Basrah Journal of Surgery

Several parameters should seriously be considered in, almost, every pathology before drawing the line of treatment. Patients are not alike even when they are twins. Individual variation is a reality that should be taken in consideration. On top of this, comes the response to pain. The best example is the delivery of a baby; while one lady shouts loudly, another is very quiet. Some consider the pain stimulus as intense, because of psychogenic factors, while others show a calm response for the same condition.

Abstract This retrospective study aimed to determine the main indications of tracheostomy in four main hospitals in Basrah centre. The study included 89 patients who were submitted to tracheostomy during a 2 year period and data was reviewed from the medical records. Patients were 70 males (78.66%) and 19 females (21.34%). The age of the patients ranged from 1-75 years with mean age of 44.367±13.18 years. Open surgical tracheostomy was performed in all patients, 89.89% of them were submitted to surgery as elective procedure and 94.39% were operated upon under general anesthesia. The main indications of tracheostomy in this study is the need for prolonged ventilation (61.80%) mostly caused by head injury, followed by upper aero-digestive tumor (19.1%) and lastly cranio-cervical trauma (8.89%). In conclusion, the commonest indication of tracheostomy in Basrah is the need for prolonged ventilation.

Abstract Acute appendicitis is the most common cause of emergency abdominal surgery with an estimated lifetime prevalence of 7%–8%. Despite advances in diagnosis and treatment, it is still associated with morbidity (10%) and mortality (1%–5%). This study was designed to investigate the results of WBC count, platelet distribution width and C-reactive protein values based on the pathology results in patients undergoing appendectomy with an early diagnosis of acute appendicitis. This prospective cross sectional study was carried out in Basrah Teaching Hospital from the period 1st of September 2015 to 1st of June 2017, a total of 154 consecutive patients were enrolled in the study. All patients were admitted to the emergency department with history suggestive of acute appendicitis, blood tests were done for inflammatory markers in form of WBC, CRP and PDW, a period of 24 hours prior to surgery was accepted, histopathological data were used to assess inflammation of the appendix. The majority of patients were males 61% while females were 39%, with age range between 14-46 years (mean 24.28 years). There was a correlation between WBC count and acute appendicitis(P value=0.004), with sensitivity range (53%-69%) and specificity range (25-89%), while positive predictive value (PPV) and negative predictive value (NPV) were 96% and 8% respectively. A significant correlation found between CRP and acute appendicitis (p value less than 0.0001) with sensitivity range (71%-85%), while specificity was (10%-74%) and PPV, NPV were 95% and 9% respectively. Regarding PDW, no correlation was found with acute appendicitis (p value=0.296) with sensitivity range (6%-16%) while specificity (17%-82%), PPV 78%, NPV 2%. There was significant correlation between inflammatory markers (WBC, CRP, PDW) and complication with a p value=0.0001, ruptured appendix and peri-appendicular abscess were the most common complications recorded, only 8(5.2%) patients had normal appendix after histopathological examination. In conclusion, acute inflammatory markers play an important role in diagnosis of acute appendicitis along with history and physical examination.

Local anesthetic drugs are used in combination with vasoconstrictors, commonly adrenaline which increases their efficacy and duration of action and reduces bleeding at the operative site. However, adrenaline might have adverse hemodynamic effects, especially in patients with cardiovascular diseases. Hypertensive patients represent a risk group in dental practice. One major apprehension of the dentist is the sudden and dramatic increase in blood pressure that could lead to life-threatening complications including sudden death during a dental procedure. The aim of this study is to measure hemodynamic parameters, blood glucose, oxygen saturation and pain score in normotensive and hypertensive patients following intraoral injection of lidocaine with adrenaline and correlate these changes to the level of pain intensity and plasma metanephrine concentration.
This prospective study was conducted at Basrah College of Dentistry from October 2016 to June 2017. One hundred patients were included in the study for teeth extraction under local anesthesia. Sixty normotensives, 30 had stage one hypertension (BP=140-159/90-99) and ten healthy volunteers for metanephrine assay. All patients were injected with two cartridges of 2% Lidocaine with 1:80,000 adrenaline. Systolic and diastolic blood pressure, heart rate, oxygen saturation, visual analogue scale, blood glucose and plasma metanephrine concentration were measured at different intervals; before anesthetic injection, 5 minutes after injection, during extraction and 10 minutes following the end of tooth extraction.
Administration of local anesthesia with adrenaline in addition to the surgical procedure resulted in a significant increase in systolic blood pressure during tooth extraction (+8.7% and +16.6% mmHg for normotensive and hypertensive patients respectively, p<0.05), also heart rate similarly affected in both groups (10.6% and 13.4% respectively), this effect was significantly higher in the hypertensive group. The blood glucose showed a significant increase (P=0.00) 30 minutes after injection as compared to baseline. Generally, the peak changes in parameters were observed during tooth extraction procedure in both groups. Metanephrine peak plasma level occurs at 10 minutes following injection and it was significantly correlated with the systolic and diastolic blood pressure.
In conclusions, the injection of lidocaine with adrenaline in addition to the surgical procedure produces significant increase in blood pressure and heart rate in both normal and hypertensive patients which were larger in the latter group. Similarly, plasma metanephrine concentration was increased during the dental procedure and linked to the increase in the systolic blood pressure.

