This was a 28-year-old mentally-challenged girl with underlying congenital Rubella syndrome. She was bilaterally aphakic after congenital cataract surgery. She then developed bilateral aphakic glaucoma and had to undergo multiple glaucoma filtering surgeries. The most recent procedure she had undergone for her left eye was a second Ahmed valve implantation with an overlying sclera patch. Postoperatively, intraocular pressure was well controlled. However, nine months later, slit lamp examination revealed the tube was adherent to the overlying cornea with surrounding deep and superficial cornea vascularization. Siedel test was negative and intraocular pressure was normal. Subsequently the tube was removed but the plate was left in situ.
Radiotherapy has been widely use as an adjuvant therapy in the breast cancer management. The usage has increased the incidence of radiation induce sarcoma. We here present a case of radiation induce sarcoma of the axilla following mastectomy and axillary lymph node dissection for infiltrating ductal carcinoma.
The decision for median sternotomy for retrosternal goiter is complex and proper consensus are lacking. Generally, it is based on clinical, radiological and intraoperative assessment. Among the few known features include primary mediastinal goiter, posterior mediastinal goiter and recurrent retrosternal goiter. We present a patient with posterior mediastinal, secondary goiter that extended until the tracheal bifurcation. The goiter was removed successfully via a low cervical incision and this was achieved by dissecting along the anatomical plane close to the thyroid capsule using blunt dissection with fingers. It is possible for these kinds of high risk retrosternal goitres to be safely removed without the need for thoracotomy when the surgery was performed along the proper plane.
Thyroidectomy for benign and malignant diseases has progressed dramatically over the last two decades. Moving from large collar incision to no scar is a very good news to the patient with neck swellings. The morbidity of the surgery remains low regardless of the technique and approaches used but scarless surgery is still limited to benign diseases and small cancers. Further study and future refinement of the technique might make these techniques also applicable to large tumours.
A surgeon’s experience plays an important role in breast conserving surgery (BCS). The common conception is that, the more junior is the operating surgeon, the surgical margin will be wider or closer to the tumour edge. Thus the aim of this study is to look into the adequacy of surgical margin performed by different level of surgeons’ experience in patients whom underwent wide local excision (WLE) and hook-wire localization (HWL) in our surgical unit. The surgical experience of the operating surgeon and their surgical margins will be analyzed. This is a retrospective study from January 2000 to December 2012. Eighty-eight patients with early breast cancer underwent WLE and HWL by 3 different groups of surgeons (breast surgeons, junior surgeons and surgical registrars) were included. The surgical margins were analyzed for involved-margin, closed-margin or excessed-margin.The incidence of involved-margin, closed-margin and excessed-margin is the lowest among breast surgeons compared to other groups. However, the results were not statistically significant. The incidence of involved surgical margin is significantly higher within junior surgeons for HWL compared to the breast surgeons. The incidence of involved, closed or excessed surgical margin were lowest when performed by breast surgeon but not significantly different between the three groups. However, for HWL the breast surgeons significantly better compared to the other groups.
Mycobacterium tuberculosis (MTB) is a rare cause of prosthetic joint infection. The diagnosis is challenging
especially in cases of latent tuberculosis. QuantiFERON-TB Gold (QFT®) is an interferon-gamma relative assay
(IGRA) which is highly specific and sensitive for detection of MTB infection. We report a case of 76-year-old lady
diagnosed with tuberculous prosthetic joint infection following total knee replacement. Histological examination of
abnormal synovial tissue taken intraoperatively reveals chronic granulomatous lesion and raised suspicion of
tuberculous infection in otherwise asymptomatic patient. The tuberculin skin test, MTB acid-fast stain and
tuberculosis polymerase chain reaction were negative. The diagnosis dilemma was solved with positive result of
QuantiFERON TB Gold Test. The patient was treated with anti-tuberculous drug without any surgical intervention.
At five months follow-up, patient was clinically well with no symptoms and signs of infection.
A 47-year-old lady, presented with progressive proptosis of left eye with deterioration of vision. She had a history of left solitary fibrous tumour and had undergone left frontal craniotomy and orbitotomy in 2004. Surveillance Magnetic resonance imaging (MRI) six years later showed tumour recurrence with intracranial extension. However, she did not follow-up and only presented again 3 years, later. Tumour resection and left exenteration was performed. Histology showed ‘patternless’ pattern of neoplastic cells, and CD34 staining was diffusely positive. Diagnosis of recurrent solitary fibrous tumour with intracranial extension was made.
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.
