Basrah Journal of Surgery

Abstract
The use of stem cells in spine surgery is compelling especially with the increasing age of the
general population. Regenerative medicine using stem cell therapy has sparked much interest
in this 21st century not only because of the controversies that surround the ethics involving
stem cells but their potential for use in the clinic. The ability of stem cells to repair and
regenerate new tissues and organs holds tremendous promise for the treatment of many
serious diseases and injuries. This review provides a brief summary of the current status of
research in stem cells with special emphasis on where we are in terms of the possible clinical
application of stem cell therapy in spine surgery and it looks at the available evidence and
examines the ethical issues and considerations associated with the clinical use of stem cell.

This is an overview of the various factors related to the substernal (retrosternal) goitre. The presentation and discussion include the terminology of the condition, its definition, type, the mechanism and way the goitre descends in the thorax, its incidence, clinical features, investigations, and possible challenges in anaesthesia and surgical exposures.

Anal fissure is a common and painful disorder. Its relation to hypertonic anal sphincter is controversial. The most common surgical treatment of chronic anal fissure is lateral internal sphincterotomy either open or closed methods, associated with a risk of pain, bleeding, recurrence and incontinence. The study was designed to compare the results of open and closed technique of lateral internal sphincterotomy and to find postoperative complications. This prospective clinical trial conducted in the Department of surgery in Basrah General Hospital between January 2006 and October 2008, one-hundred patients were randomly assigned to open or closed internal sphincterotomy. Standardized questionnaires assessing patients were administered preoperatively and at 1st, 2nd weeks and 1-6 month postoperatively. Out of the 100 patients included in the study, 50 patients underwent open lateral internal sphincterotomy and the other 50 were subjected to closed lateral internal sphincterotomy. There was no significant difference in postoperative acute complications. However, incontinence in terms of soiling and passage of flatus was 14% in open method and 10% in closed method. There was no difference in terms of recurrence rate being 4% both in open and closed methods. In conclusion, there was no significant difference between open and closed methods of lateral internal sphincterotomy in regard recurrence rate, healing rate, hospital stay and other complications, but in view of these findings, closed method of treatment is recommended if the surgeon is experienced.0

Anal fissure is a common and painful disorder. Its relation to hypertonic anal sphincter is controversial. The most common surgical treatment of chronic anal fissure is lateral internal sphincterotomy either open or closed methods, associated with a risk of pain, bleeding, recurrence and incontinence. The study was designed to compare the results of open and closed technique of lateral internal sphincterotomy and to find postoperative complications. This prospective clinical trial conducted in the Department of surgery in Basrah General Hospital between January 2006 and October 2008, one-hundred patients were randomly assigned to open or closed internal sphincterotomy. Standardized questionnaires assessing patients were administered preoperatively and at 1st, 2nd weeks and 1-6 month postoperatively. Out of the 100 patients included in the study, 50 patients underwent open lateral internal sphincterotomy and the other 50 were subjected to closed lateral internal sphincterotomy. There was no significant difference in postoperative acute complications. However, incontinence in terms of soiling and passage of flatus was 14% in open method and 10% in closed method. There was no difference in terms of recurrence rate being 4% both in open and closed methods. In conclusion, there was no significant difference between open and closed methods of lateral internal sphincterotomy in regard recurrence rate, healing rate, hospital stay and other complications, but in view of these findings, closed method of treatment is recommended if the surgeon is experienced.

