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Fulltext Transformation of surgical training through national transformation 2050 (TN50): a National agenda

Razman, J.

Journal of Surgical Academia, 2017;7(1):1-3.
MyJurnal

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.
Fulltext Hepatic Adenomatosis: Diagnosis and Management Dilemma

Norly, S., Razman, J.

International Medical Journal Malaysia, 2010;9(2):59-61.
MyJurnal

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.
Fulltext Total pancreatectomy for diffuse pancreatic adenocarcinoma

Azlanudin, A., Razman, J.

Journal of Surgical Academia, 2011;1(1):39-41.
MyJurnal

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.
Fulltext Liver abscess from retained cystic stones following laparoscopic cholecystectomy: A case report

Marjmin Osman, Razman, J., Shaharin, S.

International Medical Journal Malaysia, 2007;6(1):1-5.
MyJurnal

One of the causes of post cholecystectomy pain is due to stone in the cystic duct. This is a very rare occurrence although it can be debilitating to the patient. We report a case of a 64 year old man presented with retained cystic duct stone post cholecystectomy complicated by liver abscess and biloma. The management of this unusual presentation is discussed.
Fulltext Cutaneous tumour seeding at percutaneous transhepatic biliary drain (PTBD) site from pancreatic adenocarcinoma

Ho, C.C.K., Razman, J., Shaharin, S.

International Medical Journal Malaysia, 2007;6(1):1-5.
MyJurnal

Percutaneous needle procedures are known to carry the rare complication of seeding along the tract. Here we would like to present a case of seeding along a percutaneous transhepatic biliary drainage (PTBD) tract, to the skin, from a pancreatic adenocarcinoma.
Fulltext The TB--Crohn's affair--a never ending dilemma

Praveen S, Razman J

Med J Malaysia, 2008 Aug;63(3):259-60.
PMID: 19248705

An 80 year old lady presented with signs and symptoms of sub-acute intestinal obstruction which failed conservative management. CT scan abdomen revealed circumferential ileum thickening with proximal bowel dilatation. Laparotomy and segmental resection was done. Pathological findings were suggestive of chronic granulomatous ileits with differential of Crohn's disease and gastrointestinal tuberculosis. The patient was presumed to have gastrointestinal tuberculosis and commenced on anti tuberculosis treatment despite inconclusive evidence for confirmation and showed marked clinical improvement.
Comparison of complication outcomes in acute pancreatitis following ERCP and conservative management at UKM medical centre: a six years retrospective study

Zamri Z, Razman J

Clin Ter, 2012 Nov;163(6):467-71.
PMID: 23306739

Acute pancreatitis is one of the common reasons for surgical admission. It is a potentially lethal disease that is increasing in its incidence. The most common causes of acute pancreatitis is from gallstones and alcohol. Other causes of acute pancreatitis include hypertriglyceridaemia, hyperparathyroidism, pancreatic malignancy, Endoscopic retrograde cholangiopancreatography (ERCP), trauma, infectious agents, drugs, autoimmunity, and hereditary. The treatment of acute pancreatitis is mainly supportive. The complication of ERCP in acute pancreatitis can be divided into local complication (pancreatic abscess, pseudocyst), systemic complications (renal failure, respiratory failure, cardiogenic shock) and biliary sepsis (acute cholangitis and acute cholecystitis). However, early ERCP and possible sphincterotomy should be kept in mind for patients with severe disease and biliary obstruction who are not improving with medical therapy. This study is done to compare the complication rate of ERCP and conservative management in acute pancreatitis for past 6 years in Pusat Perubatan UKM.
Fulltext Right posterior segmental hepatic duct: role of intraoperative cholangiogram to prevent extrahepatic biliary duct injuries

Ikhwan SM, Zamri Z, Hairol O, Razman J, Affirul C

International Medical Journal Malaysia, 2015;14(2):63-66.
MyJurnal

Extrahepatic bile ducts constitute a significant anatomic site for surgeons when performing hepatobiliary
operations from minor procedure such as cholecystectomy to major operation such as hepatectomy. The
challenges for surgeon in performing such cases increase when congenital variance of biliary tree occurs which
may lead to unintentional bile duct injuries. We reported a case of a lady who presented with obstructive
jaundice secondary to huge distal common bile duct stone. The presence of right posterior segmental hepatic
duct, which rarely occurs, was discovered during intraoperative cholangiogram before common bile duct
exploration. The operation was successful without incidence of biliary duct injury.
Fulltext Surgical antibiotic prophylaxis: incidence and risk of surgical site infection

