Andee Dzulkarnaen Zakaria

Serum Procalcitonin Predicts Anastomotic Leaks in Colorectal Surgery

Background: Anastomotic leaks in colorectal surgery results in a high morbidity and mortality rate. Serum procalcitonin levels is known as a sensitive and specific marker of sepsis and could be use as a marker for early detection of a leak allowing early intervention. It may help a clinician decide to perform a CT scan even earlier especially when the diagnosis of a leak is uncertain. The aim of this study is to determine whether serum procalcitonin is a good predictor of anastomotic leak in colorectal surgery. Methodology: Between July 2014 until October 2015, 70 patients undergoing colorectal surgery were prospectively analyzed in a single-center tertiary teaching hospital. Demographic and surgical data were obtained. Serum procalcitonin was taken before surgery and at day 3 (72 hours) postoperatively. During the postoperative period, the patients were observed in the ward for features of anastomotic leak and if present, it was managed accordingly. The primary outcome was to prospectively determine an association between serum procalcitonin levels and an anastomotic leak in patients who underwent colorectal surgery with a primary anastomosis. Result: The rate of anastomotic leak was 4.5% (3 patients) with a mortality rate of 4.3% (3 patients). A rise in serum procalcitonin was statistically significant among patients with anastomotic leak. The optimal procalcitonin cut-off level at postoperative day 3 was 5.27 ng/mL, resulting in 100% sensitivity, 85% specificity, 23% positive predictive value and 100% negative predictive value. Nevertheless, none of the variables showed statistical significance with an anastomotic leak. Conclusion: Procalcitonin is a reliable biochemical marker to help diagnose anastomotic leak in colorectal surgery. Our study has shown that a level of 5 times beyond normal is statistically significant and a value of more than 5.27 ng/mL is confirmatory of a leak.

Metastasis of Sigmoid Colon Cancer to the Breast and Uterus: A Case-Study

Introduction: Colon cancer is the second most common cancer after breast and the most common cancer among males in Peninsular Malaysia. Metastasis of colon cancer to the uterus and breast rarely occur, but still the incidence could not be ignored as it could possibly happen to anyone with the disease. Clinical Presentation and Intervention: A 32-years old Malay woman complaining of pain in the right hypochondria region radiating to the back and right shoulder. The pain was constant, with moderate intensity and relieved temporarily by analgesics (Paracetamol). She also noticed a lump in her left breast following Breast Self Examination (BSE). Patient was admitted to Hospital Universitiy Sains Malaysia (HUSM) with no signs of shortness of breath, chest pain or hemoptysis. The patient had history of sigmoid colon cancer (Duke’s B) and had undergone sigmoid colectomy two years ago and completed 25 cycles of local radiotherapy and concurrent 12 cycles of systemic chemotherapy. The ultrasound of pelvic region revealed metastasis to pelvic organ. Conclusion: Surgery is the most common treatment for colorectal cancer and may be curative for localized cancers. Radiotherapy and chemotherapy be used as an adjunct treatment after surgery to increase disease free survival and overall survival but recurrence may still occur.

Giant Preputial Calculus: The First Reported Case in Malaysia

Preputial calculus is a relative surgical rarity. It usually happens in elderly men with poor hygiene and uncircumcised penis complicated with phimosis. In the paediatric group, it is usually secondary to phimosis and other urologic and/or neurologic anomalies. Surgical treatment is the mainstay of treatment. Herein, we report a 27-year-old gentleman with preputial stone presented with obstructive uropathy and was successfully treated with surgical intervention. To the best of our knowledge, this is the first reported case of the largest preputial stone in Malaysia.

Prospective diagnostic study on the use of narrow-band imaging on suspicious lesions during colonoscopy examination: Narrow band imaging

Colonoscopy is the gold standard to detect colorectal neoplasm. Narrow‐band imaging (NBI) has a good diagnostic accuracy to differentiate between neoplastic and non‐neoplastic colorectal lesions. This study explores the diagnostic validity of NBI colonoscopy as well as its associated factors related to neoplastic and non‐neoplastic colorectal lesions.

Rare case of primary leiomyosarcoma of sigmoid mesocolon

We experienced a rare case of primary leiomyosarcoma of sigmoid mesentery. A 45-year-old woman was presented to us with left iliac fossa mass and discomfort for 4-month duration. CT scan of abdomen and pelvis revealed a huge mass 14 cm×14 cm×16 cm occupying left iliac fossa mimicked having a large left ovarian carcinoma. She was subsequently planned for elective total abdominal hysterectomy and bilateral salpingo-oophorectomy by gynaecology team. During laparotomy, a huge mass was revealed arising from sigmoid mesentery invaded to the left lower ureter. Curative resection was done and pathological findings show the tumour being leiomyosarcoma with immunohistochemistry tests on caldesmon, desmin, smooth muscle actin and CD34 reagent all positive. Clinicopathological and literature review of this rare primary leiomyosarcoma of mesocolon was discussed in our case presentation

Rare and unusual case of polyarteritis nodosa involving the gastrointestinal tract leading to bowel gangrene.

