Tumour surgery for locally extensive malignant neoplasms of the extremity will sometimes result in extensive composite soft tissue defect. Local flaps are usually inadequate to cover these large defects. More than one tissue flap might be required to cover any exposed neurovascular structures, bone or prosthesis. We present two cases where two composite flaps were simultaneously used to cover extensive surgical defects after ablative tumour resections in the extremity. These resulted in uncomplicated wound healing and limb salvage.
Inflammatory Pseudotumor (IP) of bladder is one of a variety of lesions which may arise from spindle cell lesions in the bladder. It is benign in nature compared to the other end of the spectrum of spindle cell lesions, such as sarcoma, sarcomatoid carcinoma and leiomyosarcoma. The diagnosis of IP and its differentiation from a malignant pathology is a diagnostic dilemma for Urologist and Pathologist as both entities share certain similar morphological and histo-pathological appearance as well as immuno-histo chemistry staining. It is however crucial to avoid misdiagnosis as the treatment option varies significantly between a radical or partial cystectomy with future surveillance cystoscopes. Hereby, we highlight a case of a benign variant of spindle cell tumour of bladder which needed second pathology review for confirmation and thus avoiding a radical cystectomy. We also review the literature on its presentation and emphasis characteristics differentiating a benign from a malignant pathology
Extra-gonadal germ cell tumours (EGGCT) are rare. Therefore further investigations of the testis is aimed at sourcing a possible primary origin of gonadal tumour. Over the years, various case series on EGGCT have been reported questioning its true nature as in a majority of them, a primary source is found in the testis, thus representing a metastatic gonadal tumour. The testis pathology could be either a true germ cell foci, an intra-tubular epithelial neoplasia or an area of fibrosis, indicating a ‘burnt out tumour’. We report a 39-year-old male who underwent laparotomy and excision of a retroperitoneal tumour. Histopathological examination revealed retroperitoneal lymph node of mixed germ cell tumour origin. Clinical and ultrasound examination of bilateral testis was normal. The patient refused orchidectomy or a testicular biopsy. He underwent four cycles of bleomycin, cisplatin, and etoposide with no evidence of tumour recurrence on follow up and remains disease free after 12 months of diagnosis. A literature review of EGGCT, its relation and factors relating with future testicular tumour is presented.
Management of pain plays an important role during prostate biopsy. Various types of management of pain plays an important role during prostate biopsy. Various types of anaesthetic methods have been used. The present study aimed to compare the efficacy and complication rate between periprostatic lidocaine infiltration and transrectal lidocaine gel in transrectal ultrasound guided prostate biopsy. All prostate biopsy patients were included except those with lidocaine, allergy, haemorrhagic diathesis, anticoagulation therapy, the inability to rate a visual analogue scale and inability to obtain consent. They were randomized into two groups. Group 1 received 20ml 2% transrectal lidocaine gel. Group 2 received 5ml 1% lidocaine infiltration for each periprostatic nerve block with 23-gauge spinal needle. After three minutes, prostate biopsy was performed with an 18 gauge 7-inch spring-loaded biopsy gun. Six biopsies were taken for each lobe. Pain during probe insertion, biopsy and immediately after the procedure was assessed using the Visual Analogue Scale. Any complication immediately after procedure, one day or after one week, was recorded. Mean pain score was lower after periprostatic lidocaine infiltration compared to transrectal lidocaine gel (3.1 + 1.9 versus 4.9 + 2.4, p = 0.027). There was no statistically significant difference in the complication rate. Transrectal ultrasound prostate biopsy using periprostatic lidocaine infiltration provides better anaesthesia as compared to the transrectal lidocaine gel application with no significant difference in complication. Thus, the use of periprostatic lidocaine infiltration in TRUS guided prostate biopsy is recommended.
