Basrah Journal of Surgery

From inability to leave well alone;
From too much zeal for what is new and contempt for what is old;
From putting knowledge before wisdom;
Science before art, cleverness before common sense;
From treating patient as cases; and from making the cure of a disease more grievous than its endurance.
God Lord, deliver us
Sir Robert Hutchison (1871-1960)

Gastro-oesphageal reflux disease (GORD) is a multifactorial process whose importance lies in its ubiquity, diverse clinical presentation and potential morbidity. GORD is the most common disease affecting the oesophagus, the major indication for antacid consumption, and probably the most prevalent condition originating from gastrointestinal tract. This report is highlight of selected topics discussed the otolaryngological aspects of GORD, which were raised in recent years, the topics discussed included: manifestations, investigations and treatment of these GORD related ENT problems

Pancreatic cancer is the tenth most prevalent malignancy and the fifth most common cause of cancer death in the developed world. It was reported that less than 10% of patients survive for more than 1 year following diagnosis and the 5-year survival rate (0.4%), is the lowest of any cancer. This paper reflects authors experiences in pancreatic cancer and aimed to study pancreatic cancer clinically, determine the operative finding and outcome of surgical interference among our patients. Forty-five patients with pancreatic carcinoma were studied, 26(57.77%) patients were males, and 19(42.22%) patients were females, with males to females ratio of 1.36.Their age range from 27 to 80 years with an average of 58.7312.05 SD. The commonest risk factor was smoking occurred in 19(42.22%) patients, this was followed by diabetes mellitus occurred in 9(20%) patients. Jaundice was the commonest presenting symptom 32(72%) patients. Most cases were very advanced at time of diagnosis and only in one (3%) patient curative Whipple procedure was done. Tumor of the body of pancreas was very much infrequent than the head of pancreas was seen in 6 (13.3%) patients. From the patients that could follow up, non- survived for a one year.

This is retrospective study of 103 patients who attended the Emergency Department (ED) at King Hussein Medical Center (KHMC), Amman – Jordan, during the period from 1993-1999. Data was obtained from their files regarding the clinical presentation. The mean age was 13 months with a range of 1 month to 11 years. There were 69 males and 34 females. The main symptom was abdominal pain (49 patients), vomiting (34 patients), abdominal mass (15 patients) while 29 patients presented with shock or dehydration. History of a preceding illness was recorded in 16 patients; of which diarrhoea was the commonest. The latter symptom should alert the clinician regarding the diagnosis which, if made early in the course of the disease, would reduce morbidity.

This is retrospective study of splenic trauma managed at Al-Zahrawi Teaching Hospital and Saddam General Hospital in Mosul Province. The data of 108 patients during the study between the first of January 1993 and the 13th of June 1997; have been analyzed. Males were three times affected more than females. The mean age was 24 years, and the highest incidence was encountered in those below the age of 10 years (39.8%). Blunt splenic trauma was much more common than penetrating injury (73% vs 27%). Road traffic accidents (41.7%) and fall from height (25%) were the most common causes. Splenic injuries were graded in severity from one to five. Twelve percent were grade I injuries, 13% grade II, 14% grade III, 16% grade IV, 27% grade V, and 19% of unknown grade. Associated injuries were frequent, occurred in 63% of patients. The majority of the patients (94.4%) were treated by splenectomy whereas only (5.6%) had splenorraphy performed. Delayed rupture of the spleen was present in two patients (1.9%) who required splenectomy more than 48 hours post-injury. Postoperative complications were common, occurred in 47 patients (34.5%). Pulmonary infection had the higher incidence and occurred in (20.4%) of the patients. Wound infection was present in 8 patients (7.4%) and peritonitis in 7 patients (6.4%). However, complications were more frequent in those severely injured with multiple associated injuries. The overall mortality was (25%). Sixteen patients (15%) with blunt splenic injury and 11 patients with penetrating injury died. Death generally occurred in those with severe associated injuries like head injuries. The two most common causes of death were exsanguination (8.3%) and septicemia.

This is a study of fourteen cases presented with hypopharyngeal and upper esophageal tumours that underwent pharyngo-laryngo-esophagectomy with trans-hiatus gastric transposition. PLEGT-with pharyngo gastric anastomosis, done in the period between 1/2/1997 – 2/6/2001 in Alyarmouk Teaching Hospital in Baghdad. Usual complaints of the patients were dysphagia. Some of the patients had stridor that necessitated tracheotomy prior to the operation. Postoperative mortality was 14%, three of the patients developed anastomotic fistulae, all of them responded to surgical treatment, other complications included two cases of pneumothorax, the disease recurred locally in two cases, four cases of wound infection, and four cases of transient hypocalcemia. The mean period of follow up was thirty months, during this period, three patients died, two of them after recurrence of the disease and one due to C.V.A., nevertheless all of them were swallowing satisfactorily, even those who died.

