Basrah Journal of Surgery

This prospective study was done in Basrah General Hospital, from June 2009 to December 2011. It included 92 hips in eighty one patients affected clinically and radiologically by femoral head avascular necrosis. They were 50 males and 31 females, mean age 41 years with a range of 15-67 years with stage II-IV of femoral head AVN according to Ficat and Arlet radiological staging system. The aims of this study are; to know the pattern of avascular necrosis of the femoral head, and to evaluate the outcome of the different surgical modalities. Surgery was conducted in form of; group I includes twenty four hips (24.4%) which were treated by core decompression (12 hips =12.2% by multiple small drilling (group I-a); seven patients were satisfied with the result of surgery. Infection was reported in one patient. Twelve hips =12.2% by wide bore drilling "gutter" and bone graft(group I-b); nine patients were satisfied by the result of surgery). Group II includes fifty three hips (54.1%) which were treated by total hip arthroplasty (25=25.5% cemented THR (group II-a); seventeen patients were satisfied with the procedure; Complications were reported in three cases, and 28=28.6% cementlessTHR (group II-b); twenty one patients were satisfied; complications had been encountered in five cases); five patients had bilateral hip surgery. Group III includes twenty one hips (21.4%) which were tackled by Girdlestone (resection arthroplasty); six patients had bilateral hip surgery. Only nine patients were satisfied with this procedure. In conclusion, core decompression surgery in form of wide bore drilling with bone graft is suitable treatment for early stages of avascular necrosis. Total hip replacement is suitable option for AVN in advance stage. Resection arthroplasty still is an option for patients in certain situations (e.g. infection), although the results were less favorable.

Nausea and vomiting are of the main symptoms affecting patients following laparoscopic procedures with rates ranging between 5-45% in ambulatory surgery cases, they may lead to adverse effects including patients’ demoralization, increased pain level and prolonged hospital stay and so increasing costs of health services. This study determines the effects of preoperative dexamethasone on post laparoscopic cholecystectomy nausea and vomiting. One hundred patients, admitted for laparoscopic cholecystectomy, were divided into two groups. One given dexamethasone intraoperatively, the other received no drug. Both groups received similar anesthetic, surgical and postoperative drug management. The patients were followed in the first twenty-four hours for the development of nausea and vomiting. Nausea and vomiting were significantly reduced in the group receiving dexamethasone on the day of operation with statistical significance. So dexamethasone (8 mg) is recommended to be routinely given at the time of induction of laparoscopic cholecystectomy, since it reduces nausea and frequency of vomiting post laparoscopic cholecystectomy.

In patients with mitral stenosis, there is poor correlation between the severity of mitral stenosis, as measured by the mitral valve area and the magnitude of pulmonary hypertension. We tested the hypothesis that left atrial compliance is a major factor determining the height of pulmonary artery pressure in patients with pure mitral stenosis and sinus rhythm. The right sided and left atrial trans-septal catheterization data was analyzed in 84 patients (67 females, 17 males) with pure MS and sinus rhythm. Pulmonary artery peak systolic, diastolic and mean pressures were obtained through right sided catheterization. The magnitude of the LA a and v waves and the mean (m) LA pressure were measured directly through trans-septal catheterization. A non-compliant LA was considered to exist if the LA v_m pressure difference equaled to or exceeded 10 mmHg. The mitral valve area was determined by echocardiographic and Doppler methods, as were the LA size, LV systolic and diastolic dimensions, and the LV ejection fraction. Multiple regression analysis was performed to determine the most important factor in the determination of pulmonary artery pressure. Fifty four patients had PAPs≥50 mmHg, 41 of whom had non- compliant LA. Of the 30 patients with PAPs