The incidence of varicose veins and the need for treatment has shown a tremendous increase over the years. Debilitating venous ulcers and dragging edemas of the lower limb with overall improvement in cosmetic results and availability of endovenous procedures has brought many patients forward for treatment. Continuous-wave handheld Doppler usage is limited by its diagnostic capabilities, thus the need to determine its real effectiveness. Benefits of using hand-held dopplers lies in its rapidity in assessment of patients, it's low running cost and short learning curve. This is important as duplex ultrasounds are not readily available in district hospitals. This study aims to determine the clinical effectiveness of hand-held continuous wave dopplers in the local setting especially in primary uncomplicated varicose articles veins. All electively referred patients with primary uncomplicated varicose veins who were referred to the Varicose Vein Clinic were evaluated with continuous-wave handheld Doppler (CWD) and duplex ultrasound (DUS) examination. The study duration was from the 1st of July to 31st of August 2013 (2 months). All patients in the study were independently evaluated with CWD and DUS in the clinic on the same day after adequate rest time. DUS was taken as the gold standard for evaluation of CWD specificity and sensitivity. The Chi-square and T-test was used to test for statistical significance. A total of 41 patients were evaluated in this study. The specificity of CWD when compared to DUS for diagnosing Sapheno-femoral junction (SFJ) was 100% and at the Sapheno-popliteal junction (SPJ) was 87%. Meanwhile sensitivity of CWD for SFJ was 75% and SPJ was 60%. The examination time with CWD was significantly faster than when compared with DUS examination with significant faster tracing times that can be achieved with CWD. CWD also significantly shorter reflux times when compared to DUS. Continuous-wave handheld doppler proves to be an indispensable clinical tool in the evaluation of SFJ and SPJ reflux in varicose veins. CWD assessment in this study was shown to be equal if not better for evaluating reflux when compared to DUS assessment for SFJ reflux. Main advantages for CWD also lie in its low running cost, rapidity in assessment and short learning curve when compared to duplex ultrasound examinations.
This study aimed to review the risk factors and clinical outcomes of patients undergoing pars planar vitrectomy (PPV) for breakthrough bleeding (BTB) from age related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV). We performed a retrospective review of medical records of 346 patients operated by the vitreoretinal unit at Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia from January 2008 - June 2011. We found eight eyes of 8 patients with AMD/IPCV-related BTB who underwent PPV. Mean age of patients was 64.4 years (range 41-80 years) with 5 males. Five were Chinese. Duration of symptoms ranged from days to months. Four patients were on anti-coagulants. Two had history of prior photodynamic therapy. There were five cases of PCV, of which three were macular in location. All three cases of AMD were macular. Intraoperative intravitreal ranibizumab injection was given in three cases and two had combined vitrectomy and cataract extraction. All cases reported improvement in visual acuity with four cases achieving 6/60 or better post operatively including two cases of extramacular PCV achieving 6/9 vision. Mean follow-up was 60 weeks. Postoperative complications included retinal tear and detachment in one case, reattached on reoperation. Six patients had a history of hypertension including one individual with stroke. Our small series indicates a predominance of Chinese individuals with BTB. Usage of anticoagulants and hypertension may be a predisposing factor. Better visual prognosis occurs with extramacular lesions which tend to be of PCV type.
This was a prospective observational study to identify the incidence and possible risk factors for maternal desaturation following neuraxial blockade for elective caesarean section (CS). Patients with body mass index (BMI) ≥ 30 kg/m2 at the first antenatal consultation were identified and classified into the obese group. Neuraxial blockade in the form of subarachnoid block (SAB) or combined spinal-epidural (CSE) was performed. Mean arterial pressure (MAP) and oxygen saturation (SpO2) were recorded at baseline and at 5-minute intervals following neuraxial blockade. Desaturation, defined as SpO2 < 94% for more than 30 seconds without artifacts, was managed with oxygen therapy and other appropriate measures. Newborn Apgar score and umbilical cord blood gases were analysed. Among a total of 254 recruited patients, 69 (27.2%) were obese and were associated with significantly higher age, parity, previous CS and pre-existing diabetes mellitus. The incidence of oxygen desaturation was 1.2%, involving three patients in the non obese group. These desaturation episodes were short-lived and associated with intraoperative hypotension. Six patients, two of whom in the obese group, received rescue oxygen therapy following intraoperative events such as deteriorating SpO2 or hypotension. The mean MAP was significantly lower at baseline and at 5 minutes post neuraxial blockade in the non obese group, which could account for the occurrence of desaturation in this group only. There were no significant inter-group differences in terms of neonatal outcome, umbilical cord blood gases and changes in mean SpO2 post neuraxial blockade. In conclusion, the current practice of not routinely giving supplementary oxygen to patient during elective CS at our institution is deemed to be safe, provided continuous SpO2 monitoring is available throughout the surgery. Further randomised clinical trials are indicated to investigate the impact of maternal obesity and of labouring patients presenting for urgent or emergency CS on intraoperative oxygen desaturation.
