Basrah Journal of Surgery

nesthesia is a journey and a good anesthesiologist should guarantee a return ticket to his patient. Like airplane, the most difficult time is the induction, and weaning from anesthesia. It is a critical balance between early detection, clinical awareness, and experience in one end, and complications in the other. Probably, the key for success is choosing the patient in the right time, and for a particular type of anesthesia, which should be tailored to the specific pathology. Certainly, it is a matter of matching.

Abstract
Abrar A Abdul-Salam*, Jasim M Salman@ & Salam N Asfar# *MB, ChB, FICMS Anesthesiology, Al-Sadir Teaching Hospital, Basrah. @MB, ChB, DA, FICMS, Assistant Professor of Anesthesiology, Basrah College of Medicine. #MB, ChB, MSc, Professor of Anesthesiology, University of Basrah, College of Medicine, Basrah, IRAQ. Abstract From the time when succinylcholine(scoline) introduced to clinical anesthesia, intravenous route of administration of the drug has been broadly practiced. Severe bradycardia and arrhythmias may from time to time produced by single or frequent doses. The mechanism of bradycardia caused by succinylcholine administration has not been completely explained, it has been found that succinylcholine produce a unpredictable effects on the sinoatrial node. In our hospital , a second dose of succinylcholine is usually used for short surgical procedures that required good relaxation like anorectal surgery and orthopedic manipulation under anesthesia. This study aimed to discuss the conditions under which bradycardia appear during general anesthesia with oxygen, propofol, scoline, halothane, along with the use of second dose of scoline and assess the need for atropine to prevent this effect. Fifty patients aged between 20-50 years of American Society of Anesthesiologists (ASA) class I were included in this study, anesthesia was induced with propofol, scoline, along with oxygen halothane mixture, then 2nd dose of scoline was given 10 minutes later. Frequent pulse rate were recorded. There was considerable decrease in pulse rate of the patients after the 2nd dose of succinylcholine, 36% of the patients developed bradycardia (pulse rate below 60), and the mean reduction in pulse rate was (23±13 beats/min). However there is no need for the use of atropine since all of the patients return to normal rates (60-100 beats/min) within 1 minute spontaneously. Conclusion: It has been found that the use of scoline in one dose produce decrease in pulse rate but not reach to the bradycardia level, while the uses of another dose will result in significant reduction in pulse rate that can reach to the level of bradycardia. All patients return to normal level of pulse rate within 1 minute, therefore, there is no need to use atropine neither preoperatively nor after developing of bradycardia since it's a self limiting

THE EFFECT OF PERITONSILLAR INFILTRATION WITH MEPECAINE-L ON TONSILLECTOMY MORBIDITY IN ADULTS Ali J Auda*, Ahmed A Alansary#& Abdulwahab B Abdulwahab@ *MB,ChB, CABS, ENT Dept, Basrah General Hospital. #MB,ChB, FICMS, Consultant Otolaryngologist, Head-ENT Dept, Basrah General Hospital. @MB,ChB, FICMS, ENT Specialist, ENT Dept, Basrah General Hospital. Abstract Tonsillectomy is one of the most common performed procedures in ENT practice, it may be associated with bleeding and postoperative throat pain which are significant morbidities. The aim of this study is to evaluate the effects of peritonsillar infiltration with (Mepecaine-Levonottrdefrin) on tonsillectomy duration, intraoperative blood loss and early post-operative pain in adults. In this case-control study; fifty adults aged between 18-32 year were included, they were 34 females and 16 males who underwent tonsillectomy in the period between November 2011 and April 2012 at Basrah General Hospital, Iraq. Unilateral peritonsillar injection with Mepecaine-L (Mepecaine 2% - Levonorderfrin 1:20000) were infiltrated to one side and compared with the other side for the following parameters: operation duration, intraoperative blood loss and early post-operative pain score. There was no statically significant difference in the duration of operation between the test and control side (P>0.05); There was significant reduction in the blood loss in the tested side (P< 0.001); and also significant reduction of the early postoperative pain (P

