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.
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.
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.
Morbidly adherent placenta with spontaneous rupture of membrane at extreme prematurity poses poor pregnancy outcome. Various issues on different management modalities still remain perplexed and individual consideration is vital. Two cases of morbidly adherent placenta with symptomatic per vaginal bleeding and spontaneous rupture of membrane at severe prematurity were reviewed and discussed. We found that, active intervention by termination of pregnancy and methotrexate therapy at early gestation can prevent the need of hysterectomy following major obstetrics haemorrhage.
Dermoid cyst in a kidney is rarely seen. We report a case of intrarenal dermoid cyst which mimics malignant renal tumour and discuss the dilemma in managing this disease.
Effective management of cancer pain is often hampered by patients’ lack of knowledge regarding cancer pain management and other barriers related to ethnicity and religious beliefs. This cross sectional study was performed to determine the patient-related barriers to effective cancer pain management. One hundred patients receiving cancer pain management were studied. Inclusion criteria were: patients over the age of 18 years, able to communicate, with known diagnosis of cancer, experiencing persistent pain for the past two weeks. A modified version of the Barriers Questionnaire II (BQ-II) was used and a modified Brief Pain Inventory was used to assess the pain profile. Barriers such as, patient’s attitude and beliefs, communication skills and fear of side effects of pain medication were determined, given a score and the summation was recorded as the total patient related barriers score. Overall, 85% of respondents achieved more than 40% pain relief and the 72 of 100 patients reported low patient related barrier scores of 6 or less. Nevertheless, the main patient related barriers were: fear of tolerance to opioids (51%), ethnicity (p=0.003) and religious beliefs (p=0.002) which constituted the major components of the patient-related barriers score. Ethnicity and religious beliefs had significant influence on patient-related barriers score suggesting the need of further investigation into this area. In order to achieve a comprehensive view, other barriers to effective cancer pain management such as those related to the health systems and healthcare providers need to be assessed together.
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.
Popliteal artery entrapment syndrome is an important infrequent cause of serious disability among young adults and athletes. We hereby describe a case of popliteal artery syndrome and its clinical implications. Physicians should be aware of the possibility of popliteal artery entrapment in young patients presenting with progressive arterial insufficiency.
Vulvo-vaginal haematomas are not an uncommon obstetric complication. Despite advances in obstetric care, practice and technique, vulvo-vaginal haematomas do occur especially in complicated vaginal deliveries. Various management options are available for vulvo-vaginal haematomas. We describe three cases of vulvo-vaginal haematomas with different severity and presentations which were managed in different manners i.e. local haemostasis control, laparotomy with hysterectomy, and transarterial embolisation. The choice of treatment options would mainly depend on the clinical presentations, availability of expertise as well as facilities. Early identification is crucial.
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.
Primary malignant melanoma of the vagina is rare but aggressive. Various treatment options include surgery and adjuvant therapy has been advocated but the outcome remained unpredictable. Standard treatment protocol is yet to be established. We report a case of 54-year-old, Para 4+1, with malignant melanoma of the vagina. She underwent wide local excision but the surgical margin was not clear of malignant cells, hence adjuvant radiotherapy was given. Combination chemotherapy was initiated subsequently as her disease disseminated. She succumbed later due to septicaemic shock. The treatment options for vaginal melanoma were reviewed.
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.
Rapunzel syndrome, or generically known as trichobezoar, is a rare condition. It usually happens among teenage population. We are presenting a case report of Rapunzel syndrome that happened in a 4-year-old child. She was initially investigated for nephrotic syndrome, as she had high blood pressure and hypoalbuminaemia. However, it was later found out to be a trichobezoar, indirectly causing both hypertension and malnutrition. This condition demanded a combination of surgical and psychiatric discipline for diagnosis and its treatment.
Basal cell carcinoma is the commonest skin malignancy diagnosed in Malaysia. Surgery is the recommended treatment of choice with the lowest failure rate provided a clear margin is obtained. However, the defect may be too large to be repaired primarily. Formal reconstruction using grafts and flaps should be done to achieve the optimal aim of maintaining the integrity, function and cosmetic patient outcome. Three reconstructive methods are described in this series to restore the facial defect following the wide local excision. The procedures described were peri-alar crescentic advancement flap, nasolabial rotational flap and full thickness skin graft using supraclavicular skin. This series highlights the usage of the procedures based on solid foundation and principles, without compromising the desired outcomes for the patient.
