Basrah Journal of Surgery

EDITORIAL

Postoperative ileus (POI) is an inevitable adverse consequence of abdominal and other surgical procedures. Prolonged POI can lead to slow postoperative recovery, add to the patients discomfort and ultimately prolonged hospitalization and increased costs. It is believed that POI occurs as a result of inhibitory neural reflexes and inflammatory processes. The potential influence of endogenous opioids, in addition to exogenous opioids on the pathogenesis of POI has become more evident. The traditional routine use of nasogastric suction and the effects of prokinetic agents has been studied more and either challenged or refuted. Current treatment modalities, which are well studied includes the use of epidural long-acting local anaesthetics, early enteral feeding, multimodal postoperative care pathway, and less invasive surgical procedures. Recent research showed the usefulness of the newly introduced medications among the most promising is the peripherally acting �-opioid antagonist.

A prospective study was conducted to assess the frequency of acute appendicitis at different phases of menstrual cycle, 508 patients presented with acute right lower abdominal pain diagnosed as acute appendicitis and submitted to appendectomies at Basrah Teaching Hospital during a two years period from October 2000 to October 2002. There were 263 females with mean age of 25 years and 245 males as a control with the mean age of 27 years. The study reveals a higher incidence of normal appendixes were removed among females 46 patients (17.5%) as compared to 12 (4.9%)in males. Most of normal appendixes occurred during follicular phase 27 patients (58.7%) as compared to other phases. There were 23 females with normal appendixes have no any associated pathology, 20 patients (86.95%) of them were occurred around the mid cycle (day 12-16). There was difference in the incidence and the severity of acute appendicitis among different phases of menstrual cycle. It appears that the frequency of acute appendicitis was highest in the luteal phase 105 patients (61.77%) compared to other phases, while most of perforated and gangrenous appendixes occurred during menstrual and follicular phases, 13 patients (36.11%), 15 patients (41.66%) respectively.

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In the last decade the endoscope became one of the most important neurosurgical tools, its use increasing with time and gaining popularity.
Since May 2005, forty six neuroendoscopy procedures were performed in two hospitals in Basrah, 34 were Endoscopic third ventriculostomies (ETV) to treat hydrocephalus, three arachnoids cyst fenestrations, three ventricular tumor biopsies, and one operation to remove third ventricle tumor partially that already biopsied, three colloid cyst removed and one septotomy to treat encysted hydrocephalus, One case of craniopharyngioma had catheter implanted via the endoscope.
The patients� age ranged from 3 weeks to 70 years, However of the patients who had ETV, 37% (11/34) were younger than one year age.
Over one week to twenty months (mean follow up period were 11 months), During that time and for patients who had ETV symptoms of raised intracranial pressure that necessitated a shunt define the failure of treatment, That encountered in two patients , both were younger than one year age. Although time of follow up was rather short, the success rate was 100% for patients older than one year of age who had definite obstructive hydrocephalus.
ETV has become the treatment of choice for certain pediatric and adult hydrocephalic conditions. Saving patients from shunt dependence and complications improving the outcomes and avoiding subsequent morbidity and mortality.

The classical Atasoy depends on the cutting of the fibrous bands of the digital pulp in order to gain advancement of the flap to cover the fingertip injury defect. A new modification of Atasoy flap was studied in comparison to the classical Atasoy flap. Thirteen patients included in this study at Al Wasity hospital between September 2003 to April 2005 they were complaining of class III Allen's fingertip injury of different fingers,3 females and 10 males , 4 cutting and 9 crushing type injury. Seven patients underwent reconstruction by the new modified Atasoy flap and 6 patients by the classical Atasoy flap. The results show that the new modification of Atasoy flap is more fitted with the principles of pulp surgery. It improves flap viability, sensibility and aesthetic results reduce the troublesome hypersensitivity and produce more physiological cover to the bone. These results may be attributed to preservation of the fibrous septae of the pulp space and avoiding the injury of the vessels and nerves by passing subperiosteall in the flap dissection.

A total of 178 patients with 202 affected hands were studied prospectively for the management of carpal tunnel syndrome (CTS). Eighty six patients (105 hands) were treated with local steroid injection and 92 patients (97 hands) treated by surgical decompression, the follow up period ranged from 1 to 42 months. The period of relief and the risk of symptoms relapse after each management technique was evaluated. Of the total 86 hands (89%) treated surgically were free of symptoms at the follow up period, only 12 hands (11%) treated by local steroid injection were symptom free after more than one year of follow up. The results showed that local steroid injection have long term effect in the hands with mild symptoms, most were free from daily activity related pain and paresthesia with a duration less than 6 months and with mild median nerve compression in electro diagnostic studies. Surgical release provides better long period of recovery with low rate of relapse, in those hands with severe symptoms and nerve compression that lead to continuous night and daily activity complain, regardless of the duration of symptoms.

