Basrah Journal of Surgery

LOCAL PATHOLOGY AND SYSTEMIC DISEASE

Sir Zachary Cope
“Distension, rigidity, vomiting and pain, are abdominal actors which often deign to act on behalf of the chest, spine or brain”
Quoted from his book (The diagnosis of the acute abdomen)

Thamer A Hamdan
MB, ChB, FRCS, FICS, FACS, Professor of Orthopaedic Surgery, Chancellor of Basrah University, Basrah, IRAQ.

Abstract
Although retrolisthesis is not a well-known condition by many medical specialists dealing with back problems and it has been regarded as a radiological incidental finding with no clinical significance, a growing prove is now evolving stating that retrolisthesis could be a cause of many backache complaints and a sequelae of an altered spine biomechanics.
Objectives: to study and analyze the various biomechanical characteristics of retrolisthesis and its relationship with various radiological parameters of the lumbar spine and other patient’s factors. Patients and Method: Forty patients, twenty six males, and fourteen females with an age range from 40–66 years with radiological evidence of significant lumbar spine retrolisthesis (slip > 3 millimeters) were evaluated clinically and radiologically by plain radiography and MRI in Basra General Hospital and Ibn AL-Bittar Private Hospital, during the period from the 1st of August 2014 to the 1st of March 2015. After a thorough history and physical examination, various radiological parameters were obtained including the lumbar lordosis, sacral slop, pelvic incidence, pelvic tilt, all those measurements were done digitally. A statistical analysis was made via IBM SPSS ver.17 and the results were compared with that of similar studies. Results: The retrolisthesis was found to be more common with more slip distance in males than in females, males=26 (65%), females=14 (35%), P-value=0.026, the mean of slip in mm in males was (4.002) and in females was (3.71). The patients had a mean BMI equal to (26.025= overweight). The most common level at which retrolisthesis occur in this study was the L5-S1 (40%) then L4-L5 (22.5%).
All the radiological parameters (the lumbar lordosis, sacral slop, pelvic incidence, and pelvic tilt) were lower than the known normal values in healthy subjects. Conclusion: It seems that retrolisthesis is not just an incidental finding, it may be a kind of a compensatory reaction for an abnormal spine biomechanics. The males are affected more frequently than females with a more slip distance.
The L5-S1 followed by the L4-L5 are the most common sites in both sexes. The degenerative spinal disease is the main cause of retrolisthesis in all patient’s groups regardless of sex or age.

Helicobacter pylori (H. pylori) is a gram-negative bacterium that specifically colonizes the gastric epithelium causing many complications. The link between H. pylori infection and diabetes mellitus (DM) remains controversial. This study was conducted to determine the frequency of H. pylori infection among a group of subjects with DM and to compare it with that of an age and sex-matched group of non-diabetic subjects.
This case control study was conducted in Al-Sadr Teaching Hospital, Basrah, Southern Iraq from January 2013 to September 2014 on 200 subjects aged ≥ 40 years, 100 diabetic and 100 non-diabetic subjects. All subjects were required to submit fresh stool samples which were tested for evidence of H.pylori infection by stool antigen positivity.
Helicobacter pylori infection was detected in 43% of diabetic group and 25% of controls, which was found to be statistically significant ( p value=0.007).
In conclusion, the present study suggests that diabetic subjects are at more risk for H. pylori infection in comparison to non - diabetic subjects. This association is found to be higher in those with long duration of DM and those with poor glycemic control.

Pain, which is often inadequately treated, accompanies the surgical procedures may persist long after tissue healing. Preemptive analgesia, involves the introduction of an analgesic regimen before the onset of noxious stimuli. Previous studies have suggested that ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, provides a preemptive analgesic effect. In literature, its use is controversial; for this reason the aim of our research is to evaluate whether the preemptive use of ketamine decreases postoperative pain in patients undergoing appendectomy.
In double-blind, randomized clinical trial, 100 patients underwent appendectomy for acute appendicitis were studied. Patients were randomly assigned into two groups. In the operating room, patients in the ketamine group received 0.5 mg/kg of ketamine IV 10 minutes before the surgical incision. In control group the same volume of normal saline was injected. Pain intensity was assessed at time 0 (the time of complete consciousness), 4, 12, 24 hours postoperatively using the visual analogue scale (VAS). One hundred patients (50 for both groups) were enrolled. For all the evaluated times, the VAS score was significantly lower (p value <0.05) in the ketamine group compared to the control group. There was a highly significant difference between the groups regarding the interval time of analgesic need. The total dose of tramadol in the first 24 hours was 2.42±0.70mg/kg in ketamine group and 3.86±0.35mg/kg in control group (p=0.009). The occurrence of nausea and vomiting in ketamine group was less than in control group. Three patients experienced brief nondisturbing hallucination in the recovery room in ketamine group. No other drug side effects in ketamine group were noticed.
In conclusion, low dose of intravenously administered ketamine had a preemptive effect in reducing pain after appendectomy.