This is a prospective study that was carried out during the period between January 1990 to January 2000, to assess the hemodynamic changes and outcome after surgical closure of ventricular septal defect (VSD). Out of 150 patients who underwent surgical closure of VSD, 52 patients had follow up cardiac catheterisation. The main indications for recatheterisation were: persistent respiratory symptoms, clinical or echocardiographic signs of residual leak across the VSD, and improper weight gain. The time interval between recath and surgery was ranging from 3 to 6 months. Complete closure was achieved in 35 patients out of 52 (76%) who had been recatheterized, persistent severe pulmonary hypertension was noticed in one patient who underwent atrial septostomy, 4(8%) patients had significant leak across the defect and high pulmonary hypertension needed a second operation, 12(23%) patients had small residual leak. The mean pulmonary arterial pressure has dropped from 60mmHg to 27 mmHg. Two patients had complete heart block needed an insertion of permanent pacemaker. The hospital mortality of the entire group was 2% and there was no late mortality. In conclusion, hemodynamic changes following the surgical closure of the ventricular septal defect had shown further reduction in the pulmonary pressure and pulmonary vascular resistance as early as 3 months in most patients, rarely some patients needed another attempt of closure of the residual VSD leak. Surgical atrial septostomy might be needed in patients with persistent severe pulmonary hypertension to decompress the right side of the heart.

This study was done to assess the results surgery for coronary artery bypass grafting (CABG) after complicated cardiac catheterization and interventional procedures at Queen Alia Heart Institute (QAHI)-King Hussein Medical Centre (KHMC). Between January 1995 and December 2000, eighty nine patients underwent emergency coronary bypass surgery following either diagnostic or interventional coronary angiography. The following variables were obtained from the medical records. Patients characteristics, mode of presentation, extent and severity of coronary artery disease, preoperative clinical and hemodynamic status, preoperative left ventricular function, previous CABG surgery, types of constructed conduits and associated procedures, use of intraoretic balloon pump (IABP), operative outcome and in hospital major cardiac events. Follow up was obtained on all surviving patients. Emergency CABG patients tented to be males (79.9%) more symptomatic (66.4% in class III and IV) and harboring more left main coronary disease (30%). The overall hospital mortality rate was high (13.3%) compared to the low rate of (4.5%) in our elective CABG population. Internal mammary artery (IMA) grafts were used less frequently (36.6%) compared to (93%) in our CABG population. Ten patients (11.2%) had additional cardiac procedures. A mean follow up duration of 31 months was available on all surviving 79 and (83%) were completely asymptomatic.

Eighty-five patients underwent myocardial revascularization using artery grafts alone and were followed up for 30 months. Twenty-seven patients (31.7%) had single vessel disease, 28 patients (32.94%) had two-vessel disease and 30 patients (35.3%) had three or more obstructed coronary arteries. Eight of the patients had undergone previous surgical revascularization. The left internal mammary artery (LIMA) was routinely used for the left anterior descending branch (LAD). In 8 patients (9.4%), the in situ right internal mammary artery (RIMA) was used for revascularization of the right coronary artery (RCA) and its branches. The RIMA was sometimes used as a free graft from the aorta or as an artificial “Y” from the LIMA to the diagonal and marginal branches. We used the left radial artery (RA) as arterial conduit in 51 patients (60%). There were 2 intraoperative deaths. Hospital mortality was 9% (n=8). Of the fatal cases, 3 were redo surgeries, 3 underwent combined procedures (one for left ventricular aneyrysm, one for double valve replacement and one for mitral valve replacement) while only 3 of the fatal cases underwent revascularization as a primary and isolated procedure. It is concluded that complete arterial reconstruction carries an acceptably low operative mortality and excellent short-term follow-up. This strategy is particularly important for young patients to reduce the probability of future reoperation.

Eight children between 4 and 10 years old with displaced and rotated fractures of the lateral humeral condyle were treated by open reduction and internal fixation. In all cases union occurred. There were no complications apart from one case developed stiff elbow which need manipulation under anaesthesia later on.

