Case series of retained rectal foreign body. A Malaysian experience

@#Retained rectal foreign body, with its associated social stigma, is a medical condition that is infrequently reported in Malaysia. We report the surgical management of five cases of retained foreign objects in the rectum seen over a one-year period. There were three young and two elderly male patients. One of the elderly patients presented with altered bowel habits and an abdominal mass that mimicked a symptomatic colonic tumor. All patients had an abdominal radiograph which clinched the diagnosis of a retained foreign rectal body. Successfully retrieved objects included two bottles, one bidet device, and two sex toys. Open surgery for retrieval of the impacted rectal foreign body was required in one patient. All underwent successful retrievals without any adverse postoperative complications. In our case series, retained rectal foreign bodies were observed only in the male gender. The age presentation was bimodal, with age groups in the twenties and sixties. The treatment options used for the retrieval of these impacted foreign bodies included transanal extraction or explorative laparotomy. Proximal migration and delayed presentation are possible indications for the latter approach.

Unexpected complication of arteriovenous fistula of the left common carotid to internal jugular vein following central venous catheterization.

Incidence of inadvertent arterial puncture secondary to central venous catheter insertion is not common with an arterial puncture rate of <1%. This is due to the advancements and wide availability of ultrasound to guide its insertion. Formation of arteriovenous fistula after arterial puncture is an unexpected complication. Till date, only five cases (including this case) of acquired arteriovenous fistula formation has been described due to inadvertent common carotid puncture. The present case is a 26-year-old man sustained traumatic brain injuries, chest injuries and multiple bony fractures. During resuscitative phase, attempts at left central venous catheter via left internal jugular vein under ultrasound guidance resulted in inadvertent puncture into the left common carotid artery. Surgical neck exploration revealed that the catheter had punctured through the left internal jugular vein into the common carotid artery with formation of arteriovenous fistula. The catheter was removed successfully and common carotid artery was repaired. Postoperatively, the patient recovered and clinic visits revealed no neurological deficits. From our literature review, the safest method for removal is via endovascular and open surgical removal. The pull/push technique (direct removal with compression) is not recommended due to the high risk for stroke, bleeding and hematoma formation.

A Rare Case of Neurenteric Cyst of Spinal Cord with Thoracic Vertebra Fusion Successfully Managed with Spinal Cyst Excision and Posterior Instrumentation Surgery

@#The incidence of neurenteric cyst (NC) is rare amongst spine tumors. It is most often asymptomatic but may present with sensory and motor symptoms. When associated with thoracic vertebra fusion it is not reported before, this complicates the placement of pedicle screw during posterior instrumentation. Herein, we report a case of thoracic spinal neurenteric cyst in a 40-year-old man that presents with chronic back pain, left lower limb weakness and numbness. Elective excision of NC over T6-T7 with laminectomy and multilevel posterior instrumentation was successfully performed with significant improvement of the symptoms. Neurenteric cyst is a rare spinal cord lesion which may cause permanent neurological sequalae. Complete surgical excision with spine fixation in this case provides good long-term outcome.

Critical adjustments and trauma surgery trends in adaptation to COVID-19 pandemic in Malaysia / 中华创伤杂志(英文版)

Malaysia has one of the highest total numbers of COVID-19 infections amongst the Southeast Asian nations, which led to the enforcements of the Malaysian "Movement Control Order" to prohibit disease transmission. The overwhelming increasing amount of infections has led to a major strain on major healthcare services. This leads to shortages in hospital beds, ventilators and critical personnel protective equipment. This article focuses on the critical adaptations from a general surgery department in Malaysia which is part of a Malaysian tertiary hospital that treats COVID-19 cases. The core highlights of these strategies enforced during this pandemic are: (1) surgery ward and clinic decongestions; (2) deferment of elective surgeries; (3) restructuring of medical personnel work force; (4) utilization of online applications for tele-communication; (5) operating room (OR) adjustments and patient screening; and (6) continuing medical education and updating practices in context to COVID-19. These adaptations were important for the continuation of emergency surgery services, preventing transmission of COVID-19 amongst healthcare workers and optimization of medical personnel work force in times of a global pandemic. In addition, an early analysis on the impact of COVID-19 pandemic and lockdown measures in Malaysia towards the reduction in total number of elective/emergent/trauma surgeries performed is described in this article.

Inadvertent Diaphragmatic Rent Following Thoracic Surgery for Empyema Thoracis Successfully Repaired With Mesh

@#Iatrogenic diaphragmatic entry following thoracic surgery is rare with only two cases reported till date. This case reports on a 46-year-old male with persistent pleural sepsis due to right empyema thoracis despite best medical efforts. Following a right thoracotomy and decortication, the right diaphragm was inadvertently incised due to dense adhesions between the diaphragm and thickened cortex. To our knowledge, this is the third case reported of iatrogenic diaphragmatic entry following thoracic surgery for empyema thoracis. The pearls from this case report is that any evidence of empyema thoracis involving the lower lobe on imaging should warn the surgeons to be aware of inadvertent entry into the peritoneal cavity, as the diaphragm can be adherent to the cortex trapping the lower lobe.

