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2015 volume:21 issue:2

BASRAH JOURNAL OF SURGERY       2015 volume:21 issue:1 

Editorial

Good Surgeon, bad surgeon, outstanding surgeon………………………………………………1

Thamer A Hamdan

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 Current Concept

 ORBERATM  INTRAGASTRIC BALLOON SYSTEM  ……………………………………………..3

Issam Merdan

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 Original Articles

 THE FACTORS THAT INFLUENCE ON NERVE CONDUCTION IN DIABETIC PATIENTS….7

Oras Kadhim Baqer, Thamer A Hamdan & Abdul Al-Razzaq N Khudair

 Abstract

The alteration in nerve conduction is considered one of the important complaints of patients who are suffering from diabetes mellitus nowadays. Therefore, we conduct this study which aimed to evaluate the nerve conduction velocity and amplitude in diabetic patients and assess the effects of the patients’ age, severity and duration of diabetes on nerve conduction impairment. A case control study, the studied sample were 200 persons, 150 diabetic patients (93 males and 57 females) and the control group consisted of 50 participants (32 males and 38 females). All the patients attended the neurophysiology outpatient department of Al-Sader Teaching Hospital in Basrah city. The diabetic participants were selected at random from age, diabetes duration, and sex. Regarding the ages and exclusion criteria of the controls were ranged same as the diabetic. All participants were interviewed and a questionnaire form was filled prior to examination.  Both the diabetic patients and the controls were subjected to the same electrophysiological and laboratory investigations.

The results of the study showed a significant decrease in nerve conduction velocity and amplitude in diabetic patients comparing to controls in all the examined nerves. Furthermore, there was a significant association between advancing age and longer-duration of diabetes with the reduction of conduction velocity and amplitude. Also, a significant inverse correlation between increased severity of diabetes disease (HbA1c level) and decreasing of both conduction velocity and amplitude. However, the study demonstrated no statistical significant difference between patients and controls regarding the gender. In conclusion, the age of the patients, duration of the disease and the severity of diabetes (hyperglycemia control) are playing a crucial role as risk factors in developing of peripheral neuropathy in diabetic patients.

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IS SPINAL ANAESTHESIA A CONVIENIENT OPTION FOR LOWER SEGMENT CAESAREAN SECTION IN MODERATE TO SEVERE PREECLAPSIA IN PATIENTS WITH NORMAL BLOOD INDICIES? ………………………………………………………………….……14

Nawfal Ali Mubarak

Abstract

Caesarean section is a common technique of terminating pregnancy in pre-eclamptic patients. The anaesthesiologists are more possible to face a difficult airway in a pre-eclamptic patient. The hazard related to the haemodynamic consequences of laryngoscopy and tracheal intubation in a pre-eclamptic patient is noticeable. General anaesthesia (GA) in such patients may be an option when regional anaesthesia is contraindicated. Spinal anaesthesia (SA) may be considered as anaesthesia of choice for pre-eclamptic patient scheduled for caesarean delivery.

Patients included in this study were assigned into two groups, group A, spinal (50 cases) and group B, general anaesthesia (50 patients). All patients were American Society of Anaesthesiologists (ASA) class II & III.

The aim of this study is to compare the haemodynamic variability of spinal anaesthesia versus general anaesthesia in patient subjected to caesarean section.

Regarding changes in mean arterial pressure and heart rate following general & spinal anesthesia; in spinal group (50 cases), the mean BP remains stable or decreased significantly following spinal injection until the end of the operation. There was significant difference between the two groups (P< 0.001)

In conclusion, the majority of pre-eclamptic patients required caesarean delivery. Because of haemodynamic consequences of laryngoscopy and tracheal intubation and further arise in blood pressure during surgery, general anaesthesia is usually chosen only when regional techniques are contraindicated. This study proved that BP & HR in pre-eclamptic patients underwent caesarean section by spinal anaesthesia are more stable than haemodynamics observed in general anaesthesia.

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THE VALUE OF SIGNS AND SYMPTOMS IN THE DIAGNOSIS OF SPERMATIC CORD TORSION………………………………………………………………………………………………22

Salah Aldeen M Al Hakee, Adnan O Al Mayyahi & Noori H Jasim

Abstract

The aim of this study is to evaluate the most useful clinical signs and symptoms in the diagnosis of spermatic cord torsion, and so decreasing unnecessary surgical exploration and testicular loss rates for these patients.

