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it may take the form of clinical trials, surveys, retrospective studies, laboratory experiments or any other form of unpublished original work.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