Journal of the Faculty of Medicine Baghdad

Background: Laparoscopic sleeve gastrectomy (LSG)is derived from the biliopancreatic diversion with duodenal switch operation(BPD-DS). Specific and potentially severe complications of LSG are bleeding from the staple line and staple line leakage (SLL). A staple line leak may result in severe morbidity with potential sepsis and multi- organ failure.
Objectives: To review our experience with the definitive surgical management of staple line leak Post sleeve gastrectomy and its outcomes.
Patients and methods: retrospective review of patients who underwent definitive surgical treatment of staple line leak post sleeve gastrectomy from May 2014 till June 2016 at Saint Raphael center of morbid obesity, Primary surgery was laparoscopic sleeve gastrectomy in all patients. Staple line leak was diagnosed at the gastroesophageal junction in all patients.
Results: Six female patients were treated with definitive surgical management, mean body mass index was 42.7±4.0(range from 35.3-51.2 kg/m2 ), all patient had no associated co-morbidities related to obesity, the mean age of the patients was 36(range from 29-43 years), The leak was at the Gastroesophageal junction in all patients.All patients were fully recovered after definitive surgical treatment of leak, no signs of persist leak during the follow up period, with no mortality
Conclusions: Definitive surgical repair with conversion to Roux-en-Y gastric bypass, is safe and very effective and should be done when the general condition of the patient is optimized whenever possible.

Background: One of the most significant advances in the treatment of intra-abdominal collections during the past 2 decades has been the introduction of image-guided therapy with percutaneous catheter drainage. The development of improved imaging modalities, together with broad-spectrum antibiotics and soft drainage catheters, has changed the treatment of collections that previously required an urgent operation. Disease processes that have traditionally been treated with open surgical drainage and debridement can now be resolved with percutaneous catheter drainage and antibiotics. In selected cases, this will allow for better preparation of the patient for a later elective and definitive operation.
Objective: Highlight the outcome, safety and effectiveness of percutaneous drainage procedure of abdominal collections performed under imaging guide.
Patients and Methods: Forty one patients were referred from surgical wards and emergency department after diagnosing abdominal collections. Then each case discussed with radiologist to determine the route and type of catheter and imaging modality for guidance (ultrasound and/or computerized tomography). The size and site of the collections were estimated along with the most suitable approach and angle of catheter insertion. A safe drainage route was identified avoiding solid organs and bowel.
Results: Percutaneous drainage of 41 abdominal collections under imaging control was carried out in 41 patients during a one year period. No complications resulted from the procedure itself. Percutaneous drainage was sufficient to drain the collections in 35 cases (no further surgery is needed). Of those who require surgery (5 patients), the procedure considered to be as a temporary measure. One case was diagnosed as sero-mucinous tumor of bowel.
Conclusion: Percutaneous drainage of abdominal collections is a safe, effective and minimally invasive alternative approach to formal surgical drainage.The advantages include: the drainage can be done under local anesthesia, diagnosis and treatment can be achieved simultaneously in radiological department.
Key words; Percutaneous drainage, Imaging guide, Collection.

Background: The surgical treatment of pilonidal sinus varies from wide excision and laying the wound open or excision with primary closure or excision with the use of skin graft in some special cases.
Objectives: The objectives of this study is to determine the efficacy of treating non complicated pilonidal sinus disease with minimal excision and primary closure technique, complications and recurrence rate.
Patients and methods: This is a prospective study conducted in shahid ahmed ismaiel hospital in rania – As sulaimania IRAQ during the period from December 2013 to January 2016 and was carried on one hundred (100) consecutive patients with non complicated non recurrent pilonidal sinus patients who were treated with minimal excision and primary closure technique. The data were analyzed focusing mainly on complications mainly infection, gapping, wound disruption, recurrence rate and patient’s compliance to antibiotics use and local wound care.The results obtained were compared with other similar studies.
Result: One hundred patients with non complicated pilonidal sinus were treated with minimal excision and primary closure technique.Fifteen patients developed superficial wound infection, seventeen patients developed simple superficial wound gapping .Three patients developed deep wound infection with disruption. Four patients developed recurrence and they were treated with re-excision and skin graft placement. Minimal follow up was six months, Operations were done under general or spinal anesthesia .operative time ranged between 12 to 22 minutes (mean time 17 minutes).
Conclusion: Minimal excision and primary closure technique for the treatment of pilonidal sinus disease is associated with short hospital stay, shorter off work time, less cost, low complications rate and low chance of recurrence.
Key words: Pilonidal sinus, minimal excision, primary closure, recurrence rate.

