Basrah Journal of Surgery

The existing dream in the mind of every physician allover the globe is to find a solution for so many problem cases such as; an incurable condition, a degenerative process, congenital anomalies and even more serious like malignancy. Every now and then a window opens for hope and optimism, makes all the physicians happy for a while, then it collapse because it did not stand the test of time like; the biological therapy, the immune therapy, the plasma rich platelet, and the serum therapy. So far all needs further approval, and more solid bases. We are to some extent optimistic with great hope to be capable of finding a solution for so many unsolved problems.

The lack of knee flexion is an increasingly recognized complication especially after trauma. This is a significant challenge for both surgeon and patients. In 1956, Judet proposed a quadricepsplasty technique that allow a graded release without the disruption of the vastus medialis, vastus lateralis, or rectus femoris. The aim of this study is to evaluate the beneficial outcome of the Judet quadricepsplasty in improving the range of movement of knee joint in those patients complaining from post-traumatic stiffness. This research was done for evaluating the clinical outcome of 15 patients who underwent a Judet's quadricepsplasty, they were 12 men and 3 women. The definitive flexion gain was classified according to Judet's criteria; excellent, if flexion was greater than 100°; good, from 80° to 99°, fair result are from 50° to 79°; and poor flexion degree is less than 50°. Patients were operated upon after an average of 19.40±17.63 months (range, 6-72 months) after first initial surgery. Average follow-up period was 6.5±3.6 months (range, 3-15 months). According to Judet criteria, 7 patients (47%) achieved excellent, 5 patients (33%) good, 2 patients (13%) fair, with zero poor results. Final average flexion arc improvement was 97.67±18.6 degrees with a range of 60-120 degrees. The noticed complications included; one case of extension lag excluded from the study and one case of small area of skin necrosis. In conclusion, even though it was proposed in 1956, the Judet procedure seems to give a reproducible amount of good results today and still holds its leading role in the treatment of extra-articular knee stiffness. Key words: Quadricepsplasty, Post-traumatic, Stiff joint, Knee joint, Judet procedure, Surgery

Laryngoscopy and tracheal intubation are constantly connected with a reflex sympathetic reaction bringing about tachycardia, hypertension and dysrrhythmias. This may cause harm in high hazard patients. Different pharmacological methodologies have been utilized to limit or weaken such a reaction. This study aimed to assess the hemodynamic changes following laryngoscopy and endotracheal intubation following propofol induction utilizing a standard anesthesia procedure and to analyze the capability of lignocaine and fentanyl in lessening the cardiovascular reaction to laryngoscopy and intubation amid general anesthesia. Sixty patients aged between eighteen to fifty years, of either gender and ASA class I, weighing between forty to ninety kilograms were planned for elective procedures and were haphazardly allotted into three groups of 20 each. Induction of anesthesia was standard for all patients who received propofol 2mg/kg i.v. and were relaxed with succinylcholine 1mg/kg i.v. The first group received 10cc. normal saline, the second group had fentanyl 2µg/kg i.v. bolus and the third group got lignocaine 1.5mg/kg 3 minutes before laryngoscopy and intubation. Heart rate and blood pressure were recorded noninvasively on arrival to the theatre and considered as a base line record, just after induction and then 1,3,5,7 and 10 minutes following intubation. There were no difference in statistical analysis between the groups regarding number, gender, age, weight and ASA class. There is significant rise in heart rate, systolic BP, diastolic BP and MAP in control group particularly in the first 3 minutes following intubation (p<0.05). Both fentanyl and lignocaine gave minimal protection against rise in heart rate after laryngoscopy and intubation and there is no significant difference between the two drugs (p>0.05). Both fentanyl and lignocaine were equally effective in prevention of major rise in systolic blood pressure, diastolic blood pressure and mean arterial blood pressure. In conclusion, Fentanyl 2µg/kg and lignocaine 1.5mg/kg are both equally effective for attenuation of laryngoscopy and endotracheal intubation pressor response. Keywords: Attenuation, changes in hemodynamics, laryngoscopy, endotracheal intubation, propofol, fentanyl, lignocaine.