A middle-aged gentleman with history of left penetrating keratoplatsy presented with left eye perforated corneal graft secondary to infective keratitis. The affected eye was blind from absolute steroid-induced glaucoma. In view of expected poor graft survival in a blind eye, globe removal was offered. However, the patient refused the treatment and request for another corneal graft. This case highlights both the possibility of good outcome of cornea graft in such a case, and also illustrates that patient’s autonomy to refuse treatment option outweighs beneficence.
The aim of this review was to analyze the gender disparities found as well as the life expectancies in Asia. An analysis of the data on gender disparities as well as life expectancies of the different Asian countries was done based on the World Health Organization (WHO) Global Health Observatory Data Repository as well as the regional government databases. Middle Eastern countries have the highest male to female population ratio. The results show that in terms of population pyramid, Asia is moving towards a more geriatric population. Qatar has the highest life expectancy for men and is the only country in Asia where men live longer than women (difference of 2 years). In general, women in Asia live longer than men. High income countries like Hong Kong, Japan and Singapore have higher life expectancies as compared to those on the lower income nations. The life expectancy of Asian men still lags women. Men’s health care needs to be addressed urgently. The disparity in income-status reflecting the lifespan of men is an impetus for us to narrow the gap of health in Asian countries.
We report on a rare case of a child with persistent right upper lid eversion with conjunctival prolapse since birth that
failed various attempts in repositioning the right superior fornix at other centre. He was found to have a right superotemporal
orbital mass above the prolapsed area. Computerized tomography (CT) scan of orbit confirmed a right
lacrimal gland tumour with thinning of the right lesser wing of sphenoid. An excision biopsy of the tumour via
anterior orbitotomy and eyelid reconstruction were performed. Histopathology report reviewed plexiform
neurofibroma of the lacrimal gland. Further physical examination confirmed presence of multiple café-au-lait spots.
He was diagnosed as Neurofibromatosis Type 1.
We here describe a videolaryngoscope assisted fibreoptic tracheal intubation in a 17-year-old patient with Hunter Syndrome (Mucopolysaccharidosis Type II) and known difficult intubation who required posterior cervical fusion surgery for cervical canal stenosis. The patient had a history of failed nasal and oral fibreoptic intubation. The use of a videolaryngoscope enabled continuous visualization of the tracheal inlet and allowed a straightforward nasal fibreoptic intubation attempt without complications. This report suggests a viable alternative for the management of a known difficult airway in children with mucopolysaccharidosis.
The EXIT (Ex utero intrapartum treatment) procedures have been, with a high degree of success, employed to treat a myriad types of fetal airway obstruction most commonly neck masses such as cystic hygroma and lymphangioma with ample plan including prenatal diagnosis by ultrasound scan or MRI. Before the advent of EXIT, formal documentations had been published with descriptions of intubation during intrapartum period and fetal airway protection either during normal or operative delivery. We report a 28-year-old gravida 2 para 1 who was referred to our Maternal Fetal Medicine (MFM) unit at 26 weeks and 3 days gestation with a foetal neck mass. We present a case of an successful EXIT procedure performed in the Lloyd Davies position with the hips abducted and flexed at 15 degrees as is employed during gynecologic laparoscopy surgery minus the Trendelenburg tilt. Both mother and baby are well. The benefits of this position are discussed.
Renal cell carcinoma (RCC) is the one of the most common type of of cancer of the kidneys affecting adults. A 35- year-old man, with Von Hippel Lindau (VHL) syndrome was referred for bilateral renal mass in a follow up CT for evaluation. Open partial left nephrectomy was performed and the final histopathological report confirmed the diagnosis. One of the most important genetic and hereditary risk factor for RCC is Von Hippel-Lindau syndrome (VHL). RCC in VHL may occur bilaterally in some cases, so preserving renal parenchymal function is a major therapeutic goal and nephron sparing surgery provides a favorable patient outcome.
Myomectomy is rarely performed in pregnancy due to risk of miscarriage or pregnancy loss, bleeding and possible
hysterectomy. Myomectomy is mainly reserved for unavoidable indications such as rapidly growing fibroid or severe
pain with possiblity of red degeneration for which medical treatment failed. However, good outcome had been
reported in selective second trimester myomectomies.
We report the case of a 34-year-old Malay, admitted for constipation and abdominal pain at 35 weeks of gestation. Initially, she was diagnosed to have paralytic ileus and was managed conservatively. As her condition did not improve, emergency laparotomy was performed for suspected intestinal obstruction. She delivered a baby boy weighing 2.84kg with good Apgar score through a caesarean section. Intra-operatively, she was noted to have sigmoid volvulus and sigmoidopexy was performed. Post-partum, colonoscopy and bowel decompression was performed. She recovered well and was discharged on day 5. This case illustrates the need to diagnose or suspect volvulus in pregnant woman presenting with severe constipation as early surgical intervention can reduce morbidity to both mother and fetus.
