Basrah Journal of Surgery

\"Foolish who learns from his mistakes, he should learn from the mistakes of others\" Bismarck

Post-extraction alveolar ridge resorption is unavoidable phenomenon ending with insufficient
ridge width. Bone grafting, osteotome ridge expansion and ridge splitting were used to expand
narrow ridges but they are either expensive, associated with higher morbidity or require longer
treatment time. Therefore the use of screw expansion was introduced as an option for
managing deficient ridge width enhancing ridge density, facilitating immediate implant
placement and is not associated with potential complication. The aims were to evaluate of the
efficacy of bone screw expanders in widening narrow ridges, measuring bone gain and
assessing possible complications.
This clinical prospective study was performed between October 2015 & October 2016. Twenty
four patients with 45 potential sites were involved. Preoperative clinical examination and
radiographic assessment with OPG were performed for all cases. ITL bone expander kit was
used after initial osteotomy to expand the narrow ridges. Osstell ISQ was utilized to measure
the primary implant stability. After 16 weeks, patients were recalled again for the second stage
surgery and Osstell was used again to measure the secondary stability. Patients then were
referred to the prosthetic department for completion of final prosthesis after sufficient time for
healing abutments in place.
Twenty four patients were participated with 45 implants inserted. Female to male ratio was
2.4:1 with a mean age of 43.12 year ranging between 18–65 years. The original mean bone
width (Mean±SD) prior to expansion was 3.3±0.56 mm & after expansion associated with dental
implant insertion was 5.09±1.05 mm and there was statistical significance in possible mean
bone gain by 1.79 mm from baseline. The overall survival rate was 91.1% with the anterior parts
of both jaws having the highest percentages. Intraoperative complications involved cracks which
were observed in 15 sites (39.5%) and cortical malfractures which were seen in 7 sites (15.6%).
In conclusion, screw expansion is an easy solution for expanding narrow ridges with least
possible complications and allow for simultaneous implant placement.

Abstract The link between gallstones formation and diabetes mellitus remains controversial. The study aims to find the prevalence of gallstones in diabetic patients and its relation with status of control, and duration of diabetes mellitus. A case-control study was conducted in Al-Basrah General Hospital; Basrah city, southern Iraq from January 2015 to September 2015. The study enrolled 100 type 2 diabetic patients with no abdominal pain (60% females, 40% males) as a test group and 100 asymptomatic subjects with no diabetes mellitus (60% females, 40% males) as a control group. Both groups were comparable for gender, age, and body mass index and examined by ultrasound to find gallstones. Blood samples were taken for fasting blood glucose and body mass index was measured. Age, gender, family history of gallstones, and parity for females were recorded in both groups. The tested group was further divided into two subgroups with and without gallstones. The association between duration of diabetes mellitus and hemoglobin A1c level with gallstones was assessed. Gallstones were detected in (28%) of diabetic group and (12%) of controls, which was highly statistically significant (p value=0.005). The prevalence of gallstones was found to be significantly higher among those with more than 10 years of diabetes and poor glycemic control compared with those with less than 5 years and good glycemic control. The study suggested that diabetic patients are at higher risk for gallstones in comparison to non-diabetic patients. Gallstones are found to be higher in those patients with long duration of diabetes mellitus and poor glycemic control.