Scleral buckle placement is a well-established technique for the treatment of primary rhegmatogenous retinal
detachment. Complications associated with scleral buckle are uncommon and its presentations can be vary. We
report a case of recurrent orbital cellulitis with anterior segment ischemia following a forgotten episode of previous
scleral buckling surgery, presenting with blurring of vision, redness and swelling of the lids. The presence of scleral
buckle was detected by detailed examination and confirmed by orbital imaging. Orbital infection and rubeosis iridis
were successfully treated with scleral buckle removal, intravenous antibiotics and intracameral ranibizumab.
However, the retinal detachment recurred and the visual acuity deteriorated to light perception. There was no further
intervention as the family declined in view of her old age. In cases of recurrent orbital infection, detailed clinical
examination is important to look for evidence of ocular prostheses as a source of infection. Orbital imaging is an
adjunct for making the diagnosis especially in cases where history is unreliable. Anterior segment ischemia due to
scleral buckle responds well to buckle removal with ranibizumab injection.
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.
Retinal detachment is one of the common complications of pathological myopia due to presence of retinal break.
However, retinal break commonly occurs in the peripheral retina. This case report illustrates the rare incidence of
retinal break adjacent to the optic disc, highlights the possible causes of poor visual outcome following surgical
repair as well as the possible measures to treat the complications.
Diabetic retinopathy is a disease involving microangiopathic changes in response to chronic hyperglycaemia and pan retinal photocoagulation (PRP) is currently the mainstay of treatment for proliferative retinopathy. In the present study, we evaluated the effect of pan retinal photocoagulation (PRP) on retinal nerve fibre layer (RNFL) thickness in patients with diabetic retinopathy using optical coherence tomography (OCT). This was a prospective longitudinal study. Patients with Type 2 diabetes mellitus with proliferative diabetic retinopathy (PDR) or very severe non-(N)PDR requiring laser treatment were included in the study. PRP was performed by a single trained personnel. Peripapillary RNFL located 3.4 mm around the optic disc was evaluated using time-domain OCT. Examination was performed before treatment, and 2 and 4 months after laser treatment. In total, 39 subjects (39 eyes) were recruited into this study. Twenty-nine patients had PDR and 10 had very severe NPDR. Mean age was 54.97 ± 8.38 years. Male and female genders were almost equally distributed with 18 males and 21 females. Median thickness of average RNFL at baseline was 108.8 um (interquartile range [IQR] 35.3). At two months post-procedure, average RNFL thickness significantly increased to 117.4 (IQR 28.6; P = 0.006). Although, other quadrants revealed a similar trend of increasing thickness at two months but it was not significant. At 4 months post-laser treatment, RNFL thickness in all quadrants reduced to baseline levels with insignificant changes of thickness compared to prior to laser treatment. There was also no significant association between changes in RNFL thickness and HbA1c levels (P = 0.77). In conclusion, PRP causes transient thickening of the RNFL which recovers within 4 months post-laser treatment. At the same time, poor sugar control has no direct influence on the RNFL changes after PRP.
Pneumatic retinopexy is known as one of the treatment options for a specific type of retinal detachment. It is done in
an office setting and may be the most cost-effective means of retinal reattachment surgery. Location and size of the
retinal break remain as the major criteria for a successful outcome. We describe a case that fulfilled all except one
major criteria for pneumatic retinopexy and underwent multiple procedures but failed. Fluctuation in the resolution
of the retinal detachment such as in this particular case suggested possibility of early treatment failure.
This is our first experience in providing general anaesthesia for robotic-assisted thyroidectomy (RAT). It is rather a
new experience for our anaesthetic team and few issues should be addressed. The conduct of RAT must be fully
understood and familiarized as it may present with few challenges for the anaesthesiologists. The key point of
success during this learning curve period is the importance of teamwork between the anaesthesiologists and the
operating surgeons. The specific anaesthetic challenges include limited access to the patient post-docking of the
robot, the need of extra precautions of the anaesthetic circuit and IV line connections, a vigilant anaesthesiologists
and options for postoperative pain relief.