Iatrogenic inguinal chyle fistula: a rare case report.

Chyle fistula may be common in the neck and thorax region but it is a rare entity in the inguinal region. The rarity of the incidence of chyle fistula and the tremendous response to conservative management are the important aspects to be remembered. We hereby report a case of iatrogenic inguinal chyle fistula complicating a femoral vein cannulation.

Phylogenetic relationships of Malaysian monkeys, Cercopithecidae, based on mitochondrial cytochrome c sequences.

Mitochondrial DNA cytochrome c oxidase II (COII) gene sequences of Malaysian Cercopithecidae were examined to ascertain their phylogenetic relationships. Colobinae were represented by the genera Presbytis, Trachypithecus and Nasalis, while the genus Macaca represented Cercopithecinae. DNA amplification and sequencing of the COII gene was performed on 16 samples. Symphalangus syndactylus (Hylobatidae) was used as the outgroup. Data were analyzed using both character (maximum parsimony) and distance (neighbor-joining) methods. Tree topologies indicated that Colobinae and Cercopithecinae have their own distinct monophyletic clade. This result was well supported by bootstrap values and genetic distances derived from the Kimura-2-parameter algorithm. Separation of Macaca nemestrina from M. fascicularis was also well supported by bootstrap values. In addition, tree topologies indicate a good resolution of the Colobinae phylogenetic relationships at the intergeneric level, but with low bootstrap support. The position of Nasalis remained problematic in both trees. Overall, COII is a good gene candidate for portraying the phylogenetic relationships of Malaysian primates at the inter- and intra-subfamily levels.

Helicobacter pylori cagA gene variants in Malaysians of different ethnicity.

We have defined DNA repeat variability in the 3'-terminus of the cagA gene of Helicobacter pylori strains from Malaysian patients of different ethnicities. We identified different alleles based on the EPIYA repeats. cagA types A-B-D and A-B-B-D are more similar to the sequence of Japanese strains, whereas cagA types A-B-C, A-B-C-C, A-B and A-C displayed similarity to strain 26695 sequences. A significant association was found between cagA genotypes and patients' ethnicity, with cagA type A-B-D being predominantly isolated from Chinese patients and cagA type A-B-C from Malays and Indians. Our data further corroborate the possibility that variant biological activity of CagA may affect the host specificity and/or pathogenicity of H. pylori.

Fine Needle Aspiration (FNA) Cytology of the Thyroid: A Cyto-Histopathological Study of 361 Cases in Hospital Universiti Kebangsaan Malaysia

Thyroid nodules are common but thyroid malignancies are not. Fine needle aspiration (FNA) cytology is a diagnostic tool used to screen patients with thyroid nodules who require surgery. We study the diagnostic accuracy of FNA as the initial diagnostic modality in the clinical assessment of thyroid nodules. Between January 1995 until December 2000, 2131 FNA of thyroid nodules were performed. Four hundred and forty-one (20.7%) of these were unsatisfactory and 1690 (79.3%) cases were satisfactory for cytological evaluation. Histopathological diagnosis were available for 361 cases. Cyto-histopathological correlation was carried out for these cases. Our results showed a diagnostic accuracy of 96.2% with sensitivity and specificity rates of 87.7% and 98.4% respectively. Our positive predictive value is 93.4% and our negative predictive value is 96.8%. From this study, we conclude that fine needle aspiration is an important initial screening diagnostic tool for the investigation of thyroid nodules.

Initial experience of laparoscopic incisional hernia repair.

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.

Bogota bag in the treatment of abdominal wound dehiscence.

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.

Malignant melanoma of the gastrointestinal tract presenting as a bleeding gastric ulcer.

Malignant melanoma involving the gastrointestinal tract is diagnosed antemortem in only a small percentage of patients with the disease. Presenting symptoms are often non-specific, causing a diagnostic problem. The vast majority of such melanomas are metastatic from a cutaneous primary, however there is evidence that the tumour can arise de novo in the gastrointestinal system. We report a 74-year-old man with malignant melanoma with an unusual presentation simulating a symptomatic gastric ulcer. He presented with epigastric pain, haematemesis and melaena. Explorative laparotomy revealed a large ulcerated tumour with several pigmented satellite nodules in the proximal stomach, multiple ileal nodules and widespread nodal and liver metastases. Proximal gastrectomy and limited small bowel resection was performed. Histology revealed the tumour to be composed of nests of epithelioid cells with melanin pigment. The tumour cells showed immunohistochemical positivity for S100 protein and HMB45 antibodies. This report emphasizes that melanoma should be a diagnostic consideration in patients with gastric ulcer.

