Basrah Journal of Surgery

edical errors can be reduced to the minimum possibly by precautions, over- consciousness and guarding against the unexpected, particularly, anatomical malformation and congenital anomalies. Sadly, it is impossible to take medical errors out of the medical dictionary even in the best centers on this earth. The outcome of the medical errors depends on the magnitude of these errors. It ranges from no bad effect, minor damage to serious damage or even death.

Reconstructive microsurgery represents one of the most significant surgical advancement in the second half of the twentieth century. To start such kind of work for the first time in a big city is a great challenge. In this study, we will try to evaluate our work in free flap in Basrah Plastic Surgery unit, and how we manage to start this kind of work in a location and situations not ideal for it. The aim of this study is to evaluate our work (the success and failure) that Basrah center faced in the free flap work and microsurgery, so other centers in Iraq who wish to start this kind of work to benefit from our experience and avoid the mistakes that we had to solve it. This is a retrospective study of thirteen cases which were done in Al-Sadder teaching hospital in Basrah,Iraq from August 2007 to March 2013. They were 10 males and 3 females, with age range from 4-40 y (median age 17y). In all cases, the lower limb was injuries except in one case where there was scalp loss. In all of the cases Latissimus Dorsi muscle was used as a donor muscle. Seven out of the 13 cases were successful (54%). In 6 of the cases there was failure due to variety of causes discussed later in detail so as to be avoided in future work. In conclusion, it is possible to start free flap work in any Plastic Surgery unit if the facilities are available. Team work, proper preoperative evaluation and planning, team decision and equal division of roles are the key points for success.

EVALUATION OF BOTOX TREATMENT FOR PATIENTS WITH PRIMARY AXILLARY HYPERHIDROSIS IN BASRAH Alaa H Al-Farhan MB,ChB, FIBMS, Lecturer Plastic Surgery, Dept. of Surgery, Basrah Medical College, Basrah Iraq.
Hyperhidrosis is a distressing condition that affects the social life of many patients. Botox has been discovered to treat this problem. This study aimed to evaluate the response of the patients to Botulinum toxin type A (BTX-A) and the time interval between injections during which the patient is free from symptoms. The study evaluates subjectively the response of patients with axillary hyperhidrosis to Botox with 100% scale and Hyperhidrosis Disease Severity Scale (HDSS). The time interval between injections was also evaluated. The data were collected prospectively and analyzed. This study included 21 patients with mean age of 27 years. Twenty of them were males. Of the 21 patients, 33% were subjected to multiple sessions. The response in 18 (85%) of patients was between 90-100%. The average time interval between injections was 211 days. In conclusion, botulinum toxin type A (BTX-A) has significant benefit in treating patient with axillary hyperhidrosis with rapid onset and the average duration of symptom free period was 7 months.

The objective of this study was to evaluate the outcome of acute thromboembolic arterial occlusion of extremities regarding time, type of presentation and the management plane with subsequent complications after surgery. A retrospective study done on 260 patients were admitted to Al-Sader teaching hospital with signs and symptoms of acute thromboembolic arterial occlusion from January 2005 to January 2012. Patient’s age ranged from 20-85 years, 73%of them are above 50 years, males constitute (56%) and females (44%) of the patients. The onset of symptoms was sudden in 70% and gradual in (30%), only 78 patients had history of claudication. The upper limb involved in (26%) and lower limb (74%). Heart was the source of emboli in 70% while peripheral arterial atherosclerosis in 30%. One hundred eighty two patients presented with sudden onset occlusion, patients with clear source of embolism and those with no history of claudication were treated with embolectomy while patients with more gradual onset over 24hours were treated with heparin and the limb status assessed regularly. Of the patients, 46.7% were operated upon within 6 hours of the onset of symptoms, 28.6% were operated on later than 24 hours of onset of symptoms, and overall limb salvage was 83%. Amputations were necessary in 27 patients. Complications occurred in 50 patients. Twenty five patients had wound complications, most frequently wound infection. Hospital mortality was 8.2%. Over half of the total numbers of deaths were resulted from myocardial infarction (50%). Seventy eight patients with acute on chronic ischemia were treated conservatively with heparin, 60.3% responded to heparin therapy and showed a good result, 35.9% had amputation & 3.8% died during the course of treatment. In conclusion, the time of presentation is important factor in determining the outcome after surgery regarding limb survival, functional state and even mortality. Late embolectomies, although associated with increased morbidity and mortality can be done as an effective method for saving the limbs providing that the limb is still viable. Patients with acute arterial thrombosis with a viable limb can be treated with anticoagulation alone and the surgical procedure can be deferred.

