Congratulations Dr. Mohammed M.H Hajhamad!!!

Congratulations to our dear colleague, Dr. Mohammed M.H Hajhamad for winning the 1st Prize of Best Poster Award at the recent Coloproctology 2015: International Scientific Meeting held at the Holiday Inn Melaka, Malaysia from 12-15 March 2015. 

His research topic that wins the accolade for the day was Fecal M2-PK Vs. Colonoscopy As First Line Screening Tool For Colorectal Cancer: Is It Time To Change? Asian Tertiary Center Perspective.

Printed Version - Click Image for better resolution

Excerpt from the official website:

The Best Poster Award is for the best original scientific or clinical paper submitted by young surgeons in Malaysia for presentation at the Coloproctology 2015. This award will hopefully encourage a high standard of research and scientific presentations among young surgeons. The Prize There will be three (3) Best Poster Awards: 

• 1st Prize – RM1,000 
• 2nd Prize – RM750 
• 3rd Prize – RM500 

Regulations 

1. The competition is open to all young surgeons and surgical trainees currently working in Malaysian institutions who are below 35 years old as on 1st January 2015.
2. The work submitted may be from any surgical specialty, and it may take the form of clinical trials, surveys, retrospective studies, laboratory experiments or any other form of unpublished original work.
3. The bulk of the work which are submitted must be performed by the author himself/herself even though he may have done the work in conjunction with other doctors or agencies either locally or overseas. However, the work must be carried out in Malaysia.
4. The author must submit a signed declaration of his/her age, that his/her paper has not been published or presented elsewhere and the presenter has done most of the work.
5. The abstracts for poster presentation are to be submitted online at www.colorectalmy.org.
6. The closing date for receipt of abstracts is 15th February 2015.

A proud moment for Dr Mohammed. Congratulations again from all of us. May this become a catalyst for others to follow suit and for you to become a successful surgeon in the future. 

Subspecility Session 16 Feb 2015

Claudication in Young Population: A Topic Review 
by Dr Hizami Amin Tai

Dr Hizami Amin Tai

Today, our academic session was headed by Dr Hizami Amin Tai from Vascular Subspecialty. Our consultant and specialists for the session were:

1. Mr Azim Idris (Consultant Vascular Surgeon)
2. Mr Razrim Rahim
3. Mr Mustaffa
4. Mr Auzama 

Attendance: 64% (Master's Students in General Surgery rotation)

Slides: click here for the Microsoft Power Point slide download

Claudication in young patients from cosmosukm

Hizami started his presentation with 2 case summaries to help and direct the audience with the spectrum of subject of discussion today, which is claudication in young patients. The cases are stated on page 2 & 3 of the slide. 

What is the similarities in both cases?
Answer was stated in the slide presentation (page 4).

What are the differential diagnoses of a young patient who presented to you with complaint of leg pain suggestive of claudication? (Mr Azim)
Trauma (muscular injury, bone fracture), prolapsed intervertebral disc, venous claudication.
Mr Azim further clarified a term "pseudoclaudication" which is defined as painful cramps that are not caused by peripheral artery disease but rather by spinal, neurologic, or orthopedic disorders, such as spinal stenosis, diabetic neuropathy. 

Proper history taking will reveal one-third of patients who may have atypical claudication. Followed by complete physical examination (including distal pulses examination, neurological assessment).

What additional assessment (bedside) would you do?
Ankle-Brachial Systolic Index, Post-exercise ABSI.

In young patients, determination of risk factors for atherosclerotic disease must be ascertained, as risk factors modification are paramount in altering the disease progression. Hizami put up a table (from TASC II guidelines) for the risk factors associated with atherosclerotic disease which need to be modified if an atherosclerotic disease is diagnosed.

What diagnostic tests would you performed in these young patients who presented with claudication?
Duplex Ultrasound, CT Angiogram, MR Angiogram, Echocardiogram.
Rule out vasculitis/connective tissue disease (Non atherosclerotic disease of vessels).

