Comparison of continuous preperitoneal infiltration versus patient controlled analgesia for pain control in elective colorectal surgery.

Background: Post-operative analgesia is crucial in enhanced recovery after surgery and to minimize post-operative complications. There remains data paucity on the efficacy of preperitoneal analgesia (PPA) compared to patient-controlled analgesia (PCA). This study aims to examine the efficacy of preperitoneal infusion as analgesia following elective colorectal surgery. Methods: This is a prospective cross-sectional study of all patients which underwent elective colorectal surgeries, performed in a tertiary surgical referral center with dedicated colorectal unit. Patients from May 2017 to April 2021 who underwent elective colorectal surgery were included in this study. Pain scores were reviewed and analyzed at regular intervals post-operatively for comparison. Results: Amongst the 200 patients included, there were 174 patients in the PPA arm and 26 patients using PCA. Patients in the PPA group were older age (63.29 vs 56.00, P = 0.003). A total of 118 patients in PPA cohort (67.8%) and 21 from PCA cohort (80.8%) underwent open surgery and the remaining 82 patients underwent laparoscopic surgeries. Although postoperative pain scores were consistently below 5 and reduced in trend from 2 hours to 96 hours postoperatively in both groups, the pain scores on coughing markedly reduced in the PPA group when compared PCA alone. The total dosage of opioid required in PPA cohort was also significantly lower when compared to PCA group at the first 24 hours postoperatively 12.21 (±13.0) vs 20.0 (±14.43), P = 0.048. Conclusions: PPA is a comparable modality for analgesia after elective colorectal surgery that reduces the opioid requirement postoperatively giving adequate pain relief. PPA should be considered as an alternative modality for multi-modal analgesia.

Outcomes of traumatic extremity vascular injuries from a Malaysian level 1 trauma center.

BACKGROUND: In Malaysia, management of traumatic vascular injuries is at the discretion of the treating surgeon (trauma or vascular surgery). This study was conducted to report on the epidemiology, mechanism of injury and outcomes of vascular injuries managed in a regional level 1 trauma center. METHODS: This is a retrospective cohort study of all patients treated for traumatic extremity vascular injuries from January 2018 to December 2020. Demography, mechanism of injury, pre-operative physiologic vital signs, vessel injured, injury severity (NISS, RTS and TRISS score), type of revascularization surgery, fasciotomy, post-operative blood investigations, operative outcomes (amputation, length of stay and ICU admission) and long-term rehabilitation follow-up were recorded and analyzed. RESULTS: Amongst the 35 recorded vascular injuries only 28 patients had adequate data that were included in the analysis. Majority of patients were males (23/28patients; 82%). Blunt injury to vessels was more likely in motorcycle crashes (16/28patients; 76%) than in automobile crashes (5/28patients; 24%). There were three lower limb amputees (3/3patients; 100%) that had early fasciotomy and were associated with three-fold higher post-operative median (interquartile range) CK levels of 16740 (8157 to 23116) u/l. Only two thirds (16/28 patients) had active rehabilitation follow-up and were back to work after a median duration of four months. CONCLUSION: Male gender, blunt injury, road traffic crashes and motorcycles were the majority of vascular injuries. Lower limb vascular injuries had poorer outcome with three amputations performed after attempts at revascularization. Fasciotomy and high CK level may be related to higher risk of limb loss. Our study highlights the importance of rehabilitation and long-term follow-up in this cohort of patients.

Predictors of Mortality and Outcomes of Ventilated Patients Managed in a Resource-Limited Acute Surgical Ward.

BACKGROUND: Acute care surgery is an important component of health care in the developed nations. However, in Malaysia, acute care surgery is yet to be recognized as a specific subspecialty service. Due to high demands of limited ICU beds, some patients have to be ventilated in the wards. This study aims to describe the outcomes of acute surgical patients that required mechanical ventilation. METHODS: This is a retrospective review of all mechanically ventilated surgical patients in the wards, in a tertiary hospital, in 2020. Sixty-two patients out of 116 patients ventilated in surgical wards fulfilled the inclusion criteria. Demography, surgical diagnosis and procedures and physiologic, biochemical and survival data were analyzed to explore the outcomes and predictors of mortality. RESULTS: Twenty-two out of 62 patients eventually gained ICU admission. Mean time from intubation to ICU entry and mean length of ICU stay were 48 h (0 to 312) and 10 days (1 to 33), respectively. Survival for patients admitted to ICU compared to ventilation in the acute surgery wards was 54.5% (12/22) vs 17.5% (7/40). Thirty-four patients underwent surgery, and the majority were bowel-related emergency operations. SAPS2 score validation revealed AUC of 0.701. More than half of patients with mortality risk < 50% eventually were not admitted to ICU. CONCLUSIONS: ICU care for critically ill surgical patients provides better survival. There is a need to improve triaging for intensive care, especially for low-mortality-risk patients using risk scores which are locally validated.

Isolated blunt iliac artery injury successfully treated with endovascular stent.

