Basrah Journal of Surgery

 





thics is defined as moral principles that govern a person's behavior, the conductivity of an activity, or the branch of knowledge that deals with honest attitude.
 Ethics is a branch of philosophy that involves systematizing, defending, and recommending concepts of right and wrong conduct.
 Ethics was found in Hammurabi code law (Babylon 1754 B.C.), then followed by    Hippocratic Oath, prayer of Moses maimonides, declaration of Helsinki, code of ethics of the American Medical Association, and all Holy Books which insist on ethical points.
 Ethics in general is governed by four principles which are; respect for autonomy, beneficence, non maleficence, and justice. To the above, I added; respect for the dignity of the patient.
 Ethics start from humanitarian handling of the patient in the first visit with a big smile and soft welcoming words, a lot of respect, careful listening and understanding followed by very gentle physical examination.

  COVID-19, the disease caused by SARS-CoV-2, is a highly communicable disease. There is urgent need for highlighting the ongoing outbreak to be public health emergency especially in our locality. Based on current published evidence, this review systematically summarizes the causative agent, epidemiology, presentation, diagnosis, treatment, prevention and surgeon precautions against COVID-19. Hopefully, this review may put a small stone for public health building in this regard and may afford a reference for future studies in our district.

This study is a systematic review and meta-analysis. The routine use of anticoagulants for the prevention of venothromboembolism in spinal patients is controversial and the risk benefit analysis is poorly described. The objective of this study is to collate the current evidence and quantify the risk of bleeding associated with anticoagulant thrombophylaxis in the spinal patient, both in the elective and trauma settings. 
Medline, Embase, Cochrane Trial Register databases and the grey literature were searched. Data were pooled via a meta-analysis from randomized trials and cohort studies comparing the rates of spinal epidural haematoma and wound haemorrhagic complications in spinal surgery patients receiving low molecular weight and low dose unfractionated heparin (LMWH/UFH) thromboprophylaxis and those not anticoagulated. The risk of bias within individual studies and across all the studies was assessed using the Cochrane risk of bias tools and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool, respectively.
 The meta-analysis included 10 studies of 96,042 patients with 1,007 relevant bleeding complications. A significant increase in the risk of extra-spinal wound haemorrhage was found in patients receiving peri-operative LMWH/UFH thromboprophylaxis compared to controls (OR 1.56, 95% CI 1.18-2.06, p=0.002, I2=8%). The same comparison revealed no significant increase in the risk of spinal epidural haemorrhage (OR 1.20, 95% CI 0.65-2.22, p=0.56, I2=0%). The quality of evidence for both outcomes was low. There was insufficient data to conclude about the risk of haemorrhagic complications in spinal trauma and in patients receiving non-heparin thromboprophylaxis agents.
In conclusion, the results of this study raise concern about a possible increased risk of extraspinal wound haemorrhage associated with LMWH/LDUFH thromboprophylaxis in spinal surgery.  Level of evidence: Therapeutic level III.
 

The aim of this study is to determine whether there is a benefit of using stereotactic radiosurgery (SRS) versus surgery or conventional external beam radiotherapy (cEBRT) for spinal oligometastatic disease in terms of tumor control, pain control, toxicity and morbidity.
 This systematic review was conducted by searching electronic databases such as Pubmed, Medline (Ovid) and Oxford Academic using an adapted version of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses” (PRISMA) checklist. Retrospective and prospective studies were identified and investigated for methods of treatment such as SRS, surgery and radiotherapy of spinal oligometastatic disease. Local Control rates, Overall Survival (OS) rates, Pain Response (PR) and toxicities were extracted to be investigated and compared. A study eligibility criterion was made to ensure that results were valid, statistically significant and relevant to the investigation.
 One hundred and five articles were relevant to oligometastatic disease with the mention of spinal metastases however 89 of these articles were excluded based on irrelevance to investigation, title, abstract and duplication. Sixteen full text articles were thoroughly screened including 9 of them in the review. For 601 patients the average one year local control rate was 89%, average one year overall survival rate was 88%, evidence of pain relief was present, and some patients suffered low grade toxicities.
 In conclusion, stereotactic radiosurgery is an excellent modality of treatment of spinal oligometastatic disease as local control rates, overall survival rates, pain response and toxicities indicate improved outcomes in comparison to studies that investigated the same factors with the treatment of surgery or cEBRT. However, there is a lack of data here to make statistically valid claims and require more studies & data to be analyzed and compared.
 

