Basrah Journal of Surgery

LESSONS TO BE LEARNED LESSONS TO BE AVOIDED IN THE FUTURE Thamer A Hamdan MB,ChB, FRCS, FICS, FACS, Professor of Orthopedic Surgery, Chancellor of Basrah University, Basrah, IRAQ. It is a well-known fact that lucky is the one whose mistakes can be counted. There is not a single surgeon who has not had complications of one type or another. Those who deny complications either have not done enough surgery or not telling the truth. I Surgeons may have complications in spite of good judgment and proper execution of surgical procedures. Simply speaking, complications should be the pillars for future rectification of personal and colleague’s careers. It is a shame when surgeons discover at time of surgery, that something was missed prior to putting the knife on the patient’s body. Certainly, this situation is embarrassing or even perplexing for the surgeon, because he may feel, he do not know how to behave when he faces a surprise. It is really painful when he feels he is guilty by the sin of omission or commission. At the same time, we should admit that we have faced some unexpected findings at the time of surgery. However, we may not be blamed because this was not due to lack of proper pre-operative evaluation but because of similarities of clinical manifestations or due to masking of the cardinal clinical features. One of the best example is emergency operation for acute appendicitis, while the operative findings are suggestive of ovarian cys

SEPTORHINOPLASTY PATIENTS, ARE THEY SATISFIED? Ahmed M Al-Abbasi MB,ChB, FICMS, FRCS, Professor of Otorhinolaryngology, Dean, College of Medicine, Basrah University, Basrah, IRAQ. Abstract Patient satisfaction after septorhinoplasty (SR) is very important topic, few studies took this issue in consideration and up to my knowledge, no study has been performed in our country in this regard. The aim is to evaluate patient satisfaction following septorhinoplasty performed in the Department of Otolaryngology in Basrah General Hospital, Iraq. This retrospective study included 210 patients underwent SR in the period between 2008 and 2013. All surgeries were carried out by same surgeon (author). Patients were asked to fill an outcome assessment questionnaire form at any time after 9-12 months postoperatively, either by themselves or by the assistance of the ENT resident doctors. This form is specific for postoperative satisfaction evaluation. Most of the patients were females (126, 60%) and 84(40%) were males. It is found that 90(43.8%) and 80(38%) patients were completely and very satisfied with appearance of their noses respectively. In regard to nasal breathing, 112(53%) patients were very satisfied. Family and friends satisfaction with appearance of patient's noses was complete in 89(42.3%) patients and very satisfied in 87(41.4%) patients. The majority of the studied patients (204 out of 210), stated that new appearance of their noses never limits their social and professional activity. Fifty-nine (28%) patients were not confident that their nasal appearance is best possible. Seventy-three (34.7%) patients stated that second surgery to change nasal appearance was not needed, also 138(65.7%) need no further operation to change or improve nasal breathing. In conclusion, SR performed in Basrah General Hospital resulted in a good level of patients' satisfaction

