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Fulltext Recognition and management of hungry bone syndrome--a case report

Hisham AN, Aina EN, Zanariah H

Med J Malaysia, 2000 Mar;55(1):132-4.
PMID: 11072498

Hungry bone syndrome (HBS) following successful parathyroid surgery is a well described phenomenon. However, few studies have clearly addressed this syndrome or looked at the outcome of perioperative management. We report a case of HBS following successful parathyroid surgery. The perioperative management is discussed and literature pertaining to this interesting case is reviewed.
Fulltext Large adrenocortical carcinoma extending into the inferior vena cava and right atrium

Hisham AN, Sarojah A, Zanariah H

Asian J Surg, 2003 Jan;26(1):40-2.
PMID: 12527494

A case of large adrenocortical carcinoma extending into the inferior vena cava and right atrium is reported. Computed tomography showed a large mass displacing the left kidney inferiorly with an intravascular tumour thrombus extending into the inferior vena cava and right atrium. Radical surgery under hypothermia and cardiopulmonary bypass was performed and the tumour mass, together with the tumour thrombus, was successfully removed. The presence of intravascular tumour extension alone should not be a contraindication to radical surgical therapy, as it is the best hope for prolonged survival.
Fulltext Prebiopsy localisation of impalpable breast lesions

Hisham AN, Harjit K, Fatimah O, Yun SI

Med J Malaysia, 2004 Aug;59(3):402-5.
PMID: 15727388

Prebiopsy localization of impalpable breast lesions (IBL) assures removal of suspicious mammographically detected lesions. Specimen radiograph of the excised specimen is mandatory to confirm complete excision. The aim of this study was to audit our series of percutaneous hookwire localization and to determine the positive biopsy rate of the mammographically detected impalpable breast lesion in our center. Thirty-eight patients with suspicious IBL underwent excision biopsy under mammographic localization in our unit from late February 1998 to May 2003. The excised specimen is immobilized and compressed within the Transpec device. This device incorporates a reference grid visible in the specimen radiograph. Hence, the target lesion marked in the reference grid of the specimen radiograph will allow precise examination and exact localization of the suspicious lesion by the pathologist. The positive biopsy rate for malignant lesion was 26.3%, the majority fall in the range of 40-59 age group. Thirty-two (84.2%) of the patients had clustered micro-calcifications, 4 (10.5%) had impalpable mass lesions and in 2 (5.3%) spiculated lesions were seen on the preoperative mammogram. Mammographic feature of clustered micro-calcification accounts for all the malignant lesions in our series. Utilization of Transpec device has shown to be practical, reliable and cost effective in the management of IBL. Nonetheless, it should be emphasized that optimal specimen radiography and pathological correlation requires close cooperation between radiologist, surgeon and pathologist.
Fulltext Overview of breast cancer in Malaysian women: a problem with late diagnosis

Hisham AN, Yip CH

Asian J Surg, 2004 Apr;27(2):130-3.
PMID: 15140665

Breast cancer is the most common cancer among Malaysian women. There is a marked geographical difference in the worldwide incidence of breast cancer, with a higher incidence in developed countries compared to developing countries. From 1998 to 2001, new cases of breast cancer presenting to the breast clinics at Hospital Kuala Lumpur and University Malaya Medical Centre, Malaysia, were reviewed; the race, age and stage at presentation were analysed. Of 774 cases seen in Hospital Kuala Lumpur, only 5.2% (40/774) were impalpable breast cancers diagnosed on mammography. The prevalent age group was 40 to 49 years, and the median age was 50 years. The average size of the tumour was 5.4 cm in diameter. Malay women appear to have larger tumours and a later stage at presentation than other ethnic groups; 50% to 60% were in late stages (Stages 3 and 4). During the same period, 752 new cases of breast cancer were seen in the University Malaya Medical Centre. The average tumour size was 4.2 cm, and 30% to 40% were in late stages. The age incidence was similar. The delay in presentation of breast cancer was attributed to a strong belief in traditional medicine, the negative perception of the disease, poverty and poor education, coupled with fear and denial. A prospective, population-based study is required to determine the demographic pattern of breast cancer and the factors delaying presentation. These findings will have important implications in future programmes to promote the early detection of breast cancer, as well as in understanding geographical as well as racial variations in the incidence of breast cancer.
Spectrum of breast cancer in Malaysian women: overview

