followed by some tendency to decrease in mortality rate is noticed. Further comprehensive studies are highly recommended.

THE PROFILE OF PATIENTS WITH NON-VARICEAL UPPER GASTROINTESTINAL TRACT BLEEDING IN BASRAH TEACHING HOSPITAL

Basrah Journal of Surgery, Volume 24, Issue 2, Pages 39-45
DOI: 10.33762/bsurg.2018.160088

Abstract
Upper gastrointestinal tract bleeding is a common emergency and life threatening condition. During the last three decades, many factors have been evolved that might change the incidence, age of presentation, site of bleeding and the outcome of patients with non variceal upper gastrointestinal tract bleeding.
This study aimed to assess the profile and the mode of presentation of the patients with non-variceal upper gastrointestinal tract bleeding and to assess the etiology and the effect of different factors (demographic, mode of presentation and the treatment options) on the patient's outcome.
This observational prospective study was carried out from May 2008 to October 2014 in Basrah Teaching Hospital. All adult patients who were presented with non-variceal upper gastrointestinal tract bleeding were included. All the demographic, clinical and treatment modalities in addition to the mortality rate and complications data were collected and analyzed.
A total of 238 patients with non-variceal upper gastrointestinal tract bleeding were included in this study, 161 (67.6 %) patients were males and 77 (32.3 %) were females. The mean age was 50.62±17.06. Hematemesis was the commonest presentation in 125 (52.5%) followed by melena in 81 (34.03%). Duodenal ulcer was the commonest cause in 99 (41.59%) patients followed by erosive gastritis in 37 (15.5%) patients. The most common treatment modality was the medical treatment used in 186 (78.15%) patients which was successful in 179 (96.23%) with relatively low complications and rebleeding rates. Interventional endoscopy was used for 40 (16.8%) and was successful in 38 (95%) with 2 (5%) patients developed rebleeding. Surgery was done for 12 (5.04%) patients and was successful in 8(66.6%) and it was associated with highest rate of mortality (33.3%). Concerning the factors that might affect the outcome, there was a statistically significant effect of mode of treatment (odd ratio 6.42, p=0.03) and smoking (odd ratio 5.86, p=0.047) on the rate of development of complications. The mode of treatment had a statistically significant effect on mortality rate (odd ratio 20.24 p=0.001). The use of aspirin and/or NSAID affects significantly the rebleeding rate (odd ratio 7.4 p=0.025).
In conclusion, the profile of our patients with non-variceal upper gastrointestinal tract bleeding was not greatly different from that of surrounding Middle East countries. We found that peptic ulcer disease was the commonest cause for which medical treatment was the most successful mode of treatment. Among many known risk factors, the mode of treatment and smoking were the factors that increase the complication rate. The mode of treatment was the only factor that affects the mortality rate. Use of aspirin or non-steroidal anti-inflammatory drugs influenced the rebleeding rate.

BLEEDING FOLLOWING BARIATRIC SURGERY (TYPES & MANAGEMENT MODALITIES)

Basrah Journal of Surgery, Volume 24, Issue 2, Pages 49-55
DOI: 10.33762/bsurg.2018.160089

Abstract
Bleeding is a serious complication following bariatric procedures such as Minigastric bypass (MGB), Roux-En-Y Gastric Bypass (RYGB) Surgery, and Sleeve Gastrectomy (SG). Post bariatric bleeding is either acute or chronic. Although this complication is declined now, but still it is important to know because if it is not managed urgently it will lead to serious results. The source of bleeding may be from the staple lines, unexpected injury to the spleen, or to one of the blood vessels around the surgical field.
The other source of bleeding may be internal through the GIT and it is presented as hematemesis or melena. Gastrointestinal bleeding in patients underwent bariatric surgery may occur in the esophagus, gastric pouch, new sleeved stomach, the Roux limb just distal to the anastomosis, the remaining of the small intestine. The site of bleeding can be determined and treated mostly by endoscopy but in certain cases may require re-laparoscopy.
The aim of this study is to analyze the incidence, types and management of this bleeding.
This is a prospective study which has been done in Al-Sadr Teaching Hospital, Basrah, Iraq, from June 2015 to June 2017. The study included 540 case who were subjected to SG, RYGB, MGB and they were analyzed regarding; time of occurrence, postoperative bleeding, types whether intra-peritoneal or intra-luminal and type of approaches for treating this bleeding. In our study we don’t over sewn the staple line and didn't use any buttressing material or synthetic coagulation powder.
The total number of patients developed post-operative bleeding were 18 cases out of 540, 12 after sleeve gastrectomy, 3 after mini gastric bypass and 3 after Roux-En-Y. Regarding sleeve gastrectomy; two patients of the required re-laparoscopy and evacuation of hematoma with treating site of bleeding by clipping or suturing according to the condition, three patients required aspiration under ultrasound guide, while the remaining 7 cases were kept only under conservative measures. The 3 patient of the MGB were managed conservatively and the 3 cases of Roux-En-Y were managed either conservatively in 2 cases or by endoscopic intervention in one case.
In conclusion, we advise the surgeons to use reinforcement of staple line to decrease incidence of post-operative bleeding.