The role of Tamsulosin in the treatment of ureteral stent related symptoms in Basrah General Hospital Firas Shakir Attar@, Adnan Odhafa Almayyahi# & Ibrahim Mahjar Tuama Flayyih* @MB,ChB, FIBMS, Assistant Professor at Basrah College of Medicine, Department of Surgery, Consultant Urologist at Basrah Teaching Hospital. #MB,ChB, FIBMS, Consultant Urologist at Basrah Teaching Hospital. *MB,ChB, FIBMS, Specialist Urologist at Basrah Teaching Hospital, Basrah, IRAQ. Abstract This study aimed to evaluate the efficacy of tamsulosin which is an α1-blocker as a therapeutic agent to alleviate ureteral stent related symptoms. Seventy-two patients were included in this prospective study from August 2018 to August 2019 in Basrah Teaching Hospital. All patients underwent ureteroscopic management of ureteral stones and ureteral stent had been inserted for about one month period. Patients were divided into two groups; a tamsulosin group, and a control group. Then the International Prostatic Symptoms Scores (IPSS) & Quality of life (QoL) were compared after one-month period. This study shows a significant decrease in the total IPSS, irritative IPSS, obstructive IPSS and the QoL scores with the administration of tamsulosin. In conclusion: The administration of tamsulosin in patients with ureteral stent is useful in decreasing the ureteral stent related symptoms.

Endometrial pathologies represent a diagnostic challenge for radiologist and gynecologist due to dynamic changes of the endometrium, wide variability in imaging appearance and overlap between benign and malignant causes of endometrial abnormalities. Although tissue analysis via dilatation and curettage, endometrial biopsy or hysteroscopy is the backbone in the diagnosis, these tests are invasive, not without complications and may be difficult to perform in certain circumstances, hence the need for noninvasive imaging methods to aid in the diagnosis and triaging the patient for subsequent invasive procedures as well as contribution in treatment planning. This study aimed to evaluate the role of diffusion weighted imaging (DWI) with apparent diffusion coefficient (ADC) value measurement in differentiating benign from malignant uterine endometrial lesions. The study included 47 patients with endometrial lesions divided into two groups according to the result of histopathological analysis; the malignant group consisting from 18 cases and the benign group consisting from 29 cases, the latter was further subdivided into: polyp, hyperplasia and other benign entities. Pelvic magnetic resonance imaging with DWI performed for each patient with visual evaluation of signal intensity on diffusion and ADC value measurement. Subsequently mean ADC values for each group were calculated and compared, and validity measures for the optimal cut-off values for differentiating benign from malignant lesions were determined. The mean±standard deviation for ADC value (x10-3mm2/sec) for malignant group was 0.71±0.12, and for benign group was 1.52±0.42, with a significant difference between the two groups (P value <0.01), there was no significant difference in ADC value between the subdivision of benign group. At ADC cut-off value of 0.976x10-3mm2/sec, the sensitivity, specificity, positive predictive value and negative predictive value and accuracy of DWI in detecting endometrial carcinoma were 100%, 89.6%, 85.71%, 100% and 93.62% respectively. In conclusion, DWI with ADC value measurement is a valuable non-invasive diagnostic test, aiding in the differentiation of benign from malignant uterine endometrial cavity lesions. Key words: diffusion weighted imaging, apparent diffusion coefficient map, benign endometrial lesions, malignant endometrial lesions.

The Human Papilloma Virus (HPV) can play a role in the development of head and neck tumors such as oropharyngeal tumors. Nevertheless, a real impact between Human Papilloma Virus and other head and neck sites such as the larynx is not well studied. This study aimed to assess the association of Human Papilloma Virus and laryngeal tumors. It is a prospective, case control study in which a random sample of 34 patients who have laryngeal masses was included in the period between November 2017 to December 2018. The study was carried out In the Department of Otolaryngology, Basrah Teaching Hospital. Patients were evaluated by a questioner according to gender, age, marital status, full medical history, and examination. A biopsy then was taken for histopathology study to confirm presence of tumors or other lesions. Malignant tumors were evaluated according to staging and grading systems. All lesions were examined for the presence of HPV by Immunohistochemistry (IHC) study. The results of this study revealed that there was HPV infection in 30% of the patients. Moreover, HPV was found in 30% of laryngeal squamous cell carcinoma and in 30% of benign lesions. Statistical tests showed no significant association between HPV and Laryngeal squamous cell carcinoma. In conclusion, although there was thirty percent of patients having HPV infections, but there was no significant association between HPV and laryngeal malignant tumours. A larger epidemiologic and more multicentric study is mandatory to evaluate the true prevalence of HPV infection in the mucosa of larynx and laryngeal malignancies. Keywords: Human, papilloma Virus, laryngeal tumors , immunohistochemistry, laryngeal mass