Common bile duct stones have been noted in 10-15% of patients with gall stones, these stones are either primary (formed in the common bile duct) or secondary (formed in the gallbladder and migrate down to the common bile duct). Their management includes ERCP (Endoscopic Retrograde Choledochopancreatography), biliary drainage procedure and choledochal exploration. In this interventional study, we compare between transduodenal sphincteroplasty and choledochoduodenostomy regarding morbidity (anastamotic and duodenal leak, cholangitis, and pancreatitis) and mortality related to each surgical option. A review of 68 patients with lower common bile duct stones presents with different clinical presentations in an interventional study carried in Basrah General Hospital and Al–Moussawi Private Hospital, 22 patients underwent transduodenal sphincteroplasty and, 46 patients underwent choledochoduodenostomy. Both groups received general anesthesia and comparable in age and sex. Statistical analysis done by SPSS (Statistical Package for Social Sciences) version 18. Age and sex are comparable in both groups, the incidence of postoperative cholangitis is 9.09% in the transduodenal sphincteroplasty group and 32.6%in choledochoduodenostomy group which is statistically significant (P value 0.01). The incidence of duodenal and anastamotic leak is 13.6% and 10.9% in transduodenal sphincteroplasty and choledochoduodenostomy group respectively which is statistically not significant (P value 0.707). The incidence of postoperative pancreatitis is 0% and 8.7% in transduodenal sphincteroplasty and choledochoduodenostomy group respectively which is statistically not significant (P value 0.296). The mortality is 0% after transduodenal sphincteroplasty and 6.5% after choledochoduodenostomy. In conclusion, transduodenal sphincteroplasty is better than choledochoduodenostomy in the management of lower common bile duct stones, less postoperative cholangitis, pancreatitis, and lower mortality rate.

Conservative surgery (partial peri-cystectomy and cyst contents evacuation with cavity management by external drainage, omentoplasty or capitonnaige) for uncomplicated hydatid cysts of the liver is known to be safe but is often associated with bile leak in rate of 18.81% and its sequela. The cause of bile leak is almost always due to cysto-biliary communication, this is usually occult and difficult to be diagnosed pre-operatively, if remain undiagnosed intra-operatively it will be presented as post-operative bile leak. In this study, several laboratory and radiological predictors used to evaluate those patients having high risk of bile leak after conservative hepatic hydatid cyst surgery. Also it aimed to study the fate of bile leak, it’s complications, how to avoid it and the way of management. This study is a combined prospective (from 2004-2010) & retrospective cases study performed in basrah hospitals, Iraq; (Al-Mawani Hospital, Basrah General Hospital, Al-Sader Teaching Hospital, and some of Private Hospitals); we analyzed records of 183 cases of hepatic hydatid cyst undergoing conservative surgery, of them 15 patient had bile leak intra-operatively and 20 patients had bile leak post-operatively. Patients with intra-biliary rupture of hydatid cyst or obstructive jaundice are excluded from this study. Bile leak occur in 35 patients (18.81%) from total 183 patients of which intra-operative bile leak seen in 15 patients (43%) and 20 patients (57%) as post-operative bile leak represented as external biliary fistula. L aboratory predictors of biliary leakage were alkaline phosphatase >250 U/L, total serum bilirubin >17 umol/l, cyst diameter >8 cm, multilocular or degenerative cyst also increase risk of bile leak. Post-operative complications are more in patients with bile leak (57%) than those without bile leak (12%). Hospital stay is longer in patients with bile leak 4.9 weeks while it is 1.06 week in those without bile leak. In conclusion, bile leak is not uncommon after hepatic hydatid cyst surgery, it can be predicted by certain laboratory and radiological factors thus indicate the need for additional procedures during operation to detect the cysto-biliary communication and manage the biliary leakage and its complications.

This study aimed to report the clinical outcome of intravitreal injections of triamcinolone acetonide (TA) for the treatment of diabetic macular edema (DME). The study enrolled 20 eyes of 19 patients with persistent diabetic macular edema. Full ocular examination including best corrected visual acuity (BCVA), tonometry, retinal examination with +90D lens and average foveal retinal thickness using an optical coherence tomography (OCT) were monitored before and then weekly for up to four weeks after the injection. All eyes received intravitreal triamcinolone acetinide (IVTA) (4 mg/0.1 ml) under topical anesthesia with Proparacaine 0.5% eye drops. BCVA at one week improved by two lines or more in six eyes (30%) and in nine eyes (45%) at four weeks. However, no significant improvement in mean BCVA from baseline was observed at one week (p>0.05) and four weeks (p>0.05). Mean retinal thickness (RT) were 411±179µm at baseline, 349±102µm at one week after the injection (p0.05), and 380±159µm at four weeks (p>0.05). One week after the injection, significant regression of macular edema was seen. However recurrence occurred at four weeks. No significant complications such as visual loss, endophthalmitis, significant raise in intraocular pressure or systemic complications developed. In conclusion, no significant changes in BCVA, IOP and RT were observed in the short-term observation after the IVTA. These findings need a larger sample size and a longer term observation to monitor the potential systemic and ocular side effects in Iraqi patients.

