Basrah Journal of Surgery

The research of the etiology of low back pain and right leg pain has been focused on the study of histological degenerative changes of human intervertebral disc prolapse. In patients with low back pain & right leg pain and disc prolapsed according to magnetic resonance imaging (MRI), histological and histochemical studies have demonstrated several histological degenerative changes in the structure of the prolapsed intervertebral disc. Surgically excised intervertebral disc from 105 patients with lumber disc prolapsed were studied by histomorphology aided with histochemistry this include patients with prolapsed disc due to several causes. 5 control intervertebral discs were studied for comparison. Our result indicated that their was a degenerative structural changes of the intervertebral disc prolapse. Chondrocytes cloning, invasion of blood vessels into the disc matrix, disorganisation and disorientation of collagen fibers, matrix depletion and many other changes were observed.

Introduction For a variety of reasons, giant breast tumors continue to pose a challenge in diagnosis and management. These tumors are poorly understood because of their rarity and unpredictable behavior. Their rapid growth, associated with skin congestion and ulceration, and tendency to recur, gives rise to a suspicion of malignancy1,2. In addition, owing to the varied histological features seen in these tumors, there have been widely varying interpretations and diagnoses by pathologists3. This has led to inappropriate, and at times unnecessarily radical, surgical therapy. In the 1950s, breasts were amputated for this relatively non-threatening condition4. However, the present trend is towards more conservative management. In order to ensure proper surgical management, an under-standing of the natural history of the disease and its biologic behavior is essential. Bas J Surg, March, 12 2006

Introduction Up to our knowledge, this is the first case of a syndrome of unusually low placed larynx with Bat ears. There are no similar case records in the literature. Congenital laryngeal anomalies are rarely seen in daily practice, these are; laryngomalacia (60%), vocal cord paralysis (20%), subglottic stenosis (15%), and subglottic heamangioma (15%). Other malformations including laryngeal heamangioma, web, cyst and neuromuscular anomalies are very rare1. U At birth the larynx is located high in the neck between the C1 and C4 vertebrae, allowing concurrent breathing, vocalization and deglutition. By the age of 2 years, the larynx descends inferiorly and bye the age of 6 years it reaches the adult position between C4 and C7 vertebrae. The new position provides greater range of phonation (because of the wider supraglottic pharynx) at the expense of losing this separation of function, ie, deglution and breathing2-4. The auricle developed from a series of six tubercles which form around the margins of the first and second visceral cleft. The laryngeal cartilages developed from the fourth and fifth visceral arches. The trachea is formed by the cranial end of the tracheobronchial tube from the ventral wall of the primitive pharynx during the third week of the fetal life5. Bas J Surg, March, 12, 2006

Factor XIII deficiency is a rare disorder of coagulation characteri-zed by moderate to severe bleeding tendency with increased susceptibility to intracranial hemorrhages, almost normal coagulation screening tests, clot lysis in 5 M urea solution & a tendency to abnormal wound healing. It is inherited as an autosomal recessive trait. However, acquired causes for its deficiency are rarely encountered. We describe here an inherited form of F XIII deficiency in two members (a boy & a girl) in a one family in Basrah.

The Van der Woude syndrome is a rare autosomal-dominant craniofacial disorder. In its classical form consisting of a cleft lip or cleft palate, distinctive pits of the lower lips and hypodontia. This is a review of a family with VWS. The family pedigree, past history and clinical features were reviewed. The related literatures were studied, which show the variable presentations including lip pits alone, absent teeth, or isolated cleft lip and palate of varying degrees of severity, and the points for early diagnosis.

Maintenance of air way in cases of opioid induced-postoperative respiratory depression is not easily accomplished after release of neck contracture due to neck immobility and bulky dressing done by surgeon to secure the grafted skin and possible difficult intubation. We aimed to evaluate and compare the use of intravenous paracetamol to replace or to reduce morphine requirements for more safe postoperative pain management after release of post burn neck contractures. Thirty patients undergoing surgical release of post burn neck contractures were randomly allocated into 3 groups (n=10 each) where patients received immediately after extubation one of the following medications: Paracetamol 1G IX (P group), morphine 0.1 mg/kg (M group), both morphine 0.05rnglkg and paracetamol 1Gm (P-M group). Efficacy parameters were subjective pain scores, sedation and satisfaction scores, number of patients required and total dose of rescue boluses of morphine (3mg) and time to first request of analgesia. Repeated measures ANOVA and t-test were used for comparisons through SPSS software. No statistically significant difference were found between P, M and P-M groups regarding pain (except in first 15 min. in PACU) and satisfaction scores, with significantly less sedation score in P group. Time to first request for rescue analgesia was significantly longer in M and P-M groups compared with P group. Adverse events (respiratory depression and nausea or vomiting) were more frequent in morphine group. We concluded that I.V paracetamol could effectively reduce morphine requirements by 60% or even replace it with less incidence of adverse events and more safer course during postoperative pain management after release of post burn neck contracture in adults. However, it would be better if we started paracetamol earlier before extubation.

