Basrah Journal of Surgery

Fast track surgery is a novel concept in perioperative care of patients undergoing elective surgical procedures that combines recent advances in anesthesia, new approaches to pain control, techniques that reduce the perioperative stress response and organ dysfunction, and the use of minimally invasive techniques. These measures aimed to rapid mobilization, early feeding, rapid recovery, minimize complications, and shorter in-hospital stay

Local anaesthesia for ophthalmic surgical techniques is achieving prevalence now. Various local procedures were described in the literature including retrobulbar, peribulbar, subconjunctival and topical anaesthesia. This study endeavor to ascertain the efficacy of lidocaine topical-subconjunctival anesthesia technique combined with neuroleptic sedation-analgesia consisting of fentanyl and droperidol in cataract surgery, and to test patient's and surgeon's satisfaction with this method. Sixty five patients with mature cataract age range 55-70 years were scheduled for cataract extraction. Patients were 36 male and 29 female. Topical and subconjunctival local anaesthesia was supplemented by intravenous sedative and analgesic medication consisting of 50g fentanyl and 2.5 mg droperidol. A special patient's pain scoring system used in this study with another intraoperative surgeon's satisfaction score to test the reliability of this method. All patients had successful cataract extraction with an average surgery time of 20-25 minutes. Patients had minimal or no movement during surgery. No patient required additional supplement of anaesthesia as there were no intolerable pain. No postoperative complications. Cataract surgery can be safely and effectively performed by surgeons converting to topical anesthesia using this method

Prosthetic repair has become a promising method for repairing hernias. The present study try to show the benefit of open umbrella mesh repair for umbilical hernia. This is a prospective randomised study comparing umbrella mesh and Mayo’s repair for primary umbilical hernia. Children and those who needed emergency surgery were excluded. The study was conducted on 80 patients (63 females and 17 males) with age range from 18-67 years. The follow up period was 51 months. There were no statistically significant difference between both repairs in regards to operative time, hospital stay, postoperative pain and early complications. There was earlier return to activity and no recurrence in umbrella mesh repair than in Mayo’s repair. Mesh repair represent safe and effective surgical method in repairing primary umbilical hernia

A clinical trial was set to demonstrate the effect of zinc salt on the local & general condition of burned patients. One Hundred cases were selected with long standing burn with generalized weakness and features of zinc deficiency and delayed burn healing. They were divided into two groups. Group one received zinc salt. Group two received placebo. Those treated with zinc showed good improvement both in local and general condition, although 10 patients showed no improvement but these patients need a lot more than zinc to improve. From this trial, zinc is recommended as an efficient adjuvant in the treatment of all long-standing burn cases

A prospective study was performed at Saddam Teaching Hospital in Basrah over a thirteen months period to evaluate the use of mesh hernioplasty for repairing inguinal hernias. Forty-eight patients with inguinal hernias repaired electively with mesh hernioplasty. The age distribution was (17–79) years. Three of them were diabetics, three hypertensive, two with chronic obstruction airway diseases and one with bleeding tendency. Perioperatively, the hernias were classified according to Gilbert's classification. Forty-seven primary hernias repaired according to Lichtenstein technique and one through preperitoneal approach (recurrent hernia). Forty-six hernias repaired under general anaesthesia and two under local anaesthesia. Prophylactic antibiotic was given as a single dose at induction of anaesthesia and a single postoperative dose. There were thirty patients (62.5%) indirect hernias, thirteen patients (27%) of direct hernias, five patients (10.4%) of pantallon type. The mesh used was polypropylene either as plug in one patient (2%) or plug with on-lay mesh in thirty-three patients (68.75%) or as on-lay mesh in fourteen patients (29.1%). In six patients closed suction drainage used if there was unsatisfactory haemostasis, there were few post operative complications, all patients complained of mild postoperative pain that did not require strong analgesia. No urinary difficulty detected. Six patients (12.5%) developed scrotal oedema mainly at the beginning of the study, one scrotal haematoma (2%), four (8.3%) wound seroma and one (2%) superficial wound infection, neither chronic sinus nor orchitis. No recurrence with a follow up period of 2 – 12 months were recorded

This is a prospective study designed to compare the outcome of two different lines of medical therapy for Benign Prostatic Hyperplasia (BPH), namely:  blockers alone versus  blockers and androgen suppressors in combination. One hundred patients were included in the study, which was conducted during the period from September 1998 to March 2001. Detailed history was taken with thorough physical examination and investigations. Patients also underwent ultrasonography and intravenous urography to assess the upper tract function and postvoiding residual volume. The American Uorological Association (AUA) Symptom Score, urinary flow rate and the volume of residual urine were assessed in all patients and were used for comparison. The patients were randomized into two equal groups, each consisting of 50 patients. Those in group I were given Doxazosin (4 mg/day) alone while those in group II were given a combination of Doxazosin (4 mg/day) and Finasteride (5 mg/day). It is concluded that the results obtained with combination therapy are more promising and significantly better than those obtained with a single agent. All the parameters of comparison, i.e. the AUA score, urinary flow rate and volume of residual urine, improve with both methods but to a much greater extent in group II, the combination therapy group.

