Basrah Journal of Surgery

"The art of medicine consist of amusing the patient while nature cure the disease" Francois Voltaire 1697 - 1778 "Some people do have more positive outlook, but almost everyone remembers negative thing more strongly and in more details" Clifford Nass

Jaffar Shehatha* & Abdulsalam Y Taha@ *MB ChB, AMC, FICMS, FRCS, FRACS, Consultant Cardiothoracic Surgeon, Head of Cardiac Surgery, Suleimania Center for Heart Diseases. Adjunct Senior lecturer/ University of Western Australia, School of Surgery. @MB ChB, FIBMS (CTVS) Professor and Head of Cardio-thoracic and Vascular Surgery Unit, School of Medicine, University of Suleimania, Consultant Thoracic and Vascular Surgeon, Suleimania Teaching Hospital, Suleimania, Iraq Correspondence to: Mr. Jaffar Shehatha, E-mail: jaffarshehatha@hotmail.com Abstract Ibn al-Nafis was a great Arabic scholar and physician of his time. His account of coronary blood flow and pulmonary circulation in 13th century preceded the description by European researchers by almost three decades. At his time anatomical dissections were prohibited by the social and religious Muslim rules. Therefore it is not exactly known how he had reached his conclusions, whether through conjecture, observation on animals like monkeys, or by autopsy studies of humans. Because of the long period between Avicenna (the name used by the west for Ibn-Sina) and the appearance of Ibn-Al-Nafis and because of Ibn-Al-Nafis’s remarkable contributions many called him as the (second Avicenna). Ibn-Al-Nafis was a remarkable man and he deserves to be better known.

STUDENT'S PERCEPTION OF OBJECTIVE STRUCTURED CLINICAL EXAMINATION (OSCE) IN SURGERY AT BASRAH COLLEGE OF MEDICINE Mazin A Abdulla MB,ChB, CABS, Lecturer & Consultant Surgeon, Dept. of Surgery, Basrah College of Medicine, Basrah-IRAQ. Abstract The assessment method of OSCE gains popularity in most medical schools globally. The Department of Surgery in Basrah Medical College introduces this assessment format since 2010. The main objective of this study is to evaluate student's perception about preference of this test and acceptability of standardized patients. A survey of successive batches of medical students (3 batches of six year and 4 batches of fourth year), who had been examined with Objective Structured Clinical Examination, was conducted using a self-administered questionnaire. Data were analyzed. The study was conducted in the academic year 2011-2012. Two hundred and twenty one students completed the questionnaire, 100 students in the 6th year and 121 students in the 4th year. Eighty nine (40.3%) of the all respondents reported that OSCE was an easier examination than the traditional one and 106(48%) perceived that the duration of station was adequate. Moreover, 141(63.8%) preferred to have the traditional examination in addition to the OSCE. There was clear difference in opinion regarding the use of standardized patients (PSs) between 4th year students as 79(65.3%) dislike it while 58(58%) in the 6th year students accept the use of such patients. In conclusion, the overall student's evaluation of OSCE was encouraging, as the majority of participated students preferred this examination and at the same time they want to keep the traditional one. The benefit of this survey can be gained if timely feedback is offered on the performance of the candidates after applying the standards of OSCE.

The most common complication following appendectomy is postoperative wound infection and since it has major effects on patient’s health & recovery and on the health system as it consumes time and essential resources so from this fact came the importance of the researches that are done to find any means to reduce postoperative wound infection and many of them have been shown to be beneficial in reducing wound infection like the use of prophylactic antibiotics, postoperative antibiotics and laparoscopic appendectomy but in this study we look for the effectiveness of 2 simple measures which are peritoneal closure and wound irrigation with normal saline in reducing the incidence of postoperative wound infection. Aim of the study: to know if peritoneal closure and wound irrigation with normal saline would significantly reduce the incidence of postoperative wound infection after appendectomy. The study had been carried out from January 2010 to January 2012 in Al-Mawanee General Hospital and it had been done by the same surgeon and as emergency cases. The study included 297 patients divided into: The control group: include those in whom no peritoneal closure and no wound irrigation were done, patients in this group were 153. Case group: include those in whom peritoneal closure and wound irrigation with normal saline had been done and it included 144 patients. Comparison between the two groups had been done according to sex, age, and the state of inflammation of the appendix also factors affecting wound healing and increasing the incidence of wound infection had been taken in consideration. Data were analyzed using P value to determine the significance of the results. Although the incidence of acute appendicitis was slightly higher in males but the incidence of wound infection was found to be higher in females but it was not statistically different so sex is not a risk factor for the development of wound infection in both groups. Regarding age, in both control and case groups, the highest rate of incidence of acute appendicitis was in the age group 21-40 years but the highest rate of wound infection was in the age group 60 years and above, it was 50% in control group and 16% in the case group and so age is a risk factor for the development of wound infection and there is a clear reduction in the incidence of wound infection after the use of peritoneal closure and wound irrigation with normal saline and there were also reduction in the incidence of wound infection in all other age groups after using these two measures. Regarding the state of severity of inflammation of the appendix the highest rate of wound infection was found in the severe appendicitis subgroup in both the control (infection rate was 31.4%) and case (9.6%) groups but again there was a clear reduction in the incidence of wound infection. In conclusion: peritoneal closure and wound irrigation with normal saline help in reducing the incidence of postoperative wound infection after appendectomy.