Between August 2013 and November 2014, patients with suspected spermatic cord torsion were included in this study; patient case sheets were prepared; history, examination, imaging, and post-operative results were recorded. The patients then divided into non-torsion and torsion groups, the torsion group further subdivided into salvaged and orchiectomy groups. Data evaluated and correlated with the result of the surgical exploration.

Seventy-seven patients were included, 11 (15%) patients without torsion and 66 (85%) with torsion. Of the torsion group 35 (53%) were salvaged while orchiectomy done to the remaining 31 (47%).

The patients’ age ranged from 1 to 29 years with a mean of 16.22 years with standard deviation of 6 years, and they commonly presented during winter months, the salvageability rate decline with increase duration of symptoms especially after 24 hours.

There were a significant difference (p<0.05) between torsion and non-torsion groups in the testis lay, testis orientation, cremasteric reflex, high riding testis, left side, and cord knotting. There were significant difference (p<0.05) between salvaged and orchiectomy groups in duration of symptom, onset of symptom, and in presence of scrotal edema.

A univariate analysis showed that the pain was very sensitive but lacks specificity; the duration less than 6 hours, abnormal lay, absent cremasteric reflex, high riding testis, abnormal orientation, presence of cord knot, and presence of nausea and vomiting are highly specific.

The multivariate analysis then repeated for combination of nausea and vomiting, high riding testis, abnormal lay, and absence of cremasteric reflex; showed 100% specificity if three and more of these four feature were present.

In conclusion, careful history and physical examination can aid diagnosis of testicular torsion, no clinical signs and symptoms were highly specific and sensitive for torsion, and a constellation of clinical feature can aid the diagnosis.

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THE EFFECTIVENESS OF HEMILAMINECTOMY IN SINGLE LEVEL LUMBAR SPINAL STENOSIS …………………………………………………………………………………………….34

Hamid A M Jaff & Ahmed Kh Hamed

 

Abstract

Degenerative spinal stenosis is a progressive disorder that involves the entire spinal motion segment. It describes abnormal narrowing of the central canal, the lateral recesses or the intervertebral foramina to the point where the neural elements are compromised. When this occurs the patient develops neurological symptoms and signs in the lower limbs. Hemi-laminectomy is a surgical procedure, which is designed to relieve pressure on the nerves in the spine. This procedure is performed when patient has degenerative conditions leading to signs and symptoms of neural impairment, because the procedure is invasive, it is usually only recommended when other non-operative treatment approaches failed to relief the patient complain. Before the procedure can be performed, a neurological examination is conducted to determine which area of the spine is affected. We also typically order medical imaging studies of the spine so that we can clearly visualize the area that requires surgery. The patient undergoes routine blood work to check for underlying medical problems that could complicate surgery, and meets with an anesthesiologist to discuss anesthesia options and prepare for the operation.

This study is a prospective analysis of a randomized collection of 22 patients who underwent surgery for lumbar spinal stenosis at the period from April to the end of July 2012. The procedures were done by orthopaedic surgeons. The period of the follow up was 1 year post-operatively. The follow up criteria depended on the distance the patient could walk uninterrupted for the assessment of the neural claudication, for the assessment of the radicular pain; we depended on the Outcome Measure in Lumbar Spinal Stenosis questionnaire (OMLSS) which is rating from 6 to 30, & for the weakness (weak dorsiflexion) we depended on the Medical Research Council (MRC) Grading of the muscle power, which is rating from 0 to 5. The patients were suspected to have spinal stenosis on the basis of a history, physical examination, & radiological imaging. The final assessment and the decision of the operation were made by the surgeons who operated them.

Twenty two patients were included in the study, 15 of them were females (68%), and the rest were males (32%), with female to male ratio was approximately 2:1. Regarding the age, it was ranging from (55 – 78 years); the majority 14 of 22 of patients (63%) was between the ages of 61 – 65 years old. About the occupation, (50%) of the total number were housewives women & 18% of the total number were earners men. (77%) & (23%) of the patients were complaining of bilateral & unilateral neural claudication respectively, (64%) & (36%) of the patients had bilateral & unilateral radicular pain & paraesthesia respectively, (23%) & (13%) had bilateral & unilateral weak dorsiflexion respectively, who were in grade 3 according to the (MRC) grading system. Post-operatively, (81.8%) of the patients with neural claudication got improvement in the walking distance for up to more than 1 km uninterrupted. Regarding the radicular pain, (59%) had subsided in less than 3 months post-operatively, (27.5%) of them were relieved in the period of 3 – 6 months, & just one patient (4.5%) still had pain for the entire period of the follow up which was rated 15 of 30 according to the (OMLSS). Weak dorsiflexion was also improved post-operatively in the 1st 3 months in (33.3%) & (40%) of the unilaterally & bilaterally affected patients respectively, while (67%) & (60%) of the unilaterally & bilaterally affected patients relieved in the period up to the 6th month post-operatively respectively.

