Heading To Good Surgery

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Heading To Good Surgery

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Heading To Good Surgery

TABLE OF CONTENTS

Keynote Speaker ...... Error! Bookmark not defined. Breast Cancer Surgery – Tips, Tricks & Pitfalls ...... Error! Bookmark not defined. The Management Of Locally Advanced Breast Cancer: Challenging Yet Controversial Error! Bookmark not defined. The Management Of Locally Advanced Breast Cancer: What Options Are Available? ... Error! Bookmark not defined. Paediatric Abdominal Trauma In Sub Saharan Africa ...... Error! Bookmark not defined. Promoting ICS as The Best Global Place For The Best Global Surgeons ...... Error! Bookmark not defined. ICS Progress : PromotingICS as the Best Global Place for the Best Global Surgeons ...... Error! Bookmark not defined. ICS Challenge ...... Error! Bookmark not defined. The Strategy For Managing Upper Urinary Tract Stone ...... Error! Bookmark not defined. Lateral Mass Screw Fixation For Cervical Trauma ...... Error! Bookmark not defined. Education, Training, Masters, and Updates Of Neurosurgery In Japan ...... Error! Bookmark not defined. Minimally Invasive Cranial Keyhole Microsurgery: Concept & Technique ..... Error! Bookmark not defined. Max Thorek Memorial Lecture: Challenges In Surgery ...... Error! Bookmark not defined. Heading Towards Good Surgery ...... Error! Bookmark not defined. The Role of The International College Of Surgeons In Supporting Education and Research In Developing Countries...... Error! Bookmark not defined. Patient Safety in Trauma Surgery ...... Error! Bookmark not defined. Surgical Safety in Neurosurgery ...... Error! Bookmark not defined. Patient Safety In Oncologic Surgery ...... Error! Bookmark not defined. Radioisotope Occult Lesion Localization –ROLL ...... Error! Bookmark not defined. Breast Reconstruction Surgery ...... Error! Bookmark not defined. Oncoplasty Breast Reconstruction ...... Error! Bookmark not defined. Difficult Perianal Fistula ...... Error! Bookmark not defined. Starting to do Laparoscopic Colorectal Surgery ...... Error! Bookmark not defined. Sphincter Preservation Surgery for Rectal Cancer ...... Error! Bookmark not defined. Technique of robotic assisted totally proctocolorectomy and ileal pouch anal anastomosis ...... Error! Bookmark not defined. Standard procedure of laparoscopic very low anterior resection for rectal tumor ...... Error! Bookmark not defined.

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Laparoscopic-assisted abdominoperineal resection for Lower Rectal Cancer with Extraperitoneal Colostomy ...... Error! Bookmark not defined. Standardization of laparoscopic surgery for right colorectal cancer ...... Error! Bookmark not defined. New Perspectives for Choosing BPH Treatment ...... Error! Bookmark not defined. Male LUTS in Asia ...... Error! Bookmark not defined. Benign intracranial skull base tumor ...... Error! Bookmark not defined. Hydrocephalus and Its Problem ...... Error! Bookmark not defined. Personal Experience in The Management of Skull Base Tumors ...... Error! Bookmark not defined. Role of Melatonin in the expression of MDA, MPO on Microglia cells and AQP4 and VEGF in Blood Brain Barrier after Head Injury ...... Error! Bookmark not defined. Surgery for Infectious Lung Diseases in Japan ...... Error! Bookmark not defined. Operation for Pleura and Pulmonary Tuberculosis in Persahabatan Hospital, The National Respiratory Centre ...... Error! Bookmark not defined. Techniques for Pancreatic Surgery ...... Error! Bookmark not defined. Liver resection in colorectal cancer metastasis ...... Error! Bookmark not defined. Surgery of the Pancreas ...... Error! Bookmark not defined. Robotic Surgery on HPB ...... Error! Bookmark not defined. Robotic Prostate Surgery...... Error! Bookmark not defined. Endoluminal Robotic Surgery ...... Error! Bookmark not defined. Pre- and postoperative pituitary dysfunctions in patients with hypothalamo-pituitary tumors and its management ...... Error! Bookmark not defined. Current treatment strategy for functioning pituitary adenomas ...... Error! Bookmark not defined. Endoscopic transsphenoidal surgery for pituitary adenomas ...... Error! Bookmark not defined. Extended transsphenoidal surgery for sellar and parasellar tumors...... Error! Bookmark not defined. Metastases to the pituitary gland, -Current practice in diagnosis and treatment- ...... Error! Bookmark not defined. Laparoscopic pelvic lymph node dissection for rectal cancer following total mesorectal excision ...... Error! Bookmark not defined. Standardization of Laparoscopic Rectal Surgery ...... Error! Bookmark not defined. Pearls And Pitfalls In Burn Management...... Error! Bookmark not defined. Early Management Of Pelvic Trauma ...... Error! Bookmark not defined. Complex Injury Including Both Chest And Abdomen ...... Error! Bookmark not defined. Embolisation Of Arteriovenous Malformation ...... Error! Bookmark not defined. The Effectivity Of MPFF In The Treatment Of Chronic Venous Insufficiency Error! Bookmark not defined. Up-To-Date Trend Of “Computer Assisted Surgery” In Maxillofacial Surgery Error! Bookmark not defined. As A Way To Record The Location Of Cleft In CLP ...... Error! Bookmark not defined. Max Thorek Memorial Lecture: Challenges In Surgery ...... Error! Bookmark not defined. Breast Cancer In Indonesia:“Where are we now?” ...... Error! Bookmark not defined.

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Postgraduate Surgical Training In Nigeria ...... Error! Bookmark not defined. Pitfalls In Thoracic Surgery ...... Error! Bookmark not defined. High Tech Surgery And Ethical Consideration ...... Error! Bookmark not defined. Starting Epilepsy Surgery In Countries With Limited Resources...... Error! Bookmark not defined. Hepatocellular Carcinoma And Perihilarcholangiocarcinoma ...... Error! Bookmark not defined. Non Operative Management For Gastro-Duodenal Ulcer Perforation ...... Error! Bookmark not defined. Liposuction: The Art And Science Of Body Contouring ...... Error! Bookmark not defined. Our Surgery For Esophageal And Gastric Cancer ...... Error! Bookmark not defined. Transhiatal Approach For Adenocarcinoma Of Esophagogastric Junction ..... Error! Bookmark not defined. Ethical Consideration In Management Of Critical Ill Patient ...... Error! Bookmark not defined. Initial Examination And Diagnostic Of Oral Cancer ...... Error! Bookmark not defined. Adjuvant Treatment of Oral Cancer ...... Error! Bookmark not defined. Lumbar Degenerative Disc ...... Error! Bookmark not defined. The Present Conditions And Problem Of Spinal Instrumentation Surgery For Aging People In Indonesia. Innovation Instrumentation Of The Degenerative Spine, 29 Years Experiences...... Error! Bookmark not defined. Minimal Invasive Spinal Surgery ...... Error! Bookmark not defined. Laparoscopic Surgery For Infertility ...... Error! Bookmark not defined. Laparoscopic Living Donor Nephrectomy ...... Error! Bookmark not defined. Tips Tricks And Pitfalls In Female Urology ...... Error! Bookmark not defined. Pitfalls In Liver Surgery...... Error! Bookmark not defined. What Constitutes Quality Head And Neck Cancer Care ...... Error! Bookmark not defined. Advanced Treatment In Tevar ...... Error! Bookmark not defined. Video-Assisted Thoracic Surgery (VATS): The Lung Center Of The Philippines Experience ...... Error! Bookmark not defined. Non-conventional Resuscitative Procedures for Cardiovascular Catastrophes in Extremis (Rashid's Maneuver) ...... Error! Bookmark not defined. Pitfalls In Thoracic Surgery ...... Error! Bookmark not defined. Modern principles of complex chest wall reconstruction ...... Error! Bookmark not defined. Evolution of optical imaging diagnosis of colonoscopy ...... Error! Bookmark not defined. Minimally Invasive Surgery for Obstructive Colon Cancer: Laparoscopic Surgery after Stent Insertion ...... Error! Bookmark not defined. Nutritional Support for Critically Ill Patients ...... Error! Bookmark not defined. Surgical Nutrition In Abdominal Malignancy ...... Error! Bookmark not defined. Surgical Nutrition in Abdominal Infection...... Error! Bookmark not defined. Management Of Vascular Trauma ...... Error! Bookmark not defined. Lessons learned from experience of secondary aortic surgery for failure or complications of endovascular repair ...... Error! Bookmark not defined.

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Hemodialysis Access...... Error! Bookmark not defined. Syringomyelia: Past, present and future ...... Error! Bookmark not defined. Surgical management of cervical spine surgery...... Error! Bookmark not defined. Pain Management for Back Pain ...... Error! Bookmark not defined. Lumbar Canal Stenosis:Review of different types of surgical treatment options ...... Error! Bookmark not defined. Challenges In Surgical Ethics ...... Error! Bookmark not defined. Prevention of malpractice and improvement of patient safety ...... Error! Bookmark not defined. Is the omitting of axillary lymph node dissection in sentinel lymph node biopsy positive patients safe ? ...... Error! Bookmark not defined. The Role of Pathology in Breast Cancer Management...... Error! Bookmark not defined. Update of Hair Transplant ...... Error! Bookmark not defined. Safety in Aesthetic Surgery: using Laser liposuction under tumescence anaesthesia as model ...... Error! Bookmark not defined. Maxillofacial Reconstructive Surgery including Bone, Soft tissue and Function ...... Error! Bookmark not defined. Oral Presentation ...... 20 PODA001. Intramuscular Hemangiomas ...... Error! Bookmark not defined. PODA002. Limb Salvage With Free Tissue Transfers For Diabetic Patients With End-Stage Renal Disease On Dialysis ...... Error! Bookmark not defined. PODA003. Utilizing Monitor Flaps In Free Muscle Flaps - Old Dogs, Old Tricks ...... Error! Bookmark not defined. PODA004. A Case Of Difficult Treatment Of Intrahepatic Stones After Surgery For Congenital Biliary Dilatation ...... Error! Bookmark not defined. PODA005. The Incidence Of Roux Stasis Syndrome After Distal Gastrectomy ...... Error! Bookmark not defined. PODA006. Current Status Of Various Cholecystectomy Techniques Including Button-Hole Cholecystectomy In Era Of Laparoscopic Cholecystectomy ...... Error! Bookmark not defined. PODA007. Applicability Of Buccal Fat Pad Grafting For Oral Reconstruction Error! Bookmark not defined. PODA008. Retrospective Clinical Study On Reliability Of Pectoralis Major Myocutaneous Flap For Reconstruction Of Surgically Induced Oral And Maxillofacial Defect Following Oral Cancer Resection Error! Bookmark not defined. PODA009. 5-Aminolevulinic Acid In Urine As A Potential Tumor Marker For Colorectal Cancer Screening ...... Error! Bookmark not defined. PODA010. The Initial Experience Upon Surgical Ablation Of Large Liver Tumor By Microwave System With Tissue Permittivity Feedback Control Mechanism ...... Error! Bookmark not defined. PODA011. The First Episode Of Postoperative Small Bowel Obstruction Is A Significant Factor Predicting The Need For Surgical Exploration...... Error! Bookmark not defined.

