Basrah Journal of Surgery

The journey of treatment which is, sometimes short or long or even very long, starts with a step in the consultation clinic, hoping to find a wide smile, soothing words, sympathy and empathy from the treating physician

THE EFFECT OF DENERVATION ON FRACTURE HEALING , AN EXPERIMENTAL STUDY ON RABBITS Thamer A Hamdan , Mubder A Mohammed Saeed & Abbas Salman Ismael Abstract Many studies suggested a relation between denervation and fracture healing either in positive or negative effect. This is a prospective experimental study on 20 rabbits carried out in the experimental animal’s research laboratory of Basrah University, Medical College from April 2014 to November 2014 according to ethical rules of institution. They were housed under controlled conditions of temperature and lighting, same diet was given for all animals. The rabbits was divided into two groups; group A with sciatic denervation and fracture of the tibia while group B, with fracture tibia only. The state of fracture healing was studied radiologically after 4 weeks and histopathologically at 6 weeks. The results showed significant difference between the two groups, the denervated group had poor fracture healing compared with non denervated group. In conclusion, denervation affects fracture healing negatively in rabbits.

Thamer A Hamdan , Mubder A Mohammed Saeed Abdulhusein Allawi *FRCS, FRCP, FICS, FACS, American Board (Ortho.), Professor of Orthopedic Surgery. #FICMS (Ortho.)Assistant Prof. of Orthopedic Surgery. College of Medicine, University of Basrah, Basrah, Iraq. MB, CHB, Postgraduate Iraqi Board Medical Specialization (Ortho.) Abstract Pregnancy related musculoskeletal impairment is a common complaint among pregnant women. It can potentially have a negative impact on their quality of life. The aim of this study is to calculate the incidence of pregnancy related musculo-skeletal disorders, evaluate the most common disorders and to determine the possible risk factors. This is a prospective analytic study conducted in Basrah Governorate between January 2013- January 2014. Pregnant women attended the Primary Health Care Centers and the Gynecological & Obstetric Outpatient Department in Basrah hospitals were asked about any history of musculoskeletal conditions during the current pregnancy, further information was obtained and physical examination was done for patients who had history of musculoskeletal conditions, no investigation was done and there was no follow-up of the patients. A total of 500 pregnant women with complete data were recruited. Statistical analyses were performed using SPSS version 14, incidence and frequency were calculated using standard technique. Two hundred-sixty of the patients out of the 500 had pregnancy related musculoskeletal conditions during their current pregnancy with overall incidence of 52%. One hundred-sixty two of the patients have pregnancy related low back pain which represent 62.3% of the total disorders, followed by carpal tunnel syndrome(CTS) in 54 patients who had pregnancy related carpal tunnel syndrome (20.8%), calf pain in 28 patients, knee pain in 27 patients, hip pain in 21 patients, plantar fasciitis in 16 patients, neck pain in 6 patients, Dequverain’s disease in 5 patients and one patient only had meralgia parasthetica. In conclusion, the pregnancy related musculoskeletal disorders are common and it is not trivial, for some women it may be the beginning of lifelong chronic discomfort and for others it may cause considerable disability and distress during pregnancy. Most of these problems can be identified early and treated effectively by active self-management strategies; administered through good antenatal care.

Laparoscopic cholecystectomy has become a standard technique for gallbladder surgery of symptomatic cholelithiasis. However, pain is the dominant complaint after this surgical procedure.
This study aimed to evaluate the efficacy of long acting local anesthetic (Bupivacaine), infiltrated at port sites in amelioration of pain following laparoscopic cholecystectomy.
Seventy two patients underwent elective laparoscopic cholecystectomy enrolled in this study, patients were divided into treatment and control groups of 36 patients each. Following removal of
the gallbladder, treatment group received 20 ml of 0.25% Bupivacaine in divided doses at the trocar sites, unlike control group which receive no treatment. The evaluation of postoperative pain
was done at fixed time intervals by McGill Pain Questionnaire, and the dosage of narcotic analgesic Tramadol, was also recorded.
Mean pain scores at 6 hours postoperatively in treatment group was less than that of the control group (4.5 and 7.6) respectively with (p<0.05). Pain scores at 12 and 24 hours postoperatively did
not differ between the two study groups (p>0.05). The mean total narcotic analgesic dose used during the first 24 hours postoperatively was less in the treatment group compared to the control
group (92 mg and 158 mg) respectively with (p<0.05). The localization of pain during the first 24 hours postoperatively was 58% incisional, 36% intra-abdominal, and shoulder tip pain 6%.
In conclusion, postoperative infiltration of long lasting local anesthetic (Bupivacaine) into the port sites of laparoscopic cholecystectomy may be desirable. This is simple, inexpensive, and effective
technique to minimize early postoperative pain which can be practiced for elective laparoscopic cholecystectomy.

