Print ISSN: 0027-1446

Online ISSN: 2309-6217

Main Subjects : Surgey

Neonatal gastro-intestinal tract perforation in Mosul city

Bassam Khalid Alhajjar; Ibrahim Shukur Alhadidi; Ahmad Mahmud Al-Sharabi

Annals of the College of Medicine, Mosul, 2022, Volume 44, Issue 1, Pages 61-69
DOI: 10.33899/mmed.2021.131611.1115

Background: Gastro-intestinal perforation (GIP) of neonates considered as one of the foremost emergency problems faced by pediatric surgeons around the world. It represents important challenges with a high mortality of 15-70% has been reported. Despite enhancements in anesthesia, as well as, intensive care, mortality has remained high, especially in premature babies.
Patients and Methods: A retrospective series study including 50 patients diagnosed as GIT perforation were admitted to the neonatal pediatric surgery center in Al-Khansaa teaching hospital, allocated over the period extending from April 2017 to June 2019. Records were reviewed for the age, sex, gestational age, weight, duration of symptoms, associated anomalies, causes of GIT perforation, procedure done, mortality, amorbidity, and hospital stay period. Leak from intestinal anastomosis secondary to resection as surgical interference were  excluded from the study.
Results: The presentation age varied between 12 hours to 27 days with a median age of 3.5 days. The weight mean is 2.93 kg. The mean gestation age was 34 weeks, ranging from 30-42 weeks. The majority had the symptoms before 30 hours. Most of the sample is within the 1st week representing 86.0%. The males are representing 76.0% while the females are 24.0% with a ratio about of (3:1). About 56.0% of the perforations occur in the small bowel and only 4.0% in appendix. The large bowel represents 28.0% and the stomach 12.0%. The positive findings of abdominal X-Ray are found in 80.0% of patients. 40.0% of patients are died. The frequent site is the ileum, found in 8 patients (40.0%) of all deaths. Next are the Jejunum and colon, representing 20.0% for each. The stomach pathology found in 10.0%, as well as, the cecum 10.0%.
Conclusion: The commonest site of perforation is small bowel. History, clinical picture and erect abdominal X-ray are very important for the diagnosis. The risk factors raise the mortality rate include malnutrition, the appearance of complications, lack of certain drugs, delayed diagnosis, prematurity, and associated anomalies. The outcome is improved with early identification, diagnosis, and treatment.
AIM OF THE STUDY : To study the causes and outcome of neonatal GIT perforations in Mosul city and its drainage areas in the north of Iraq.

Bowel Injuries after Laparoscopic Ovarian Drilling: Observation of Three Cases with Review of Literatures

karam Kamal younis

Annals of the College of Medicine, Mosul, 2022, Volume 44, Issue 1, Pages 42-47
DOI: 10.33899/mmed.2022.133534.1145

Background : Bowel injury remains a potential serious complication of gynecological laparoscopy. Electro thermal energy, especially in the form of monopolar diathermy, is used widely during Laparoscopic Ovarian Drilling (LOD) by diathermy for clomiphene-resistant polycystic ovary disease (PCOD). Occasionally there can be unrecognized transfer of energy in the operating area, resulting in electro thermal bowel  injury. If iatrogenic bowel injury  is not recognized  at the time it occurs, it can have devastating consequences.
Objectives : Through personal observations of 3 patients who underwent (LOD) for clomiphene-resistant (PCOD) followed by bowel perforation ,we highlighted their  ways of presentation , recognition ,  avoidance  and management  of such complication.
Setting : Surgical wards of Al-Jamhoori Teaching Hospital in Mosul City  
Patients and Methods : Through personal observation, we report a series of 3  infertile women   who underwent laparoscopic ovarian drilling for clomiphene resistant infertility  but were readmitted 2-3 days later with pinhole leaks from perforated bowel  .
Results : After (LOD ) ,two patients out of three were urgently explored via laparotomy and multiple  bowel perforations were found and  repaired. Consequently they improved .The third patient presented lately after rupture of  bowel and peritonitis. Although she underwent explorative laparotomy but her condition was potentially fatal and died from sepsis.
Conclusion : Gynecologists should be aware for the proper, safe and judicious use of diathermy during (LOD) to avoid complications with consultation and involvement of surgeons early following the procedure. High clinical suspicion is crucial for early diagnosis of bowel injuries. When diagnosis is delayed, then morbidity and mortality rises.

Knowledge, Attitude and Practice of Nursing Staff toward Working at Emergency Unit

Rawaa Y Al-Rawee; Mohammed Faris Abdulghani; Ashraf Abdul-Rzzaq Mohammed AlSalih; Emad Hussain Mohammed; Bashar Abdul-Ghani Tawfeeq

Annals of the College of Medicine, Mosul, 2022, Volume 44, Issue 1, Pages 22-28
DOI: 10.33899/mmed.2021.131807.1118

Highlights : Emergency department need essentisl careful assessment as it deal with acute, urgent health situations so should have high skilled well trained staff.
Aims : Study involves assessing the emergency nurse's knowledge, attitude, and practice regarding the practical obstacles that impede nurses from working in the Emergency Departement and taking necessary measures to resolve them.
Material and Method : The current study was a cross-sectional study conducted upon (400) nurses.  Questionnaire form to assess nurses' knowledge, attitude, and practice in Mosul's teaching hospitals / Iraq related to working in the Emergency Departement. The acceptability score was established at 61.2 mark / 85%; less than this limit was considered unsatisfied as degree 85% (61.2 marks) was considered as acceptable. The data were surveyed applying the (SPSS version 25) descriptive and inferential statistics.
Result : The study showed that there were statistically significant differences in the level of knowledge. The mean ± S.D of the knowledge was (33.15 ± 11) .  The mean of practice was (23±9). The majority of nurses was in the accepted level 196 (49%) and statistically highly significant P-value was 0.01. Attitude answering questions show high agreement on questions (Number of the good training staff is essential in the emergency department? , and Handwashing is necessary before preparation and administration? ) with answers  percentage are [ 96.25% and 93.75% respectively].  The difference between nurses was highly significant  p-value was 0.001.
Conclusion : This study concluded that the awareness or knowledge of nurses is satisfactory with  the level of attitude and practice with respect to Emergency Department