Frantz’ tumour of the pancreas is also known as solid pseudopapillary tumour (SPT) of the pancreas. It is a rare pancreatic neoplasm and represents about 3% of all the pancreatic cystic neoplasm.It occurs predominantly in young woman in 2nd to 3rd decade of life. These tumours exhibit indolent behaviour and very often reach considerable size before the first symptoms appear. Despite this presentation these tumours have low malignant potential and complete surgical resection render excellent prognosis. We reported a case of a 16-year-old girl who presented with upper abdominal mass with symptoms of gastric outlet obstruction for 7 months duration. Clinical examination revealed a huge epigastric mass measuring 10 x 12 cm in size. CT scan showed presence of mass arising from the body of the pancreas which was hypervascular, well-encapsulated with mixed cystic and solid components. She then underwent successful distal pancreatectomy and splenectomy and recovered uneventfully.
Mediastinal mature cycstic teratomas are rare germ cell tumors most commonly found in the anterior mediastinum, and constitute about 3-12% of all mediastinal tumors. They grow slowly and are usually diagnosed incidentally. This is a rare presentation of a young lady with mediastinal mature cystic teratoma (dermoid cyst) presenting with chronic cough and haemoptysis.
Intraoperative active warming in daycare surgery may be least popular compared to major elective surgeries due to the lesser risk of perioperative hypothermia. This prospective, single blind, randomized, controlled trial in daycare breast lumpectomy was done to evaluate the routine use of intraoperative forced-air warmer in the presence of other warming modalities in prevention of perioperative hypothermia. Fifty patients were randomized into two groups; Group 1 received forced-air warmer and Group 2 received a standard cotton thermal blanket. Both groups received circulating-water mattress. Intraoperatively, all patients received pre-warmed intravenous fluid with an in-line warmer. Ear and ambient temperature was recorded using infrared ear thermometer and digital thermo-hygrometer respectively. Measurement was done before induction, every 15 minutes intraoperatively, upon arrival in recovery room and 30 mins later, postoperatively. All patients were normothermic prior to induction of anaesthesia. During the initial half an hour post-induction, both groups mean core temperature decreased at approximately 0 ̊.C5 . Both showed no statistical difference in mean core temperature (0.04 ̊C) within the initial half an hour. The next half an hour, both groups had approximately 0 ̊.C2 decrement but this time, Group 2 had a slightly higher mean core temperature than Group 1 which maintained until the end of surgery. Overall, within the initial one hour post- induction of GA, there was a drop of 0.7 ̊C and 0.6°C in Group 1 and Group 2 respectively, however the difference in final mean core temperature between the two groups was 0.05°C and it was not statistically significant (p value < 0.05). None of the patients experienced intraoperative hypothermia (< 36 ̊C) and all remained in the normothermic range with no shivering or sense of feeling cold, postoperatively. The results of the present study found no significant difference in the changes of final core temperature with or without the usage of intraoperative forced-air warmer in the presence of other warming measures in daycare breast lumpectomy.
Supraglottic airway devices have been used as safe alternatives to endotracheal intubation in appropriate types of surgery. This was a prospective, randomised, single blind study comparing the use of LMA™ and SLIPA™ in terms of ease of insertion, haemodynamic changes and occurrence of adverse effects (e.g. blood stains on the device upon removal and sore throat). A total of 62 ASA I or II patients, aged between 18 to 70 years were recruited for this study. Patients were randomised into two groups; LMA™ and SLIPA™ group. Following induction of anaesthesia, an appropriate sized LMA™ or SLIPA™ was inserted after ensuring adequate depth of anaesthesia. Anaesthesia was maintained with oxygen, nitrous oxide and sevoflurane. The ease of insertion was graded and haemodynamic changes were recorded at 2 minute intervals up to 10 minutes after insertion of the airway devices. The presence of blood stains upon airway device removal at the end of surgery and incidence of sore throat was also recorded. No difficult insertion was experienced in either of these devices. Insertion was either easy [LMA™ 87.1% versus SLIPA™ 80.6% (p = 0.49)] or moderate [LMA™ 12.9% versus SLIPA™ 19.4% (p = 0.16)]. Throughout the study period, the haemodynamic changes that occurred in both groups were not statistically different. Traces of blood were noted on the surface of the device in 9.7% of patients in the SLIPA™ group versus 6.5% of patients in the LMA™ group. The incidence of sore throat was recorded in 12.9% versus 19.4% of patients in the SLIPA™ and the LMA™ groups respectively. These findings were not statistically significant. In conclusion, this study showed no significant differences between the use of LMA™ and SLIPA™ in terms of ease of insertion, haemodynamic changes and adverse effects in patients undergoing minor surgical procedures.