Diffusecoronaryarterydisease(CAD)isasurgicalchallengeinwhichconventionalcoronary arterybypassgrafting(CABG)maynotachieveadequatemyocardialrevascularizationunless adjuvantproceduressuchascoronaryendarterectomyandcoronarypatchangioplasty(CPA) areadded.Theaimofthisprospectivestudyistoevaluatetheoutcomeoftheseproceduresin ourinstitution in viewofthe relevantliterature. DataofallpatientswhounderwentCPA±CABGbyonesurgeoninourinstitution (n=22) betweenApril2018andApril2019werecollected.Patientsunderwentopencoronary endarterectomyandonlaypatchofleftinternalmammaryartery(LIMA)oravenouspatchunder cardiopulmonarybypass(CPB). Of167CABGprocedures,22werecombinedwithCPA.Therewere15(68.2%)males.Age rangedbetween43-72yearswithameanof59.patientsincluded19isolatedleftanterior descendingarteries(LADs),tworightcoronaryarteriesandoneobtusemarginalbranch.The CPBtimewas88-198minutesandtheaorticcrossclamptimewas40-125minutes.The patientshad(includingLAD)2-4vesseldiseases.TheaverageICUstaywas29±14hoursand meanhospitalstaywas5dayswithnocomplicationsapartfromatrialfibrillation(n=4,18.2%). Thefollow-upperiodrangedfrom4to14months.Onthe40thpostoperativeday,coronaryCT angiographyrevealedpatentgrafts.Nopatientdied duetoCAD. Inconclusion,coronaryendarterectomyandangioplastyisasafeandhighlyrewarding procedure in potentiallyinoperable patients with diffusecoronaryartery disease. Keywords:Coronaryarterydisease,endarterectomy,angioplasty,venous,patch,leftanterior descending, left internal mammaryartery

Abstract The incidence of acute kidney injury (AKI) after on-pump coronary artery bypass graft (CABG) varies among studies but can be reduced if pulsatile flow is used. The aim of this study is to evaluate pulsatile flow impact on renal function of elderly patients undergoing CABG. Over one year (April 2014 to April 2015) 48 patients above the age of 65 underwent on-pump CABG in our institute. Patients were divided into two groups; pulsatile flow (PFG) and non-pulsatile flow (NPFG) groups. Serum creatinine (S.Cr), creatinine clearance (Cr.Cl) and per-perfusion urine output (UO) were measured. AKI Network criteria were adopted for diagnosis. Mean age was 68 in PFG and 69 in NPFG. Males constituted 83.3% of PFG and 79.2% of NPFG. Although 37.5% of PFG and 41.7% of NPFG were hypertensive, all patients had normal ejection fraction (EF). Both groups had nearly 3 coronary anastomoses, cardiopulmonary bypass (CPB) time of 90 min, cross clamp time of 71 min and mean perfusion pressure of 70 mmHg. Mean S.Cr was the same (0.8 mg/dl) in both groups on 1st postoperative day (POD) but UO was significantly larger (708 ml in PFG vs. 648 ml in NPFG). On 3rd POD, S. Cr didn’t change in PFG but it has significantly increased in NPFG (from 0.76 to 1.0 mg/dl). Moreover, Cr.Cl has significantly improved in PFG (81 vs. 72 ml/min in NPFG). Seven of 48 patients (14.6 %) developed AKI (6; 25% in NPFG). In conclusion; Pulsatile perfusion technique is a simple and safe measure to minimize AKI in the elderly. Keywords: Coronary artery bypass graft, elderly, cardiopulmonary bypass, pulsatile flow, non-pulsatile flow, acute kidney injury, serum creatinine, creatinine clearance

Rhinoplasty is the most demanding aesthetic procedure that is currently shifted from ablative to conservative surgical procedures, one of these procedures is using cartilage grafts for correction and augmentation of congenital and acquired nasal deformities. The Autologous costal cartilage graft (ACCG) is a good choice for reconstruction of these deformities because its ample amount and good strength. The aim of this study is to assess the outcome of using autologous costal cartilage graft in augmentation rhinoplasty in severe congenital and acquired nasal deformities. This is a prospective study of 10 patients aged between 16-45 years (7 females and 3 males) in form of 4 cases of saddle nose, 3 cases of cleft lip nasal deformity, two cases of post-traumatic severely deviated nose, and one case of African nose. Patients underwent augmentation rhinoplasty by ACCG, from July 2018-June 2019. The follow-up period was 6-12 months concentrating on preoperative and postoperative structural and functional evaluation. The outcome of augmentation rhinoplasty by ACCG was evaluated by 2 independent surgeons and the results were accepted by both surgeons and patients in 9 out of 10 cases (apart from one case that she had infection of the graft) with donor site complication rates near to the related studies. In conclusion, ACCG is one of the best choices for severe nasal deformities that need ample amount of cartilage for structural and functional support and good aesthetic outcome with low complication rate. Keywords: Autologus graft, Costal cartilage, Surgery, Rhinoplasty, Augmentation.