Surgical Training of Undergraduate Students at Mosul College of Medicine: A Preliminary Evaluation

Mahmood Sulaiman; Khalaf Alluaizy; waleed ahmad; Abdulsalam Almasry

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 2, Pages 115-122
DOI: 10.33899/mmed.2021.130408.1095

Background: There is an idea  that the level of medical college graduates is less than the expected. The improvement of medical training level for the undergraduates in medical schools need a re-evaluation and improvement  for creation of new training programs including a better  surgical training.
Objective: Is to evaluate the clinical surgical training of undergraduates at College of Medicine , University of Mosul .
Participants and methods: The study carried out at College of Medicine , University of Mosul during the year 2019. The study depends on questionnaire  directed to  46  final year students who recently finished their clinical surgical training, 53 resident doctors  graduated from the same college working among surgical wards, and 50 surgical department teachers and expert surgeons interested in medical education. The questionnaire asked about : does the student gain sufficient knowledge and clinical surgical skills during training, does the training provide safe doctor in work, does the training provide  proper communication skills and ability to work properly in teams, and does the graduate able to gain the confidence of patients and other health workers. The participants score freely their answer in grade extend from 1-10, and asked to add any other notes up on surgical training of students including deleting or adding or any  other suggestion.
Results:  Knowledge gaining mean score by medical students, resident doctors, and  expert surgeons  was 6.9 ±1.45 ,  6.68 ± 1.82 &  6.68 ± 1.95  respectively, while mean score for providing  safe doctor to community was 6.04 ± 1.39 ,   6.52 ± 1.40 &   6.17 ± 1.17  respectively. On the other hand the mean score gaining regarding communication skills and ability to work in teams was  6.30 ± 1.44 ,   6.37 ± 1.41  &  6.59 ± 1.13  respectively, while gaining the confidence of patients and other health workers mean score was  6.47 ± 1.18 ,  6.74± 1.45  and   6.66 ± 0.99  respectively.  In all , there was no significant differences. The clinical surgical skills gaining mean score by medical students , resident doctors and expert surgeons was  6.26± 1.61 ,   4.92 ± 1.70 , and  5.8 ± 1.84  respectively. Which reflect the presence of a significant differences between resident doctors in comparison to students and expert surgeons.
Conclusion: There is lower mean score in gaining clinical surgical skills of graduates and  there is a need for more clinical training, improvement, development of clinical training, and a   re-evaluation of clinical training to improve the quality of medical teaching to get competent graduates.

Capitonnage surgery is effective in all types of pulmonary hydatid cysts

Omer Mothafar Hammodat; Bassam Khalid Alhajjar; Ahmad Mothafar Hammodat

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 2, Pages 109-114
DOI: 10.33899/mmed.2021.129832.1085

Background: Hydatid cyst still has worldwide distribution with many cases discovered yearly in endemic areas. It has a predilection to involve the liver and the lung. Capitonnage has been practiced long time to avoid postoperative complications mainly air leak in addition to empyema formation. It may be still controversy concerning the efficiency of capitonnage especially for complicated hydatid cyst which led us to evaluate.
Aim of the study: To assess the efficacy of capitonnage surgery in minimizing the postoperative complications and hospital stay in complicated and non complicated pulmonary hydatid cysts.
Patients and Methods: A prospective study has been done at the department of thoracic surgery in Al-Jumhory teaching hospital at right side of Mosul, Department of pediatric surgery in Al-Khansaa teaching hospital and in Al-Rabee private hospital at left side of Mosul / Iraq between February 2017 and December 2019. Totally 118 patients with hydatid cyst of lung, including all ages and on different types of complicated and non-complicated cysts were included for this study. Co-morbid diseases like acute myocardial ischemia and uncontrolled diabetes mellitus were excluded from our study. Patients were evaluated in responce to the gender, age, clinical presentation, cyst condition (size, site and where ruptured or not) and postoperative hospital stay. Enucleation of the HC and capitonnage were carried out  for all patients. The patient followed for three months at monthly interval, then each year with the mean follow up of 22 months.
Results: One hundred eighteen patients with median age of 32 years were operated using capitonnage method. In this study 49 (41.5%) of the patients found to have intact cyst and the remaining 69 (58.5%) had ruptured cyst. We recorded the early postoperative complications which include air leak in 10 cases, Atelectasis 8, pneumothorax 3, wound infection 3 and Hemoptysis in 2 cases.
Conclusion: Capitonnage can decrease the incidence of air leak and shorten hospital stay in complicated and non-complicated lung hydatid cysts.

A successful Laparoscopic surgery for multiple hydatid cysts (7 cysts) of liver : Case Report

Sameer Hasan

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 2, Pages 212-215
DOI: 10.33899/mmed.2021.131592.1114

Case report : To the best of our knowledge this could be the first report of a successfully performed laparoscopic surgery for female patient having had multiple  liver hydatid cysts ( 7 in number) in both lobes of liver.
Background: Laparoscopic hydatid surgery ( LHS) was almost gaining acceptance all over the world. But still there are contraindications to this approach of particular are those with multiple cysts ( >3 cysts)1.On reviewing the literature most of the reports of LHS were for patients with solitary hydatid cyst and  exceptionally for a maximum of  three cysts. Herein an initial effort to expand the application of  LHS in managing multiple hydatid cysts of  liver (>3)  with all the advantages of laparoscopic approach; less pain, good cosmetic results, rapid recovery and less complications

Endoscopic Findings in Adults with Nasal Obstruction: A case series study

Hassan Myasar Abdulwahid; Anmar Abdula Jassim; Islam Ghanim Mahmood; Raghdan Mohammed Dawood