Fadzwani B, Raha A.R, Nadia M.N, Wan Rahiza WM, Razman J, Nordiah A.J

IIUM Medical Journal Malaysia, 2020;19(1):45-53.
MyJurnal

Introduction: This prospective cross sectional study assessed surgical antibiotic prophylaxis (SAP) practice,
the incidence of surgical site infection (SSI) and its associated risks in Universiti Kebangsaan Malaysia Medical
Centre. Methods: Patients for elective colorectal, hepatobiliary, upper gastrointestinal, breast and
endocrine surgery, who received SAP were included and followed up until day-30 postoperatively. Types of
antibiotic, preoperative–dose timing, intraoperative re-dosing and its duration were recorded. The incidence
of SSI was calculated and its associated risks expressed in odds ratio. Results: Out of 166 patients recruited,
121 (72.89%) patients received SAP preoperatively, and 91 (75.21%) of them were prescribed the appropriate
antibiotic as per our institutional guideline. Three patients who continued to receive therapeutic antibiotic
postoperatively were excluded from statistical analysis. Eleven (9.10%) patients received SAP beyond the
preoperative–dose timing of 60 minutes (p=0.001), which was an independent risk factor for SSI (adjusted OR
4.527, 95% CI; 1.058-19.367, p=0.042). The risk of SSI also remained in patients who continued to receive
SAP beyond 24 hours (OR 4.667, 95% CI; 1.527-14.259, p=0.007). The overall rate of SSI was 17.18%.
Conclusion: We found that the choice of antibiotic prescribed for SAP was in accordance to institutional
guideline and the relatively high SSI incidence was similar to a recent local report. Although the number of
patients receiving preoperative dose-timing of > 60 minutes was low, it was nonetheless an independent risk
factor for SSI. The postoperative continuation of SAP for more than 24 hours showed no benefit in reducing
SSI.
Fulltext Surgical antibiotic prophylaxis: incidence and risk of surgical site infection.

Fadzwani B., Raha A.R., Nadia M.N., Wan Rahiza WM., Razman J., Nordiah A.J

IIUM Medical Journal Malaysia, 2020;19(1):45-53.
MyJurnal

This prospective cross sectional studyassessed surgical antibiotic prophylaxis (SAP) practice, the incidence of surgical site infection (SSI) and its associated risks in Universiti Kebangsaan Malaysia Medical Centre. Methods: Patients for elective colorectal, hepatobiliary, upper gastrointestinal, breast and endocrine surgery, who received SAP were includedand followed up until day-30 postoperatively. Types of antibiotic, preoperative–dose timing, intraoperative re-dosing and its duration were recorded. The incidence of SSI was calculated and its associated risks expressed in odds ratio.Results: Out of 166 patients recruited, 121 (72.89%) patients received SAP preoperatively, and 91 (75.21%) of them were prescribed the appropriate antibiotic as per our institutional guideline. Three patients who continued to receive therapeutic antibiotic postoperatively were excluded from statistical analysis. Eleven (9.10%) patients received SAP beyond the preoperative–dose timing of 60 minutes (p=0.001), which was an independent risk factor for SSI (adjusted OR 4.527, 95% CI; 1.058-19.367, p=0.042). The risk of SSI also remained in patients who continued to receive SAP beyond 24 hours (OR 4.667, 95% CI; 1.527-14.259, p=0.007). The overall rate of SSI was 17.18%. Conclusion:We found that the choice of antibiotic prescribed for SAP was in accordance to institutional guideline and the relatively high SSI incidence was similar to a recent local report. Although the number of patients receiving preoperative dose-timing of > 60 minutes was low, it was nonetheless an independent risk factor for SSI. The postoperative continuation of SAP for more than 24 hours showed no benefit in reducing SSI.
Fulltext Extra-gonadal germ cell tumour – what about the testis!

Johann, F.K., Praveen, S., Christopher, C.K.H., Goh, E.H., Razman, J., Zulkifli, M.Z.

Journal of Surgical Academia, 2011;1(1):28-31.
MyJurnal

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.
Fulltext Frantz’ tumour: a rare pancreatic neoplasm

Ikhwan Sani, M., Boo, H.S., Affirul, C., Zamri, Z., Razman, J.

