Congenital diaphragmatic hernia through the foramen of Bochdalek may present after infancy. A 21/2-year-old Malay girl presented with acute respiratory distress. Chest examination showed reduced chest expansion and decreased breath sounds on the left side. Chest radiograph showed a large "cyst" in the left chest, which was thought to be a lung cyst under tension. Tube thoracostomy resulted in clinical improvement. Results of a barium study showed that the cyst perforated by the thoracostomy tube was the stomach, which had herniated through a Bochdalek diaphragmatic defect. Surgical repair of the diaphragmatic defect and closure of the perforated stomach was performed successfully. Congenital diaphragmatic hernia should be included in the differential diagnosis of respiratory distress in young children. Nasogastric tube placement must be considered as an early diagnostic or therapeutic intervention when the diagnosis is suspected.
Brain herniation is generally thought to be unlikely to occur in newborns due to the presence of the patent fontanelles and cranial sutures. A review of the literature published from 1993 to 2008 via MEDLINE search revealed no reports on neonatal brain herniation from intracranial tumour. We report a preterm Malay male infant born via elective Caesarean section for antenatally diagnosed intracerebral tumour, which subsequently developed herniation. Cerebral magnetic resonance imaging showed features that were compatible with a large complex intracranial tumour causing mass effect and gross hydrocephalus. Tumour excision was scheduled when the infant was two weeks old. Unfortunately, on the morning of the surgery, he developed signs of brain herniation and had profuse tumour haemorrhage during the attempted excision. Histopathological examination revealed an embryonal tumour, possibly an atypical rhabdoid/teratoid tumour. This case illustrates that intracranial tumours in newborns can herniate and should therefore be closely monitored.
In symptomatic young patients with gastroesophageal reflux symptoms, early identification of progressive gastroesophageal reflux disease (GERD) is critical to prevent long-term complications associated with hiatal hernia, increased esophageal acid and nonacid exposure, release of proinflammatory cytokines, and development of intestinal metaplasia, endoscopically visible Barrett's esophagus, and dysplasia leading to esophageal adenocarcinoma. Progression of GERD may occur in asymptomatic patients and in those under continuous acid-suppressive medication. The long-term side effects of proton-pump inhibitors, chemopreventive agents, and radiofrequency ablation are contentious. In patients with early-stage disease, when the lower esophageal sphincter function is still preserved and before endoscopically visible Barrett's esophagus develops, novel laparoscopic procedures, such as magnetic and electric sphincter augmentation, may have a greater role than conventional surgical therapy. A multidisciplinary approach to GERD by a dedicated team of gastroenterologists and surgeons might impact the patients' lifestyle, the therapeutic choices, and the course of the disease. Biological markers are needed to precisely assess the risk of disease progression and to tailor surveillance, ablation, and management.
Traumatic diaphragmatic hernia is a well known complication of blunt trauma to the abdomen and thorax. In the acute setting, laparotomy is mandatory. In this current era, this condition can be managed with minimally invasive surgery. We hereby report a case of delayed large left diaphragmatic hernia that was repaired with a combination of laparoscopic and thoracoscopic approach.
A review of 24 children with posterolateral (Bochdalek) diaphragmatic hernia over a five-year period was carried out to highlight the problems of diagnosis and' management. Nine children were delivered in the Maternity Hospital Kuala Lumpur, giving an incidence of 1:10,000 live births which is half the expected incidence. Difficulty in diagnosis is apparent from the large number of initially misdiagnosed cases (29%) and those not detected
soon after birth (71% diagnosed after 24 hours). Less than half the babies had associated anomalies, commonest being malrotation and ipsilateral lung hypoplasia. Mortality (20.8%) appears to be related to the degree of lung hypoplasia and shunting, and the birthweight of the babies. Current evidence indicates that pulmonary hypertension is the main factor in the chain of events beginning with lung hypoplasia, which ultimately leads to their demise. Various methods to overcome this complication have been evolved which appear to give some hope for these high-risk infants.
Congenital diaphragmatic hernia (CDH) is rare in adults. We report a 24 year old woman presenting with shortness of breath, chest pain and nausea after the birth of her first baby. Clinical examination, plain radiography and a CT scan revealed herniation of abdominal contents into her left chest. Via a midline laparotomy, the contents were reduced and the defect repaired, using a mesh. She remains symptom-free three years since her surgery and even after a second childbirth. A brief review of the literature reporting adult diaphragmatic hernia of congenital origin accompanies this case report. We conclude that symptomatic CDH in adults usually presents as an emergency with gastrointestinal and occasionally respiratory complications. Early diagnosis and repair is essential to avoid subsequent morbidity and mortality.