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 2, Pages 123-131
DOI: 10.33899/mmed.2021.130671.1098

Background: The obstruction of the nasal is known as the most distinct disturbing complain of nasal disease and nasal sinus. The nasal obstruction could either be found unilateral (in one nasal cavity), bilateral (in both cavities), intermittent, progressive or persistent. The rhino-scopy  (anterior and posterior) provides limited information when compared to nasal endoscopy. In certain cases, the structure which lies under the sight line and the posterior rhino-scopy is not possible. Furthermore, the early diagnosis of many unpleasant lesions will be very difficult unless using nasal endoscopy.
Objectives: This study was designed to identify the real & precise causes of nasal obstruction in adults &  properly evaluate the condition of nasal cavity ,post nasal space and nasal mucosa by direct vision through nasal endoscopy. and evaluate the value of naso endoscopy in diagnosis of the cause of nasal obstruction.
Methods: This study was conducted to analyze noses related to 75 patients with nasal obstruction who underwent clinical and endoscopic nasal examination for the period from May 2014 to April 2015 in Mosul namely; Al-jumhoori Teaching hospital.
Results: This case series study included 75 patients complaining from nasal obstruction The study include 43 male patients (57.3%), and 32 female patients (42.6%) with a M:F ratio of (1.3:1). The patients’ ages ranged between 15-70 years of age whose mean age was 42.5 years. endoscopic findings for adults patients with nasal obstruction in our study were: congested nasal mucosa 40 (53.3%) patients, septal deviation 26 (34.6%) patients, inferior turbinate hypertrophy 18 (24.0%) patients, pale swollen mucosa with watery nasal secretion 14 (18.6%) patients, bilateral nasal polyposis 10 (13.3%), post nasal drip 10 (13.3%), crustation 8 (10.6%), mucopurulent discharge from middle meatus  & congested mucosa 7 patients (9.3%), adenoid hypertrophy 5 patients (6.6%), no abnormal findings 4 patients (5.3%), bluish tinged  mucosa with watery nasal secretion 3 patients (4.0%).
Conclusion: Nasal endoscopy includes evaluating the passages of the nasal cavity and the nasal sinus, and post nasal space using a magnified high-quality view and serves as an objective diagnostic tool in the evaluating of nasal mucosa, sinonasal anatomy, nasal cavity, and post nasal space pathology.
In this study, nasal endoscopy is recommended in cases where patients complain of obstruction in the nasal specifically when anterior and posterior rhino-scopic examinations do not succeed in diagnosing causes of nasal obstruction

Factors Influencing Outcome and Mortality of Brain Abscess in Mosul City

Ali Hikmat Azeez; Ali Al-shalchy; Omar Khalid Agha

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 2, Pages 198-206
DOI: 10.33899/mmed.2021.130630.1097

Background: Brain abscess by definition is a crucial pus collection inside the brain, resulted from the infection by a variety of bacteria, fungi, and parasite. It can be single or multiple. The size, position, and number of lesions, as well as the organism's pathogenicity, host reactions, and the severity of cerebral edema, all influence the presentation.
Objective: To assess how well a brain abscess was managed and to evaluate the patients with favorable and unfavorable Glasgow outcome scale (GOS). 
Patients and methods: From January 2014 to January 2021, the study was achieved and conducted in the Neurosurgical Department of Ibn-Sina Teaching Hospital on Mosul's left coast. The neurosurgery unit managed a case series investigation of 70 patients who had a brain abscess. Age, sex, duration of illness, initial neurosurgical status, and abscess features are among the clinical data.
A comparison was performed between patient with Favorable Glasgow outcome scale (GOS), moderate disability or those with good recovery and those with Unfavorable GOS, death or persist vegetate status outcome at discharge.
Results: The study involved 48 male and 22 female patients (male / female ratios 2.2:1). The series consist of 52 patients who experienced favorable outcome and 18 resulted from an unfavorable outcome. The mean of age for those patients was 20 years. The difference between males and females regarding favorable and unfavorable outcomes is insignificant. P-value was significant in cyanotic congenital heart diseases as cause of brain abscess were particularly prevalent among the children (adult VS children = 1:9). The most common site for single abscesses was the frontal lobe (25 patients), and majority of patients treated with burr hole drainage, which had the best results.
Conclusion: Although there were technological improvement of imaging and antibiotics treatment, the mortality of brain abscesses is still relatively high, especially among those with decreased level of consciousness on admission.  

Review of Different Methods of Uncinectomy in Endoscopic Sinus Surgery

Haitham Alnori

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 70-75
DOI: 10.33899/mmed.2021.129601.1079

Uncinectomy is a safe procedure in experienced hands whatever technique is used. It is usually the first step in endoscopic sinus surgery and the first surgical maneuver the new rhinologist has to learn. The most familiar two methods of doing uncinectomy are the classic method, introduced by Stammberger in 1986, and Wormald’s swing-door technique in 1998. The swing-door technique appears to be associated with a slightly higher risk of injury to the lacrimal duct. Simultaneously, failure to identify maxillary ostium and orbital penetration are both more common in the classic method.
This study aims to review the different methods of doing uncinectomy during endoscopic sinus surgery and compare the most standard techniques regarding their efficiency and safety.