Journal of Surgical Academia, 2017;7(1):43-46.
MyJurnal

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.
Leptospirosis complicating with acute large bowel gangrene: a case report

Zamri Z, Shaker AH, Razman J

Clin Ter, 2012;163(5):399-400.
PMID: 23099969

Leptospirosis is a zoonosis with worldwide distribution. It is often referred to as swineherd's disease, swamp fever or mud fever. In recent years there is increase incidence in leptospirosis in human. The incidence varies from sporadic in temperate zones to endemic in the tropical countries. Leptospirosis generally present with features of bacterial infection in acute phase following with multi organs complications. Acute bowel ischaemia with perforation following leptospirosis is a rare presentation . To the best of our knowledge, this is the first case report of such condition. The surgical management of this rare incidence will be discussed.
Fulltext Bogota bag in the treatment of abdominal wound dehiscence

Sukumar N, Shaharin S, Razman J, Jasmi AY

Med J Malaysia, 2004 Jun;59(2):281-3.
PMID: 15559181

A patient who underwent emergency laparotomy for rectal prolapse developed repeated abdominal wound dehiscence and subsequently an enteric fistula. The management of abdominal wound dehiscence is discussed, specifically with regards to the Bogota bag. Use of Bogota bag has been reported worldwide but this may be the first report here.
An interesting case of isolated pancreatic teratoma: lessons to learn

Razman J, Azlanudin A, Eyad AJ, Zahiah M, Das S

Clin Ter, 2012 Nov;163(6):495-7.
PMID: 23306744

Mature cystic teratomas of the pancreas are extremely rare tumours encountered in day-to-day clinical practice. Only few cases have been reported to date involving all age groups. The management, diagnosis and evaluation of this tumor are questionable, with definitive diagnosis taking place intra-operatively. We hereby report the case in a 30 year-old-male who presented with newly diagnosed diabetes mellitus and during the follow up he was noted to have elevated liver enzymes clinically, he was asymptomatic. The computerized tomography revealed a retropancreatic mass and pushing the mesenteric veins anteriorly. The mass was hypodense in nature and there was presence of calcification. Although the patient was asymptomatic, the decision for resecting the mass was made in view of the size and possibility of malignancy. In conclusion, considering the size and approximity of the mass to the pancreas, Whipple procedure's is the most appropriate approach although the histological diagnosis has not been established preoperatively.
Currarino triad with dual pathology in the presacral mass: report of a case

Thambidorai CR, Muin I, Razman J, Zulfiqar A

Dis Colon Rectum, 2003 Jul;46(7):974-7.
PMID: 12847376

PURPOSE: Currarino triad, which comprises anorectal stenosis, anterior sacral defect, and a presacral mass, is an uncommon cause of constipation in children and adults. The presacral mass in this triad is most often caused by an anterior sacral meningocele, a teratoma, or an enterogenous cyst, but rarely may be caused by dual pathology. A neonate with Currarino triad and dual pathology in the presacral mass is described in this report.
METHOD: A male Chinese neonate, who presented with abdominal distention and constipation on the second day of life, was found to have features of Currarino triad. Colostomy was done in the neonatal period, and the presacral mass was excised by posterior sagittal perineal approach at the age of six months.
RESULTS: The excised presacral mass consisted of an anterior meningocele and a teratoma. The patient continued to have constipation during follow-up and required anorectoplasty to correct residual anorectal stenosis. At the time of this report the patient was three years old and growing normally with normal anorectal function.
DISCUSSION: Of a total of about 200 cases of complete Currarino triad found in the literature, in only 22 patients did the presacral mass contain both meningocele and teratoma. The features of these 22 patients and the current views on the surgical management of Currarino triad are discussed.
Fulltext Pancreatic pseudopapillary tumour: A rare misdiagnosed entity

Affirul CA, Qisti FN, Zamri Z, Azlanuddin A, Hairol AO, Razman J

Int J Surg Case Rep, 2014;5(11):836-9.
PMID: 25462046 DOI: 10.1016/j.ijscr.2014.09.021

Solid pseudo papillary pancreatic tumour is a rare entity. The atypical presentation causes a delayed or misdiagnosis of these pathology. It commonly affects the female population in the 2nd and 3rd decade of life. The presentation varies from non-specific abdominal pain to incidental findings in asymptomatic patients. It is a low-grade premalignant condition that is curable by excision of the tumour.
Fulltext Initial experience of laparoscopic incisional hernia repair

