SWORD goes international

Today SWORD was a bit different. There were Mongolian surgeons which attended the meeting.

Case 1:
Goh presented a 70 years old man post stapler heamorroidectomy day 4 presented with PR bleed. Hemodynamically stable, Hb 14.5. Brought to OT, EUA showed oozing at anastomotic site - figure of 8 suturing was done and bleeding stopped.

Q - "For pt with post stapler bleed, how to tackle or how far to examine in the ward or should bring them to OT instead?" - Prof Jasmi
A- "I don't have an answer how far to examine but I can assure you it is difficult to see it in the ward, better to bring to OT" - Prof Ismail

Q - "How about temponade dressing" - Prof Jasmi
A - "You can temponade it, but if active bleed it won't stop, most of the time bring to OT for suturing" -Prof Ismail

Q - "Empirical antibiotics?" - Mr Azim
A - "Flagyl" - Prof Ismail

Q - "If still bleeding?" - Mr Hanafiah
A - "Refer vascular!" - Prof Jasmi....... everybody laugh.. except surgeons from Mongolia
A - "More than 90% will stop, but if its still bleed I would packed and suture it (packed dressing)" - Prof Ismail


Case 2:
Fuad presented a man underwent lap chole 4/12 ago, presented again with obstructive jaundice signs and symptoms. US showed stone in mid portion of CBD.

Q - "Is it missed stone or primary stone?" - Prof Jasmi

Q - "How long after lap chole if develop stone define as primary stone?" - Prof Jasmi
A - "before 2 years missed stones, after 2 years primary stone" - Prof Jasmi

Q - "Difference in management?" - Prof Ismail
A - "if primary stone one has to consider chances of developing recurrent stone and also have to consider intrahepatic stone" - Prof Jasmi

Case 3:
Spontaneous DVT, no pelvic or abdominal mass. Medical refuse to take over, as usual surgical team save the day.

Q - "If pt DVT comes to A&E who will take?"
A - "DVT is a no mans land. Predict the cause of DVT, if spontaneous it goes to medical, if fracture goes to ortho" - Prof Ismail

zairul

SWORD

1. A case of undiagnosed AAA before which presented to A&E after an alleged MVA. Brought in GCS 13/15 hypotensive. US abd showed a leaking infrarenal AAA. Also sustained 5th rib fracture with no underlying hemo/pneumothorax. Operated on him, and aneurysm was repaired. Total of 12 pint of blood and 3 DIVC regime was given .Currently in ICU. New development respiratorty system not good, suggestive of transfusion related acute lung injury

Q - Define TRALI - Mr. Hanafiah
A - keyword to hear is non cardiogenic lung injury + the other criterias

Q - Why DIVC regime was ordered for this man? - Prof. Ismail

Q - Complication of massive blood transfusion? - Mr. Hanafiah

Mr. Lukman asked Mr. Hanafiah if this type of case was seen in other centre without vascular surgeon what will we do?
A - pray..... clamped the aorta and call for help (vascular surgeon) and pray

zairul

No SWORD

Too bad sword was canceled, UKM vice chancellor had to give a speech

Longest SWORD ever

A lot of cases being presented.... the juicy ones are..

Wahab presented:

1. an MVA case which sustained 4th rib # with pneumothorax. Clinically trachea was deviated, reduce air entry and resonant on percussion.
Unfortunately CXR was ordered and surgical team was referred before inserting a chest drain!

"Decision for CXR for a clinical suspicious pneumothorax is dangerous" - Prof Jasmi

"Take home msg, to put a chest tube first in a suspected pneumothorax.. it is not a mistake to put a chest tube" - Prof Jasmi


2. 36 year old Indian man complaining of abdominal pain, notice a mass in his abdomen for the past 5/12. There was also bilateral axillary LN which was matted and firm. The mass was supraumblical and mobile, hepatosplenomegaly present. Hb was 5.4........ A differential of lymphoma and TRO CA stomach was made

"if lymphoma the LN would be discrete and rubbery" - Prof Jasmi

"very unlikely CA stomach with present of axillary LN" - Prof Jasmi

Q - "how often gastric lymphoma present with axillary LN" - Prof Jasmi
A - everybody look away from Prof Jasmi....... looking for answers

"mysenteric LN in lymphoma is rare, there are usually paraaortic LN which are lobulated and fixed" - Prof Rohaizak

"LDH can carry prognosis of lymphoma" - Prof. Rohaizak

Wahab would like to transfuse PC in this pt but..

Q - "Hb of 5 in a asymptomatic chronic anemia why transfuse 2 pint PC, how much to bring up? how long to transfuse? when to transfuse?" - Prof. Jasmi

3. 17 year old Chinese Man presented with perianal abscess

Q - "what are the predisposing factors in a young man developing perianal abscess?" - Prof. Rohaizak

A - somebody answered homosexuality

Prof. Jasmi rebutted, "is it evidence base homosexuals are prone to develop perianal abscess,..... I am not trying to defend them" ha.....ha.....ha....ha..

Hasnul presented:

1. A 57 year old obese Chinese lady with late presentation of abdominal pain, amylase 51 TW 8.0, no free gas under diaphragm and clinically peritonitis. A differential dx of PGU was made and decision to operate. However a CT Abdomen was ordered

Q - "Why CT-Scan?" - Mr Lukman
A - "if CT shows severe pancreatitis, hold tight and not to go in" - Mr Hanafiah

"In obese pt, diagnostic laparoscopic would be ideal...less wound infection" - Prof Jasmi