Double pylorus.

Double pylorus (DP) or duplication of the pylorus is an uncommon condition that is either congenital or acquired. Acquired double pylorus (DP) results from a peptic ulcer eroding through and creating a fistula between the duodenal bulb and the distal stomach. We report a case of an acquired double pylorus in an adult gentleman that resulted from the erosion of a duodenal and prepyloric ulcer.

Combined needlescopic cholecystectomy and laparoscopic splenectomy for the treatment of thalassaemic splenomegaly and cholelithiasis.

Gallstone disease is a common association in patients with haematological splenomegaly. When indicated, simultaneous splenectomy and cholecystectomy should be performed and traditionally this is accomplished by open surgery. We report a 17 year old thalassaemic girl with splenomegaly complicated by gallstone pancreatitis. We treated her with a combination of needlescopic cholecystectomy and laparoscopic splenectomy as well as delivering the huge spleen via a pfannenstiel incision to hide the scar. We believe this technique is an acceptable alternative mainly for rapid delivery of the spleen and to minimize visible scars hence improving cosmesis.

Perforated malignant gastric ulcer in a pregnant young adult: a case report.

Gastric cancer in the young adult is rare and has been said to be more aggressive than gastric cancers of the older age group. Its unique association with pregnancy is even rarer. However, they have similar complications of haemorrhage, obstruction and perforation. We report a 27 year old lady at 16 weeks gestation who presented with a perforated malignant gastric ulcer and carcinomatosis peritonei. Reviewing the literature, we realised that such complication of a gastric cancer occurring in a pregnant young adult has not been previously documented.

Pancreatic insulinomas--a study of 15 cases from 1978-98.

Fifteen cases of insulinoma were managed at HUKM over a period of 20 years. Although all patients presented with neurological symptoms, the diagnosis was delayed in all. Fasting hypoglycaemia and the measurement of C-peptide levels eventually made the diagnosis. Pre-operative localization investigations were not particularly useful. Intraoperative ultrasound (IOUS) detected 72% of the insulinomas, while 93% of the insulinomas were identified intraoperatively by palpation. All the insulinomas were detected intraoperatively with the combination of the two techniques. Twelve of 15 patients had benign adenomas including one patient with MEN-1 syndrome. Two patients had malignant insulinomas. One patient refused surgery. Nine patients underwent pancreatic resections and the remaining 5 patients had the adenomas enucleated.

Typhoid thyroiditis.

Acute suppurative thyroiditis in a 62 year old lady with enteric fever is reported. Plain radiography of the neck showed a distinct localised abscess cavity with air fluid level. A rare causative agent Salmonella typhi was isolated. Needle aspiration and antibiotics resulted in complete recovery.

The surgical treatment of adrenal diseases.

Between January 1978 to December 1993, 130 cases of adrenal diseases were diagnosed and surgically treated at the National University of Malaysia. They were 58 cases (44.6%) of Conn's syndrome, 40 cases (30.7%) of Cushing's syndrome, 20 cases (15.3%) of phaeochromocytoma and 12 cases (9.2%) of adrenocortical carcinoma (ACC). The commonest cause of Conn's syndrome was an adenoma (96.5%) which affected the left gland four times more than the right gland. Cushing's syndrome was caused by adrenocortical adenoma (32.5%), diffuse bilateral adrenal hyperplasia (40.0%), pigmented macronodular hyperplasia (20.0%) and adrenal carcinoma (7.5%). Twenty-five percent of the phaeochromocytomas were extraadrenal in origin arising mainly from the abdominal sympathetic chain. More than 50% of ACCs were non-functioning tumours. Fifty percent of the patients with ACC had inoperable tumours. The prognosis was poor even with adjuvant chemoradiotherapy. The main surgical approach was the anterior transabdominal route. There was no operative mortality or morbidity in all operated cases.

Large bowel cancer in a young adult presenting as an acute intussusception--a case report.

A 14 year old Malay boy with an adenocarcinoma of the transverse colon is reported. A lesion was discovered early when he presented with an uncommon complication in the form of a bowel intussusception. Emergency segmental colonic resection was performed, followed later by an extended left hemicolectomy following histological confirmation of the disease. Benign adenomatous polyp is believed to be the predisposing condition. Both rarities, colorectal cancer in young adults and adult intussusception, are discussed.