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Articles

 

RANIBIZUMAB MONOTHERAPY VERSUS COMBINED RANIBIZUMAB PLUS TRIAMCINOLONE FOR TREATING DIABETIC MACULAR EDEMA; EVALUATION AFTER SINGLE INJECTION…………………………………………………………………………………..43

Fareed A AL-Laftah

Abstract

Anti vascular endothelial growth factor (Anti-VEGF) have been proved to be the main treatment for DME and also steroids showed a significant role in resolution of diabetic macular edema(DME). Based on concept of multifactorial causes of DME, this study proposed theoretically an adjuvant effects for steroids in combination with anti-VEGF for DME, the multifactorial complex pathogenetic mechanisms require a comprehensive approach.

This study compares the outcome of monotherapy of intravitreal Ranibizumab injection in one eye versus combined therapy of Ranibizumab+Triamcinolone in other eye of the same patient.

This study includes prospective consecutive interventional case series study. Patients with bilateral diabetic macular edema given Lucentis dose was 0.05 ml = 0.5 mg in on eye and Triamcinolone 0.05 ml = 2 mg in the other eye.

Thirty patients with bilateral diabetic macular edema were enrolled in this study, all have perfused macula. The mean age at the start of the study was 54 years.

The study has shown a promising results for the treating diabetic macular edema with combined therapy of Ranibizumab and Triamcinolone

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INFANTILE HYPERTROPHIC PYLORIC STENOSIS: POSTOPERATIVE MANAGEMENT WITHOUT PROLONGED FASTING OR NASOGASTRIC TUBE……………………………….50

Abbas Abdulzahra Alhassani

Abstract

Infantile hypertrophic pyloric stenosis is the most common condition requiring surgery in the first few months of life and also the most common surgical cause of vomiting in infancy.

All pediatric surgeons agreed that Ramstad’s operation (pyloric sero-myotomy) is the standard choice of surgical correction, however, the perioperative management is controversial, specially that is related to and recommended for the time of resumption of feeding postoperatively.

The present work is prospective comparative study reviews 55 infants diagnosed as having hypertrophic pyloric stenosis over a 2 years period and subjected to pyloromyotomy. Postoperatively, 22 (40%) patients managed without the use of nasogastric tube and early introduction of oral feeding. The remaining 33 (60%) patients were managed classically with nasogastric tube decompression and delayed introduction of oral feeding until the next morning. This study was designed to compare between the two groups and to verify if there will be any significant effect on the postoperative course.

Statistical analysis of the postoperative incidence of vomiting, postoperative complications, and hospital stay showed that there were no significant differences between the two groups of patients. Therefore, non-use of postoperative nasogastric tube and early feeding are safe postoperative approach in the management of infantile hypertrophic stenosis and may be the preferred method of postoperative management.

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COMBINATION OF ROCURONIUM WITH PROPOFOL TO AID ENDOTRACHEAL INTUBATION IN EMERGNCY CESAREAN SECTION………………………………………….55

Mohammad Radhi Al-Rekaby & Edwar Z Khosho

Abstract

This study aimed to verify that rocuronium can be used as an alternative to succinylcholine for rapid sequence intubation in emergency cesarean section. A study conducted on 300 ladies in Al-Basrah Maternity and Childbirth Hospital between February 2013 to November 2014. Assessment of the effectiveness of rocuronium 0.6 mg/kg with propofol as an intubating dose for emergency caesarean section. The intubation conditions of rocuronium was compared with succinylcholine 1mg/kg as standard muscle relaxant of choice.

Rocuronium 0.6 mg/kg with propofol resulted in 94% clinically acceptable (good to excellent) intubation conditions but for succinylcholine it was 95-97%.

