Hepatic adenomatosis is a rare, benign tumour of the liver. It was first described by Flejou et al as multiple adenomas in an otherwise normal liver parenchyma. Although benign, it can present as a diagnostic
challenge because the lesions can be diffi cult to distinguish from other hepatic tumours. Patients can be
asymptomatic and the diagnosis may only be made incidentally. We describe the case of 40-year-old Malay lady who was incidentally found to have hepatomegaly. Radiological examinations revealed a complex left ovarian cyst with multiple liver lesions. Biopsy of the liver lesion showed features of hepatic adenomatosis. Literature review was done and the dilemma in managing her was discussed.
A 64-year-old lady presented with a brief history of abdominal pain associated with obstructive jaundice. Endoscopic retrograde cholangiopancreaticography (ERCP) revealed a short segment stricture with contact bleeding and the brush cytology confirmed presence atypical cells. Ca 19.9 levels were markedly elevated. She was planned for a Whipple’s procedure but was instead subjected to a total pancreatectomy based on intraoperative findings of a diffusely hard and nodular pancreas. Histopathological examination confirmed our diagnosis of diffuse pancreatic adenocarcinoma. This rare presentation of a locally contained and fully resectable diffuse pancreatic adenocarcinoma is being discussed.
Surgical training worldwide has been reformed from
the since 19th century until the present era. It started as
a trade which eventually was transformed into a
profession that acquires skills and knowledge. The
apprenticeship model was introduced amongst the
Western surgeons as the standard approached for
surgical training. The surgery was learned through
direct observation without any formal and structured
education. William S Halstead had introduced the new
approach of training the surgeons in America
following his landmark lecture at Yale University in
1904 (1). His principle was based on direct the
German Surgical training which emphasized on basic
sciences in the curriculum and Sir William Ossler
concepts of bedside rounds. This has lead to the
development of Halsted principals of surgical training
which included intense and repetitive exposure in
managing surgical patients under the supervision of
skilled surgeons, acquiring the knowledge of scientific
basis of surgical diseases and as the surgical trainee
received enhanced responsibility and independence
with each advancing year (2). Since then, Halsted
principle of surgical training has become the
foundation of most established surgical training
worldwide. The principles have been expanded and
upgraded and since then six cores competencies have
been identified for the surgical residents to achieve
and master during the training course (3). There were
medical knowledge, patient care, interpersonal and
communication skills, professionalism, practice-based
learning and improvement and system based practice.
From the Malaysia perspective, surgical training was
done through the overseas Royal colleges after the
independence in 1957. The local programme started in
1982 through the initiative of local universities that
initially offered surgical training programme in
General surgery, Orthopedics and otorhinolaryngology
(4). Since then through the collaborations of Ministry
of Health and other professional bodies various
surgical training programme has been established to
provide training opportunities which will eventually
serving the nation. The subcommittee of the National
Conjoint Board for General Surgery was the
consultative body to oversee and manage the
implementation of the surgical training. Since the
establishment, the subcommittee was responsible in
streamlined the training curriculum for all the
universities that offered the course, centralized and
standardized the intake of the trainees, coordinating
the national exit examination and advising new
application for graduate training in general surgery.
The important milestone of the subcommittee was the
task given to develop the national surgical
postgraduate curriculum for the doctors who are
interested in becoming a surgeon in the country. The
curriculum is being developed to create a pathway for
surgical training from the internship until subspecialty
training. The development encompasses the
governance, the curriculum development, the training
process and learning outcome according to the latest
evidence based on post graduate training. The
programme should be the foundation in producing well
trained surgeons towards 2050 through TN50.