Abstract This study aimed to isolate mycoplasmas from oral cavity of patients with oro-dental diseases, to evaluate their role in pathogenesis of these diseases, and to evaluate the effects of some antibiotics on them. The population enrolled in this study was individuals attending the dental out-patient clinics in the dental specialty center in Basrah, from private dental clinic, and from otolaryngology out–patient clinic. It consisted of 154 patients with periodontal diseases (gingival diseases & periodontal abscesses) and oral ulcers of different types, in addition to that, 50 healthy subjects were included as control group. It included 112 males and 92 females, their age ranged from 6 to 68 years. This study extended from the period between August 2010 to December 2011. Samples from gingival sulcus or periodontal spaces were obtained by using paper points and swabs from ulcer surface, all specimens were cultured within one hours of sampling. For the isolation of mycoplasma, each specimen was directly inoculated into the liquid phase of MDCS. Mycoplasma spp. were isolated from 120 individuals out of 204 enrolled in this study, males affected more than females, the commonly affected age group was 20-29 years. Smoking play a clear role in causation of dental diseases and mycoplasma found more in smoker patients, (62 were smokers, 36 were non-smokers).Gingival diseases were commonly presented (62 patients), followed by inflammatory oral ulcers (45 patients). Mycoplasma salivarium was the frequently isolated species (70.8%), followed by mycoplasma orale (isolated from 16.6%). Single mycoplasma infection was found in 4 cases, 3 in gingival diseases which were 2 mycoplasma salivarium and one M.orale. The last spp. was M. pneumoniae, it was isolated from periodontal abscess. Tertracycline and erythromycin showed good inhibitory effects against mycoplasmas. In conclusion, Mycoplasma isolated from males with oro dental diseases more than females. The mostly affected age group was 20-29 years of age. Mycoplasma salivarium was the commonest isolated species, followed by mycoplasma orale. It is rare to find single mycoplasma infection in the oral cavity, just 4 cases were documented from total 98 patients. Tetracycline and erythromycin can significantly inhibit the growth of mycoplasma

ANTHROPOMETRIC FACE IN BASRAH

Nada H Al-jassim , Zuhair F Fathallah & Nawal M Abdullah
MB,ChB, DGO.
Anatomy.

Abstract
Anthropometry is the systematic quantitative representation of the human body, it is used to measure the absolute and relative variability in size and shape of the human body. Over the
centuries, there have been remarkable changes in anthropometric measurements due to geographical, cultural, genetic and environmental factors. The studying of human face and the
assessment of facial dimensions attract the attention of the artists, poets and scientists and takes a prime importance in medical and dental fields in both diagnosis and treatment planning.
Anthropometry also used for the design of clothing and equipment, e.g. Gas masks, oxygen masks, dust masks and respirators as well as design of military and industrial helmets. There
had been no studies done on facial measurement in Basrah therefore, this study is to be considered as the first in this field and the baseline for further studies. This study had attempted
to quantitatively measure the human face in different ethnic groups of the local population and to identify the differences between individuals of different races and sexes, also to identify the differences between the people of Basrah and other people worldwide. These differences which
are responsible for the special facial features in different ethnic groups should be maintained during reconstructive or aesthetic surgery otherwise the patients will lose their ethnic features.
The people of Basrah have different racial and ethnic background, there are Semites which are the Arabs and Syrian (Assyrian & Chaldean), Arian, who are the Armenian, Kurdish and
Persian, and then there is the mixed group result from interracial marriages.
This study is a cross sectional study with a comparative component conducted in Basrah governorate. The data was randomly collected from volunteers, for the period from February to
July 2013. Raw data used in this study was originated from a total number of 1000 Iraqi adults (526 females and 474 males) living throughout Basrah governorate and were used to create a
database for statistical analysis.
The result of this study shows that there are differences between the races and between the local people and the surrounding countries and indeed there is a great difference from the
standard measurement advocated by western researchers.

