A 5-year retrospective study of abdominal aortic aneurysm repair in a Malaysian hospital.

INTRODUCTION: Prevalence and mortality due to abdominal aortic aneurysms (AAAs) have reduced; however, trends in Malaysia are difficult to determine due to the low prevalence and volume of published data. Our aim was to study current trends in AAA treatment in a national referral unit and compare them to previous reports. MATERIALS AND METHODS: A retrospective study was conducted on all patients who had AAA repair between 2015 and 2019 in Kuala Lumpur Hospital (HKL). Operating logbooks from the study period were digitised, and details of aortoiliac aneurysm surgery were analysed. We compared these findings to a previous study on AAA treatment conducted in HKL between 1993 and 1995. RESULTS: Over the course of 5 years, 496 abdominal aortic surgery were performed. There were 451 patients (90.9%) with AAA, whereas 41 patients (8.3%) had mycotic aneurysms. Among patients with AAA, the median age was 70 (IQR 11) and was mostly male (89.3%), whereas inlay repair was the most common technique (n = 395, 87.5%) while EVAR was employed in 36 patients (8.0%). A two proportion z test comparing emergency surgery proportions between our study cohort (56.1%) and the 1993-1995 cohort (39.3%) was significant (p = .017). CONCLUSION: There has been a significant increase in the proportion of emergency surgery in HKL. Open surgery remains the most frequent repair technique. The increase in volume likely reflects the accessibility of healthcare, though other factors may play a role. Improvements in outcomes will benefit from research on the standard of care based on prospective data.

Perspectives from Young South African and Zimbabwean Women on Attributes of Four (Placebo) Vaginal Microbicide Delivery Forms.

INTRODUCTION: Incorporating end-user input into the design of new vaginal microbicides for women is key to optimizing their uptake, consistent use, and, ultimately, success in combatting the heterosexual HIV epidemic. METHODS: The Quatro Study assessed four placebo forms of vaginally inserted HIV-microbicides among young microbicide-naïve African women: on-demand film, insert and gel, and monthly ring. Participants randomly used each product for 1 month and provided product satisfaction ratings (1-5 scale), and opinions on product attributes and potential alternative designs. Qualitative data were collected through focus group discussions at study exit. Multivariable associations between attribute opinions and overall product rating were examined using Poisson regression models with robust standard errors to assess the attributes most influential to satisfaction. RESULTS: Overall opinions of products and their individual attributes were generally positive; all products were rated either 4 or a 5 by ≥ 50% of participants. Attributes related to ease of use and interference with normal activities were the most salient predictors of satisfaction. Preferences for duration of use tended toward relatively shorter use periods for the ring (i.e., 1-3 months vs. 12 months) and for coitally independent dosing for the on-demand products. CONCLUSIONS: How well a product fit in with participants' lifestyles was important to their overall satisfaction. For on-demand products, greater flexibility around timing of use was desired, to avoid coital dependency of the dosing.

Steroids in cardiac surgery: a systematic review and meta-analysis.

BACKGROUND: Cardiopulmonary bypass (CPB) induces a systemic inflammatory reaction that may contribute to postoperative complications. Preventing this reaction with steroids may improve outcomes. We performed a systematic review to evaluate the impact of prophylactic steroids on clinical outcomes in patients undergoing on-pump cardiac surgery. METHODS: We searched MEDLINE, EMBASE, and Cochrane CENTRAL for randomised controlled trials (RCTs) comparing perioperative corticosteroid administration with a control group in adults undergoing CPB. Outcomes of interest included mortality, myocardial infarction, and new onset atrial fibrillation. We assessed the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: Fifty-six RCTs published between 1977 and 2015 were included in this meta-analysis. Mortality was not significantly different between groups [3.0% (215/7258 patients) in the steroid group and 3.5% (252/7202 patients) in the placebo group; relative risk (RR), 0.85; 95% confidence interval (CI), 0.71-1.01; P=0.07; I2 = 0%]. Myocardial injury was more frequent in the steroid group [8.0% (560/6989 patients), compared with 6.9% (476/6929 patients); RR, 1.17, 95% CI, 1.04-1.31; P=0.008; I2=0%]. New onset atrial fibrillation was lower in the steroid group [25.7% (1792/6984 patients) compared with 28.3% (1969/6964 patients), RR, 0.91, 95% CI, 0.86-0.96, P=0.0005, I2=43%]; this beneficial effect was limited to small trials (P for interaction <0.00001). CONCLUSIONS: After randomising 16 013 patients, steroid administration at the time of cardiac surgery had an unclear impact on mortality, increased the risk of myocardial injury, and the impact on atrial fibrillation should be viewed with caution given that large trials showed no effect.

Epiploic Appendagitis: An uncommon surgical diagnosis.

Epiploic appendagitis or appendices epiploicae, is a rare cause of abdominal pain in patients with mild signs of abdominal pathology. It mimics diverticulitis or appendicitis clinically as there are no pathognomonic features. It is a surgical diagnosis presenting with localised, sharp, acute abdominal pain, not associated with symptoms like nausea, vomiting, fever or suggestive laboratory values. With the availability of abdominal CT scans and ultrasound, it will frequently be a differential diagnosis preventing unnecessary surgery for patients. However, it may be erroneous and therefore clinical judgement is of paramount importance. This report highlights this rare presentation and identifies management guidelines.

Computed tomography of the thorax with 3D reconstruction in penetrating chest injury.

Penetrating chest wounds is less common but more deadly then blunt trauma. Majority of penetrating chest trauma can be managed conservatively with observation and simple thoracotomy. This case report highlights a bizarre occupational hazard causing a penetrating chest injury and the option of non-invasive management with the aid of computed tomography with 3D reconstruction.