Strabismus is one of the most common ocular problems affecting the preschool population and the aim of strabismus surgery is to correct abnormal alignment of the eyes. A 5-year-old girl with strabismus underwent an uneventful surgery and was discharged on the same day with topical medications. Two days later, she returned with a painful right lower eyelid swelling, eye discharge and fever which started 1 day post-surgery. She was admitted for intravenous (IV) antibiotic. Symptoms initially improved after 24 hours of treatment, but later she had worsening eyelid swelling. An urgent CT scan of the orbit showed a right lower lid abscess with orbital cellulitis. Subsequently an examination under anaesthesia (EUA) and incision and drainage (I&D) of the lower lid abscess were performed. Culture from the pus grew Community Acquired Methicillin-resistant Staphylococcus aureus (CA-MRSA), sensitive to Vancomycin. At day 2 post I&D she subsequently developed another episode of localised right lower lid swelling. Another EUA was done but showed the lower lid and wound was free of pus. She was later found to have a toxic reaction to topical Gentamicin and hence this medication was stopped. She responded well to treatment and was discharged after completing her IV antibiotics. At 14 months outpatient follow up, she was well and orthophoric in primary gaze. While treating a disease, we should be opened to all possibilities and not to treat with multiple antibiotics once susceptibility is known
A 21-year-old Chinese gentleman with no known medical illness, presented with a history of right painless blurring of vision with central scotoma of two weeks duration. He also had a history of multiple episodes of seizures prior to presentation. Visual acuity was 1/60 with unremarkable anterior segment findings and no relative afferent pupillary defect. Fundus examination of the right eye revealed dilated and tortuous retinal veins with multiple retinal capillary hemangiomas and sub retinal hard exudates at the macula with edema. A diagnosis of Von Hippel Lindau disease was made when a posterior fossa mass suggestive of hemangioblastoma with obstructive hydrocephalus was seen on computed tomography of the brain. Craniotomy with nodule excision was performed. The retinal capillary hemangiomas were treated with the combination of laser photocoagulation and intravitreal Ranibizumab injections. Visual acuity subsequently improved to 6/36.
Penetrating injuries to bladder occur in 20 % of cases. Synchronous bladder and rectal perforation occur in 30-64 % of cases. The management of rectal and bladder injuries depend on whether it is an extra-peritoneal or intra-peritoneal injury. We hereby, report a case of penetrating trauma in a 13 year old boy who fell off a tropical fruit (Rambutan - Nephelium lappaceum) tree. He sustained an extra-peritoneal rectal injury with intra-peritoneal bladder injury. The rectal injury was repaired primarily via per anal route while the bladder injury needed an open repair following laparotomy. Upon removal of bladder clots, a leaf of the ‘Rambutan’ tree was found intra-vesically. It was removed and bladder repaired as per standard method. We review the literature on rare intra-vesicle foreign bodies and discuss the treatment of synchronous rectal and bladder injuries.
This retrospective study is aimed at evaluating the role of CT scan in predicting parametrium involvement in early stage of cervical carcinoma. It was conducted in a Gynaecologic Oncology Centre, Hospital Alor Star from January 2004 till December 2008. All patients with operable stage I and II cervical cancer had pelvic CT scan for evaluation of parametrium involvement before undergoing radical hysterectomy and pelvic lymphadenectomy. Parametrial streakiness or presence of infiltration suggested local invasion. Following radical hysterectomy, the specimens sent for histological confirmation and the correlation between the CT scan finding and the histopathology result was studied. The result revealed a total of 104 patients with operable stage cervical carcinoma had pelvic CT scan. The sensitivity and the specificity of CT scan in assessing parametrial involvement was 33.3% and 84.8%, respectively. In conclusion, CT scan had high specificity but low sensitivity in determining parametrial involvement in early stage of cervical cancer. Hence, routine preoperative pelvic CT scan has a limited role in assessing parametrial involvement in early stage cervical carcinoma.
Breast carcinoma to the colon and rectum is rare type of metastatic spread. We report a case of colonic metastasis
from a lobular carcinoma of the breast twelve years after the initial diagnosis. Accurate diagnosis and early treatment
of systemic therapy can be done if awareness is increased.