HEMORRHOIDAL ARTERY LIGATION WITH RECTO-ANAL REPAIR VERSUS TRADITIONAL HEMORRHOID-ECTOMY, A COMPARATIVE STUDY

Basrah Journal of Surgery, Volume 24, Issue 2, Pages 61-66
DOI: 10.33762/bsurg.2018.160090

Hemorrhoids, are vascular structures present in the anal canal as cushions that facilitate stool control. When swollen or inflamed they are regarded as hemorrhoidal disease; sometimes they are asymptomatic specially in the internal type which are presented with painless rectal bleeding while external type may present with painful swelling.
Although the traditional open hemorrhoidectomy (Milligan Morgan) is standard and effective technique, it is associated with many complications; the most important is post-operative pain and delayed return to normal activities. Nowadays Doppler-guided hemorrhoidal artery ligation (DG-HAL) with recto-anal repair (RAR) is a minimally-invasive technique for hemorrhoids, it is developed recently to overcome these complications.
The purpose of this prospective study is to compare between the classical open hemorrhoidectomy and HAL-RAR procedure, by assessment of post-operative pain, postoperative complications and outcome of the procedures.
This prospective, study was done between September 2014 and September 2016. Ninety six patients complaining of hemorrhoids were studied at Al-Sadr Teaching Hospital, Basrah, Iraq. They were divided equally into two groups; group A and B, group A underwent surgery by DG HAL and RAR, and group B were subjected to traditional procedure. Patients were followed for one year by evaluation at 1 week, 1 month, 6 months, and 1 year.
In conclusion, DG-HAL with RAR is an effective technique compared with traditional hemorrhoidectomy regarding complications, postoperative pain, in hospital stay, and time of return to normal activities.

MANIPULATION OF FRACTURED NASAL BONES UNDER LOCAL ANESTHESIA, ITS EFFICIENCY AND PATIENT SATISFACTION

Basrah Journal of Surgery, Volume 24, Issue 2, Pages 77-80
DOI: 10.33762/bsurg.2018.160091

MB,ChB, FICMS, CABS (ENT), Consultant ENT Surgeon, Al-Sadr Teaching Hospital, Basrah, IRAQ.

Abstract
The nose is the most prominent structure in human face, making it more susceptible to trauma which may reach more than one third of all facial injuries. Although fracture nose is a common surgical problem, very few studies are conducted in Iraq on it.
The aim of this study is to evaluate the efficiency of local anesthesia in fracture nose manipulation and to assess the degree of patient’s satisfaction from the functional and esthetic point of view.
The majority of patients attended ENT department were males (68.5%) lying in the age group between 21–30 years and the reason for their injuries was personal assault. Waiting for complete resolution of edema results in some complications such as bleeding and pain.
Fracture nose manipulation under local anesthesia gives high degree of satisfaction both for the functional (83.3%) and esthetic (88.9%) point of view, so this procedure can be recommended in ENT clinical practice in the view of these results as it is more safe, time saving and cost effective.

MANAGEMENT OF CRISES DURING ANESTHESIA AND SURGERY. PART XV: SEPSIS

Basrah Journal of Surgery, Volume 24, Issue 2, Pages 86-87
DOI: 10.33762/bsurg.2018.160092

Sepsis which is defined as systemic response to infection may potentially causes multiple structures physiological stress and dysfunction such as; respiratory, renal, cardiovascular, and hematological. Because quick consideration should be paid to so many body systems, prepared approach during anesthesia for a septic patient is a must1.
Patients with sepsis show signs of systemic inflammatory response syndrome, as result from generalized reaction to inflammation which may be caused by a wide range of infectious and non-infectious causes for example, burns, pancreatitis and multiple trauma2.

abituary Dr. Ghassan

Basrah Journal of Surgery, Volume 24, Issue 2, Pages 89-89
DOI: 10.33762/bsurg.2018.160093

Dr. Ghassan, one of the giant shining stars of surgery, departed to heavens in the 30th November 2018. he was a graduate of Baghdad College of Medicine in 1971 and received the fellowship of The Royal College of Surgeons of Edinburgh in 1981. He served in Basrah General Hospital until 2000 when he shifted to Baghdad to work in the Medical City Teaching Hospital as an active member in the Gastro-Enterology Department. During his stay in Basrah, he proved to be a distinguished surgeon, teacher and father for so many generations. He was a man of manners, very much respected by patients and colleagues.

INDICATIONS OF TRACHEOSTOMY IN BASRAH

Basrah Journal of Surgery, Volume 24, Issue 2, Pages 3-7
DOI: 10.33762/bsurg.2018.160094

Abstract
This retrospective study aimed to determine the main indications of tracheostomy in four main hospitals in Basrah centre. The study included 89 patients who were submitted to tracheostomy during a 2 year period and data was reviewed from the medical records.
Patients were 70 males (78.66%) and 19 females (21.34%). The age of the patients ranged from 1-75 years with mean age of 44.367±13.18 years. Open surgical tracheostomy was performed in all patients, 89.89% of them were submitted to surgery as elective procedure and 94.39% were operated upon under general anesthesia.
The main indications of tracheostomy in this study is the need for prolonged ventilation (61.80%) mostly caused by head injury, followed by upper aero-digestive tumor (19.1%) and lastly cranio-cervical trauma (8.89%).
In conclusion, the commonest indication of tracheostomy in Basrah is the need for prolonged ventilation.