Microscopic study was done on surgically collected samples of prolapsed intervertebral disc. These samples were collected from patients suffered from low back pain associated with right or left leg pain. The study was focused on patients below 40 years. Magnetic resonance imaging (MRI) was used to confirm the diagnosis.
The study demonstrates the degenerative changes that occur early in these patients which may be resulted from any traumatic causes which lead to series of degenerative changes that occur faster and differ from that changes which occur with age progress.
Forty samples of prolapsed intervertebral discs were collected surgically and 5 control intervertebral disc were studied for comparison.
Nerve ingrowths have demonstrated (histological and histochemical) in region of the excised tissue of prolapsed disc. This feature is accompanied with several degenerative changes like cloning of chondrocytes, irregularity of collagen fibers, and invasion of newly formed blood vessels into the disc matrix.

Removal of all stone and fragments is an important goal of every operations of renal stone. In spite of using modern techniques for stone manage still residual calculi (retained calculi) is an ever existing problem. Of a total 1059 patients with renal stone seen between 1994-2004, 557 patient under went operation, of these 117 showed false recurrent calculi with a total incidence of 21% false recurrent rate. The reasons for incomplete removal of renal calculi are discussed, methods of decreasing the incidence are mentioned. Accurate intra-operative localization of stones is the most important factor.

This is prospective study to assess the use of clomipramine as daily dose to improve premature ejaculation when on demand dose fail to achieve it. The study included 38 men with premature ejaculation who fail to response to clomipramine as on demand treatment were divided into two groups: group A used a daily dose of 10 mg clomipramine in 1st 3weeks increased to 25 mg in the next 3 weeks and group B used placebo for the same period. The patients were asked to determined the intravaginal ejaculation latency time (IELT) and any unpleasant symptoms. The subjects were contacted every 3 weeks to assess the improvement, satisfaction and presence or absence of side effects. We found a significant dose dependant increase in the mean IELT in group A from 47.7 � 21.2 sec to 76.5 � 33.9 sec with 10 mg of clomipramine and to 143.1 � 53.9 sec with 25 mg while in group B the increase was from 45.5�10 sec to 51.2 � 15.2 sec after 3 weeks and to 55.4 � 14.9 sec after 6 weeks. The IELT in group A was statistically significantly (p < 0.05) longer than that in group B. The patients' sexual satisfaction rates were statistically significant (p <0.05) after treatment with clomipramine and placebo which were 54% and 21% respectively. The side effects in both groups were mild. We conclude that a daily dose of clomipramine is effective treatment for patients with premature ejaculation to improve their IELT with high patients' satisfaction and accepted side effects.

The objective of this work is to study the epidemiology of the proximal femoral fracture (hip fracture), which is regarded as abig public health problem especially in elderly. The study was conducted in the teaching hospital in Najaf between Feb.1999 till Feb.2002, for all hospitalized patients who they had hip fracture. There were 272 patient divided into two groups: The first aged 0-49 years, and the second aged 50 years and over. The first group included 40 patients: 30 male and 10 female, the mean age was 23 year. The causes of the fracture were fall from height 50%, road traffic accident 30%, and fall in 20% of the cases.
The second group included 232 patient: 156 woman and 76 man. Female to male ratio was 2:1.The mean age for this group was 68 years. The causes of the fracture were fall in 83%, fall from height in11%, and road traffic accident in 6%. The incidence of the fracture in the second group was 86/100,000 inhabitant/year in Al-Najaf. In conclusion: Hip fracture occurs more commonly in elderly especially women. Fall is the main cause of the fracture in elderly. New strategy is needed to face this health problem aiming to decrease its rate of occurrence.

A prospective study on a sample of patients living in Alnajaf,related to osteoarthritis of the knee and some factors affecting it. The objectives of this study is to find the relation between age, sex and overweight to osteoarthritis of the knee joint. Between Nov. 2000 and Nov. 2002, all the patients attended the teaching hospital in AlNajaf, complaining of knee pain were clinicaly examined. Those who proved clincaly to have primary (idiopathic) osteoarthritis of the knee joint were included in this study. From those patients a sample of 126 patient were further investigated; The body mass index of each was calculated from their weights and hights. Bilateral weightbearing x-ray of the keens were taken to see the radiological features of osteoarthritis in details. Total number of patients was 730, 606 females and 124 males .The ratio of females to males was 4.8:1.The mean age of the females was 54.7 years and of the males was 60.6 years. For the sample of 126 patients the mean body mass index of the females was 30.5Kg/m2, and of the males was 27.5 Kg/m2. They were 61 obese, 55 overweight and 8 patient with accepted weight. Decrease joint space especially on the medial compartment was the most common radiological feature, followed by the sub-chondral sclerosis which occurred mainly on the medial compartment, and osteophytes occurred mainly on the lateral compartment. In conclusion: Idiopathic osteoarthritis of the knee occur more in women.Age and overweight has a direct effect on the development of primary osteoarthritis of the knee joint.l