Endoscopic Dacryocystorhinostomy: A Case Series Study from Mosul City

Islam Ghanim Mahmood; Professor Ali Abdulmuttalib Mohammed; Hassan Myasar Abdulwahid

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 81-86
DOI: 10.33899/mmed.2021.129046.1064

Background: Dacryocystorhinosty is a technique applied to patients who complain of excessive tearing (epiphora) and demonstrate obstruction of the lacrimal outflow system.
Objectives: The present study aims at studying the outcome and complications
of endoscopic dacryocystorhinostomy EnDCR.
Methods: This case series study was conducted to analyze 70 eyes related to 66 patients with epiphora and recurrent attacks of dacryocystitis who underwent EnDCR for the period from January 2018 to June 2019. Surgeries were done in 2 hospitals in Mosul namely; Al-jumhoory Teaching hospital and Al-Rabee Private hospital.
Results: This case series study included 70 eyes of 66 patients (62 unilateral and 4 bilateral cases) complaining from epiphora excessive tearing and/or chronic dacryocystitis. There was 45 females (68.2%) and 21 males (31.8%) with F:M ratio of 2.1:1. The patients, ages ranged between 4-74 years of age with a mean age of 39 ± 18.31. The success rate of endoscopic dacryocystorhinostomy EnDCR in the present study was 97.15 % depending on clinical improvement of epiphora , endoscopic assessment for patency of the new ostium and passage of tears aided by pressing over the medial canthus. Hemorrhage was the most common complication and there was no serious orbital complication in our study neither during surgery nor in the follow up period.
Conclusion: Endoscopic dacryocystorhinostomy EnDCR carries very good success rate with relatively not critical and low complication rate. Moreover, it has the advantage of overlooking unnecessary scar, the ability to operate both sides simultaneously and revising the operation in case of failure of surgery.

Surgical Outcome and Prognosis of Spinal Missile injuries

Ali Hikmat Azeez; Nashwan Yaseen Sallama; Saad A. Yahya Alsaqa

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 55-59
DOI: 10.33899/mmed.2021.129309.1070

Background: The spinal cord is so sensitive to injury. Once it is damaged; it shall lose its ability to repair itself .Unfortunately spinal cord injuries (SCI)are common in Iraq . It could be either complete or incomplete SCI. In the complete injury there is a total loss of sensation and motor function in the level below the site of the injury, while in the incomplete one there is some remaining neurological functions below the level of the injury.
Objectives: The aim of this study is to compare the surgical and conservative management of complete and incomplete spinal cord Injuries due to missile in Mosul city.

Patients and methods: A case series study of (60) patients with missile cord injury of the spine who were managed in the Neurosurgical Department at Ibn-Sina Teaching Hospital in Mosul from August 2011 – August 2013. The mean patient age was 30 years. Thirty three (55%) patients were surgically treated. The mean time of follow up was 9 months ranged from 6-18 months. All patients had complete radiological assessment, CT scan and one patient with through and through bullet injury magnetic resonance imaging( MRI) was done after initial resuscitation.

Results: All patients with complete spinal cord injury did not improved after non-surgical management, after surgical removal of bullet and it's pressure effect from the spinal cord just one case with conus medullaris injury gets improvement. Those with incomplete injuries show good improvement after surgical management.
Conclusion: Conus medullaris and cervical injuries show a better outcome in surgical treatment than those out surgical intervention in incomplete spinal cord injuries. There were no difference between the outcomes of surgical and non- surgical management of complete neurological injuries of the spinal cord.

Spontaneous Rupture of Hydatid Cyst of the Liver in Pediatric Age Group Four Rare Cases with Literature Review

Professor Abdulrahman sulaiman

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 35-41
DOI: 10.33899/mmed.2021.129224.1068

Hydatid cyst of the liver is usually asymptomatic, it may be diagnosed accidentally or when there is complications. It is more seen in endemic areas like Iraq and frequently seen in children. The author reports four rare cases of spontaneous rupture liver hydatid. They were admitted and treated at pediatric surgery center at Alkhansaa teaching hospital in Mosul. One of them ruptured to pleura, the second case had rupture to peritoneum with intact endocyst, while the third rupture to extra peritoneal space. The forth patient has direct rupture to peritoneal cavity with hundreds of daughter cysts. Liver hydatid cyst rupture is a serious complication. It comes in the differential diagnosis of acute abdomen in endemic areas. It needs urgent management. Anti helminthic therapy is needed post operatively in all of them
Case summaries
Four Iraqi children aged between 5.5-10 years (three boys and one girl) were referred to pediatric surgery center with differing presentation. Abdominal pain is the main presenting feature. One of them with predominant respiratory infection symptoms while the forth one with allergic reaction (tab1). Ultrasound and Chest X-ray were our main tool for the diagnosis. CT was used in two of them. Laparotomy was done in three of them while thoracotomy was performed in one.

Huge Biloma in a child with unusual presentation

Professor Samir Ibrahim Hasan AlSaffar

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 76-80
DOI: 10.33899/mmed.2021.129534.1077

The term "biloma" describes a well-demarcated, encapsulated or not, intra-abdominal (extrahepatic or intrahepatic) bile collection outside the biliary tree, secondary to iatrogenic, traumatic or spontaneous rupture of the biliary tree. The clinical symptoms of bilomas are usually nonspecific, ranging from no symptoms to abdominal pain, jaundice, and fever. There were only few cases of huge bilomas in the literature but no report of conincidental extrahepatic and intrahepatic biloma in the same patient.
Case report:
We report herein a 12 years boy with huge biloma (20cm in vertical diameter) after blunt abdominal trauma, presented with unique clinical features of marked emaciation and diffuse abdominal distention . To our knowledge this is the largest biloma ever reported in paediatric age group and the first biloma with such unique clinical presentation, and the first case with both extrahepatic and intrahepatic bilomas in single setting.
Although biloma is rare condition but it needs to be considered in differential diagnosis of diffuse abdominal distension in patients following abdominal trauma or surgery.