This study aimed to learn the incidence of Helicobacter pylori infection in
patients with various gastroduodenal endoscopic lesions and the frequency of
virulence H.pylori associated genes CagA and VacA in these patients.
One hundred seventy six patients (96 males and 80 females) attending
endoscopy units for various dyspeptic symptoms were studied.
Antral biopsies were obtained to detect H.pylori by rapid urease test, culturing
and histopathologic examination. Twenty five patients with positive H.pylori
isolates who were found to be mannose resistant, were tested for cytotoxic
associated (CagA) and vacuolating cytotoxin A (VacA) genes.
Among studied patients, positive H.pylori detected by rapid urease test,
culturing and histopathologic examination (from 50 patients only) were 113
(63%), 127 (71%) and 25 (50%) respectively.
Out of 25 patients with positive H.pylori isolates who were found to be
mannose resistant, positive genes of either CagA or VacA were detected in 18
(72%) patients with positive isolates, while positivity of both genes were
detected in 13(52%) patients with positive isolates. Five (45.4%) and 5 (45.4%)
out of patients with duodenal ulcers and gastritis respectively were positive for
both (CagA) and (VacA) genes.
In conclusion, the highest detection rate of H.pylori infection was by bacterial
culture. A correlation between CagA and VacA genes and endoscopic lesions of
duodenal ulcers and gastritis was found.

Acute appendicitis is the most common abdominal emergency. In 150 patients with acute appendicitis treated by appendectomy in AL-Sader Teaching Hospital in Basrah, a prospective study was made to study the delay prior to admission to the hospital and subsequent delay before induction of anesthesia. In 67 (44.66 %) patients, the appendix was perforated or gangrenous and in 83 (55.34%) patients it was acutely inflamed. The median duration of abdominal pain to the induction of anesthesia was 18 hours ranged 3-69 hours for the acutely inflamed group and 35 hours ranged 8-70 hours for the perforated /gangrenous group. The median preadmission delay was 12 hours and 25 hours for acutely inflamed group and gangrenous /perforated group respectively, while the median post admission delay to the theatre was 2 hours ranged 1-15 hours and1hour ranged 1-13 hours for acutely inflamed and perforated / gangrenous groups respectively. Patients arriving at hospital during the hours 08:00 to 14:00 from Sunday to Thursday waited longer than those seen out of routine working hours before going to the theatre. In conclusion, Increasing age and preadmission delay were both associated with an increasing risk of perforated / gangrenous appendix. Cases of acute appendicitis should be given the same priority as cases of peritonitis if morbidity is to be minimized.

The efficacy of extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy (URS) are com
pared for the treatment of distal ureteral calculi with respect to patient satisfaction and efficacy.
This is a prospective study where a total of 85 patients with solitary radiopaque distal ureteral
calculi were treated with ESWL (n = 55) using Siemens lithotripter (Electromagnetic lithotripter )
or URS (n = 30). Patient and stone characteristics, treatment parameters, clinical outcomes,
and patient satisfaction were assessed for each group.
The two groups were comparable in regard to patient age, sex and stone size. The stone-free
status for ESWL and URS at 3 months was 76.3% and 97.5%, respectively (p<0.0001). No ure
teral perforation or stricture occurred in the URS group. Patient satisfaction was high for both
groups including 90% for URS and 80% for ESWL (p = 0.002).
In conclusion, URS is more effective than ESWL for the treatment of distal ureteral calculi.
ESWL was more often performed on an outpatient basis and showed a trend towards less flank
pain and dysuria, fewer complications and quicker convalescence. Patient satisfaction was sig
nificantly higher for URS according to the questionnaire used in this study

Abstract
Ninety patients who sustained closed humeral shaft fractures were treated in Basrah General
Hospital from March 2007 to June 2008. They were 67 males and 23 females. Age ranged from
17 to 60 years. Forty-five patients (50%) were treated conservatively and the other forty-five
treated surgically by open reduction and internal fixation using AO plate and screws. Middle
third fractures occurred in 50 patients (55%) and the transverse fracture geometry was reported
in 54 patients (60%). In conservatively treated patients, solid fracture union was achieved in 36
patients (80%) with restoration of nearly full range of motion in the shoulder and elbow joints,
the average time of union was 45-60 days clinically and 60-75 days radiographically. The only
complication of conservative treatment was nonunion which had occurred in 20% of cases. In
surgically treated group the indications for surgery were multiple fractures in 19 patients (43%),
inadequate alignment in 10 (22%), primary radial nerve palsy in 5 (11%), floating elbow in 5
(11%), non compliance in 5 (11%) and bilateral humeral fractures in one patient (2%). Following
operative fixation bony union was achieved in 80% (36 patients) at an average time of 112-140
days with restoration of nearly full range of motion in shoulder and elbow joints.
Complications encountered were nonunion in 9 patients, post-operative simple wound infection
in 3, osteomyelitis in 1 and secondary radial nerve palsy in 5 patients.
This study recommends conservative methods as the treatment of choice for closed fractures
of the humeral shaft. Open reduction and internal fixation gives good results provided that
correct indications and principles of fixation are adhered to