Development and validation of a new simplified anatomic trauma mortality score.

BACKGROUND: Most trauma mortality prediction scores are complex in nature. GAP (Glasgow Coma Scale, Age, Systolic blood pressure) and mGAP (mechanism, Glasgow Coma Scale, Age, Systolic blood pressure) scores are relatively simple scoring tools. However, these scores were not validated in low and middle income countries including Malaysia and its accuracies are influenced by the fluctuating physiologic parameters. This study aims to develop a relevant simplified anatomic trauma scoring system for the local trauma patients in Malaysia. METHOD: A total of 3825 trauma patients from 2011 to 2016 were extracted from the Hospital Sultanah Aminah Trauma Surgery Registry. Patients were split into a development sample (n = 2683) and a validation sample (n = 1142). Univariate analysis is applied to identify significant anatomic predictors. These predictors were further analyzed using multivariable logistic regression to develop the new score and compared to existing score systems. The quality of prediction was determined regarding discrimination using sensitivity, specificity and receiver operating characteristic [ROC] curve. RESULTS: Existing simplified score systems (GAP & mGAP) revealed areas under the ROC curve of 0.825 and 0.806. The newly developed HeCLLiP (Head, cervical spine, lung, liver, pelvic fracture) score combines only five anatomic components: injury involving head, cervical spine, lung, liver and pelvic bone. The probabilities of mortality can be estimated by charting the total score points onto a graph chart or using the cut-off value of (>2) with a sensitivity of 79.2 and specificity of 70.6% on the validation dataset. The HeCLLiP score achieved comparable values of 0.802 for the area under the ROC curve in validation samples. CONCLUSION: HeCLLiP Score is a simplified anatomic score suited to the local Malaysian population with a good predictive ability for trauma mortality.

Intrauterine contraceptive device embedded in bladder wall with calculus formation removed successfully with open surgery

@#An Intrauterine contraceptive devices (IUCD) is commonly inserted by the primary health care physician. It can migrate into pelvic or abdominal organs. When a pregnancy occurs following an insertion of an IUCD, there should be a high suspicion of uterine perforation or possible migration. A radiograph can be done in the primary health care clinic to search for a missing IUCD. Early referral to the urology service is warranted when a patient presents with recurrent urinary tract infections. Removal of an intravesical IUCD can be managed with cystoscopy, laparoscopy or open surgery. Herein, we report a case of IUCD migration into the bladder. This case will highlight the importance of proper technique, careful insertion and the role of ultrasound.

Clinical characteristics of 1653 injured motorcyclists and factors that predict mortality from motorcycle crashes in Malaysia / 中华创伤杂志(英文版)

PURPOSE@#Amongst the ASEAN countries, Malaysia has the highest road fatality risk (>15 fatalities per 100 000 population) with 50% of these fatalities involving motorcyclist. This contributes greatly to ward admissions and poses a significant burden to the general surgery services. From mild rib fractures to severe intra-abdominal exsanguinations, the spectrum of cases managed by surgeons resulting from motorcycle accidents is extensive. The objective of this study is to report the clinical characteristics and identify predictors of death in motorcycle traumatic injuries from a Malaysian trauma surgery centre.@*METHODS@#This is a prospective cross-sectional study of all injured motorcyclists and pillion riders that were admitted to Hospital Sultanah Aminah and treated by the trauma surgery team from May 2011 to February 2015. Only injured motorcyclists and pillion riders were included in this study. Patient demography and predictors leading to mortality were identified. Significant predictors on univariate analysis were further analysed with multivariate analysis.@*RESULTS@#We included 1653 patients with a mean age of (35 ± 16.17) years that were treated for traumatic injuries due to motorcycle accidents. The mortality rate was 8.6% (142) with equal amount of motorcycle riders (788) and pillion riders (865) that were injured. Amongst the injured were male predominant (1 537) and majority of ethnic groups were the Malays (897) and Chinese (350). Severity of injury was reflected with a mean Revised Trauma Score (RTS) of 7.31 ± 1.29, New Injury Severity Score (NISS) of 19.84 ± 13.84 and Trauma and Injury Severity Score (TRISS) of 0.91 ± 0.15. Univariate and multivariate analysis revealed that age≥35, lower GCS, head injuries, chest injuries, liver injuries, and small bowel injuries were significant predictors of motorcycle trauma related deaths with p < 0.05. Higher trauma severity represented by NISS, RTS and TRISS scores was also significant for death with p < 0.05.@*CONCLUSION@#Age, lower GCS, presence of head, chest, liver, small bowel injuries and higher severity on NISS, RTS and TRISS scores are predictive of death in patients involved with motorcycle accidents. This information is important for prognostic mortality risk prevention and counselling.

