Transcutaneous electric nerve stimulation of acupuncture points improves tolerance in adults undergoing diagnostic upper gastrointestinal endoscopy: a single-center, double-blinded, randomized controlled trial.

BACKGROUND: Oesophagogastroduodenoscopy (OGDS) is the most common diagnostic procedure for upper gastrointestinal diseases. It often causes discomfort and anxiety, which are only mitigated by systemic sedation. However, sedation poses additional risks of adverse cardiopulmonary events, increased medical costs, and prolonged recovery. Transcutaneous electrical nerve stimulation of acupuncture points (Acu-TENS) is a non-invasive and innovative approach that induces analgesic effect during endoscopy. This trial is the first to be reported in English that explores the potential of Acu-TENS to increase patient tolerance during non-sedated elective diagnostic OGDS. METHODS: A double-blinded randomized controlled trial involving 348 subjects was conducted at a tertiary hospital to evaluate the success rate of OGDS with Acu-TENS. Subjects aged 18-75 years scheduled for their first elective diagnostic OGDS were randomized into the intervention (Acu-TENS) and placebo arms. OGDS success was assessed based on subjects' satisfaction ratings on a Likert scale and procedure's technical adequacy. Secondary measures included subjects' willingness to undergo future OGDS under similar conditions, procedure duration, and the endoscopist's perceived ease of the procedure. RESULTS: OGDS success rates were significantly higher with Acu-TENS (77.8%) than with the placebo (68.0%; odds ratio [OR] 1.64, 95% confidence interval [CI] 1.01-2.66, p = 0.043). Subjects who received Acu-TENS expressed higher willingness for future OGDS (78.9%) than those who received the placebo (68.6%; OR 1.71, 95% CI 1.04-2.79, p = 0.031). Procedure duration were significantly shorter in the intervention arm (6.0 min) than in the placebo arm (10.0 min; p = 0.002). No adverse effects were reported, and endoscopists perceived similar procedure ease in both arms. CONCLUSIONS: Acu-TENS improved OGDS success and enhanced patients' experiences during non-sedated OGDS. It demonstrated safety with no side effects and reduced the procedure completion time. It could be used as an adjunct in non-sedated diagnostic OGDS.

A comparative analysis of Charlson's weighted index of comorbidity and perforated peptic ulcer scores in predicting postoperative mortality and high comprehensive complication index.

BACKGROUND: Limited data exists on Charlson's weighted index of comorbidity (WIC) predictability for postoperative outcomes following perforated peptic ulcer (PPU) surgery. This study assesses the utility of WIC and other predictive scores in forecasting both postoperative mortality and morbidity in PPU. MATERIALS & METHODS: Patients with PPUs operated between 2018 and 2021 in a Malaysian tertiary referral center were included. Clinical data were retrospectively analyzed for association with mortality and morbidity measured with the Comprehensive Complication Index (CCI). Predictability of WIC and other predictors were examined using area under receiver-operator characteristic (ROC) curve (AUC). RESULTS: Among 110 patients included, 18 died (16.4%) and 36 (32.7%) had significant morbidity postoperatively (High CCI, ≥26.2). Both mortality and high CCI were associated with age >65 years, female sex, comorbidities (diabetes mellitus, hypertension, and renal disease), and American Society of Anesthesiologist score >2. Most patients who died had renal dysfunction, metabolic acidosis, lactate >2 mmol/L upon presentation preoperatively. While surgery >24 h after presentation correlated with mortality and high CCI, the benefit of earlier surgery <6 h or <12 h was not demonstrated. WIC (AUC, 0.89; 95% CI, 0.81-0.99) showed similar predictability to Peptic Ulcer Perforation (PULP) (AUC, 0.97; 95% CI, 0.93-1.00) for mortality. PULP effectively predicted high CCI (AUC, 0.83; 95% CI, 0.73-0.93; p < 0.001). CONCLUSION: WIC is valuable in predicting mortality, highlighting the importance of comorbidity in risk assessment. PULP score was effective in predicting both mortality and high CCI. Early identification of patients with high perioperative risk will facilitate patients' triage for escalated care, leading to a better outcome.