MODIFIED SHOELACE REPAIR OF LARGE ABDOMINAL INCISIONAL HERNIAS Ali Abdul-Aziz Al-Shawi MB,ChB, FICMS, CABS, Department of Surgery, College of Medicine, Chancellor Missan University, Missan, IRAQ. Abstract This study aimed to evaluate modified shoelace darn repair. An abdominal incisional hernia represent defect in the musculo-fascial layers of the abdominal wall. It considers one of the commonest hernia in middle aged women. surgical site wound infection is the most common causative factor and there are different method of surgical repair. This prospective study was conducted on 127 patients of incisional hernia who were managed by modified shoelace darn procedure, they had reinforce the repair by onlay mesh to bridge the defect in anterior rectus sheath. The highest proportion of patients aged 41-50 years (37% with a mean of 43.6 years). Regarding distribution of gender, the pattern was similar in both sexes. Most of the patients were overweight (76.4%). Further 14.9% were obese and only 7.9% were normal, 29.9% developed some kind of complication. The recurrence rate was 1.6%. In conclusion, modified shoelace darn repair is simple, safe, extra-peritoneal with less tissue damage and it seems a good surgical technique for management of large ventral incisional hernia.

CIPROFLOXACIN OTIC DROPS FOR PREVENTION OF OTORRHOEA FOLLOWING MYRINGOTOMY AND VENTILATION TUBE INSERTION AMONG CHILDREN Ammar A Selman*, Ahmed A Alansary# & Abdulwahab B Abdulwahab@ *MB,ChB, Arab board candidate, ENT Dept., Basrah General Hospital. #MB,ChB, FICMS, Consultant Otolaryngologist, Head-ENT Dept, Basrah General Hospital. @MB,ChB, FICMS, ENT Specialist, ENT Dept, Basrah General Hospital. Abstract This study aimed to determine the effect of topical otic drops on the rates of postoperative ventilation tube otorrhoea and ventilation tube occlusion in children after myringotomy and ventilation tube insertion in children. A randomized comparative interventional study was carried out on 45 children (84 years) attending Basrah General Hospital, they were 32 males (71%) and 13 females (28.9%), 39 cases have bilateral otitis media with effusion and 6 with unilateral disease, the age range was 3-17 years old. After full assessment of patients, myringotomy and ventilation tube insertion was done for every one with or without adenoidectomy and tonsillectomy or both. They were divided into three groups: first group with no local intervention, second group with single application of ciprofloxacin otic drops at surgery, third group with continuous application of ciprofloxacin otic drops for four days after surgery. A follow-up visit was instructed after 14 days for all. The rates of postoperative ventilation tube otorrhoea and ventilation tube occlusion were recorded. With application of statistical analysis on the results, there was a statistically significant reduction in the rate of postoperative otorrhoea with using the ciprofloxacin otic drops for four days after surgery (P-value 0.043) with a reduction in the incidence of otorrhoea from 29.6% to 7.6% as compared to the group without using the drops. No significant results obtained with a single drops application at time of surgery. There were no statistically significant results in regard to the rates of postoperative ventilation tube occlusion among the study groups. In conclusion, ciprofloxacin otic drops application for few days after myringotomy and ventilation tube insertion appears to be effective to reduce the rate of postoperative ventilation tube otorrhoea. Neither the single nor the continuous otic drops applications could reduce the rates of postoperative ventilation tube occlusion

ESTIMATION OF MEAN CENTRAL CORNEAL THICKNESS USING SIRIUS SCHEIMPFLUG–PLACIDO TOPOGRAPHER IN BASRAH Aymen Majeed Fadil* & Salah Zuhair Al-Asadi@ *FIBMS Ophthalmology, Basrah General Hospital. @FRCS, FIBMS, FICO (Ophthalmology)
Assistant Professor, College of Medicine, University of Basrah, IRAQ. Abstract This study aimed to assess the mean of central corneal thickness (CCT) in a sample of normal Iraqi population (Basrah and its surrounds as a sample). Pachymetry was done by Sirius Scheimpflug–Placido Topographer for 1774 eyes of 887 healthy participants 10–68 years old. The parameters studied included central corneal thickness and the results were compared with other studies. This study included 414 healthy male and 473 healthy females and it revealed mean CCT equals to 531.49±34.92 μm with range from 426.5–632. The mean CCT in those who are 10-19 years old (543.7±32.3μm) was significantly higher than the other age groups (p value 0.1). In conclusion, normative data regarding central corneal thickness were reported in Iraqi population. Means of central corneal thickness was generally lower than those reported in Turkey and Iran.