HEMODYNAMIC CHANGES FOLLOWING INTRAORAL INJECTION OF LIDOCAINE IN COMBINATION WITH ADRENALINE DURING TOOTH EXTRACTION

Basrah Journal of Surgery, Volume 24, Issue 2, Pages 14-23
DOI: 10.33762/bsurg.2018.160095

Abstract
Local anesthetic drugs are used in combination with vasoconstrictors, commonly adrenaline which increases their efficacy and duration of action and reduces bleeding at the operative site. However, adrenaline might have adverse hemodynamic effects, especially in patients with cardiovascular diseases. Hypertensive patients represent a risk group in dental practice. One major apprehension of the dentist is the sudden and dramatic increase in blood pressure that could lead to life-threatening complications including sudden death during a dental procedure. The aim of this study is to measure hemodynamic parameters, blood glucose, oxygen saturation and pain score in normotensive and hypertensive patients following intraoral injection of lidocaine with adrenaline and correlate these changes to the level of pain intensity and plasma metanephrine concentration.
This prospective study was conducted at Basrah College of Dentistry from October 2016 to June 2017. One hundred patients were included in the study for teeth extraction under local anesthesia. Sixty normotensives, 30 had stage one hypertension (BP=140-159/90-99) and ten healthy volunteers for metanephrine assay. All patients were injected with two cartridges of 2% Lidocaine with 1:80,000 adrenaline. Systolic and diastolic blood pressure, heart rate, oxygen saturation, visual analogue scale, blood glucose and plasma metanephrine concentration were measured at different intervals; before anesthetic injection, 5 minutes after injection, during extraction and 10 minutes following the end of tooth extraction.
Administration of local anesthesia with adrenaline in addition to the surgical procedure resulted in a significant increase in systolic blood pressure during tooth extraction (+8.7% and +16.6% mmHg for normotensive and hypertensive patients respectively, p<0.05), also heart rate similarly affected in both groups (10.6% and 13.4% respectively), this effect was significantly higher in the hypertensive group. The blood glucose showed a significant increase (P=0.00) 30 minutes after injection as compared to baseline. Generally, the peak changes in parameters were observed during tooth extraction procedure in both groups. Metanephrine peak plasma level occurs at 10 minutes following injection and it was significantly correlated with the systolic and diastolic blood pressure.
In conclusions, the injection of lidocaine with adrenaline in addition to the surgical procedure produces significant increase in blood pressure and heart rate in both normal and hypertensive patients which were larger in the latter group. Similarly, plasma metanephrine concentration was increased during the dental procedure and linked to the increase in the systolic blood pressure.

FEASIBILITY OF TRANSHEPATIC ULTRASONIC EVALUATION OF INFERIOR VENA CAVA DIAMETER TO GUIDE FLUID MANAGEMENT IN COMPARISON WITH ANTERIOR APPROACH

Basrah Journal of Surgery, Volume 24, Issue 2, Pages 30-38
DOI: 10.33762/bsurg.2018.160096

Abstract
Non-invasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava using ultrasound machines is nowadays promising with the increasing availability of these machines in emergency departments, critical care units and in operating theaters. The learning curve of these tools is steep and they are becoming less expensive and give quick, non-invasive, dynamic clue to the preload status.
The aim of this study is to evaluate the transhepatic inferior vena cava (IVC) diameter by non-invasive sonographic imaging and compare it with that measured by subxiphoid approach to reveal the degree of agreement between them.
This is a prospective study, done in a tertiary care referral hospital at intensive care unit in Al-Sadr Teaching Hospital over a period of four months from 1st February 2017 to 5th of June 2017. Eighty shocked patients were included for assessment of volume status. Bedside ultrasound images were obtained with the patient in supine position to determine the dimensions and collapsibility of IVC. Evaluation of each patient included the standard anterior subxiphoid IVC assessment and lateral transhepatic assessment of IVC by ultrasound using liver as an acoustic window in mid-axillary line. The IVC diameter was measured 2 cm caudal to the hepatic vein-IVC junction, or approximately 3-4 cm caudal to the junction of IVC and the right atrium. Then IVC maximal diameter, IVC minimal diameter and collapsibility index were calculated for both approaches. A comparison between these data was made.
A total of eighty patients were included, 31 (37.5%) were females and 49 (62.5%) were males. Mean age was 45.81±14.89 years. The results showed that there is no statistically significant difference between transhepatic and subxiphoid approaches in regard to IVC diameter and its collapsibility. In conclusion, transhepatic lateral view of IVC provides a good alternative when subxiphoid anterior view cannot be obtained to guide fluid management in shocked patients.

