Basrah Journal of Surgery

Obese patients loss more weight with bariatric surgery than with medical weight loss treatment. ‎The laparoscopic Roux-en-Y gastric bypass procedure results in more short term weight loss ‎than laparoscopic adjustable gastric banding, but the latter has fewer postoperative ‎complication and lower mortality rate; long term comparative data are currently lacking. The ‎decision regarding which procedure to perform should be based on individual patient and ‎surgeon factors.‎ Early complications of gastric bypass surgery are bleeding, anastomotic leak, wound infection, ‎thromboembolism, and anastomotic stricture. Longer term complication scan include marginal ‎ulcers, bowel obstruction, gallstones, and nutritional deficiencies.‎ Complication of adjustable gastric banding includes prolapsed and erosion. Patient typically ‎loses more than 50% of their excess weight after bariatric surgery. Obesity related diseases ‎markedly improve after bariatric surgery, reducing cardiovascular risk and improving life ‎expectancy. Patient undergoing bariatric surgery must commit to a program of lifestyle ‎changes, diet, vitamin supplementation, and follow-up.‎

Almost four decades ago, the Committee on Trauma (COT) of the American College of ‎Surgeons (ACS) developed a list of standardized equipment for ambulances. Since 1988, the ‎American College of Emergency Physicians (ACEP) has published a similar list. Both of those ‎organizations collaborated on the existing joint document, published in 2000. With this revision, ‎the National Association of Emergency Medical Service Physicians (NAEMSP) has agreed to ‎participate in this collaboration. All three organizations adhere to the principle that emergency ‎medical technicians (EMTs) at all levels must have the appropriate equipment and supplies to ‎optimize prehospital delivery of care, since EMTs care for patients of all ages, with a wide ‎variety of medical and traumatic conditions.‎

Our aim is to investigate the levels of blood lead, serum copper, zinc and iron in patients with ‎retained missile. Blood lead, serum copper, zinc and iron concentrations were measured in 54 ‎patients with retained missile and compared with 60 control apparently healthy individuals by ‎flame atomic absorption spectrophotometry technique. Blood lead levels were significantly ‎higher in the patients than in the controls, while no significant differences in serum copper, iron ‎and zinc concentrations were noticed. There were significant positive correlations between ‎blood lead levels and duration of exposure of the retained missile, as well as the size of ‎retained missile, but insignificant correlation between (copper, iron and zinc) with either the size ‎or the duration of exposure of retained missile was observed. These findings suggest that the ‎patients with retained missile had higher blood lead level and consequently undergoes lead ‎poisoning when compared to the control individuals. Also this data indicates an involvement of ‎size and duration of exposure of retained missile as important factors to lead poisoning.‎

Osteosarcoma is a malignant tumor of mesenchymal cells characterized by the direct formation of bone or osteoid tissue by the proliferating malignant tumor cells. Grading of tumor is a good prog¬nostic indicator. It constitutes a basic factor of the current Enneking osteosarcoma staging system. The detection and identification of markers able to differentiate a high from a low malignant osteosarcoma which would substantially help the diagnosis, the prognosis and consequently the therapeutic approach of these tumors. This study is aimed to determine: The contribution of osteosarcoma to the total number of the malignant bone tumors registered in Basrah during the period of the study. The various histological subtypes and grades of osteosarcoma. A total number of thirty-seven cases of osteosarcoma diagnosed during the period 2000-2004 inclusive were collected from private and governmental hospital histopathological labrotaries in Basrah province. Clinical data concerning the age, sex, clinical presentations, radiological fea-tures and gross appearance of affected bone were evaluated. Histological sections of 25 out of 37 cases, were collected, re-evaluated and grades. Osteosarcoma was the most common primary malignant tumor of bone classified according to the tumor matrix into histological subtypes and analyzed for histological accounting for 35.92% of the primary malignant and 20.55% of the total malignant bone tumors. Of these 37 osteosarcoma cases, 35 (94.59%) were intramedullary and 2 (5.40%) were parosteal surface osteosarcoma. The male to female ratio was 1.1:1. The second decade was the most common age group of occurrence accounting for 23 out of 37 cases (62.2%). The main presenting clinical features were painless swelling recorded in 51.4%.The distal end femur, proximal end tibia and proximal end humerus were the most common sites of affection accounting for 27.02%, 32.43%, 16.21% respectively. The most common subtypes of osteosarcoma was osteoblastic (52%) followed by fibroblastic (Osteosarcoma 24%) and chondroblastic (20%); while telangiectatic subtypes was rare (4%). Parosteal osteosarcoma was a rare variant in our locality and other variants were not diagnosed during the period of the study. The majority of osteosarcoma cases (76%) were of grade III, followed by grade II (16%) and grade I (8%).

Sclerosing encapsulated peritonitis or abdominal cocoon is a rare disease that is characterized by a total or partial encasement of the small bowel by a thick and fibro tic membrane. Thirty eight cases were reported since it was first described. It occurs primarily in adolescent females in tropical and subtropical regions. Preoperative diagnosis is a matter of challenge and usually made at laparotomy. We report a patient with partial intestinal obstruction and abdominal co-coon that was diagnosed during surgery. We review the literature and discuss the etiology of this disease.