Emergency repair of blunt traumatic bronchus injury presenting with massive air leak.

Blunt traumatic tracheobronchial injury is rare, but can be potentially life-threatening. It accounts for only 0.5%-2% of all trauma cases. Patients may present with non-specific signs and symptoms, requiring a high index of suspicion with accurate diagnosis and prompt treatment. A 26-year-old female was brought into the emergency department after sustained a blunt trauma to the chest from a high impact motor vehicle accident. She presented with signs of respiratory distress and extensive subcutaneous emphysema from the chest up to the neck. Her airway was secured and chest drain was inserted for right sided pneumothorax. CT of the neck and thorax revealed a collapsed right middle lung lobe with a massive pneumothorax, raising the suspicion of a right middle lobe bronchus injury. Diagnosis was confirmed by bronchoscopy. In view of the difficulty in maintaining her ventilation and persistent pneumothorax with a massive air leak, immediate right thoracotomy via posterolateral approach was performed. The right middle lobar bronchus tear was repaired. There were no intra- or post-operative complications. She made an uneventful recovery. She was asymptomatic at her first month follow-up. A repeated chest X-ray showed expanded lungs. Details of the case including clinical presentation, imaging and management were discussed with an emphasis on the early uses of bronchoscopy in case of suspected blunt traumatic tracheobronchial injury. A review of the current literature of tracheobronchial injury management was presented.

The role of quantitative radiological measures of visceral adiposity in diverticulitis.

BACKGROUND: Diverticular disease has been linked to obesity. Recent studies have assessed the role of visceral adiposity with diverticulitis and its complications. The aim of this study was to evaluate the association of quantitative radiological measures of visceral adiposity in patients with diverticulitis with vital signs, biochemistry results, uncomplicated versus complicated diverticulitis and its interventions. METHODS: A retrospective analysis of all patients with diverticulitis admitted from November 2015 to April 2018 at a single institution was performed. Data collected included demographics, vital signs, biochemistry results, CT scan findings and management outcomes. The patients were divided into uncomplicated (U) and complicated diverticulitis (C) groups. Visceral fat area (VFA), subcutaneous fat area (SFA) and VFA/SFA ratio (V/S) were measured at L4/L5 level by the radiologist. Statistical analysis was performed to evaluate the association of VFA, SFA, V/S with the parameters in both U and C groups. RESULTS: 352 patients were included in this study (U:C = 265:87). There was no significant difference in vital signs and biochemistry results in both groups. There was no significant difference in VFA, SFA, V/S ratios in both groups. In patients with V/S ratio > 0.4, they were 5.06 times more likely to undergo emergency intervention (95% CI 1.10-23.45) (p = 0.03). On multivariate analysis, a heart rate > 100 (OR 2.9, 95% CI 1.2-6.7), CRP > 50 (OR 3.4, 95% CI 1.9-6.0), WCC < 4 or > 12 (OR 2.1, 95% CI 1.2-3.6) and V/S ratio > 0.4 (OR 2.8, 95% CI 1.5-5.4) were predictive of complicated diverticulitis. CONCLUSION: The quantitative radiological measurement of visceral adiposity is useful in prognostication in patients presenting with diverticulitis.

Clinical characteristics of 1653 injured motorcyclists and factors that predict mortality from motorcycle crashes in Malaysia.

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.

Novel calcium infusion regimen after parathyroidectomy for renal hyperparathyroidism.