How frequent do our Vascular Subspecialty unit perform Duplex Ultrasound for assessment of arterial disease? (Mr Razrim)
Answer was provided by Mr Azim: In view of the Duplex ultrasound assessment is an operator dependant procedure, UNLESS it is performed by a well versed radiologist whom frequently performing the procedure or by an experienced vascular surgeon, then the result of the assessment is of ascertain value. Plus, the procedure is time consuming as the assessment would include a long segment of vessels (aorta, iliac, femoral, distal vessels), and technically challenging for distal vessels (especially infragenicular vessels). Certain patients will have the difficulties for the operator to insonate the vessels due to surrounding oedema, presence of ulcers, heavy calcification of the vessels and obsesity. 

However, in EXAM, it is not wrong to mention the test as first line as it was a non-invasive, non-contrasted  with its value in preparation of surgery (choosing suitable angioplasty balloon). 

What would you look for in a Duplex Ultrasound assessment of arterial disease?
Answers were not given. 
However, in the paper as per link here, these following features are use to diagnose occlusion in an artery on duplex US (DUS): segmental loss of signal in the insonated vessels, dampened distal signal compared to proximal signal, proximal exit collaterals  and distal exit collaterals. 

How would you treat patient with peripheral arterial disease?
According to Trans-Atlantic Inter Soceity Consensus on Management of Peripheral Arterial Disease (TASC II) guidelines: 

With reference to the case presented, young patients with claudications,  would you implement similar strategy as TASC II recommendation? (Mr Azim)
If the cause of the disease is atherosclerosis of peripheral vessels, the TASC II recommendation would be the most suitable strategy for management of the patients. In cases of young patients with atherosclerotic vessels, it is advisable to implement a more aggressive approach i.e early revascularisation as PAD is a life limiting disease. 

If the cause is non atherosclerotic, then the best management plan would be to identify the cause with aim for treatment of the primary cause (i.e vasculitis) and to achieve early revascularisation (if required). 

The session continued with Hizami's presentation on several diseases that could possibly be the cause in a young patients with claudications: Buerger's disease, Popliteal artery entrapment syndrome and Cystic adventitial disease. 

Thank you very much to Dr Hizami Amin Tai follwoing a wonderful discussions and knowledge sharing  of Vascular Surgery subspecialty. May this effort brings the good knowledge to all of us.

Below are several key papers shared by Dr Hizami for our references to read on vascular surgery. You may download here (click the link for the list of papers to download).

Quotes of the day

RECAP (Registrar Case Presentation )

Tumor and GI Bleeding: A Case Review by Dr Rajaie. 

Today the case of gastrointestinal bleeding presented by our colleague from outcampus UKM Master's candidate, Dr Rajaie, who is currently doing his Vascular rotation in PPUKM. 

Our specialists and consultants for the sessions were: 

1. Prof Norlia
2. AP Datuk Dr Ismail Sagap
3. Ms Saladina
4. Mr Razrim
5. Mr Mustaffa
6. Mr Khairul
7. Mr Ikhwan (HPB Fellow) 
8. Mr Auzama (Colorectal Fellow).

Attendance: 75% (Master's Students in General Surgery rotation)

Slides: click here for the Microsoft Power Point Slide download



Rajaie started his presentation with chief complaint of his case (melaena) and threw couple of questions to medical students.

What relevant further history would you ask to the patient? 
Hematemesis, anaemia symptoms, constitutional symptoms, previous similar presentation

What other relevant medication/drugs history would be relevant to the case?
Patient was on steroid (risk factor for upper GI bleeding).

Presentation was continued with physical examination findings of a centrally lobulated mobile mass palpable in the abdomen with no palpable hepatomegaly or splenomegaly. OGDS revealed a normal findings and followed by colonoscopy  which showed an intraluminal altered blood with no stigmata of recent hemorrhage over the bowel mucosa. 

The case was presented up until the management of the patient, with Q&A sessions headed by AP Datuk Dr Ismail Sagap started.