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PODA012. Surgical Treatment Of Retrosternal Goitre ...... Error! Bookmark not defined. PODA013. The Characteristic Of Tetanus Patients At RSUP NTB ...... Error! Bookmark not defined. PODA014. Surgical Treatment Of Chronic Calcifying Pancreatitis ...... Error! Bookmark not defined. PODA015. The Effect Of Coffee To Gastrointestinal Motility After Colon Resection With Anastomosis (Experimental Study To Assess Time To First Flatus, Defecation, And Tolerance Of Solid Food) ...... Error! Bookmark not defined. PODA016. Gastric Banding Reduces Weight Through Ghrelin And Adiponectin Plasma Concentration In Obese Rat Models ...... Error! Bookmark not defined. PODA017. Existence Of Vesicular Invasion In The Metastatic Liver Tumor May Have A Role Of Early Relapse After Hepatectomy ...... Error! Bookmark not defined. PODA019. Embolectomy Followed Metallic Stent For Acute Bilateral Aortoiliac Occlusion ...... Error! Bookmark not defined. PODA020. Temporary Diverting Ileostomy Via The Umbilicus - A Small Case Series Umbilical Stoma . Error! Bookmark not defined. PODA021. Surgical Outcomes Of Hepatocellular Carcinoma Showing High Intensity In The Hepatobiliary Phase Of Gadoxetic Acid Disodium-Enhanced Magnetic Resonance Imaging Error! Bookmark not defined. PODA022. Fluorescent Detection Of Peritoneal Metastasis In Human Colorectal Cancer Using 5- Aminolevulinic Acid ...... Error! Bookmark not defined. PODA023. Hepatic Adenoma Showing Uptake Of 18FDG On Positron Emission Tomography ...... Error! Bookmark not defined. PODA024. Management Strategy Have Definite Change Over The Past Decade Of Splenic Injury- A Nationwide Population Based Study ...... Error! Bookmark not defined. PODA025. Incidence, National Trend, And Outcome Of Nontraumatic Subarachnoid Haemorrhage In Taiwan: Initial Lower Mortality, Poor Long-Term Outcome...... Error! Bookmark not defined. PODA026. The Role Of Repairing Lung Lacerations During Video-Assisted Thoracoscopic Surgery Evacuations For Retained Haemothorax Caused By Blunt Chest Trauma...... Error! Bookmark not defined. PODA027. Association Of Head, Thoracic And Abdominal Trauma With Delayed Diagnosis Of Co-Existing Injuries In Critical Trauma Patients ...... Error! Bookmark not defined. PODA028. Gasoline Immersion Burn Without Fire ...... Error! Bookmark not defined. PODA029. Reduced Port Surgery For Colorectal Cancer ...... Error! Bookmark not defined. PODA030. Endoscopic Treatment Or Laparoscopic Surgery For T1 Colorectal CancerError! Bookmark not defined. PODA031. Video Endoscopic Treatment Of Complex Anal Fistula-An Emerging Modality. Error! Bookmark not defined. PODA032. Endoscopic Thyroid And Breast Surgery ...... Error! Bookmark not defined. PODA033. Clinical Research Of Mortality In Emergency Air Medical Transport (EAMT) ... Error! Bookmark not defined.

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PODA034. 5-Aminolevulinic Acid Mediated Photodynamic Diagnosis In Primary Gastric/Colorectal Cancer ...... Error! Bookmark not defined. PODA035. A Case Of Mirizzi Syndrome, In Which Great Omentum Plombage Was Performed For The Lost Portion Of The Bile Duct...... Error! Bookmark not defined. PODA036. Analysis Concerning The Accuracy Of The Diagnosis For Sentinel Lymph Node Metastasis In The Breast Cancer ...... Error! Bookmark not defined. PODA037. Rotavirus Enterotoxin As One Of The Inducing Factors From The Invagination Occurrence In The Children ...... Error! Bookmark not defined. PODA038. Duhamel Procedure With Double Stapler Technique In Adult Hirschprung Disease ...... Error! Bookmark not defined. PODA039. Open Heart Surgery On Jehovah Witness Patient: Indonesian Experience. . Error! Bookmark not defined. PODA040. Starting Stereotactic Neurosurgery For Movement Disorders In Developing Country; 2 Years Clinical Experiences ...... Error! Bookmark not defined. PODA041. Surgery For Intramedullary Tumor ...... Error! Bookmark not defined. PODA042. Pure Endoscopy Transphenoid Surgery For Tumor At The Sella Region ..... Error! Bookmark not defined. PODA043. The Superior Mesenteric Artery Syndrome ...... Error! Bookmark not defined. PODB001. Effects Of SEMA3 Polymorphisms In Indonesian Hirschsprung patients ..... Error! Bookmark not defined. PODC001. Surgical Apgar Score In Patients Undergoing Lumbar Fusion For Degenerative Spine Diseases ...... Error! Bookmark not defined. PODC002. Effectivity 2-Oxo-1-Pyrrolidine Acetamide To Decrease Blood Viscosity And Increase Glasgow Coma Scale For Moderate Brain Injury Patients ...... Error! Bookmark not defined. PODC003. Leucocytosis As Predictor Factor In Trauma Brain Injury ...... Error! Bookmark not defined. PODC004. Single Burrhole Drainage Under Local Anesthesia On Chronic Subdural Hematoma In Adult Comatose Patients ...... Error! Bookmark not defined. PODC005. Pilocytic Astrocytoma Of The Cerebellum In Children ...... Error! Bookmark not defined. PODC006. Lactate Dehydrogenase B Effect The Malignant Processes In Glioblastoma Multiforme ...... Error! Bookmark not defined. PODC007. The Clinicopathological Study Of Vascular Adhesion Protein-1 (VAP-1) In Human Brain Astrocytoma ...... Error! Bookmark not defined. PODD001. A Case Of Pancreatic Neuroendocrine Tumor: Laparoscopic Warshaw Procedure ...... Error! Bookmark not defined. PODD002. Migration Of Forgotten Biliary Stent Causing Duodeno-Jejunal Fistula ...... Error! Bookmark not defined. PODD003. Intracranial Meningeal Hemangiopericytoma Metastasized To The Small Intestine: A Case Report...... Error! Bookmark not defined.

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PODD004. The Prediction Of Postoperative Hyperbilirubinemia After Hepatectomy Using Ascialoscintigraphy That Was Established As New Technique ...... Error! Bookmark not defined. PODD005. A Case Of Leiomyosarcoma Of The Small Intestinal Mesentery With Rapid Growth ...... Error! Bookmark not defined. PODD006. The Benefit Of Fibrinogen Examination In The Diagnosis Of Acute Appendicitis in The Surgery Department, Mohammad Hoesin Hospital, Palembang ...... Error! Bookmark not defined. PODD007. A Case Of Neuroendocrine Tumor Of Meckel’s Diverticulum ...... Error! Bookmark not defined. PODD008. Comparative Effectiveness Of Eating Chocolate By Chewing Gum Shorten The Duration Of Postoperative Ileus In Laparotomy Because Abdominal Trauma ...... Error! Bookmark not defined. PODD009. 5 Cases Of Crohn’s Disease With Intraperitoneal Abscess Which Underwent Surgical Treatment ...... Error! Bookmark not defined. PODD010. Comparison Between TPA Index Of Proximal Gastrectomy And Total Gastrectomy...... Error! Bookmark not defined. PODD011. A Case Of Idiopathic Mesentric Phlebosclerosis (IMP) ...... Error! Bookmark not defined. PODD012. Spontaneous Mesenteric Haemorrhage ...... Error! Bookmark not defined. PODD13. Difference Of Expressions LMP-1 And EBNA-1 Of Epstein Barr Virusbetween High And Low Grade Colorectal Carcinoma ...... Error! Bookmark not defined. PODD014. Case Series: Management Of Esophageal Achalasia Without Fundoplication With Gastrotomy For Patency Checking Of Lower Esophageal Sphincter ...... Error! Bookmark not defined. PODE001. Extravasation Of Intravenous Chemotherapy In RSUP Sanglah Denpasar ...... 20 PODE002. The Effects Of Phaleria Macrocarpa Extract On Mitotic Index And Tumor Mass Progression In Epidermoid Carcinoma Of Swiss Mice In Vivo Experimental Study In Swiss Mice Which Given Neoadjuvant Paclitaxel And Cysplatin ...... Error! Bookmark not defined. PODE003. Effect Of Phaleria Macrocarpa Supplementation On Interferon-γ Expression And Tumor- Infiltrating Mononuclear Cells Of Swiss Mice With Epidermoid Skin Cancer Error! Bookmark not defined. PODE004. Difference In Breast Cancer Diagnosis And Treatment By Age Among Balinese Women: Analysis Of The Local Cancer Registry ...... 23 PODE005. Biologic Characteristics Of Breast Cancer In Balinese Elderly Women ...... 26 PODE006. A 38-Year-Old Japanese Female With Infarcted Fibroadenoma Of The Breast During Lactation ...... Error! Bookmark not defined. PODE007. Sub-Classification Of Cancer Using DNA Methylation Patterns At Imprinted Loci And Its Potential For Diagnostic And Prognostic Markers ...... Error! Bookmark not defined. PODE008. Epigenetic Silencing Of Hsa-Mir-183 In Cancer And Its Potential For Diagnostic And Prognostic Markers ...... Error! Bookmark not defined. PODE009. Giant Lipofibromatosis In A 5 Year Old Girl: A Case Report ...... 30 PODE010. Neoadjuvant Chemotherapy For Advanced Rectal Cancer ...... Error! Bookmark not defined. PODE011. Breast Cancer Trends In Semarang: An Analysis Of Histological And Molecular Types ...... Error! Bookmark not defined.