Abstract It is previously reported that cancer prognosis is affected by mutations of P53 gene. However, the prognostic significance of P53 mutated gene detection in breast cancer is a subject demanding numerous investigations in a view of numerous facts such as presence of different tumor subtypes, P53 positivity in early breast cancer, different overall survival and disease free period as well as variability of tumor response to chemotherapeutic agents and presence of primary resistance of tumor among patients whether same or different grade and stage. Hence, it is of interest to detect this mutated gene in our area and evaluate its relation to other prognostic factors in terms of age, stage, histological grade and lymph node status. This study aimed to evaluate the relation of P53 mutated gene expression in female with breast cancer in respect to the other prognostic factors such as age, grade, stage and lymph node status. Fifty female patients diagnosed as a breast cancer, underwent clinical and pathological staging (I,IIA,IIB,IIIA,IIIB,IIIC, and IV), histopathological grading (I,II,III). All patients underwent same surgical operation which was modified radical mastectomy and axillary dissection. All specimens were sent to histopathological study and P53 mutated gene detection study by using immunohistochemistry (IHC). P53 mutated gene was detected by immunohistochemistry in 72% of patients with breast cancer. P53 positivity showed a statistically significant direct proportion to histological grade, stage and lymph node status. In addition, more P53 mutated gene expression was detected in younger patients (age group ≤49 years old) and this probably explaining more advance stage observed in this group in this study. All these data leads to a conclusion that the presence of mutated p53 gene is associated with worse prognosis. This study detected P53 mutated gene by IHC for the first time in our region and showed a statically significant association between status of P53 gene mutations and the other prognostic factors such as age, histological grade, stage and lymph node status and consequently to tumor aggressiveness and thereafter to prognosis.

Abstract This study was done to evaluate a newly introduced technology to my country to determine the safety of the procedure, to what extent can it reduce patient’s symptoms and what are the possible complications that are associated with it. In addition to balance the benefits of the procedure to the draw backs, risks and complications. The study enrolled forty-one patients with Benign prostatic hyperplasia, with high international prostate symptom score and low flow rate excluding other causes for that like stricture, stone or neurological causes. A high power 180 W diode 980 nm LASER was used to vaporize the prostate recording data regarding the procedure and all patients were checked one month later for symptom scoring, flow-rate and ultrasound examination. The mean size of the prostate gland 53.07 gm ±11.75 SD, the Mean operative time was 61.51 min. The mean I-PSS was 9.82±1.88 SD compared to the pre-operative mean of 20.24±2.62 SD which is statistically significant (t (41) =17.66, P≤0.001). The maximum flow-rate was 7.94 ml per second ± 2.41 SD before surgery and there was a significant rise of 14.15 ml per second ± 2.502 SD postoperatively (t (41) = -14.86, P≤0.001). The only significant complication patients had was voiding irritative symptoms. The results show clearly that 980 diode LASER is an effective procedure for the treatment of patients with benign prostatic hypertrophy, as well as being safe procedure that could be recommended as replacement for transurethral resection of the prostate with some reservations regarding the cost of the fiber.

Abstract This study deals with a new way for the treatment of cutaneous haemangiomas in children and adults by using a boiling hypertonic saline, the material used is safe and nontoxic even if absorbed. A total of 309 patients with 354 haemangiomas were studied. The sample consisted of 233 females and 76 males ranging in age from 2 months to 50 years. Patients were divided into three groups; Group I: observation, Group II: excision and reconstruction, Group III: injection & excision. Each patient in group III received 2-4 shots of boiling saline intra-lesional at an interval of 3-4 weeks, to allow time for the post injection swelling to subside and fibrous tissue to mature. The female to male ratio was 3.1:1. The lesion appears within the first weeks after birth in 189 children (61.3%). Among the 309 patients, 288 (81.4%) haemangiomas were located on the head and neck, 39 (11%) on the trunk, 25 (7%) on the extremities, and 2 (0.6) in the perineal area. The three groups are as follows: group I: observation; 161 patients (52%). group II: excision and reconstruction. 42 patients (13.7); group III: injection & excision, 106 patients (34.3%). The presenting symptoms at consultation were parents worry 200 patients (64%), obstruction of orifices 38 (12.3%), ulceration 32 (10.6 percent), bleeding 26 (8.2%), infection 10(3.2%), and pain 3 (0.8percent). The complications after treatment of the 106 patients were; bleeding 3 patients (2.3%), infection 7 (6.8%), skin necrosis 20 (19.3%); the remaining patients 76 (71.6%) tolerate the injection easily and show no effect. The evaluation of patients treated with boiling saline sclerotherapy is based on improvement of volume, color, and texture as follow, poor 10 (9.1%); good 54 (51.1%); and excellent 42 (39.8%). In conclusion, treatment of cutaneous Haemangioma is indicated when there is no sign of involution. Injection sclerotherapy with boiling saline proved to be safe, nontoxic, cheap and effective.