Razman J, Shaharin S, Lukman MR, Sukumar N, Jasmi AY

Med J Malaysia, 2006 Jun;61(2):142-6.
PMID: 16898302 MyJurnal

Laparoscopic repair of ventral and incisional hernia has become increasingly popular as compared to open repair. The procedure has the advantages of minimal access surgery, reduction of post operative pain and the recurrence rate. A prospective study of laparoscopic incisional hernia repair was performed in our center from August 2002 to April 2004. Eighteen cases (n: 18) were performed during the study period. Fifteen cases (n: 15) had open hernia repair previously. Sixteen patients (n: 16) had successful repair of the hernia with the laparoscopic approach and two cases were converted to open repair. The mean hernia defect size was 156cm2. There was no intraoperative or immediate postoperative complication. The mean operating time was 100 +/- 34 minutes (75 - 180 minutes). The postoperative pain was graded as mild to moderate according to visual analogue score. The mean day of discharge after surgery was two days (1 - 3 days). During follow up, three patients (16.7%) developed seroma at the hernia sac which was resolved with conservative management after three weeks. One (5.6%) patient developed recurrence six months after surgery. In conclusion, laparoscopic repair of incisional hernia particularly recurrent hernia has been shown to be safe and effective in our centre. However, careful patient selection and acquiring the necessary advanced laparoscopic surgical skills coupled with the proper use of equipment are mandatory before embarking on this procedure.
Fulltext Mechanical thrombolysis as an adjunct therapy to management of portal vein thrombosis following Radio Frequency Ablation

Hairol AO, Affirul CA, Azlanudin A, Zamri Z, Razman J, Choi SY

Clin Ter, 2017 Jan-Feb;168(1):e5-e7.
PMID: 28240755 DOI: 10.7417/CT.2017.1974

Radiofrequency ablation (RFA) has evolved to become the treatment of choice for non-resectable recurrent colorectal liver metastasis. It is however, not without complications. Portal vein thrombosis following RFA is rare but can be fatal to the outcome of the patient. Here, we present a case of a 66-year-old man who developed portal vein thrombosis following RFA. CT scan revealed a left portal vein thrombosis. This case report highlights the challenges and multimodal treatment of portal vein thrombosis following Radiofrequency ablation (RFA) in a cirrhotic patient.
Fulltext Prolapsing Gastric Polyp Causing Intermittent Gastric Outlet Obstruction

Kosai NR, Gendeh HS, Norfaezan AR, Razman J, Sutton PA, Das S

Int Surg, 2015 Jun;100(6):1148-52.
PMID: 25578789 DOI: 10.9738/INTSURG-D-14-00205.1

Gastric polyps are often an incidental finding on upper gastrointestinal endoscopy, with an incidence up to 5%. The majority of gastric polyps are asymptomatic, occurring secondary to inflammation. Prior reviews discussed Helicobacter pylori (H pylori)-associated singular gastric polyposis; however, we present a rare and unusual case of recurrent multiple benign gastric polyposis post H pylori eradication resulting in intermittent gastric outlet obstruction. A 70-year-old independent male, Chinese in ethnicity, with a background of diabetes mellitus, hypertension, and a simple renal cyst presented with a combination of melena, anemia, and intermittent vomiting of partially digested food after meals. Initial gastroscopy was positive for H pylori; thus he was treated with H pylori eradication and proton pump inhibitors. Serial gastroscopy demonstrated multiple sessile gastric antral polyps, the largest measuring 4 cm. Histopathologic examination confirmed a benign hyperplastic lesion. Computed tomography identified a pyloric mass with absent surrounding infiltration or metastasis. A distal gastrectomy was performed, whereby multiple small pyloric polyps were found, the largest prolapsing into the pyloric opening, thus explaining the intermittent nature of gastric outlet obstruction. Such polyps often develop from gastric ulcers and, if left untreated, may undergo neoplasia to form malignant cells. A distal gastrectomy was an effective choice of treatment, taking into account the polyp size, quantity, and potential for malignancy as opposed to an endoscopic approach, which may not guarantee a complete removal of safer margins and depth. Therefore, surgical excision is favorable for multiple large gastric polyps with risk of malignancy.

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