The objective of this study is to evaluate the effect of tonsillar fossa closure after tonsillectomy on the amount of intra-operative blood loss, post-operative pain and bleeding.
 Sixty patients enrolled in this single blind case control study held at Basrah Teaching Hospital in the period from July 2017 to November 2018.  Patients age was between 7 to 50 years, of them 28 (46.7%) females and 32 (53.3%) males. One of tonsillar fossae was selected for closure and the other was left open as a control side, the duration of dissection, the amount of bleeding for each side, the level of post-operative pain on (0, 3, 7, 10-14) days was estimated utilizing Visual Analogue  Score (VAS) together with any evidence of post-operative bleeding.
 There was statistically significant reduction in the level of post-operative pain in the sutured side compared to the control for all the follow-up periods. No significant differences in the amount of intra-operative blood loss between both sides were found. None of the patients experienced post-operative primary or secondary hemorrhage.
 In conclusion, Closure of tonsillar fossa has beneficial effect in reducing the level of
post-operative pain after tonsillectomy with no effect on post-operative bleeding. No difference was noted regarding the amount of intra-operative bleeding.

As both life expectancy and average population age continue to rise, so too does the incidence of cervical spine (c-spine) injuries. C-spine fractures are associated with high morbidity and mortality, but the question is how best to treat them?
This review is to compare the safety and efficacy of c-spine immobilisation in a rigid collar with other treatment modalities in elderly population. Available literature was reviewed to determine how treatment efficacy is assessed, with particular focus on whether osseous union or fibrous non-bony union should be considered as a successful outcome.
  This study was designed in accordance with PRISMA guidelines. Pubmed/Medline databases were selected for analysis.
  When considering patients over the age of 65, it is unclear whether management with a collar is safer than operative management or immobilisation with HALO vest. However, amongst studies that further subdivide elderly patients according to age there is more of a consensus; it appears that in those under the age of 75, operative management is safer, whereas in those over the age of 85, immobilisation in a collar is associated with lower mortality rates. Between the ages of 75-85 there is less clarity. Osseous union occurs more commonly in patients managed operatively, but fibrous non-bony union was not associated with any adverse outcomes in these studies.
  Conclusion: At present, there are no randomised controlled trials that have tried to delineate whether management in a collar is safer or more effective than other treatments such as HALO vest or operative fixation. However, evidence from various cohort studies does suggest that “elderly” patients with c-spine fractures should not be considered as one homogenous cohort, but should instead be subdivided according to age. Interestingly, these studies suggest that fibrous non-bony union may be an adequate treatment outcome in older. Further research into this complex field is required.
Keywords: Trauma, elderly care, spinal fractures, treatment outcome, survival rate

This study aimed to find out the frequency of hypocalcemia in different thyroid procedures and the risk factors for its development.
 One hundred thirty six patients underwent different thyroid surgeries for different thyroid diseases in the Surgical and Otolaryngology Departments of Basrah Teaching Hospital for three years from July 2016 to July 2019.
 Patients mean age was 34.8±7.5 years (range: 18-65 years). Male to Female ratio was 2:5. Of the total 136 patients, 35 patients underwent isthmusectomy and lobectomy, no case of hypocalcemia was reported (0%). Out of 71 patients who underwent sub-total thyroidectomy, three of them developed hypocalcemia (4.2 %). Out of 30 patients who underwent near-total or total thyroidectomy, nine of them developed hypocalcemia (30%). Whether the inferior thyroid artery was ligated or not, there was no significant difference in the development of hypocalcemia. Of the total 136 patients, 129 patients had benign pathology, 9 of them developed hypocalcemia (6.9 %); 7 patients had malignant pathology; 3 of them developed hypocalcemia (42.8%).
 In conclusion, the frequency of hypocalcemia is correlated with the extent of thyroid resection; and it is more in malignant lesions but in most of the patients it was transient.

Central venous catheterization has an essential role in the management of patients who are critically ill, and patients who have special operative interventions. In general, the bigger the vein cross sectional area and diameter the easier the catheterization will be. There are different maneuvers to increase internal jugular vein caliber. These include; passive legs elevation, hepatic or abdominal compression, Trendelenburg position, Valsalva maneuver, and positive end-expiratory pressure.
The objective of the study is to evaluate the effect of passive legs elevation and hepatic compression on the diameter and the cross-sectional area of the right internal jugular vein.
 This prospective study included 80 adult patients ASA class I and II. Patients who had any contraindication to the passive legs elevation or hepatic compression, or those with disruption of the local neck anatomy; were excluded from the study. Patients were evaluated for their right internal jugular vein cross-sectional area and diameter by the use of linear high frequency two-dimensional ultrasound. Each patient has three stages of measurement; supine, Passive legs elevation at (30o-45o) for one minute, and hepatic compression.
  Of the 80 patients, 70% were males, the age range was (19–55 years) with a mean of (37.75±12.16) years, and the majority were overweight. The maximum diameter was achieved during hepatic compression with a stepwise statistically significant increase of about (0.44±0.27 cm) from the baseline in supine position, when compared to only (0.26±0.21 cm) during passive legs elevation. The cross-sectional area is significantly and maximally increased from the baseline of (0.93 ± 0.59 cm2), during hepatic compression. The increase in the diameter and the cross sectional area was more significant in males irrespective to age and weight.
 In conclusion, Hepatic compression is significantly superior to the passive legs elevation in achieving more right internal jugular vein diameter and cross-sectional area.