Cancer is a growing health problem with substantial mortality. A high mortality reflects high incidence, late detection and inadequate management.
The objective of this study is to examine the time changes of mortality rate of cancer in Basrah. The results presented in this article are all based on officially registered cancer deaths in Basrah Governorate on selected years.
Cancer of lung and bronchus, breast cancer, CNS tumors, all types of leukemia, secondaries of unknown primary site, urinary bladder cancer, stomach cancer, cancer of pancreas and cancer of liver and biliary system were the leading causes of cancer related death and accounted for 68.7%. The time trend showed some tendency for mortality rates to increase over years for most cancers except a noticeable decline in recent years.
In conclusion, cancer is a major cause of death in Basrah accounting for nearly 10% of all officially registered deaths. An initial modest increase followed by some tendency to decrease in mortality rate is noticed. Further comprehensive studies are highly recommended.

Abstract Non-invasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava using ultrasound machines is nowadays promising with the increasing availability of these machines in emergency departments, critical care units and in operating theaters. The learning curve of these tools is steep and they are becoming less expensive and give quick, non-invasive, dynamic clue to the preload status. The aim of this study is to evaluate the transhepatic inferior vena cava (IVC) diameter by non-invasive sonographic imaging and compare it with that measured by subxiphoid approach to reveal the degree of agreement between them. This is a prospective study, done in a tertiary care referral hospital at intensive care unit in Al-Sadr Teaching Hospital over a period of four months from 1st February 2017 to 5th of June 2017. Eighty shocked patients were included for assessment of volume status. Bedside ultrasound images were obtained with the patient in supine position to determine the dimensions and collapsibility of IVC. Evaluation of each patient included the standard anterior subxiphoid IVC assessment and lateral transhepatic assessment of IVC by ultrasound using liver as an acoustic window in mid-axillary line. The IVC diameter was measured 2 cm caudal to the hepatic vein-IVC junction, or approximately 3-4 cm caudal to the junction of IVC and the right atrium. Then IVC maximal diameter, IVC minimal diameter and collapsibility index were calculated for both approaches. A comparison between these data was made. A total of eighty patients were included, 31 (37.5%) were females and 49 (62.5%) were males. Mean age was 45.81±14.89 years. The results showed that there is no statistically significant difference between transhepatic and subxiphoid approaches in regard to IVC diameter and its collapsibility. In conclusion, transhepatic lateral view of IVC provides a good alternative when subxiphoid anterior view cannot be obtained to guide fluid management in shocked patients.