C-REACTIVE PROTEIN IN PATIENTS WITH OPEN ANGLE GLAUCOMA

Basrah Journal of Surgery, Volume 24, Issue 2, Pages 46-48
DOI: 10.33762/bsurg.2018.160097

Abstract
This study aimed to evaluate the C-reactive protein (CRP) levels in patients with open angle glaucoma. This cross sectional study included 36 patients diagnosed with glaucoma compared to 36 healthy controls. Each patient went through a complete ophthalmic examination and blood sampling for CRP.
A thirty six cases (23 males, 13 females, mean age 60±11.7 years) with glaucoma and 36 age-matched controls (18 males, 18 females, mean age 58.25±10.45 years) were evaluated. Serum CRP levels were significantly higher in glaucoma cases than in controls (median 3.43, range 0.2-8.47 mg/dL) compared to 0.97, 0.17-6.30, P<0.002. The mean serum CRP levels were significantly elevated in the glaucoma cases compared with the controls (3.27±2.79 mg/dL and 1.50±1.56mg/dL respectively).
Conclusion: The findings of this study suggest that higher CRP levels are associated with glaucoma. It is possible that there is a link between vascular inflammatory process and glaucoma.

A MODIFIED STAINING STRATEGY IN STAIN-ASSISTED VITRECTOMY

Basrah Journal of Surgery, Volume 24, Issue 2, Pages 56-60
DOI: 10.33762/bsurg.2018.160098

The objective of this study is to assess pros and cons of intraoperative Briliant Blue G dye (BBG) injection in the early phase of Pars Plana Vitrectomy.
This is a prospective non-consecutive case series study, a modification in timing for dye injection during vitrectomy. A single injection of 0.1 ml of Briliant Blue G (BBG dye) was used in the early phase of pars plana vitrectomy (PPV) promptly after an initial small core vitrectomy, and continued directly in completing vitrectomy; including induction of posterior vitreous detachment and peripheral vitrectomy +/- vitreous base shaving. View of the underlying retina is initially obscured immediately after dye injection, however dye density fade gradually with continuation of vitrectomy.
Fluid Turbulence caused by vitrectomy and continuous fluid infusion enhance dye dissemination within vitreous cavity and stain transparent tissues and also increase colour contrast between blue hued retina and underlying naturally red coloured choroid. Early staining technique will remove necessity for Air-Fluid Exchange for staining at end of vitrectomy.
This study was conducted in the Ophthalmology department at Hamad General Hospital in Doha, Qatar in 2016 and General Port Hospital in Basrah, Iraq in 2017. Patients requiring vitrectomy for various indications were included.
Thirty four eyes (34 patients) were involved in this study: 20 men and 14 women, average age 56 was years. Indications for surgery were variable, diabetic vitrectomy (20 cases, 5/16= Macular Epiretinal Membrane), Rhegmatogenous Retinal Detachment (10 cases), Full Thickness Macular hole (2 case), Penetrating Injury with Posterior IOFB (2 cases). Single case required additional re-injection of dye to augment staining. Non-diathermy drainage Retinotomy was done by soft tipped cannula in 5 cases of retinal detachment. No single case has developed a surgically significant discolouration of lens posterior capsule or seepage of dye to the subretinal space.
In conclusion, this modified staining technique allows better visualization of the various vitreoretinal tissues during all steps of PPV and improve surgical techniques

COMPARISON OF PRE-OPERATIVE PERITONEAL WASH AND DRAINAGE VERSUS URGENT LAPAROTOMY STRATEGY IN PATIENTS WITH LATE STAGE PERFORATION PERITONITIS. A RANDOMIZED CONTROLLED TRIAL

Basrah Journal of Surgery, Volume 24, Issue 2, Pages 67-76
DOI: 10.33762/bsurg.2018.160099

Peritonitis is inflammation of peritoneum which is most commonly due to generalized or localized infection. Secondary peritonitis is the commonest form and a large percent of them is due to perforation or impending gastrointestinal perforation. The prognosis depends on multiple factors by which Mannheim Peritonitis Index (MPI) appears to be more practical.
This study aimed to assess the value of pre-operative aspiration of peritoneal fluid followed by peritoneal wash and drainage before proceeding to definitive surgery in patients with MPI score>20.
This prospective study was conducted in Al-Hussein Teaching Hospital in Al Nasserya city and Basrah Teaching Hospital in Basrah city from October 2003 to July 2014. Each patient admitted to the emergency department in these hospitals with the provisional diagnosis of perforation peritonitis was evaluated with MPI score. If the score was less than 20; the patient managed with resuscitation and broad spectrum antibiotics for 2-3 hours then by definitive surgery while those with MPI more than 20 were randomly divided into two groups; the first were managed with 2-3 hours resuscitation with intra-venous fluid resuscitation and antibiotics followed by urgent surgical exploration (USE). The second group were managed with percutaneous peritoneal drainage (PPD) with aspiration of the fluid and then irrigation of the peritoneal cavity with isotonic saline and followed by a drainage with aid of the gravity through another catheter located in the right ileac fossa.
Sixty two patients included in this study who fulfilled the criteria of perforation peritonitis and MPI score more than 20. Around half of them the score was between 26-30. Perforated peptic ulcer is the commonest etiology. The most common cause of their high MPI score is the late presentation and the evidence of organ failure. Renal failure is the most prevalent organ failed in both groups. The overall mortality is decreased in (PPD) group. Those with urgent surgical exploration(USE) showed no improvements in the pre-operative vital signs, prolonged operation time and a higher mortality and more severe post-operative complication than PPD group.
In conclusion, the pre-operative percutaneous peritoneal aspiration of the fluid followed by peritoneal irrigation and drainage in patients with advanced stage perforation peritonitis is associated with a significant improvement in the pre-operative pulse rate and blood pressure, decrease in the operation time, a decrease in the overall mortality and deep seated wound infection and dehiscence but it is associated with a higher mortality in the first post-operative day.