Acute appendicitis is the most common causes of abdominal emergencies that necessitate surgical intervention. This study aimed to evaluate the accuracy of abdominal ultrasonography in the diagnosis of acute appendicitis.
 This prospective study was performed in Alsadr Teaching Hospital from November 2015 to January 2017 involving 131 patients.
 The results showed that 84.7% of the patients who presented with positive features of acute appendicitis were confirmed by ultrasonographic study, while 15.2% of the patients showed negative ultrasound examination confirmation.
 In conclusion, ultrasound study is effective in the assessment of patients presented with clinical features of acute appendicitis.
 

There are different techniques for tonsillectomy other than traditional such as; cold steel technique, bipolar diathermy, and nowadays the new plasma technology which is known as coblation (controlled ablation) tonsillectomy.
This study aimed to assess the first 24 hours postoperative pain and bleeding after coblation tonsillectomy.
Fifty patients aged between 4-10 years who underwent coblation tonsillectomy were included in this prospective descriptive study, the main indications for tonsillectomy were; recurrent tonsillitis and obstructive sleep apnoea.
The results showed that no bleeding at all within the first 24 hours with significant reduction in feeling of pain after.
In conclusion, coblation tonsillectomy is a promising technique to perform tonsillectomy.
 

 Congenital intestinal malrotation is an impaired embryological development of the gut causing incomplete rotation and attachment of the intestines to the abdominal wall.
 Three cases with congenital intestinal malrotation in adult patients were reviewed regarding their presentation, diagnosis and management. Two cases presented as emergency and the other one was incidental. Signs and symptoms of intestinal obstruction were the dominant presentation. A contrast computer tomography and upper gastrointestinal series confirmed the diagnosis of these cases. Ladd’s procedure was done in two cases.
 In conclusion, Intestinal malrotation should be considered as a cause of intestinal obstruction in all age groups. A contrast computer tomography is the best way to reveal this malformation. Surgical treatment is the greatest choice to relieve symptoms.
 

In females with right lower quadrant acute abdominal pain, gynecological & obstetric pathologies are the main disorders that should be eliminated from the diagnosis of acute appendicitis. This study included pathologic findings in 120 appendectomies in Al-Sadr Teaching Hospital in which exploration was performed as emergency acute appendectomies in 52 cases, while other pathologic processes related to gynecological diseases are distanced from appendicitis intraoperatively.
 There is a high percentage of coexistence with ovarian cyst in all its types whether twisted, ruptured, hemorrhagic or corpus luteal cyst. Other conditions included: ectopic pregnancy, uterine fibroid, Pelvic Inflammatory Disease (PID), Tubo-Ovarian Abscess (TOA), benign cyst adenoma & endometriosis. Also rarely, meckel's diverticulum that was either incidental finding or discovered by imaging techniques.
 

This is a prospective comparative study of adenoid size assessment by using radiography versus nasopharyngoscopy using examination of the adenoid under general anesthesia (GA) as a standard method. This study was conducted on 35 children presented with signs and symptoms of adenoid hypertrophy. All patients were examined by both lateral radiograph view of the postnasal space and nasopharyngoscopy, then both results were compared.
The results for small size adenoid can not be calculated because of small sample size. For medium sized adenoid, the sensitivity for radiography and nasopharyngoscopy are 36.36%, 54.54% respectively, the specificity was 47.36%, 84.21% respectively and the accuracy was 43.33%, 73.33% respectively. For large sized adenoid the sensitivity for radiography and nasopharyngoscopy was 38.89%, 83.33% respectively, the specificity was 100%, 66.66% respectively, and the accuracy was 63.33%, 76.66% respectively. 
In conclusion, nasopharyngoscopy is a simple, safe, repeatable, readily available at the ENT unit, with no radiation hazards, and with negligible trauma. Over all, nasopharyngoscopy has a higher sensitivity, specificity and accuracy than radiography.