Breast cancer is the most common malignancy in females all over the word. It represents about 34% of total malignancies among IRAQI females with high mortality rate representing 1-2% of female mortality &16% of cancer deaths in females in IRAQ. Many prognostic factors which can affect the treatment outcome have been studied to identify patients at high risk of disease relapse who might benefit from post-operative adjuvant therapy. The Aim of this study was evaluation of different prognostic factors to drive a reliable (Prognostic Index) that best fits our breast cancer patients, hoping to give the adjuvant treatment accordingly. This is a study analysis of 566 female patient treated for primary breast cancer between 1992 and 2001 at Oncology Unit, Marjan teaching Hospital. Modified prognostic index (PI.). Was used to identify different prognostic group. We could divide patients into 4 groups : Group 1 with PI with PI >2.5-3,group 3 with PI>3-3.5 and group 4 with PI>3.5. The 5 year overall survival (OS) and relapse free survival (RFS) were calculated for the whole group and for the different 4 prognostic groups as well as for influence of systemic adjuvant treatment. The 5 year O.S and RES were 75% and 55% respectively for patient with PI< 2.5 and decreased with the increase of the value of PI to reach 50% and 10% respectively in patients with PI> 3.5. The difference in both 5 year O.S, RFS for different prognostic groups was found statistically significant only between patients with PI3. (Groups 3 &4) with P < 0.001. It was shown those patients with PI 3. It was concluded that more intensive adjuvant treatment my be warranted for group 3 and 4 of patients

This paper presents a personal experience with a technique for indirect inguinal hernia repair, first described by Antonio Guarnieri et al. from Rome, Italy in 1992. Thirty patients with indirect inguinal hernia were operated upon, using this technique, from June 1995 to October 1996. The main characteristics of this technique are the creation of a deep neo-inguinal ring in a more medial site, shortening of the inguinal canal by transposition of the superficial ring to the point where the inferior border of the internal oblique muscle is well represented, reinforcement of the inguinal canal by overlapping the external oblique aponeurosis in a double-breast fashion, and maintenance of the cremasteric muscle. Follow up was carried out at 1,6,12 and 24 months in all the patients. There were no recurrences, no mortality and no testicular atrophy. Two patients (6.6%) had subcutaneous seroma. One patient (3.3%) had hematoma, 5 patients (16.5%) had temporary testicular oedema. The wound infection rate was (3.3%)

Recurrent urolithiasis after surgery is considered as one of the global problems in surgery. Our aim is to see the benefit of high water intake, different diet regimes and drug treatment in the prevention of this problem. A prospective study of 3 years duration (1993-1995) was carried out in Sulaimania Teaching Hospital, surgical ward, including 100 patients having urolithiasis. Only triphosphate stones (56%) and calcium oxalate stones (44%) were found in our patients. Twenty percent had recurrent stones before, 32% had associated predisposing features, mainly UTI. Only 5% developed recurrence despite all measures of prevention, probably due to ignorance of the preventive measures beside working in hot whether and associated UTI. In conclusion, high water intake, diet and drug therapy can be an effective method for prevention of recurrent urolitiasis

To determine the risk of complications of adenotonsillectomy if they are discharged after a short period of postoperative observation, this study was conducted. The records of all patients, 14 years of age or less who underwent tonsillectomy with or without adenoidectomy from July 1996 through August 2000, were reviewed. A total of 250 patients were identified, 17 patients were excluded from the study because of various medical conditions which was found to have required planned overnight hospitalization. The occurrence and severity of postoperative complications, which happened during the postoperative period, were recorded from their medical files.Complications, which were recorded, included bleeding and vomiting. The total complication rate was 9.4%, primary bleeding occurred in 2.1%, all these cases happened during the first 3 hours of the postoperative period. Secondary hemorrhage occurred in 3%. Vomiting occurred in 4.2% of the patients. we concluded that, short periods of observation could be safe, with low rate of early complications if they are discharged after a period of 4-6 hours, in appropriately selected patients