Hisham AN, Yip CH

World J Surg, 2003 Aug;27(8):921-3.
PMID: 12784146

Breast cancer is the most common cancer among Malaysian women. Nonetheless, in Malaysia there is a marked geographical difference in the incidence of breast cancer with advanced stage of presentation. The breast clinic in Kuala Lumpur Hospital diagnosed approximately 150 to 200 new cases of breast cancer a year. This number, however, represents only 12.0% to 15.0% of all breast disease seen annually in Kuala Lumpur Hospital. Between 1998 and 2001, of a total of 774 cases of newly diagnosed breast cancer in Kuala Lumpur Hospital, only 5.0% (40/774) were impalpable breast cancers. The peak age group for the three major ethnic distributions (Malay, Chinese, and Indian) ranged from 40 to 49 years. The mean tumor size at presentation was 5.4 cm (range: 1-20 cm), and the advanced stage of breast cancer is observed to be highest among the Malay ethnic group. Although it appears that the incidence of breast cancer in Malaysia is lower than in the developed countries, the difference may be attributable to the difficulty in getting accurate statistics and to underreporting of cases. Nonetheless, from the available data, it is clear that breast cancer continues to be the most common cancer among Malaysian women. The strongly negative social-cultural perception of the disease, made worse by the geographical isolation of many rural areas, accounts for the delayed diagnosis and the often advanced stage of disease at presentation. A prospective population-based study is called for to verify the demographic patterns of breast cancer, particular in Malaysia and other developing countries. The findings of such a study may have implications for future breast screening programs and for facilitating the understanding of differing risks of breast cancer among women around the world.
Mapping timely access to emergency and essential surgical services: The Malaysian experience

Hoh SM, Wahab MYA, Hisham AN, Guest GD, Watters DAK

ANZ J Surg, 2021 Jun 01.
PMID: 34075677 DOI: 10.1111/ans.16986

BACKGROUND: Surgical conditions form a significant proportion of the global burden of disease. Since the 2015 World Health Assembly resolution A68.15, there is recognition that the provision of essential surgical care is an integral part of universal access to health care. The Lancet Commission on Global Surgery proposed its first surgical indicator to measure a population's access to the Bellwether procedures (laparotomy, caesarean section and treatment of open fracture) within two hours. Bellwether access is a proxy for emergency and essential surgical care. This project aims to map essential surgical access to the Bellwether procedures in Malaysia.
METHODS: The location and capability of hospitals to perform the Bellwether procedures was obtained from the Ministry of Health (MoH) and MoH hospital specific websites. The Malaysian population data were retrieved from the national department of statistics. Times for patients to travel to hospital were calculated by combining manual contouring and geospatial mapping.
RESULTS: There were 49 Bellwether-capable MoH hospitals serving a national population of 32.5 million. Overall 94% of Malaysia's population have access to the Bellwethers within two hours. This coverage is universal in West (Peninsular) Malaysia, but there is only 73% coverage in East Malaysia, with 1.8 million residents of Sabah and Sarawak not having timely access. Malaysia's Bellwether capacity compares well with other countries in World Health Organisation's Western Pacific region.
CONCLUSION: There is good access to essential and emergency surgical services in Malaysia. The incomplete access for 1.8 million people in East Malaysia will inform national surgical planning.
The surgical treatment of adrenal diseases

Meah FA, Abdullah T, Jasmi AY, Hisham AN, Tan TT, Khalid BA, et al.

Ann Acad Med Singap, 1996 Mar;25(2):251-4.
PMID: 8799016

Between January 1978 to December 1993, 130 cases of adrenal diseases were diagnosed and surgically treated at the National University of Malaysia. They were 58 cases (44.6%) of Conn's syndrome, 40 cases (30.7%) of Cushing's syndrome, 20 cases (15.3%) of phaeochromocytoma and 12 cases (9.2%) of adrenocortical carcinoma (ACC). The commonest cause of Conn's syndrome was an adenoma (96.5%) which affected the left gland four times more than the right gland. Cushing's syndrome was caused by adrenocortical adenoma (32.5%), diffuse bilateral adrenal hyperplasia (40.0%), pigmented macronodular hyperplasia (20.0%) and adrenal carcinoma (7.5%). Twenty-five percent of the phaeochromocytomas were extraadrenal in origin arising mainly from the abdominal sympathetic chain. More than 50% of ACCs were non-functioning tumours. Fifty percent of the patients with ACC had inoperable tumours. The prognosis was poor even with adjuvant chemoradiotherapy. The main surgical approach was the anterior transabdominal route. There was no operative mortality or morbidity in all operated cases.
RACS and its Fellows: a contribution to sustainable healthcare improvement in South East Asia

Hollands M, Hisham AN, Kong J, Moss D, Pusponegro A, Wora-Urai N, et al.