An Unusual Complication of Colonic Perforation Following Percutaneous Nephrostomy in a Grade IV Blunt Renal Injury Patient

Percutaneous nephrostomy is relatively safe for temporary urinary diversion. However, colonic perforation due to percutaneous nephrostomy can happen with an incidence of 0.2% as reported in the English literatures. To our knowledge, this is the first case being reported as a complication following treatment for traumatic renal injury. This paper is to share our treatment approach which differs from the usual approach according to existing literatures. We report on a young man who sustained grade IV renal injury due to blunt trauma and was managed conservatively. The treatment of traumatic renal injury via urinary diversion was complicated with an iatrogenic colonic perforation. The management and subsequent treatment of this patient is discussed in this case report.

Major tracheobronchial injuries: Management of two rare cases

suspicion is needed for immediate diagnosis and prompttreatment. In this case series, two rare cases oftracheobronchial injuries is described showing variableclinical presentations with different levels of injury. Our firstcase was seen in a 20 years old male whom had a directimpact on the neck and presented with upper tracheal injury.On arrival, this patient was in respiratory distress and hadbilateral pneumothorax. Bilateral chest tube was insertedwith subsequent neck exploration. During the neckexploration, anastomosis of the injured trachea wasperformed. The second case was represented by a 35 yearsold man with right main bronchial injury. Upon initialpresentation, this patient appeared well and wascomfortable under room air. However he graduallydeteriorated one week after the trauma requiring surgicalintervention. Eventually a thoracotomy with primaryanastomosis of the bronchial tear was performed. Details ofboth cases including clinical presentation, imaging andprocedures done will be discussed in this article.

A Rare Case of Ileocecal Tuberculosis with Pulmonary Embolism and Deep Vein Thrombosis.

Venous thromboembolism in tuberculosis is not a well recognised entity. It is a less frequently reported complication of severe pulmonary tuberculosis. It is exceedingly rare when it complicates extrapulmonary tuberculosis. Here, we present a case of 22-year-old young female with abdominal tuberculosis complicated with reverse ileocecal intussusception, deep vein thrombosis and pulmonary embolism. An emergency vena cava filter was inserted prior to a limited right hemicolectomy. In this article, we discuss the rare association of venous thromboembolism with ileocecal tuberculosis.

Large adrenal leiomyoma presented as adrenal incidentaloma in an AIDS patient: A rare entity

The literature on adrenal gland tumour in HIV-infected patients is scarce. We report a 46-year-old Malay man with HIV and Hepatitis C infection presenting with a large nonfunctioning adrenal tumour. Computed tomography showed a large right adrenal tumour with heterogeneous enhancement and central necrosis. A high index of suspicion of a malignant tumour or pheochromocytoma led us to surgical removal of the adrenal gland. In this case report, we highlight important features to look for during pre-op evaluation of a large adrenal mass. Appropriate action should be taken when there is a suspicion of a pheochromocytoma or malignancy.

Rockall risk score in predicting 30 days non-variceal upper gastrointestinal rebleeding in a Malaysian population

Objective: the aim of this study was to determine the usefulness of Rockall score in predicting outcomes of 30 days rebleeding, mortality and need for surgical intervention of bleeding gastric and duodenal ulcers. Methods: this is a retrospective cohort study of all the emergency endoscopies performed in Hospital sultan Ismail from January 2009 to October 2014 for indications of upper gastrointestinal bleeding (UGIb). Data was extracted from hospital's electronic database and only non-variceal bleeds were included. Rockall score was calculated and outcomes of 30 days rebleeding, mortality and need for surgery was recorded. For each outcome, calibration was done using the Goodness-of-fit tests and discriminative ability was reflected by area under the receiver operating characteristic curve (AUROc). Results: A total of 1323 patients were included with a male preponderance of 64%. the overall rates of rebleeding were 11.2%, mortality rate of 8.7% and need for surgery was 2%. Low AUROc values for rebleeding (0.63), mortality (0.58) and surgery (0.67) showed poor discriminative ability of Rockall score. the Goodness-of-fit test also revealed that the scoring system was poorly calibrated in outcomes of rebleeding (p <0.001), mortality (p = 0.001) and surgery (p = 0.038) with p-value <0.05. Patients with high risk (scores ≥8) displayed highest rebleeding and mortality rates of 20% respectively in comparison to the moderate (score 3-7) and low (score ≤2) risk groups. conclusion: Rockall score has a poor discriminative ability and is poorly calibrated for rebleeding, mortality and need for surgery in upper gastrointestinal bleeding. However, it is the best tool we have now to stratify patients into risk groups.