The creation of pneumoperitoneum is an essential step in laparoscopy, Veress needle, direct trocar entrance and modified open methods with their different modifications are the three widely used methods nowadays. Each method has its own advantages & disadvantages and each surgeon has his own preferred method of creating pneumoperitoneum based on his training and experience. The aim is to compare the safety and efficacy of modified open insertion technique (MOIT) with the direct trocar insertion (DTI) and Veress needle techniques (VN). From January 2013 to December 2015, two hundred ten patients with different indications for laparoscopic surgery were included in this study for evaluation of three different methods of creating pneumoperitoneum, one hundred forty of them were operated upon in Al-Sadir teaching hospital by same laparoscopic surgeon with closed technique, this group was equally divided in to two groups; Veress needle technique (VN group) and direct trocar insertion technique (DTI group) each group included 70 patients, the remaining seventy patients were operated upon in Al Shiffa general hospital by same laparoscopic surgeons with modified open trocar insertion technique (MOTI group). Of the 210 patients; 70 (33.33%) patients operated with Veress needle (VN) technique in patients, 70 (33.33%) patients operated with Direct trocar insertion (DTI) technique and 70 (33.33%) patients operated with Modified open trocar insertion (MOTI), the patient’s ages ranged from 17 to 76 years, 172 (82%) patients were females and 38 (18%) patients were males. The mean time required for entry in patients subjected to VN technique was 3.63±0.64 minutes in comparison to 1.79±2.39 minutes and 2.01±1.82 minutes for (DTI) and (MOTI) techniques respectively, this difference is statistically significant (p-value <0.001), the VN technique associated with high rate of minor complications 32 (45.71%) patients in comparison with 7 (10%) patients and 5 (7.14%) patients reported during DTI and MOTI respectively, this difference is statistically significant (p-value <0.001), there were no reported major complication in this study like visceral or vascular injury and gas embolism. In conclusion, both DTI and MOTI techniques are safe and effective procedures to create pneumoperitoneum during laparoscopic surgery, they are associated with few minor complications and no failer rate in comparison to VN technique.

Abstract The role of platelet-rich plasma in the pain relief and treatment of many orthopedic problems had gained lot of studies & practice. Yet, it hadn’t been practiced in our locality. Thus, the study of its role in the treatment of certain enthsiopathies (plantar faciitis, achillis tendinitis and lateral epicondylitis) had been planned for. A total of 63 cases of the three diseases were chosen for a case control study. They were divided into two groups: the case group who had been treated with local injection of autologous platelets rich plasma (prepared by the Trima accel cell separating machine) and the control group who were treated by local steroid injections. Pre and three post-treatment follow up of cases were done to assess the pain perception level using the simple visual analog scale (VAS). Results had shown a statistically significant reduction in pain among cases compared to control. These results were comparable to many studies elsewhere in the world. This had led us to conclude the advice to encourage this type of therapy on a large scale of patients in the future with more detailed further studies about.

Abstract The Snodgrass technique or the tubularized incised plate (TIP) repair is considered as excellent option for treatment of distal and mid-shaft hypospadias. Urethro-cutaneous fistula remains the most frustrating complication of hypospadias repair. After performing a tubularized incised plate (TIP) repair, the incidence of fistulae is reported to be up to 17% of cases. This study aimed to evaluate the use of dorsal dartos flap for the prevention of fistula formation after Snodgrass repair for distal hypospadias. The current study included 35 patients aged 2-6 years during the period between February 2013 to January 2016. All the patients had distal hypospadias and underwent Snodgrass or TIP repair. The neo-urethra was covered by dorsal preputial interpositional flap transposed ventrally via a button hole maneuver as a method to prevent fistula formation. Patients were followed up and their complications were assessed based on the patients’ medical records. The procedure was completed successfully in all patients, with no intraoperative complications. All patients had good functional results with straight penis and vertical slit shaped meatus at the tip of the glans. Thirty four (97.14%) patients had no evidence of fistula development. One patient only (2.8%) developed fistula. Meatal stenosis occurred in 3 patients (8.5%). In conclusion, the neo-urethral covering with well-vascularized dartos flap, harvested dorsally and button holed at its base for ventral transposition, represents a good choice for fistula prevention after Snodgrass repair.