This study aimed to determine the MMR in Basra hospitals for 20 years (1983-2002), to determine the main causes of maternal deaths with regards to direct, indirect & fortuitous causes & to verify the impact of major events including wars & sanction on the trend of maternal deaths. This is a retrospective study included all maternal deaths occurred in hospitals as well as deaths recorded in emergency departments, forensic medicine department & statistical units throughout the study period. Detailed information was taken to verify the cause of death in each woman. A total of 206 deaths occurred during the study period, MMR did not run a steady fashion, they showed gradual decline during 1980s. Following the second gulf war, there was considerable increase in MMR with the peak one observed in 1996. There after the ratio decline gradually to pre 2nd war levels. Direct obstetric causes remain the major causes of maternal death throughout the 20 years with, in a decreasing frequency, hemorrhage, sepsis & AFE were the major direct causes. However, indirect causes showed some, but noticeable increment during the sanction years. We concluded that the major political events, including wars that Iraq & Iraqi peoples exposed to had substantial adverse influence on the trends of maternal deaths. Although a direct maternal death outweigh indirect death, however, sanction years caused obvious increment in direct deaths.

Abstract The management of penetrating colon injuries (PCI) in the civilian population has evolved over the last three decades. The role of resection and primary ileocolic anastomosis is well accepted for right colon injuries but the controversy still exists in the injuries involving the other parts. Some authors mandate a colostomy and others recommend primary repair with or without resection. Aim of the study is to evaluate the adopted method of surgical management of PCI in our hospital in comparison to the reported methods and to evaluate the colon-related complications in correlation with surgical options. This study was conducted for patients with PCI admitted to the Surgical Department in Basrah General Hospital between Jan.2003and Oct.2005. A total of 85 patients were included. Mean age was34.17+/-12.2 years. Seventy-three (85.9%) of them were males and 12 (14.9%) were females (male: female=6.08:1). Gunshot injury was the cause in 75(88.2%) patients and stab wound in 10 (12.8%). Right colon injuries (RCI) were found in 42 patients (49.4%) and left colon injuries (LCI) in 43(50.6%). Primary repair (PR) was performed for 27 patients (31.8%) while 58(68.2%) underwent colonic diversion (15 of them with RCI and 43with LCI). Nine colon-related complications (CRC) were developed in the PR group and 20 CRC in the diversion group (33.3% and 34.5% respectively). Four patients died (4.7%), 1(3.7%) in the PR group and 3(5.1%) in the diversion group. In conclusion, the role of colostomy has evolved from a mandatory option to a more selective one. In our study the colon-related complications and mortality rates are not significantly different between the PR and the diversion groups and this is in consistence with the reported results worldwide. We are in need to conduct a prospective controlled randomized study at least in selected patients to compare the primary repair with the diversion procedure in PCI.

Abstract Arachnoids cyst is a common pathology although it is rarely to be in the third ventricle. A twelve years child has a third ventricle arachnoids cyst that leads to hydrocephalus, the cyst has been fenestrated by endoscope, most of the symptoms that sustained over five years has been relieved.

Introduction norectal abscess is one of the common surgical problems of the anorectal region1-4. It is a suppurative process of the anal canal that originates from infection of an obstructed anal gland5,6. Once infection gains access to the intersphincteric space, it has easy access to the adjacent perirectal spaces7. Men are affected more than women with 3rd and 4th decades of life as the peak age of incidence7,8. In a descending order of frequency; perianal, ischiorectal, sub-mucosal and supralevator are abscess types according to anatomical location7-12. The bacterial profile of an abscess, which is usually a mixed infection involving aerobic and anaerobic microorganisms, is considered as a prognostic factor for recurrent abscess and fistula formation1,5, 7,10,13,14. Diagnosis is made on basis of history and anorectal examination and is usually easy except in case of deep abscess9,15. All cases require urgent incision and drainage4,16.