DIAMETER, THICKNESS AND DISCORDANCE DEGREE OF SOLITARY PULMONARY CAVITARY LESION TO DIFFERENTIATE BENIGN FROM MALIGNANT LESIONS, A MUTLISLICE CT STUDY. Ammar Mosa Jawad *, Mohammed Abd kadhim# & Husham Jubran Mousa@ *MB,ChB, Radiologist in The Medical Collage, Al-Nahrain University. #MB,ChB, FIBMS, Radiologist, Professor in The Medical Collage, Al-Nahrain University, Consultant Radiologist in Al-Imamain AlKadhimain Medical City, Baghdad Iraq. @MB,ChB, FIBMS, Specialist Radiologist in Al-Sader Teaching hospital, Basrah, IRAQ. Absctract Cavities are frequent image findings in a variety of pulmonary diseases including both lung cancer and pulmonary tuberculosis, Computed Tomography (CT) is accepted as the modality of choice for detection of possible cavitating pulmonary nodules. The aim of this study is to assess the role of diameter, thickness and discordance degree of solitary pulmonary cavitary lesion to differentiate benign from malignant lesions in multislice CT. This cross sectional study was done in the Computed Tomography Unit of Al-Imamain Al Kadhimain Medical City, Baghdad, Iraq and Al-Sader Teaching Hospital, Basrah, Iraq between October 2016 and June 2017. All patients are with solitary pulmonary cavitary lesions detected by chest x-ray referred for different reasons. Exclusion criteria included: multiple cavitary lung lesions, patients with known lung carcinoma or pulmonary tuberculosis on treatment, and patients receiving chest radiotherapy for different reasons. CT examination of the chest was performed by multi-detector CT (Somatom definition edge, SIEMENS (256 slices)) with 2 sets of CT examination one before and another after giving IV nonionic iodinated contrast medium (Ultravist 370 mg /ml), 1.5 ml/kg Body weight. The final diagnosis was obtained depending on the sputum culture for AFB, bronchoscopy and biopsy, bronchoscopy and brush cytology and true cut biopsy. Eighty percent of the patients were diagnosed as having benign lesions and 20% were diagnosed as having malignant lesions, the most frequent diagnosis was TB (60%), followed by squamous cell carcinoma (14%), lung abscess (10%), hydatid cyst (10%), adenocarcinoma (4%), and metastasis (2%). The discordance of CT scan (FDCW3) show highly significant association with malignant solitary cavitary lesions, while CT concordance (FCCW1 and FCCW2) were significantly associated with benign solitary cavitary lesions (p

BONE SPUR DRILLING, A NEW TECHNIQUE TO CORRECT DEVIATED MAXILLARY CREST Sajjad Halboos Mohammed Almansoori MB, ChB, FICMS, CABS ENT. Consultant ENT Surgeon, Alsadr Teaching Hospital, Basrah, IRAQ. Abstract The nasal septum consists of both bony and cartilaginous components which could be deviated resulting in different types of deformities that lead to unilateral or bilateral nasal obstruction in addition to dryness, crustation, and bleeding from the nose. Headache and facial pain may be other presenting features and sinusitis is a possible complication. ENT surgeons tried different surgical techniques to correct these types of septal deviations to ensure the best results and least complications. Forty eight patients (32 males and 16 females) were admitted to Al-Sadr Teaching Hospital with septal deviation in the form of bony spur alone or associated with other nasal septal deflections. Correction of the deviated crest was performed following good exposure by elevating mucoperichondrial flap, and using high speed drill with cutting bur to remove the deviated part or fracturing and repositioning. Patients were monitored for intraoperative bleeding and followed for at least four weeks regarding the development of upper incisors numbness. The results of this study showed that bleeding was much reduced during surgery and only one patient (2.1%) developed upper incisors anesthesia who have sever maxillary crest deviation that necessitated total excision of the spur. This study gives another option for bony spur correction by providing more controlled excision with less intraoperative hemorrhage and postoperative numbness, this improves patients health and relieves discomfort after surgery.

SAFETY AND EFFICACY OF THE BIPOLAR RADIOFREQUENCY ABLATION DEVICE FOR HEMOSTASIS IN THYROIDECTOMY IN COMPARISON WITH THE CONVENTIONAL KNOT-TYING TECHNIQUE Sadq Ghaleb Kadem*, Sarmad Manea Habash# & Mohammed Khalaf Raheem@ *#@MB,ChB, FICMS, Department of Surgery, Al-Shiffa General Hospital, Basrah, IRAQ Abstract The conventional method of hemostasis by using knot-tying technique is safe and effective in thyroid surgery but it is time consuming. A new energy devices like ultrasonic scalpel and advanced bipolar electrosurgical cautery have been proven to be safe and effective in shortening the length of thyroid surgery but the high cost of these advanced generators that designed to work only with an expensive disposable hand pieces, make its use difficult to justify in some hospitals. Radiofrequency ablation device is a refined type of electrosurgical cautery that utilizes a wave of electrons at a frequency between 2 and 4MHz to seal and divide the targeted tissue and the ablation property of this device act as an extra vessel sealing effect, it can be used with conventional reusable bipolar electrosurgical cautery hand pieces. The aim is to evaluate the safety and efficacy of a simple bipolar radiofrequency ablation device for hemostasis in thyroidectomy in comparison with the conventional knot-tying technique. This study was conducted in Alshiffa General Hospital following the approval of the local ethical committee. Fifty patients with different thyroid gland pathologies underwent total thyroidectomy in which hemostasis was achieved mainly with bipolar radiofrequency ablation device. The results of this group were compared with results of conventional knot-tying technique by the same surgical team at an earlier period. This study showed that bipolar radiofrequency ablation device significantly reduced; mean operative time, amount of foreign suture material, significant reduction in the mean volume of postoperative drainage, early patient discharge from hospital, and less complications. In conclusion, the use of the bipolar radiofrequency ablation device with conventional reusable bipolar cautery forceps for hemostasis in thyroidectomy is a safe, simple technique and effective in reducing the operative time in comparison with the conventional knot-tying technique.