Abstract Fractures of distal radius including colles’ fracture are common and account for one sixth of all fractures in adult. Achievement of good realignment of the fracture is essential from a functional and cosmetic point of view. The modalities for treatment of this treatment are varied and much confusion is present as regards appropriate treatment of various fracture types. This study aimed to compare functional and radiological outcome of percutaneous pinning procedure with traditional cast immobilization in patient with displaced colles’ fracture. This is prospective study was carried out from October 2013 to October 2014. Forty cases of displaced colles’ fracture were studied. Their age was 20 to 70 years, they were divided into two groups 20 cases were treated by closed reduction with percutaneous k-wire fixation and other 20 cases were treated by closed reduction with conventional POP casting. The results were evaluated and compared both clinically and radiologically. Patients treated with percutaneous K-wiring had statistically significant improvement both functionally (p value=0.032) and radiologically (p value=0.019) compared with conventional casting group. In group of closed reduction and K- wire fixation, functional evaluation was done according to Gartland and Werley scoring system showed excellent results in 4 patients (20%), good result in 10 (50%), fair results in 5 (25%) patients and poor result only in 1 patient (5%). The anatomical evaluation using Sarmiento’s Criteria showed excellent results in 3 patients (15%), good results in 10 (50%), and fair results in 7 (35%) patients and there was no patient with poor result (0%). While in group of closed reduction and casting, functional evaluation showed excellent results in 1 patient (5%), good results in 4 (20%), fair results in 13(65%) patients and poor result in 2 patients (10%) and anatomical evaluation showed excellent results in 1 patient (5%), good results in 3 (15%), and fair results in 14 (70%) patients and poor results in 2 patients (10%). In conclusion, closed reduction with percutaneous k-wire fixation of displaced colles’ fracture is a minimally invasive technique which provides extra stability in the treatment of displaced colles’ fracture with good clinical and radiological outcome. Conservative treatment is to be considered in elderly patients and where resources of implants and radiological control are limited.

Abstract Traditional haemostatic technique in thyroidectomy may cause some damages to surrounding tissues and it is time consuming. It is believed that these damages and the time can be reduced using ultrasonic dissector devices like Harmonic Scalpel. In this study, we investigate the benefits of harmonic Scalpel haemostasis (HS) versus conventional haemostatic techniques (CT) in total thyroidectomy. Analysis of patient’s data was done for cases with total thyroidectomies performed between 2011and 2015 by the same surgeons using either the conventional technique (Clamp and Tie technique) or the harmonic scalpel for haemostasis. Gender, age, preoperative clinical information, histopathology results,and procedure type were analyzed. and according to the type of haemostatic techniques the collected patient’s data was divided in to two groups; conventional group (CT group) in which the haemostasis was done with Clamp and Tie technique and harmonic scalpel group (HS group) in which the haemostasis was done with Harmonic Scalpel (Sonicbeat Olympus). The outcome and the complications of the both procedures were analyzed statistically and compared. The use of harmonic scalpel in total thyroidectomy significantly decreases mean operative time by (-37.635 min) 60.49±7.78 SD for HS group vs 98.13±14.165 SD for CT group with very significant P-value (0.0000). Statistical significant difference in the mean volume of postoperative drainage in (ml) through redivac drain observed between the two groups; 63.02±19.91SD for HS group and 72.50±22.79 SD for CT group with significant P-value (0.0000). There were no significant difference in the other parameters of the outcome and complications after total thyroidectomy in both groups. It is concluded from this study that main impact of harmonic scalpel in total thyroidectomy is the significant reduction in operative time and its use is safe and not associated with increase in the rate of the complications.