Intertrochanteric Femoral Neck Fractures Treated by External Fixation

Professor Mahmood A Aljumaily; yakdhan al saleem; Saher H ALbanna

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 16-20
DOI: 10.33899/mmed.2021.129464.1075

Background: Intertrochanteric femoral fracture (ITFF) is common injury in old age group, there are many options of treatment. External fixation used in the high risk patients.
Objective: To present a case series of ITFFs treated by external fixators.
Patients and method: Twenty six patients with ITFF were treated by external fixation in Alzahrawy private hospital in Mosul, during the period from July 2017 through October 2019.
Results: The mean time of follow-up was 11 months. Twenty two patients showed full union of the fracture by the end of the 4th month and the external fixators were removed. Two patients died due to unrelated medical diseases, and one patient developed pathological fracture in the shaft of femur. The patients had good range of motion in both hip and knee joints. Pin tract infection was the commonest complication.
Conclusion: External fixation is simple, mini-invasive, cost-effective alternative method in the treatment of intertrochanteric femoral fractures.
Key word: Intertrochanteric, Femoral Neck, Fracture, External, Fixation.

Implementing a modified intraoperative grading system for a difficult laparoscopic cholecystectomy

Yarub Momtaz Tawfeek Al-Hakeem; Professor Nashwan Qahtan Mahgoob

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 91-99
DOI: 10.33899/mmed.2021.128336.1047


Objective: To analyze intraoperative grading findings during elective laparoscopic cholecystectomy by which we can assess the surgical performance regarding its safety, achievability and to determine a safe operative approach and/or time for conversion.

Design: An observational prospective case series study.

Setting: During the period from June 2018 to January 2020, operations were done by 4 qualified consultant surgeons and their teams at 4 hospitals in Mosul and Erbil.

Participants: Two hundred and fifty-five patients.

Patients and Methods: All patients underwent elective laparoscopic cholecystectomy for symptomatic gallbladder disease after full evaluation and taking their informed consents. An intraoperative difficulty calculation score has been implemented that divide the situation into 4 grades: easy, difficult, very difficult and extremely difficult, depending on the appearance of the gall bladder wall color, amount of adhesion, the presence of anatomical abnormalities, and the ability to achieve the critical view of safety. Perforation of the gallbladder, slipped stones, bleeding, using extra instruments, the need for extending the epigastric incision, the use of a drain and conversion to open procedure as well as the duration of surgical intervention had been recorded as predictors for the assessment of the difficulty level during surgery.

Results: The first grade included 168 (66%) patients, the second grade included 62 (24%) patients, while grades 3 and 4 represent 15 (6%) and 10 (4%) of patients respectively. Perforation showed no significance in the grading. Bleeding was more common in grades 3 and 4. Using accessory equipment was mandatory to complete the operation in grade 4 as well as an extension of epigastric port and the need for putting a drain. Conversion to open cholecystectomy was done in 2 operations (0.7%), both belonged to grade 3 and 4. The time needed to accomplish the operation was significantly high in grades 3 and 4.
Conclusion: This modified grading score can provide a tool for reporting operative findings and technical difficulties during laparoscopic cholecystectomy that allow the surgeon to know the seriousness of the situation and taking effective measures to overcome it.

The white banner test. A simple intra-operative leak test during laparoscopic sleeve gastrectomy.

Professor Nashwan mahgoob

Annals of the College of Medicine, Mosul, 2020, Volume 42, Issue 2, Pages 190-194
DOI: 10.33899/mmed.2020.127882.1043

Objective: To evaluate the efficacy of a simple intra-operative test (white banner test) for the detection of a leak during laparoscopic sleeve gastrectomy.
Design: A prospective case series study.
Setting: Obesity center at Soran private hospital, Erbil, Iraq, during the period from January 2017 to June 2019.
Participants: eighty patients underwent the white banner test during laparoscopic sleeve gastrectomy. The records of intraoperative findings and post-operative follow up were analyzed.
Patients and methods: After completing the sleeve process and hemostasis, a gauze of 4*12 cm was introduced through the 12mm trocar and displayed along the course of remaining sleeved stomach, nasogastric tube inserted to the upper portion of the stomach, compression of the pylorus by grasper against the vertebrae, 100 milliliters of saline stained by methylene blue dye were injected slowly by the anesthetist through the nasogastric tube, waiting for 30 seconds, any discoloration of the gauze was recorded and the site of leak (if any) was identified and managed. If the gauze appeared white, gauze withdrawn and the procedure finished.
Results: In 80 patients, only two patients showed a blue spot at the gauze, which were fixed by suture. In all other patients, the gauzes were completely clean and (white). Postoperatively no early leak was detected.
Conclusion: This is a simple and not time-consuming intraoperative procedure that can be used to detect intra-operative leaks during laparoscopic sleeve gastrectomy.
Keywords: obesity. Sleeve gastrectomy. Leak. Intraoperative test.
Acknowledgment: The author thanks all the staff who works at the obesity center at Soran Private Hospital for their unlimited support for this study.
The study received no outside funding and no relevant financial disclosures.
The researcher declares that there is no conflict of interest regarding the publication of this research


Saad Muawafaq Attash; Nazar Mohammed Jawhar; Mohammed tahseen yahya; Professor Muzahm K. Al-Khyatt

Annals of the College of Medicine, Mosul, 2020, Volume 42, Issue 2, Pages 199-206
DOI: 10.33899/mmed.2020.128441.1050

Objectives: To assess the methods of preoperative parathyroid adenoma localization and to compare it with operative findings.
Patients and methods: Between June 2017 and June 2019, we had operated 8 cases of parathyroid adenomas. Three patients were males and 5 patients were females. Age ranged from 26 year old to 72 year old with average of 42 year old. Seven cases were sporadic while one case was part of MEN2a. All patients had ultrasonography for preoperative localization, all had CT scan and 4 patients had Sestamibi scan. In all patients, intraoperative measurements of parathyroid hormone was done before and 10 minutes after surgical excision.
Results: Ultrasonography was successful in localizing only one case with certainty. CT scan located the adenoma in another 2 patients. In 4 patients who performed Sestamibi scan, the adenomas were located precisely in all of them including one case of ectopic parathyroid adenoma behind the sternum. In one patient, all the modalities failed in localization which was achieved easily intraoperatively. Single adenoma was found in 6 patients and two adenomas in two patients. The adenomas were located in the neck in 7 patients and in the anterior mediastinum in one patient .Surgical removal was done through neck incision in 7 cases while midline sternotomy in one case. All the patients had resolution of symptoms within the follow up period.
Conclusion: Sestamibi scan is the best investigation in preoperative localization of parathyroid adenoma. Ultrasonography and CT scan can aid in the diagnosis with less sensitivity. Intraoperative localization is possible even in cases of negative investigations.