Background: Infection with Hepatitis C virus (HCV) is a major cause of chronic liver disease, WHO estimated that about 170 million people are infected with Hepatitic C virus, Silymarin (Legalon) have been recently shown to be effective in treatment of Hepatitic C virus infection.
Objectives: The effectiveness of Legalon (Silymarin) on viral load in patients with Hepatitic C virus infection.
Patients and methods: A prospective case – control study included 400 patients with Hepatitis C virus infection. 200 patients (group A) were treated with (peg-interferon, ribavirin, silymarin) the other 200 patients (group B) were treated with (peg-interferon, ribavirin) . only G1 & G4 genotypes were included , viral load were assessed initially and after 3 months in patients with positive viral load.
Results: Viral load follow in group A, Hepatitis C Viral load was reported in 150 cases giving a response rate of 75% while in the 200 cases of group B the response was reported in 110 giving an overall response rate 55% , this indicate that cases in group A had a significant higher response rate than those in group B.
Conclusion: Patients taking Silymarin (420 mg/day) for 3 months showed a decrease in viral load, effectiveness of silymarin was more in Genotype 1 than in the Genotype 4, the response was better in low viral load patients ( less than 600000 IU/ml).
Keywords: Hepatitis C, Treatment, Silymarin effects on treatment.

Background: Postpartum hemorrhage is an important cause of maternal morbidity and mortality. Considerable difference of opinion exist regarding the optimal approach to the management of the 3rd stage of labour, practice varies between countries &between units.
Objectives: To evaluate the effectiveness of intra umbilical vein injection of oxytocin and umbilical cord driange in shortening the duration of third stage of labour.
Patient and Methods: In this randomized controlled study, 100 women were enrolled in this study they divided into three groups. (Group 1 ,N =30 )received 20 units of oxytocin diluted in 20 ml 0.9% saline solution injected in the umbilical vein after clamping.(Group 2, N = 34) placental cord drainage.(Group 3, N= 36) with no intervention. The primary outcome was mean duration of third stage of labor.
Results: The third stage of labor was significantly shorter in group 1 and 2 as compared to group 3. Groups 1 shorten the duration of third stage of labor by 3 min. and group 2 shorten the duration of third stage of labor by 4.27 min.There were no reports of need for manual removal of placenta or retained placenta.
Conclusion: The use of intraumbilical injection of oxytocin and placental cord drainage in the third stage of labor significantly reduced the duration of the third stage.
Key word: intraumbilical cord oxytocin, umbilical cord drainage, third stage of labour.

Background: Since 1985 the World Health Organization (WHO) had stated: “There is no justification for any region to have Caesarian Sections (CS) rates higher than 10-15%”. Since then, CSs have become increasingly common in both developed and developing countries. The rate of CS has been reported to be as high as 24.5% and 25.8% among Iraqi women in the years 2009 and 2010 respectively.
Objectives: The study was designed to provide data on the level of existing knowledge, attitudes and preference of modes of delivery, which can be used as a platform to raise knowledge among pregnant women and their partners and thereby empowering women to make informed choices.
Patients and Methods: This cross-sectional study was undertaken in an antenatal care clinic in Baghdad Teaching Hospital, Medical City, and Baghdad from 1st Feb. -31st May 2016. All 300 pregnant attending antenatal clinic were interviewed with a structured questionnaire that solicited information on their knowledge, attitudes and preference towards modes of delivery.
Results: Mean age of pregnant women was 28.3 ± 9.8SD years and84.7% were not employed. More than half of them (54.3%) had married at younger age (<20 years). Educational levels were 43.3% primary, 18% secondary and 20.4% university levels. Knowledge of majority of pregnant mothers (82.6%) about modes of delivery were obtained from relatives. Half of pregnant women had good knowledge about modes of delivery, 51.3% of them had negative attitude toward CS, and 62% had positive attitude towards CS delivery in current pregnancy.
Conclusion: Study results emphasize the need for educating families, especially pregnant women and their partners about the pros and cons of different modes of giving birth to their babies.
Keywords: pregnant women .Knowledge, Attitude, Mode of delivery, Baghdad.