Abstract Intussusception is the commonest cause of bowel obstruction in children and is the second most common cause of acute abdominal emergency in this age group, mostly it is idiopathic (primary) and of ileocolic type. Typically, colicky abdominal pain, "currant jelly stool" and a palpable abdominal mass are the triad of presentation. The best mean for early diagnosis is abdominal ultrasound scan. Unless contraindicated, non-operative approach (using either pneumostatic or hydrostatic reduction) is the best way for management with a success rate up to 95%, otherwise, surgical intervention is indicated. Unfortunately, non-operative approaches, were not ever safe options in our health institutes because of the lack of the required hospital facilities and trained staff, so all cases of intussusceptions were managed surgically by laparotomy and manual reduction. This study enrolled 70 children with Intussusception who were managed in two main children's hospital in Basrah city between April 2008 and December 2015 by one pediatric surgeon. The mean age of study population was 11.6 months and male to female ratio was 3.6:1. Primary intussusception was found in 91.4% of the patients and the most common anatomical pattern was ileocolic type (62.9%). Intra-operatively, manual reduction was reported to be easy in about half of the patients, those were presented early in the course of the illness (79.4% were presented within the first 24 hours) that made them very good candidates for non-operative management. Both postoperative complications and hospital stay were significantly related to the intraoperative procedure used for reduction, an easy manual reduction was associated with a less incidence of complications and a shorter hospital stay although generally longer hospital stay when compared with other studies in which intussusception is usually managed nonoperatively.

Abstract Diaphyseal tibial fracture is the most common fractured long bone because of it is subcutaneous position anteromedially and thinner diaphysis distally. Tibial diaphysis has poor blood supply and poor soft tissue envelope around it so it is more susceptible to infection, delay union, and non-union. For these reasons many modalities including cast and brace, external fixation, plate and screws, and locking intramedullary nail were used for treating diaphyseal tibial fracture. The aim of this study is to compare the outcome of locking intramedullary nail(LIMN) fixation versus plate and screws fixation in treating diaphyseal tibial fracture in term of operation time, early weight bearing, time to union, and complications. The study was carried out in Sulaimaniyah Teaching Hospital, Department of Orthopedics prospectively from May 2010 to July 2014 on 74 patients, 40 of them underwent surgical fixation by locking intramedullary nail (26 close method and 14 by open method), and 34 of them underwent open reduction and internal fixation by plate and screws. The outcome was assessed by clinical and radiological evaluation. The results show that young male are more affected by trauma, and the main mechanism of injury was Road Traffic Accident. Operation time was shorter among plate and screws group with a mean of 51.4±4.9 minutes, than locking intramedullary nail group with a mean of 88.5±12.5 minutes. Weight bearing(WB) time achieved earlier in the locking intramedullary nail group with a mean of 2.6±0.8 weeks than the plate and screws group with a mean of 4.2±1.4 weeks. There were no significant difference between the two groups regarding time to full weight bearing(FWB), time to union, and complications. In conclusion, Locking intramedullary nail and plate fixation are ideal option for treatment of diaphyseal tibial fractures since there were no significant differences between them in time of union and the post-operative complications.