Abstract Upper gastrointestinal tract bleeding is a common emergency and life threatening condition. During the last three decades, many factors have been evolved that might change the incidence, age of presentation, site of bleeding and the outcome of patients with non variceal upper gastrointestinal tract bleeding. This study aimed to assess the profile and the mode of presentation of the patients with non-variceal upper gastrointestinal tract bleeding and to assess the etiology and the effect of different factors (demographic, mode of presentation and the treatment options) on the patient's outcome. This observational prospective study was carried out from May 2008 to October 2014 in Basrah Teaching Hospital. All adult patients who were presented with non-variceal upper gastrointestinal tract bleeding were included. All the demographic, clinical and treatment modalities in addition to the mortality rate and complications data were collected and analyzed. A total of 238 patients with non-variceal upper gastrointestinal tract bleeding were included in this study, 161 (67.6 %) patients were males and 77 (32.3 %) were females. The mean age was 50.62±17.06. Hematemesis was the commonest presentation in 125 (52.5%) followed by melena in 81 (34.03%). Duodenal ulcer was the commonest cause in 99 (41.59%) patients followed by erosive gastritis in 37 (15.5%) patients. The most common treatment modality was the medical treatment used in 186 (78.15%) patients which was successful in 179 (96.23%) with relatively low complications and rebleeding rates. Interventional endoscopy was used for 40 (16.8%) and was successful in 38 (95%) with 2 (5%) patients developed rebleeding. Surgery was done for 12 (5.04%) patients and was successful in 8(66.6%) and it was associated with highest rate of mortality (33.3%). Concerning the factors that might affect the outcome, there was a statistically significant effect of mode of treatment (odd ratio 6.42, p=0.03) and smoking (odd ratio 5.86, p=0.047) on the rate of development of complications. The mode of treatment had a statistically significant effect on mortality rate (odd ratio 20.24 p=0.001). The use of aspirin and/or NSAID affects significantly the rebleeding rate (odd ratio 7.4 p=0.025). In conclusion, the profile of our patients with non-variceal upper gastrointestinal tract bleeding was not greatly different from that of surrounding Middle East countries. We found that peptic ulcer disease was the commonest cause for which medical treatment was the most successful mode of treatment. Among many known risk factors, the mode of treatment and smoking were the factors that increase the complication rate. The mode of treatment was the only factor that affects the mortality rate. Use of aspirin or non-steroidal anti-inflammatory drugs influenced the rebleeding rate.

Abstract This study aimed to evaluate the C-reactive protein (CRP) levels in patients with open angle glaucoma. This cross sectional study included 36 patients diagnosed with glaucoma compared to 36 healthy controls. Each patient went through a complete ophthalmic examination and blood sampling for CRP. A thirty six cases (23 males, 13 females, mean age 60±11.7 years) with glaucoma and 36 age-matched controls (18 males, 18 females, mean age 58.25±10.45 years) were evaluated. Serum CRP levels were significantly higher in glaucoma cases than in controls (median 3.43, range 0.2-8.47 mg/dL) compared to 0.97, 0.17-6.30, P

Abstract Bleeding is a serious complication following bariatric procedures such as Minigastric bypass (MGB), Roux-En-Y Gastric Bypass (RYGB) Surgery, and Sleeve Gastrectomy (SG). Post bariatric bleeding is either acute or chronic. Although this complication is declined now, but still it is important to know because if it is not managed urgently it will lead to serious results. The source of bleeding may be from the staple lines, unexpected injury to the spleen, or to one of the blood vessels around the surgical field. The other source of bleeding may be internal through the GIT and it is presented as hematemesis or melena. Gastrointestinal bleeding in patients underwent bariatric surgery may occur in the esophagus, gastric pouch, new sleeved stomach, the Roux limb just distal to the anastomosis, the remaining of the small intestine. The site of bleeding can be determined and treated mostly by endoscopy but in certain cases may require re-laparoscopy. The aim of this study is to analyze the incidence, types and management of this bleeding. This is a prospective study which has been done in Al-Sadr Teaching Hospital, Basrah, Iraq, from June 2015 to June 2017. The study included 540 case who were subjected to SG, RYGB, MGB and they were analyzed regarding; time of occurrence, postoperative bleeding, types whether intra-peritoneal or intra-luminal and type of approaches for treating this bleeding. In our study we don’t over sewn the staple line and didn't use any buttressing material or synthetic coagulation powder. The total number of patients developed post-operative bleeding were 18 cases out of 540, 12 after sleeve gastrectomy, 3 after mini gastric bypass and 3 after Roux-En-Y. Regarding sleeve gastrectomy; two patients of the required re-laparoscopy and evacuation of hematoma with treating site of bleeding by clipping or suturing according to the condition, three patients required aspiration under ultrasound guide, while the remaining 7 cases were kept only under conservative measures. The 3 patient of the MGB were managed conservatively and the 3 cases of Roux-En-Y were managed either conservatively in 2 cases or by endoscopic intervention in one case. In conclusion, we advise the surgeons to use reinforcement of staple line to decrease incidence of post-operative bleeding.