TETHERED SPINAL CORD: REVIEW OF LITERATURE

Basrah Journal of Surgery, Volume 24, Issue 2, Pages 81-85
DOI: 10.33762/bsurg.2018.160100

Mohamed El Husseini*, Hussein Mouawia#, Adnan Mrad# & Taghrid Chaaban@
*MD, PhD, Neurosurgeon, Hôpital Libano Français, Zahle, Lebanon, #Director, Lebanese University, 4th Branch, Lebanon. #Dean, Islamic University of Beirut, @Vice dean, Islamic University of Beirut, Lebanon

Abstract
Tethered cord syndrome is a stretch-induced functional disorder associated with the fixation (tethering) effect of inelastic tissue on the caudal spinal cord, limiting its movement. This abnormal attachment is associated with progressive stretching and increased tension of the spinal cord as a child ages, potentially resulting in a variety of neurological and other symptoms. The condition is closely linked to spina bifida, and such presentation in childhood may accompanied with the cutaneous stigmata of dysraphism (hairy patch, dimple, subcutaneous lipoma). There may be associated foot and spinal deformities, leg weakness, low back pain, scoliosis and incontinence.
The condition may go undiagnosed until adulthood with the development of sensory and motor problems and loss of bowel and bladder control.

abituary

Basrah Journal of Surgery, Volume 24, Issue 2, Pages 87-87
DOI: 10.33762/bsurg.2018.160101

Dr. Abdulameer, a lengthy serving competent ophthalmic surgeon, was born in Basrah in 1946. He obtained MB,ChB from The Medical College of Ain-Shams University in Cairo, Egypt in 1973.

TO TREAT OR TO SATISFY THE PATIENT; WHICH ONE IS THE BEST?

Thamer A Hamdan

Basrah Journal of Surgery, Volume 23, Issue 2, Pages 1-2
DOI: 10.33762/bsurg.2017.141312

L
uckily, there is increasing interest in patient satisfaction in the present days. Many writers started differentiating between the two issues; treatment or satisfaction. Patient satisfaction is a top priority and it should be the target. Perfect treatment is not always satisfactory to the patient. Some surgeons, sadly, spoil their ideal treatment by misconduct. They are good enough to offer treatment, but not good enough in performing the art of communication, which is really vital. They do not know how to respect the dignity, the honor and rights of the patient. The first meeting is the key for success in achieving life-long friendship or, on the other hand “putting salt on the wound”

SILENT OSTEOPOROSIS IN ASSOCIATION WITH OTHER ORTHOPEDIC DISEASES

Thamer A Hamdan; Mubder A Mohammed Saeed; Saad J Abdulsalam

Basrah Journal of Surgery, Volume 23, Issue 2, Pages 3-8
DOI: 10.33762/bsurg.2017.141313

Thamer A Hamdan*, Mubder A Mohammed Saeed# & Saad J Abdulsalam@
*FRCS, FRCP, FACS, FICS, Professor Of Orthopedic Surgery, Chancellor of Basrah University. #FICMS, Assistant Professor Of Orthopaedic Surgery, Basrah General Hospital, @FACMS, Orthopedic Surgeon, Al-Karkh General Hospital, Baghdad.

Abstract
Osteoporosis is the most common metabolic bone disease. It is a major global health problem that increases dramatically as people getting older than before because of good health services.
The aim of the study is to assess how far osteoporosis is associated with orthopedic diseases and to increase the awareness in the mind of orthopedic surgeons for osteoporosis in patients who are not suspected apparently to have this disease.
A sample of 522 patients referred to Dual-energy X-ray absorptiometry (DXA) clinic by orthopedic surgeons or rheumatologists was taken during a seven months period, in two centers, Basrah, 259 patients and Mosul, 263 patients. All the patients had back pain, joint pain, bone pain, fracture or other musculoskeletal complains. The only method used to assess osteoporosis in our patients was the DXA scan.
Of the total 522 patients, the results of DXA scan was normal in 136 patients (26%), osteopenia in 178 patients (34%), and osteoporosis in 208 patients (40%). Back pain was the main cause of referral 184 (35%), followed by joint pain 138 (26.5%), bone pain 74 (14%), fracture 28 (5.5%), and others 98 (19%).
In conclusion, osteoporosis may be a silent disease, even in patients with complains like joint pain, bone pain, or radicular symptoms.

COMPARATIVE STUDY BETWEEN STAPLER AND HAND SEWING IN GASTROINTESTINAL ANASTOMOSIS

Mustafa Adnan Maatooq; ssam Merdan

Basrah Journal of Surgery, Volume 23, Issue 2, Pages 21-25
DOI: 10.33762/bsurg.2017.141316

COMPARATIVE STUDY BETWEEN STAPLER AND HAND SEWING IN GASTROINTESTINAL ANASTOMOSIS

Mustafa Adnan Maatooq* & Issam Merdan@
*MB,ChB, Board candidate, Al-Sadir Teaching Hospital, Basrah. @MB,ChB, FICMS, CABS, Professor of Surgery, Department of Surgery, College of Medicine, University of Basrah, IRAQ.

