Basrah Journal of Surgery

L uckily, there is increasing interest in patient satisfaction in the present days. Many writers started differentiating between the two issues; treatment or satisfaction. Patient satisfaction is a top priority and it should be the target. Perfect treatment is not always satisfactory to the patient. Some surgeons, sadly, spoil their ideal treatment by misconduct. They are good enough to offer treatment, but not good enough in performing the art of communication, which is really vital. They do not know how to respect the dignity, the honor and rights of the patient. The first meeting is the key for success in achieving life-long friendship or, on the other hand “putting salt on the wound”

Thamer A Hamdan*, Mubder A Mohammed Saeed# & Saad J Abdulsalam@ *FRCS, FRCP, FACS, FICS, Professor Of Orthopedic Surgery, Chancellor of Basrah University. #FICMS, Assistant Professor Of Orthopaedic Surgery, Basrah General Hospital, @FACMS, Orthopedic Surgeon, Al-Karkh General Hospital, Baghdad. Abstract Osteoporosis is the most common metabolic bone disease. It is a major global health problem that increases dramatically as people getting older than before because of good health services. The aim of the study is to assess how far osteoporosis is associated with orthopedic diseases and to increase the awareness in the mind of orthopedic surgeons for osteoporosis in patients who are not suspected apparently to have this disease. A sample of 522 patients referred to Dual-energy X-ray absorptiometry (DXA) clinic by orthopedic surgeons or rheumatologists was taken during a seven months period, in two centers, Basrah, 259 patients and Mosul, 263 patients. All the patients had back pain, joint pain, bone pain, fracture or other musculoskeletal complains. The only method used to assess osteoporosis in our patients was the DXA scan. Of the total 522 patients, the results of DXA scan was normal in 136 patients (26%), osteopenia in 178 patients (34%), and osteoporosis in 208 patients (40%). Back pain was the main cause of referral 184 (35%), followed by joint pain 138 (26.5%), bone pain 74 (14%), fracture 28 (5.5%), and others 98 (19%). In conclusion, osteoporosis may be a silent disease, even in patients with complains like joint pain, bone pain, or radicular symptoms.

RHINO-ORBITO-CEREBRAL MUCORMYCOSIS IN BASRAH - IRAQ Ahmed M Al-Abbasi@, Ali Abdil-Wahab#, Abdil Razak Al-Jezani$, Haider Sabri Hashim* & Duraid Ahmed Al-Temimi&. @FICMS, FRCS, Professor of Otolaryngology, Basrah College of Medicine. #CABS, Otolaryngologist, Basrah General Hospital. $FICMS, Neurosurgeon, AlSadir Teaching Hospital. *FICMS, Otolaryngologist, Basrah General Hospital. &CABS, Otolaryngologist, Al Sadir Teaching Hospital, Basrah, IRAQ. Abstract This study was designed to through some light on mucormycosis infection, its stages, risk factors, presenting clinical features and to suggest early diagnostic techniques. A prospective explanatory study was carried out in the period between March 2011 to March 2016 for patients proved to be affected by this disease in Basrah General Hospital and different departments from all teaching hospitals in Basrah. The total studied patients were 32 with male to females ratio 2.2:1. The mostly affected age group was those between 51-60 years (16 patients, 50%). Seventeen patients (53.1%) belonged to stage I, nine (28.1%) to stage II, the remaining 6 patients(18.7%) to stage III. Majority of affected patients were immuno-compromised 27(84.3%). Diabetes mellitus was the main single risk factor (12 patients, 44.4%). The commonest recorded symptom was facial pain and numbness in 27 patients (84.3%), and the most common sign was nasal crustations and eschar in 28 patients(87.5) . This study concluded that surgeons should have an index of suspicion to be aware about this condition among the community, this can help in taking early preventive measures