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PODF001. The Expression Of NF-Κb And IL-1 In The Bladder Mucosa Of Catheterized Benign Prostatic Hyperplasia Patients With Urinary Retention ...... Error! Bookmark not defined. PODF002. Citrus Aurantifolia Swingle Effect To Calcium Urin Content Urine And Urin Volume From Patients With Urine Calcium Stones Urinary Tract ...... Error! Bookmark not defined. PODF003. Effect Of Nigella Sativa For Serum Level Of Magnesium, Uric Acid, Calcium And Phosphat On Rabbits With Bilateral Ureter Obstruction ...... Error! Bookmark not defined. PODF005. The Outcome Of Kidney Transplantation; A Single Unit Experience ...... Error! Bookmark not defined. PODF006. Erectile Function After Anastomotic Urethroplasty For Pelvic Fracture-Urethral Distraction Defect Injuries In Hasan Sadikin Hospital ...... Error! Bookmark not defined. PODF007. Predictive Factors Of Renal Impairment In Patients With Obstructive JaundiceError! Bookmark not defined. PODG001. The Effect Of Colostrums Bovine On The Level Osteocalsin And Bone Alkali Phospatase Reactive Phase In The Healing Femur Bone Fracture New Zealand Rabbits ...... Error! Bookmark not defined. PODG002. Cunningham Technique For Reduction Of Anterior Shoulder Dislocation .. Error! Bookmark not defined. PODH001. Percentage Difference Between Take Split Thickness Skin Graft Using Feracrylum 1% Treatment With Povidone-Iodine 10% On Lower Extremity Granulation Tissue...... Error! Bookmark not defined. PODH002. Clinical Comparison The Using Of Hydrophilic Polyurethane Foam Dressing On Split Thickness Skin Graft Donor Area To Conventional Dressing ...... Error! Bookmark not defined. PODH003. Comparison Of The Effectiveness Of Healing Between Opened Treatment Using Moist Exposed Burn Ointment (Mebo) With Closed Treatment Using Nacl 0,9% At II Degree Burns In Dr. Moewardi General Hospital, Surakarta ...... Error! Bookmark not defined. PODH004. Sociodemographic And Clinical Profile Of Patients With Surgical Wound Debridement At BIMC Hospital Nusa Dua: A Descriptive Study ...... 31 PODI001. Development of Vascular Calcificationin Animal Model ...... Error! Bookmark not defined. PODI002. A Successful Surgical Diagnostic And Treatment Of Inflammatory Pseudotumor ...... Error! Bookmark not defined. PODI003. Lower Limb Angioplasty- Is It Effective? A Single Unit Experience ...... Error! Bookmark not defined. PODI004. Outcome Of Lower Extremity Bypass Surgery; A Single Vascular Unit Experience ...... Error! Bookmark not defined. PODI005. Diabetic Patients – Do They Know Foot Care? ...... Error! Bookmark not defined. PODI006. Infected Aneurysm With Helicobacter Cinaedi ...... Error! Bookmark not defined. PODJ001. Shark Bite On Surfers In Bali: A Serial Cases Report ...... 37 PODJ002. The Role Of Initial Hematocrit In Predicting Shock And Blood Loss In Trauma Patients ...... Error! Bookmark not defined.

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Poster Presentation ...... 44 POSA001. Incarcerated Massive Paraumbilical Hernia In A Morbidly Super-Super-Obese Patient ...... Error! Bookmark not defined. POSA002. Local Advanced Papillary Cell Carcinoma Of Thyroid With Tracheal Invasion Presented With Stridor ...... Error! Bookmark not defined. POSA003. Anastomotic Leak Rate After Laparoscopic And Open Colorectal Cancer Resection SurgeryError! Bookmark not defined. POSA004. Cerebral Fat Embolism Syndrome Following Bilateral Knee Replacement: A Rare Complication ...... Error! Bookmark not defined. POSA005. Foramen Of Winslow Hernia As A Rare Surgical Emergency: Case Report And Literature Review ...... Error! Bookmark not defined. POSA006. Ultra-Low Anterior Resection And Colo-Anal Anastomosis For Low Rectal Cancer: Reappraisal By Anal Function ...... Error! Bookmark not defined. POSA007. Persistent Chylothorax Caused By Diffuse Small Lymphocytic Lymphoma - A Case Report . Error! Bookmark not defined. POSA008. Perforated Jejunal T-Cell Lymphoma In A Young Adult Male-A Case Report ...... Error! Bookmark not defined. POSA010. Primary Lymphoepithelioma-Like Carcinoma Of The Lung Presented With Cervical And Mediastinal Lymphadenopathy In An Elderly Patient: A Case Report ...... Error! Bookmark not defined. POSA011. Role Of The K-Cl Cotransporter KCC3 In Cell Migration In Human Esophageal Squamous Cell Carcinoma ...... Error! Bookmark not defined. POSA012. Surgical Outcomes Of Laparoscopy-Assisted Total Gastrectomy In Stage I Gastric Cancer Patients ...... Error! Bookmark not defined. POSA013. Body Mass Index And The Short- And Long- Term Outcomes in Esophageal Cancer Treated With Esophagectomy ...... Error! Bookmark not defined. POSA014. Photodynamic Diagnosis (PDD) Of Hepatocellular Carcinoma Using 5-Aminolevulinic Acid (5- ALA) ...... Error! Bookmark not defined. POSA015. Higher Incidence Of Complications In The Elderly After Major Surgery Under General Anesthesia ...... Error! Bookmark not defined. POSA016. Intraoperative Fluorescence Diagnosis For Gastric Cancer Using 5-Aminoluvulinic Acid ..... Error! Bookmark not defined. POSA017. A Case Of Mediastinal Recurrence Of Esophageal Cancer After Subtotal Esophagectomy Diagnosed By Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA) .... Error! Bookmark not defined. POSA018. Efficacy Of 5-Aminolevulinic Acid-Mediated Photodynamic Therapy Using Light-Emitting Diodes in human Colon Cancer Cells ...... Error! Bookmark not defined. POSA019. A Sımple, Safe And Effectıve Targetıng Method Combıned Wıth Intraoperatıve Ultrasound For Small Subcortıcal Intracranıal Lesıons ...... Error! Bookmark not defined.

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POSB001. Anorectal Malformation with Perineal Fistula and Rectourethral Fistula .... Error! Bookmark not defined. POSB002. Ovarian Teratoma: A Case Report ...... Error! Bookmark not defined. POSB003. Intestinal Malrotation ...... Error! Bookmark not defined. POSB004. Amyand Hernia on the Left Side in Children with Ages of 11 Months Old .... Error! Bookmark not defined. POSB005. Pediatric Small Bowel Volvulus due to Mesenteric Cyst: Case Report ...... Error! Bookmark not defined. POSB006. Acute Small Bowel Obstruction due to Congenital Bands from Vitteline Remnants and Meckel’s Diverticulum: A Case Report ...... Error! Bookmark not defined. POSB007. Esophageal Achalasia in Children ...... Error! Bookmark not defined. POSB008. Thyroid Surgery in Children: A Case Series and Literature Review ...... Error! Bookmark not defined. POSB009. Serial Case Report: Primary Non-Hodgkin’s Lymphoma of the Maxilla in Pediatric ...... Error! Bookmark not defined. POSB010. Gastric Perforation in Neonates: A Report of Three Cases ...... Error! Bookmark not defined. POSB011. Hirschsprung's Disease in Zainoel Abidin Hospital 2010- 2014 .... Error! Bookmark not defined. POSB012. Retrosternal Colonic Interposition and Esofagoplasty in Female Patients 1 year 6 months with Esophageal Atresia Type A, Post Gastrostomy and Esofagostomy ...... Error! Bookmark not defined. POSC002. Effects of Turmeric Extract Exposure on ICP, GCS, and GOS in Head Injury with GCS 5-8 Through IL-1β/IL-10 ...... Error! Bookmark not defined. POSC003. Anterior Meningocele (Fronto-Ethmoidalis) ...... Error! Bookmark not defined. POSC005. CASE REPORT: A Man with Cerebral Arteriovenous Malformation ...... Error! Bookmark not defined. POSC006. Case Report : Chronic Epidural Hematoma ...... Error! Bookmark not defined. POSC007. Lipomyelomeningocelelumbo-sacral: case report ...... Error! Bookmark not defined. POSC009. Surgical Intervention of Thoracic Spinal Dural Arteriovenous Fistula ...... Error! Bookmark not defined. POSC010. The Indications and Results of Exploratory Burr Hole in Traumatic Brain Injury ...... Error! Bookmark not defined. POSC11. Epidemiology of Moderate and Severe Traumatic Brain injury resulting from Motorcycle Accidents in Hasan Sadikin Hospital ...... Error! Bookmark not defined. POSC012. Epidemiology of Traumatic Brain Injury with Effect of Alcohol Consumption in Hasan Sadikin Hospital ...... Error! Bookmark not defined. POSC013. Characteristic of Traumatic Brain Injury in Elderly Patient in Hasan Sadikin Hospital, Bandung ...... Error! Bookmark not defined. POSC014. The Expression of Extracellular Signal-Regulated Kinase1/2 (ERK1/2) and Cyclin D1 in Human Glioma ...... Error! Bookmark not defined.