What would you do in this case, if patient in presented with shock (grade 2), persistent tachycardia despite adequate fluid resuscitation, symptomatic of anemia with Hb level 7.9 g/dL, is having fresh melaena, with a palpable mobile abdominal mass? (AP Datuk Dr Ismail Sagap)

In cases like the presenting lady, it is most likely a bleeding small bowel tumor, with probaility of a bleeding small bowel GIST as high as 70-80%.It is likely to be a resectable tumor as evidence by the mobility of the tumor on clinical examination. A laparotomy would be a choice of management plan to control the bleeding and to remove the tumor. 

What is the role of CT scan in this case (acute gastrointestinal bleed)? (AP Datuk Dr Ismail Sagap)

CT scan abdomen with angiogram will onlt delay the definitive treatment in this case. A selective mesenteric angiogram may play a role. However in this case, as evidence by patient in shock may necessitate the surgery rather than delaying the surgery with a CT scan. 

Case was further discussed and diagnosis of BLEEDING TUMOR was made. Patient went on to proceed with laparotomy. AP Datuk Dr Ismail Sagap commented on the diagnosis made need to be precise and specific, i.e: not bleeding tumor, it should had been Bleeding Small Intestinal Tumor.

Why laparotomy? (AP Datuk Dr Ismail Sagap)
At that time of managing the patient, the valid argument was, a CT scan will only delay a definitive management. However, UNLESS the decision for a CT scan is going to impact the decision of surgery significantly in the outcome (i.e. no need of surgery), then the decision for laparotomy is the best choice. 

How do you counsel patient for surgery? (Mr Mustaffa)

We need to explained the need and reason for the surgery to be done. Patient will need to be informed of the risk of stoma, possible anastomosis leak (if our diagnosis is correct). 

If there is possibility of our diagnosis to be wrong, we are to consult patient of possibility on the referral to the appropriate team and still proceed with necessary procedure.

How do you describe this lesion (image as in presentation)? (AP Datuk Dr Ismail Sagap)

This image is the intra-operative finding of what appears to be like small bowel stuck to a lobulated tumor with capsular breach. 

What is the possible diagnosis (from the photo)?

GIST. Why? It is an extra-luminal tumor.

What is your differential diagnosis?
Lymphoma (mesenteric), secondary (i.e mesenteric secondary tumor, from colon - usually inside mesentery, and size is smaller)

If i am to take a photo, what else would I include?  (AP Datuk Dr Ismail Sagap)

Lift up the tumor before taking the photo, this will tell us about intra or extraperitoneal tumor.

Is it dangerous if we rupture the tumor?  (AP Datuk Dr Ismail Sagap)

Will it cause recurrence? Yes, it can cause seedlings. 

Surgery, how to resect the tumor?  (AP Datuk Dr Ismail Sagap)
Principle for resection of small bowel tumor is to do en bloc resection, with margin of 5cm to achieve oncologic resection.

If this is GIST , (referring to the image) is it a malignant lesion? (AP Datuk Dr Ismail Sagap)

Yes

What would you like to see in the HPE? (Dr Rajaie)

Answer is in the slide.
HPE report as per below (in summary)

Malignant spindle cells in storiform pattern.

Spindle cell: nerve/smooth muscle origin.

Immunohistochemical staining is Positive for:
CD117
Vimentin
CD34
DOG-1

Negative for 
SMA

Desmin
S100

Mitotic count: 7/50 hpf.

What does all these mean? (AP Datuk Dr Ismail Sagap)

GIST tumor. 

Which information in the HPE will inform you that this is a malignancy? (AP Datuk Dr Ismail Sagap)
Mitotoc count of >5/hpf.

Size of tumor >5cm

Nucleus criteria. 

The case HPE impression was Malignant GIST of small bowel.

Why the word "malignant" is important? (AP Datuk Dr Ismail Sagap)

Management is totally different. In case of a malignancy, the mainstay of treatment is oncological resection and followed by chemotherapy (in this case it was Glivec). 

The session continued with comments from AP Datuk Dr Ismail Sagap with regards to registrars answering style of alway trying to give a "vague " terminology.