ANZ J Surg, 2021 03;91(3):245-248.
PMID: 33580574 DOI: 10.1111/ans.16534

The question of whether small non-government organizations with comparatively small budgets can make a substantial contribution to sustainable improvement in health care in low- and middle-income countries is crucial to funding global surgical projects. The Royal Australasian College of Surgeons and its Fellows have partnered with local organizations and clinicians to deliver a wide range of projects in South East Asia. These projects have proved sustainable and have increased healthcare capacity in these nations. This provides strong evidence that small non-government organizations such as the Royal Australasian College of Surgeons can make a major contribution to global surgeryI.
Huge adrenal haemangioma

Hisham AN, Samad SA, Sharifah NA

Australas Radiol, 1998 Aug;42(3):250-1.
PMID: 9727258

Adrenal tumours are either functioning or non-functioning. Non-functioning adrenal tumours are generally asymptomatic and usually of enormous proportions at the time of presentation. A case is presented here of a patient with a huge right adrenal haemangioma which was successfully treated surgically. This unusual tumour was 25 cm in diameter, was well encapsulated and weighed 4 kg. The literature pertaining to this interesting case is reviewed.
Total thyroidectomy: the procedure of choice for multinodular goitre

Hisham AN, Azlina AF, Aina EN, Sarojah A

Eur J Surg, 2001 Jun;167(6):403-5.
PMID: 11471662 DOI: 10.1080/110241501750243725

OBJECTIVE: To review our experience of total thyroidectomy for bilateral multinodular goitre.
DESIGN: Prospective open study.
SETTING: Teaching hospital, Malaysia.
SUBJECTS: 98 consecutive patients whose bilateral multinodular goitres were treated by total thyroidectomy, January 1998-November 1999.
INTERVENTION: A revised technique of total thyroidectomy in which more attention than is customary was paid to the exposure and safety of the laryngeal nerves and the parathyroid glands. All patients had at least 1 parathyroid gland autotransplanted.
MAIN OUTCOME MEASURES: Morbidity and mortality
RESULTS: There were no injuries to the recurrent laryngeal nerves and no patient developed persistent hypocalcaemia; 27/98 developed transient hypocalcaemia, but this had settled by 6 months postoperatively. 59 patients had persistent symptoms of pressure preoperatively, and these all resolved by 3 months postoperatively. 6 patients had occult malignant disease discovered on histological examination, and 3 developed minor wound infections.
CONCLUSIONS: Total thyroidectomy is the procedure of choice for bilateral multinodular goitres, provided that sufficient attention is paid to the preservation of the laryngeal nerves and the parathyroid glands.
Fulltext Polycystic liver disease treated by fenestration and segmental liver resection

Haron A, Hisham AN, Samad SA

Med J Malaysia, 1994 Mar;49(1):86-9.
PMID: 8057997

A case of symptomatic polycystic liver disease treated by fenestration and segmental liver resection is reported. The intraoperative use of ultrasound to define the plane of liver resection is emphasised. No significant post-operative complication was encountered. The clinical presentation, management and treatment are discussed.
Fluorescence in situ hybridization analysis using PAX8- and PPARG-specific probes reveals the presence of PAX8-PPARG translocation and 3p25 aneusomy in follicular thyroid neoplasms

Chia WK, Sharifah NA, Reena RM, Zubaidah Z, Clarence-Ko CH, Rohaizak M, et al.

Cancer Genet. Cytogenet., 2010 Jan 1;196(1):7-13.
PMID: 19963130 DOI: 10.1016/j.cancergencyto.2009.08.001

