Print ISSN: 0027-1446

Online ISSN: 2309-6217

Main Subjects : Surgey


RARE AND DEMANDING: PARATHYROID ADENOMA LOCALIZATION, SURGERY AND OUTCOME.

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

ABSTRACT
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.

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
diverticulum,
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.

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

ABSTRACT:
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

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.

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

Abstract
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.

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.

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.

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.