AIM: Calcium infusion is used after parathyroid surgery for renal hyperparathyroidism to treat postoperative hypocalcaemia. We compared a new infusion regimen to one commonly used in Malaysia based on 2003 K/DOQI guidelines. METHODS: Retrospective data on serum calcium and infusion rates was collected from 2011-2015. The relationship between peak calcium efflux (PER) and time was determined using a scatterplot and linear regression. A comparison between regimens was made based on treatment efficacy (hypocalcaemia duration, total infusion amount and time) and calcium excursions (outside target range, peak and trough calcium) using bar charts and an unpaired t-test. RESULTS: Fifty-one and 34 patients on the original and new regimens respectively were included. Mean PER was lower (2.16 vs 2.56 mmol/h; P = 0.03) and occurred earlier (17.6 vs 23.2 h; P = 0.13) for the new regimen. Both scatterplot and regression showed a large correlation between PER and time (R-square 0.64, SE 1.53, P < 0.001). The new regimen had shorter period of hypocalcaemia (28.9 vs 66.4 h, P = 0.04), and required less calcium infusion (67.7 vs 127.2 mmol, P = 0.02) for a shorter duration (57.3 vs 102.9 h, P = 0.001). Calcium excursions, peak and trough calcium were not significantly different between regimens. Early postoperative high excursions occurred when the infusion was started in spite of elevated peri-operative calcium levels. CONCLUSION: The new infusion regimen was superior to the original in that it required a shorter treatment period and resulted in less hypocalcaemia. We found that early aggressive calcium replacement is unnecessary and raises the risk of rebound hypercalcemia.

A comparative study of anxiety and depression among healthcare workers and non-healthcare workers in Johor, Malaysia during the Covid-19 era.

The outbreak of Coronavirus disease 2019 (Covid-19) has a significant impact on the mental health of the global population. Updates are needed regarding the mental health status among the local population since limited studies were done so far. This research compared the prevalence of anxiety and depression symptoms among HCWs and non-HCWs. We also evaluated the factors associated with anxiety and depression symptoms among these 2 groups. This was a cross-sectional study conducted between September to December 2022. Online questionnaire was distributed to HCWs from 2 tertiary government hospitals. Non-HCWs from various occupational fields were recruited randomly. Generalised Anxiety Disorder 7 (GAD-7) and Patient Health Questionnaire 9 (PHQ-9) were used to screen for anxiety and depression symptoms respectively. Data were analyzed using IBM SPSS version 28.0. 200 questionnaires were distributed to HCWs and non-HCWs respectively. The response rate was 74.5% from HCWs and 82.5% from non-HCWs (P = .07). A total of 236 individuals (105 HCWs and 131 non-HCWs) were included in the study. Majority were female, married, highly educated and worked more than 8 hours per day. There was no significant difference for the prevalence of anxiety (37.2% vs 44.3%, P = .34) and depression symptoms (37.3% vs 35.1%, P = .75) between HCWs and non-HCWs. Among HCWs, poor workplace support (P = .009) and low income (P = .04) were associated with anxiety symptoms. Younger age (P = .02), single status (P = .01) and poor workplace support (P = .006) were associated with depression symptoms. More non-HCWs with a higher educational level were having anxiety and depression symptoms. Single status (P = .03), working away from home (P = .02), poor family support (P = .03) and quarantine as Covid-19 close contact (P = .04) were also associated with depression symptoms among non-HCWs. There is no significant difference between HCWs and non-HCWs experiencing possible anxiety or depressive symptoms in this study. However, attention should be paid to address associated factors identified among each group to promote good mental health.

Predictors for success of non-operative management of adhesive small bowel obstruction.

BACKGROUND: Majority of adhesive small bowel obstruction (SBO) cases can be managed non-operatively. However, a proportion of patients failed non-operative management. AIM: To evaluate the predictors of successful non-operative management in adhesive SBO. METHODS: A retrospective study was performed for all consecutive cases of adhesive SBO from November 2015 to May 2018. Data collated included basic demographics, clinical presentation, biochemistry and imaging results and management outcomes. The imaging studies were independently analyzed by a radiologist who was blinded to the clinical outcomes. The patients were divided into group A operative (including those that failed initial non-operative management) and group B non-operative for analysis. RESULTS: Of 252 patients were included in the final analysis; group A (n = 90) (35.7%) and group B (n = 162) (64.3%). There were no differences in the clinical features between both groups. Laboratory tests of inflammatory markers and lactate levels were similar in both groups. From the imaging findings, the presence of a definitive transition point [odds ratio (OR) = 2.67, 95% confidence interval (CI): 0.98-7.32, P = 0.048], presence of free fluid (OR = 2.11, 95%CI: 1.15-3.89, P = 0.015) and absence of small bowel faecal signs (OR = 1.70, 95%CI: 1.01-2.88, P = 0.047) were predictive of the need of surgical intervention. In patients that received water soluble contrast medium, the evidence of contrast in colon was 3.83 times predictive of successful non-operative management (95%CI: 1.79-8.21, P = 0.001). CONCLUSION: The computed tomography findings can assist clinicians in deciding early surgical intervention in adhesive SBO cases that are unlikely to be successful with non-operative management to prevent associated morbidity and mortality.