This study aimed to investigate and assess the nutritional status of patients admitted to the general surgery wards and define the correlation between the risk of malnutrition, hospital course, clinical outcome, any coexistence between malnutrition and obesity in adult surgical patients and to correlate between two systems used in the assessment of malnutrition.
This is a cross sectional study done between December 2012-April 2013, on 214 patients, randomly selected admitted to public and private surgical wards in Basra General Hospital. They underwent two screening tools; the Malnutrition Universal Screening Tool (MUST) and Malnutrition Screening Tool (MST). The 214 patients were divided into two groups, both were included in the two validated screening tools for identification of the risk of malnutrition.
Patients who were at risk of malnutrition in the private wards in the MST group were 6 out of 43(13.9%) while in the public ward were 10 out of 64 (15.6%). Regarding the MUST risk score in the private wards, there were 11 patients in the medium and high scores out of 54 patients( 20.3%) while in the public wards were 7 out of 53(13.2%).
In the MST group, there were 7 positive females out of 58(12%) and males were 9 out of 49(18.3%). In the MUST group, 7 out of 53(13.2%) females were positive and 11 of 54(20.3%).
In the MST group, there were 2 positive <30 patients out of 30(6.6%) and 10 patients (30-60) out of 62(16.1%) and above 60 years were 4 out of 15(26.6%). Regarding the MUST group, there were 3 patients at positive risk in <30 y out of 17(17.6%) and in 30-60 y they were 9 out of 69(13%) and in above 60 y they were 6 out of 21(28.5%).
The MUST tool depends on BMI in its scoring. The results of this study showed there was not even a single patient with BMI <18.5 and the majority of the patients were either overweight or obese.
In conclusion, the prevalence of under nourishment in the surgical inpatients in this trial is low; there is slight difference in the prevalence of malnutrition risk between MST and MUST. Malnutrition according to BMI is rare in patients included in MUST, over weight and obesity are the main problems in this study not the malnutrition. Patients with positive risk of malnourishment are not malnourished primarly but influenced by their diseases.

Limb length discrepancy is the most common complication reported after femoral shaft fractures in children, usually resulting from overgrowth of the injured femur. The exact cause of this overgrowth is still not known but it has been attributed to age, gender, fracture type, fracture level, handedness and amount of overriding of the fracture fragments.
This study aimed to evaluate femoral length discrepancy and rate of femoral overgrowth after one year of union following diaphyseal fracture of femur in children and find possible factors that accelerates this phenomenon.

Radiographical evaluation by orthopantomography (OPG) and surgical extraction of impacted lower third molar are done to 67 patients (32 male) and (35 female) visiting Basrah Dental College, department of oral and maxillofacial surgery (2013-2014). Thirty nine patients are between 18-29 years, 77.6% are partially impacted and 22.4% completely impacted, the main complaint is pericoronitis (55.2%). The OPG accuracy in this study was as follows: concerned with dilacerated roots, K-value was <0, which means: Less than chance agreement of the OPG radiography in compare with clinical appearance of the teeth, also in relation to the normal appearance of the roots radiographically show (0.64) which is substantial agreement with the clinical appearance. While K-value gives a perfect agreement of the OPG to both fused (0.97) and extra-root >1 morphology.

Ali A Alwan Al-Tamimi*, Qahtan Maaroof Rahman# &Warzer Fatah Shali@
*MB,ChB, FICMS (Orth.), Lecturer, College of Medicine; University of Sulaimaniyah. # MB,ChB, Diploma (Orth.), Orthopaedics surgeon, Azadi teaching hospital; Kirkuk, Iraq. @MB,ChB, Diploma (Orth.), FRCS (London), Head of Orthopaedic Department, Sulaimaniyah Teaching Hospital, IRAQ.

Abstract
The treatment options for fractures of the femoral neck whether displaced or nondisplaced, are osteosynthesis, hemiarthroplasty, and total joint arthroplasty. Numerous reports have favored osteosynthesis over hemiarthroplasty. However, the high rates of non-union and a vascular necrosis associated with osteosynthesis, has led others to advocate femoral head replacement over internal fixation.
This is a prospective study carried on 96 patients (36 male and 60 female) having intracapsular femoral neck fractures who were admitted to the department of the orthopaedic surgery in Sulaimaniyah Teaching Hospital between September 2008 and September 2013.
The patient's ages ranged from 62-88 years (average 71 years). All patients were treated by hip hemiarthroplasty (partial hip replacement) with two types of approaches. Watson Jones (antero-lateral) approach was used in 40 cases (41.7%) and Moore (posterior) approach in 56 cases (58.3%). The aim of this study is to compare the outcome between these two approaches peroperatively and postoperatively to determine which approach is better for hip hemiarthroplasty.
The outcome of these two approaches were studied and analyzed monthly and the results of both approaches compared with each other and compared also with other studies.The duration of follow-up ranged between 12-48 months with average of 34 months.
In conclusion, rate of dislocation, infection, deep vein thrombosis and sciatic nerve injury were more in Moore approach, while liability to fracture femur during operation and time of surgery were more in Watson-Jones approach.

