Mechanical thrombolysis as an adjunct therapy to management of portal vein thrombosis following Radio Frequency Ablation.

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.

Randomized Controlled Trial Comparing Daycare and Overnight Stay Laparoscopic Cholecystectomy.

BACKGROUND: This present study sought to review the feasibility and patients' satisfaction of laparoscopic cholecystectomy to be perform as daycare procedure. MATERIAL AND METHODS: Sixty-two patients with symptomatic gallstones were recruited within a year. They were randomized into overnight stay and daycare groups. The outcomes and post-operative complications were analyzed. RESULTS: Fifty-eight patients were eligible for analysis and four patients were excluded because of conversion to open cholecystectomy. All patients in daycare group reported no fever but two patients in the overnight stay group complaint of post-operative fever (p=0.150). The mean pain score using Visual Analogue Score (VAS) in daycare group was 2.93 but in the overnight stay was recorded as 3.59 (p=0.98). Five patients had post-operative nausea and vomiting (PONV) in daycare group compared to 2 patients in the overnight stay group (p=0.227). Patient's satisfaction were higher in the daycare group (p=0.160). All patients in daycare group were back at work within a week but in overnight stay, 11 patients had to stay off work for more than one week (p=0.01). CONCLUSIONS: Daycare laparoscopic cholecystectomy is safe and feasible. The satisfaction of daycare surgery is higher than overnight stay group. Patients' selection is an important aspect of its success.

Pancreatic pseudopapillary tumour: A rare misdiagnosed entity.

INTRODUCTION: 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. PRESENTATION OF CASE: This paper presents a 17-year-old girl with intra-abdominal mass diagnosed with solid pseudo papillary tumour that underwent Whipple's procedure. DISCUSSION: We discuss the presentations, diagnosis and pathology findings of this rare pathology. CONCLUSION: The diagnosis remains an enigma in view of the nature and location of the tumour. Resection is still the best choice remains for this condition.

Single incision laparoscopic surgery (SILS) inguinal hernia repair - recent clinical experiences of this novel technique.

Inguinal hernia remains the most commonly encountered surgical problem. Various methods of repair have been described, and the most suitable one debated. Single port access (SPA) surgery is a rapidly evolving field, and has the advantage of affording 'scarless' surgery. Single incision laparoscopic surgery (SILS) for inguinal hernia repair is seen to be feasible in both total extraperitoneal (TEP) and transabdominal pre-peritoneal (TAPP) approaches. Data and peri-operative information on both of these however are limited. We aimed to review the clinical experience, feasibility and short term complications related to laparoscopic inguinal hernia repair via single port access. A literature search was performed using Google Scholar, Springerlink Library, Highwire Press, Surgical Endoscopy Journal, World Journal of Surgery and Medscape. The following search terms were used: laparoscopic hernia repair, TAPP, TEP, single incision laparoscopic surgery (SILS). Fourteen articles in English language related to SILS inguinal hernia repair were identified. Nine articles were related to TEP repair and the remaining 5 to TAPP. A total of 340 patients were reported within these studies: 294 patients having a TEP repair and 46 a TAPP. Only two cases of recurrence were reported. Various ports have been utilized, including the SILS port, Tri-Port and a custom- made port using conventional laparoscopic instruments. The duration of surgery was 40-100 minutes and the average length of hospital stay was one day. Early outcomes of this novel technique show it to be feasible, safe and with potentially better cosmetic outcome.

Persistent Mullerian Duct Syndrome: an interesting case report.

Transverse testicular ectopia is an uncommon disorder of testicular ectopia. Nearly thirty percent of the cases is associated with Persistent mullerian duct syndrome which is characterized by karyotypically normal males with retained mullerian derivatives. Understanding the natural process of the condition and the association with malignant potential will allow for a better understanding of the optimal surgical approach. This is a case report of young male presented a left sided inguinal hernia in which the sac contained both testes and uterus. The literature review of the syndrome will be discussed.

Arterial embolization of a bleeding gastric Dieulafoy lesion: a case report.

Dieulafoy's lesion is one of an unusual cause of upper gastrointestinal bleeding (U GIB). Endoscopic intervention has always been a preferred non-surgical method in treating UGIB including bleeding from Dieulafoy's lesion. Owing to recent advances in angiography, arterial embolization has become a popular alternative in non- variceal UGIB especially in cases with failed endoscopic treatment. However, managing bleeding Dieulafoy's with selective arterial embolization as the first line of treatment has not been exclusively practiced. We hereby, report a case of bleeding Dieulafoy lesion which had been primarily treated with arterial embolization.

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

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.

Comparison of complication outcomes in acute pancreatitis following ERCP and conservative management at UKM medical centre: a six years retrospective study.

INTRODUCTION: 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. MATERIALS AND METHODS: The study is conducted retrospectively and the study population was from January 2003 until December 2008. About 100 patients involving 51 males and 49 females were included in this study. All of them were diagnosed acute pancreatitis based on the serum amylase level of 4 times than normal value detected from Chemistry Pathology record, Pathology Department, PPUKM. Then, data were collected from the patient's file which include the demographic data and patient clinical presentation, ultrasound finding, either patient went for ERCP within 72 hours or not. If ERCP not done within 72 hours of admission then it will considered that the patient is under conservative management. RESULTS: From 100 patients that involved in this study about 44% was Malay, 36 % was Chinese, 18 % was Indian and the other 2 % was from other origin. There were 28 cases (28%) where ERCP was done within 72 hours, and the other 72 cases (72%) the treatment was conservative. Among 28 cases that ERCP was done within 72 hours after admission, 20 cases are mild where as only 8 cases are severe. However, in conservative group about 56 cases are mild and the other 16 are severe. Among the conservative group there are 12 cases which have complications. The complications are respiratory failure, renal failure, sepsis, shock and pancreatic necrosis. There are 7 cases whose have respiratory failure alone, 1 case developed renal failure and 1 case has a shock. 1 case developed both pancreatic necrosis with sepsis. 1 case each developed respiratory failure with sepsis and respiratory failure with renal failure. However no complications were noted in early ERCP group. CONCLUSION: As a conclusion in this study we found out that early ERCP have a significant role in acute pancreatitis compare to conservative management.

An interesting case of isolated pancreatic teratoma: lessons to learn.

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.

The TB--Crohn's affair--a never ending dilemma.

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.

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.

Currarino triad with dual pathology in the presacral mass: report of a case.

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.