Total percutaneous endovascular aneurysm repair (pEVAR): the initial experience in Hospital Kuala Lumpur.

INTRODUCTION: There has been a paradigm shift in the treatment of AAA with the advent of endovascular aneurysm repair (EVAR). Rapid progress and evolution of endovascular technology has brought forth smaller profile devices and closure devices. Total percutaneous endovascular aneurysm repair (pEVAR) involves the usage of suture-mediated closure devices (SMCDs) at vascular access sites to avoid a traditional surgical cutdown. MATERIALS AND METHODS: We retrospectively reviewed our experience of pEVAR between April 2013 and July 2014. Primary success of the procedure was defined as closure of a common femoral artery (CFA) arteriotomy without the need for any secondary surgical or endovascular procedure within 30 days. RESULTS: In total there were 10 pEVAR cases performed in the study period, one case in Queen Elizabeth Hospital during visiting vascular service. Patients have a mean age of 73.4 year old (66-77 year old) The mean abdominal aortic size was 7.2 cm (5.6-10.0cm). Mean femoral artery diameter was 9.0 mm on the right and 8.9 mm on the left. Mean duration of surgery was 119 minutes (98- 153 minutes). 50% of patients were discharged at post-operative day one, 30%- day two and 20%- day three. Primary success was achieved in 9 patients (90%) or in 19 CFA closures (95%). No major complication was reported. DISCUSSION: We believe that with proper selection of patients undergoing EVAR, pEVAR offers a better option of vascular access with shorter operative time, less post- operative pain, shorter hospital stay and minimises the potential complications of a conventional femoral cutdown.

Bleeding Jejunal GIST: An uncommon cause of Gastrointestinal Bleeding.

Gastrointestinal stromal tumours (GIST) are rare gastrointestinal tumours and are one of the causes of obscure gastrointestinal bleeding. We report a case of massive gastrointestinal bleeding secondary to bleeding jejunal GIST in a 43 years old gentleman. Endoscopic intervention failed to identify the source of bleeding and CT Angiography (CTA) showed a jejunal mass and patient underwent laparotomy and resection of the bleeding jejunal GIST. This article highlights the rare cause of the massive GI bleeding and also emphasise the role of CTA in obscure GI bleeding.

Rare cause of lower limb deep venous thrombosis: a case report.

deep venous thrombosis (dVT) in lower limbs caused by abdominal aortic aneurysm (AAA) is rare. A combination of anatomical obstruction with surrounding inflammatory tissue and reduced blood flow in venous limb were probably the main reasons for the occurrence of the dVT. we report a case of infra-renal AAA presented as lower limb dVT and symptomatic pulmonary embolism.

Endovascular Aneurysm Repair (EVAR) for Infra-renal Abdominal Aortic Aneurysm (AAA) under Local Anaesthesia - Initial Experience in Hospital Kuala Lumpur.

This is our initial report on the first 4 cases of infra-renal abdominal aortic aneurysm undergoing Endovascular Aneurysm Repair (EVAR) with local anaesthesia, controlled sedation and monitoring by an anaesthetist. All four patients were males with a mean age of 66.7 years. Only one required ICU stay of two days for cardiac monitoring due to bradycardia and transient hypotension post procedure. No mortality or major post operative morbidity was recorded and the mean hospital stay post procedure was 3.5 days (range 2-5 days).

Endovascular Aneurysm Repair (EVAR) for infra-renal Abdominal Aortic Aneurysm(AAA) under Local Anaesthesia - Initial Experience in Hospital Kuala Lumpur.

This is our initial report on the first 4 cases of infra-renal abdominal aortic aneurysms undergoing Endovascular Aneurysm Repair (EVAR) with local anaesthesia, controlled sedation and monitoring by an anaesthetist. All 4 patients were males with a mean age of 66.7 years. Only one (1) required ICU stay of 2 days for cardiac monitoring due to bradycardia and transient hypotension post procedure. No mortality or major post operative morbidity was recorded and the mean hospital stay post procedure was 3.5 days (range 2-5 days).

Hybrid procedure in pseudoaneurysm of the descending thoracic aorta in Hospital Kuala Lumpur.

Conventional open repair for Thoracoabdominal aortic aneurysm (TAA) is associated with high morbidity and mortality. Spinal cord ischemia (SCI), renal failure, bowel ischemia and mortality are established complications following this procedure. With the advent of endovascular stent technology, various novel approaches have been described to reduce these complications, namely fenestrated stent graft and hybrid procedure. We present a case of hybrid procedure in a pseudoaneurysm of descending thoracic aorta done in Kuala Lumpur Hospital.

Subclavian artery stent fracture.

We report a case of a 52 year-old dentist who had stent implantation for a left subclavian artery stenosis. However, this was later complicated by a stent fracture within one week of stent placement. A chest radiograph showed two pieces of the fractured stent, which was confirmed by computed tomographic angiogram (CTA) of the affected artery. We then discuss the occurrence of stent fractures, which are not uncommon but serious complications of endovascular therapy.

Primary aorto-duodenal fistula.

Primary aorto-duodenal fistula is a rare and life-threatening cause of upper gastro-intestinal bleed. In this case report, a patient presented acutely with several episodes of haematochezia and pulseless lower limbs bilaterally. Primary aorto-duodenal fistula with peripheral vascular disease was diagnosed after an urgent CT angiogram was performed. She underwent left axillo-bifemoral bypass, resection of the fistula, Rouxen-Y gastro-jejunostomy, pyloric exclusion and controlled duodenal fistula the following day.