Thirty-three patients with flexor tendon injuries in 68 fingers were studied. They were 78.8% males 21.2% females. Age was range between 16 - 45 years. Patients were assigned into two zone groups; zone II & V. Twenty six fingers (38.2%) were in zone II, and 42 (61.8%) were in zone V. Primary repair was done in 42.6% and delayed in 57.4%. Both tendons (FDS*& FDP**) were repaired in 43 fingers, isolated FDP were repaired in 25 fingers. Postoperatively, only 31 fingers were managed with early active extension/passive flexion technique. The final results were evaluated by Louisville criteria and were Satisfactory (excellent and good) in 41 fingers (60.4%). The results were correlated to the involved zones, timing of the repair, type of the repair and the post-operative management program. It is concluded from this study that it is preferable to repair both tendons if possible by delayed primary repair with early mobilization when a trained surgeon and surgical resources are available

The objectives of this study are to compare caudal analgesia supplemented by sedation with general anaesthesia technique and to study the relative safety and difficulties of each technique on the patient and its benefit. A prospective study on 90 patients was performed. These patients required anorectal surgery within a period of 6 months from May-Nov. 1998. Divided into 2 groups, there were 45 operations performed under CA, and 45 operations under GA at King Hussein Medical Centre (KHMC) and Prince Hashim ben Al-Hussein Hospital (PHH) RMS JA Forces. General anaesthesia group showed uneventful course, but at the end of surgery restlessness during recovery was seen in 10 patients, demand for analgesia in 70% patients which was particular to that group. Caudal anaesthesia group: absolute failure to institute the block occurred in 4 patients in whom general anaesthesia was given. Relative difficulties were encountered in 3 patients, but the block was complete after repeated trials. O2 commenced at a rate of 4 liters/minute through oxygen mask was needed for 3 cases of mild respiratory depression. Table II showed anaesthesia for various operations and the sex distribution. The view of the patients in regard to the technique employed is demonstrated in Table III and in regard to the post operative pain is shown in Table V. Caudal anaesthesia was a useful technique when supplemented by intravenous sedation which gave sedation during the operation period and delayed onset of post operative pain

The study was designed to see the effect of diazepam 0.2mg/kg I.V. before the usual induction dose of ketamine 2 mg/kg I.V. on the cardiovascular parameters (heart rate, diastolic and systolic blood pressures). Eighty patients were scheduled for elective surgery allocated in two groups: [group A: (n=40) received ketamine 2mg.kg IV and cardiovascular parameters were measured], and [group B: (n=40) diazepam 0.2mg/kg I.V. preceded ketamine by 5 minutes and cardiovascular parameters were measured]. Group A showed a significant increase in (heart rate and blood pressure) on test period. In group B: there is a significant decrease in (heart and blood pressure). The study support the idea that diazepam is effective in reducing cardiovascular effects of ketamine to make smooth induction of anaesthesia.

FNAC for the diagnosis of cancer has been used for over a half century to diagnose tumors of almost any organ. In bone however FNAC has not been widely applied because of concerns about its diagnostic accuracy. The present study aimed to determine the value of FNAC in the diagnosis of bone lesions.Between October 2000 and September 2001, FNAC was performed on 60 patients with bone lesions. The material was smeared on glass slides fixed in 95% ethanol stained with Haematoxylin & eosin or Papanicolaous stains. In 54 out of the 60 cases open biopsies were performed and the results were statistically analyzed. Of the 60 patients with bone lesions, the male to female ratio was 1.07:1 The age ranged from 6 to 93 years and the mean age was 37.2 years. Most of the cases were in the second and third decades of life. The cytological diagnoses were malignant in 33 cases (55%) including 25 primary malignant and 8 metastatic tumors. Benign diagnoses were found in 16 cases (26.7), suspicious in 2 cases (3.3%) and unsatisfactory results in 9 cases (15%). Two false positive (3.3%) and two false negative (3.3%) results were encountered.. The sensitivity and specificity were 86.2% and 87.5% respectively; while the overall accuracy was 86.7%. FNAC is a simple, safe and relatively accurate screening procedure for differentiating benign from malignant bone lesions. However specific diagnosis and grading are often difficult to make and therefore it must never be regarded as a substitute for histopathological diagnosis

Histopathological reports of 1011 patients with squamous cell carcinoma (SCC) of the head and neck diagnosed in the pathology department in Basrah Saddam Teaching Hospital and in Al-Wiswasy Private Laboratory in the period 1984-2000 and in two periods 1984-1990 and 1991-2000 were retrospectively evaluated. The patients were classified according to their age, sex and primary tumour localization. There were 763(75.5%) male and 248(24.5%) females with a male to female ratio of 3:1. The three commonest primary tumour localization were the larynx 560 cases (55.4%), the oral cavity 305 cases (30.2%) and the nasopharynx 90 cases (8.9%). The peak age incidence for all primary tumour localization was observed in the 6th decade. Among all primary tumour localization male predominance was found. The total numbers of the cancer cases in the 2nd period were more than the 1st period with arises of 50%