Abstract
Gastrointestinal anastomosis is an important part of gastrointestinal operations and can be achieved by hand sewn anastomosis or by the newly developed staplers.
The study aims to compare between the two surgical methods of anastomosis in a prospective , randomized design, regarding: operation time, post operative hospital stay and the incidence of post operative anastomotic leak in both groups. The study was carried out in Department of Surgery at Alsader Teaching Hospital in Basrah, Iraq from October 2015 to December 2016, it included 40 patients of both gender and with a different age, they divided into 2 groups (hand sewn and stapler groups), each group included 20 patients, comparing the following parameters: time of anastomosis, duration of surgery, post operative leak and hospital stay.
There were no significant differences in the age, gender distribution, the indication for resection, post operative anastomotic leak (p=1) and hospital stay (P Value 0.15 ) in both group but there was significant differences in duration of anastomosis (P Value0 .00001) and operation time (P Value 0.00001). Our study concluded the superiority of stapler on hand sewing in gastrointestinal anastomosis in term of reducing operative time.

A COMPARATIVE STUDY BETWEEN HARMONIC SCALPEL HEMOSTASIS AND CONVENTIONAL HEMOSTASIS IN TOTAL AND SUBTOTAL THYROIDECTOMY

Mohammed Salim Mohammed; Jasim D Saud; Mansour Amin Mohammed; Mazin H Al-Hawaz

Basrah Journal of Surgery, Volume 23, Issue 2, Pages 15-20
DOI: 10.33762/bsurg.2017.141315

A COMPARATIVE STUDY BETWEEN HARMONIC SCALPEL HEMOSTASIS AND CONVENTIONAL HEMOSTASIS IN TOTAL AND SUBTOTAL THYROIDECTOMY

Mohammed Salim Mohammed*, Jasim D Saud#, Mansour Amin Mohammed$ & Mazin H Al-Hawaz@
*MB,ChB, Board Candidate. #MB,ChB, FICMS, CABS, Consultant Surgeon, Basrah General Hospital. $MB,ChB, DS, CABS, MRCS, Lecturer, Dept. of Surgery, College of Medicine. @ MB,ChB, CABS, DGS, FRCS, Prof. of General Surgery, Basrah Medical College., Basrah, IRAQ.

Abstract
Thyroid gland is highly vascularized organ, so good hemostasis during total or sub-total thyroidectomy is crucial to decrease the complications and to improve the outcome.
This study aimed to evaluate the advantages and disadvantages of using harmonic scalpel device in comparison with conventional hemostasis for total and subtotal thyroidectomy in terms of operative time, nerves injury, post-operative blood loss, hematoma development, hypocalcemia and length of hospital stay.
This study included 80 patients who underwent total or subtotal thyroidectomy. They were divided into two groups according to the type of hemostasis: conventional hemostasis group and harmonic hemostasis group. Different diseases were included (multinodular goiter, toxic goiter and malignant diseases).
The results showed that time of operation was significantly shorter in the harmonic hemostasis group (79.52±14.98 min) than conventional hemostasis group (100.92 ±10.64 min) with p value 0.0001, also post-operative blood loss was lower in harmonic hemostasis group (52.5±26.23 ml) than conventional hemostasis group (75.13±17.8 ml) with p value 0.0001. Other outcome such as recurrent laryngeal nerve injury, post-operative hematoma, post-operative hypocalcemia and length of hospital stay did not show significant difference between the groups.
In conclusion, using harmonic scalpel device in total or subtotal thyroidectomy reduced the operative time and post-operative blood loss, without any change in the incidence of nerve injury, hematoma, hypocalcemia and the length of hospital stay.

ENDOSCOPIC BIOPSIES , CELIAC DISEASE, SEROLOGICAL TEST

Zahraa A Hashim; Sarkis K Strak; Wassan M Jazi; Sura A AL-Namil

Basrah Journal of Surgery, Volume 23, Issue 2, Pages 34-39
DOI: 10.33762/bsurg.2017.141318

THE VALUE OF ENDOSCOPIC BIOPSIES FROM FIRST AND SECOND PARTS OF DUODENUM IN THE DIAGNOSIS OF CELIAC DISEASE IN CORRELATION WITH A SEROLOGICAL TEST
Zahraa A Hashim*, Sura A AL-Namil@, Wassan M Jazi# & Sarkis K Strak$
*MB,ChB, Postgraduate board student. @MB,ChB, FIBMS, Consultant pathologist. #MB,ChB, FIBMS, Consultant pathologist, Al-Sadir Teaching Hospital. $MRCP, FRCPLond., FRCPI., Professor of Medicine, University of Basrah, IRAQ.