Common or external iliac artery injury due to blunt trauma is unusual without an associated pelvic fracture. Here we report on a 62 years old man that sustained left external iliac artery thrombosis due to blunt trauma following fall from motorbike. There was no immediate circulatory compromise. Contrasted CT of abdomen revealed an associated left lower abdominal wall traumatic hernia. The iliac artery was intervened with an endovascular stent to restore luminal flow and the hernia was repaired electively. The entire clinical course and management dilemma are described in this article.

Complete sigmoid colon erosion by an intrauterine contraception device in an ectopic pregnancy: a case report.

INTRODUCTION An intrauterine contraceptive device (IUCD) is a common contraception method used for family planning. IUCD erosion into adjacent organs is a rare but serious complication of IUCD use. CASE PRESENTATION A 41-year-old female presented to us with a leaking left ectopic pregnancy. Emergency laparotomy and left salpingectomy were performed. A copper ICUD was found intraperitoneally and part of it had completely eroded into the sigmoid colon. Sigmoid colotomy was performed and the IUCD was removed successfully. Further history revealed that the patient had her IUCD inserted 12 years previously but was forgotten. The patient was discharged well after 4 days of admission. DISCUSSION Erosion of an IUCD into the colon is uncommon and may be asymptomatic or present with bowel perforation and obstruction. There should be a high index of suspicion for pregnancy occurring among women post-IUCD insertion. A misplaced IUCD can cause chronic inflammation of the fallopian tube, which may alter tubal functionality and increase the risk of ectopic pregnancy. Family planning is commonly done in primary health care. Primary care education and counselling are essential to improve awareness of fertile women to prevent similar complications. Periodic examination of IUCD string either by users or primary health-care practitioners is crucial. Ultrasound can be advocated if there are difficulties with the insertion. An abdominal radiograph is useful and should be performed in the case of missing IUCDs.

Critical adjustments and trauma surgery trends in adaptation to COVID-19 pandemic in Malaysia.

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.

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.

Older age and duration of exposure to type 2 diabetes in selective screening of asymptomatic carotid artery stenosis for primary stroke prevention-A single institution experience.

AIMS: To evaluate the incidence and risk factors for carotid artery stenosis amongst asymptomatic type 2 diabetes from a single Malaysian tertiary institution. METHODS: This is a prospective cross-sectional study of asymptomatic type 2 diabetics selected from the outpatient ophthalmology and endocrine clinics for carotid duplex ultrasound scanning performed by a single radiologist. The duplex ultrasound criteria were based on the North American Symptomatic Carotid Endarterectomy Trial (NASCET) classification of carotid artery stenosis. Univariate and multivariate analysis was performed to identify possible risk factors of carotid artery stenosis. RESULTS: Amongst the 200 patients, the majority were males (56%) and Malay predominance (58.5%). There were 12/200 patients (6%) with mean age of 69.2 years identified to have carotid artery stenosis. Univariate analysis of patients with asymptomatic carotid artery stenosis identified older age of 69.2 years (p=0.027) and duration of exposure to diabetes of 17.9 years (p=0.024) as significant risk factors. CONCLUSION: Patients with longer exposure of diabetes and older age were risk factors of carotid artery stenosis in asymptomatic type 2 diabetics. These patients should be considered for selective screening of carotid artery stenosis during primary care visit for early identification and closer surveillance for stroke prevention.

Predictors of mortality and validation of burn mortality prognostic scores in a Malaysian burns intensive care unit.

BACKGROUND: Majority burn mortality prognostic scores were developed and validated in western populations. The primary objective of this study was to evaluate and identify possible risk factors which may be used to predict burns mortality in a local Malaysian burns intensive care unit. The secondary objective was to validate the five well known burn prognostic scores (Baux score, Abbreviated Burn Severity Index (ABSI) score, Ryan score, Belgium Outcome Burn Injury (BOBI) score and revised Baux score) to predict burn mortality prediction. METHODS: Patients that were treated at the Hospital Sultan Ismail's Burns Intensive Care (BICU) unit for acute burn injuries between 1 January 2010 to 31 December 2017 were included. Risk factors to predict in-patient burn mortality were gender, age, mechanism of injury, total body surface area burn (TBSA), inhalational injury, mechanical ventilation, presence of tracheotomy, time from of burn injury to BICU admission and initial centre of first emergency treatment was administered. These variables were analysed using univariate and multivariate analysis for the outcomes of death. All patients were scored retrospectively using the five-burn mortality prognostic scores. Predictive ability for burn mortality was analysed using the area under receiver operating curve (AUROC). RESULTS: A total of 525 patients (372 males and 153 females) with mean age of 34.5 ± 14.6 years were included. There were 463 survivors and 62 deaths (11.8% mortality rate). The outcome of the primary objective showed that amongst the burn mortality risk factors that remained after multivariate analysis were older age (p = 0.004), wider TBSA burn (p < 0.001) and presence of mechanical ventilation (p < 0.001). Outcome of secondary objective showed good AUROC value for the prediction of burn death for all five burn prediction scores (Baux score; AUROC:0.9, ABSI score; AUROC:0.92, Ryan score; AUROC:0.87, BOBI score; AUROC:0.91 and revised Baux score; AUROC:0.94). The revised Baux score had the best AUROC value of 0.94 to predict burns mortality. CONCLUSION: Current study evaluated and identified older age, total body surface area burns, and mechanical ventilation as significant predictors of burn mortality. In addition, the revised Baux score was the most accurate burn mortality risk score to predict mortality in a Malaysian burn's population.