This is a prospective study done on 27 hips in 25 patients presented with Perthes’ disease between December 1999 and August 2002. Fourteen hips were treated operatively by mean of upper femoral osteotomy (group A), and the other remaining 13 hips were treated conservatively by mean of Scottish Rite abduction brace (group B). All hips were classified preoperatively as Catterall group III and IV, furthermore, two or more “head at risk signs” were seen in all hips with particular emphasis placed on lateral uncovering of the femoral head. Of the 25 patients, 20 (80%) were boys and 5 (20%) were girls, the left side was affected in 18 hips (66.7%), while the right side was involved in 9 hips (33.3%), two patients had bilateral involvement and were encountered in group A. The average time between onset of symptoms and time of treatment for group A and groups B was 9 months and 8.5 months respectively, while the mean duration of follow up was 2.2 years and 1.8 years respectively. It was concluded that group A showed better results than B regarding hip pain (100% vs 15.4%), hip motion (85.7% vs 7.6%), gait (28.5% vs 7.6%), limb-length discrepancies (93.6% vs 30.7%) and centre-edge angle (100% vs 15.4%). Femoral varus derotation osteotomy was found to be the treatment of choice for containment of Perthes’ disease with Catterall group III and IV. Both age and sex at the time of the treatment, influences the final outcome, however, longer period of follow-up may allow better final evaluation

Pure tone screening audiometry was carried out on 400 school children at three different ages, 10,13 and 15 years old during the period 1998-1999. The results showed that the dip at 4KHz (>20dB) was found in 50 (12.5%) of the study sample, 35 boys (8.7%) and 15 (3.8%) girls. The 4KHz dip was unilateral in 42 children (10%) and bilateral in 8 children (2.5%). The number of children with 4KHz dip increased with age. At the age of 15 years, it was found in 17(4.2%) boys and 7(1.7%) girls, two or more frequencies were affected in 5 and hearing thresholds of 40 dB and worse were found in 7 of the children. The results clearly indicate that noise pollution is one of the causes of hearing loss among school age children. Therefore, it is recommended to implement a hearing conservation programme at school.

Forty three patients with congenital nasolacrimal duct obstruction were examined by an E.N.T. specialist in Prince Ali Hospital for presence or absence of otitis media with effusion to investigate the association, if any, between otitis media with effusion and congenital nasolacrimal duct obstruction along with its impact on prognosis. Otitis media with effusion were detected in 17 patients (39.5%). A favourable response to treatment was less likely in the presence of otitis media with effusion. It is concluded that otitis media with effusion has significant association with congenital nasolacrimal duct obstruction and affects its response to medical treatment unfavourably

Six hundred and forty patients (65 of them were children) with acute and chronic anal fissure were randomized to receive topical 0.2%-0.8% Glyceryl trinitrate (G.T.N.) or Isosorbide dinitrate (ISDN) 1%-3% three times daily digitally applied ointment. Patients were followed for 6-26 months. A course of 2-6 weeks treatment was needed. Resting and maximum anal sphincter pressure (MARP) were measured by manometry for 40 patients and showed a very significant decrease in maximum anal sphincter pressure after application of ointment with progress of days of treatment (p =0.02). After 1-2 weeks of treatment 90.4% of acute fissure patients were free of symptoms and 83.73% of them were later cured. Four to eight weeks of treatment were needed to abolish pain in 85.5% chronic fissure patients, and cure was clear in 80% of them (p = 0.008). Side effects of treatment were negligible. Recurrence rate was 4%, while 24 patients (3.8%) were sent for internal sphincterotomy and 81 patients (12.6%) requested revision of medical treatment. In this study we concluded that surgery can be avoided in most cases of anal fissure, and it kept for recurrent cases. Recurrent cases after surgery can also be treated medically

Eighty six patients with chronic anal fissures were treated at Al-Kindy Teaching Hospital from 1992-1996 by fissurectomy and internal midline posterior sphincterotomy. All patients had satisfactory results with a period of follow up ranging from 4-7 years, no recurrence of the symptoms or major complications resulted from this operation. The advantage of this operation and its safety is discussed. We have found this procedure is useful and safe for the treatment of chronic anal fissure

This is a prospective study of 105 thyroid specimens during one-year period with the aim of evaluation of the prevalence and pattern of thyroid cancer in multinodular goiter. Only specimens with histologically proved multiple nodules were considered. Carcinomas were found in 8 cases (7.6%). The incidence was higher in males (11%) than in females (6.8%). Of all carcinomas seen in multinodular goiters 63% were of papillary type.