In conclusion, although succinylcholine creates excellent intubation conditions in emergency caesarean section, rocuronium proved its efficacy as a good alternative choice for succinylcholine.

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PEDIATRIC INGUINAL HERNIA IN BASRAH……………………………………………………61

Sadik H Kadhem, Haithem H Ali & Haider A Jassim

 

Abstract

Inguinal hernia repair is one of the most frequently performed surgical procedure in pediatric patients. An inguinal hernia does not resolve spontaneously and must be repaired because of high risk of complications. The aim of this study is to determine epidemiologic index and complications of inguinal hernia in pediatric patients.

This retrospective study was carried out in the Basrah Children Hospital. All patients who underwent surgeries for inguinal hernia from 2012 to 2014 were included in this study. Their hospital records were reviewed for age, sex, side of the hernia, presentation, wound infection, recurrence, and other complications.

In this study, 877 children were included. 766 (87.3%) were boys and 111 (12.7%) were girls. Most common age of presentation is between 6 months to 6 years which compromise 54.6%. Right-side and left-side inguinal hernia was observed in 531 (60.5%) and 276 (31.5%) cases, respectively. Bilateral inguinal hernia was observed in 70 (8%) cases. One hundred forty eight (16.9%) children presented as emergencies with irreducible hernia. Emergency presentation was more in male gender and more in the first 6 months of life. Postoperative complication rate for elective was 3.2% and for emergency groups was 51.7%.

In conclusion, most of the hernias involved male patients. Postoperative complications were observed in 51.7% of the emergency cases, so inguinal hernia in children should be operated as early as possible to avoid incarceration and to decrease post-operative complications.

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A COMPARATIVE STUDY BETWEEN OSSEOINTEGRATION SUCCESS RATE OF ONE STAGE AND TWO STAGE PROCEDURE IN IMPLANT SURGERY IN BASRAH PROVINCE……………………………………………………………………………………………66

Riad G Altaee

Abstract

This study aimed to evaluate the osseointegration success rate of one stage procedure in comparison with two stage procedure in implant surgery.

Eighty patients (28 males, 52 females) received 128 implants, 36 in the mandible and 92 in the maxilla. Fifty nine implants were inserted in the one stage procedure & 69 implants in the two stage procedure. All implants were followed-up for 6 months according to the success criteria (Albrektssons criteria).

Total success rate was 97.6%. In the one stage procedure it was 96.6% and 98.5% in the two stage procedure. There was no statistical significant difference between the two procedures.

In conclusion, the one stage procedure can be employed as successful alternative to two stage procedure when there is good primary stability and no bone augmentation at the time of implant placement.

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EVALUATION OF THE EFFICACY OF TADALAFIL IN IMPROVING LOWER URINARY TRACT SYMPTOMS IN PATIENTS WITH SYMPTOMATIC BENIGN PROSTATIC ENLARGEMENT………………………………………………………………………………………70

Firas Shakir Attar

Abstract

Lower urinary tract symptoms (LUTS) are common bothersome association with benign prostatic enlargement (BPE). The relationship between erectile dysfunction(ED) and LUTS/ BPE has been studied in the Multinational Survey of the Aging Male and in several epidemiologic studies, suggesting that the two diseases may share a common pathophysiology.

The aim of the present study is to evaluate the efficacy and safety of use of tadalafil monotherapy in improving LUTS in patients with symptomatic BPE.

Sixty patients aged more than 50 years with symptomatic BPE with LUTS more than 6 months were included from January 2013 to May 2015. These patients were assessed for their International Prostate Symptoms Score (IPSS) which was ≥7 and maximum urinary flow rate (Q max) which was >10 and < 20 ml/s. Patients were given tadalafil tablet 5 mg once daily without other therapy. The treatment was continued for three months and the patients were asked to come back for follow up each four weeks.

Among the 60 patients, 50 (83.3%) showed significant improvement in their IPSS by achieving ≥3- points total IPSS improvement in symptoms. There was also significant improvement in the maximum urinary flow rate. The end point was at 12 weeks.

It is concluded that, Tadalafil 5 mg once daily can be considered as an option for relieving LUTS in patients with symptomatic BPE.