The right wrist of twenty cadavers were examined to measure the three dimensions of the carpal tunnel by using a Vernia (INOX), the cross sectional area and volume were then calculated for males and females separately. All were above 40 years. Males were found to have larger carpal tunnel than females of the same age group, both in cross sectional area and volume. It was found also that the volume of the tunnel change according to the age. The pattern by which the volume changes is different in males and females. In active age group i.e. fourth to sixth decade, the tunnel volume in females’ collapse but it expand in males, this may explain the high incidence of carpal tunnel syndrome in females in this age group and the low number of affected males. The age / volume relation may shed some light on the etiology of the “Idiopathic” carpal tunnel syndrome

A comparative study of hysterosalpingography (HSG) and laparoscopy in the Investigation of infertility is presented. Laparoscopy with permeability testing was performed in 68 patients previously investigated by HSG. Complete history of factors that may predispose to tubal occlusion was obtained. Patients with problems of ovulatory failure or poor semen analysis that may contribute to their infertility were excluded. There was agreement between the two techniques in 19 (27.9%) of cases where both tubes were patent i.e. all the cases that identified to be patent in HSG, were patent in laparoscopy. Similarly, agreement between the two techniques in terms of bilateral blockage (26.4%), right tubal blockage in only (5.8%), and the left tubal blockage, there was (4.4%) agreement between two techniques. The overall agreement between the two methods was (64.5%) of cases. However, the diagnostic accuracy of the two methods differed significantly. It would appear that laparoscopic hydrotubation, despite its invasive nature has an edge in diagnostic accuracy when compared with HSG. It would be advantageous to subject patients in whom HSG has shown tubal blockage to laparoscopy or any of the newer techniques of hysteroscopy or sonographic hydrotubation

Thirteen cases of DIC were studied retro and prospectively for the period from 1st June 1999 till 30th June 2000 in Basrah Maternity and Children Hospital, with an age range of 25-42 years and a parity range of 1-7. They were proved clinically by combined supervision of a Physician and an Obstetrician and the assessment of prothrombine time and platelets count. Seven of them eventually died due to uncontrollable bleeding. The remaining six survived the attack. Genital tract injuries (3 cases), placenta accretes (2 cases), amniotic fluid embolism (2 cases), postoperative Caesarian section (2 cases), incompatible blood transfusion (1 case), induced abortion (1 case), pre-eclampsia (1 case) and hydatidiform mole gestation (1 case) were noticed to be the major precipitating factors for the problem. The total number of deliveries during the period of the study was (11235).This gives an incidence rate of 1.15/1000 live births. Eight cases (62%) were of low social class, four cases (40%) of medium social class and only one case (8%) of high social class. The present study also probed the role of different other parameters in DIC like parity, presence/absence of ANC and the availability of fresh blood. The presenting study was also compared to different other studies done on the same subject, which shows that there was only seven cases of Maternal death due to DIC (for the period 1988-1992) in Basrah Maternity and Children Hospital. So we think that our results indicates that the problem of DIC is increasing during recent years, probably due to defective management

The effect of interpregnancy interval (I.PI) on birth weight and gestational age of infant was investigated in this prospective study among 250 post delivery women at Basrah Maternity and Child Hospital from the period of 1st December 1999 to 1st September 2000. Seventy five (30%) were found to have I.P.I. < 6 months, 84 (33.6%) of 6-12 months and 91 (36.4%) were found to have >12 months. Preterm rate in study group was 18/250(7.2%) with a high incidence among women with short I.P.I (16%) in comparison to other two groups, this difference was statistically significant. Small for gestational age (S.G.A) were 15/250 (6%) with a significant association among short I.P.I (12%). Women with short I.P.I were younger (21-30) years (56%), of low parity (p1-2) (56%) while high parity group (p5-6) have long I.P.I (17.5%). Women with short I.P.I were of low social class, (40%) of women with

We describe a newly diagnosed case of non-Hodgkin’s lymphoma with clinical and haematological features of bone marrow necrosis in a three-year old female who sustained a rapidly progressive and terminal course

Three patients with upper gastro intestinal (UGI) bleeding have been admitted to Baghdad Teaching Hospital over the period from 1999-2002. The first patient was a 35-year old female with recurrent UGI bleeding; the investigations and operative findings proved that the cause of bleeding was due to false aneurysm of the splenic artery communicating with the pancreatic ducts. The second patient was a 70-year old male, the cause of the attacks of bleeding was due to malignant endocrinal tumor of the head of pancreas eroding the duodenum. The third patient was a 65-year old female with gastric perforation and bleeding due to tuberculosis of stomach as shown by histopathology results.

This case report of rare and dangerous obstetric condition, advance abdominal pregnancy, includes the clinical presentation of the patient, pre-operative diagnosis and surgical management of such case with maternal survival in Basrah Maternity Hospital