Otitis media with effusion (OME) is a chronic accumulation of fluid within the middle ear cleft and sometimes the mastoid air cells system. The disease is more common among children. Surgical management is cost effective and carry complications from anaesthesia and surgical intervention. The condition can be resolved with high percentage by using mucopeptide breaking agent N-acetylcysteine The aim of this study is to evaluate the effect of N-acetylcysteine on the resolution of otitis media with effusion in children. Fifty seven children (107 ears) aged between 4-15 years with OME were included in this study. Patients underwent a thorough otorhinolaryngological examination and were divided into two groups; in the study group of 30 patients, N-acetylcysteine was administered, and the control group of 27 patients did not receive this treatment. Patient were followed-up at attendance, one month, two months and three months later with microscopical ear examination, tympanometric and pure tone audiometric examination. Patients were 39 males (68.4%) and 18 females(31.6%), 50 of them were with bilateral and 7 with unilateral disease. Following the treatment, there was improvement in the hearing loss as air bone gap was decreased. This improvement was statically significant in comparing the study and control groups (P value= 0.022). Number of ears with type A tympanogram increased to a rate of 74%, 71% in the right and left ears respectively in the study group. This rate was statically significant in comparing with the control group (P value=0.014). In conclusion, N-acetylcysteine is effective in the treatment of children with OME as well as that N-acetylcysteine has minimal side effect and can be used safely in patients who are medically unfit for general anaesthesia

In healthy individuals, the bile is usually sterile, however, in cases of cholecystolithiasis and/or choledocholithiasis, it could be colonized with bacteria (bactibilia) and may lead to surgical site infection after cholecystectomy. In our hospital, the local regimen is to use antibiotics prophylaxis only for patients with high-risk factors, while in case of low-risk patients, the antibiotics used as postoperative treatment; this local regimen has no demonstrated bacteriological or epidemiological basis. The aim of this study is to determine the nature of bacteria in bile and their antimicrobial susceptibility in low-risk patients and the relationship between bactibilia and the presence of some predisposing factors as well as developing postoperative infectious complications. This study was conducted in Al-shiffa General hospital, Basrah, Iraq from April 2018 to May 2019. Forty-three patients with uncomplicated symptomatic gallstones who were candidates for elective laparoscopic cholecystectomy and have no risk factors for infection were included in the study. Under fully aseptic technique, a sterile laparoscopic needle connected to a sterile 10ml disposable syringe used to aspirate 5–7ml of bile from the fundus of gallbladder for culture and antibiotic sensitivity. In this study culture assessment of bile demonstrate that, 20 patients (46.51%) have infected bile; Klebsiella spp. 7(35%) and Pseudomonas spp. 7 (35%) are the most frequent causative agents. Factors like gender, age, duration of complaint and number of stones were found not significantly increase the risk of infection. Antibiotics sensitivity revealed maximum sensitivity to Meropenem (100%), Amikacin (90%) and less sensitivity to the most commonly used Ceftazidime. No cases of superficial or deep-seated surgical site infections were reported. In conclusion, bile infection reported in a significant rate in low risk patients for infection subjected to elective laparoscopic cholecystectomy. Klebsiella spp. and Pseudomonas spp. are the most common isolate which shows high sensitivity to Meropenem and Amikacin and less sensitivity to third generation Cephalosporine; so we recommend the use of Amikacin as a prophylactic antibiotic instead of third generation Cephalosporine. Keywords: Bile infection, Cholecyctectomy, elective surgery, laparoscopy, low risk patients

This study aimed to evaluate the necessity for silicone tube insertion following endonasal endoscopic dacryocystorhinostomy (DCR), and the optimal time for its removal. A prospective study was done at Al-sadr Teaching and Al-Shafaa General Hospitals in Basrah, Iraq on seventy two patients with nasolacrimal duct obstruction diagnosed and referred from ophthalmologist to ENT clinic. Preoperative assessment with investigations were done and all patients were subjected to endoscopic endonasal DCR. The patients were divided into three groups; the first group included those with long period stenting (silicone tube removed three months or more), the second group included those patients with short period stenting (tube removed 2-3 weeks after surgery), and the last group included those with no silicone tube stenting. The success rate and complications after surgery were studied in each group for more than one year. The 72 patients were; 63 females (87.5%) who affected more than males (9, 12.5%). the most common age group was 21-45 years. Left side of disease 41(56.9%) is more than right side 31(43.1%). Sixty eight operations (94.4%) out of 72 were primary surgery while four (5.6%) were revision surgery. Ancillary procedures were done also; 13 (18%) septal surgery and 3(4.1%) endoscopic sinus surgery. Success rate was more among short period stenting group 22 out of 24 (91.6%), then without stenting group 19 (82.6%) and those with long period stenting was only 20 from 25 (80%). In conclusion, no statistical significant difference (benefit) about the usage or not of the silicone tube and also about how long keeping the tube, but it is preferable to use silicone tube (for 2-3 weeks only) to improve success rate. Keywords: Silicone tube, Insertion, Endonasal, Endoscopic, Surgery