 

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RISK FACTORS OF EXTRA PULMONARY TUBERCULOSIS IN BASRAH………………….76

Rafid Abdul Jabbar Mohammed, Dheyaa Al-Rubeai, Mohammed Salim Yaseen, Ali Wafi Ghazi & Ali Ahmed Khaz’al

Abstract

This article aimed to study the risk factors of extra pulmonary tuberculosis (EPT) in Basrah.   A case-control study of 78 known cases of extra pulmonary tuberculosis (EPT) and 156 control subjects studied in “TB and Respiratory Diseases Center” in Basrah from December 2014 to March 2015.

Forty four (56%) of EPT cases were females (P>0.05) and the males were 34 (44%). Lymph nodes were the commonest site for EPT (33%), followed by tuberculosis pleural effusion and osteal tuberculosis (19% each). 34.6% of EPT patients consume raw milk while only 4.5% of the control group (free from EPT) consume raw milk with an odds ratio of 11.2, P<0.01. Some 6.4% of EPT patients had family history of having tuberculosis, and the odds ratio is 10 and P<0.01. The risk of development of EPT in people of less than 120.000 ID monthly incomes is 3.2 times greater than those with higher income, P<0.01. Regarding Body Mass Index (BMI), when comparing people having normal BMI (18.5-25 Kg/M2) with people having subnormal BMI, the risk of having EPT is 3.9 times in underweight patients, P<0.01.

In conclusion, risk factors for EPT are; consumption of raw milk, family history of TB, BMI<18 (Kg/M2) and a monthly income <120.000 ID.

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MORTALITY RISK FACTORS FOR NEONATAL INTESTINAL OBSTRUCTION………….…82

Haithem Hussein Ali Almoamin

Abstract

This study aimed to determine the type of neonatal intestinal obstruction, their mortality, and the significance of the direct causes of death.

A retrospective study of all neonates managed for neonatal intestinal obstruction (total number studied was 161 child) at Basrah Children’s Specialty Hospital (BCSH) between June 2012 and June 2014. Data were collected from patients’ hospital records (neonatal intensive care unit) and analyzed for age, sex, clinical features, diagnosis, surgical procedure performed, prematurity, birth weight, duration of symptoms, complications and their management.

The mortality due to neonatal intestinal obstruction is still high in our setting (25.5%). The significant factors associated with mortality were prematurity, birth weight, sepsis; reoperation, short bowel syndrome, and proximal intestinal stoma. Certain causes of neonatal intestinal obstruction were associated with high mortality e.g. jejunoileal atresia (52.6%), meconium ileus (50%), perforated viscus (46%), and duodenal atresia. Male are affected more than female with M:F ratio of 2.4:1. The most common cause of intestinal obstruction in neonates in this series was anorectal malformations (33.5%). Other causes of neonatal intestinal obstruction included Hirschsprung’s disease (24.2%), small intestinal atresias (11.8%), intestinal malrotation with or without volvulus (9.3%), perforated viscus (8.1%), meconium ileus (7.5%), duodenal aresia (2.5%), annular pancreas (1.2%), and meconium plug syndrome, necrotizing enterocolitis and segmental dilatation (0.6%, each).

In conclusion, neonatal intestinal obstruction is a common cause of admission accounting for 28.2% of all admission. Mortality from intestinal obstruction is still high in our society and strict measures regarding prenatal, natal and postnatal management should be addressed to save those neonates.

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MANAGEMENT OF CRISES DURING ANESTHESIA AND SURGERY.  PART IX  REGURGITATION, VOMITING, AND ASPIRATION………………………………………………87

Salam N Asfar & Jasim M Salman

 

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Case Report

TRANSCERVICAL APPROACH: IS IT ENOUGH FOR PARAPHARYNGEAL TUMORS EXCISION? A REPORT OF FIVE CASES………………………….……………………………….91

Isam Mohammad Alsheraida

Abstract

Para pharyngeal space (PPS) masses are uncommon lesions. The complex anatomic relationships and proximity of vital neurovascular structures necessitates careful preoperative evaluation and precise surgical techniques. Various surgical approaches are used to remove these masses. This study explores the utility of transcervical approach as surgical technique to enhance exposure for resecting PPS masses.

Five cases were included in this study with PPS tumor, all had thorough investigations and tumours were completely excised by transcervical approach. One case only had postoperative complication which was haematoma and was explored next day.

In conclusion, transcervical approach is a very good way to treat PPS tumors.

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Obituary

Dr. Muslim Mahdi Al-Hasan…………………………………………………………………100

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