Introduction
he human face is a living mirror held
Tout to the world, it has the power to common expression is “I may forget a
name, but I’d never forget a face’
Anthropometry
quantitative representation of the human
individual
understanding human physical variations .
Over
remarkable
measurements
cultural,

Oculocardiac reflex (OCR) is an event seen during the cataract operation revealed as bradycardia. The situation is triggered by pulling or stitching of external ocular muscles. Anesthesiologists used atropine for controlling this reflex if ensues. This study aimed to estimate the incidence of the oculocardiac reflex during cataract surgery under local anesthesia (LA) and to assess the need for atropine to avoid this event. This study included eighty patients aged 45-80 years with class I or II ASA physical status listed for elective cataract extraction and intraocular lens (IOL) implantation under peribulbar block. The past medical history, drugs history, investigations and baseline vital signs were all observed and recorded. The observer continuously monitors heart rate readings. Oxygen was given to all patients through nasal cannula while spontaneously breathing. The results showed a significant drop in the heart rate following superior rectus muscle grasp and stitching (5.69%). This finding was observed following sedation (6.19%) and after removing of the stitch (6.22%), which indicates triggering of OCR. This slowing in heart rate did not require the use of atropine as bradycardia did not reach a serious level. In conclusion, the alterations in heart rate during cataract surgery observed mainly at handling of the extra-ocular muscles and following sedation. Atropine is not essential as a routine premedication in cataract surgery, particularly in geriatric populations in order to avoid the major side effects of atropine such as: tachyarrhythmias, central nervous system toxicity and urine retention, however, it should be accessible for administration if bradycardia ensues.

his study aimed to evaluate the validity of the BTA STAT and BTA TRAK as biomarker tests in patients with suspected urinary bladder cancer (UBC) using histopathology as a reference method, and to clarify the relationship between the results of these tests and tumor grades.
This is a cross sectional study that was carried out in Basrah, Southern of Iraq, from 1st of October 2010 to the 31st of March 2012. A total of 102 patients with signs and symptoms suggestive of UBC admitted to the urology ward in Basrah General Hospital were enrolled. A voided urine sample was obtained from each patient for analysis of BTA STAT and BTA TRAK prior to cystoscopy.
The sensitivity and specificity of the BTA STAT test were 93.1% and 33.3% while for the BTA TRAK test were 97.7% and 33.3%, respectively. The sensitivity of the two studied urinary bladder cancer biomarkers rose with the increase in the grade of UBC and there was an elevation in the median and mean values of BTA TRAK test with the increase in the grade of UBC, although it was not significant.
In conclusion, the sensitivity of both BTA STAT and BTA TRAK tests was very high; but their specificity was very low with high false positive results, however, they may be helpful in early detection and monitoring of recurrence of the disease in patients suffering from UBC.

Developmental dysplasia of the hip is a challenging surgical problem, there are many controversies regarding its management. Open reduction via medial approach is one of its treatment options, which needs further work to evaluate its role in management of Developmental dysplasia of hip. In this study, we tried to put an answer whether the medial incision of open reduction of developmental dysplasia of the hip is valuable in terms of stability, avascular necrosis, effect of age and the need for further procedures. Out of the ninety Children with DDH received within two years, twenty five of them needed open reduction through Ludloff’s approach; they were subjected to full assessment including detailed history and clinical examination in addition to radiographic evaluation. The remaining sixty five patients underwent closed reduction and hip spica cast application. Regarding those patients treated by open reduction, seven were males while eighteen were females, sixteen of them are below one year of age, trials of closed reduction under general anesthesia with arthrographs taken during the procedure to obtain the optimal range of hip movement with no benefit, so they were operated upon through the medial (Ludloff) approach. We found that this approach have more easy access to the hip joint, no need for blood transfusion and shorter time (20-30) minutes for each hip in relation to other approaches in the same age group. Serial follow up clinically and radiographically was performed to all patients. Postoperative complications included six hips with avascular necrosis of femoral head according to Kalmachi and MacEwan classification. No redislocation and infection was recorded. In conclusion, this method provides a stable and concentrically reduced hip.