A prospective clinical study was carried out in the ICU at Al-Basrah & AI-Tahreer General Hospitals to determine the percentage of positive sputum culture among intubated & mechanically ventilated patients compared to non-intubated patients, reflecting the impact of intubation and mechanical ventilation on increased risk of nosocomial infection and subsequent increased frequency of morbidity and mortality in ICU patients. One hundred & twenty patients were admitted to these ICUs during a 6-months period (November 2008 to April 2009), they were 55 Females and 65 Males with mean age of 44.14 year (range 4-86year). Among 60 intubated ventilated patients, 25 (41.7%) had positive sputum culture. The bacteriology of positive sputum culture was caused predominantly by Pseudomonas aeruginosa in 36% followed by Klebsiella species in 28%, streptococcus pneumonia 24% and Escherichia coli in 12%. Among 60 non intubated patients, 8 (13.3%) had positive sputum culture. The bacteriology of positive sputum culture was caused predominantly by Streptococcus pneumonia in 50% followed by Pseudomonas aeruginosa in 25% and Klebsiella species in 25%. This study confirmed that intubation and mechanical ventilation (mechanical interference) are risk factors that lead to increase the rate of nosocomial infection and subsequent increased frequency of morbidity and mortality in ICU patients.

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, biliary drainage procedure and choledochal exploration. In this interventional study we reviewed transduodenal sphincteroplasty as an option for surgical treatment of impacted lower CBD stones from a point of morbidity and mortality. A prospective study conducted over a period of 10 years from 2000 to 2010 in Basrah Teaching General Hospital and private hospitals in Basrah. Twenty three patients with impacted lower CBD stones, there were 17 females (73.9%) and 6 males (26.1%) included in this study. The impacted lower CBD stones and surgical jaundice are the main indications for surgery to which 23 patients underwent TDS. All surgeries done in elective lists. In this prospective study, 23 patients who were diagnosed as impacted lower CBD stones managed by TDS,17 (73.9%) were females and 6 (26.1%) were males. In patients with impacted lower CBD stones who underwent TDS as an option for surgical treatment, 3 patients (13.04%) developed duodenal leak, 2 of them treated conservatively and improved, while 1 patient re-explored. Two patients (8.69%) developed mild cholangitis which respond to conservative measures. The hospital stay for all patients ranges 5–14 days postoperatively, with mean stay of 7 days. No reported cases of postoperative pancreatitis following TDS in this study. No mortality reported (0 %) in follow-up for 2 years in our study. It is concluded from this prospective study that TDS in the surgical management of impacted lower CBD stones with fibrosed ampulla (sphincter of oddi) is a feasible option with accepted incidence of duodenal leak and cholangitis among the biliary drainage procedures especially in an area where the facility of ERCP are not present or failed in addition of dense adhesions in supraduedenal area intra-operatively when decisions of open abdominal exploration done, make supraduedenal CBD exploration difficult and hazardous.

HBA1C AS A MARKER FOR HIGH RISK DIABETIC SURGICAL PATIENT Nawfal Ali Mubark MB,ChB, DA, FICMS, Lecturer in Anesthesiology, Department of Surgery, College of Medicine, University of Basrah, Basrah, IRAQ. Abstract The objective of this study is to determine high levels of HbA1c in diagnosed diabetics who are considered to be euglycemics. This prospective study was conducted in 2 hospitals, Al- Taalemee Teaching Hospital and Al-Basrah General Hospital. Data collection began in September 2008 to March 2009. Sixty two diabetic patients were included in this study, all were adults aging between 18 to 80 years. They were type I or II diabetics and their last measured blood glucose was 120-150mgdl. Patients physical status was ASA classification I or II and will be subjected to elective major and super major operations. Twenty six (42%) patients appeared to have high level of HbA1c (more than 6.5%), so HbA1c level is more accurate than the blood glucose in determining the good glycemic controlled patients and in isolation of high risk diabetic surgical patients. The baseline glucose levels and HbA1c are useful in checking the efficacy of the therapeutic control of diabetes.