A congenital urethrocutaneous fistula is a rare anomaly which was first described in 1962 by Gupta. Clinically, children present when their guardian is alarmed by either frequent urinary dribbling or unusual stream when they pass urine. This congenital anomaly can present in isolation or be accompanied by a chordee, hypospadia and anorectal malformations in a newborn. The surgical management will either be a primary repair of the fistula or converting it to a hypospadia before proceeding with a single or staged hypospadia repair. Surgical technique will depend on the local tissue factors and associated anomalies.
Microperforate hymen is a rare vaginal anomaly that is usually reported in childhood due to recurrent urogenital infections. Unlike imperforate hymen where the presenting complaints are classical due to complete vaginal obstruction, the less profound and varied presentation of microperforate hymen may go unnoticed. We report a case of a 39-year-old, with a background history of amenorrhea, who presented with acute abdomen suggestive of tubo-ovarian abscess, and was finally diagnosed to have microperforate hymen. She underwent hymenectomy to correct the anomaly. To our knowledge, this is the oldest age of presentation of a congenital form of microperforate hymen. A high index of suspicion and early detection of microperforate hymen and properly timed intervention is essential to prevent acute symptoms and long term detrimental sequalae to women’s reproductive and psychosexual health.
Pyogenic granuloma of the eyes usually occurs after ocular surgery or inflammation related to the eyes, itself. This lesion is commonly related to procedures associated with chalazia, strabismus, or even enucleation. However, the incidence of pyogenic granuloma that arises directly from the lower canaliculi of the nasolacrimal system is rare and not being extensively reported. We report a case of an elderly lady who presented with pyogenic granuloma post EDCR with silicone stenting for left nasolacrimal duct obstruction. She presented with persistent left eye epiphora following procedure. The unusual site for pyogenic granuloma and it occurrence after EDCR raise the possibility that the condition is related to previous procedure and the material being used.
We report a case of dislodged Levornogestrel-intrauterine system (LNG-IUS, Mirena®) without evidence of uterine perforation. A 37-year-old Para 4+1presented with 3 months history of lower abdominal pain. Examination and imaging showed that the device was not present in the uterine cavity. She underwent laparoscopic retrieval of Mirena®. There was no evidence of uterine perforation intra-operatively. This case illustrated the rare possibility of dislodged Mirena®intra-abdominally without evidence of uterine perforation. The management for missing IUS was reviewed.
Renal angiomyolipoma is a rare disease seen during pregnancy. Rupture of renal angiomyolipoma could be catastrophic and might result in maternal and even perinatal mortality. Management includes conservative vs surgical approach. A 29-year-old woman Para 2 with history of bleeding renal angiomyolipoma in her first pregnancy at 11 weeks treated with selective arterial embolisation. The pregnancy was terminated. Even though having small residual tumour, her subsequent pregnancy progressed well with conservative management. Intervention is advisable in the presence of large or symptomatic renal angiomyolipoma prior to pregnancy in order to minimise potential life-threatening haemorrhage during pregnancy. For those with small tumour of less than 4cm, perhaps conservative approaches i.e. frequent follow-up and close monitoring would assist in early identification of any rupture or bleeding.
We report a case of rare, Mullerian vaginal cyst with intracystic haemorrhage in the absence of endometrial components. To date, this is the second case reported in the literature. A 51-year-old post-menopausal woman with history of anterior vaginal wall cyst was misdiagnosed to have cystocele. The cyst was excised and the content was old blood mixed with mucous. Histopathological examination revealed a Mullerian vaginal cyst without endometrial component. Thus, diagnosis and management of vaginal cyst was revisited and discussed.
Post-intubation airway related adverse effects such as coughing on the endotracheal tube (ETT), restlessness, hoarseness and sore throat are common and undesirable outcomes of anaesthesia using endotracheal intubation. This prospective randomized single blind study was carried out to compare the effectiveness of intra-cuff dexamethasone and alkalinized lignocaine in reducing the incidence of post-intubation airway related adverse effects. Eighty four patients aged 18 – 60 years, of ASA status I or II, were randomly allocated into three groups: air, dexamethasone and alkalinized lignocaine. Their ETT cuffs were inflated according to the group they were allocated to. The incidence of coughing on the ETT, restlessness, hoarseness and sore throat was assessed, postoperatively. The results showed a significant difference in the incidence of cough, restlessness, hoarseness and sore throat in the dexamethasone group compared to the air group. All the patients had minimal or no sore throat at all documented times. Both intra-cuff dexamethasone and alkalinized lignocaine significantly reduced the incidence of hoarseness. However, alkalinized lignocaine additionally lowered the incidence of restlessness, significantly.