A COMPARATIVE STUDY BETWEEN HARMONIC SCALPEL HEMOSTASIS AND CONVENTIONAL HEMOSTASIS IN TOTAL AND SUBTOTAL THYROIDECTOMY Mohammed Salim Mohammed*, Jasim D Saud#, Mansour Amin Mohammed$ & Mazin H Al-Hawaz@ *MB,ChB, Board Candidate. #MB,ChB, FICMS, CABS, Consultant Surgeon, Basrah General Hospital. $MB,ChB, DS, CABS, MRCS, Lecturer, Dept. of Surgery, College of Medicine. @ MB,ChB, CABS, DGS, FRCS, Prof. of General Surgery, Basrah Medical College., Basrah, IRAQ. Abstract Thyroid gland is highly vascularized organ, so good hemostasis during total or sub-total thyroidectomy is crucial to decrease the complications and to improve the outcome. This study aimed to evaluate the advantages and disadvantages of using harmonic scalpel device in comparison with conventional hemostasis for total and subtotal thyroidectomy in terms of operative time, nerves injury, post-operative blood loss, hematoma development, hypocalcemia and length of hospital stay. This study included 80 patients who underwent total or subtotal thyroidectomy. They were divided into two groups according to the type of hemostasis: conventional hemostasis group and harmonic hemostasis group. Different diseases were included (multinodular goiter, toxic goiter and malignant diseases). The results showed that time of operation was significantly shorter in the harmonic hemostasis group (79.52±14.98 min) than conventional hemostasis group (100.92 ±10.64 min) with p value 0.0001, also post-operative blood loss was lower in harmonic hemostasis group (52.5±26.23 ml) than conventional hemostasis group (75.13±17.8 ml) with p value 0.0001. Other outcome such as recurrent laryngeal nerve injury, post-operative hematoma, post-operative hypocalcemia and length of hospital stay did not show significant difference between the groups. In conclusion, using harmonic scalpel device in total or subtotal thyroidectomy reduced the operative time and post-operative blood loss, without any change in the incidence of nerve injury, hematoma, hypocalcemia and the length of hospital stay.

COMPARATIVE STUDY BETWEEN STAPLER AND HAND SEWING IN GASTROINTESTINAL ANASTOMOSIS Mustafa Adnan Maatooq* & Issam Merdan@ *MB,ChB, Board candidate, Al-Sadir Teaching Hospital, Basrah. @MB,ChB, FICMS, CABS, Professor of Surgery, Department of Surgery, College of Medicine, University of Basrah, IRAQ. Abstract Gastrointestinal anastomosis is an important part of gastrointestinal operations and can be achieved by hand sewn anastomosis or by the newly developed staplers. The study aims to compare between the two surgical methods of anastomosis in a prospective , randomized design, regarding: operation time, post operative hospital stay and the incidence of post operative anastomotic leak in both groups. The study was carried out in Department of Surgery at Alsader Teaching Hospital in Basrah, Iraq from October 2015 to December 2016, it included 40 patients of both gender and with a different age, they divided into 2 groups (hand sewn and stapler groups), each group included 20 patients, comparing the following parameters: time of anastomosis, duration of surgery, post operative leak and hospital stay. There were no significant differences in the age, gender distribution, the indication for resection, post operative anastomotic leak (p=1) and hospital stay (P Value 0.15 ) in both group but there was significant differences in duration of anastomosis (P Value0 .00001) and operation time (P Value 0.00001). Our study concluded the superiority of stapler on hand sewing in gastrointestinal anastomosis in term of reducing operative time.

MICRO-ENDOSCOPIC DISCECTOMY, A MODERN APPROACH FOR LUMBAR DISC PATHOLOGY Mohamed El Husseini* & Taghrid Chaaban@ *MD, PhD, Neurosurgeon, Hôpital Libano Français, Zahle, Lebanon. @MS Nursing, IUL, Beirut, Lebanon. Abstract In the last decade, the neuro-endoscope has been used increasingly in the surgical management of spinal diseases, both intradural and extradural. Endoscopic discectomy is increasingly performed in lumbar region. This study included 200 patients with lumbar disc pathology operated upon with both techniques: Classic and Endospine Karl Storz system technique introduced by Destandau. Based on results (Macnab modified criteria), microendoscopic discectomy should be used in properly selected patients. Key words: endoscopic, lumbar disc hernia, Endospine, Destandau technique