Incidentally diagnosed papillary carcinoma in a thyroglossal duct cyst. What is the next step? A case report and review of the literature

Professor Nashwan mahgoob

Annals of the College of Medicine, Mosul, 2020, Volume 42, Issue 2, Pages 184-189
DOI: 10.33899/mmed.2020.127674.1042

Thyroglossal duct cyst is the commonest congenital disorders of the thyroid gland. Rarely, it can be a malignant tumor which is picked up incidentally in postoperative histopathology. Although management is still a controversy, a careful treatment and follow up planning is necessary for the management of such condition. We present a case of a 16-year-old female patient with thyroglossal duct cyst carcinoma.

Comparative study between sharp dissection and electro cautery dissection in incisional hernia surgery.

Omar Saad Mahmood; khalaf rasheed jadoa

Annals of the College of Medicine, Mosul, 2020, Volume 42, Issue 2, Pages 169-176
DOI: 10.33899/mmed.2020.128390.1048

Background: Incisional hernia is a common problem in our surgical practice and it poses a challenge due to its high incidence of complications like seroma and surgical site infection (SSI).
The objective of this study is to assess the contribution of diathermy to postoperative seroma formation and wound complications in incisional hernia surgery and also to assess other predictors for wound complications including comorbidities, personal and hernia characteristics.
Patients and Methods: This is a prospective case series study comparing two types of flap dissection in cases of open incisional hernia mesh repair. Sixty patients randomized in to two groups of abdominal flap dissection, one group with electro cautery dissection and other group with sharp dissection by scissors and knife. Surgical procedure was the same between the two groups. Primary outcome measures were postoperative seroma, SSI and wound dehiscence.
Results: There was no significant difference in seroma formation (p=0.738), SSI rate (p=0.641) and wound dehiscence rate (p=0.150) between the electro cautery group and the sharp dissection group. The use of cautery leads to reduction in the intraoperative blood loss (p<0.0001) and operative time (p<0.0001). The relation between body mass index (BMI), diabetes mellitus (DM), hernia length, width and postoperative seroma was highly significant (p=0.002, 0.034, 0.002, Conclusions: The use of cautery instead of scissors during flap dissection does not result in increased postoperative wound complications in incisional hernia patients. The use of cautery lead to reduction in the operative time and intraoperative blood loss. The relation between DM, BMI, hernia defect size and increased rate of wound complications was significant.

complications related to posterior hypospadias repair

Professor Abdulrahman sulaiman; Thayer Mohammed Ameen Aboush; ahmad mothafar hamodat

Annals of the College of Medicine, Mosul, 2020, Volume 42, Issue 2, Pages 184-189
DOI: 10.33899/mmed.2021.128957.1060

Background: Proximal hypospadias repair carries high complications rates. single
stage is the standard practice for management but sometimes it is not easy to perform
single stage for posterior hypospadias and here appears the need for staged surgery
in this study we assess the out coms and complications of the most commonly used
techniques in Mosul pediatric surgery center at alkhansaa teaching hospital
Objective: To assess the results of management of posterior hypospadias by
Tubularized incised plate as single stage and staged repair and to knew the most
important complications associated with these two procedures.
Methods: this is prospective study for forty patients who were admitted to Mosul
pediatric surgery center at alkhansaa teaching hospital from October 2011 till
October 2013, their age ranged from 9 month to 15 years, five of them were operated
before with complete failure, 31 patient operated by single stage Tubularized Incised
Plate technique and the other 9 by two stage technique and they were followed for
6-18 months.
Results: The total complications rate was (52%) as follow: (7) cases (17.5%)
develop meatal stenosis, (4) patients (10%) develop retrusive meatus, No one
develops stricture, (10) cases (25%) develop fistula and none of them develop
the total complication rate for Single stage TIP technique was (48.3%) the total
complication rate of complications for staged surgery was (66.6%).
Conclusion: proximal hypospadias repair is very challenging with high
complication rate which need a good experience to deal with it. Single stage or
multistage procedure can be utilized to repair this type of hypospadias. Most of the
published papers has low number of cases in comparison to the anterior type which
represent 70_80% of all cases and for that reason may be the great difference in
between different centers in the incidence of complications rate.

Wide local excision and sentinel lymph node biopsy in early breast cancer in Duhok city

Sardar Hassan Arif; Ayad Ahmad Mohammed

Annals of the College of Medicine, Mosul, 2020, Volume 42, Issue 1, Pages 19-26
DOI: 10.33899/mmed.2020.126969.1025

Objectives: Breast conservation surgery widely in form of wide local excision and sentinel lymph node biopsy in the management of patients presenting with early breast cancer.
The aim of this study is to analyze the effectiveness of the of the breast conservation surgery and sentinel lymph node biopsy using the methylene blue dye.
Methods: this retrospective cross sectional study conducted at Nov.2014 – Dec.2019 Ninety-six females Patients with stage I and II breast cancer were included in this, patients with stage III and IV, clinically suspicious axillary lymph nodes, and male patients were excluded from this study.
Injection of methylene blue dye done around the breast mass. Resection of the breast tumor done until negative margins achieved, then dissection of the axilla was done and the stained lymph node or nodes were excised and were sent for frozen section examination, when the result was negative no further axillary dissection were done, but when result was positive we did axillary lymph node dissection.
Results: The current study showed a sensitivity of 93%, specificity of 82%, positive predictive value of 85%, negative predictive value of 92%, and the accuracy of the procedure was 88%.
The most frequent complication was seroma formation and wound infection in 12.5% and 7.3 % respectively, some dye related complications were reported including tattooing of the skin in 10.4% of patients, blue urine in 3.1% of patients and mild allergic reactions in 2% of patients.
Conclusions: The technique of wide local excision and SLN biopsy using the methylene blue dye is safe and effective technique for breast conservation surgery especially in the regions were no facilities are available for the radiolabeled colloid.