COVID-19 related acute limb ischaemia: A case series.

COVID-19 infection or vaccination is rarely associated with arterial occlusive disease of the extremities. The surgical department of a hospital in Johor, Malaysia, recorded a significant increase in the number of COVID-19-related acute limb ischaemia when the rates of COVID-19 were high both locally and internationally. The clinical presentation and management of acute limb ischaemia associated with COVID-19 infection or vaccination are largely underreported in Johor. Herein, we report a case series of 12 patients managed with strategies ranging from purely anticoagulation to catheter-directed thrombolysis and surgical embolectomy. This case series describes the clinical presentation, risk profiles, treatment approaches and limb outcomes of the patients. The amputation rate was high in view of unfavourable factors, including delayed presentation, high-risk factors and severe COVID-19. Three cases of potential COVID-19 vaccine-related acute limb ischaemia were included. COVID-19-related acute limb ischaemia can be minimised with heightened alert, preemptive optimisation with proper hydration and consideration for early prophylactic anticoagulation in high-risk cases.

Non-operative management of solid organ injuries in a middle-income country, how does it stack up?

INTRODUCTION: The first trauma surgery unit in Malaysia was established in 2011. After 10 years, we examine our experience in the management, and outcomes of blunt liver, spleen, and kidney injuries. METHODS: This is a cross-sectional study of patients with blunt liver, spleen, and kidney injuries in a level 1 trauma centre in Malaysia between January 2018 to June 2021. Patients' characteristics, new injury severity score, organ-specific AAST injury score, type of primary management (operative management [OM], non-operative management [NOM]), causes of failed NOM, management of failed NOM, and outcome of treatment were recorded and analysed. RESULTS: Among 448 patients, 83.9% were male and in the working-age range of 15-64 years old (93.5%). Road traffic crashes made up 92.0% of blunt trauma resulting in 65.5% of isolated organ injuries and 34.5% combined injuries. An overwhelming 84.2% of the patients had major trauma (NISS>15). Three hundred and thirty-four patients (74.6%) underwent initial non-operative management. Patients in the OM group showed lower mean GCS scores (p = 0.022) and higher NISS scores (p < 0.001). High-grade liver and kidney injuries were mostly treated with NOM (p < 0.001). In contradistinction, patients with high-grade spleen injuries had more OM performed (p < 0.001). NOM had been successful in 325 patients (97.3%) with 9 failures. Underlying causes for NOM failure were hemodynamic instability due to secondary bleeding and infectious complications. Overall mortality was 11.2%, which was significantly higher in the OM group (23.7%) than in the NOM group (6.9%). CONCLUSION: This study represents one of the largest single centre experiences on the blunt liver, spleen, and kidney injuries in Malaysia and South-East Asia. With good selection and adequate resources, non-operative management of blunt liver, spleen, and kidney injuries is a safe and effective therapeutic approach with a high success rate of 97.3%, avoiding the morbidity of unnecessary laparotomies.

Case series of gallstone ileus with one- or two-stage surgery.