A case of classical congenital diaphragmatic hernia is discussed. The rare right-sided classical type - incidence of 1 in 30,000 to 1 in 81,000 live births - and diaphragmatic eventration are often grouped together as Congenital Diaphragmatic Herniae. We had nine in 57,783 live births in ten years.
Trans-mesenteric hernia is a form of internal hernia which is an extremely rare cause of intestinal obstruction in adults compared with the pediatric population. It often presents with complications such as acute intestinal obstruction and peritonitis requiring immediate surgical intervention. We report a case of a 21-year-old woman who presented to us with an acute abdomen and peritonitis that required an immediate exploratory laparotomy. She was found to have a small congenital mesenteric defect with strangulated segment of ileum. Gangrenous portion of the ileum was resected and the congenital defect was closed. The patient made an uneventful recovery. The occurrence of trans-mesenteric hernia in adults is rare and difficult to be diagnosed clinically; thus, the patient's clinical features may lead to early surgical intervention in order to reduce morbidity and mortality.
Obesity is a major reason for the recent increase in incidence of reflux disease and cancers at the distal esophagus and gastroesophageal junction (GOJ) and is mediated through a rise in the intra-abdominal pressure (IAP) but the exact mechanisms are unclear. Raised IAP from obesity and with application of waist belt produces mechanical distortion of the GOJ through formation of partial hiatus hernia. Even though there is no trans-sphincteric acid reflux, there is increased ingress of acid into the lower sphincter (intra-sphincteric reflux) as a consequence of raised IAP. In addition, short segment acid reflux is more evident in obese subjects with a belt on. Acid pocket is also enlarged in hiatus hernia, and acts as a reservoir of acid available to reflux whenever the sphincter fails. Above mechanisms may explain the common occurrence of cardiac lengthening and inflammation found in asymptomatic obese subjects. The inflamed cardia is also immunohistochemically similar to non-intestinal Barrett's mucosa, which is of etiological importance for cancers at the GOJ. Interventions that can reduce the mechanical distortion and acid exposure at the GOJ, including diet, exercise, drugs, sphincter augmentation therapy, and surgery, are clinically relevant in the treatment of gastroesophageal reflux disease but more data are needed whether if these strategies are also effective in preventing cancer. As a conclusion, raised IAP produces silent mechanical disruption of the GOJ, which may explain the high occurrence of cancers in this region and it is potentially reversible with early interventions.
Introduction: Laparoscopic fundoplication is performed for the management of symptomatic hiatus hernias and gastro-oesophageal reflux disease (GORD) refractory to medical therapy. We adopted the use of Gore Bio-A® for selected laparoscopic hiatus hernia repairs in 2011 and with this case series aimed to establish whether mesh augmentation affects symptomatic outcomes. Methods: A retrospective review of prospectively collected data from all laparoscopic fundoplications performed by a single surgeon between October 2011 and January 2013 was performed. Patient specific data were entered into a proforma and analysed using Microsoft ExcelTM. Patient reported outcomes were assessed with a system specific quality of life questionnaire (GORD-HRQL) both pre and post-operatively. Results: Twenty-three patients underwent laparoscopic fundoplication during the study period. Gore Bio-A® re-enforcement of the hiatal repair was used in 14 patients and was the preferred option for those with pre-operative evidence of a large hiatus hernia. Whilst overall there was a statistically significant difference between pre and post-operative scores (21 vs 0, p=
Down syndrome may be associated with many complications. Among the malignancies associated with Down syndrome, leukaemia is the most common. This is a case report of a patient with Down syndrome associated with both a retroperitoneal teratoma and a Morgagni hernia.
This prospective observational study was conducted to determine the outcome of newborns with congenital diaphragmatic hernia (CDH). They were managed with a protocol of gentle ventilation to avoid barotraumas, and inhaled nitric oxide (iNO) or intravenous magnesium sulphate for treatment of persistent pulmonary hypertension of newborns (PPHN).
Recent studies indicate that the prevalence of gastroesophageal reflux disease in Asia is either increasing or better recognized. There is a paucity of reliable data on the prevalence of reflux disease in the various races in general and in Malaysia, in particular. The prevalence of erosive esophagitis and Barrett's esophagus in a multiethnic Malaysian population was studied, as well as the relationship of various factors associated with reflux disease. Chinese, Malay, and Indian patients undergoing gastroscopy in a tertiary referral center were assessed for the presence of esophagitis, hiatus hernia, and Barrett's esophagus. Patient demographics and risk factors associated with gastroesophageal reflux disease were also documented. The prevalence of endoscopically documented esophagitis among 1985 patients was 6.1%, the majority of which were mild, Grade I or II (88%). There was a preponderance of Indians with esophagitis, as well as males (P < 0.05) and those with the presence of a hiatus hernia (P < 0.01). Long-segment Barrett's esophagus was found in 1.6% of patients, and short-segment Barrett's in 4.6%. Indians had the highest prevalence of Barrett's esophagus compared with Chinese (P < 0.05) or Malays (P < 0.01). Hiatus hernia and erosive esophagitis were both positively associated with Barrett's metaplasia (P < 0.01). A significant proportion of Malaysian patients undergoing endoscopy has mild reflux esophagitis and Barrett's esophagus. Indian ethnicity and the presence of a hiatus hernia were significantly associated with endoscopic esophagitis and Barrett's metaplasia. These observed racial differences warrant further study.