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POSC015. The Role of 4E-BP1-Related Pathway in Human Glioma ...... Error! Bookmark not defined. POSD002. Intussusception in Adults Profile in Manado ...... Error! Bookmark not defined. POSD003. Choledochal Cyst in an Adult: Case Report ...... Error! Bookmark not defined. POSD005. Jejunal Volvulus: Case Report ...... Error! Bookmark not defined. POSD006. Effect of Platelet Rich Plasma (PRP) in Perianal Fistula Recurrence Incidence . Error! Bookmark not defined. POSD007. Effect of Eicosapentaenoic Acid and Docosahexaenoic Acid on Nutritional Status, CRP, 15-HETE in Unresectable Colorectal Cancer with Cachexia Patient ...... Error! Bookmark not defined. POSD008. Spontaneous Evisceration Through Epigastria Hernia in A Patient with Relapse Lung Tuberculosis: Case Report ...... Error! Bookmark not defined. POSD010. Differences in Preoperative CEA Serum Levels and Relationship with Metastasis between Colon Cancer and Rectal Cancer in Dr Kariadi Hospital Semarang in the Period of January 2010 - December 2012 ...... Error! Bookmark not defined. POSD011. 3D-Simulation with DIC-CT Before Re-anastomosis of Hepatico-jejunostomy for Intrahepatic Biliary Stones After Living Donor Liver Transplantation ...... Error! Bookmark not defined. POSD012. Factors Affecting Post-operative Pain after Doppler Guided Hemorrhoid Artery Ligation and Recto-anal Repair (DGHAL-RAR) of Internal Hemorrhoid ...... Error! Bookmark not defined. POSD013. Right Colon Interposition on Patient with Caustic Esophageal Stricture ...... Error! Bookmark not defined. POSD014. A Case of Ulcerative Colitis in Which Negative Pressure Wound Therapy Was Performed for Peritonitis Caused by Perforation ...... Error! Bookmark not defined. POSD015. Effect of Methylene Blue to Prevent Intra-peritoneal Adhesion .... Error! Bookmark not defined. POSD016. Intestinal Ischemia Reperfusion Injury: Comparison Between Ischemic, Ischemic PreConditioning, And Ischemic Hypothermia on Oryctolagus cuniculus, Preliminary Report ...... Error! Bookmark not defined. POSD017. Catastropic Appendicitis Operation: Successful Repair of Complicated Operation ...... Error! Bookmark not defined. POSD018. Characteristic of Perforated Peptic Ulcer in Hasan Sadikin Hospital, Bandung from January 1st 2012 – December 31st 2013...... Error! Bookmark not defined. POSD019. Strangulated Internal Hernia Associated with Trauma: Case Report ...... Error! Bookmark not defined. POSD020. Roux-en-Y Hepaticojejunostomy Stricture After Excision Choledocal Cyst (Case Report) .... Error! Bookmark not defined. POSD021. Gastric Perforation: Laparotomy vs Non Laparotomy Procedure Error! Bookmark not defined. POSD022. Distribution and Frequency of Chronic Appendicitis at Dr. M. Djamil Padang Hospital in The Periode of January 1, 2009 to December 31, 2013 ...... Error! Bookmark not defined. POSD023. Primary Stones of Intrahepatic Duct and Common Bile Duct: Case Report Error! Bookmark not defined.

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POSD024. APACHE-II and BOEY Scoring Characteristic in Gaster Perforation Patient at General Hospital Dr Hasan Sadikin ...... Error! Bookmark not defined. POSD025. Sensitivity and Specificity of Boey Score and Jabalpur Score in Evaluating the Mortality of Peptic Ulcer Perforation Patients from January 2013 - December 2013 ...... Error! Bookmark not defined. POSD026. Successful Management of ARDS After Esophagectomy Treated with Low Dose Steroid Therapy: A Case Report ...... Error! Bookmark not defined. POSE001. Profile of Tongue Carcinoma in Dr. Sardjito Hospital Yogyakarta Period of 2010-2014 ...... Error! Bookmark not defined. POSE002. Liposarcoma of Breast ...... Error! Bookmark not defined. POSE003. Delayed Giant Cell Tumor of The Radius Bone ...... Error! Bookmark not defined. POSE004. Squamous Cell Carcinoma of SCALP - Reconstruction with Double Rotational Flap: Serial Case Reports ...... 44 POSE005. Large Recurrent Pleomorphic Parotid Tumor ...... Error! Bookmark not defined. POSE006. Management Complex Type Odontoma in Oral Cavity ...... Error! Bookmark not defined. POSE007. A Woman with A Giant Breast Fibrosarcoma: A Rare Case ReportError! Bookmark not defined. POSE008. Anaplastic Carcinoma of Unknown Origin ...... Error! Bookmark not defined. POSE009. Breast Cancer Patients Loco – Regional Recurrence After Mastectomy and Chemotherapy in Dr. Moewardi General Hospital Surakarta, January 2011 - December 2013 ...... Error! Bookmark not defined. POSE010. Giant Fibromyxoma on Crista Iliaka ...... Error! Bookmark not defined. POSE011. Intrathoracic Goitre (Case Report) ...... Error! Bookmark not defined. POSE012. Case Report: Bilateral Phyllodes Tumors in 13 Years Old Female Error! Bookmark not defined. POSE013. Characteristic of Soft Tissue Sarcoma Patients in RSUP Dr. Hasan Sadikin Bandung During Period of June 1st 2010 to June 30th 2014 ...... Error! Bookmark not defined. POSE014. Bilateral Breat Carcinoma: Case Report ...... Error! Bookmark not defined. POSE015. The Problem Of Thyroid Cancer Management In Children...... Error! Bookmark not defined. POSF001. Case Report: Spontaneous Bladder Rupture ...... Error! Bookmark not defined. POSF003. Case Report: Urinoma Due To Bilateral Ureteral Injury Following Hysterectomy ...... Error! Bookmark not defined. POSF004. Bladder Irrigation Effectiveness with 0.9% Sodium Clorida Solution In Preventing Catheter Associated Urinary Tract Infection (CAUTI) at Hasan Sadikin Hospital, Bandung ...... Error! Bookmark not defined. POSF005. Levofloxacin Effectiveness in Detained Catheter Associated Urinary Tract Infection (CAUTI) in Patient with Indwelling Urethral Catheter at Hasan Sadikin Hospital, Bandung ...... Error! Bookmark not defined. POSF006. Characteristic of Ureteral Trauma Patient in Hasan Sadikin Hospital during January 1st, 2009 until December 31st, 2013 ...... Error! Bookmark not defined. POSF007. Intraperitoneal Bladder Rupture Due to Normal Labor: Case Report ...... Error! Bookmark not defined.

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POSF008. Testicular Torsion Over 48 Hours with Viable Testicle: Case Report ...... Error! Bookmark not defined. POSF009. Characteristics of Kidney Stones Patients in Hasan Sadikin Hospital Bandung Year 2010-2013 ...... Error! Bookmark not defined. POSF010. Retroperitoneal versus Transperitoneal Laparoscopic Ureterolithotomy: A Preliminary Study ...... Error! Bookmark not defined. POSF011. Case Report: Laparoscopic Excision of Urachal Cyst ...... Error! Bookmark not defined. POSF012. Testicle Tumour Caused by Leukemic Infiltration: A Case Report Error! Bookmark not defined. POSF013. Mesothelioma Retroperitoneal Cysts ...... Error! Bookmark not defined. POSF014. Case Report: Wunderlich Syndrome ...... Error! Bookmark not defined. POSF015. High Grade Urothelial Carcinoma of Ureter and Pelvis Renalis ...... Error! Bookmark not defined. POSF016. Boari Flap Procedure in Ureteral Trauma: Case Report ...... Error! Bookmark not defined. POSF017. Descriptions of Intraoperative Genitourinary Injury Were Consulted to Urology Department of M Djamil Hospital from January 1, 2010 to December 31, 2013 ...... Error! Bookmark not defined. POSF018. Retroperitoneal Laparoscopic Dismembered Pyeloplasty for Ureteropelvic Junction Obstruction ...... Error! Bookmark not defined. POSF019. A Comparative Study of Catheter Flushing Effect Using Netilmicin in Catheter Associated Urinary Tract Infection ...... Error! Bookmark not defined. POSF020. The Comparison between Transabdominal and Transrectal Ultrasound for Measuring Prostate Volume in Patients with Benign Prostatic Hyperplasia and Therapy Decision in Dr. Sardjito Hospital. Error! Bookmark not defined. POSG002. The Role of Chondroitin Sulphate in Increasing Compressive Strength ...... Error! Bookmark not defined. POSG003. Methylprednisolone Improve Tensile Strength and Degree of Adhesion After Tenorrhaphy Rat Model of Achilles Tendinopathy ...... Error! Bookmark not defined. POSG004. Increasing GSH level in rat’s skeleton muscle that have Ischemic Reperfusion Injury with administration of Nigella Sativa extraction (THYMOQUINONE) ...... Error! Bookmark not defined. POSG005. Effect of Extract Leaves of the Soursop (Annona muricata) Levels of Malondialdehyde (MDA) to Injury Ischemia Reperfusion Framework of Rat Muscle ...... Error! Bookmark not defined. POSG006. Latarjet-Bristow Procedure For Recurrent Shoulder Dislocation: Case Report Error! Bookmark not defined. POSG008. Serial Case: Giant Cell Tumour of the Distal Radius: Wide Resection and Reconstruction by Non- Vascularised Proximal Fibular Autograft ...... Error! Bookmark not defined. POSG009. Megaprosthesis Procedure in Giant Cell Tumor ...... Error! Bookmark not defined. POSG010. Deep Femoral Pseudoaneurysm as A Rare Complication of Malunion Comminuted Fracture of Shaft Femur ...... Error! Bookmark not defined. POSH001. Pedicled Anterolateral Thigh Flap - Versatile Loco-regional Flap Error! Bookmark not defined.