OPEN REDUCTION AND INTERNAL FIXATION WITH CORTICOCANCELLOUS BONE GRAFT FOR TREATMENT OF VOLARY MALUNITED FRACTURE OF DISTAL RADIUS Falih Waheed Hashim MB,ChB, FICMS Orthopedics, Lecturer, Department of Surgery, College of Medicine, University of Basrah, IRAQ. Abstract Malunion of the distal radius is actually a late complication, not salvageable by re-manipulation or a change of immobilization, it requires different management technique. The aim of this study is to choose a technique that corrects the deformity as much as possible, with less complications. An assessment was done for 24 patients with unilateral malunited fractures of the distal radius. The mean age was 42 years (range 25-61 years). They were treated by open-wedge volar osteotomy with corticocancellous graft from upper tibia. Both osteotomy and graft were fixed by volarly applied plate and screws. Preoperative antero-posterior and lateral wrist radiographs were obtained and fracture pattern and radio-carpal alignment were assessed. Radial length and palmar tilt were also measured. The clinical outcome was assessed depending on the modified Gartland and Werley score. Radiological assessment of the parameters was done postoperatively to detect how much these parameters were corrected. This study shows that volar open-wedge osteotomy with corticoocancellous bone graft and internal fixation is a method for correction of malunited distal radial fractures with encouraging results. About 90% of the patients were satisfied with their results regarding the correction of the deformity and improvement of wrist and hand function, as well as limited complications when it is done carefully with appropriate facilities. In conclusion, the corrective osteotomy should be considered only when there is a clear-cut indication. It is actually a method to correct the deformity, rather than treatment of symptoms, specially pain.

COMPARISON OF EARLY AND DELAYED LAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS: EXPERIENCE FROM TWO CENTERS IN BASRAH Habeeb Flayyih Hussein@, Rafid Abduljabbar Mohammed$, Mushtaq C Abu-Al-Hail#, & Omran S Habib% @MB,ChB, CABS, General and Laparoscopic Surgeon, Alsadr Teaching Hospital. $MB,ChB, CABS, MRCS, General Surgeon and Lecturer at Basrah College of Medicine. #MB,ChB, CABS, Consultant General and Laparoscopic Surgeon, Basrah Teaching Hospital. %PhD, Professor of Epidemiology and Health Care, Department of Community Medicine, Basrah College of Medicine, Basrah, IRAQ. Abstract Calculous cholecystitis is a major and common health problem, and nowadays laparoscopic cholecystectomy is the preferred approach for its surgical management but timing of surgery is a matter of debate especially in presence of acute inflammation of the gall bladder. The aim of this study is to compare the outcome of early and delayed laparoscopic cholecystectomy for acute cholecystitis. This retrospective comparative study was done in two tertiary hospitals in Basrah from July 2010 to July 2017. It involved 122 cases (98 females 80.3% and 24 males 19.7 %). Forty two (34.5%) underwent early laparoscopic cholecystectomy within 4 days of symptoms and 80 patients (65.5%) underwent delayed operation within 6-12 weeks of first presentation. The two groups were comparable in regard to demographic and clinical points of view. The age of studied patients lies between 20-65 years. The operative time was not identical for the two groups (P=0.004), early treated cases tended to take longer operative time. Hospital stay was significantly longer in early cases as compared to delayed cases (p=0.000). Bile leak happened in only one case (2.4%) of the early group and was managed successfully and discharged well. Bleeding and respiratory infection were extremely rare in both groups. Conversion rate was 4.8% and 5% for the early and delayed group respectively and the difference was statistically not significant (p value 0.661). In conclusion, early laparoscopic cholecystectomy in acute cholecystitis is safe and feasible in selected patients with no difference in morbidity and mortality if it done during the 1st four days of beginning of symptoms, but the operative time is longer than delayed operation.