Assessing the Effect of Ventriculo-peritoneal Shunt Treatment for Congenital Hydrocephalus

Mohammad Shaker; Najlaa Al-Sammak; Safwan Hashim Alhamdani

Annals of the College of Medicine, Mosul, 2020, Volume 42, Issue 1, Pages 62-67
DOI: 10.33899/mmed.2020.127286.1032

Context: Congenital hydrocephalus is one of the common neurological problems in infants, characterized by excessive accumulation of cerebrospinal fluid (CSF) in the central nervous system. Numerous babies delivered every day with this anomaly all over the world most of them in the developing countries. There are several forms of treatment; the commonest one is ventriculo-peritoneal shunt that transfers the CSF to the peritoneal cavity. It is associated with relatively low morbidity and mortality rates. Aim: This study aimed to evaluate the ventriculo-peritoneal shunt therapy outcomes for congenital hydrocephalus and find its complications.
Patients and methods: In this research, an observational case series study design had been adopted in Ibn-Sina teaching hospital applied on a convenient sample of 52 infants of both sexes with congenital hydrocephalus over a period of three years. Ethical consents were obtained from their parents. Then, clinical evaluation was done through head circumference and fontanel examinations followed by CT-scan and ultrasonic testing to confirm the diagnosis. All patients were subjected to the ventriculo-peritoneal shunt (VP) surgery with full coverage of appropriate antibiotics, and then they were followed for 6 months to assess the effectiveness of VP shunt in the treatment of hydrocephalus and to identify any complication associated with this surgery.
Results: Most cases (79%) were below 3 months of age and 55.5% of them were males. Only 13.5% of cases developed complications including upper and lower shunt obstruction, shunt infection (28.6% for each), and skin laceration in 14.2% of those 13.5% complicated cases. Most of these complications happened to infants older than 3 months of age.
Conclusion and recommendation: The study concluded that Ventriculo-peritoneal shunt was associated with low complication rate especially among young infants. Thus, it is recommended to adopt this procedure for the treatment of infantile hydrocephalus particularly among infants below 3 months of age.
Key words: Congenital, Hydrocephalus, Ventriculo-peritoneal, Shunt.

Glycosylation Gap in Gallstone Patients

Ahmed T. Hamed; Muzahm Al-khyatt; Muhammad A. Alkataan; Israa Al-banaa

Annals of the College of Medicine, Mosul, 2019, Volume 41, Issue 1, Pages 86-90
DOI: 10.33899/mmed.2019.161331

Background: Gall stones are one of the commonest biliary diseases. Interest in the formation and clinical management of the disease dates back to ancient times. Gall stones continue to be one of the major health problems in the world today, although the exact number of patients is unknown, because there are no signs and symptoms related to the disease when there are no complications. The majority of the patients are diagnosed incidentally. However, some patients come with acute complication of gall stones. Gall stones are classified into; cholesterol gall stones, pigment gall stones, and mixed gall stones. However, all stones even pure cholesterol gall stones usually contain bilirubin (conjugated and unconjugated bilirubin) and cholesterol.
Aim: To determine the changes in glycosylation gap and glycation profile and the relation of this change to the changes in age and BMI on the measured parameters.
Patients and methods: Serum samples were collected from 40 individuals included in this work. They are divided into 2 groups. The first group included 20 apparently healthy individuals (10 males and 10 females). The second group included 20 individuals (5 males and 15 females) with Gall stone diagnosed in out-patient Clinic at Al-Jamhoory General Hospital and Neinawa private Hospital. Gall stone patients with metabolic diseases, infections and other inflammatory diseases were excluded.
Results: The study demonstrated a significant elevation in serum glucose, mean blood glucose, serum fructosamin, measured and predicated HbAc1 in GS patients in comparison with controls. Regarding the relation between age and measured parameters, the study showed a non-significant correlation between age and measured parameters in the control group, while in GS group there were a significant correlation (r = 0.05) between ages and predicted HbAc1 and BMI (p ≤ 0.03). Regarding the relation between BMI and measured parameters, the study showed a significant correlation between measured parameters and BMI in GS individuals, while in control group only serum glucose and MBG in control group (r = 0.01) (p ≤ 0.01) with MBI.
Conclusion: The study shows that there is a significant change in glycosylation gap and glycation profile in gall stone patients.

Parathyroidectomy under Local Anesthesia: A Case Report

Khalaf Allwayzy; Mahmood A Aljumaily

Annals of the College of Medicine, Mosul, 2019, Volume 41, Issue 1, Pages 91-94
DOI: 10.33899/mmed.2019.161332

A fifty four years old lady presented with severe generalized bone pain, having history of multiple fractures for the last two years, biochemical tests proved to be primary hyperparathyroidism and parathyroid adenoma localized with ultrasonography. Parathyroidectomy was carried out under local anesthesia, and the patient improved dramatically after surgery.

