Firdaus Hayati

Gangrenous giant Meckel's diverticulitis masquerading acute appendicitis: a surgical conundrum: Images for Surgeons

A 24-year-old man presented to the casualty with typical presentation of acute appenditis. On examination, there were generalized tenderness in the abdomen with guarding and rebound tenderness at right iliac fossa. The total white blood count was 17.2 × 10 μL with normal electrolytes levels. At that juncture, his surgical diagnosis was acute appendicitis and the decision for open appendicectomy was decided. Upon entry through a Lanz incision, there was a large gangrenous diverticulum measuring 20 × 5 cm identified (Figs 1,2). A wedge resection was done and primary closure was made. The normal appendix was resected to avoid confusion in the future. The abdomen was closed in layers. Postoperatively, the patient was recovered uneventfully and discharged home after 2 days. Histopathological examination was consistent with Meckel’s diverticulitis without presence of gastric heterotopia. Meckel’s diverticulum (MD) is a true diverticulum, develops after persistent vitellointestinal duct during embryonic life. It is well-known after the traditional ‘rule of 2s’. Commonly found in 2% of the population, it often presents before the age of 2, twice as likely to be symptomatic in boys compared to girls. The incidence is increasing up-to-date due to enhanced imaging modalities and widely used minimally invasive surgery. It is situated approximately 2 ft from the ileocaecal valve measuring 2 cm wide with 2 in. long. This rule however is frequently imprecise since certain literatures have described cases of giant MD. A diverticulum measuring more than 5 cm is considered as giant MD. Majority of MD usually are 1 to 10 cm in size with average of 3 cm. In our patient, we have discovered a gangrenous Meckel’s diverticulitis measuring 20 cm at longest axis during surgery (Fig. 2). As far as we concern, this case is among the longest and biggest ever reported case of MD in the literatures. The diagnosis of MD is always dubious as mostly asymptomatic. However, it is often discovered after investigation of obscure gastrointestinal bleeding, accidental findings of acute abdomen and during release of intestinal obstruction that puzzle the initial clinic presentations. According to Yamaguchi et al., in a series of 600 candidates looking at the aetiology of MD, 37% were due to obstruction, 10%–14% were after diverticulitis, perforation and bleeding while remaining were due to fistula and neoplasm. Among those who present with intestinal obstruction, they are mostly caused by intussusception. Usually, traditional intussusception happens after telescoping of thickened Peyer’s patches of the ileum. In contrast to intussusception secondary to MD, the diverticulum itself acts as an intussusceptum. Typical presentations include a colicky abdominal pain and vomiting, which then followed by a production of red currant jelly stool in severe form. This event happens in childhood most of the time but less in adulthood. Apart from intussusception, presence of mesodiverticular band can cause internal herniation which lead to intestinal obstruction. Patients may present with acute abdomen which include a migratory abdominal pain associated with low grade fever, nausea and anorexia. The pain is characterized by a periumbilical pain that shifts to the right iliac fossa. Since its nature as a diverticulum, it has a predilection to be inspissated by faeces and become inflamed which mimics acute appendicitis. It also has tendency for

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.

Cystic Biliary Atresia: A Delayed Diagnosis of Obstructive Jaundice

Cystic biliary atresia is an uncommon variant of biliary atresia. It is the most usual cause of neonatal jaundice which requires surgical intervention and liver transplantation in children. Herein, we present a case of a 2-month-old baby with persistent obstructive jaundice, who was not properly investigated prior to this. After the diagnosis has been established, we proceeded with the Kasai-type portoenterostomy. Even slightly delayed, the patient recovered well postoperatively and subsequently jaundice resolved.

Role of co-expression of estrogen receptor beta and Ki67 in prostate adenocarcinoma

Purpose To evaluate the expression of estrogen receptor (ER)-beta and Ki67 in prostate cancer and study their relationship. Materials and Methods We analyzed 101 cases of prostate adenocarcinoma diagnosed from January 2011 to June 2015 in 100 patients. Immunohistochemical staining of ER-beta and Ki67 was analyzed according to Gleason score categorized into prognostic groups of 1 to 5. Double-immunofluorescent staining of ER-beta and Ki67 was performed in a total of 20 cases to study the co-expression and the relationship between these markers within the same tumor. Results A total of 53 of 101 cases (52.5%) were positive for ER-beta expression. There was a positive correlation whereby a high percentage of ER-beta expression was seen in the higher prognostic groups (groups 4 and 5; p=0.007). High Ki67 expression was observed in the higher prognostic group, whereas low Ki67 or negative expression was found in the lower prognostic group (p<0.001). The majority of cases evaluated with double-immunofluorescent staining (14/20) showed co-expression of ER-beta and Ki67 at the individual cell level. Conclusions ER-beta and Ki67 are independent tumor markers in high prognostic groups. Hence, co-expression of ER-beta and Ki67 indicates a more aggressive tumor with a poorer prognosis.

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.

Various presentations of breast tuberculosis and tuberculous lymphadenopathy: A case series of surgical rarity

received: 08.12.2016 Accepted: 17.01.2017 1Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia 2Department of Pathobiology and Medical Diagnostic, Faculty of Medicine and Health Sciences, Universiti Malaysia, Sabah, Kota Kinabalu, Sabah, Malaysia 3Breast and Endocrine Unit, Department of Surgery, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia Yazışma adresi: Firdaus Hayati, Department of Surgery, Faculty of Medicine and Health Science, Universiti Malaysia Sabah, Sabah, Malaysia e-mail: firdaushayati@gmail.com INtrODuCtION

Embolization in Haemorrhage-associated Transurethral Resection of Prostate: An Advancement of Endovascular Technique

Received: 19.02.2017 Accepted: 19.03.2017 1Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Sabah, Malaysia 2Department of General Surgery, Surgical Sciences Cluster, Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia 3Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Sabah, Malaysia 4Interventional Radiology Unit, Department of Radiology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia 5Urology Unit, Department of Surgery, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia Yazışma adresi: Firdaus Hayati, Department of Surgery, Faculty of Medicine and Health Science, Universiti Malaysia Sabah, Sabah, Malaysia e-mail: firdaushayati@gmail.com INTROdUCTION

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).