Abdulsalam Y Taha*, Nazar Q Sheikho@ & Akeel S Yousr#
*Department of Cardiothoracic & Vascular Surgery, School of Medicine, University of Sulaimaniyah and Sulaimaniyah Teaching Hospital, Sulaimaniyah, Region of Kurdistan. @#Department of Cardiothoracic & Vascular Surgery, Ibn-Alnafis Teaching Hospital, Baghdad, Iraq.

Abstract
Femoropopliteal bypass (FPB) refers to revascularization of the ischemic lower limb using venous or synthetic graft to bypass occluded superficial femoral or proximal popliteal artery. Our aim was to evaluate the outcome of FPB for critical limb ischemia (CLI) or severe intermittent claudication (IC) in 2 vascular centres in Baghdad, Iraq.
Forty eight patients (39 male) with CLI or IC were studied over 19 months. The mean age was 57.5±13.2 yr. All except 5 were studied retrospectively by medical charts review. Diagnosis included Doppler ultrasonography (DUS) and angiography. Standard operative technique was followed.
Atherosclerosis was the main etiology (n=45, 93.7%). The main presentation was CLI (n=43, 89.6%). Diabetics stayed longer whereas patients receiving synthetic or vein grafts had similar hospitalization periods. DopplerUS was done in 33.4% of patients; and was conclusive in 43.8%. Angiography was done in 17 patients (35.4%); all except one had CT angiography. The predominant graft was the PTFE (n=34). There was one death (2.1%).
Despite drawbacks of the study, early complications were nil, mortality was low, and twenty five out of 30 grafts (83.3%) remained patent during 6 months -1 year follow-up period. Longer follow-up is needed to evaluate the late outcome.

Diabetes was reported to be frequently associated with inflammation of biliary tract and cholelithiasis. The definite cause of gallstones in diabetics is not well clarified. However, due to autonomic neuropathy, the contraction of gallbladder is poor resulting in hypomotility, impaired gallbladder emptying and biliary stasis resulting in increased gallbladder volume, which to predispose to gallstone formation.
This study aimed to determine the prevalence of asymptomatic gallstones and its associated factors among diabetic patients in Basrah.
This cross sectional study was carried out in diabetic Centre in Al-Fayhaa Hospital, Basrah, Iraq from November 2014 to February 2015. We recruited 210 patients with diabetes (type1 and 2), 89 males and 121 females, questionnaire used to include the sociodemographic features. BMI measurement and ultrasound examination to find gallstone was done.
Blood samples were taken for HbA1C, FBS, Lipid profile and the association between duration of diabetes, lipid levels, FBS, with gallstone was evaluated.
Gallstone was seen in 25.2% of diabetic patients. Gallstone was higher in patients with increased duration of diabetes, in patients with BMI more than 25kg/m, with increased cholesterol and triglycerides levels and with high level of HbA1C.
In conclusion, the prevalence of asymptomatic gallstones in diabetic patients in Basrah increases with increased duration of DM, high level of HbA1C, BMI, cholesterol, and triglyceride levels and with hyperglycemia. No significant association was found with; age, parity, gender and type of diabetes.

Lateral partial internal sphicterotomy has been the goal standard for the treatment of chronic anal fissure. The main drawback of this approach remains its effect on the anal continence. Intrasphincteric of botulinum toxin seems to be a reliable and safe option resulting in temporary paralysis of the internal sphincter spasm and so promoting the chronic fissure to heal. The aim of this prospective control randomized study was to compare the effectiveness and the outcome of botulinum toxin injection with the lateral internal sphicterotomy in the treatment of the chronic anal fissure.
Ninety male patients who have been presented with chronic uncomplicated anal fissure, were randomized to either lateral internal sphincterotomy or intrasphincteric injection of botulnium toxin. Postoperative complications and pain, healing rate of the fissure, anal incontinence and recurrence of the fissure after treatment during six months follow up period were studied and assessed.
The healing rate was 95.5% in the surgical group with recurrence noted in only one patient and one patient had a partial permanent incontinence while in the botulnium toxin group the healing rate was 84.4%. Two patients had transient incontinence which improved spontaneously over six months period. Five patients had recurrence within the same follow period.
Lateral internal sphicterotomy and botulinum toxin injection both seems to be effective treatment of the chronic anal fissure. Although surgical approach is still the most common and gold standard treatment for the chronic anal fissure, It shows a higher incidence of incontinence and greater morbidity and pain than botulinum toxin injection. We conclude that the use of botulinum toxin to treat chronic anal fissure is safe, simple and effective approach especially in patients older than 50 years or those with risk of anal incontinence despite the higher rate of recurrence which can be minimized by the second session of botulinum toxin injection.