FIVE YEARS EXPERIENCE OF USING ULTRAPORTABLE SONOGRAPHY FOR UROLOGICAL EMERGENCIES Mahmood Sh Abdulkarim MB,ChB, FICMS, FRCS Glasgow, Assist. Prof. of Urology, Department of Surgery, College of Medicine, Basrah University, Basrah, IRAQ. Abstract This study aimed to evaluate the use of ultraportable sonography in the emergency department for urological emergency conditions by one urosurgeon. The results were compared to the final diagnosis after performing a second sonography, computed tomography and cystoscopy so to calculate the specificity and sensitivity of this test and outline its advantages and disadvantages for the emergency department and the examining urologist. This prospective study was done between 2010 and 2015. A 217 patients with either flank pain or hematuria were included. An ultraportable sonography was used to examine all patients at the emergency department and the results were compared to the final diagnosis after evaluating those patients with another ultrasound, contrast study, computed tomography and cystoscopy. The statistical analysis of the results showed a very high sensitivity of 97%, with a specificity of 75%, the false positive ratio was 25% which is high but the false negative result rate is 3.0% which was low, there was a high predictive value of 98% for positive, and only 66.7% for negative with a likelihood ratio of 3.881 for positive results. In conclusion, ultraportable sonography can be used with high efficacy and accuracy in emergency urological conditions, it carry a lot of satisfaction for both the patient and the physician, it can improve patient management by reducing the time needed for diagnosing and assessing the patient condition. It is strongly recommend for primarily use in the emergency department.

IMMUNOHISTOCHEMICAL EXPRESSION OF STEM CELL MARKERS CD44, CD166 AND ALDH1A1 IN NON-NEOPLASTIC POLYPS OF THE COLON IN SAMPLE OF IRAQI PATIENTS Nawal M Abdullah*, Mustafa M Ibraheem@ & Basim Sh Ahmed# *MB,ChB, MSc, Assist. Prof., Department of Anatomy, College of Medicine, University of Basrah. @MB,ChB, MSc, PhD, Assist. Prof., Department of Anatomy, College of Medicine, University of Al-Mustansiryah. #MB,ChB, FICMS, Assist. Prof. Department of Pathology, College of Medicine, University of Al-Mustansiryah, IRAQ. Abstract The aim of this retrospective study on tissue specimens of benign colorectal polyps is to evaluate the significance of IHC markers CD44, CD 166 and ALDH1A1 expression in non-neoplastic (Juvenile and Hamartomatous) polyps and their association with different clinicopathological parameters & to compare their expression in benign polyps with that of normal colonic tissue . Seventy cases enrolled in the study including benign polyps (juvenile & hamartomous polyps) & benign looking colonic tissue obtained from archive of histopathology unit in Gastroenterology and Hepatology hospital in Baghdad Medical City and histopathology unit in Al-Sadder Teaching Hospital in Basrah city for the period Sept. 2015 to Dec. 2016. Four micrometer sections were obtained from formalin fixed paraffin-embedded blocks treated IHC with CD44, CD166 and ALDH1A1 tumor markers. Majority of polyps were juvenile, no difference regarding gender distribution. The common location was rectum/rectosigmoidal region. CD166, CD44 and ALDH1A1 showed high expression regarding age, gender and location in benign tumors when compared with healthy looking tissue. In conclusion, colorectal polyps are critical clinical entity and many of them are a precursors to malignant diseases so colonoscopy is essential screening test, polypectomy and follow up is mandatory for patients with colorectal polyps even if they are benign.