Background: Preeclampsia is most common medical disordersduring pregnancy, and the rate of hypertension ranges from 5 – 8 % f or all types of pregnancy. There was a significant difference between cancer antigen -125, plasma fibrinogen and C- reactive protein to the severity of preeclampsia.
Objective: To determine the level ofserum CA-125 level, C-reactive protein and plasma fibrinogen in preeclampsia and their association with the severity of disease and progression of mild preeclampsia to severe type.
Patients and method: A prospective case-control studywhich was carried out in the department of gynecology and obstetric at Baghdad teaching hospital from 1st ofJanuary 2015 to 1st of July 2015.One hundred forty pregnant women were included; they were selected and divided into three groups:
Group A: Thirty five (35) pregnant women with mild preeclampsia.
Group B: Thirty five(35) pregnant women with severe preeclampsia.
Both group A and B are selected according to the clinical signs, symptoms and investigations and admitted to obstetrics ward for evaluation.
Group C: seventy (70) pregnant women with uncomplicated singleton pregnancies as control group .
Blood samples were taken for measurement of serum cancer antigen -125, C- reactive protein and plasma fibrinogen for all groups
Results: The mean level of Cancer antigen- 125in control , mild and severe preeclampsia groups was ( 14.4±4.11) , (33.60± 4.52) and ( 37.35± 4.85) respectively which was a significant difference between control ,mild groups ( p value < 0.0001) and between control and severe preeclampsia groups ( p value < 0.0001), the mean level of C-reactive protein in mild and severe preeclampsia was( 15.62± 2.6)and ( 29.3± 7.02) which was significant higher in comparison to control group which was ( 8.17 ± 1.56 ) the P value was < 0.0001 . theplasma fibrinogen levels in mild and sever preeclampsia was (470.37±51.1) and (563.14±48.28) which were markedly higher than that of control group (342. 97±56.6) in third trimester pregnant women.
Conclusion:Serum Cancer antigen -125, Serum C - reactive protein and Serum plasma fibrinogen were significantly higher in preeclampsia groups in comparison to the control group and these increments was directly correlated with the severity of preeclampsia .
Key Words:preeclampsia, plasma fibrinogen, CA 125, C – reactive protein.

Background: preeclampsia is characterized by endothelial dysfunction with vasoconstriction due to cell adhesion molecules or mediators released by defective placentation. Soluble platelet selectin, one of the cell adhesion molecules, is elevated in many inflammatory conditions including preeclampsia.
Objective: To investigate if soluble platelet-selectin levels can be used as a marker for adverse outcomes in pregnancy complicated with sever preeclampsia
Patients and methods:This study involved 115 pregnant women in their third trimester of pregnancy; divided into Group A: involves 25 pregnant women with preeclampsia complicated by intrauterine growth restriction.Group B: involves 35 pregnant women with preeclampsia without intrauterine growth restriction.Control group: involve 55 pregnant women with normal blood pressure and normal fetal growth .The data were conducted from patients by special questionnaire, this involve name, age, parity, examination included vital signs, abdominal, obstetrical examination and investigations including :Liver function test, Renal function test, Complete blood picture and maternal serum levels of soluble platelet selectin was measured by enzyme-linked immunosorbent assay ,albumin in urine and serial obstetrical ultrasound scan to confirm the diagnosis of intrauterine growth retardation and Doppler study to determine fetuses at risk .
Results: this study revealed a significantly higher concentration of soluble platelet selectin levels in serumofpreeclamptic women with and without intrauterine growth retardation versus normotensive and normal fetal growth. The maternal serum levels of sP-selectin in preeclampsia without intrauterine growth restriction were significantly higher than preeclampsia complicated by intrauterine growth restriction .Sensitivity was 91.7% and specificity 100% at cut off value 6.975 ng/ml of maternal soluble platelet _selectin for prediction of adverse pregnancy outcome .
Conclusion: soluble platelet -selectin levels have a positive significant correlation with the severity of preeclampsia, so it can beconsidered as a marker for its severity and can be used as a predictor for adverse outcomes as itsnegatively correlated with these complications
Keywords:soluble platelet-selectin ,preeclampsia with & without intrauterine growth retardation versus normotensive pregnancy .

