Basrah Journal of Surgery

Departed to heavens in the 15th of September 2013, the Professor of Medicine and the leader of all Iraqi doctors, Dr. Ezzidin Shkara. Although he died far away in Britain, but he was too close to homeland Iraq by his continuous work and advices to promote the health services in his country.

Every now and then, we face the problem of terminally ill patient or what looks incurable lesion, like disseminated malignancy. Certainly, all of us prefer not to face such a bitter reality. But sadly, this is unavoidable. Problems almost always arise from this type of patients if not from their relatives, hence, the importance of proper handling, fine communication, gentle words and precise estimation of the surgeon's sentences. By doing so, the surgeon can spare himself a lot of problems. Sorry to say, some surgeons fall in this trap because they mishandle these peculiar and difficult patients. It is vital to appreciate the psyche of those miserable patients, sympathize with them as much as possible, make them feel that you are serious and keen to help them, and you are a friend rather than a physician.

Husam M H Alaamir* & Zakaria Y Arajy# *MBChB, FICMS, Plastic Surgeon. #FRCS Assist. Prof. Plastic Surgeon, Baghdad Medical City (Al-Shaheed Gazi Al-Hariri) Hospital, Baghdad-Iraq Abstract The skin of the nose is relatively adherent to the underlying structures secondary to deficient subcutaneous tissues. This may interfere with local flap recruitment, as in the nasal tip, and thus it is difficult to utilize traditional V-Y flaps to close large nasal defects. The addition of an amplified limb as a transposition flap onto the advancing edge of the V-Y flap is considered. This limb is utilized from the remaining nasal skin adjacent to the defect being reconstructed and is attached to the end of the V-Y flap after its advancement to close the remaining defect. The objective is to assess the use of amplified V-Y flap in closure of relatively large nasal defects incorporating nasal tissue itself on one session. Nasal defects as large as 3.2 cm have been closed with this flap following excision of skin tumors on the nose in 14 patients over 40 years old. Most of the patients were satisfied with aesthetic end results, except in two patients with only trivial complications.There was partial necrosis at the tip of the amplified portion of the flap in the nasal dorsum and sidewall regions. Other patients were concerned about dog ears at the base of the transposed flaps that settled later on spontaneously. Conclusion and recommendation: It is advisable to use the amplified V-Y flap in reconstruction of relatively large nasal defects as one stage procedure with expected good aesthetic outcome.

Thaer Jasim Chasib*, Mazin Al-Hawaz@ & Noori H Jasim# *MBChB Arab Board Candidate, Basrah General Hospital. @MBChB, CABS, FRCS. #MBChB, FICMS, PhD, Department of Surgery, College of Medicine, Basrah, IRAQ. Abstract Breast Cancer is a disease characterized by its tremendous heterogenicity in its course and treatment that demand the physicians and patients. It is the commonest type of malignancy among Iraqi women. Hormone receptors study in breast cancer is mandatory because it determine the prognosis and the course of treatment and has a wide acceptance in the management of breast cancer. this study aimed to evaluate the relation of estrogen and progesterone receptors positive (+ve) or negative (–ve) in respect to the age, grade and stage. A sixty seven female patients diagnosed as a breast cancer were undergone a surgery in term of mastectomy and axillary dissection and specimens were sent to a histopathology and receptor detection studies. All specimens were processed by same procedure of tissue preparations which include formalin fixation, paraffin embedded, receptor detection methods (Immuno-histochemistry and enzyme immuno assay studies). Most of affected cases in this study are equal or less than 47 years (37 cases representing 55.22%. Mean age group in this study was 47 year. The tumor mainly in Grade II (42 cases 62.68%) and mainly in stage IIA and IIIA (20 cases 29.86% for each one). Estrogen (ER) receptor expression represents higher positivity (49 cases 73.13%), while for progesterone (PR) receptor expression (45 cases 67.16%) representing more than two third of cases. The ER, PR expression in relation to the age was statistically significant (P value is 0.01). While, the ER and PR receptor expression in relation to the grade and stage was not significant (P values are 0.8, 0.5 respectively). In conclusion, breast cancer is a disease of early age group with moderately advanced stage and grade and about two thirds of patients have a positive estrogen and progesterone receptor expression which was more in older than in younger patients.