THE VALUE OF ENDOSCOPIC BIOPSIES FROM FIRST AND SECOND PARTS OF DUODENUM IN THE DIAGNOSIS OF CELIAC DISEASE IN CORRELATION WITH A SEROLOGICAL TEST Zahraa A Hashim*, Sura A AL-Namil@, Wassan M Jazi# & Sarkis K Strak$ *MB,ChB, Postgraduate board student. @MB,ChB, FIBMS, Consultant pathologist. #MB,ChB, FIBMS, Consultant pathologist, Al-Sadir Teaching Hospital. $MRCP, FRCPLond., FRCPI., Professor of Medicine, University of Basrah, IRAQ. Abstract Celiac disease is a chronic immune-mediated enteropathy of the small intestine caused by environmental exposure to gluten in genetically susceptible individuals. This study was conducted to evaluate and correlate the serological with histopathological findings of duodenal biopsies for the diagnosis of celiac disease. Sixty-eight patients, 40 (59%) females whose ages ranged from 13-75 year (mean age 36.4 years), and 28 (41%) males whose ages ranged from 13-65 year (mean age 37.8 years), with symptoms of chronic diarrhea, weight loss, bloating and unexplained iron deficiency anemia, were tested for anti-tissue transglutaminase IgA tTG, and correlated with histopathological findings of duodenal biopsies obtained from 1st and 2nd parts according to modified Marsh's classification. Histopathological findings from the 1st and 2nd duodenal parts were also compared with each other. The results of the 68 patients who were enrolled in the study showed that: 24(35.3%) patients tested positive for anti-tissue transglutaminase (titer >18U/ml), 37(55.8%) patients had positive histopathological changes (stage I–III). Twenty-three (33.8%) patients who had both positive anti tTG and histopathological changes were classified as a celiac disease. The sensitivity of 1st and 2nd parts of duodenal biopsies in detecting celiac disease were 83.7% and 100% respectively. In conclusion; the histopathological changes from the 1st and 2nd parts of duodenum in detecting celiac disease were equally representative especially in stage IIIa, b, and c.

Isam M Al-Shareda* & Ghanem Sikhi Ghanem# *MBChB, FICMS, Assist. Prof. of Otolaryngology, Dept. of Surgery, College of Medicine, Basrah University. #MB,ChB, CABS, Basrah General Hospital, Basrah, IRAQ. Abstract Nasal packing is carried out in many nasal surgeries specially in septoplasty for hemostasis and internal stabilization of the cartilaginous & bony skeleton of the nose. However, these packing methods are not a harmless procedures and for this reason their benefit has been tested. The study was performed to compare the use of plastic intranasal splints with or without anterior nasal packing to determine the need of nasal packing after septoplasty. This is a prospective comparative study which was carried out in Basrah General Hospital, Otolaryngology Department, Basrah, Iraq in the period from July 2014 to April 2015. Forty seven patients of different age and gender groups were included in the study. Analysis was done regarding their history and examination including nasendoscopy which was done before septoplasty. The patients were randomly selected at the end of the procedure into two groups; one had plastic intranasal splints without anterior packing and the other had plastic intranasal splints with two different types of packing materials (ribbon gauze impregnated with Vaseline and glove fingers). Patients were compared for postoperative pain, headache, discomfort, bleeding, sleep difficulty, epiphora, septal hematoma on the day of the operation, 24 hours and 48 hours postoperatively. The collected data was analyzed by using SPSS v.17. The age of patients in this study ranged from 18 to 44 years with mean age of (29.6±6.2) years and most of them were between 28 to 37 years (48.9%). Among those 47 patients, 28 (59.6%) were males and 19 (40.4%) were females with male:female ratio was 1.47:1. Pain, headache, discomfort and bleeding was higher in patients in group two with anterior nasal packing materials especially during removal of the packing. there was significant reduction in the frequency of sleep disturbance, epiphora among the patients in group one without nasal packing, however there was no significant difference in septal hematoma between two groups. In conclusion, the plastic intranasal splints can be used alone without the need of anterior nasal packing materials after septoplasty as it can be considered as a type of packing methods that offers the advantages of elimination of pain and discomfort and reduce the complications of packing. The anterior nasal packing should be reserved only for selected cases.