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POSH002. The Usage of Crocodile Oil on Cutaneous Wound Healing: First Case Report and Literature Review ...... Error! Bookmark not defined. POSH003. Severe Burn Injury: Case Series ...... Error! Bookmark not defined. POSH004. Effects of Use Topical Hydrocortisone 1% and Policresulen Compare to Occlusive Dressing on Improving Hypergranulation in IIB-Degree Burn ...... Error! Bookmark not defined. POSH005. Skin Graft in Management of Dorsum of the Foot Complex Avulsion in Pediatric Patients ... Error! Bookmark not defined. POSH006. Profile Germs and Antibiotic Resistance Patterns of Burn Patients in Burn Units Sardjito Hospital between 2009-2013 ...... Error! Bookmark not defined. POSH008. Facial Reconstruction ...... Error! Bookmark not defined. POSH009. Superomedial Thigh Flap: A Case Report ...... Error! Bookmark not defined. POSH010. Replantation of Wrist Joint Dextra: Case Report ...... Error! Bookmark not defined. POSH011. Skin Graft Radial Forearm Free Flap With Patient On Electricity Burn ...... Error! Bookmark not defined. POSH012. Excision Parafinoma Penile and Reconstruction With Full thickness Skin Graft: Case Series ...... Error! Bookmark not defined. POSH013. Correlation of APACHE-II Score with Mortality in Burns Injury Patients in Hasan Sadikin Hospital ...... Error! Bookmark not defined. POSH014. External Validation of Belgian Outcome of Burn Injury (BOBI) Score on Burn Patient at Cipto Mangunkusumo Hospital 2012-2013 ...... Error! Bookmark not defined. POSH015. Basal Cell Carcinoma Maxilla Defect IIIB Type with Forehead Flap Reconstruction ...... Error! Bookmark not defined. POSH016. Surgical Correction of Congenital Constriction Band Syndrome in Children with Z-plasty .. Error! Bookmark not defined. POSH017. Transpositional Flap with Perforator on Defect on Male After Lymphadenectomy Bilateral Inguinal Lymph Nodes with SCC of Penis ...... Error! Bookmark not defined. POSH018. Mammoplasty Reconstruction on Juvenile Breast Hypertrophy .. Error! Bookmark not defined. POSI001. Description of Waiting Time for Patients Who Are Indicated for Thoracotomy Decortication at RS Dr Hasan Sadikin in The Period of January 2013 to December 2013...... Error! Bookmark not defined. POSI002. Hemopneumothorax Dextra with Total Rupture Brachial Artery Dextra ...... Error! Bookmark not defined. POSI003. Traumatic of The Right Subclavian Artery and Vein, Case Report . Error! Bookmark not defined. POSI004. Traumatic Carotid Cavernosus Fistula: Case Report ...... Error! Bookmark not defined. POSI005. Thoracic Blunt Injury with Laceration One Lobe of Lung Without Thoracic Wall Injury ...... Error! Bookmark not defined. POSI006. Wandering VA-Shunt Catheter into Intraluminal Pulmonary Artery Right Upper Lobe ...... Error! Bookmark not defined. POSI007. Acute Limb Ischemia: A Single Unit Experience ...... Error! Bookmark not defined.

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POSI008. Carotid Endarterectomy; A Case Series from A Single Unit Experience ...... Error! Bookmark not defined. POSI009. Pseudo aneurysm of Lower Extremity in Samarinda: A Serial Case ...... Error! Bookmark not defined. POSI010. Acute Hemiplegia due to Acute Occlusion of Abdominal Aorta: A Case Report ... Error! Bookmark not defined. POSI011. Prevalence of and Risk Factors for Abdominal Aortic Aneurysm: A Meta-Analysis ...... Error! Bookmark not defined. POSI013. Incomplete Rupture Femoral Artery Dextra ...... Error! Bookmark not defined. POSI014. Case Report: Complete Sternal Cleft Associated with Ventricular Septal Defect and Patent Ductus Arteriosus in A 87-days Old Baby Girl ...... Error! Bookmark not defined. POSI015. Trachea Resection Anastomosis in Adenoid Cystic Carcinoma of the Trachea: Case Report .. Error! Bookmark not defined. POSI016. The Correlation between Fibrinogen and HbA1c in Diabetes Mellitus Patients with Diabetic Ulcer in Hasan Sadikin Hospital, Bandung ...... Error! Bookmark not defined. POSJ002. Duodenal Obstruction caused by Abdominal Blunt Trauma ...... Error! Bookmark not defined. POSJ003. Penetrating Neck Trauma due to Panah Wayer (Traditional Catapult Arrow Head): Case Series ...... Error! Bookmark not defined. POSJ004. Case Report: Hemothorax due to Blunt Trauma without Rib Fractures ...... Error! Bookmark not defined. POSJ005. Repair of Total Tracheal Rupture with Tracheo Esophageal Fistula Secondary to Tracheostomy; A Delayed Diagnosis ...... Error! Bookmark not defined. POSJ006. Characteristics of Non-Operative Management of Blunt Abdominal Injury to Solid Organs at Hasan Sadikin Hospital in January 2011 to December 2013 ...... Error! Bookmark not defined. POSJ007. Splenic Injury in Pregnant Woman After Blunt Abdominal Injury: Case Report . Error! Bookmark not defined. Poster Exhibition ...... Error! Bookmark not defined. EX001. Finger Replantation Cases in Sanglah General Hospital ...... Error! Bookmark not defined. EX002. Nephrectomy In Patient With Rupture Of Pseudoaneurism Renal Artery ...... Error! Bookmark not defined. EX003. Surgical Repair Of Congenital Diaphragmatic Hernia In The Neonate ...... Error! Bookmark not defined. EX004. Esophageal Damage Due To Button Battery Ingestion ...... Error! Bookmark not defined. EX005.Yolk Sac Tumor In The Anterior Mediastinum WithNeck And Supraclavicula Lymphatic Metastatic ...... Error! Bookmark not defined. EX006. Comparison Of Germ Pattern Of The Penile Gland Before Catheter Insertion And The Outer Surface Of Intravesical Catheter ...... Error! Bookmark not defined.

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EX007. Cerebral Salt Wasting Syndrome In Traumatic Brain Injury: Pitfall And Management ...... Error! Bookmark not defined. EX008. Sternal Chondrosarcoma ...... Error! Bookmark not defined. EX009. Embryonal Rhabdomyosarcoma ...... Error! Bookmark not defined. EX010. Brain Cystisercosis ...... Error! Bookmark not defined. EX011. PATENT OMPHALOMESENTERIC DUCT ...... Error! Bookmark not defined. EX012. Meckel´s Diverticulum ...... Error! Bookmark not defined. EX013. Strangulated Umbilical Hernia ...... Error! Bookmark not defined. EX014. High Grade Blunt Renal Trauma In Pediatric With Contralateral Renal Hypoplasia ...... Error! Bookmark not defined. EX015. ETV In Tuberculous Meningitis With Hydrocephalus And Allergic Reaction To VP Shunt ...... Error! Bookmark not defined. EX016. Correlation Between Serum Levels Of Cortisol In Response To Stress With Increased Level Of Interleukin-10 And The Degree Of Adhesion After Laparotomy And Laparoscopy : Experimental Research In Rabbit Which Performed Ileum Abrasion ...... Error! Bookmark not defined. EX017. The Effects Of Increase In Diuresis For Preventing Catheter Associated Urinary Tract Infection (CAUTI) In Patient With Indwelling Urethral Catheter...... Error! Bookmark not defined. EX018. Profile Of Undescended Testis Patients In Pediatric Surgery Division, Dr. Hasan Sadikin General Hospital ...... Error! Bookmark not defined. EX019. Kimura Disease ...... Error! Bookmark not defined. EX020. Management Of Klippel Trenaunay Syndrome In Surabaya ...... Error! Bookmark not defined. EX021. Tendon Transfer ...... Error! Bookmark not defined. EX022. Bilateral Coronal Synostosis, Microcephali, & CTEV: A Case Report . Error! Bookmark not defined. EX023. Pneumoperitoneum Without Hollow Organ Perforation in Thoraco-abdominal Trauma ...... Error! Bookmark not defined. EX024. Correlation Between Cortisol Level Toward Interferon Gamma Level Of Patient With Invasif Ductal Breast Carcinoma ...... Error! Bookmark not defined. EX025. Berberine, Encapsulated In Nano-Sized PLGA, Attenuates Nuclear Factor Erythroid Related Factor 2 And Subarachnoid Hemorrhage Induce Early Brain Injury In Rats ...... Error! Bookmark not defined. EX026. Cerebral Fat Embolism Syndrome: A Rare Complication Of Bilateral Knee Arthroplasty ...... Error! Bookmark not defined. EX027. Foramen Of Winslow Hernia: A Rare Surgical Emergency ...... Error! Bookmark not defined. EX028. Ectopia Cordis ...... Error! Bookmark not defined. EX029. Laparoscopic Radical Cystectomy With Ileal Conduit Urinary Diversion: Our First Experience Error! Bookmark not defined. EX030. Tumescence Technique For Latissimus Dorsi Flap Harvesting In Breast Carcinoma ...... Error! Bookmark not defined.

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EX031. Her2/Neu And Ki-67 Expression Profile In Various Age Groups Of Breast Cancer Patient In Adam Malik Hospital ...... Error! Bookmark not defined. EX032. Impact Of Surgical Wait Time On Incarceration Of Pediatric Inguinal Hernia .. Error! Bookmark not defined. EX033. Resistence of Pseudomonas aeruginosa to Empiric Antibiotic on Hospitalized Burn Patient in RSUP H. Adam Malik Medan ...... Error! Bookmark not defined. EX034. Ki-67 Expression Profiles In Different Stage Breast Cancer In Haji Adam Malik Hospital, Medan ...... Error! Bookmark not defined. EX035. Negative Exploratory Burr Hole, Continue With Craniectomy ...... Error! Bookmark not defined. EX036. Comparison Between C-Reactive Protein And Erythrocyte Sedimentation Rate As The Early Detection of Open Fracture Infection In Long Bones at H. Adam Malik General Hospital, Medan ...... Error! Bookmark not defined. EX037. Ascites After Ventriculoperitoneal Shunting ...... Error! Bookmark not defined. EX038. Characterictics of Amyand’s Hernia in Banjarmasin General Hospital ...... Error! Bookmark not defined. EX039. Successful Transvenous Subclavian Bipolar AV Sequential Permanent Pacemaker In Cardiogenic Shock Patient Due To Total AV Block...... Error! Bookmark not defined. EX040. Gracilis Myocutaneous Flap For Repair Rectovaginal Fistula ...... Error! Bookmark not defined. EX041. Experience On Beating Heart Surgery With Continuous Coronary Artery Perfusion Without Aortic Cross Clamp ...... Error! Bookmark not defined. EX042. Management Procedure Patient With Pelvic Fracture Urethral Distruction Defect At RSUDZA Banda Aceh ...... Error! Bookmark not defined. EX043. Profile Of Hypertrophic Pyloric Stenosis In Pediatric Surgery Division Of Hasan Sadikin Hospital ...... Error! Bookmark not defined. EX044. Characteristic Appearance Of Patient With Collum Femur Fracture Posthemiarthroplasty In Dr. Zainoel Abidin General Hospital Of Banda Aceh ...... Error! Bookmark not defined. EX045. Saha Procedure In Brachial Plexus Lesion ...... Error! Bookmark not defined. EX046. Suralis Flap for Weight-Bearing Defect ...... Error! Bookmark not defined. EX047. Thalamic Abscess ...... Error! Bookmark not defined. EX048. Chest Wall Reconstruction Surgery Using Tahalele’s Method In Surabaya – Indonesia ...... Error! Bookmark not defined. EX049. Serum Lactate After Resuscitation As Indicator Morbidity And Mortality In Multiple Trauma In H. Adam Malik General Hospital, Medan ...... Error! Bookmark not defined. EX050. Modified Roux – Goldthwait Procedure As An Operative Management For Habitual Dislocation Of The Patella...... Error! Bookmark not defined. EX051. Recurrent Bilateral Occlusion Of Iliac Artery Due To Left Ventricle Thrombosis; A Challenging Case Of Successfull Limb Salvage, What Should We Learn ? ...... Error! Bookmark not defined. EX052. Penetrating Intracranial Gunshot Wound ...... Error! Bookmark not defined.