At the present time, the differentiation between follicular thyroid carcinoma (FTC) and adenoma can be made only postoperatively and is based on the presence of capsular or vascular invasion. The ability to differentiate preoperatively between the malignant and benign forms of follicular thyroid tumors assumes greater importance in any clinical setting. The PAX8-PPARG translocation has been reported to occur in the majority of FTC. In this study, a group of 60 follicular thyroid neoplasms [18 FTC, 1 Hurthle cell carcinoma (HCC), 24 follicular thyroid adenomas (FTA), 5 Hurthle cell adenomas (HCA), and 12 follicular variants of papillary thyroid carcinomas (FV-PTC)] were analyzed to determine the prevalence of the PAX8-PPARG translocation by fluorescence in situ hybridization. The PAX8-PPARG translocation was detected in 2/18 FTC (11.1%). In addition, 2/18 (11.1%) FTC and 1/5 (20%) HCA showed 3p25 aneusomy only. The frequency of the translocation detected in the study was lower compared to the earlier studies conducted in Western countries. This might be attributed to the ethnic background and geographic location. Detection of either the PAX8-PPARG translocation or the 3p25 aneusomy in FTC indicates that these are independent genetic events. It is hereby concluded that 3p25 aneusomy or PAX8-PPARG translocation may play an important role in the molecular pathogenesis of follicular thyroid tumors.
Histoplasmosis presenting with progressively worsening backache--a case report

Lachmanan SR, Haniza O, Hisham AN, Subramaniam J, Merican I

Ann Acad Med Singap, 2001 Nov;30(6):656-8.
PMID: 11817299

INTRODUCTION: Bilateral adrenal enlargement is often the result of disseminated malignant disease, and this diagnosis is particularly likely in a patient with severe weight loss. We describe a case with bilateral adrenal enlargement presenting with progressively worsening backache as a prominent symptom.
CLINICAL PICTURE: A 55-year-old man presented with intermittent low back pain which was progressively worsening, fever, anorexia, low back pain and a 10-kg weight loss. He had underlying diabetes mellitus and ischaemic heart disease. He gave a history of travel to caves for worship. Clinically, the most significant findings included nodular lesions in the anterior fauces and left palatoglossal region. Computed tomographic scan revealed bilateral adrenal masses. Biopsies were taken from the palatal nodules, which revealed histiocytes with numerous histoplasma organisms.
TREATMENT: He was commenced on itraconazole 200 mg daily for a period of 9 months. There was a dramatic initial response with settling of his fever and this was followed by subjective improvement in his well-being.
OUTCOME: He is presently on follow-up and has completed 9 months of itraconazole therapy with resolution of all his symptoms and has gained about 10 kg of weight.
Recurrent laryngeal nerve in thyroid surgery: a critical appraisal

Hisham AN, Lukman MR

ANZ J Surg, 2002 Dec;72(12):887-9.
PMID: 12485227 DOI: 10.1046/j.1445-2197.2002.02578.x

BACKGROUND: Identification and preservation of the recurrent laryngeal nerve (RLN) is of major concern in surgery of the thyroid gland. The purpose of this study was to review the surgical anatomy of the nerve and to describe its relationship to other important structures.
METHODS: A total of 325 patients were accrued in this prospective non-randomized study from January 1999 to December 2000. All patients who had total, subtotal and hemithyroidectomies were included in this study. Each side of the thyroid gland was considered as a separate unit in the analysis of the results.
RESULTS: Two hundred and seventy-six patients had thyroidectomies as their primary operation, while 49 patients had them as a reoperative procedure. There were 276 women and 46 men (6:1 female to male ratio) with a mean age of 43.1 years (range: 10-84 years). The total number of dissections was 502. The RLN was clearly identified in 491 (97.8%) dissections: single trunk in 323 dissections (65.8%), two extralaryngeal branches in 164 dissections (33.4%), and three extralaryngeal branches in three dissections (0.6%). One non-recurrent laryngeal nerve was encountered (0.2%) in the series. The proximity of the RLN to the inferior thyroid artery (ITA) was noted in 444 (90.4%) dissections: 372 (83.8%) nerves were described to be posterior and intertwined between the branches of the ITA, and in 72 (16.2%) RLNs, they were observed to be anterior to the ITA. The close association of RLN to an enlarged tubercle of Zuckerkandl was documented in 381 dissections (73.7%). A total of 231 RLNs (60.8%) was seen in the tracheoesophageal groove, 18 (4.9%) nerves were observed to be lateral to the trachea, and in 109 (28.3%), they were posterior in location. Of concern in 23 (6.0%) dissections the RLN was on the anterior surface of the thyroid gland, which is at highest risk of injury before curving down to pass behind the tubercle of Zuckerkandl. It appears that the anterior course of the RLN was seen more often in the reoperative procedures to the thyroid gland (20%).
CONCLUSIONS: Although various methods of localizing the RLN have been described, surgeons should be aware of the variations and have a thorough knowledge of normal anatomy in order to achieve a high standard of care. This will ensure the integrity and safety of the RLN in thyroid surgery. The anatomical variation may be minor in degree, but is of great importance as it may affect the outcome of the surgery and the patient's quality of life.
Fulltext Prevertebral soft tissue measurements in thyroid enlargement: the value of lateral neck radiographs