Gallstone ileus is an uncommon cause of intestinal obstruction. It may present with typical symptoms of intestinal obstruction with or without biliary sepsis. Its management strategies vary depending on the patient and operative factors. Enterotomy and stone removal alone versus synchronous cholecystectomy and fistula disconnection at the same stage, often pose a debate among surgeons. The decision for operative strategies largely depends on the surgeon's experience, patient's physiology, and operative difficulties. As literature on gall stone ileus remains insufficient at a regional level, we report four cases of gallstone ileus managed with different approaches. Three patients were managed in a staged-manner, whereas one patient received a definitive procedure performed at index surgery. Clinical challenges and associated operative strategies are discussed. Findings of the current study were compared to those of the literature. The need for a definitive fistula disconnection and repair or cholecystectomy following stone removal in these patients was subsequently discussed.

Post-colonoscopy diverticulitis: A systematic review.

BACKGROUND: Post-colonoscopy diverticulitis is increasingly recognized as a potential complication. However, the evidence is sparse in the literature. AIM: To systematically review all available evidence to describe the incidence, clinical course with management and propose a definition. METHODS: The databases PubMed, EMBASE and Cochrane databases were searched using with the keywords up to June 2020. Additional manual search was performed and cross-checked for additional references. Data collected included demographics, reason for colonoscopy, time to diagnosis, method of diagnosis (clinical vs imaging) and management outcomes. RESULTS: A total of nine studies were included in the final systematic review with a total of 339 cases. The time to diagnosis post-colonoscopy ranged from 2 h to 30 d. Clinical presentation for these patients were non-specific including abdominal pain, nausea/vomiting, per rectal bleeding and chills/fever. Majority of the cases were diagnosed based on computed tomography scan. The management for these patients were similar to the usual patients presenting with diverticulitis where most resolve with non-operative intervention (i.e., antibiotics and bowel rest). CONCLUSION: The entity of post-colonoscopy diverticulitis remains contentious where there is a wide duration post-procedure included. Regardless of whether this is a true complication post-colonoscopy or a de novo event, early diagnosis is vital to guide appropriate treatment. Further prospective studies especially registries should include this as a complication to try to capture the true incidence.

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.

Outcomes of Early Simultaneous Removal of Ureteric Stent With Indwelling Urethral Catheter After Kidney Transplant in Pediatric Recipients: A 10-Year Review.

OBJECTIVES: A ureteric stent is routinely placed to minimize urological complications during kidney transplant. However, some complications may occur in association with the ureteric stent, such as urinary tract infections, and the optimal duration for stent placement is unclear. We reviewed the outcomes following early simultaneous removal of the ureteric stent with the urethral catheter in pediatric kidney transplant recipients. MATERIALS AND METHODS: We reviewed all kidney transplants from January 2009 to January 2019. The data we collated included demographics, donor and recipient characteristics, and perioperative details, including urological complications, stent-related complications, and kidney graft function. The financial cost of late stent removal was calculated. The early stent removal group was defined as 5 days, and the late removal group was about 4 to 6 weeks. The median follow-up time was 60 months (interquartile range, 31.5-91 months). RESULTS: There were 32 transplants in 31 patients during the study period (early vs late group = 23:9). No urine leak occurred in either group. One patient in the early group developed distal ureteric stenosis, and this condition was managed with interventional balloon dilatation. The median time for stent removal was 6 days in the early group and 39 days in the late group. There were 5 episodes of symptomatic urinary tract infections in 3 patients in the early group and 10 episodes of symptomatic urinary tract infections in 3 patients in the late group. The mean estimated glomerular filtration rate at 12 months was comparable between the 2 groups (84 ± 54 vs 64 ± 21 L/min/1.73 m²; P = .3). The average cost for each early removal was A$772.65 compared with the late group. CONCLUSIONS: Early simultaneous removal of the ureteric stent with the urethral catheter in pediatric kidney transplant recipients is feasible, safe, and cost-effective.

Smartphone-controlled patch electro-acupuncture versus conventional pain relief during colonoscopy: a randomized controlled trial.