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EX053. Caspase-3,TNF-α And TGF-β As Risk Factors Of Kidney Fibrosis In Obstructive Nephropathy Of Kidney Stone ...... Error! Bookmark not defined. EX054. Review MorphometryCervical Vertebrae 3 - 7 Based On Multislice ComputedTomography Scan ...... Error! Bookmark not defined. EX055. Correlation Between Depression Level And Cortisol Level In Locally Advanced Breast Cancer (Clinical Study Of The Effect Of Depression Level Measured By The Beck Depression Inventory To Blood Serum Cortisol) ...... Error! Bookmark not defined. EX056. Effect Characteristics Of Microorganisms Aerobic And Anaerobic In Complications After Surgery In Perforated Appendicitis In Children ...... Error! Bookmark not defined. EX057. Correlation Between Cortisol And TNF α Serum Level As A Psychological Impact To The Severity Of The Advanced Breast Cancer Patient ...... Error! Bookmark not defined. EX058. The Effect Of Metformin As Complementary Medicine To Anthracycline Based Chemotherapy Neoadjuvant To Therapeutic Response And Mitotic Index In Locally Advanced Breast Cancer ...... Error! Bookmark not defined. EX059. Increasing GSH Level In Rat’s Skeleton Muscle That Have Ischemic Reperfusion Injury With Administration Of Nigella Sativa Extraction (Thymoquinone) ...... Error! Bookmark not defined. EX060. Sectoral Based Hepatectomy In Metachronous Liver Metastases...... Error! Bookmark not defined. EX061. Comparison Of Commercial Formula Enteral Nutrition With Hospital-Made Formula In Clinical And Laboratories Results On Abdominal Sepsis Patients In Dr. Soetomo Hospital ...... Error! Bookmark not defined. EX062. Right Main Bronchus Transection Due To Blunt Chest Trauma: A Case Report...... Error! Bookmark not defined. EX063. The 29 Years Experience Of Treating Penetrating Cardiac Trauma In Surabaya Indonesia...... Error! Bookmark not defined. EX064. Orthopedic Case Profile In Zainoel Abidin Hospital Since 2012 To 2013...... Error! Bookmark not defined. EX065. Total Colonic Aganglionosis: A Case Report...... Error! Bookmark not defined. EX066. Comparison The Effectiveness Between Hidrogen Peroxyde 1% And Povidone Iodine 1% As Intraoral Antiseptic For Post Operative Patients With Maxilofacial FractureError! Bookmark not defined. EX067. Relationship Analysis And Hyperbilirubinemia As A Prognostic Factors In The Incidence Of Complicated Acute Appendicitis ...... Error! Bookmark not defined. EX068. Transperitoneal Versus Retroperitoneal Laparoscopic Simple Nephrectomy: A Preliminary Study ...... Error! Bookmark not defined. EX069. Urologic Laparoscopic Surgery In Hasan Sadikin Hospital, Bandung Error! Bookmark not defined. EX070. Osteofibular Free Flap Reconstruction Following Mandibular Ameloblastoma Tumour Resection ...... Error! Bookmark not defined. EX071. Intractable Epilepsy On Schizencephaly And Polymicrogyria – A Case Report...... Error! Bookmark not defined.

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EX072. Comparison Of Epithelialization Rate In Deep Burn Injury Between Moist Exposed Burn Ointment, Silver-Sulfadiazine, And Honey Treatment (An Experimental Model) ...... Error! Bookmark not defined. EX073. Surgical Intervention Of Thoracic Spinal Dural Arteriovenous Fistula ...... Error! Bookmark not defined. EX075. Characteristic Of Operated Gastric Perforation Patients At Department Of Trauma Sanglah General Hospital Period Of June 2013-June 2014 ...... Error! Bookmark not defined. EX075. The Effect Of Dioscorea Esculenta (Gembili) Extract On P53 Gene Expression And Apoptotic Index On Breast Adenocarcinoma C3H Mice ...... Error! Bookmark not defined. EX076. Primary Breast Lymphoma Malignant ...... Error! Bookmark not defined. EX077. Profile Of Social Demography Traumatic Brain Injury In Surabaya At 2011 ..... Error! Bookmark not defined. EX079. Unusual Community Complications After Circumcision In Hasan Sadikin Hospital 2013-2014 Error! Bookmark not defined. EX080. Nigella Sativa Effect On Kidney Function Observed From Urea And Creatinine Levels On Bilateral Ureter Obstruction In Rabbit ...... Error! Bookmark not defined. EX081. Reconstruction Of Basalioma Lips Defect Using Local Flap ...... Error! Bookmark not defined. EX082. Locally Advanced Colon Cancer With Abdominal Wall Abscess ...... Error! Bookmark not defined. EX083. Total Rupture Of Jejunum Following Abdominal Blunt Trauma...... Error! Bookmark not defined. EX084. Primary Adenocarcinoma Of The Ileum ...... Error! Bookmark not defined. EX085. Redundant Colon Presented With Rectal Prolapsed On A 40 Years Old Male With Mental Retardate ...... Error! Bookmark not defined. EX086. External Validation Of Belgian Outcome Of Burn Injury (BOBI) Score On Burn Patient At Cipto Mangunkusumo Hospital 2012-2013 ...... Error! Bookmark not defined. EX087. Ductal Carcinoma In Situ On 65 Years Old Male ...... Error! Bookmark not defined. EX088. Successfully Non Operative Management Of Grade IV Blunt Renal Trauma ...... Error! Bookmark not defined. EX089. Laparoscopic Splenectomy In Immune ThrombocytopenicPurpura (ITP) ...... Error! Bookmark not defined. EX090. Adrenal Cortex Adenoma ...... Error! Bookmark not defined. EX091. Fibrous Dysplasia of the Maxilla with Osteosarcoma of the Mandible: A Case Report ...... Error! Bookmark not defined. EX092. Traumatic Rupture Of The Diaphragm With Herniation And Perforation Of Stomach And Ruptured Pedicle Of The Spleen ...... Error! Bookmark not defined. Ex093. Case Report: Cholestatic Syndrome With Systemic Lupus Erythematous In 44 Year Old Female Patient ...... Error! Bookmark not defined. EX094. Case Report: Colon Interposition In A 19 Year Old Male With Esophageal Stenosis Due To Chronic Injury By Consumption Of Corrosive Substance ...... Error! Bookmark not defined.

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EX095. CASE REPORT: MALE BREAST CANCER T1N0M0 IN 65YEAR OLD MAN ...... Error! Bookmark not defined. EX096. Scapulothoracic Dissociation: Report of Two Cases ...... Error! Bookmark not defined. EX097. Case Report: Giant Mesenteric Lipoma in 6 Year Old Female ...... Error! Bookmark not defined. INDEX ...... 49