Abstract
Celiac disease is a chronic immune-mediated enteropathy of the small intestine caused by environmental exposure to gluten in genetically susceptible individuals. This study was conducted to evaluate and correlate the serological with histopathological findings of duodenal biopsies for the diagnosis of celiac disease.
Sixty-eight patients, 40 (59%) females whose ages ranged from 13-75 year (mean age 36.4 years), and 28 (41%) males whose ages ranged from 13-65 year (mean age 37.8 years), with symptoms of chronic diarrhea, weight loss, bloating and unexplained iron deficiency anemia, were tested for anti-tissue transglutaminase IgA tTG, and correlated with histopathological findings of duodenal biopsies obtained from 1st and 2nd parts according to modified Marsh's classification. Histopathological findings from the 1st and 2nd duodenal parts were also compared with each other.
The results of the 68 patients who were enrolled in the study showed that: 24(35.3%) patients tested positive for anti-tissue transglutaminase (titer >18U/ml), 37(55.8%) patients had positive histopathological changes (stage I–III). Twenty-three (33.8%) patients who had both positive anti tTG and histopathological changes were classified as a celiac disease. The sensitivity of 1st and 2nd parts of duodenal biopsies in detecting celiac disease were 83.7% and 100% respectively.
In conclusion; the histopathological changes from the 1st and 2nd parts of duodenum in detecting celiac disease were equally representative especially in stage IIIa, b, and c.

TO TREAT OR TO SATISFY THE PATIENT; WHICH ONE IS THE BEST?

Thamer A Hamdan

Basrah Journal of Surgery, Volume 23, Issue 2, Pages 1-2
DOI: 10.33762/bsurg.2017.141312

L
uckily, there is increasing interest in patient satisfaction in the present days. Many writers started differentiating between the two issues; treatment or satisfaction. Patient satisfaction is a top priority and it should be the target. Perfect treatment is not always satisfactory to the patient. Some surgeons, sadly, spoil their ideal treatment by misconduct. They are good enough to offer treatment, but not good enough in performing the art of communication, which is really vital. They do not know how to respect the dignity, the honor and rights of the patient. The first meeting is the key for success in achieving life-long friendship or, on the other hand “putting salt on the wound”

SONOGRAPHIC EVALUATION OF RIGHT UPPER QUADRANT ABDOMINAL PAIN

Amer H Alkhuzaie

Basrah Journal of Surgery, Volume 20, Issue 1, Pages 66-69
DOI: 10.33762/bsurg.2014.91013

A large number of conditions can cause right upper quadrant abdominal pain. The aim of this paper is to report the sonographic abnormalities associated with right upper quadrant abdominal pain in a sample of 155 adult patients from Basrah. During the period from 1st of March to 1st of July 2013, 155 adult patients aged between 20 to 70 years (107 females, 48 males) with right upper quadrant abdominal pain were observed at The Port Hospital and private clinics in Basrah. A detailed medical history was taken and a thorough physical examination was made. All the patients were examined with abdominal ultrasound with aim of detecting any sonographic abnormalities that can help in the diagnosis and treatment of the patients. Eight patients had no sonographic abnormalities, 197 ultra-sonographic abnormalities were detected in 147 patients. Genito-urinary abnormalities were found in 95 patients, hepato-biliary abnormalities were found in 82 patients and gastrointestinal abnormalities were found in 20 patients. In conclusion, genito-urinary sonographic abnormalities found to be the most common sonographic abnormalities associated with upper quadrant abdominal pain as it were found in 95 patients (48%).

TRANSDUODENAL SPHINCTEROPLASTY VERSUS CHOLEDOCHODUODENOSTOMY IN MANAGEMENT OF LOWER COMMON BILE DUCT STONES

Ali H Al-Azzawi

Basrah Journal of Surgery, Volume 18, Issue 1, Pages 33-39
DOI: 10.33762/bsurg.2012.54970

Common bile duct stones have been noted in 10-15% of patients with gall stones, these stones are either primary (formed in the common bile duct) or secondary (formed in the gallbladder and migrate down to the common bile duct). Their management includes ERCP (Endoscopic Retrograde Choledochopancreatography), biliary drainage procedure and choledochal exploration.
In this interventional study, we compare between transduodenal sphincteroplasty and choledochoduodenostomy regarding morbidity (anastamotic and duodenal leak, cholangitis, and pancreatitis) and mortality related to each surgical option.
A review of 68 patients with lower common bile duct stones presents with different clinical presentations in an interventional study carried in Basrah General Hospital and Al–Moussawi Private Hospital, 22 patients underwent transduodenal sphincteroplasty and, 46 patients underwent choledochoduodenostomy. Both groups received general anesthesia and comparable in age and sex. Statistical analysis done by SPSS (Statistical Package for Social Sciences) version 18.
Age and sex are comparable in both groups, the incidence of postoperative cholangitis is 9.09% in the transduodenal sphincteroplasty group and 32.6%in choledochoduodenostomy group which is statistically significant (P value 0.01). The incidence of duodenal and anastamotic leak is 13.6% and 10.9% in transduodenal sphincteroplasty and choledochoduodenostomy group respectively which is statistically not significant (P value 0.707). The incidence of postoperative pancreatitis is 0% and 8.7% in transduodenal sphincteroplasty and choledochoduodenostomy group respectively which is statistically not significant (P value 0.296). The mortality is 0% after transduodenal sphincteroplasty and 6.5% after choledochoduodenostomy.
In conclusion, transduodenal sphincteroplasty is better than choledochoduodenostomy in the management of lower common bile duct stones, less postoperative cholangitis, pancreatitis, and lower mortality rate.