ASSESSMENT OF THE OUTCOME OF EARLY VERSUS DELAYED SPICA CAST IN THE TREATMENT OF CLOSED FEMORAL SHAFT FRACTURE IN CHILDREN Hamid A Jaff MB,ChB, DM, FICMS, Orthopedic Surgeon, College of Medicine, University of Sulaimaniyah, IRAQ. Abstract This study aimed to assess the results of early versus late spica cast in the treatment of femoral shaft fracture in children. This is a descriptive study performed at Al-Sulaimaniya Teaching Hospital during the period between June 2009 and October 2010. Twenty eight patients with a mean age of five years ranged (2-8 years) with closed isolated femoral shaft fractures were included in this study. They were four females and twenty four males. Fifteen patients had left sided fractures while right sided fractures were in thirteen patients. Patients having compound fractures and those with associated injuries were excluded from the study. Ten patients were treated by skin traction for about 2-3 weeks then hip spica cast was applied. The other 18 patients treated by early spica within 2-5 days. All patients were followed for a period of about 4 months after removal of spica cast. The study reveals that boys are affected more than girls. The causes of the fracture in this study were 15 cases (53.6%) fall from height; 8 cases (28.6 %) road traffic accident and lastly 5 cases (17.9%) for other causes like direct trauma. Average duration of skin traction in delayed Spica cast group was 2-3 weeks. Immediate complications after removal of the spica; patients treated with early spica were 3 cases for side way angulation, 1 case for shortening, while for anterior angulation 1 case. Patients treated with delayed spica following skin traction complicated by anterior angulation was 1 case and side way angulation was 1 case while no case of shortening reported. The patients considered here to have a shortening or angulation are only those having a deformity of more than accepted limits (20 mm shortening, 15 degrees side way angulation and 20 degrees for anterior angulation), but after 10 months of follow up for all of the patients, most of the initially observed complications were corrected to the accepted limits. The shortening which was reported initially overcomed by overgrowth and only 0.8 cm length discrepancy was there. For both anterior and side way angulation, they were within the accepted limits. In early spica, the hospitalization ranged from 2-5 days; while in delayed spica, the hospitalization time ranged from 16-23 days. It is concluded that little significant difference in late outcome between early and delayed spica cast application regarding the complications of treatment and functional outcome, but early spica decreased the hospitalization time and the cost of treatment significantly.

CLINICOPATHOLOGICAL COMPARISON OF FIBROUS DYSPLASIA AND OSSIFYING FIBROMA Seta A Sarkis* & Sami Kh Jabba# *Department of Oral Pathology, College of Dentistry, Baghdad University. #Department of Oral Pathology, College of Dentistry, Maysan University, Maysan, IRAQ. Abstract Fibrous dysplasia and Ossifying fibroma of jawbones share the conduct of similar clinicopathological characteristics and this can be a challenge for the histopathologists. The purpose of this study was to evaluate the differences in clinicohistopathological features in fibrous dysplasia cells compared with ossifying fibroma of jaws bones. The study included 30 formalin-fixed, paraffin embedded tissue blocks; of which fifteen for patients with fibrous dysplasia and fifteen sample of ossifying fibroma of jaws. The histopathological examination was conducted on 4µm thick of H & E tissue sections. Results: showed where most cases were females; 11 cases (73.3%) for fibrous dysplasia, as well as ossifying fibroma. Most of FD cases presented in the maxilla (66.76%) while for OF most ofthe cases presented in the mandible (73.33%). FD cases were more predominant in molar area (60%) whereas OF cases were more predominant in premolar & molar area(33.33%). Regarding the histopathological components, in all cases of FD (100%) the presence of bone trabecule with large osteocytes within the lacunae was found, while OF featured more irregular osteoid or cementoid masses( 80%) compared to ( 33.3%) osteoid observed in FD. Remarkable, (80%) of the OF cases had osteoblastic rimming , while it is presented in only two cases ( 13.3%) of total FD sample. However further studies are required to investigated other features for differentiation. Although several clinicopathological features can separate FD from OF, it is still difficult to arrive at a definitive diagnosis by using a single diagnostic modality.