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damage may progress over days and weeks and Oral Presentation cause pain, necrosis of skin, subcutaneous tissue, nerves, tendon and vessels damage. Patients also PODE001. Extravasation Of Intravenous suffer from functional defects, physiological Chemotherapy In RSUP Sanglah Denpasar distress, cosmetic changes, infection, and 2,3,6,7,8,16 Inge Kurniawati*, Putu Anda Tusta Adiputra** interruption of their treatment . Another *General Surgery Resident, Medical Faculty, consequences is litigation – nurses are now being Udayana University-Sanglah General Hospital. names in malpractice allegations and ** Subdivision of Surgical Oncology, General extravasation injury are an area for concern. The Surgery Department, Medical Faculty, Udayana frequency of cytotoxic drugs extravasation in University-Sanglah General Hospital, Bali- adults is considered to be between 0,01% and 3,4,5,7,10 Indonesia. 6% . Abstract Based on their potential to cause local tissue Introduction: Extravasation of intravenous injury, drugs are classified as vesicant and irritant chemotherapeutic agents is one of the most (table 1). Vesicant drugs have the capability to devastating complications, which unacceptable induce the formation of blister and or cause 1,9 condition either to patient nor to medical tissue damage . Irritant drugs can cause pain at services. Many health care providers realize that the injection pain, with or without an even one extravasation injury is too many, since inflammatory reaction, this drugs have the this injury is preventable. Published incidence potential to cause soft tissue ulcers only if a large rates of chemotherapy extravasation range from amount of concentrated drug solution is 1,9 0,01% to 6%, but in our institution, inadvertently extravasted . chemotherapy extravasation was not well Cytotoxic extravasation should lead us to be recorded, so the incidence rate are unclear and more aware about it, better to diagnose and the number of injuries are underestimated. treat it quickly to avoid sequalae or even better Method: We observed chemotherapy to avoid it by taking care of the venipunctures extravasation occurence during 6 months period and infusions. 4,11,15 in our institution, from September 2013 until Table 1. Vesicant and Irritants drugs March 2014. We recorded the chemotherapy Vesicant drugs Irritans drugs agents, patient’s clinical presentations, and High vesicant Low vesicant extravasation management. During that period, potential potential Bleomycine 1374 chemotherapies administered, and 10 Actinomycin D Aclacinomycin Carboplatin cases of chemotherapy extravasation occur, Amsacrine Cisplatin Cyclophosphamide Bisantrene Dacarbazine Carmustine particularly doxorubicine was the main Daunorubicine Docetaxel Gemcitabine chemotherapy agent. Almost all treated Doxorubicine Etoposide Ifosfamide conservatively, only 10% handled with surgical Epirubicine Esorubicin Irinotecan management. Eventually, 20% of cases have Idarubicine Flurouracil Melphalan Mechlorethamine Menogaril Pentostatin implanted port placed. Mitomycin C Mitoxantrone Plicamycin Conclussion: Extravasation of cytotoxic agents is Vinblastine Oxaliplatin Streptozocin a serious problem, it cause tissue damage, Vincristine Paclitaxel Topotecan prolong length of stay, increase hospital cost and Vindesine Vinorelbine psychological damage to cancer patients who under chemotherapy. It preventable but always Adequate identification of the potential factors underestimate by some clinicians, the use of for extravasation is important to minimize the central venous access device is one of the risk in some patients. In case of an increased risk solution to minimize the damage. of extravasation, preventive measures should be Introduction encouraged or in some cases, insertion of a Cytotoxic drugs in the treatment of malignancy CVAD (Central Venous Access Device) should be are well established, and the role of systemic considered. These factors can be classified under intravenous chemotherapeutic agents is patient associated and procedure risk factors10. increasing day by day 1,2. In addition to their therapeutics on malignant cells, cytotoxic agents Table 2. Patient and procedure-associated risk have the potential of causing destruction of factors 10,15,18 healthy cells 3,4,7. For all types of chemotherapeutic agents, extravasation is Patient related Cannulation and infusion feared and serious complication, the tissue procedure related - Small and fragile veins - Untrained or

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- Hard and/or sclerosed veins inexperienced staff venous catheter may be indicated as they as a consequence of - Multiple attempts at decrease the risk of extravasation20. multiple previous cannulation site 19 chemotherapy courses or - Unfavorable cannulation Types of Central Venous Access Devices : drug abuse site Chest Site Skin Tunnelled Catheter - Prominent but mobile veins - Bolus injection Implantable Port (e.g elderly persons) - High flow pressure Peripheral Site Peripheral Inserted Central - Known diseases or - Choice of equipment ( situations associated with peripheral catheter Catheter (PICC) an altered or impaired choice, size, steel Implantable Port circulation like Raynaud “butterfly” needle) Method syndrome, advanced - Inadequate dressing or This study was first time done in the Surgical diabetes, severe peripheral poor cannula fixation vascular disease, Oncology Subdivision, General Surgery lymphedema or superior Department, Medical Faculty, Udayana cava syndrome University - Sanglah General Hospital. We - Predisposition to bleeding, observed in the period of September 2013 to increased vascular permeability or those with March 2014 at Sanglah General Hospital. Six coagulation abnormalities. months of retrospective data was studied of - Obesity in which peripheral patients who had extravasation of chemotherapy venous access is more drugs. Totally 1374 chemotherapy administered, difficult - Sensory deficits that impair there were 10 patients (table 3) out of which the patient’s ability to eight were females (80%) and two were males detect a change in sensation (20%) have cytotoxic drug extravasation. They at the site of chemotherapy were aged 34-63 years, with the mean age of administration - Communication difficulties 45,6 years. Most of the patients belonged from or young children, which lower socioeconomic strata and not well hinder the early reporting of educated. Doxorubicin was resposible for the sign and symptoms extravasational side effects in all cases. allowing the identification of extravasation Table 3. Cases with site of the lesion - Prolonged infusion - Tumourous infiltration of No Age (years) Sex Site of lesion the area or other skin 1 50 Female Dorsum manus infiltrating disease 2 43 Male Forearm - “recall phenomenon” after 3 52 Female Cubital fossa previous radiotherapy, 4 38 Male Dorsum manus, administration of forearm doxorubicin and paclitaxel - Former vessel obstruction 5 49 Female Dorsum manus due to any reason 6 34 Female Dorsum manus 7 36 Female Forearm Management of chemotherapy extravasation 8 38 Female Dorsum manus 9 50 Female Dorsum manus, divided into pharmacological management (e.g wrist, lower leg using antidotes or corticosteroids) and non- 10 63 Female Forearm pharmacological management (e.g heat 5,13 application, topical cooling or surgery) . But In term of area involved, the dorsum of the hand extravasation has been termed “a preventable was involved in 6 cases (60%), the wrist in one catastrope”, so the best management is cases (10%), forearm in three cases (30%), prevention, in every department where cubital fossa and lower leg each in one case anticancer chemotherapy is administered (10%). There were one case with bulae and regularly, should establishing an adequate erythema, one case with massive subcutaneous 15 protocol and training the medical staff , having abscess, and the remaining eight cases had dry legitimate documentation and revised tissue necrosis. None of the patients had any “extravasation kit”. nerve, vessels or bone exposure. Nine cases had One of the preventable action, is by choosing immediate management consisted of hot or cold 17 CVAD than peripheral vein access . For those compressed only (90%) and one must undergo who have small, fragile veins and are in need of debridement (10%). All of them used peripheral long-term indefinite chemotherapy, continous vena access with abbocath size 20-22 G. After infusion of vesicant drugs, or both, a vascular the incidence, eventually, two cases (20%) have access device such as an implanted port, implanted port placed. tunneled catheter, or a nontunneled central Discussion

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The etiopathogenesis of tissue damage by 5. Schulmeister L. Vesicant Chemotherapy Extravasation extravasation of drugs enumerated in literature Antidotes and Treatments. Clinical Journal of Oncology includes: direct cellular toxicity of drug, Nursing. 2008; vol. 13(4): 395-398. vasoconstriction leading to ischemic necrosis, 6. Mouridsen HT, Langer SW, Buter J, Eidtmann H, Rosti G, De Wit M, et al. Treatment of Anthracycline osmotic damage, extrinsic mechanical Extravasation with Savene (Dexrazoxane): Result from compression by large volumes of extravasated Two Prospective Clinical Multicentre Studies. Annals of solutions which again leads to ischemic necrosis Oncology. 2007; 18: 546-550. and superimposed infection of skin sloughing 7. Thakur JS, Chauhan CGS, Diwana VK, Chauhan DC, Thakur 7 occurs . A. Extravasational Side Effects of Cytotoxic Drugs: A The majority of the patients will complain of Preventable Catastrophe. Indian J Plast Surg. 2008; vol. excruciating pain, and itching in the infusion site. 41(2): 145-150. Within a few hours, the extravasation area will 8. Mitsuma A, Sawaki M, Shibata T, Morita S, Inada M, show erythema, edema and induration. Within a Shimokata T, et al. Extravasation of Pegylated-Liposomal few days, these sign and symptom will increase Doxorubicin: Favorable Outcome after Immediate and the skin will show discoloration and Subcutaneous Administration of Corticosteroids. Nagoya desquamation of the epidermis or blister J Med.Sci. 2012; 74: 189-192. 9. Lancashire and South Cumbria Cancer Network. Policy formation. If a large dose of a cytotoxic drug is for The Management of Extravasation. Ver 3.1. Jun 2011. extravasated, the area will show ischemic Rev Jun 2013. changes and ulcer formation will be inevitable. 10. Fidalgo JA, Fabregat LG, Cervantes A, Marguiles A, Vidall In Indonesia, there still no legitimate C, Roilla F. Management of Chemotherapy Extravasation: documentation of cytotoxic drug extravasation, ESMO-EONS Clinical Practice Guidelines. Annals of so the incidence still unclear. Many health Oncology. 2012; 23 (supplement 7): wii67-wii73. provider with cancer center underestimating this 11. Gilleece C. Policy and Procedure Extravasation of injury, so there were no guidelines or protocol Cytotoxic Chemotherapy. Royal United Hospital Bath either no trained staff to early detect and to NHS. Aug 2009. Rev Aug 2012. manage the extravasation. The used of CVAD still 12. Langer SW, Sehested M, Jensen PB. Treatment of rare because of the price, but never compared Antracycline Extravasation with Dexrazoxane. American Association for Cancer Research. 2000; vol 6: 3680-3686. with the cost of prolonged hospitalization, extra 13. WOSCAN Cancer Nursing and Pharmacy Group. surgical management and ligitimate side. Chemotherapy Extravasation Guidelines. Sept 2009, Rev This study were very limited, need more data Sept 2012. and more time, but can be a starter to increase 14. Ho CH, Yang CH, Chu CY. Vesicant-type Reaction Due to the awareness all health providers who have Docetaxel Extravasation. Acta Derm Venereol. 2003; 83. cancer center exspecially in Indonesia. Maybe in DOI: 10.1080/00015550310013079. the next step we will have extravasation 15. Piko B, Laczo I, Szatmari K, Basssam A, Szabo Z, Ocsai H, guidelines, more trained staff and national et al. Overview of Extravasation Management and health insurance covers the used of CVAD. Possibilities for Risk Reduction Based on Literature Data. Conclussion Journal of Nursing Education and Practice, 2013; vol. 3 Extravasation of cytotoxic drugs further increase No. 9: 93-105. the suffering of cancer patients. It’s preventable 16. Schulmeister L, Preventing and Managing Vesicant Chemotherapy Extravasations. The Journal of Supportive so health providers who had cancer center Oncology. 2010; vol. 8, No. 5: 212-215. should have guidelines to administered cytotoxic 17. Evans L, Galloway J, Hall K, Martin J, Oncu L, Pledge P, et drugs, professional staff and also had protocol al. Extravasation Guidelines. North Trent Cancer Network for chemoterapeutic agents extravasation. V4. App 2011. Rev 2013. References 18. Ashwoth L. Anthracycline Extravasation: Reducing Risk 1. Una Cidon E, Contaldo A, Cocozza G. A Silent and Improving Quality in the Community Setting. Chemotherapy Extravasation as the Unexpected Enemy: Oncology Issues. 2010; 20-25. A Case Report. WebmedCentral Oncology. 2011; 2(9): 19. North East Yorkshire and Humber Clinical Alliance WMC002261. (Cancer). Guidelines for the Management of 2. Langer SW, Sehested M, Jensen PB. Anthracycline Chemotherapy Extravasation in Adults. Ver 1.5, 2011; Extravasation: A Comprehensive Review of Experimental Rev. 2014. and Clinical Treatments. Tumori. 2009; 95: 273-282. 20. Stoios N, Prevention of Extravasation in Intravenous 3. Ener RA, Meglathery SB, Styler M. Extravasation of Therapy: A Review of The Research Evidence. Nuritinga Systemic Hemato-Oncological Therapies. Annals of Electronic Journal of Nursing. 1999; vol. 2 : 2-8. Oncology. 2004; 15: 858-862. 21. Leung M, Bland R, Baldassarre F, Green E, Kaizer L, Hertz 4. Schrijvers DL. Extravasation: A Dreaded Complication of S, et al. Safe Administration of Systemic Cancer Therapy: Chemotherapy. Annals of Oncology. 2003; 14 Administration of Chemotherapy and Management of (Supplement 3): iii26-iii30. Preventable Adverse Events. Cancer Care Ontario. 2014; Evidence-Based Series #12-12: part 2.