BACKGROUND: Smartphone-controlled patch electro-acupuncture (SCEA) is a novel device which gives the same analgesic effect as with conventional acupuncture. There are no published articles in the English literature on the use of this device as a primary mode of pain relief during colonoscopy. Primary aims of this study were to investigate the efficacy of SCEA as a substitute for pain relief during colonoscopy. METHODS: Thirty-seven patients were randomized to receive SCEA (n = 19) or placebo (n = 18) during colonoscopy. Additional rescue sedation was administered to patients if they had pain or discomfort during the procedure. Visual analogue scale was used to quantify the intensity of pain from the beginning to end of the procedure. Other variables analysed were the amount of sedation used, duration from start to caecal intubation, length of time for completion of colonoscopy and recovery time to home discharge. RESULTS: Patients who received SCEA had a lower median pain score of 4.6 (interquartile range 5.7) compared to the placebo group of 6.0 (interquartile range 3.2). Statistical analysis comparing the groups revealed a non-significant P-value of 0.12, although more than 90% of the patients indicated willingness for SCEA as the primary analgesia if they were to repeat the procedure. Throughout the study, there were no adverse complications that occurred during the use of SCEA. CONCLUSIONS: Even though this study did not demonstrate, a significance in pain reduction, SCEA remains a safe modality which, more than 90% of patients favoured as a substitute for pain relief during colonoscopy.

Pinch-off syndrome from a chemoport catheter successfully managed with endovascular retrieval.

INTRODUCTION AND IMPORTANCE: A totally implantable venous access device (TIVAD), also referred to as 'chemoport', is frequently used for oncology patients. Chemoport insertion via the subclavian vein access may compress the catheter between the first rib and the clavicle, resulting in pinch-off syndrome (POS). The sequela includes catheter transection and subsequent embolization. It is a rare complication with incidence reported to be 1.1-5.0% and can lead to a devastating outcomes. CASE PRESENTATION: 50-year-old male had his chemoport inserted for adjuvant chemotherapy 3 years ago. During the removal, remaining half of the distal catheter was not found. There was no difficulties during the removal. Chest xray revealed that the fractured catheter had embolized to the right ventricle. Further history taking, he did experienced occasional palpitation and chest discomfort for the past six months. Electrocardiogram and cardiac enzymes were normal. Urgent removal of the fractured catheter via the percutaneous endovascular approach, under fluoroscopic guidance by an experience interventional radiologist was done. The procedure was successful without any complication. Patient made an uneventful recovery. He was discharged the following day, and was well during his 3rd month follow up. CONCLUSION: Early detection and preventive measures can be done to prevent pinch-off syndrome. Unrecognized POS can result in fatal complications such as cardiac arrhythmia and septic embolization. Retrieval via the percutaneous endovascular approach provide excellent outcome in the case of embolized fractured catheter.

First Feasibility Study and Short-term Outcomes of Laparoscopic-Assisted Anterior Resection in Colorectal Cancer in Malaysia.

PURPOSE: The purpose of this study was to demonstrate the feasibility and safety of laparoscopic-assisted anterior resection (LAAR) for colorectal cancer in a local Asian population. METHODS: This is a retrospective review of all patients with colorectal cancer operated from November 2017 to October 2018. Main variables of interest were demography, type and surgery, length of stay (LOS), and the involvement of proximal and distal doughnut. Postoperative complications were analysed using chi-square or Fisher exact and Mann-Whitney tests. RESULTS: There were 23 patients with a mean age of 62.5 ± 12.2 years. The mean time from diagnosis to surgery was 97.1 ± 154.84 days. There were 12 patients in the LAAR group and 11 in the open anterior resection (OAR) group. Duration of surgery was shorter in OAR (129.58 ± 51.38 minutes) compared to LAAR (147.91 ± 39.37 minutes). Mean LOS was shorter in the LAAR group with 5±1.5 days compared to the OAR group of 7.42 ± 4.25 days. However, there was no significant P-value for both duration of surgery (P = 0.322) or LOS (P = 0.87). A total of 3 complications were recorded after OAR and 2 after LAAR. Both groups had clear proximal and distal margins with 16 (12-18.5) harvested lymph nodes in LAAR and 18 (16-22) in OAR, which were equal (P = 0.155). CONCLUSION: This study reports a shorter LOS in the minimally invasive group of 2 days with similar oncologic resection outcomes. This shows that LAAR is feasible in Malaysia and has potential outcome benefits.