Polyarteritis nodosa (PAN) is a systemic necrotising vasculitis preferentially targeting medium-sized arteries and not related with glomerulonephritis or small vessel involvement. Clinical manifestations of PAN are multisystem. The gastrointestinal, renal, cardiac, musculoskeletal, skin and central nervous systems may be involved. The aetiology remains unknown, and the ensuing vasculitis may lead to aneurysm formation and thrombosis in any organs of the body with resultant ischaemia. PAN of the intestines is a relatively common manifestation of this disease but rarely causes bowel ischaemia resulting in necrosis. Here we report a case of a young Chinese patient who presented with an acute abdomen requiring surgery and made good recovery post operatively. He remains free of symptoms while on steroid therapy.

Giant Mediastinal Germ Cell Tumour: An Enigma of Surgical Consideration

We present a case of 16-year-old male, who was referred from private centre for dyspnoea, fatigue, and orthopnea. The chest radiograph revealed complete opacification of left chest which was confirmed by computed tomography as a large left mediastinal mass measuring 14 × 15 × 18 cm. The diagnostic needle core biopsy revealed mixed germ cell tumour with possible combination of embryonal carcinoma, yolk sac, and teratoma. After 4 cycles of neoadjuvant BEP regime, there was initial response of tumour markers but not tumour bulk. Instead of classic median sternotomy or clamshell incision, posterolateral approach with piecemeal manner was chosen. Histology confirmed mixed germ cell tumour with residual teratomatous component without yolk sac or embryonal carcinoma component. Weighing 3.5 kg, it is one of the largest mediastinal germ cell tumours ever reported. We describe this rare and gigantic intrathoracic tumour and discuss the spectrum of surgical approach and treatment of this exceptional tumour.

Wandering spleen: a unique cause of acute abdomen

We present the case of a 16-year-old boy presented with 2-week episode of wor-sening lower abdominal pain. Clinically, there was a tender palpable mass on the suprapubic region. Ultrasonography showed an absent spleen at its usual area, instead suprapubic mass suggestive of ectopic spleen was identified. An emer-gency laparotomy revealed a congested spleen in the pelvic cavity. Splenectomy was undertaken as it was non-viable. The patient was discharged uneventfully with triple vaccinations. We describe this unique entity with its literature review. (Folia Morphol 2018; 77, 2: 400-402).

Analysis of Hereditary Nonpolyposis Colorectal Cancer in Malay Cohorts using Immunohistochemical Screening.

BACKGROUND Lynch syndrome (LS) is an inherited predisposition to colorectal, endometrial (uterine) and other cancers. Although most cancers are not inherited, about 5 percent (%) of people who have colorectal or endometrial cancer have the Lynch syndrome. It involves the alteration of mismatch repair (MMR) genes; MLH1, MSH2, MSH6 or PMS2. In this study, we analyzed the expression of MMR proteins in colorectal cancer in a Malay cohort by immunohistochemistry. MATERIALS AND METHODS A total of 17 patients were selected fulfilling one of the Bethesda criteria: colorectal cancer diagnosed in a patient aged less than 50 years old, having synchronous and metachronous colorectal cancer or with a strong family history. Immunohistochemical staining was performed on paraffin embedded tumour tissue samples using four antibodies: MLH1, MSH2, MSH6 and PMS2. RESULTS Twelve out of 17 patients (70.6%) were noted to have a family history. A total of 41% (n=7) of the patients had abnormal immunohistochemical staining with one or more of the four antibodies. Loss of expression were noted in 13 tumour tissues with a negative staining score <4. Of 13 tumour tissues, four showed loss expression of MLH1. For PMS2, loss of expression were noted in five cases. Both MSH2 and MSH6 showed loss of expression in two tumour tissues respectively. CONCLUSIONS Revised Bethesda criteria and immunohistochemical analysis constituted a convenient approach and is recommended to be a first-line screening for Lynch syndrome in Malay cohorts.

WIDE LOCAL EXCISION OF BREAST LUMP AND EXCISION OF GLUTEAL LIPOMA

Wide local excision (WLE) is an operation to remove a lu mp in patients breast cancer ous tissues with a small amount of surrounding normal tissue s and is done under general anaesthetic. Excision biopsy (EB) is an operation done to remove entire area of suspicious tissue/lipom a from an area of concern in the body under a local anaesthetic . A 38 year old Malay female was admitted to Hospital Universiti Sains Malaysia (HUSM) due to breast lump operation. This patient is in moderate risk of bacterial infection patient due to mitra l valve prolapsed, nulliparious and have family history of cardiac diseases. Previous s tudies showed that physician should employ a patient - specific strategy for preoperative aspirin management due to aspirin withdrawal syndrome may significantly increase the risk of major thrombo embolic complication while bleeding complication is minimum . This patient was given SBE prophylaxis before surgery to avoid complications. WLE and EB are the better choices for treatment of lump in the body . Surgery may be either proceeded with or followed by radiotherapy or chemotherapy when ne eded if cancer tissue detected. Several drug treatments such as antibiotics prophylaxis need to be taken into consideration to prevent these complications.