Lymphomas of the bone and musculoskeletal tissue are uncommon. Yet, they constitute a certain frequency that they merit certain consideration. A study was conducted to clarify the behavior of such type of lymphomas in the South of Iraq, epidemiologically, clinically, pathologically, biochemically and immunologically. Results show that they form minority among total lymphoma cases, but they were the third common type among extranodal lymphomas with male gender, adult age and urban residency predominance. There was a predominance of low performance status, absence of B symptoms, neurological and musculo-skeletal manifestations, secondary bone, especially the spine, involvement. Non- Hodgkin lymphoma (NHL) was the most predominant, mainly the intermediate grade, with diffuse large cell lymphoma (DLCL) and Burkitt lymphoma (BL) as the main histological types encountered. Hematologically, there was mild anemia, rapid ESR (> 50 mm), normal platelets count in the majority, leucocytosis in < half and monocytopenia predominance. Biochemically they were characterized by normal liver function tests with the exception of high serum alkaline phosphatase, normal total serum proteins, hypoalbuminemia, normal serum urea, creatinine & uric acid, hypercalcemia, with serum LDH and B2MG elevation in the majority. Serum anti EB virus antibodies were seen in 1/4th of cases and the majority were of the higher IPI scores (both high intermediate & high). Those results were comparable to some and contradicting to other studies elsewhere.

This study aimed to examine the value of anti peptidylarginine deiminase (anti-PADI-4) antibody and anti-cyclic citrullinated peptide (anti-CCP) antibody among Iraqi patients with RA and to determine whether the activity and severity in RA patients are associated with anti-PADI- 4 and anti-CCP antibodies positivity. In a case control study, we determined the seropositivity of these two serological markers anti- PADI-4 and anti-CCP antibodies in100 RA patients and 100 healthy controls subject. Activity of disease was measured by disease activity score in 28 joints (DAS 28) and severity was assessed using Scott modification of the Larsen method. Antibodies to PADI-4 were detected in (32%) among RA patients and present (1%) in controls (p < 0.001). Anti-CCP was present in (74%) of the RA patients and present in 2% in controls (p < 0.001), sensitivity was highest for anti-CCP antibody (74%) followed by anti-PADI-4 antibody (32%). Specificity was highest for anti-PADI-4 antibody (99%) followed by anti-CCP antibody (98%). A significant correlation with disease activity was observed in both markers, RA patients on remission had negative PADI-4 test (0/12) but patients with high disease activity showed higher percentage (86.4%) of PADI-4 seropositivity in compared to anti-CCP where patients on remission had (8.3%) seropositivity and RA patients with high disease activity had (91%) anti- CCP seropositivity. However, seropostivity to PADI-4 was significant correlated with RA severity (p < 0.001) as evaluated by scott grade (59.3%) in grade 5. Similarly, there were a significant correlation between anti-CCP seropositivity and radiological finding but less than that associated with seropositivity to PADI-4 antibody (p < 0.05). In conclusion, with their excellent specificity, both anti-PADI-4 and anti-CCP antibodies can be useful in establishing the diagnosis of RA, also both markers are good predictors of disease activity and severity.

This study aimed to assess the option of choice concerning venous reconstruction and simple venous ligation especially in unstable patient with life threatening visceral injuries. A retrospective study of 347 patients operated upon for injuries of the venous system at vascular surgical unit, Al-Sader teaching hospital, from 1st of January 2005 to 31st of March 2012. Males were affected more than females with ratio of 6.7:1, however we had increased number of the injured female. Most of the cases had either shell injury (38.3%) or bullet injury (32.6%) with total percentage (70.9%). The majority of the patients had associated injuries (90%). In this series amputation rate, and revision surgeries done for ischemic limbs were lower when patients underwent repair. Disappearance of edema in post-operative period was significantly more rapid when the injured vein was repaired. The site of venous injury was found in this study to be the major factor that determines the morbidity. In conclusion, repair of the vein is favored when the conditions are optimal. In the presence of uncontrolled bleeding with persistent hemodynamic instability, ligation is recommended.