Clinical Audit of Urosepsis Treated in a Malaysian Surgery Unit.

This is a retrospective audit of all patients admitted to the surgical unit for urosepsis from June 2014 to June 2015 at the General Surgery Unit of Hospital Sultan Ismail, Malaysia. Demographics, comorbidities, presenting symptoms, length of stay (LOS), mortality, and associated risk factors were recorded. There were 35 patients treated for urosepsis with a male preponderance of 21/35 patients. Hypertension (n=18) and diabetes (n=10) were the two most common comorbidities. There were five deaths (mortality rate=14.3%) and the main bacterium cultured was Escherichia coli. Age >65, presence of underlying comorbid disease, presence of cancer, urine and blood culture positivity had higher incidence of death but were not statistically significant for urosepsis mortality. However, this result is limited by the small sample size and single centre retrospective data.

Pulmonary artery catheter entrapment after mitral valve surgery and the use of transesophageal echocardiography to accurately determine the site of entrapment.

The prevalence of pulmonary artery catheter (PAC) entrapment in open-heart surgery is scarce with a prevalence rate of 0.065%. Challenges in managing such cases lie particularly in choosing the modalities (chest roentgenogram, fluoroscopy, and transesophageal echocardiography) to accurately identify the anatomic location and cause of entrapment. In this case, we report a 42-year-old man who underwent mitral valve replacement with PAC entrapment discovered on postoperative day 2 and subsequently underwent retrieval after re-sternotomy. This case also highlights the usefulness of transesophageal echocardiography by the cardiac anesthetist in aiding the surgeons to locate the anatomic location where the catheter was entrapped.

A Rare Presentation of Anterior Mediastinal Teratoma Mimicking Valvular Heart Disease with A Systolic Murmur.

Extrinsic pulmonary artery stenosis caused by anterior mediastinum teratoma presenting with an ejection systolic murmur is a rare phenomenon. Till date, 15 cases have been reported (inclusive of this case) in the English literatures. Herein we report a 20 year old female with extrinsic pulmonary artery stenosis because of compression by an anterior mediastinal teratoma with a loud ejection systolic murmur. The case report aims to highlight the awareness of such rare presentation of anterior mediastinal teratomas that may mimic congenital valvular heart diseases among clinicians.

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.

Prognostic predictors of early mortality from exsanguination in adult trauma: a Malaysian trauma center experience.

BACKGROUND: Trauma mortality due to exsanguination is the second most common cause of death. The objective of this study is to investigate the predictors for early death from exsanguination. METHODS: A prognostic study was done to identify predictors of early mortality due to exsanguination. Data were extracted from our Trauma Surgery Registry database of Sultanah Aminah Hospital, Johor Bahru, Malaysia. All patients who were treated from May 1, 2011 to April 31, 2014 by the trauma team were included. Adult trauma patients included from the Trauma Surgery Registry were divided into two groups for analysis: early death from exsanguination and death from non-exsanguination/survivors. Univariate and multivariate analysis was performed to look for significant predictors of death from exsanguination. Variables analyzed were demography, mechanism of injury, organ injury scale, physiological parameters (systolic blood pressure (SBP), respiratory rate, heart rate, temperature), Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), New Injury Severity Score (NISS), Trauma and Injury Severity Score (TRISS) and cause of death. RESULTS: A total of 2208 patients with an average age of 36 (±16) years were included. Blunt trauma was the majority with 90.5%, followed by penetrating injuries (9.2%). The overall mortality is 239 out of 2208 (10.8%). Seventy-eight patients (32.6%) died due to central nervous system injury, 69 due to sepsis (28.9%) and 58 due to exsanguination (24.3%). After multivariate analysis, age (OR 1.026 (1.009 to 1.044), p=0.002), SBP (OR 0.985 (0.975 to 0.995), p=0.003) and temperature (OR 0.203 (0.076 to 0.543), p=0.001) were found to be the significant physiological parameters. Intra-abdominal injury and NISS were significant anatomic mortality predictors from exsanguination (p<0.001). Patients with intra-abdominal injury had four times higher risk of mortality from exsanguination (OR 3.948 (2.331 to 6.686), p<0.001). DISCUSSION: In a Malaysian trauma center, age, SBP, core body temperature, intra-abdominal injury and NISS were significant predictors of early death from exsanguination. LEVEL OF EVIDENCE: II.