11- ONLAY MESH IN THE MANAGEMNT OF LARGE OR COMPLEX INCISIONAL HERNIA

Basrah Journal of Surgery, Volume 14, Issue 1, Pages 53-56
DOI: 10.33762/bsurg.2008.55521

The aim of this study is to evaluate the use of onlay mesh in the management of large or
complex incisional hernia. A prospective study of 80 patients with incisional hernia
operated on at al-Sadr Teaching Hospital treated with onlay mesh between Jan 2001 to
Jan 2006. Thorough history and physical examination was done, data sheet was
designed include numerous factors that effect operative and healing process. Of 80
patients, 61.2% female &38.8 % male with median age 40.1 years for female & 53
years for male. Patients were with different associated medical problems. Main incision
was lower midline incision 26.2% &main post operative complications was seroma
7.5% & wound infection 7.5% while recurrence of hernia observed in 2.5%.This study
showed that, the big incisional hernias can be efficiently treated by the onlay
positioning of polypropylene mesh.

THE RELATIONSHIP BETWEEN CLINICAL EXPERIENCE AND QUALITY OF CARE AND ITS OUTCOME.

MAJEED H ALWAN

Basrah Journal of Surgery, Volume 14, Issue 2, Pages 0-0
DOI: 10.33762/bsurg.2008.55531

Quality assurance and performance evaluations, have become central issues in medicine.
There are several studies which indicates that general patients care is suboptimal in many
different medical conditions and clinical settings1,2. Delivering high-quality care is important to all
clinicians, but this issue may be more relevant to certain subgroups, such as those with less
specialised training and those who deal with smaller number of patients3. There is also a
general believe that the longer clinicians are in practice the more experienced they will be, and
therefore it is assumed that this group of medical doctors are able to provide a high quality of
care. But there are some studies that found a consistently or partially negative association. The
aim of this report is to discuss this subject further and reach some conclusions.

GIANT FIBROADENOMA; CASE REPORT AND REVIEW OF LITERATURE

Issam Merdan

Basrah Journal of Surgery, Volume 12, Issue 1, Pages 0-0
DOI: 10.33762/bsurg.2006.55319

Introduction
For a variety of reasons, giant breast tumors continue to pose a challenge in diagnosis and management. These tumors are poorly understood because of their rarity and unpredictable behavior. Their rapid growth, associated with skin congestion and ulceration, and tendency to recur, gives rise to a suspicion of malignancy1,2. In addition, owing to the varied histological features seen in these tumors, there have been widely varying interpretations and diagnoses by pathologists3. This has led to inappropriate, and at times unnecessarily radical, surgical therapy. In the 1950s, breasts were amputated for this relatively non-threatening condition4. However, the present trend is towards more conservative management. In order to ensure proper surgical management, an under-standing of the natural history of the disease and its biologic behavior is essential. Bas J Surg, March, 12 2006

SURVEY OF URINARY TRACT CALCULI IN SULEIMANIYAH

Ismaeel Ham Ameen

Basrah Journal of Surgery, Volume 10, Issue 1, Pages 87-88
DOI: 10.33762/bsurg.2004.55603

A total of 1339 patients operated on from 1994 to 2000 for urinary tract calculi. There were 851 male patients (63.5%) and 488 female patients (36.5%) with 891 renal stones. Three hundred eighty three ureteric stones and 103 vesical stones. The age incidence, sex differences, anatomical sites, residency and seasonal variation were studied.

16- A COMPARATIVE STUDY FOR MANAGEMENT OF CLOSED TIBIAL SHAFT FRACTURES BY EXTERNAL FIXATION VERSUS PLATING......................................................................

ALAA ABDUL HUSSAINt

Basrah Journal of Surgery, Volume 15, Issue 1, Pages 89-95
DOI: 10.33762/bsurg.2009.55394

In this prospective study, 25 patients with closed tibial shaft fractures were treated by two
different methods of treating fracture tibia ie, external fixation and plating. Thirteen patients were
treated by uniplanar unilateral external fixation device AO/ASIF type and 12 patients treated by
plating.
There were 22 male and 3 female, there age ranges from 12-45 years. Seventeen patients
sustain car accident as a cause of tibial fracture, associated fibular fractures were in 17
patients. There was no case of malunion in both modalities of treatment. Average time of
fracture union with external fixation was 24 weeks.
In external fixation union rate was 46%, delayed union 31% and non union 23%, complications
were pin tract infection 46%, ankle stiffness 31%, algodystrophy 31% and broken schanz
screws in 15.3%. Average time of fracture union with plating was 22.5 weeks.
In plating, union rate was 59%, delayed union 33% and non union 8%; while complications
were superficial infection 8%, deep infection 8% and ankle stiffness 8%. The non union was
100% in the middle 1/3 and 75% was transverse fracture configuration. The degree of soft
tissue injury, fracture site and configuration has a great effect on union, delayed union, non
union and infection also will affect the choice of treatment. In our study we try to evaluate two
different modalities of treatment, which are plating and external fixation as definitive method of
treatment of closed tibial shaft fracture and we try to compare between the 2 as regards of
different aspect like; time of union and complication in each modality and its relation with type of
fracture site, configuration, degree of soft tissue injury, this in turn will guide us to a better or
more proper choice of treatment modality in the future.

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