Descriptive Study of Colorectal Cancer in Iraq, 1999-2016

Taha HT Al-Saigh; Shahbaa A Al-Bayati; Shatha A Abdulmawjood; Faris A Ahmed

Annals of the College of Medicine, Mosul, 2019, Volume 41, Issue 1, Pages 81-85
DOI: 10.33899/mmed.2019.161330

Background: Colorectal cancer has increased in the last decades, which constitutes about 10% of cancer mortality. It becomes the second and third most common cancer in women and men respectively.
Objective: To explore the factors for colorectal cancer in Iraq including age, gender, family history, diabetes, smoking, serum carcinembryonic antigen (CEA) as a predictor factor, stages of cancer, bowl habit, and symptoms.
Patients and methods: This study was conducted in surgical unit at Alkathymia Teaching Hospital, Baghdad and in Al-Jammhory Teaching Hospital, Mosul, during the period from Feb-1999 to June-2016. This is a case series study for 956 patients with colorectal cancer. The data gathered included: age, gender, family history, diabetes and smoking, serum CEA, stages of the disease, bowl habit and symptoms. Data are presented as mean and percentage, and were analyzed by using Chi square goodness of fit test.  p values ≤ 0.05 were considered significant.
Results: Colorectal cancer patients with ages between 25-50 years were significantly (p≤0.01) higher than the patients with > 50 years or 5 ng/mL presented the high percentage (83.6%) and they were highly significant (p ≤ 0.001) than patients with serum CEA less than 5. Stage 2 (48.2%) was significantly (p≤0.01) higher than stage 1 (16.6%), 3 (20.6%) and 4 (14.5%), respectively. For bowl habit, constipation presented 75.8% was significantly higher than diarrhea (14.5%). In addition, symptoms of bleeding per rectum (71.1%) were significantly higher than symptoms of pain (28.2%).
Conclusion: Colorectal cancer is significant disease in Iraq. Middle age patients presented the highest percentage. Education of patients about bowl habit and symptoms of colorectal cancer should be applied especially constipation and bleeding per rectum.

The Relationship between Cardiopulmonary Exercise testing (CPET), other Related Factors and Outcomes in Patients Undergoing Major Upper Gastrointestinal Surgery

Janan Alrefaee; Donald McMillan; Roger Carter; Jane Nally

Annals of the College of Medicine, Mosul, 2019, Volume 41, Issue 1, Pages 1-10
DOI: 10.33899/mmed.2019.161246

Background: Assessment of patient’s fitness prior to major surgery is mandatory because co-morbidities predispose to postoperative complications; however the ability of pulmonary function tests to predict postoperative cardiopulmonary complications is still poorly defined.
Objective: to examine the role of preoperative measurements of cardiopulmonary exercise testing and other lung function tests in predicting postoperative outcomes in patients undergoing major upper gastrointestinal surgery (stomach, oesophagus, small intestine, gall bladder and pancreas surgery).
Patients and methods: A 193 patients who had major upper gastrointestinal surgery’ age, sex and smoking status were recorded and they underwent a range of tests including body mass index, flow-volume curve spirometry, blood gas analysis, transfer factor for carbon monoxide (TLCO) and CPET at the Pulmonary Function Laboratory of Glasgow Royal Infirmary between August 2008 and December 2011. Post-operative morbidity and mortality was analysed for all patients who underwent major surgery.
Results: Comparisons between patients that did or did not have post operative pulmonary complications showed significant differences in anaerobic threshold as % predicted maximum oxygen consumption during exercise (VO2; p<0.05), length of high dependency care stay (p<0.001), length of ward stay (p<0.01) and length of hospital stay (p<0.001).  There were significant differences between those patients with and without operative anastomotic leak in body mass index (BMI; p<0.05), length of high dependency care stay (p<0.001), length of ward stay (6 vs.15, respectively; p<0.001), length of hospital stay (14 vs. 28, respectively; p<0.001) and duration between date of surgery and date of commencing postoperative chemotherapy (p≤0.01). 
Conclusion: CPET and in particular anaerobic threshold % maximum predicted is useful in predicting the likelihood of the development of pulmonary complications in patients undergoing upper gastrointestinal surgery.

Isolated Sphenoiditis, Hidden Cause of Headache

Saad Y. Sulaiman

Annals of the College of Medicine, Mosul, 2019, Volume 41, Issue 1, Pages 36-42
DOI: 10.33899/mmed.2019.161333

Background: Many patients present to otorhinologists daily complaining of headache due to rhinosinusitis which generally has a specific findings. Nonetheless, isolated sphenoiditis is a rare type of sinusitis, but associated with more serious complications due to its contiguity with vital intracranial structures, and is usually associated with non-specific findings that may be missed as a cause of headache.
Objectives: To highlight cases with headache due to isolated sphenoiditis that present with non-specific signs and symptoms of sinusitis, and to discuss the best methods of diagnosis and treatment to avoid serious complications.
Patients and methods: A case series study of 27 patients (21 males, 8 females) aged between 18-32 years-old (mean age 25 years old), were evaluated during the period between June 2015 and December 2017 in the author's private clinic at PAR Hospital, Erbil, Iraq. Those patients were misdiagnosed as cases of primary headache (migraine or tension-type headache). The diagnosis of isolated sphenoiditis in those patients was based on clinical findings, nasal endoscopy and it was proved by computerized tomography scan.
Results: The study was performed on adult patients, half of them were between 24-28 years-old, with a male to female ratio of 7:3. Headache was the presenting symptom with minimal expression of other symptoms of sinusitis, i.e.; nasal obstruction in 10 patients (37%), postnasal discharge in 5 patients (18.5%), visual symptoms in 3 patients (11%) and sneezing and itching in 6 patients (22%). Nasal endoscopic findings were negative in 5 patients (18.5%), while septal deviation was noted in 14 patients (52%), concha bullosa in 1 patient (3.7%), postnasal discharge in 5 patients (18.5) and granular pharyngitis in 10 patients (37%). Computerized tomography scanning of the paranasal sinuses was performed for all patients and proved the diagnosis of isolated sphenoiditis. Headache was relieved by medical treatment in 22 patients (81.5%). Five patients (18.5%) required surgical treatment.
Conclusion: Although it is uncommon, isolated sphenoiditis must be suspected in patients with headache. It is a potentially dangerous disorder due to the contiguity of the sinus with vital neuro-vascular structures. Therefore, ENT specialists must be alert of this rare condition and radiological examination of paranasal sinuses should always be performed in prolonged and intractable cases of headache. Computerized tomography scan is the best tool in diagnosis and follow up of such cases.