The complex anatomical structures of the Cervico-Facial area, makes the knowledge of the anatomical extent of the tissue damaged by war injury, and the location of the foreign body or shell, quite difficult. The terms perforating, penetrating and avulsive wounds used in war injuries are merely superficial description; they hide the nature and the actual amount of the tissue damage. The critical nature of some of these wounds and their fatal consequences such as those who had sever bleeding and or sever airway obstruction mandates a quick diagnosis of the injured tissue and a quickly intubated and anesthetized patients. It usually takes time and effort of imagination by the surgeon to follow the path of travel of the shell or bullet in different anatomical structures of the cervico-facial area in order to anticipate the amount and extent of the damaged tissues. A simple division of the cervico-facial area into anatomical quadrants by two coronal planes, two transverse planes and two sagittal planes, helps the surgeon to remember and define the injured anatomical area, have a better localization of the foreign body and if these planes are used routinely and in a systematic way, the cervical vertebrae might be defined for any injury, and lastly these anatomical quadrants can be used by the maxillo-facial surgeon to communicate more easily with other specialists whose cooperation is of utmost important for the management of such injuries.

Bradycardia is a known problem in laparoscopic cholecystectomy especially during pneumoperitoneum and gall bladder dissection which might necessitate the use of intravenous atropine. The clinical significance of the latter as prophylactic issue in laparoscopic cholecystectomy has not been studied much to clarify its importance and to know how and when it could be used. We conducted a prospective study to evaluate the significance of preoperative intravenous atropine sulphate to reduce bradycardia during laparoscopic cholecystectomy. One hundred and forty patients were analyzed in a prospective study; seventy of them were atropine group and another seventy were non atropine group. Heart rate changes were studied in both groups in respect to preoperative, pneumoperitoneum and postoperative period. As well as the heart rate changes were evaluated separately in each group in concern of preoperative and pneumoperitoneum period. The results showed that age, sex, body mass index, duration of surgery and previous operations were comparable in both groups. Significant bradycardia was seen in non-atropine group during pneumoperitoneum as compared to atropine group (p0.05). In conclusion, this work shows that a preoperative intravenous dose of atropine sulphate might be of value in preventing bradycardia during laparoscopic cholecystectomy.

This study aimed to evaluate the safety and efficacy of percutaneous epididymal and testicular sperm aspiration as a diagnostic technique to confirm sperm production and as a therapeutic technique to harvest sperms for use in the intracytoplasmic sperm injection and the indications for performing testicular biopsy in azoospermic infertile males. Thirty married patients were included in this prospective study from February 2011 to December 2012 seen in Basrah General Hospital. Their age ranged from 20 to 40 years. All patients underwent full medical examination with laboratory tests which included seminal fluid analysis, serum leutinising hormone (LH), follicular stimulating hormone (FSH), testosterone, and prolactin in addition to color Doppler ultrasonography of the scrotum. Patients with history of undescended testes, varicocele, & testicular pathology were excluded from this study. All patients showed normal physical examination with normal secondary sexual characters. The external genitalia were normal with normal sizes of their testes. The percutaneous epididymal and testicular sperm aspirations were positive in 12 out of 30 patients (40%). The rest had negative aspirations (60%). The testicular biopsy which performed in the patients with negative aspiration showed normal germinal epithelium with mature spermatozoa in only 5 patients out of 18 (28%) while the rest 13 patients had spermatogenic arrest (72%). In conclusion, percutaneous epididymal and testicular sperm aspiration has been found helpful as a diagnostic technique for patients with non-reconstructable azoospermia. It is a minimally invasive sperm retrieval technique and appears to be an effective alternative to microsurgical epididymal sperm aspiration, which is more invasive and costly. It is less invasive than testicular biopsy and preferably performed as a first step procedure in an attempt to obtain sperms for both diagnostic and therapeutic purposes.