Prognosis of the case? (AP Datuk Dr Ismail Sagap)
GIST has a high risk of recurrence and well known to be notorious in local recurrence. 

Prognosis will be based on:

1. Tumor size
2. Mitotic index
3. Site of origin

 AP Datuk Dr Ismail Sagap suggest for the masters candidate to memorize the immunohistochemistry algorithm in diagnosing GIST. This algorithm was prepared by Dr Rajaie in the slide. 

Why they use "recurrence free survival" rather than "overall survival?" - (AP Datuk Dr Ismail Sagap)

Because it is a tumor with borderline malignancy. Overall survival is not being used because usually patients with GIST has a very long overall survival. So, the recurrence free survival has become a better measurement index for GIST to project the prognosis index.  

How many percent of small bowel tumor is GIST? (AP Datuk Dr Ismail Sagap)

He asked us to look for the answer. By the way, the answer is 10% (Uptodate)

Surveillence of the GIST patients? (AP Datuk Dr Ismail Sagap)

Based on current consensus, it is advised for CT scan to be done every 6 month (for patients with malinant GIST on chemotherapy i.e. Glivec) - Dr Rajaie

The session ended following a very fruitful discussion and Q&A session. Thank you to Dr Rajaie for a very good case being discussed and a good review for an overview of the disease. Hope we can always continue to have great sessions of RECAP in the future. 

Happy learning. 

QUOTE OF THE DAY:

“Lack of direction, not lack of time, is the problem. We all have twenty-four hour days.” - Zig Ziglar

Journal club

Next journal club - 24th January 2011
Presenter : Dr. Rizal

Meckel’s Diverticulum—A High-Risk Region for Malignancy
in the Ileum
Insights From a Population-Based Epidemiological Study and Implications
in Surgical Management

Pragatheeshwar Thirunavukarasu, MD∗, Magesh Sathaiah, MBBS∗, Shyam Sukumar, MD†,
Christopher J. Bartels, MD∗, Herbert Zeh, III, MD∗, Kenneth K. W. Lee, MD∗, and David L. Bartlett, MD∗

Annals of Surgery Volume 253, Number 2, February 2011

Abstract

Background: Surgical management of incidental Meckel’s diverticulum (MD) is a highly debated controversial issue that has never been discussed from the oncological standpoint.

Objective: To describe the epidemiology and risk of Meckel’s diverticulum cancer (MDC) and compare it with other ileal malignancies.

Methods: Data were obtained from 163 cases of MDC and 6214 cases of non-Meckelian ileal cancer, between 1973 and 2006, from the Surveillance, Epidemiology, and End Results database.

Results: Mean annual incidence was 1.44 (± 1.12) per 10 million population, with a 5-fold increase in the last few decades. Incidence increases with age, with a mean age at diagnosis of 60.6 (±15.1) years. Adjusted risk of cancer in the MD was at least 70 times higher than any other ileal site. Disease was localized in 67% at presentation and malignant carcinoids constituted the major histologic type (77%). One-third of patients have had lifetime occurrence of other malignancies and in 13% of these patients, MDC was the first malignancy. Median tumor size was 7 mm. Median overall survival was 173 months (95% confidence interval [CI], 124–221 months), with 1- and 5-year relative survival rates of 85.8% (95% CI, 76.9%-91.4%) and 75.8% (95% CI, 64.9%-83.8%), respectively. Cox proportional hazards model revealed that age, histologic type, and metastatic disease were independent factors affecting survival.

Conclusions: MD is a “hot-spot” or high-risk area for cancer in the ileum. With risk that increases with age and high possibility of curative resection with negligible operative mortality, incidental MD is best treated with resection.