Ihsan S Mahmood*, Jamal A Al-Dohan@ & Murtatha M Salih$ *,@Department of Biochemistry, $Department of Surgery, College of Medicine, University of Basrah, Basrah, IRAQ. Abstract The objective of this study is to investigate the relationship between sex hormone levels and prostate volume in patients with lower urinary tract symptoms (LUTS). This study involved 66 patients suffering from LUTS for more than one month, with age ranged from 36 to 85 years who attended Basrah General Hospital outpatient clinic of urological surgery seeking management, eleven of them were suffering from non-insulin dependent diabetes mellitus (NIDDM). The medical and surgical history were taken through special questionnaire and the severity of LUTS was assessed by International Prostate Symptom Score (IPSS). General and urological examinations were done to them. Four ml of venous blood was drawn from each patient to measure luteinizing hormone (LH), follicle stimulating hormone (FSH), total testosterone (TT), free testosterone (fT), estradiol (E2) and prostate specific antigen (PSA) and the results were used to assess the presence of any association with IPSS or prostate volume. Also fasting blood sugar, blood urea, serum creatinine and thyroid stimulating hormone (TSH) were measured to identify unknown diabetic patients and exclude those with renal failure or dysthyroidism. Mean±SD of age and prostate volume of the patients were (63.8±9.5) years and (45.5±24.8) ml, respectively. The IPSS and bother scores were (17.3±6.5) and (3.8±1.4), respectively. Mean serum FSH, LH, TT, fT and E2 were (11.5±13.0) mIU/ml, (6.7±5.9) mIU/ml, (4.6±2.4) ng/ml, (6.5±4.8) pg/ml and (47.9±24.4), respectively. Patients with larger prostate volume (>40 ml) had significantly higher mean age and also had higher mean estradiol level after age adjustment (p value

Muayad J Lefta* & Qais K Baqir@ *MBChB, FICMS, CABS, General Surgeon, Department of Surgery, Al-Sadr Teaching Hospital, Basrah, Iraq, @MBChB, FICMS, CABS, General Surgeon, Department of Surgery, Al-Sadr Teaching Hospital, Basrah, Iraq. Lecturer, Dept. of Surgery, Basrah College of Medicine. Abstract Anal stenosis is an uncommon condition usually resulted from hemorrhoid surgery. It is one of the common disabling anal conditions and a lot of surgical techniques have been described to treat this condition. Sixteen cases of severe anal stenosis were included in a prospective study from July 2002 to January 2012 in Al-Sadr Teaching and private Hospitals; there were 14 males and 2 females. All patients received preoperative antibiotics and single enema for bowel preparation. Internal anal sphincterotomy done for all patients, four patients required bilateral flap anoplasty and twelve required only unilateral diamond flap anoplasty. This study included a total of 16 patients, 14 males and 2 females. Mean age was 35.3 years. Main etiology was hemorrhoidectomy (15 cases), most patients suffer from obstructed defecation, painful evacuation and episodes of minor rectal bleeding. Most patients express improvement in postoperative pain and good functional satisfaction (using visual analogue scale VAS). Complications were minor and treated successfully. Anal stenosis although uncommon, is a feared disabling anal condition mostly resulted from hemorrhoid surgery, a lot of surgical techniques have been described to treat severe anal stenosis, no one regarded as superior but all share the property of achieving patient’s satisfaction. In conclusion, diamond flap anoplasty is easy procedure with low complication rate and gives good results for treatment of severe anal stenosis.

Ali Adnan Mohsin* & Sarkis K Strak@ *MBChB Registrar, @MBChB, MRCP, FRCP, Professor, Department of Medicine, University of Basrah, Basrah, IRAQ. Abstract Experimental evidence supports a significant association between H. pylori infection and mosaic appearance of gastric mucosa. This study was carried out to find the significance of gastric mosaic mucosal pattern as a predictor of H. pylori related infection. A total of one hundred consecutive patients were selected from those attending endoscopy unit at Al-Sader Teaching Hospital for various dyspeptic symptoms; fifty with mosaic gastric mucosa as patients and fifty with normal gastric mucosa as controls. They were classified according to their ages, gender, and smoking habits. Two endoscopic biopsies from the antrum and corpus were taken from each patient and control and were tested for H. pylori by rapid urease test. Mosaic gastric mucosal pattern was significantly associated with H. pylori infection, as compared with normal mucosa. Age was an important determinant for mosaic mucosal pattern and H. pylori infection, however; gender did not contribute to mosaic mucosal appearances and H. pylori infection, while smoking can contribute to mosaic mucosal appearance but not H. pylori infection. In conclusion, mosaic mucosal pattern is a good indicator in predicting H. pylori related infection.