Hisham AN, Sarojah A, Mastura T, Lim TO

Asian J Surg, 2004 Jul;27(3):172-5.
PMID: 15564155

Measurement of prevertebral soft tissue is commonly used to assess prevertebral abnormalities, such as retropharyngeal abscess or injury to the cervical spine. In the presence of goitres, the widened prevertebral tissue seen on plain lateral neck radiograph may be diagnostic of an enlarged tubercle of Zuckerkandl (ZT), which may be responsible for most pressure symptoms. The aim of this study was to substantiate the value of plain lateral neck radiographs in preoperative demonstration of enlarged ZT.
Fulltext Fracture of the penis

Kamil N, Hisham AN, Abdullah M, Khairullah A

Med J Malaysia, 1993 Sep;48(3):373-6.
PMID: 8183157

Fracture of the penis is not an uncommon urological emergency. Six patients with this injury, treated at the Institute of Urology, General Hospital, Kuala Lumpur, since 1988, were reviewed. Their ages ranged from 21 to 30 years old (mean 25). Four cases were self-inflicted by abnormal bending and 2 cases occurred during sexual intercourse. A sudden "cracking sound", violent pain, rapid flaccidity and deformity of the penis were documented. Duration of injury at presentation ranged from 12 to 90 hours (mean 35 hours). Primary repair of the tunica albuginea with absorbable suture was performed in all cases. The results of surgery was excellent, with restoration of normal function in 4 patients (2 patients defaulted follow-up). We advocate immediate surgical repair for this injury.
Fulltext Chilaiditi's syndrome presenting as acute abdomen

Hisham AN, Gunn A, Jamil AA

Med J Malaysia, 1995 Sep;50(3):281-3.
PMID: 8926911
Fulltext Primary lymphoma of the thyroid: diagnostic and therapeutic considerations

Sarinah B, Hisham AN

Asian J Surg, 2010 Jan;33(1):20-4.
PMID: 20497878 DOI: 10.1016/S1015-9584(10)60004-8

Primary thyroid lymphoma is uncommon and accounts for less than 2-5% of all thyroid malignancies. The aim of the present study was to review our experience and management of primary thyroid lymphoma and to discuss the diagnostic and therapeutic considerations.
Adrenal tuberculosis: the atypical presentations of eggshell-like calcifications

Imisairi AH, Hisham AN

ANZ J Surg, 2009 Jun;79(6):488-9.
PMID: 19566876 DOI: 10.1111/j.1445-2197.2009.04953.x
Fulltext Emergency thyroid surgery: a surgical challenge

Rohana A, Hisham AN

Asian J Surg, 2009 Apr;32(2):81-4.
PMID: 19423453 DOI: 10.1016/S1015-9584(09)60015-4

BACKGROUND: Acute life threatening presentations of thyroid disease are uncommon. The aim of this study was to review our experience of emergency thyroid surgery with regard to the incidence, management and outcome to this approach.
METHODS: Forty patients who underwent emergency thyroid surgery from December 1998 to December 2007 were prospectively accrued in this study. There were 30 female and 10 male patients. The mean age was 63.8 years (range, 33-83 years). All patients had total thyroidectomy, except one patient who only had a right hemithyroidectomy for a dominant right multinodular goiter. Eight of the patients had been intubated before referring to our centre.
RESULTS: The mean weight of specimen was 219 g (range, 32-800 g). A histopathology report confirmed 16 patients had multinodular goiters, eight patients had papillary thyroid carcinomas, seven patients had anaplastic cancers, four patients had follicular thyroid carcinomas, two patients had thyroid lymphoma, one patient had medullary carcinoma, one patient had sarcoma and one patient had thyroid abscess. A total of 28 patients were discharged well postoperatively.
CONCLUSION: Acute life threatening presentations of thyroid disease are uncommon. However, early recognition of these problems is crucial and may life saving. Emergency thyroidectomy is important to release the critically obstructed airways. Nonetheless it is associated with higher risk of surgery and complication rate then any elective thyroid surgery.

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