Subtyping of Meningiomas into benign, atypical and malignant entities is of supreme importance in respect to treatment options of surgery, radiation therapy, or a combination of the two, in addition to that, embolization procedure for the feeding arteries is a successful consideration in most of the highly vascular or potentially more malignant meningiomas to evaluate the role of MRI in defining the characteristic pattern of intracranial meningiomas and to correlate MRI with the histopathological findings in an attempt to predict the histological diagnosis (subtype) prior to surgery. A cross-sectional analytic study was performed on Magnetic Resonance Imaging (MRI) of surgically and biopsy verified intracranial meningiomas in 62 patients (21 males and 41 females) in an attempt to predict the histological features. The study was done in Al-Jirahat Specialized Surgical Hospital and in Al-Sadir teaching Hospital, department of radiology beside Alameer MR private center in Alnajaf AlAshraf city during a period between October 2002 and September 2005. On MRI appearance, atypical and malignant meningiomas in contrast with the more benign histology had more heterogeneous signal intensity and enhancement in (80%) and (100%) respectively, less obviously showed meningioma cleft sign, more cystic appearance in (60%) and (100%) respectively, surrounded by marked edema (+++) degree, exert more mass effect and invade the dural venous sinus in almost all the cases. Overall, MRI is an excellent non-invasive tool for the preoperative evaluation of intracranial meningiomas and can predict with a good degree of certainity the aggressive behavior of the more atypical and malignant meningiomas. This study showed lower rate of atypical and malignant meningiomas than other similar studies. Other findings are similar to what have been found in other studies performed on intracranial meningiomas.

Monitoring of patients in the recovery room is considered the most serious part for safe anesthesia. Anesthesiologists are some times so busy in completing the list of the operations so they can not follow up thoroughly their discharged patient from the theatre. This study determines the most common recovery room incidents in the last three years at AlSadir Teaching Hospital in Basrah. Of the about 7000 patients operated upon in this period, 669 patients (9.5%) had some event in the recovery room. The most common incident was respiratory problems (26%), irritability (22%), thermal (19%), cardiovascular (18%), nausea and vomiting (9%), low urine output (5%) and fall from couch (1%). Most of these incidents were treated immediately at the recovery room. The outcome was 5 deaths and 61 ICU admissions. Skilled anesthesia assistant present in the recovery room is the keystone for taking care and reducing recovery room incidents.z

Zuhair A Al-Barazanchi*, Alwan H Al-Shiwaeli#
*M.Sc Haematol. Consultant Haematologist, Post-graduate Supervisor & Lecturer, Laboratory Department,
Basrah General Hospital.
#
M.Sc Haematol. Specialist Haematologist, Al-Faeha General Hospital.
Bone marrow necrosis (BMN) is a rare clinical-pathological entity. It is mostly associated with post-mortem changes. Ante-mortem existence of BMN is quite rare and usually indicates a poor prognosis. However, its association with non-hematological malignancies seems not to be as poor prognostic feature as in post-mortem changes. One of the most commonly disorders associated with BMN is sickle cell disease (SCD), which is common among people in Basrah province. The current study probably can put light on the incidence of such pathology among those with SCD, its most clinical presenting features and its relation with specific sickle disease genotypes. The incidence of BMN in this study was 4.9 %. The mostly encountered features with wide spread necrosis were bone pains, fever, and pallor. Peripheral blood showed a florid leuco-erythroblastic picture with reticulocytosis and leucopenia in another case with focal necrosis. On comparison with those patients without BMN, patients with BMN showed a significantly lower Hb concentration, higher Hb S concentration, lower Hb F concentration, smaller splenic size, higher number of irreversibly-sickled cells and more frequent painful crises during their life. Those results were compatible with some observations and contradict with other. However, there is no previous study conducted in Iraq to compare with.

Penile tumors represent a difficult diagnostic and therapeutic issue to solve, mainly because of their psychological implications. The diagnosis may be delayed because many patients tend to disregard early asymptomatic lesions. Circumcision soon after birth confers almost complete immunity against carcinoma of the penis. Later circumcision does not seem to have the same effect, and Moslems circumcised between the ages of 4 and 9 years are still liable to the disease1.

CASE REPORT