This is a prospective study performed from December 2005 to November 2007 on 25 children with closed traumatic femoral shaft fractures admitted to the orthopedic department of Sulemani Teaching and Causality Hospital. Their ages ranged from 3 to 13 years with male to female ratio of 17:8. All cases were treated by gentle fracture reduction and application of monolateral external fixation by the closed method. The average time needed for the fracture to unite was 72.6 days (ranged from 45 – 121 days). The complications reported in the study were: 12 % pin tract infection, 8% of temporary knee joint stiffness and 4% of heterotopic ossification at the site of pin insertion. Neither bone refracture or clinical shortening of the injured limb were reported. The study concluded that unilateral external fixation is a good method of holding femoral shaft fractures in children. The treatment is associated with minimum morbidity and will result in satisfactory bony union, low rates of complications, and early return to school.

Calculus cholecystitis with secondary bile duct stones is a surgical problem that solved by many surgical/conservative options. In our study we use oral Ursodeoxycholic acid as a medical dissolution therapy for secondary common bile duct stones in preparation for cholecystectomy. The study aimed to see the effects of ursodeoxycholic acid on biliary stone dissolution in our locality. A prospective study on twenty one patients presented with calculus cholecystitis and CBD stones from January 2010 to January 2011 involved in this study, they received oral Ursodeoxycholic acid (ursogall, UDCA) in a dose of 300 mg twice daily p.o over period of four to six weeks & some of them repeat course of treatment. During the period of observation, seventeen patients respond to medical treatment showed decrease or absence of jaundice and four patients show no response. It is concluded that: This study illustrate that we can use bile acids as medical dissolution treatment in some indicated patients with CBD stones, there is a chance of conservative treatment to be a way of treating patients with obstructive jaundice due to common bile duct stones, although the number of patient is small owing to the natural occurrence of such cases all over the world and we are lacking the standard facilities of identical research equipment and the comparative differentiation between diseased patients and control cases ; our results need further research with big number of patients and more elements of investigations.

Abstract
Laparoscopic cholecystectomy is now considered as a treatment of choice for symptomatic gall stones. Although the difference in the outcome, including conversion rate, operation time, hospital stay, complications and the effect of gender, is emphasized, but no enough data could be found in the literature regarding the effect of gender on the outcome of elective laparoscopic cholecystectomy for chronic cholecystitis. This study aimed to define the effect of gender on the laparoscopic cholecystectomy for Chronic Cholecystitis. A randomized, coherent and prospective clinical trial was carried out at Hatwan Private Hospital for Endoscopic Surgery and Al Sulaimania Teaching Hospital to evaluate the sex difference as predictor for difficult laparoscopic cholecystectomy. From a total number of 712 patients, who were underwent laparoscopic cholecystectomy for Chronic Cholecystitis from 1st June 2002 to 1st of January 2011) three hundred and eighty eight patients were excluded according to exclusion criteria and the remaining 313 patients were included. All the operation were done by the same team and by the same surgeon , Standard four-port technique through a 'closed' method, was used, with first entry port in the periumblical region. Anesthetic technique and peri-operative management were not modified during the study period. Patients who were candidates for elective cholecystectomy, were mostly females with (F:M ratio= 3/1), mean age 28 years (range 20-50 years) with mean age of 34 years(range 20-49 years) for the females, 37years (range 20-50 years) for the males. There were more difficult cholecystectomies in males in comparison to female patients for chronic cholecystitis. In conclusion, male gender is a predictor for difficult laparoscopy for symptomatic gallstones presented as chronic cholecystitis.

Tracheostomy is one of the oldest operations that performed as a life saving procedure and it is commonly performed in ENT Department in Al-Yarmouk Teaching Hospital for various indications and different age group. This study designed to review the indications of tracheostomy and the age group commonly involved in AL-Yarmok Teaching Hospital. This is a cross sectional study in 150 patients in AL-Yarmouk Teaching Hospital for the period from August 2009 to September 2011. Cases involved in the study aged more than 10 years for whom tracheostomy was done in the AL-Yarmouk Hospital. Upper airway obstruction was the most common indication for tracheostomy and mostly involved age group was 40-90 years. Airway obstruction caused by tumor, trauma and infection. Tracheostomy performed as a part of another procedure was the 2nd common indication and involved commonly age group 20-39 years. It was caused by trauma, tumor and difficult intubation. Prolonged ventilation was the 3rd common indication that involved mainly the age group 40-90 years. It caused by systemic medical illness, trauma, tumor and infections. Conclusion: Main indication was the upper airway obstruction. The age group 40-90 years most commonly involved.