Incisional hernia is frequently met by the general surgeon, its frequently complicate (3.8-11.5%) of patients after abdominal surgery. Repair of large incisional hernia is a difficult surgical problem with recurrence being a common. Numerous methods of repair have been described simple opposition in one layer or complex opposition and the use of prosthetic mesh. The aim of this study is to report our experience with use of mesh repair and risk factors that influence post operative complications. A prospective study done in Basrah General Hospital, Department of Surgery between January 2003 to December 2006.One hundred and ten patients with prosthetic repair of incisional hernia were included in this study. History was taken and thorough examination was done, all patients were asked for history of diabetes mellitus, obesity, corticosteroid use, their original operations, primary or recurrent hernia and examined for their body mass index, size and duration of the hernial defect were recorded. A proforma was completed for each patient, noting prophylactic antibiotics had been given or not, type of the sac and whether opened or inverted, type and size of mesh had been used, intraoperative and postoperative complications and postoperative hospital stay. Of (110) patients, (62) were females, (48)were males,their median age was (45.5) years for women and (58) years for men,(31)patients(28.2%)weighted more than their ideal body weight and had body mass index equal or more than(30).Forty eight patients (43.6%) were diabetic and (24)patients(21.8%)were corticosteroid used. The original operations were bowel related and gynecological in the majority of patients. Previous incisions were long midline in(38). Twenty patients had one past operation, (13)had two,(5) had three and one patient had four past repair, the remaining were new Incisional hernia patients. The main hernia size was (12.3) cm and (4.6) cm in vertical and horizontal direction respectively. Forty four patients had additional surgical procedures, consisted of Fallopian tube ligation in (12) ,division of small bowel adhesions in (8) ,suturing of small bowel perforation in (4) and abdominoplasty in (20) patients. In the majority of patients (78), standard polypropylene mesh had been used and vicryl-prolene (Vypro) mesh in the remaining (32) patients. The main postoperative complications were seroma formation (17.3%), wound haematoma (10%), wound infection (9.1%), chest infection (6.4%), one patient developed intestinal fistula and mesh need to be removed. Five recurrent incisional hernias occurred. Most patients developed complications were obese, diabetic and corticosteroid used. No death in our series. It is concluded that tension free incisional hernia repair using prosthetic mesh is a safe and easy procedure with no major morbidity or recurrence. The patient-doctor should advice weight loss to help reduce risks of surgery and improve the surgical results. Control of diabetes, corticosteroid drug use and smoking cessation are recommended for better results. Rigid sterile condition, precise and meticulous technique with the use of closed suction drains is important.

Anal fissure represents one of the most common diseases of the ano-rectum in which there is denuded epithelium of the anal canal overlying internal sphincter. In this study 110 patients underwent posterior midline sphincterotomy as the treatment for their chronic anal fissures. Mean operating time was 5 minutes and no patient stayed at hospital overnight. All patients were followed-up for 6 months. Symptoms were relieved right following surgery. Four patients developed wound infection. Other 4 patients experienced some difficulty in micturition but none had retention. Six patients experienced relative incontinence to flatus for a couple of weeks postoperatively but all of them regained their sphincter control after that. No patient complained of incontinence for feces. There were no serious scarring of the area like keyhole deformities or its variants and none of the patients developed recurrence. Almost all the patients were satisfied with the outcome. We recommend posterior midline internal sphincterotomy as the surgical treatment of choice for chronic anal fissure because it is simple to perform and results in quick relief of pain and rapid healing in almost all cases, with very few complication and negligible recurrence.

The aim of this study was to evaluate the effect of acute maternal hydration on amniotic fluid volume in pregnancies with third tri¬mester olighydramnios. The study was done at Al-Basrah General and Al-Basrah Maternity and Child Hospitals. A prospective case control study in which amniotic fluid volume was evaluated in 100 pregnant women be¬tween (32-40) weeks of gestational age with oligohyramnios (Case) and normal amniotic fluid index (AFI) and normal AFI (Control). Fifty women of oligohydramnios and fifty of control were made to drink 2 litres of water over 2 hours before repeating AFI measurement. The pre & post-hydration AFI were compared between the two groups. The AFI in olighydramnios & control groups were increased significantly by mean of 1.91 ± 0.61, P< 0.001 and 2.57 ± 1.37, p< 0.001 respectively . The data were analyzed with paired t-test for statistical significance . In conclusion, maternal oral hydration could be of therapeutic value in women with oligohydramnios.

Gastrointestinal stromal tumour (GIST) is the most common mesenchymal tumour of the gastrointestinal tract. Although GIST has been clinically recognized for almost 20 years, a standard definition has only recently been clarified. These tumours were frequently classified as leiomyomas, leiomyosarcomas, leiomyoblastomas, or gastrointestinal autonomic nerve tumours1. Over the past few years, scientists have begun to unravel the molecular abnormalities that underlie the pathogenesis of these tumours. They are now considered to share a common progenitor cell with the interstitial cells of Cajal2. GISTs are characterized by immunohistochemical expression of the CD117 antigen. Surgery is the main line of treatment in operable cases. GISTs are highly resistant to conventional chemotherapy and radiotherapy. Imatinib, a tyrosine kinase inhibitor is an approved specific target for systemic therapy. The author had the chance of managing several patients diagnosed to have GISTs, recently three of them were managed during the last few months, and two more new cases are awaiting their surgery. This report is a presentation of these cases and a highlight of the clinical features, pathology, diagnosis and management of GISTs.