Abstract The aim of this prospective study was to document clinical experience in the surgical management of posterior horse shoe fistula of cryptogalndular origin with a modified Hanley procedure using hybrid elastic glove as a one stage cutting seton. A modified Hanley procedure was applied to 28 patients (20 males and 8 females) presented with posterior horseshoe anal fistula (mean age 41 years) for the period from February 2007 to March 2012, and the surgical results were analyzes. The seton used was fashioned from a surgical glove and was tied around the sphincter under less tension in addition to the excision of superficial segment of the lateral tract and deeper extension into ischiorectal spaces were curetted and packed with gauze socked with povidon iodine. Complete healing was achieved in all 28 patients within three months post-operative period. Recurrence was found in only three patients after six month follow up period. All patients were discharged on the same post-operative day (day case surgery). None required readmission and post-operative pain was mild and bearable. Narcotic analgesics were not needed after discharge. All patients were able to return to their works and daily activity in 2-3 weeks. In conclusion, posterior complex horseshoe anal fistula can be safely and successfully treated with modified Hanley procedure with the use of the hybrid elastic seton.

Viral hepatitis is a worldwide health problem which requires a thorough knowledge and orientation. Clinical awareness of medical and paramedical staff regarding hepatitis portfolios so important to avoid serious short and long term sequel of hepatitis distribution to other individuals therefore a fundamental strategy has been planned and made in our local surgical field to highlight that issue in different types of surgery. Patients and methods: Retrospective descriptive study was carried out at Basrah General Hospital; Department of Surgery between Sept 2012 and Sept 2013 for patients underwent elective surgery in surgical department. Data was collected on the patients’ clinical history and laboratory findings of hepatitis screen for preoperative patients. The findings were recorded in a structured compilation. Results: A total of one thousand and seven hundred and thirty patients entered the study and those were analyzed in terms of general patient data in respect to age and sex as well as analysis of hepatitis screening findings. There were 1034 (59.7 %) males and 696 (40.3 %) females, with ages ranging from 8 months -70 year. The highest prevalence of Hepatitis B and C occurred in the same age group of 40 to 49 years. The sex related distribution of Hepatitis in general patients revealed more female patients than male ones (45/43).This figure is similar among patients in Hepatitis C (22/19) and both Hepatitis B and C (2/1). Hepatitis B showed a reverse pattern of being male predominance with a male to female distribution (23/21). In conclusion: Clinical awareness is the master of prevention of Hepatitis spread as proper knowledge about transmission and precautions could be of value in reducing disease transmission.

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%).

Renal tuberculosis is the third most frequent form of extra-pulmonary tuberculosis. About 25% of cases are asymptomatic. It is more common in male and in age group 20-40 years. Urine culture for mycobacteria is the gold standard for the diagnosis. The aim of this study is to use certain clinical criteria that helps in the diagnosis of renal tuberculosis. This is a prospective study of patients with recurrent urinary tract infections from September 2009 to September 2012. Certain clinical criteria were used for the diagnosis. Thirty five patients with renal tuberculosis were studied. Seven (20%) patients had evidence of old pulmonary TB. The most common presenting complaint was frequency in 43.3%. Sterile pyuria in 82.9%. The tuberculin skin test was positive in 74.3%. The intravenous urography (IVU) showed abnormalities in 82.9%. The urine culture for mycobacteria was positive in 5.7%. In conclusion, diagnosis of renal tuberculosis require high index of suspicion with the aids of certain clinical criteria and cheap investigations with a high accuracy.

Difficult intubation occurs relatively commonly in association with general anaesthesia. Its true incidence is unknown but is estimated to be 1–3%. Approximately half of all cases are not predicted1. A difficult intubation can be anticipated in a number of circumstances including a previous history of difficulty with intubation, syndromes known to be associated with difficulty to intubate, and some pathoanatomical states involving the head and neck region.

Tuberculosis is a chronic granuloma- tous disease which in humans is mainly caused by Mycobacterium Tuberculosis, Mycobacterium Bovis and atypical Mycobacteria1. The disease can affect various parts of the body but oral involvement is rare. Tuberculosis of extra- oral region is uncommon and is rarely primary. It is commonly seen secondary to pulmonary tuberculosis2. It is estimated that only 0.05% of total tuberculosis cases may present with oral manifestations. The descending order of incidence of tubercular involvement of oral region is as follows: the tongue, soft palate, uvula, gingiva, lips and salivary glands3.

Mohammad Zeki Al-Sherifi 1947-2013
For this is a journey that we all must take and each must go alone
Dr. Mohammad Zeki Al-Sherifi, a long serving ophthalmic surgeon in Basrah, was born in Hilla in 1947. He was educated in Baghdad and obtained his M.B.Ch.B. from Baghdad Medical College in 1970.