Acute appendicitis is still one of the most common surgical abdominal emergencies. Ultrasound could increase the diagnostic accuracy in those patients presented with unclear symptoms and signs of acute appendicitis. The aim of this study is to evaluate the effectiveness of U/S in the diagnosis of acute appendicitis. This prospective study was conducted at the department of general surgery in AL-Sader Teaching Hospital from June 2008 to October 2011. It included 129 patients suspected to have acute appendicitis. Ultrasound (U/S) was done for all these patients. There were (66) males represent (51%) and (63) females represent (49%). These patients are grouped according to gender, age, signs & symptoms, laboratory tests, operative finding, the result of U/S examination and histopathological result. Ultrasound was positive in (111) patients (86 %) and negative in (18) patients (14%). Six patients out of (18) had true negative results while (12) patients were false negative. Ultrasound sensitivity was (90 %) in diagnosing acute appendicitis, specificity was (66.6%), accuracy rate was (88.3%), positive predictive value (97.2%) and negative predictive value (33.3%). It is concluded that U/S is a useful tool in providing valuable information for the diagnosis of suspected cases of acute appendicitis.

This is a prospective study done in Basra Petro–Chemical Factory Health Center, from the period of Jan. 2001 to Des. 2001. Eighty workers aged 20-50 years were included in this study; they were subjected to a questionnaire including history of noise exposure, drug and medical history, full ENT and audiological examinations. They were divided into two groups (control and noise exposed workers). The majority of noise exposed workers fell in the age group 31-40 years (20.5%). Twenty three workers of this group (57.5%) exposed to noise more than eight hours per day. The main complaint were bilateral deafness (22.5%) and aural fullness (20.5%).The audiological results were 18 workers (45%) had bilateral high frequency sensorineural hearing loss (SNHL), 10 workers (25%) of the high frequency SNHL have mild hearing loss with 20-35 dBA. Only two workers (engineers) using ear protection have no aural complaint. We conclude from this study that noise induced hearing loss is preventable disease by ear protection and decrease daily exposure.

A study to compare the efficacy and local toxicity of combining anticancer drugs immunotherapy and chemotherapy (Sequential BCG and mitomycin c) versus mitomycin alone in the treatment of superficial bladder cancer after complete transurethral resection. The study was designed as a prospective study done in Al-hussain Teaching Hospital in Thiqar from July 2007 to August 2010. After transurethral resection and multiple biopsies, eighty-three patients (62m, 21f) from 38-75 years old, suffering from primary superficial (Ta-T1) TCC of the bladder, were randomly assigned to receive intravesical instillations of Mitomycin C (MMC) alone for 41 patients, and the sequential BCG and Mitomycin c, for 42 patients (81 mg BCG infused over 120 min once a week for 2 weeks, followed by 40 mg Mitomycin c once a week for four weeks. The patients evaluated for complications and recurrence and progression rate, they have follow up cystoscope every 3 months for the 1st year then every 6 months for the 2nd year and then yearly . Mean follow-up time was 36 months. The main object of the study were evaluation of recurrence and progression rate and estimate the safety with evaluation of subjective and objective side effects and clinical complications. Of the 83 randomly assigned patients, the analysis demonstrated a significant statistical difference in the recurrence rate. Patients assigned sequential BCG and Mitomycin c had lower recurrence rate 16.6 % (7 patients) versus 29.2% (12 patients) in those assigned for Mitomycin c alone, the difference between groups 12.6%; The progression rate in patients assigned sequential BCG and Mitomycin c about 7 % (3 patients) versus 17 % (7 patients) in those assigned for Mitomycin c alone, the difference between groups 10%. However the side-effects were mainly localized to the bladder, the complications after the treatment more common in patients receive sequential BCG and Mitomycin c than in those receive Mitomycin c alone. Cystitis occur in about 35 patients (83%) in those receiving sequential BCG and Mitomycin c, and two patient 4.7 % developed fever and chills. While in patients receive Mitomycin alone the complications were less cystitis in 4 patients 10%, rash in about 3 patients (7%) and myelosuppression two patients 5%. Conclusion: In this series, sequential BCG and Mitomycin c appears to be more effective than Mitomycin c alone in the treatment of superficial bladder tumors at 36-month follow-up, despite an increased but acceptable local toxicity.This probably because the BCG-induced inflammation might increase the permeability of the bladder mucosa such that Mitomycin c can reach the target tissue more easily and exert its anticancer effect.