The objective of this study is to assess pros and cons of intraoperative Briliant Blue G dye (BBG) injection in the early phase of Pars Plana Vitrectomy. This is a prospective non-consecutive case series study, a modification in timing for dye injection during vitrectomy. A single injection of 0.1 ml of Briliant Blue G (BBG dye) was used in the early phase of pars plana vitrectomy (PPV) promptly after an initial small core vitrectomy, and continued directly in completing vitrectomy; including induction of posterior vitreous detachment and peripheral vitrectomy +/- vitreous base shaving. View of the underlying retina is initially obscured immediately after dye injection, however dye density fade gradually with continuation of vitrectomy. Fluid Turbulence caused by vitrectomy and continuous fluid infusion enhance dye dissemination within vitreous cavity and stain transparent tissues and also increase colour contrast between blue hued retina and underlying naturally red coloured choroid. Early staining technique will remove necessity for Air-Fluid Exchange for staining at end of vitrectomy. This study was conducted in the Ophthalmology department at Hamad General Hospital in Doha, Qatar in 2016 and General Port Hospital in Basrah, Iraq in 2017. Patients requiring vitrectomy for various indications were included. Thirty four eyes (34 patients) were involved in this study: 20 men and 14 women, average age 56 was years. Indications for surgery were variable, diabetic vitrectomy (20 cases, 5/16= Macular Epiretinal Membrane), Rhegmatogenous Retinal Detachment (10 cases), Full Thickness Macular hole (2 case), Penetrating Injury with Posterior IOFB (2 cases). Single case required additional re-injection of dye to augment staining. Non-diathermy drainage Retinotomy was done by soft tipped cannula in 5 cases of retinal detachment. No single case has developed a surgically significant discolouration of lens posterior capsule or seepage of dye to the subretinal space. In conclusion, this modified staining technique allows better visualization of the various vitreoretinal tissues during all steps of PPV and improve surgical techniques

Hemorrhoids, are vascular structures present in the anal canal as cushions that facilitate stool control. When swollen or inflamed they are regarded as hemorrhoidal disease; sometimes they are asymptomatic specially in the internal type which are presented with painless rectal bleeding while external type may present with painful swelling. Although the traditional open hemorrhoidectomy (Milligan Morgan) is standard and effective technique, it is associated with many complications; the most important is post-operative pain and delayed return to normal activities. Nowadays Doppler-guided hemorrhoidal artery ligation (DG-HAL) with recto-anal repair (RAR) is a minimally-invasive technique for hemorrhoids, it is developed recently to overcome these complications. The purpose of this prospective study is to compare between the classical open hemorrhoidectomy and HAL-RAR procedure, by assessment of post-operative pain, postoperative complications and outcome of the procedures. This prospective, study was done between September 2014 and September 2016. Ninety six patients complaining of hemorrhoids were studied at Al-Sadr Teaching Hospital, Basrah, Iraq. They were divided equally into two groups; group A and B, group A underwent surgery by DG HAL and RAR, and group B were subjected to traditional procedure. Patients were followed for one year by evaluation at 1 week, 1 month, 6 months, and 1 year. In conclusion, DG-HAL with RAR is an effective technique compared with traditional hemorrhoidectomy regarding complications, postoperative pain, in hospital stay, and time of return to normal activities.