EVALUATION OF HEARING IN PATIENTS WITH BETA THALASSEMIA MAJOR Ahmed Fadhil Hasan*, Husam Haider Salman# & Jaafar Muhsen Khalaf@ *MB, ChB, FICMS, CABS ENT HNS, ENT Senior Surgeon at Al Shafaa General Hospital. #FRCS, DLO. Retired, Department Of Surgery, College Of Medicine, Basrah University. @MB,ChB, FICMS ENT, ENT Surgeon, Basrah Teaching Hospital, Basrah, IRAQ. Abstract This prospective study was conducted in Basrah Teaching Hospital to evaluate the hearing of β thalassemia major patients, and to find the association between desferoxamine (DFO) therapy and hearing loss (HL). Pure tone eudiometry (PTA) and tympanometry was done to determine hearing thresholds of (23) β thalassemia major patients and (50) non thalassemic subjects. All subjects were more than 4 year old to allow PTA to be done. The criteria of evaluation included a full otological history, drug history, otological examination, audiological evaluation using PTA and tympanometry. This study found that (6) out of (23) thalassemic patients and (6) out of (50) non thalassemic patients have hearing loss. From those thalassemic patients with HL, (5) patients have conductive hearing loss (CHL) and one have sensorineural hearing loss (SNHL), while the non thalassemic patients with HL all have CHL, also we found that (3) out of (5) thalassemic patients not on desferoxamine therapy have HL. In conclusion, β thalassaemia major has no significant statistical association with hearing problems, and there is no significant statistical association between desferoxamine therapy and hearing loss.

COMPARISON BETWEEN SINGLE DRAIN VERSUS TWO DRAINS IN THE PREVENTION OF POSTMASTECTOMY SEROMA Ahmed N Abdulnabi MB,ChB, CABS, Specialist Surgeon, Al-Fayhaa General Hospital, Basrah, IRAQ. Abstract Breast cancer is managed with many surgical options. Modified radical mastectomy with axillary dissection is the commonest procedure done nowadays. It is not free from complications, where seroma one of these. A comparative study was conducted to evaluate the effectiveness of single delayed removed drain versus two drains early removed for the prevention of seroma formation. One hundred and fifty patients were treated by modified radical mastectomy with axillary dissection for breast cancer between January 2010 and September 2016 in Al-Fayhaa General Hospital. Patients were divided into two groups, fifty patients were managed with single drain left for nine to ten days and the other one hundred patients had two drains removed after five days for prevention of seroma formation under mastectomy flaps. The highest age group affected by breast cancer was the 36-45 years and the lowest one was the 25-35 years. The incidence of seroma was 12% for the first group and 30% for the second one. The wound infection slightly more in the first group (14%) when compared with the other group (12%). In conclusion, the use of single drain for slightly longer time is better than two drains removed early in the prevention of seroma formation.

MANAGEMENT OF STAPLE LINE LEAKS FOLLOWING SLEEVE GASTRECTOMY Nasseif Jassim Mohammed@ & Falih M Algazgooz* @MB,ChB, CABS, FICMS, General and Laparoendoscopic Surgeon, Al-Sadr Teaching Hospital. *MB,ChB, CABS, FICMS, FACS, MRCS, Consultant Bariatric and Laparoendoscopic Surgeon, Al-Sadr Teaching Hospital, Basrah, IRAQ. Abstract Bariatric surgery is a growing specialty and the number of laparoscopic sleeve gastrectomies (LSG) has increased dramatically in the latest years all over the world. Gastric leak is considered one of the most serious complications following laparoscopic sleeve gastrectomy, it can become chronic, recurrent, and need multiple interferences. The purpose of the present study is to determine the clinical presentation of gastric leak after LSG, its management, postoperative course, and to show the effectiveness of various ways of managing such complication. This study included 200 patients who underwent sleeve gastrectomy at Al-Sadr Teaching Hospital for morbid obesity, they were 60 males(30%) and 140 females(70%). The mean age was 35 years and the mean body mass index (BMI) was 39 kg/m2. Out of the 200 patients who underwent laparoscopic sleeve gastrectomy, 6 patients (3%) were recognized to have leak complication. All leaks were proximal and identified at the gastroesophageal junction. Management was accomplished by putting T tube at the site of leak for 2 patients, direct closure for one patient, just drainage for one patient, and Roux-en-Y Gastric Bypass (RYGB) for the remaining 2 patients. In conclusion, prompt diagnosis and treatment is vital in the management of a leak. However, it can be treated securely via numerous management ways depending on the time of diagnosis and magnitude of the leakage.