A review of the histopathological examination reports of 1167 cases of peripheral lymphadenopathy (LAP) received in the Department of Pathology in Basrah Saddam Teaching Hospital (1980-1997) and from Al-Wiswasy Private Laboratory (1984-1997) in two different periods (1980-1989) and (1990-1997) was done. Tuberculous lymphadenitis was the commonest pathological lesion in both periods. It was responsible for 36.9% and 46.3% of the total cases respectively, with an 80% rise of cases per year in the 2nd period. Neoplastic LAP was responsible for 32.9% and 37.2% of the total cases in the two periods respectively, with 61% rise in the average number of cases per year in the 2nd period. In both periods, primary lymphoid tumours were more frequent than metastatic malignancy, with 106/74 cases in the 1st period and 141/90 cases in the 2nd period respectively with a ratio of 1.5:1 for both. Non-specific reactive hyperplasia and other inflammatory lesions account for 30.2% and 16.5% of peripheral LAP in the two periods respectively, with a 23% decrease in the average number of cases per year. The mean age, sex and site distribution of different pathological lesions were demonstrated. In all these varieties of peripheral LAP, males were affected more than females except in tuberculosis. Cervical lymph nodes were most frequently involved in both periods. A comparison of the results were made with similar studies.

In this study, 20 patients with oral cancer (confirmed by histopathological examination) and 21 control subjects were included, to evaluate the degree of lipid peroxidation (LP) in oral cancer. Serum malondialdehyde (MDA) was significantly higher among oral cancer patients (5.842.19 nMol/L) compared to control subjects (1.790.61 nMol/L), (P<0.001). We conclude that oral cancer is accompanied with a significant degree of free radicals formation resulting in increased LP. Therefore, serum MDA level may serve as a marker for oral cancer.

This prospective study was carried out during nine months period (first of December 2000 until the end of August 2001) in Basrah Maternity and Children Hospital to evaluate whether oxytocin augmentation would shorten the length of labour, lower cesarean section rate or has any adverse effects on neonatal outcome. Data were collected and analyzed on 506 low risk multiparous (p1-3), at term, in spontanous labour. Two hundred forty nine of them needed oxytocin augmentation while 257 had spontaneous effective uterine contractions. This study confirmed that the mean duration of first stage of labour in oxytocin augmented patients shortened by 1.3 hours (from 5.8 hours in control to 4.5 hours in oxytocin augmented women), p value <0.001. Other finding in our study is that the rates of emergency cesarean section in oxytocin augmented women and controls were 1.6% and 2.7%, respectively. The difference was statistically not significant. The rate of low forceps delivery in oxytocin augmented patients was 0.4% in comparison to 1.2% in control group, the difference was statistically not significant. No case of uterine rupture was recorded. Our study has confirmed that perinatal mortality was 0.4% for both groups. These results provide reassurance about maternal and fetal safety in oxytocin treated group. It is used as part of protocol of active management of labour to correct dystocia when spontaneous multiparous labour with vertex presentation fails to progress

Hydatid cyst is endemic in animal breeding area. Local reports from Iraq indicates that its prevalence in the central and southern zones. It usually affects the liver followed by the lungs. Reports of rare infection of different organs in the body are presented in the literature. In this report, we present a young lady with a hydatid cyst excised from the back muscles. Investigations proved that this was the only cyst. We believe that this is a rare occurrence.

A 39 year-old woman presented with clinical features which consistent with primary lymphoedema (lymphoedema praecox) associated with rosacea lymphoedema. She had clinical and radiological evidence of bilateral pleural effusion and ascites. Skin biopsy revealed perivasculitis. The treatment of this particular type of lymphoedema is extremely difficult

Aggressive fibromatosisrepresents (AF) a semimalignant tumour which has a locally destructive and invasive growth tendency but does not metastasize because of its high recurrence rate, the tumour remains a surgical problem. AF is rare group of fibroproletlative tumour started initially as painful masses developing slowly affecting mainly the limbs, neck, trunk, and the abdomen in that order. The disease process of (AF) regardless of the site of presentation, sex, or the age of the patient, endocrine, genetic and physical factors seem to play an important role in the development of the disease. Recent innovation in the field of molucular biology showed the abnormalities in (AF) is at the level of chromosomes in the form of gene mutation and chromosomal anomalies. Other studies showed that the pathogenesis of (AF) is related or modulates by hormone. Physical trauma seemed to have role in the development of the tumour. Whether (AF) is benign or malignant tumour is still in the field of theories. Many investigators put this type of tumour in the category of malignant lesion even in the absence of distal metastasis. The modalities of treatment of (AF) is widely different but surgery makes the major bulk, provided there is a good preoperative demonstration of the lesion by contrast solution and MR imaging, in the recurrent types of (AF) the combination of other modalities of treatment, radiotherapy, chemotherapy, cytotoxic and noncytotocix with and without surgery could be the most appropriate way of management. In this paper the character, pathogenesis, development method of detecting and the different modalities of treatment have been reviewed from literature