Distal vaginal aplasia and functional uterus is an uncommon congenital malformation. Reconstructive therapy is controversial. Mental problems may result. The objective in this case was to restore menstruation, and preserve reproductive performance by avoiding hysterectomy, in order to prevent psychological impacts of amenorrhoea and sterility. This case is a 14 years old girl presented with classical features of vaginal obstruction and functional uterus. Physical examination revealed absent vagina and a pelvic mass. The patient and her family were very concerned about menstruation and fertility. Neovagina was constructed successfully using the modified McIndoe vaginoplasty. Eventually abdominal Vagino-neovaginal anastomosis was necessary to restore reproductive tract continuity. The outcome was restoration of menstruation and made future marriage and fertility more actual. This required six surgical interventions over a period of ten months. Associated pelvic endometriosis was observed and right salpingectomy was thought necessary. Although hysterectomy is a shortcut procedure to relieve complications of menstrual retention in vaginal obstruction, it will cause psychological trauma to the patient and her family. Construction of artificial vagina and Vagino-neovaginal anastomosis can be successfully performed to provide the patient an opportunity for conservative management, resulting in menstruation, and some potential for fertility.

VIDEO CAPSULE ENDOSCOPY The first rigid endoscope that allowed inspection of the upper gastrointestinal tract under a general anaesthetic was introduced by Bruening in 1907. Forty years later, the first flexible fiber optic instrument allowed procedure to be done under light sedation. A major advance occurred in 1998 when capsule endoscopy was developed in Europe and introduced into clinical practice, which enabled complete visualization of the small intestine. The U.S Food and Drug administration (FDA) approved its use in August 2001. Since then, more than 50000 capsules have been used in more than 50 countries. Historically, the small intestine was considered technically difficult to examine because of its length, location, and tortuosity. Esophago-gastro-duodeuoscopy allows for direct inspection of the duodenum, similarly, incubating the ileocecal valve at colonoscopy or so called terminal ileoscopy can access the very distal portion of the small intestine. Evaluating the more than 20 feet of small bowel that lie beyond the reaches of these instruments has been impeded by difficult technical challenges. Yet, examination of this segment is especially important in evaluating patients with various disorders including gastrointestinal bleeding from an obscure source. Previously the small intestine could be partly assessed by a push enteroscope, which is longer (about 2 meters) than a standard gastroscope and therefore allows examination of up to 80-120 cm beyond the ligament of Treitz, while intraoperative enteroscopy required a general anasethetic and laparotomy where the enteroscope is manually fed though the small intestine and gradually pulled back to allow for close inspection of the mucosa. Barium follow though and enteroclysis allow indirect examination of the small Bowel but have a low diagnosis rate1, relatively insensitive for flat diminutive, infiltrative or inflammatory lesions. Given the limitation of these tests, there has been a surge in investigations on the practical diagnostic ability and clinical utility of capsule endoscopy that allows for direct visualization of the entire small intestine lining2,3. T Bas J Surg, March, 12, 2006

Neuroendoscopy has been one of the fastest growing technologies in neurosurgery this decade. Just as in the fields of general surgery, gynecological surgery, orthopedic surgery, thoracic surgery, and urological surgery, neurosurgeons have been exploring this technology and adding indications for its use with increasing frequency over the past several years. duction N This article review of neuroendoscopy, described the techniques used, indications, their out come and complications encountered, although it is seems variable but at the end leads to same rules.

Fournier’s gangrene is uncommon acute fulminating cellulitis of scrotum, perineum and groin which develops suddenly and often without any apparent causes. The aim of this study is to elucidate the effectiveness of early and extensive surgical excision with primarily performed complete diverting colostomy in outcome of patients. Fourteen patients with Fournier’s gangrene were included from January 2000 to October 2005 at Basrah General Hospital. History and examination has been taken. Treatment was in form of giving triple antibiotics. Early wide extensive excision of necrotic skin with complete diverting colostomy at the same occasion has been done in all patients. There were all male patients, their ages ranged between 4-75 years old, the average is 50 years. Determining the possible underlying cause finding that five patients has no obvious cause , three had perianal abscesses , determining the extent of disease , finding that in ten patients sloughing of tissue involved perineum , scrotum plus groin and or penis mortality were two out of fourteen patients ( 14%). Fournier’s gangrene is a rapidly progressive, fulminate infection. With institution of aggressive treatment, including early Surgical intervention, formation of completely diverting colostomy in first operation, haemo- dynamic support if needed, intensive care monitoring and broad spectrum antibiotic coverage, the disease has a greatly reduced mortality.