Acute appendicitis is still considered the most common cause of acute abdomen in young adult age group. Appendectomy is the most frequent urgent abdominal operation and often is the 1st major procedure performed by surgeons in training. This study aimed to find whether laparoscopic appendectomy is superior to open approach or not.
This study was done in Al-Mawanee General Hospital in Basrah, Iraq. One hundred and sixty seven patients were randomized into open appendectomy group (OA) and laparoscopic appendectomy group (LA). Different parameters were studied to find which approach is the best. The study showed longer operative time in the LA group, while there was no significant difference regarding the hospital stay, post-operative pain and post-operative complication.
In conclusion, laparoscopic appendectomy is not found to be superior to open appendectomy as there was no clear significant difference between them regarding the parameters used in this study.

F
istula in ano is a track lined by granulation tissue which connects perianal skin superficially to anal canal, ano rectum or rectum deeply. It is usually occurs in a pre-existing anorectal abscess which either bursts spontaneously or inappropriately drained. Other rare causes include inflammatory bowel disease, tuberculosis, carcinoma and trauma1. Perianal fistulous disease has significant implications for patient's quality of life as sequelae range from minor pain and social hygienic embarrassment to frank sepsis. The management of the anal fistula remains one of the most challenging and controversial topic in anorectal surgery2. Surgery remains the mainstay of therapy with ultimate aim of draining the abscess, eradicating the fistulous tract and avoiding recurrence with preserving anal sphincter function3. Treatment depends on where the fistula lays, which parts of the anal sphincter it crosses, etiology, duration of the fistula as well as previously performed procedures3,4. Most anal fistulae are simple and can be treated using a fistulotomy which has good results, low recurrence rate and an acceptable rate of morbidity5. Treatment of a complex anal fistula, however, which is defined as these fistulae which open into the anal canal at or above the internal ring and whose treatment poses an increased risk for a change in continence still represent a challenge. Complex are anatomically higher, involve significant portions of the sphincter musculature, may have multiple tracts, involve other organs

The carpal tunnel release is usually a curative treatment for the carpal tunnel syndrome (CTS), but not without complications, it may ranges from wound infection to nerve laceration. Study population included 150 patients (157 wrists) who had surgery for CTS. Patients were observed for the outcome and associated problems during and after operative procedure.
Thirty seven wrists (23%) developed complications, these complications were; intraoperative in 7 wrists, early postoperative (within first 2 weeks) in 10, and late postoperative (after 2 weeks) in 20.
This finding indicates that failure or complications following surgical release may occur, and in some situations may relate to the dissection or operating surgeon

This is a prospective study performed on 20 children with isolated fracture shaft femur between January 2010 to December 2010 at Al-Husain Teaching Hospital in Al-Samawa city. They were 12 boys and 8 girls, their age ranged between 1 to 6 years(average 3.2).
All patients were treated by immediate single leg spica as an outpatient technique. This study found that immediate hip spica casting and discharging to home is associated with few complications, no functional limitation and minimal limb length inequality.

This is a prospective study performed on 20 children with isolated fracture shaft femur between January 2010 to December 2010 at Al-Husain Teaching Hospital in Al-Samawa city. They were 12 boys and 8 girls, their age ranged between 1 to 6 years(average 3.2).
All patients were treated by immediate single leg spica as an outpatient technique. This study found that immediate hip spica casting and discharging to home is associated with few complications, no functional limitation and minimal limb length inequality.

This is a prospective study of 270 patients presented with renal stone over four years. Side of the renal stone whether in left kidney or right kidney was considered. The size of the stone was measured by imaging techniques (ultrasound or by CT scan) in 166 patients, in the remaining 104 patients imaging was done only for diagnosis, but without measuring the renal stone size (for different reasons). Residency was considered as urban or rural for any of these patients. The study shows that urban residency has increased risk for developing renal stone (63.7%) as compared to rural areas (37.3%), this effect was clearly significant for stone size between 1-2 centimeters

Heterotopic ossification is a rare and benign condition which occurs when bone develops in tissues that do not normally ossify.
We report a 53-year-old man who underwent laparotomy for recurrent pyloric obstruction. A segment of abnormal hard tissue was found in the abdominal wall and so was excised. Histopathology revealed metaplastic bone deposition.
Heterotopic ossification may occur at various sites and is a recognized but infrequent sequela of abdominal surgery. This case highlights clinical, aetiological and histopathological features of this rare finding.