Abstract Meconium ileus accounts for 9–33% of all neonatal intestinal obstructions, with an incidence of 1:2500 newborns, representing the third most common cause of neonatal small bowel obstruction after atresia and malrotation. This study aimed to compare various surgical procedures used in the treatment of meconium ileus and to assess their efficacy regarding survival and complications. A retrospective study was done to all cases of meconium ileus admitted to the neonatal intensive care unit of Basrah hospital of maternity and children and Basrah children specialty hospital during the period of 10 years (2005 to 2015). The medical records of 57 cases of meconium ileus were studied. The comparison included: Mikulicz procedure, Bishop-Koop procedure and resection with primary anastomosis in both simple and complex meconium ileus. The parameters used for comparison were anastomotic leaks, high output diarrhea with dehydration and failure to thrive, sepsis, need for reoperation, wound complications, early adhesions, hospital stay and mortality. The mean age of presentation of neonates with meconium ileus was 3.9 days. Male to female ratio was 0.9: 1. About 10.5% were preterm. About 33.3% of cases were diagnosed as simple meconium ileus. Intestinal Volvulus is the predominant complications encountered (47.4%). Non-operative treatment was effective in 45.5%. The most common procedures done in our center were Mikulicz procedure (61.5%), followed by Bishop-Koop procedure (30.8%), and resection with primary anastomosis (7.7%). There was a significant association between mortality and high output fistula, anastomotic leaks, sepsis, and reoperation. Predominant complications in Mikulicz procedures were high output fistula (50%) and skin excoriation (53.1%), while in Bishop-Koop procedure were sepsis (75%), reoperation (50%), and adhesions (25%). In primary anastomosis, significant complications were anastomotic leak (75%), sepsis (50%), and reoperation (50%). Mortality was highest in primary anastomosis (75%), followed by Bishop-Koop procedure (62.5%), and lowest with Mikulicz procedure (40.6%). The overall mortality of meconium ileus was high 45.6% (42.9% for simple meconium ileus and 52.6% for complex meconium ileus). All neonates treated non-operatively survived, while the survival rate for those treated surgically was 50%. In conclusion, resection with stoma creation is superior to primary anastomosis. Mikulicz procedure is the safest procedure to be done with best survival and less complications. Bishop- Koop procedure is of value in a situation where the surgeon is afraid from high output diarrhea so proximal stoma is mandatory.

Abstract The propose of this study is to evaluate the effect of Botulinum A intradetrusor injection on patients with overactive bladder refractory to oral anticholinergics and safety of the drug. Patients with overactive bladder (excluding patients with neurological or pathological causes) were enrolled in this study, those patients did not benefit of oral medications with anticholinergic effect, and they were assessed for history of their problem and kept a urinary diary for three days before the start of the procedure. They were also examined, and ultrasound for post voiding residue with urinary flow rate was kept in records. Injection of 200 IU of onabotulinom toxin-A in the detrusor muscle. The drug effect was studied one month after injection on patient’s symptoms, including day and night frequency, urgency and urge incontinence by keeping a three days’ urinary diary postoperatively. The maximum flow rate and the post voiding volume were also measured. Postoperative complications in the form of haematurea, urinary tract infection and retention of urine were recorded. There was a significant decrease in the number of voiding during both day and night from 10.7±1.68 SD, 2.09±0.93 SD to 4.407±1.394 SD, 1.257±0.752 SD respectively which is statistically significant difference (t (135) =6.377, P≤0.001), (t (135) =0.837, p≤0.001), this was associated with a reduction in the number of episodes of incontinence from 1.37±0.975 SD to 0.6815±0.676 SD. The postvoiding volume was increased remarkably. Complications includes urinary tract infection and retention of lower tract local effects only. In conclusion, the use of onabotulinom toxin-A in the treatment of refractory overactive bladder is effective in reducing patients’ symptoms and discomfort as well as being a safe option for treatment.