CORRELATION BETWEEN CONTRAST ENHANCED ABDOMINAL COMPUTERIZED TOMOGRAPHY SCAN AND HISTOPATHOLOGY IN EVALUATION OF RENAL MASSES Mustafa Saleh Mutar Al-Sukainy*, Rana Tahseen Mehsen@, Muthanna Habeeb Abid Al-Athari$ & Inaam Abduljabbar Mussa# *MB,ChB, FIBMS(Radiodiagnosis), Radiologist Specialist, Al-Sadar Teaching Hospital, Basrah Health Directorate. @MB,ChB, FIBMS(Radiodiagnosis), Jabir Ibn hayan College of Medicine. $MB,ChB, FIBMS(Urology), College of Medicine, Kufa University. #MB,ChB, DMRD, Karbala Health Directorate. Abstract Renal tumors are divided into benign and malignant. The most common malignant renal tumor is renal cell carcinoma (RCC) with a rising incidence of about 3% per year since 1975, RCC accounts for nearly 3% of all solid tumors in the body and 65% of all renal tumors. According to contrast enhancing computerized tomography (CECT), The enhancing masses are classified as solid or complex cystic, 85% percent of solid masses are malignant. Contrast medium rapidly redistributes from the vascular to the interstitial spaces of the organs, the more vascular the organ or pathologic mass the more enhanced one. Therefore, a solid, enhancing mass must be considered malignant until proved otherwise. The aim of this study is to evaluate the role of contrast enhanced CT scan in the assessment of renal masses and its correlation with the histopathological type. Over a period of eight months (from February 2013 to September 2013) 45 patients presented with renal masses (diagnosed by ultrasound) submitted to abdominal CECT scan, then the renal masses radiologicaly evaluated in the form of site, size, degree and pattern of enhancement, then the radiological findings were correlated with the postoperative specimen histopathological results. Different histopathological types of renal tumors have different degree and patterns of enhancement. Regarding the degree of enhancement: The enhancement in Hounsfield units in order of frequency are as follows: Conventional renal cell carcinoma (Clear cell carcinoma) (27HU). Chromophobe renal cell carcinoma (19 HU). Onchocytoma (18.5 HU). Wilms (16.66HU). Transitional cell carcinoma (9.75 HU). Angiomyolipoma (5.33 HU). According to the homogeneity of enhancement: There is difference between type of tumors and homogeneity of enhancement, as follows: Conventional renal cell carcinoma (clear cell carcinoma) have heterogeneous in 75% and homogenous in 25% of tumors. Chromophobe renal cell carcinoma, 50% have homogenous, while other 50% have heterogeneous pattern. Oncocytomas and Transitional cell carcinoma have 100% homogenous enhancement. Wilms tumors have 100% heterogeneous patterns. Angiomyolipomas have homogenous pattern in 66.7 % while heterogeneous enhancement seen in 33.3 %. In conclusion, contrast enhanced CT Scan is highly valuable in differentiating types of renal masses in correlation with histopathological results.

ULTRASONIC DISSECTION VERSUS CONVENTIONAL LIGATION COAGULATION IN THYROIDECTOMY Abdulameer Muhsin Aldaraji MB, ChB, FICMS, General Surgeon, Al-Faiha General Hospital, Basrah, IRAQ. Abstract Ligation and diathermy coagulation was the standard method of hemostasis in thyroid surgery for more than a century. New hemostatic techniques were developed in the 1990th. Ultrasonic dissector used for the first time in thyroidectomy in 1999 by Tokami. Many studies compared the conventional method of thyroidectomy with new ultrasonic dissector technique. These studies found many advantages of the new method including reduction of operative time, shorter incision, decrease blood loss, decrease post operative drainage, shorten hospital stay and decrease complications. This study compared the two methods of hemostasis regarding incision length, operative time and complications. Between March 2012 and March 2015, 143 patients underwent open thyroidectomy involved in a prospective study at Al-Faiha General Hospital. The patients were divided into 2 groups: Group 1, conventional thyroidectomy technique(clamp, tie and diathermy coagulation) included 104 patients. Group 2, ultrasonic dissection technique (sutureless thyroidectomy) included 39 patients. The patient characteristic and postoperative complications were reported. The incision length and the operative time was measured. All patients underwent surgery by the routine pre tracheal strap muscle cutting transeversly (not splitting). In group 2, the ultrasonic dissector was used in strap muscle cutting, sealing §ion of the blood vessels and in the final resection of the gland. The surgical incision length and operative time were compared in both groups. In lobectomy, there was no significant reduction in the length of incision with use of ultrasonic dissector( z value0.05), while in subtotal, total or near total thyroidectomy there was significant reduction in the length of incision (p value