This study aimed to compare the efficacy of single intrauterine insemination (IUI) with double IUI in controlled ovarian hyperstimulation (COH) and IUI cycles for subfertile males. This is a prospective, nonrandomized study in hospital based outpatient infertility center.
The subfertile males were diagnosed by at least two sperm analyses. The study included ovulatory women having patent tubes and undergoing COH cycles with either single or double IUI.
Controlled ovarian hyperstimulation was induced by either clomiphene citrate (CC) with gonadotropins or only gonadotropins. Intrauterine insemination of husband’s sperm was performed 36 hours after hCG administration in single IUI group. In the double IUI group, first IUI was performed 12-18 hours and second IUI 36 hours after hCG administration. The decision as to which intervention group a patient was placed in was determined by the day of hCG administration. Ovarian response to hyperstimulation was the only factor influencing the day of hCG administration. Statistical analyses was carried out by using the student’s t test and chi-squared test. The main outcome measure is Clinical Pregnancy rate (CPR). Pregnancy was determined ultrasonographically by the presence of fetal cardiac activity.
A total of 191 couples underwent 216 COH-IUI cycles; 110 couples underwent 124 cycles with single IUI and 81 couples underwent 92 cycles with double IUIs. Cycle pregnancy rates were 9.2% (12/124) in the single IUI group and 8.2% (9/92) in the double IUI group, respectively (p=0.782).
It is concluded that a single IUI may be as effective as double IUI for couples undergoing COH/IUI for subfertile males.

Hadi Showaish Al-Khafaji* & Mohammed Hasan Jaafar# *General Surgeon in Al-Sadder Teaching Hospital in Missan. #General Surgeon in Al-Sadder Teaching Hospital, Missan, IRAQ. Abstract Burn is one of leading causes of trauma and hospitalization, with mortality, morbidity and in many occasions permanent handicaps. It comes second to car accidents in both developing and developed countries. Burns are serious health problem and are the most frequent injury among pediatric patients. Fortunately, the majority of these burns can be treated by most practitioners, and most of them can be prevented by education programs. Burn victims who were admitted to Burn unit in Al-Sadder Teaching hospital during the years 2009 and 2010 are the target of this study. Data were collected from the patients' clinical and police records along with clinical follow up. The concentration was on the causes and the mechanism of the pediatric patients burns in relation to their age and sex, disregarding the extent or depth of their burns. From 522 patients 280 were children (up to 14 years) forming 53.636% of total admissions. Children within the age of 4 years were 61.428% of the total pediatric admissions, followed by 24.285% for age group 5-6 years. There was very slight difference in sex incidence. Regarding the causes; scalding burn was 69.642% of pediatric victims, the majority are within 4 years of age 53.928%, whereas the flame burns were 28.571% of pediatric admissions, mainly in 5-7 years age group where they were 13.571%. Burn is one of leading causes of trauma and hospitalization, with mortality, morbidity and in many occasions permanent handicaps. It comes second to car accidents in both developing and developed countries. Burns are serious health problem and are the most frequent injury among pediatric patients. Fortunately, the majority of these burns can be treated by most practitioners, and most of them can be prevented by education programs. Burn victims who were admitted to Burn unit in Al-Sadder Teaching hospital during the years 2009 and 2010 are the target of this study. Data were collected from the patients' clinical and police records along with clinical follow up. The concentration was on the causes and the mechanism of the pediatric patients burns in relation to their age and sex, disregarding the extent or depth of their burns. From 522 patients 280 were children (up to 14 years) forming 53.636% of total admissions. Children within the age of 4 years were 61.428% of the total pediatric admissions, followed by 24.285% for age group 5-6 years. There was very slight difference in sex incidence. Regarding the causes; scalding burn was 69.642% of pediatric victims, the majority are within 4 years of age 53.928%, whereas the flame burns were 28.571% of pediatric admissions, mainly in 5-7 years age group where they were 13.571%.

BRAIN GRAY MATTER HETEROTOPIA WITH HEMIPARESIS Wisam Abdullah Jasim MB,ChB,FICMS, MICN. Neurosurgeon, Basrah Teaching Hospital. Abstract Definition: Heterotopia (H.) of gray matter is one of congenital migration brain anomalies in which there is a clumps of gray matter being located in a wrong place of the brain (white matter). Aim: This case has three significant points: It is a rare condition. It is one of very good examples for the superiority of MRI Brain to CT Brain in diagnosis of parynclymal brain disease. The most unique point for this case is the presence of hemi paresis which is un known manifestation for H. Conclusion: we have to think about H. as a cause of hemi paresis.

GIANT MULTIPLE PYOGENIC GRANULOMA

Ahmed M Kohil* & Zuhair F Fathallah@

*MB,ChB, Al-Sadir Teaching Hospital. @MB,ChB, MSc, Assist. Prof. of Plastic & Reconstructive Surgery, Department of Surgery, College of Medicine, University of Basrah, IRAQ.