Abstract A retractile testis is the testis that can be brought down into the scrotum but then after a period retract upward outside the scrotum by the action of cremasteric muscle. The aim of this study is to identify the effect of age of the patient, location of the RT, and whether unilateral or bilateral on the response to HCG therapy. This is a prospective study conducted in the pediatric surgery compartment in Basrah Children Hospital over 3 years (2013-2016). Thirty two boys with a diagnosis of retractile testis (RT) are included in this study. All cases were treated with intramuscular injection of HCG as following: in boys aged 1-4 years: 1000 IU twice weekly for 3 weeks (total 6000 IU) and in those aged more than 4 years: 1500 IU twice weekly for 3 weeks (total 9000 IU). The response to treatment was evaluated in 2 weeks, one month, and 6 months after completing the course of treatment of HCG. In this study, the diagnosis of retractile testis was confirmed in 32 boys aged (1.25-9.5) years (mean: 5.28 years). Ten boys (31%) were with unilateral retractile testis. Twenty two boys (69%) were with bilateral retractile testis, 15 (27.7%) testes in the prescrotal area, and 39 (72.2%) testes in the inguinal area. From a total 54 retractile testes; 40 (74%) testes respond (descended into the scrotum). The mean age for responder was 5.49 years and the mean age for boys who did not respond was 4.69 years. Six (60%) of 10 unilateral retractile testes and 34 (77.3%) of 44 bilateral retractile testes respond to HCG treatment. Response to HCG occurred in 12 (80%) of the pre-scrotal retractile testes, and in 28 (71.8%) of the inguinal retractile testes. Re-ascending (recurrence) occurred in 6 (15%) testes. In conclusion, HCG treatment is an effective way of treatment of retractile testis especially in preschool children, bilateral cases, and in those with prescrotal testicular position.

Abstract Medical treatment using misoprostol has been recommended as an alternative to surgical evacuation for missed miscarriage in the first trimester in order to avoid anesthesia, surgical operation and hospitalization. Our aim is to assess the efficacy and safety of vaginal misoprostol in out-patient management of early miscarriages. This prospective study included patients with missed miscarriage of ≤10 weeks gestation. The protocol used 800 microgram of misoprostol on day 1 at clinic, followed by another dose of 800 microgram of misoprostol on day 2 if miscarriage was not complete. The included 150 patients, had missed miscarriage or anembryonic pregnancies. The success rate defined has complete miscarriage without need for surgical evacuation and without shortterm complications. Complete expulsion occurred within 2 days in 90.7% of cases. There were 14 patients needed surgical evacuations and admission to hospital (5 for method failure, 2 for incomplete miscarriage and 7 according to women decision). No one required blood transfusion. In conclusion, it is possible to use misoprostol as an out-patient treatment, since it gives satisfactory efficacy and is sufficiently safe.

PULMONARY OEDEMA/ARDS ulmonary edema is a potential cause of hypoxia in the perioperative patient. The accumulation of excessive alveolar fluid results in hypoxia due to interference with diffusion across the alveolar capillary membrane. Frothy (sometimes blood-stained) sputum may be expectorated or observed in the endotracheal tube. the abnormal accumulation of fluid in the interstitial or alveolar spaces of the lung can be explained on the basis of a disturbance in the normal Starling equation1. It involves changes in hydrostatic or oncotic pressure across the alveolar membrane or in the permeability of the alveolar membrane such that fluid moves across from the capillaries into the alveolar space. P

Abstract This is a report of two patients (brothers) with unusual generalized skin disorder, a recessive dystrophic epidermolysis bullosa (RDEB) that appeared at childhood, who developed a progressive squamous cell carcinoma (SCC) in their right hands. Later both patients underwent wide local tumor excision, and during the follow-up after surgery, axillary lymph node metastasis observed in the first case, and local recurrence in the second. Therefore early recognition of EBD is important to assist in the diagnosis and treatment of malignant lesions at an early stage in these patients to prevent the subsequent complications.

Robert W Bucholz, MD 1947-2016 Former AAOS President Asked to name the career achievement of which he was most proud, Robert W. Bucholz, MD, replied, "Waking up every day with the privilege of being an orthopedic surgeon" obert W Bucholz, MD, passed away at home in Dallas, Texas, on May 20, 2016. He attended Westside High School. Graduated from Yale Medical School in 1973. He worked in Yale for his orthopedic surgery residency. He spent his professional career at the University of Texas Southwestern Medical School.