Soft tissue defects like hernia and post-surgical fistula formation can be resolved with modern biomaterials in the form of meshes without post-operative complications. In the present study hand knitted silk meshes were surface coated with regenerated silk fibroin hydrogel and pure natural extracts. Two phytochemicals (Licorice extract (LE) and Bearberry extract (BE)) and the two honeybee products (royal jelly (RJ) and honey (HE)) were incorporated separately to induce antibacterial, anti-inflammatory, and wound healing ability to the silk hydrogel coated knitted silk meshes. Meshes were dip coated with a blend of 4 % silk hydrogel (w/v) and 5 % extracts. Dried modified meshes were characterized using SEM, DMA, GC-MS and FTIR. Antimicrobial testing, in-vitro cytotoxicity, in-vitro wound healing and Q-RT-PCR were also performed. SEM analysis concluded that presence of coating reduced the pore size up to 47.7 % whereas, fiber diameter was increased up to 17.9 % as compared to the control. The presence of coating on the mesh improved the mechanical strength/Young's modulus by 1602.8 %, UTS by 451.7 % and reduced the % strain by 51.12 %. Sustained release of extracts from MHRJ (62.9 % up to 72 h) confirmed that it can induce antibacterial activity against surgical infections. Cytocompatibility testing and gene expression results suggest that out of four variables MHRJ presented best cell viability, % wound closure and expression of wound healing marker genes. In-vivo analyses in rat hernia model were carried out using only MHRJ variant, which also confirmed the non- toxic nature and wound healing characteristics of the modified mesh. The improved cell proliferation and activated wound healing in vitro and in vivo suggested that MHRJ could be a valuable candidate to promote cell infiltration and activate soft tissue and hernia repair as a biomedical implant.
Hysterectomy is one of the most common non-obstetric surgical procedures performed on women. Little is known about the factors affecting decision making process regarding hysterectomy in Malaysia. The study aimed to explore factors affecting women decision regarding hysterectomy among Malaysian women. This study has enrolled 100 women eligible for hysterectomy in the department of general gynecology ward in the university of Malaya hospital, Malaysia. A structured questionnaire was administered by interview. Descriptive analysis was used to obtain the frequencies. Chi square test and simple logistic regression test were performed to assess the association between variables. The majority of participants aged 41-50 years (52%) and married (74%). Twenty seven out of 100 participants made their decision on the operation within one month while 73 women decided after one month. Some complications were only known by the minority of patients such as injury to ureter (47%), injury to nerve (8%), incision hernia (18%), vault prolapse (21 %), and deep vein thrombosis (43%). Most of women delay their decision on the surgery (73%). Factors associated significantly with decision were ethnicity, religion, knowledge on complication, discussion with spouse and doctor.. Cultural factors, opinion of husband and doctors and knowledge of the complication play an important role in the decision of women. It is important to provide suitable information and social support for patients to help them in their decision-making. Participation and support from spouses and doctors should also be encouraged.
Skoliosis kongenital adalah perkembangan tulang belakang yang tidak normal yang merangkumi pembentukan sebahagian tulang sahaja, kurangnya pemisahan di antara tulang belakang atau kehilangan bahagian tertentu tulang belakang. Etiologi sebenar skoliosis kongenital masih tidak jelas. Walau bagaimanapun, ia dipengaruhi oleh kecenderungan genetik dan faktor persekitaran. Kami melaporkan siri kes skoliosis kongenital dengan ciri-ciri dismorfik dalam empat orang adik-beradik dan membincangkan mengenai sindrom spondylocostal dysostosis yang mempunyai kaitan dengan skoliosis kongenital. Ciri-ciri dismorfik termasuk hipertelorisme, ‘ptosis’ kedua-dua mata, 'high arch palate', langit-langit yang tinggi dan leher ‘webbed’. Pembedahan instrumentasi tulang belakang dilakukan dalam tiga adik beradik. Semua pesakit pulih dengan baik selepas pembedahan tanpa komplikasi kecederaan saraf. Rawatan susulan pada tahun pertama dan kedua selepas pembedahan menunjukkan tiada perubahan pada kadar lengkung dan tulang belakang telah bercantum.