MANAGEMENT OF SPINAL DURAL ARTERIOVENOUS FISTULA, A REVIEW WITH ONE CASE REPORT Mohamed El Husseini@, Hussein Mouawia#, Adnan Mrad$ & Taghrid Chaaban* @MD, PhD, Neurosurgeon, Hôpital Libano Français, Zahle, Lebanon. #Director, Lebanese University, 4th Branch, Lebanon. $Dean, Islamic University of Beirut. *Vice dean, Islamic University of Beirut, Lebanon. Abstract Spinal dural arteriovenous fistulas (SDAVFs) are rare acquired vascular malformations of the spinal cord which if not treated properly, can lead to inevitable severe morbidity with progressive spinal cord symptoms. The management is still at high interest among specialists. If microsurgical treatment is still considered as a treatment of choice for SDAVFs, endovascular treatment is increasingly growing in interest with the development of endovascular techniques and new embolization materials. In this article, a short discussion is made about the spinal dural arteriovenous fistulae in respect to anatomy, etiology, diagnosis and treatment. Careful patient selection, a multidisciplinary approach and standardized surgical techniques can lead to excellent results with virtually no complications.

MANAGEMENT OF CRISES DURING ANESTHESIA AND SURGERY. PART XIV: ALLERGY & ANAPHYLAXIS Salam N Asfar@ & Jasim M Salman# @MB, ChB, MSc, Professor of Anesthesiology, College of Medicine, University of Basrah. #MB,ChB, DA, FICMS, Assist. Prof. & Consultant Anesthesiologist, College of Medicine, University of Basrah, Basrah, IRAQ. Bas J Surg, June, 24, 2018 72 lthough serious allergic reactions to drugs and materials used in anesthesia and surgery are rare but it could be life threatening. Anesthesiology personnel should be trained for immediate recognition and successful management of this situation. Careful history taking in atopic patients is vital. Investigations should be done later to find out the causative agent to avoid or treat such condition

NEUROFIBROMATOSIS PRESENTING WITH A LARGE MASS OVERLYING THE SACRUM A CASE FROM THE ARCHIVE OF A RETIRED ORTHOPEDIC SURGEON Hassan K Mohammed MB,ChB, FRCS (Eng), FRCS (Ed), Consultant Orthopedic Surgeon, Shefa Centre for Bone & Reconstructive Surgery, Erbil, IRAQ Intro eurofibromatosis is well recognized for its variable manifestations which include features such as café-au-lait pigmentation, cutaneous and deep fibromata, pseudarthrosis of long bones particularly the tibia, and scoliosis1. Local hypertrophy of soft tissues may also occur and may be associated with megalodactyly or gigantism of an entire limb2. Here is a report of a case of neurofibromatosis with local hypertrophy of soft tissues in an unusual site. This case was presented to and managed in the Department of Trauma and Orthopedics at Basrah General Hospital in 1977.

RECURRENT PILOMATRIXOMA Abdulameer Muhsin Aldaraji MB,ChB, FICMS, General Surgery, Al-Faiha General Hospital, Basrah, IRAQ Abstract Pilomatrixoma is a rare tumor of the matrix cells of the hair follicle, it commonly occurs in young male patients and the commonest site is the head and neck region. Here is an odd case at which the tumor developed in the lower limb of a 65 year old male patien

Dr. Ahmed Mustafa Al-Salman Al-Manaseer 1923-2018