Background: The annual incidence of stroke in children after the newborn period is approximately 2.3 per 100000. Half are ischemic, and half are non-traumaticintracerebral and subarchnoidal hemorrhages.
Objectives: To study the etiologic factors, clinical presentation andoutcome of stroke among children admitted to children welfare teaching hospital/Baghdad.
Patient and methods: A prospective study was carried out in Children Welfare Teaching Hospital;Children age ranged between 1 month -13 years and was admitted to pediatric neurology ward between 1st of November 2013 and 1st of November 2014. After carful clinical history, physical and neurological examinations, the diagnosis of brain stroke was confirmed in all patients by computerized tomography (CT) and/or magnetic resonance imaging (MRI). Patients included in this study were those diagnosed as having ischemic stroke, hemorrhagic stroke.
Results: The total number of cases were 61, 36 were male (59%). The age at onset ranged from 1-156 months. Ischemic stroke constituted 39 patients (63.9%). The most common etiologic factors for the ischemic stroke were protein C deficiency (9, 23.1%). The most common etiologic factor for hemorrhage was bleeding disorders in about 50% of patients. The most common presenting features were hemiplegia, seizure, alteration of consciousness; Cranial nerves palsy is mostly present in the ischemic stroke (14,35.9%) and only in one patient (4.5%) of hemorrhagic stroke.
Conclusions: Ischemic stroke is more common than hemorrhagic stroke in pediatric age group. The significant risk factors for ischemic stroke are protein C deficiency, Congenital heart disease(CHD) and positive family history, while vitamin K deficiency, prolong Partial thromboplastin time (PTT) and trauma are significant for hemorrhagic stroke. The most common clinical features of both types of stroke are hemiparesis, siezure and alteration of consciousness.
Keywords:Ischemic stroke, Hemorrhagic stroke, Children Welfare Teaching Hospital.

Background: neonatal period is the most vulnerable and high risk time in the life because of the highest mortality incidence in human life during this period. Neonatal mortality rate is defined as the number of deaths twenty seven completed days of live per 1000 live births.
Objectives: To determine the neonatal mortality rate (NMR) in Al-Ramadi province, the center of Al-Anbar Governorate, Western Iraq, from 2003-2013 with rate comparison of the two different stages of that period.
Methods: Data were collected from the births and deaths certificate center in Al- Ramadi province, Western Iraq, included; age, sex, address ,date of birth and cause of death. Data collected in two different periods, the first period from 2003- 2007 and the second period from 2008- 2013. The neonatal mortality rates (NMRs) were analyzed and compared with other studies.
Results: The neonatal mortality rate (NMR) of the first period was 34.5/1000 and neonatal mortality rates NMR of the second period was 24.3/1000. During the 11 studied years the higher rate of neonatal mortality was in 2006 (36.8/1000) and lower rate in 2012 (21.3/1000). Approximately two-third of neonatal deaths occurred during the early neonatal period and one third in the late neonatal period. Males had higher neonatal rate (NMR) than females, and rural residence higher than urban.
Conclusions: Al-Ramadi province had high neonatal mortality rate comparing with national Iraqi neonatal mortality rate (NMR) ,due to deterioration of socioeconomic and security conditions. There was significant association between NMR and residency and significant association between NMR and gender.
Key words: Neonatal mortality, early neonatal mortality rate, late neonatal mortality late.