This study aimed to evaluate the cardiac changes and complications that occurred in patients who underwent upper gastrointestinal tract endoscopy. The study was conducted from January 2002 to December 2002at Basrah General Hospital and Al-Sadir Teaching Hospital. One hundred and forty eight patients complaining of upper gastrointestinal tract disorders were included in this study. Detailed history, physical examination and ECG was taken before, during and half hour after endoscopic examination. Patients were divided into two groups according if they have previous cardiopulmonary diseases. One hundred and forty eight patients included in the study, 91 males and 57 females. The age group between 20–40 years represent the commonest group underwent oesophago-gastroduodenoscopy (O.G.D) examination. All ECG changes that developed in patients before endoscopic examination arise from those who had cardiopulmonary diseases. Forty-two (40.4%) and 21 (47.7%) patients from group I. and group II. respectively showed abnormal ECG changes while 18 (17.3%) and 13 (29.5%) patients from group I. and group II. respectively showed abnormal ECG findings half hour after endoscopic examination . Bradycardia represents the commonest ECG changes occurred during and half hour after examination. We concluded that OGD is a safe procedure but in elderly patients and those with cardiopulmonary disease ECG monitoring should be done during endoscopic examination Bas J Surg, March, 12, 2006

Abstract This study aimed to find the effective method of induction of ovulation; in obese infertile patients with polycystic ovary syndrome. It is a prospective case-control study done at Infertility clinic of Basra Maternity and Child hospital. Sixty obese, hirsute infertile patients for more than two years; with ultrasound findings of polycystic ovary syndrome, subjected to the following investigations: Serum LH, FSH, Testosterone, Prolactin &fasting blood sugar. All investigations were carried on early follicular phase of the cycle. Patients were divided randomly into two groups: Group A and group B. All patients received clomiphene citrate 50-150mg for five consecutive days beginning on day 5 of the cycle. The patients with group B also received 500mg of Metformin tablet three times daily for 6 months. Ovulation- which assessed by transvaginal folliculometry, and ovarian artery Doppler velocimetry; triggered with hCG when one or more follicle measuring ≥ 18 mm in diameter, and blood flow indices of the active ovary; showing the dominant follicles were good; on ultrasonic examination. Ovulation response and pregnancy rate were assessed in both groups. Results obtained from this study pointed out the beneficial effect of Metformin on ovulation induction in obese hirsute women with PCOS. It is concluded that PCOS remains an enigmatic disease. Once considered relatively benign, PCOS is implicated in medical disorders related to hyperinsulinism and hyperandrogenemia. Restoring fertility and treating abnormal hair growth remain important considerations in the physical and psychological health of reproductive-age women. Metformin has shown great promise in the treatment of insulin-resistant PCOS, but whether it would benefit all women who have PCOS remains unclear. Weight loss is the most important primary recommendation that can be made in the treatment of PCOS.

A total of 100 conjunctival samples were cultured to investigate the bacteriologic outcome, focusing on the incidence of methicillin resistant staphylococci. Bacteria was identified in 91 cases (91%). Cultural and clinical diagnosis were found 100% compatible in neonates, 96.6% in children and 86% in adult patients. Staphylococci were isolated from 65 cases (71.4%). Methicillin resistant staphylococci (MRS) were identified in 37 cases (40.6%) of bacterial conjunctivitis, 22 of which (59.5%) were methicillin resistant coagulase positive staphylococci (MRCOPS) and 15 (40.5%) were methicillin resistant coagulase negative staphylococci (MRCONS). This study highlights the need for more work to establish the role of MRS commensals and ocular infections.

Staging of cancer will lead to better treatment decisions. Analyses of cancer survival data are commonly used to assess cancer treatment and to monitor the progress of cancer control programs. In Basrah, there is a need to study the cancer survival rates and to evaluate the case management in Basrah Oncology Center. A follow up study was designed, and all of the cases of breast cancer or lymphoma that attended Al-Sadar Teaching Hospital for chemotherapy during the period from September 2001 to September 2002 were included in the study. The cases then were followed up for one and three years following diagnosis. The study started with 480 cases; 175 cases of lymphoma and 305 of breast cancer. At the time of study, 45.7% of lymphoma cases and 16.7% of breast cancer were none-staged. 33% of lymphomas and 45% of breast cancers were diagnosed at advanced stages; most of them (84.1%) were of low family income. The study also found that 42.1% of lymphoma and 57.1% of breast cancer patients survived after one year of diagnosis, while 32.6% of lymphoma patients and 40.5% of breast cancer patients were still alive after three years of diagnosis. The suggestion is that cancer in Basrah is diagnosed at too late stages with low survival rates. So that screening programs and management of cancer in Basrah needs re-evaluation.