Peritonitis is inflammation of peritoneum which is most commonly due to generalized or localized infection. Secondary peritonitis is the commonest form and a large percent of them is due to perforation or impending gastrointestinal perforation. The prognosis depends on multiple factors by which Mannheim Peritonitis Index (MPI) appears to be more practical. This study aimed to assess the value of pre-operative aspiration of peritoneal fluid followed by peritoneal wash and drainage before proceeding to definitive surgery in patients with MPI score>20. This prospective study was conducted in Al-Hussein Teaching Hospital in Al Nasserya city and Basrah Teaching Hospital in Basrah city from October 2003 to July 2014. Each patient admitted to the emergency department in these hospitals with the provisional diagnosis of perforation peritonitis was evaluated with MPI score. If the score was less than 20; the patient managed with resuscitation and broad spectrum antibiotics for 2-3 hours then by definitive surgery while those with MPI more than 20 were randomly divided into two groups; the first were managed with 2-3 hours resuscitation with intra-venous fluid resuscitation and antibiotics followed by urgent surgical exploration (USE). The second group were managed with percutaneous peritoneal drainage (PPD) with aspiration of the fluid and then irrigation of the peritoneal cavity with isotonic saline and followed by a drainage with aid of the gravity through another catheter located in the right ileac fossa. Sixty two patients included in this study who fulfilled the criteria of perforation peritonitis and MPI score more than 20. Around half of them the score was between 26-30. Perforated peptic ulcer is the commonest etiology. The most common cause of their high MPI score is the late presentation and the evidence of organ failure. Renal failure is the most prevalent organ failed in both groups. The overall mortality is decreased in (PPD) group. Those with urgent surgical exploration(USE) showed no improvements in the pre-operative vital signs, prolonged operation time and a higher mortality and more severe post-operative complication than PPD group. In conclusion, the pre-operative percutaneous peritoneal aspiration of the fluid followed by peritoneal irrigation and drainage in patients with advanced stage perforation peritonitis is associated with a significant improvement in the pre-operative pulse rate and blood pressure, decrease in the operation time, a decrease in the overall mortality and deep seated wound infection and dehiscence but it is associated with a higher mortality in the first post-operative day.

Abstract
MB,ChB, FICMS, CABS (ENT), Consultant ENT Surgeon, Al-Sadr Teaching Hospital, Basrah, IRAQ. Abstract The nose is the most prominent structure in human face, making it more susceptible to trauma which may reach more than one third of all facial injuries. Although fracture nose is a common surgical problem, very few studies are conducted in Iraq on it. The aim of this study is to evaluate the efficiency of local anesthesia in fracture nose manipulation and to assess the degree of patient’s satisfaction from the functional and esthetic point of view. The majority of patients attended ENT department were males (68.5%) lying in the age group between 21–30 years and the reason for their injuries was personal assault. Waiting for complete resolution of edema results in some complications such as bleeding and pain. Fracture nose manipulation under local anesthesia gives high degree of satisfaction both for the functional (83.3%) and esthetic (88.9%) point of view, so this procedure can be recommended in ENT clinical practice in the view of these results as it is more safe, time saving and cost effective.

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 Tethered cord syndrome is a stretch-induced functional disorder associated with the fixation (tethering) effect of inelastic tissue on the caudal spinal cord, limiting its movement. This abnormal attachment is associated with progressive stretching and increased tension of the spinal cord as a child ages, potentially resulting in a variety of neurological and other symptoms. The condition is closely linked to spina bifida, and such presentation in childhood may accompanied with the cutaneous stigmata of dysraphism (hairy patch, dimple, subcutaneous lipoma). There may be associated foot and spinal deformities, leg weakness, low back pain, scoliosis and incontinence. The condition may go undiagnosed until adulthood with the development of sensory and motor problems and loss of bowel and bladder control.

Sepsis which is defined as systemic response to infection may potentially causes multiple structures physiological stress and dysfunction such as; respiratory, renal, cardiovascular, and hematological. Because quick consideration should be paid to so many body systems, prepared approach during anesthesia for a septic patient is a must1. Patients with sepsis show signs of systemic inflammatory response syndrome, as result from generalized reaction to inflammation which may be caused by a wide range of infectious and non-infectious causes for example, burns, pancreatitis and multiple trauma2.

Dr. Abdulameer, a lengthy serving competent ophthalmic surgeon, was born in Basrah in 1946. He obtained MB,ChB from The Medical College of Ain-Shams University in Cairo, Egypt in 1973.

Dr. Ghassan, one of the giant shining stars of surgery, departed to heavens in the 30th November 2018. he was a graduate of Baghdad College of Medicine in 1971 and received the fellowship of The Royal College of Surgeons of Edinburgh in 1981. He served in Basrah General Hospital until 2000 when he shifted to Baghdad to work in the Medical City Teaching Hospital as an active member in the Gastro-Enterology Department. During his stay in Basrah, he proved to be a distinguished surgeon, teacher and father for so many generations. He was a man of manners, very much respected by patients and colleagues.