Journal Club

Next journal club - 13th December 2010
Presenter : Dr. Krishna

Radiofrequency Ablation in Barrett's Esophagus with Dysplasia
The New England Journal of Medicine
May 28, 2009
Vol 360 No 22

Background
Barrett’s esophagus, a condition of intestinal metaplasia of the esophagus, is associated
with an increased risk of esophageal adenocarcinoma. We assessed whether
endoscopic radiofrequency ablation could eradicate dysplastic Barrett’s esophagus
and decrease the rate of neoplastic progression.
Methods
In a multicenter, sham-controlled trial, we randomly assigned 127 patients with dysplastic
Barrett’s esophagus in a 2:1 ratio to receive either radiofrequency ablation
(ablation group) or a sham procedure (control group). Randomization was stratified
according to the grade of dysplasia and the length of Barrett’s esophagus. Primary
outcomes at 12 months included the complete eradication of dysplasia and intestinal
metaplasia.
Results
In the intention-to-treat analyses, among patients with low-grade dysplasia, complete
eradication of dysplasia occurred in 90.5% of those in the ablation group, as compared
with 22.7% of those in the control group (P<0.001). Among patients with highgrade
dysplasia, complete eradication occurred in 81.0% of those in the ablation group,
as compared with 19.0% of those in the control group (P<0.001). Overall, 77.4% of
patients in the ablation group had complete eradication of intestinal metaplasia, as
compared with 2.3% of those in the control group (P<0.001). Patients in the ablation
group had less disease progression (3.6% vs. 16.3%, P = 0.03) and fewer cancers
(1.2% vs. 9.3%, P = 0.045). Patients reported having more chest pain after the ablation
procedure than after the sham procedure. In the ablation group, one patient had
upper gastrointestinal hemorrhage, and five patients (6.0%) had esophageal stricture.
Conclusions
In patients with dysplastic Barrett’s esophagus, radiofrequency ablation was associated
with a high rate of complete eradication of both dysplasia and intestinal metaplasia and
a reduced risk of disease progression. (ClinicalTrials.gov number, NCT00282672.)

Need help.

I'm seeking help from the medical officers/registrar for contributing more to our blogspot. You are required to jot down the question and answers during our morning discussion i.e. journal club, RECAP etc.. then post it our blogspot.

Pls email me if you are interested so i can give clearance.

Thank you,

Zairul

The Major have spoken!

Thanks to Major (Dr.) Ngoo for his contribution. Gun-salute!

Question for Part II (Viva) Ms

Principles of surgery tables (i) and (ii)

1. Scenario: 70 years old man PR bleed came to you. Whilst assessing him, the patient developed torrential PR bleed. You are preparing to take him to OT for emergency total colectomy. Patient’s daughter came and asked about (a) her father’s prognosis, (b) whether you can guarantee that his father will recover.

2. You said no guarantee. So she said no need to go for OT because the patient is already old and unlikely to survive anyway. So what do YOU want to do now?

3. So you would still proceed with emergency surgery. But her daughter would not consent it. What next?

4. So you would get 2 consents from senior consultants for the patient. But your anaesthetist would not agree to consent. Furthermore, your anaesthetist is agreeable with the patient’s daughter, that is, no need surgery. What next?

5. Ok the patient survived and thanked you for saving him. Tell me the body’s physiology of this patient when he was losing blood per-rectally (Answer: discuss Baskett’s classification of shock…read Prof Mike Wyatt’s article in Surgery International published just before exams).

1. You are a senior consultant. Your elective OT has listed a 7 y/o boy for herniotomy, a 70 y/o Diabetic man for some surgery, and two other middle-aged ladies for operations too. Tell me the principles of organizing the OT list.

2. You said pre-operative work-up must be done. What is the concern here? (Answer: make it safe for surgery) and how do you address the concern? (Answer: tell all the characteristics of Safe Surgery initiative by WHO)

3. Now, how would you prepare the patients individually? (Answer: focus more on diabetic man, whether he has good DM control, diet-controlled, OHA-controlled, or insulin-controlled DM).

4. How would you prioritise?

5. Why would you prioritise?

6. Why should a young boy go before an elderly diabetic man? If you do not list the boy as the first in the list, what difficulties will your run into?

7. Can you prioritise the diabetic man instead, and if so, give your reasons.

1. Tell me in what situations of trauma that patients can be managed conservatively?

2. In what situation of abdominal trauma would you consider conservative management?

3. Tell me about the grading of solid organ injury and how you would re-act to it.

4. So a patient with abdominal trauma came to you, how would you assess for bleeding intra-abdominally and how this would influence your management (what parameters come to mind and how do you address this).