SHORT TERM OUTCOME OF DOPPLER GUIDED HEMORRHOIDAL ARTERY LIGATION AND RECTO-ANAL REPAIR IN COMPARISON WITH CONVENTIONAL OPEN HEMORRHOIDECTOMY AS A TREATMENT METHOD FOR PROLAPSED HEMORRHOIDS. Sadq Ghaleb Kadem MB, ChB, FICMS, General Surgeon, Al-Shiffa General Hospital, Basrah, IRAQ. Abstract Conventional hemorrhoidectomy is the most common surgical procedure used to treat hemorrhoids, but it is associated with significant side effects and complications. Doppler-guided hemorrhoidal artery ligation and recto-anal repair is a new minimally invasive treatment option to avoid the complications of conventional hemorrhoidectomy. This study aimed to evaluate the short term outcome of doppler-guided hemorrhoidal artery ligation and recto-anal repair in comparison with conventional open hemorrhoidectomy as a method for treating patients with prolapsed hemorrhoids. This study was conducted at Al-Shiffa General Hospital in Basrah, Iraq, during the period from January 2015 to December 2016. One hundred patients with symptomatic hemorrhoids who are candidates for surgery were included in the study and were divided into two equal groups; the first group operated upon with conventional open hemorrhoidectomy and the second group operated upon with doppler guided hemorrhoidal artery ligation and recto anal repair technique which utilizes a special doppler ultrasound proctoscope to identify and ligate the hemorrhoidal arteries and to gather up and lift back into position. Both groups were similar in patients characteristics, all operations have been done under general or spinal anesthesia and in lithotomy position by the same surgeon. During intra and postoperative periods of follow-up, the outcome and the complications of both procedures were analyzed statistically and compared. Doppler guided hemorrhoidal artery ligation and recto-anal repair technique significantly reduce postoperative pain and according to the Visual Analogue Scale; the majority of patients (64%) in doppler guided hemorrhoidal artery ligation and recto anal repair group have no pain at the night of the surgery while 82% of patients in conventional open hemorrhoidectomy group complained of moderate pain. It also significantly reduce the mean duration to return to normal daily activity to 5.44±2.02 days in comparison to 15.40±4.18 days for conventional open hemorrhoidectomy (p

MANAGEMENT OF CRISES DURING ANESTHESIA AND SURGERY. PART XII: EMBOLISM Salam N Asfar@ & Jasim M Salman# @MB, ChB, MSc, Professor of Anesthesiology, College of Medicine, University of Basrah. #MB,ChB, DA, FICMS, Lecturer & Consultant Anesthesiologist, College of Medicine, University of Basrah, IRAQ. EMBOLISM E mbolism can occur unexpectedly and unpredictably during anesthesia, causing a diagnostic and management dilemma for the anesthesiologist. Types of embolus: Embolism may result from: intravascular gas such as; air, carbon dioxide, oxygen or nitrogen. It can also occur due to thrombus, amniotic fluid, fat, bone marrow, aggregated blood components, and a multiplicity of foreign bodies such as cannula fragments.

GASTRO-JEJUNAL FISTULA DUE TO MAGNET FOREIGN BODY, A CASE REPORT Issam Merdan MB,ChB, FICMS, CABS, Professor of Surgery, Dept. of Surgery, Basrah Collage of Medicine. Consultant Surgeon, Al-Sader Teaching Hospital, Basrah, IRAQ.

VOLAR PERILUNATE CARPAL FRACTURE DISLOCATION: A CASE REPORT OF UNCOMMON INJURY PATTERN Mohammed A Akrawi* & Avadis A Muradian@ *MB,ChB, FDSOT, Senior Consultant Orthopaedic Surgeon, Newroz Orthopaedic Hospital. @MB,ChB, FICMS, Assist. Prof., Consultant Orthopaedic Surgeon, Erbil, IRAQ. Abstract Carpal fracture dislocations are relatively uncommon category of wrist injuries that often easily unrecognized and can be difficult to treat. We report a case of missed volar perilunar fracture dislocation in a 16 year old boy, and was treated operatively 40 days after injury by open reduction with the repair of ligaments. The outcome was satisfactory despite of the delay in diagnoses and surgery.