Diabetes mellitus (DM) is known as an important risk factor for surgical site infection(SSI) in spine surgery. A chronic state of impaired glucose metabolism affects multiple components of the immune system, possibly leading to an increased incidence of post-operative infection. Such infection increases morbidity, length of stay, and overall cost. The present study was designed to assess the correlation between pre-operative hemoglobin A1c (HbA1c) and the incidence of post-operative infection in surgical patients undergoing decomperssive spine operations. Forty diabetic patients who underwent decompressive spine surgery at different levels of spine were included in this retrospective study. These include 23 females and 17 males with mean age of 57.5 years. The patients data were collected from hospitals and private clinics archives including value of preoperative hemoglobin A1c, random blood sugar, postoperative C-reactive protein (CRP) and white blood cells count (WBC) as a diagnostic laboratory tests for identification of postoperative infection in follow-up periods. The overall rate of infection in our study was 12.5%, which was categorized into 2 groups (Uncontrolled diabetes hemoglobin A1c >7 and controlled hemoglobin A1C ≤7), so the rate of infection was 19.2% among patients with uncontrolled diabetes compared with 0% among patients with controlled diabetes (p=0.143). The mean hemoglobin A1c among patients with uncontrolled diabetes who developed infection was 9.72% compared with 7.34% among those with no infection (p <0.001) In conclusion, diabetic patients whose blood glucose levels were poorly controlled before surgery as indicated by high hemoglobin A1c were at high risk for postoperative wound infection. Preoperative hemoglobin A1c above 7.34% could serve as a threshold value for significant increased risk of postoperative surgical site infection. Key words: Diabetes Mellitus, HbA1C, decompressive spine surgery, infection, complications.

Septal extension graft is a unique technique for controlling nasal lengthening and tip projection, rotation, and shape by which a graft is fixed to the septum, leading to a strong and stable supporting structure. Nasal tip three-dimensional positioning is a vital and difficult component in the overall appearance of the tip. A total of 12 Middle Eastern patients with thick nasal envelope skin were subjected to rhinoplasty using the septal extension graft (SEG) method. Eleven out of the 12 patients, had pleasing results after primary rhinoplasty with SEG, while only one patient had SEG as a secondary procedure. In conclusion, septal extension graft in rhinoplasty is an effective technique for achieving a strong supporting force of the nasal tip for adequate projection. Keywords: Nasal tip, surgery, septal extension, graft, rhinoplasty

Low body temperature can affect the body in many ways such as; O2 dissociation curve shift to the left, acid base balance alteration, cardiovascular system changes, central nervous system will be affected by low cardiac output, metabolism also changed as there will be reduced functions of the liver and kidneys that’s why glucose and drugs in minimal doses should be given, electrolyte changes expressed in high serum potassium may affect the cold sensitive heart, as well as there is alters of non-depolarizing agents effect1. Normally, the human body can initiate mechanisms to maintain or generate heat but anesthesia disturbs these homeostatic mechanisms. Along with, exposure to the cold procedural situation and vasodilation induced by general or regional anesthesia contribute to intraoperative hypothermia development2

Dr. Abdul-khalik Zaki Benyan, Professor of Cardiovascular and Thoracic Surgery, graduated from MedicalCollege, University of Mosul in 1970. He was born in Mesan, Iraq in 1946 and passed away in 2019. He got his Fellowship of the Royal College of Surgeons, UK in 1982. After returning back to Iraq, he worked in many hospitals in Basrah Health Directorate as a specialist in cardiovascular and thoracic surgery. In 1985, he also worked in BasrahMedicalCollege, where he proved himself as an outstanding active person with participation in teaching and examining both undergraduate students in the Department of Surgery as well as postgraduate Iraqi board of cardiovascular and thoracic surgery for several years. He published large number of articles in different local and international journals for which he got professorship. He also worked as head of Department of Anatomy at Basrah College of Medicine till his retirement. The departure of Professor Abdul-Khalik, hopefully to heavens, was a real loss of an academic person who was keen, loveable, hard working, and caring for thousands of patients over his long career. Certainly his students and colleagues shall never forget him. He is alive by his wife, sons and daughters. God bless his soul.