5. What would make you go for operative management subsequently?

1. As a surgeon, what influences your surgical incision. Tell me the principles of creating a surgical wound.

2. You commonly encounter surgical patients needing dialysis. Tell me, in what situations would dialysis be required.

3. You said renal failure. Can you tell me about renal failure, how you would assess for it and what are the implications of renal failure?

4. What types of dialysis do you know of and how do you choose.

5. You said haemodialysis through a femoral access. Tell me what are the complications associated with central venous catheterization.

6. The patient ended up needing a long-term haemodialysis. How would you go about this?

7. Where do you want to create your haemodialysis access?

8. What are the principles of creating a haemodialysis access?

Pathology Table

If given picture slides, start with, “I can see (describe like you see an alien)…”

Questions using picture slides – this is variable

1. A man’s buttock with a huge swelling (describe). It drained pus. What are the possibilities? Who gets this type of swelling? What is the possible micro-organism? What are the other more sinister causes of this swelling ? (Answer: psoas abscess, tuberculous spinal abscess)

2. Bilobar structure joined in the middle, lobulated (Dx: thyroid gland, multinodular goiter)

   1. What is this and why do you say so?

   2. So you say it is a multinodular goiter, what is your management?

   3. You want to offer total thyroidectomy. What are the complications?

   4. What if you do a subtotal thyroidectomy ?

3. Interjected question

   1. You mention tumour thrombus. What is your understanding of it?

   2. Give other examples where you get tumour thrombus apart from renal carcinoma

Using picture slides – this is variable

1. bladder calculi and prostate gland (identify the specimens and mention why)

   1. What is the relationship?

   2. What is the effect of bladder outlet obstruction?

   3. What is the effect of bladder calculi?

2. CT scan (please describe >> cystic lesion of the right kidney, loss of architecture of the left kidney)

   1. What do you think this is?

   2. How do you diagnose renal cell carcinoma? (Answer: change in Hounsfield unit on CT scan by 20-25, pre and post contrast)

   3. What treatment would you offer assuming that the contralateral kidney is normal?

Non-picture slide question:

1. What is an incidentaloma and give some examples.

2. How would you go about investigating for one?

3. What would suggest to you that an incidentaloma needs to be treated?

Operative table:

As I describe the procedure, he will intercept and focus on fine nitty, gritty details.

1. How do you perform a femoral embolectomy ?

2. How do you consent the patient for the surgery?

3. What sizes of Fogarty’s catheter would you prepare and how do you prepare it?

4. So you would obtain proximal and distal control. What would you be using ?

   1. So you said vascular loops. How do you apply them? Are you going to use vascular clamps?

   2. How do you keep your loops taut?

5. Hold on, before you perform the arteriotomy, would you not want systemic heparinisation? What dose of heparin ?

6. What arteriotomy incision would you make and why?

   1. So you choose a longitudinal incision, why not a transverse?

   2. So what is the problem with a transverse incision?

   3. What is the problem with a longitudinal incision?

7. So you have opened up the vessel, and you said you will assess from proximal inflow but usually there will be poor inflow anyway, otherwise you will not end up with an acute limb ischaemia. What catheter size would you choose for proximal embolectomy?

   1. How about distally?

   2. And how much air or water are you inflating the balloon catheter with?

8. Would you be satisfied after removing the emboli?

1. Describe how you would go about a performing a proximal ureterolithotomy.

2. How do you identify the 12^th rib?

3. Do you muscle cut or muscle split?

4. So you have seen the ureter and you said that you want to apply distal and proximal control. Is that really necessary?

   1. Ok I agree with proximal control but why do you think it is important?

   2. How about distal control, is it necessary?

   3. Now you have removed the stone, what else would you do?

   4. You said you want to insert a ureteric stent, which type and how do you place it?

   5. How are you going to manage the stent?

Good luck !

KS Ngoo
Nov 2010