EFFICACY OF DIFFERENT THERAPEUTIC MODALITIES FOR PRIMARY MONOSYMPTOMATIC PEDIATRIC NOCTURNAL ENURESIS Murtadha M Almusafer@ & Aymen Adel* @FICMS, Professor of Urology, University of Basrah, College of Medicine, Department of Surgery. *FICMS, Urology Specialist, Basrah General Hospital, Basrah, IRAQ. Abstract Primary monosymptomatic nocturnal enuresis (PMNE) is still a common bothersome complaint that makes the children and their families looking for help. Primary MNE is defined as abnormal urination that occurs involuntarily during sleep. Its incidence varies with age, with 15%-20% at 5 year old and fades with increasing age to reach 1-2% at 15 year old. Owing to its complicated pathophysiology and sharing of different body systems, multiple lines of treatment were attempted. This study aimed is to explore the efficacy of different treatment modalities for PMNE in the study patients. Ninety two patients were enrolled in this prospective randomized trial and divided into 4 groups; group A instructed to use the behavioral measures, group B given intranasal Desmopressin, group C given Oxybutynin and group D given combination of the 3 treatments. Fourteen participants were excluded because they were lost during followup and the remaining 78 patients' data were analyzed. Patients were reassessed at 4th and 12th weeks. Wet nights/week significantly reduced in all treatment groups as compared to baseline. Percentage reduction of wet nights/week for behavioral group was 38.9%, Desmopressin was 83%, Oxybutynin was 78% and for Combination was 87.8% at 12th week. According to the ICCS definitions of success there is no full response in behavioral group with partial response of 42.1%, for Desmopressin group the full response was 57.1% and partial response 28.6%, for Oxybutynin group was 50%, and 33%, for combination group 60%, 30% at 12th week of treatment. In conclusion, although behavioral therapy reduces wet nights but not reaching to a full improvement and its use is preferably combined with other treatment modalities. Desmopressin, Oxybutynin, and Combination treatment significantly decreases wet nights with high full response rate.

LAPAROSCOPIC VERSUS OPEN REPAIR OF PERFORATED PEPTIC ULCER Abutalib B Alluaibi@, Ali Y Al-Wajeeh$ & Mansour Amin Mohammed* @MB,ChB, FIBMS, General Surgeon, Al-Mawanee General Hospital, Basrah. $MB,ChB, CABS, General Surgeon, Al-Mawanee General Hospital, Basrah. *MB,ChB, DS, CABS, MRCS, Lecturer, Dept. of Surgery, College of Medicine, Basrah, IRAQ. Abstract Peptic ulcer is the most common GIT disorder with a prevalence of 2%, peaking around the age of 70 years. Laparoscopic repair of perforated peptic ulcer began to evolve and replace the ordinary upper laparotomy. We studied 47 patients suffering from perforated duodenal or gastric ulcer in Al-Mawanee General Hospital in Basrah in the period 2014-2017, the patients were categorized into 2 groups: 1st group(24 patients) managed laparoscopically and the 2nd group (23 patients) managed by open approach. Perforation found to occur more with duodenal ulcer (29 pt. 61.70%) and more in male patients (26 pt. 55.33%). The peak perforation seen in age group >60 years and the commonest risk factors was the NSAIDs usage. Operative time was insignificantly longer in laparoscopic approach. However, the laparoscopic approach has less post operative pain and less overall complications (4 pt. 16.6% vs. 8 pt. 34.7%). In conclusion, laparoscopic repair of perforated peptic ulcer is a feasible operation and considered promising with less postoperative pain, less postoperative complications and better cosmetic results.

DUODENAL OBSTRUCTION IN CHILDREN: AN EIGHT YEAR EXPERIENCE IN BASRAH Abbas Abdulzahra Alhasani MB, ChB, FIBMS, MRCS Glasgow, Pediatric Surgeon, Lecturer, Department of Surgery, College of Medicine, University of Basrah, IRAQ. Abstract Duodenum is a common site for congenital anomalies that might result in partial or complete obstruction. Intestinal rotational anomalies that involve the midgut put the duodenum at a potential risk of obstruction. This is a retrospective hospital record based study displaying an 8 year single center experience in the Basrah center of pediatric surgery. The study enrolled 60 children with congenital duodenal obstruction with a mean age of 2.8 months and a male to female ratio of 1.14:1. Thirty two patients (53.3%) were diagnosed as duodenal atresia and stenosis, while intestinal malrotation was reported in 28 patients (46.7%). Repeated vomiting was the most common presenting symptom, it was bile stained in 60%. Associated congenital anomalies were seen in 23.3% of the study population, Down's syndrome and congenital heart defects were the most commonly reported abnormalities. Intraoperatively, fenestrated duodenal web was the commonest finding (59.4%) in duodenal atresia/stenosis, which was corrected by a diamond anastomosis in 1.9% of cases and by duodenotomy with web excision in 28.1%. Malrotation was corrected by Ladd's operation in 92.9%. Postoperative complications were reported in one third of the studied population, and the type of surgical procedure used in duodenal atresia/stenosis did not have a significant impact neither on postoperative complications nor on the hospital stay.