Abstract
This study present and evaluate the feasibility and outcome of same-day different types of
thyroidectomy in Sulaimania in the last 8 years.
From Jan. 1999 to Jan. 2007, all patients consecutively operated on for thyroid disease, were
admitted on the day of operation and discharged the day after. A prospective study was
performed for them, the clinico-pathological aspects of the disease and the outcome of the
thyroid surgery were assessed regarding hospital stay, the time when the drains were removed,
postoperative complications, interventions and readmissions and postoperative requirement for
thyroxin.
Three hundred and two patients were consecutively operated on, with a mean age of thirty
seven years; they were 265 females and 37 males. All patients were hospitalized less than 24
hours with the mean hospital stay of 15.7 hours (10-23h). Complications were few with 1.6%
minor wound infection; 1.3% seroma; 0.9% hematoma; 0.6% for both transient hoarseness of
voice and transient stridor.
In conclusions, same-day thyroid surgery is a safe and feasible procedure with minimal
morbidity and no mortality

Abstract
Clinical observation has shown that the growth rate and regional metastasis of squamous cell
carcinoma of the oral cavity is more aggressive in younger patients than in patients older than
60 years. Secondly, any surgical interference, such as incisional biopsy and/or incomplete
surgical excision, has been shown to aggravate the clinical behavior of the tumor. Accordingly,
the objective of this study was to examine the effect of patient age and incisional biopsy on
outcomes.
This prospective study enrolled 35 patients with oral squamous cell carcinoma who were
divided into 2 groups. Group I consisted of patients ≥ 60 years, whereas group II consisted of
patients < 60 years. Clinical comparisons between these 2 groups were made. Patients in
groups I and II were subjected to different treatment plans according to patient age and the
presence or absence of neck metastasis.
Patients in-group II presented with a greater frequency of neck metastasis than patients in
group I (56% vs. 18%; p< 0.05). Five years of follow-up after aggressive surgery revealed a
survival rate of 67% in group II and 65% in group I (p > 0.99) after conservative surgery. In
group I, there was a trend towards a greater percentage of patients with no initial evidence of
neck metastasis developing neck metastasis after incisional biopsy compared with patients who
did not undergo biopsy (80% vs. 22%, p=0.09).
In conclusion, age is considered a predictive factor in nodal metastasis of oral squamous cell
carcinomas, and incisional biopsy aggravates the clinical behavior of the tumor.

This study aimed to assess the impact of laparoscopy on surgical site infections (SSIs) following
laparoscopic cholecystectomy. Previous investigations have demonstrated that laparoscopic
cholecystectomy is associated with a shorter postoperative stay and fewer overall
complications. Less is known about the impact of laparoscopy on the risk for SSIs.
A prospective study was performed in Basrah General Hospital on patients undergoing
laparoscopic cholecystectomy (LC) for three years period (2006-2008) to identify the Surgical
Site Infections (SSIs) based on definition of the National Nosocomial Infections Surveillance
(NNIS) System.
For 369 patients with laparoscopic cholecystectomy, the overall percentage of SSI was 2.4%.
Infecting organisms were similar for superficial, deep and organ/space infection. The overall risk
of SSI rates were higher in patients with a contaminated or dirty wound (gall bladder retrieval
wound), with open first access technique, following emergency procedures, in males, in
patient's age 60 years or more, and with an American Society of Anesthesiologist (ASA) class
III and more. In conclusion, Laparoscopic cholecystectomy is associated with a lower risk For
SSI.