Beta 2 microglobulin is a known marker used in the follow up and monitoring therapy of patients with hematological malignancies. However, its assistant role in the diagnosis of some of them, like lymphomas is less highlighted. Thus, this study was designed as a part of a larger, wide scale study, to clarify the help of B2MG in the support of the diagnosis of different types of lymphoma. A total of 669 newly diagnosed, pre-treated lymphoma cases were investigated for B2MG using the ELFA/mini VIDAS system and the results showed an elevated level of B2MG among both Hodgkin & non-Hodgkin, adults and childhood and nodal and extranodal lymphomas, with a significant increase among non-Hodgkin and extranodal type of lymphomas, a finding that may make its use as a diagnostic marker is helpful. Those results were comparable to some and contradicting to other studies. Further future studies are in need to consolidate this.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the digestive tract and Computed tomography (CT) is an imaging modality of choice for the detection and evaluation of GISTs. This study aimed to describe the computed-tomographic imaging features of gastrointestinal stromal tumors in our clinical work and to evaluate and improve our CT protocols in the diagnosis of GIST. This is a cross-sectional study conducted in the period of October 2011–December 2012 in the Radiology Institute and the GIT Center of Medical City in Baghdad. Twenty cases of GIST were analyzed by multidetector abdominal CT including fifteen male and five female patients of age (20-70) years. Images were analyzed for tumor location, size, definition, diameter, shape and other features. The results showed that 13 (59%) of tumors were located in the stomach and five (23%) were located in the mesentery. GISTs were extraluminal in 13 (59%) patients. The tumor margins of 13 (59%) tumors were well defined, and irregular in eight (36%). Location of GISTs did not correlate with their definition, diameter or shape; while a significant correlation had been found with the hemorrhage and enhancement. In conclusion, CT scan is the most common imaging technique for the detection, localization and initial evaluation of GIST extension. The stomach was the commonest location of GIST occurrence among our patients. The CT features of GISTs were well-defined tumor margins, extraluminal site and fungating morphology.

The aim of this trial is to evaluate the protocol of treating selected cases of adult acute appendicitis by non-surgical measures.
Appendicitis is the most common cause of acute abdomen, for many years the adapted treatment of this disease is by immediate surgery to avoid the serious morbidity and mortality, now a small study suggest that using non-surgical treatment using antibiotic may give same result in curing patients and avoidance of surgery may eliminate the possible morbidity and even mortality in selected patients.
This is a prospective non-randomized study of 84 adult patients with acute appendicitis, clinically diagnosed, from both genders were treated in Basra General Hospital from 2005-2009, by intravenous anti biotic, nothing by mouth and clinical monitoring.
From the 35 female patients, only six cases did not show clinical improvement, surgery revealed perforated appendicitis in two, pathology other than appendicitis in four (salpingitis, ectopic gestation, ruptured graafian follicle, twisted ovarian cyst respectively).
From the 49 male patients, five cases did not show clinical response, operations showed gangrenous and perforated appendicitis in two, other pathology in three (pelvic lymphadenitis, gastroenteritis and urinary tract infection).
In conclusion, the non operative regime for treatment of early acute appendicitis is successful, it can be used to treat certain types of patients including high risk patients and when surgical facilities are not available.

P
neumothorax is a possible dangerous situation which may arise suddenly during
anaesthesia. The diagnosis is one of exclusion, as initial changes in vital signs
(cardiorespiratory decompensation and difficulty with ventilation) are non-specific, and
other causes of such changes are more common, whereas local signs may be difficult to
obtain, especially without full access to the chest. Diagnosis of pneumothorax during
general anaesthesia is difficult, especially as this problem is uncommon. Although there
are a number of well recognized high risk conditions, pneumothorax may occur all of a
sudden in a patient with no known risk factors. A small, undiagnosed, asymptomatic
pneumothorax may become a tension pneumothorax on doing positive pressure
ventilation of the lungs after induction of or during anaesthesia. As the systemic signs of
pneumothorax are non-specific and the local signs difficult to elicit if access to the chest
is restricted, a high level of suspicion and a systematic approach is required for the rapid
detection of this potentially hazardous problem1.
Pneumothorax is an uncommon problem, especially during general anaesthesia, when
the patient cannot complain of respiratory difficulty or pain, and with positive pressure
ventilation, which increases the risk of a tension pneumothorax2.

CYSTIC FOREIGN BODY GIANT CELL GRANULOMA IN XERODERMA PIGMENTOSUM Ali Abbas Alshawi FFDRCSI, FDSRCS. Assist. Prof. Consultant Maxillofacial Surgeon, Basrah General Hospital, Dean of Basrah Dental College, Basrah, Iraq. Abstract A case of cystic foreign body giant cell granuloma is presented. The patient, nineteen years of age, known case of Xeroderma Pigmentosum, presented to the maxillofacial unite, Basrah General Hospital, Iraq, with slowly enlarging cervical cystic mass. Examination revealed cystic swelling in the mid-left side of the neck of six months duration. The mass was not tender and was immobile. Aspiration revealed straw colored fluid. The excised mass, showed cystic lesion, the base of which had an extensive soft tissue growth, histologically consisted of foreign body giant cell granulomas. There was no recurrence at a follow-up of 17 years.