EXCISION WITH MIDLINE CLOSURE VERSUS MODIFIED BASCOM PROCEDURE IN TREATMENT OF SACROCOCYGEAL PILONIDAL SINUS Ahmed Falih Noori*, Nasseif Jassim Mohammed# & Zeki A AL-Faddag@ *MB, ChB, #CABMS, FICS, Dept.of Surgery, Al-Sadir Teaching Hospital. @CABS, FRCS, Professor of General Surgery, Dept. of Surgery, Basrah College of Medicine, University of Basrah, IRAQ. Abstract Pilonidal sinus is a frequently encountered condition in young adults. It is commonly found in the mid-line skin that covers sacrum and coccyx. Sinus can be found elsewhere, sometimes between the fingers in hair dressers, and in the umbilicus. It is characterized by chronic inflammation in one or more sinuses in the mid-line of the natal cleft that contain hairs and debris. Pilonidal disease is a significant social and economic problem affecting predominantly young males in the second decade of life. This study aimed to compare the results of excision and midline closure with those of lateral approach (Modified Bascom's procedure) in the treatment of sacro-coccygeal pilonidal sinus in regard to the duration of the procedure and wound complication. This prospective randomized study was performed on 53 patients operated upon for a pilonidal sinus between June 2014 and December 2015 in Al-Sadir Teaching Hospital in Basrah. Patients were divided into two groups randomly. Group A (25) patients underwent modified Bascom procedure and group B (19) patients underwent excision and midline closure. The modified Bascom technique showed a significantly short wound healing time (30±10 days) compared to primary closure (55±25 days), p

MANAGEMENT OF CRISES DURING ANESTHESIA AND SURGERY. PART XIII: REGIONAL ANESTHESIA 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, IRAQ. Regional anesthesia is broadly utilized and has been considered to pose few risks once the block is set up. However, dangerous issues can happen both during the establishment and maintenance periods of a regional block which require prompt recognition and management. The risks includes; local anesthetic toxicity1,2, misdirected or misplaced needles and cannulae, and a variety of other problems both amid and after blockade can lead to morbidity or mortality3–5. Some of these may be obscure and not related to the regional anesthetic method itself.

SOLITARY RECTAL ULCER MIMIC RECTAL CANCER Ibrahim Falih Noori MB,ChB, CABS, FICS, DS, Assist. Prof., Department of Surgery, College of Medicine, Basrah University Abstract Solitary rectal ulcer (SRU) is rare benign disease of poorly understood etiology. The term solitary ulcer is misnomer because the lesion is solitary in only 20% of patients and ulcer present in 40% of the patients only. The lesion has various sizes and shapes that ranges from mucosal erythema to single or multiple ulcers to ulcer-nodular lesion or could be a polypoid or fungating mass. The estimated incidence of solitary rectal ulcer is about 1:100000 annually. Males and females are affected equally with slight predominance toward female patients. The disease can affect children and elderly patients also, although rare. The disease involves straining during defecation, a sense of incomplete evacuation, digital evacuation of the rectum, rectal prolapse and occasionally passing of blood and mucus by rectum. Clinical awareness confirmed by flexible sigmoidoscopy and biopsy are main diagnostic tools. Furthermore, the colonoscopic findings may mimic that of rectal cancer and inflammatory bowel disease and the histopathological results are inadequate due to fibrotic rectal mucosa. Treatment of solitary rectal ulcer depends on the severity of the condition with conservative measures, bowel regimen, and change of life style for mild cases and surgical procedure for sever refractory cases.

Temporal bone can be affected by different conditions. In our area, the most common disease
conditions of the temporal bone are fibrous dysplasia, histiocytosis X and squamous cell
carcinoma.
This is a report of three females who have temporal bone disease conditions. They have poor
clinical symptomatology. Since the incidence of malignancy is rare so differentiation between
chronic inflammation and tumors is difficult and a biopsy is a must.
Computed tomography (CT) was the diagnostic aid of choice which also was very helpful for
follow-up to assess the disease progression, while Magnetic resonance imaging (MRI) was
useful to identify intracranial extension. Treatment of these conditions included surgery,
radiotherapy and chemotherapy.

Dr. Auda Hasan Al-Jabiri 1968-2017 Dr. Khalaf Lefta Hajim 1973-2017