Firas Shakir Assistant professor, Urology division, Surgery Department, Basrah College of Medicine Abstract Percutaneous nephrolithotomy (PCNL) was reported to cause fewer complications and to reduce the length of hospital stay compared with anatrophic nephrolithotomy. Percutaneous nephrolithotomy does carry a risk of significant morbidity. Moreover, perioperative renal bleeding is one of the most common and worrisome complications of PCNL. Furthermore, delayed renal bleeding seems to be a serious complication. Various factors can increase the risk of bleeding. Delayed renal bleeding after PCNL can be managed successfully by conservative therapy. This is a retrospective analysis of patients who underwent PCNL. The aim of this study was to evaluate risk factors for development of delayed renal bleeding following PCNL and evaluation of the role of conservative management of that bleeding. The study included fifty patients who underwent PCNL inside and outside Iraq and were admitted to urology ward at Basrah General Hospital between February 2010 to May 2013. Average age of patients was 45 year. The patients were 40 males and 10 females. They presented with gross hematuria and anemia in the days following PCNL. The presentation varied between 7 up to 14 days following surgery. The patients were admitted to the emergency ward at our hospital and immediate and prompt evaluation and resuscitation was initiated. Forty five (90%) patients received blood transfusion. Forty seven (94%) patients were successfully managed with conservative treatment and the hematuria resolved. The average stay in the hospital was 5 days. Three patients (6%) needed surgical intervention. The complication rate of PCNL is up to 83%, but they are generally minor complications. Renal hemorrhage requiring intervention is a rare complication of PCNL, and its frequency is 0.6–1.4%. The bleeding risk was significantly correlated with factors such as renal cortical thickness, location and size of renal stones and the severity of hydronephrosis prior to PCNL. Only minority of patients failed to respond to conservative measures and they needed open surgical exploration which ended with a decision for nehprectomy. Conclusion: Although PCNL is a safe procedure for the treatment of renal calculus, it sometimes results in some complications. Bleeding after PCNL can be treated with conservative measures. However, it is important to determine the time for emergent intervention. It is important to be aware about factors that increase the risk of bleeding.

Abdul-Razzaq H Alrubaiee* & Ansam Ghazi Abdulwahed@ *CABS, DLO,@MB,ChB. Department of E.N.T Al-Sadr Teaching Hospital Basrah-Iraq. Abstract The prevalence of chronic suppurative otitis media (CSOM) is high worldwide. However, knowledge of associated risk factors is sparse; we report the sociodemographic and clinical risk factors of CSOM in our society in Basrah city with aiming to control the disease and complications; and putting possible preventive strategies. The aim of this study is to determine the frequency of sociodemographic and clinical risk factors for development of CSOM in Basrah city, Iraq. This is questionnaire-based survey included 100 patients having CSOM examined in Al-Sadr Teaching hospital outpatient department (68 females and 32 males), Statistical analysis was done using the Statistical Package for the Social Sciences (SPSS) program (Version 15.0). The difference between many variables was assessed to be statistically significant, by using tests of significance between two sample proportions. Among those questioned, 33 patients (33%) were children below 14 years of age, 54 patients (54%) came from rural areas, 41 adult patient (61.1%) were either illiterate or just read and write, 20 patients of 14 years old or younger (60.6%) had mothers who were illiterate and 8 patients of this age group (24.2%) had mothers who could just read and write, 83 patients (83%) had low income, 51 patients (51%) of patients lived in congested (crowded) houses of 10 people or more, 44 patients (44%) were passive smokers, 55 patients (55%) had history of recurrent URI, 28 patients (28%) had history of allergic rhinitis and 18 patients (18%) had history of adenoid, 76 patients (76%) had onset of the disease at childhood, of whom 20 patients (20%) had age of onset below 6 months of age. The prevalence of CSOM was significant in age group below 14 years. With P value 0.017. Residency and feeding history were found to be not significant risk factors for development of CSOM, with P value of 0.427 and 0.394 respectively. Income was highly significant risk factor, P value 0.000. Family size of 10 and more was significant risk factor for development of CSOM with P value of 0.041. Clinical risk factors like history of URI, Allergic rhinitis and adenoid were found not significant risk factors. In conclusion, Important risk factors for development of CSOM included sociodemographic factors like education level, income, congested (crowded) house with 10 and more people, presence of a smoker in the house hold, and early age of onset. Residency whether urban or rural did not have influence upon prevalence of CSOM, so did bottle feeding. Clinical risk factors like history of URI, allergic rhinitis and adenoid were found not significantly associated with the disease. The greater impact would be to sociodemographic risk factors on development of CSOM in our society.

Salam N Asfar@ & Jasim M Salman# @MB, ChB, MSc, Professor of Anesthesiology, College of Medicine, University of Basrah, Basrah, Iraq. #MB,ChB, DA, FICMS, Lecturer & Consultant Anesthesiologist, Basrah University and AlSadir Teaching Hospital, Basrah. C lose and continuous monitoring of patients at risk of myocardial ischaemia during anaesthesia is necessary as ischaemia represents 1% of all reported anaesthesia incidents1. It is well recognized that even sophisticated ECG devices with automated segment analysis detect only a proportion of ischaemic events1,2. Furthermore, electronic filtering, lead selection, the number of leads monitored, and only intermittent checking of the ECG trace may reduce this still further2,3. Correct lead selection is particularly important and a full 12-lead ECG, although often impractical intraoperatively, remains the ‘‘gold standard’’ if accurate electrical diagnosis is required. For the high risk patient, intraoperative monitoring of leads V5 and V4 and II (in that order of priority) is likely to optimize the chances of ischaemia detection, but requires a more complex system than the usual 3 lead ECG in common use which is insensitive4,5. The diagnosis of myocardial ischemia is often difficult because most occur without symptoms in anesthetized or sedated patients, ECG changes are slight and/or transient, and the creatine kinase has limited sensitivity and specificity because of coexisting skeletal muscle injury, but cardiac troponin assays have more specificity6.