Opportunistic use of radiological measures of visceral adiposity for assessment of risk of colorectal adenoma.

BACKGROUND: Recent evidence suggested that radiological measures of visceral adiposity are a better tool for risk assessment of colorectal adenomas. The aim of this study was to investigate the association of visceral adiposity with the development of colorectal adenomas. METHODS: A retrospective review of all cases of computed tomography-confirmed acute diverticulitis from November 2015 to April 2018 was performed. Data collated included basic demographics, computed tomography scan results (uncomplicated versus complicated diverticulitis), treatment modality (conservative versus intervention), outcomes and follow-up colonoscopy results within 12 months of presentation. The patients were divided into no adenoma (A) and adenoma (B) groups. Visceral fat area (VFA), subcutaneous fat area (SFA) and VFA/SFA ratio (V/S) were measured at L4/L5 level. Statistical analysis was performed to evaluation the association of VFA, SFA, V/S and different thresholds with the risk of adenoma formation. RESULTS: A total of 169 patients were included in this study (A:B = 123:46). The mean ± standard deviation for VFA was higher in group B (201 ± 87 cm2 versus 176 ± 79 cm2 ) with a trend towards statistical significance (P = 0.08). There was no difference in SFA and V/S in both groups. When the VFA >200 cm2 was analysed, it was associated with a threefold risk of adenoma formation (odds ratio 2.7, 95% confidence interval 1.35-5.50, P = 0.006). Subgroup analysis of gender with VFA, SFA and V/S found that males have a significantly higher VFA in group B (220.0 ± 95.2 cm2 versus 187.3 ± 69.2 cm2 ; P = 0.05). CONCLUSIONS: The radiological measurement of visceral adiposity is a useful tool for opportunistic assessment of risk of colorectal adenoma.

Survival analysis and mortality predictors of hospitalized severe burn victims in a Malaysian burns intensive care unit.

BACKGROUND: Prognostic measures to determine burn mortality are essential in evaluating the severity of individual burn victims. This is an important process of triaging patients with high risk of mortality that may be nursed in the acute care setting. Malaysian burn research is lacking with only one publication identified which describes the epidemiology of burn victims. Therefore, the objective of this study was to go one step further and identify the predictors of burn mortality from a Malaysian burns intensive care unit (BICU) which may be used to triage patients at higher risk of death. METHODS: This is a retrospective cohort study of all admissions to Hospital Sultan Ismail's BICU from January 2010 till October 2015. Admission criteria were in accordance with the American Burn Association guidelines, and risk factors of interest were recorded. Data was analyzed using simple logistic regression to determine significant predictors of mortality. Survival analysis with time to death event was performed using the Kaplan-Meier survival curve with log-rank test. RESULTS: Through the 6-year period, 393 patients were admitted with a male preponderance of 73.8%. The mean age and length of stay were 35.6 (±15.72) years and 15.3 (±18.91) days. There were 48 mortalities with an overall mortality rate of 12.2%. Significant risk factors identified on simple logistic regression were total body surface area (TBSA) > 20% (p < 0.001), inhalation injury (p < 0.001) and presence of early systemic inflammatory response syndrome (SIRS) (p < 0.001). Survival analysis using Kaplan-Meier survival curve showed similar results with TBSA > 20%, presence of SIRS, mechanical ventilation and inhalation injury which were associated with poorer survival (p < 0.001). CONCLUSION: The predictors of mortality identified in a Malaysian BICU were TBSA > 20%, early SIRS, mechanical ventilation and inhalation injury which were associated with poorer survival outcome. The immunological response differs from individual patients and influenced by the severity of burn injury. Early SIRS on admission is an important predictor of death and may represent the severity of burn injury. Patients who required mechanical ventilation were associated with mortality and it is likely related to the severity of pulmonary insults sustained by individual patients. This data is important for outcome prognostication and mortality risk counselling in severely burned patients.

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.