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22. Thomson D, Adult and Paediatric Chemotherapy cancer known as an age-related disease. Second Extravasation Policy. 2014; Ver. 1.3. to female gender, advancing age is the most 23. Turner J, Oakley C, South East London Cancer Network important risk factor for breast cancer. Age (SELCN) Cytotoxic Extravasation Guidelines. 2012; Ver. interactions are frequently reported in studies 3.1. that examine etiology, prognosis and treatment.1 Almost 50% of women will be aged 65 or older at PODE004. Difference In Breast Cancer Diagnosis diagnosis. The estimated risk of new breast And Treatment By Age Among Balinese Women: cancer at 1 in 14 for women aged 60 to 79 Analysis Of The Local Cancer Registry compared with 1 in 24 women aged 40 to 59 and Yulan Permatasari1, Pande K. Aditya Prayudi1, 1 in 228 women aged 39 and younger.2 Hendra P. Setiawan1, Putu Anda Tusta Adiputra2 Because aging is a heterogeneous process, older 1) Faculty of Medicine, Udayana University, Bali, patients with cancer need individualized Indonesia. management.3 However; the challenge of 2) Division of Surgical Oncology, Surgery managing older patients with cancer is the ability Department, Sanglah General Hospital, Bali, to accurately assess whether the expected Indonesia. benefits of treatment outweigh risks. The lack of ABSTRACT comprehensive evaluation and efficacy data Introduction: Breast cancer characteristics restricts the basis of treatment modifications to including diagnosis and treatment among factors such as chronologic age and has retarded women of different age have not been the development of interventions to optimize extensively studied in Indonesia, especially cancer treatment in older adults. Despite among Balinese elderly. documented under-treatment, surgery and Objective: The aim of this study is to evaluate adjuvant treatment are well tolerated, effectively the trend in diagnosis and treatment of breast decrease relapse, and improve survival in many cancer among Balinese women aged 60 years older patients with cancer, including women and more compared with those of younger with breast cancer ≥ 80 years old. patients (< 60 years). Epidemiologic data is of paramount importance Method: This is a hospital-based analytic cross to research and progress of medical science in sectional study. Data are obtained from the the future. Currently, the incidence of breast breast cancer registry of admitted patients in cancer in Indonesia is 26 per 100.000 Sanglah General Hospital. populations but none is known about the Results: During the period of 1997-2013, 1045 incidence among the elderly.4 The lack of cases of breast cancer among Balinese women of epidemiologic data that concerns on breast various ages were recorded, of which only 134 cancer among older adults in Indonesia, and (12.8%) cases were attributed to the elderly (age particularly Bali, becomes the ground of our ≥ 60 years). The stadium at diagnosis did not effort to study the epidemiology of breast cancer differ significantly between younger and older among older adults. This problem should be patients (early stage: 23.1% vs. 26.1%; locally addressed by clinicians since the proportion of advanced: 48.5% vs. 49.3%; metastatic: 28.4% vs. elderly in Indonesia is now growing due to the 24.6%; p-value = 0.581). For early stage breast increased life expectancy. The aim of this study is cancer (stadium I and II), the rate for surgery did to describe the trend in diagnosis and treatment not differ significantly between younger and of breast cancer among older Balinese women older patients (94.3% vs. 88.6%, p-value = 0.257). aged 60 years and more compared with those of The rate for palliative care also did not differ younger patient (< 60 years). significantly between younger and older patients METHODS with metastatic breast cancer (18.9% vs. 24.2%, This study is a hospital-based cross sectional p-value = 0.528). study of all breast cancer cases recorded in local Conclusion: The diagnosis and treatment of cancer registry of Sanglah General Hospital. breast cancer did not differ between younger Sanglah General Hospital’s registry is the largest and older Balinese women. hospital registry in Bali that covers all Balinese INTRODUCTION population in nine districts, including Denpasar, Breast cancer is by far the most common cancer Badung, Tabanan, Negara, Gianyar, Bangli, among women of both developed and Klungkung, Karangasem, and Buleleng. We got developing countries. Breast cancer accounts for 1.045 cases of primary breast cancer diagnosed 22.9% of all female cancers and also the leading between 1997 and 2013 with various ages. cause of cancer death in females accounting for We defined elderly as those who aged 60 years 13.7% of their cancer related mortality.1 Breast and older. Then, we analyze the trend in

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Adjuvant Therapy diagnosis and treatment among our patients. We Age Surgery Radio- Chemo- Hormonal No Adjuvant Surgery therapy therapy Therapy Therapy made the cross-tabulation to compare the trend Yes 12 95 0 91 198 - in diagnosis and treatment in elderly patient < 60 6.1% 48.0% 0% 46.0% 94.3% years versus younger group. We recorded the distant No n = 210 3 10 1 17 12 - metastasis at time of diagnosis and staging of 9.7% 32.3% 3.2% 54.8% 5.7% Yes breast cancer. The kinds of treatment are 4 0 4 4 31 - ≥ 60 33.3% 0% 33.3% 33.3% grouped depend on staging of the patients. 88.6% years No We use Statistical Packages for Social Science n = 35 0 1 0 3 4 - 0% 25% 0% 75.0% (SPSS ver.16) to aid the analyses. The rates for 11.4% each characteristic within each group of age Most of women with LABC (79.5%) received were presented within percentage. Chi-square or surgery as their main treatment. In cross Fisher-Exact test was used to test for significance tabulation as seen in Table 3, women age < 60 between 2 proportions. The risk was estimated years with LABC were not significantly more by using Odd Ratio (OR) and 95% Confidence likely than older women to be treated with Interval (CI). surgery (80.1% vs. 75.8%, p-value = 0.662). RESULTS Table 3. Surgery therapy for LABC according to Out of 1.045 cases of breast cancer registered in age Sanglah General Hospital between 1997 and Surgery

2013, 134 cases (12.8%) were elderly and 911 Yes No (87.5%) cases were in non-elderly group. The < 60 years 354 88 n = 442 80.1% 19.9% mean age was 44.3±7.9 years among the Age younger women and 66.3±5.4 years among the ≥ 60 years 50 16 n = 66 75.8% 24.2% older women (mean age ± SD). The rate for palliative care also did not Stage of disease is the most important determinant of prognosis in breast cancer and differ significantly between younger and older therefore plays a key role in treatment planning. patients with metastatic breast cancer (18.9% vs. 24.2%, p-value = 0.528); as showed by Table 4. We describe the staging using the TNM system Unfortunately, no data about survival were by the American Joint Committee on Cancer (AJCC). Stage I and II are classified as early stage available. Table 4. Palliative therapy for metastatic stage breast cancer (245 patients); stage III also known according to age as LABC (508 patients); and stage IV are classified Palliative as metastatic stage (292 patients). The stadium Yes No at diagnosis did not differ significantly between < 60 years 49 210 younger and older patients (p-value = 0.581). The n = 259 18.9% 81.1% Age comparison showed in Table 1. ≥ 60 years 8 25 Table 1. Staging of breast cancer according to n = 33 24.2% 75.8% age Stage of breast cancer DISCUSSION Early stage LABC Metastatic < 60 years 210 442 259 According to Surveillance Epidemiology and End n = 911 23.1% 48.5% 28.4% Results (SEER) database, patients aged 60 years Age ≥ 60 yeas 35 66 33 and older constitute about 70% of breast cancer n = 134 26.1% 49.3% 24.6% patients, and about 46% are aged 70 years and Surgery and adjuvant treatment are well older.5 In USA, approximately 50% of breast tolerated, effectively decrease relapse, and cancers occurs in women 65 years of age or older improve survival in many older patients with and more than 30% occur after the age of 70.6 cancer. However, elderly patients with breast Incidence for women 70 years or older diagnosed cancer frequently present with one or more co- with breast cancer varied from 100 to 350 per morbid conditions in addition to their cancer, 100.000 per year during 2000-2004 in Europe.7 In and this can complicate clinician’s treatment Egypt, the peak incidence of breast cancer occurs decisions. Moreover, older patients with cancer in the age group 40-59 years; with the increase are seldom comprehensively evaluated. As seen of life expectancy, breast cancer among elderly in Table 2, for early stage breast cancer (stadium Egyptians is expected to rise markedly in the I and II), the rate for surgery did not differ future.6 Based on 1045 cases of breast cancer significantly between younger and older patients among Balinese women that were recorded (94.3% vs. 88.6%, p-value = 0.257). during 1997-2013, only 134 cases (12.8%) were Table 2. Treatment method for early breast cancer according to age

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Heading To Good Surgery attributed to the elderly (age ≥ 60 years); in experience higher mortality from early-stage which 24.6% came with distant metastasis. breast cancer.10 Their study is corresponding to Stage of disease is the most important our result that less elderly undergo surgery determinant of prognosis in breast cancer and procedure (88.6% vs. 94.3%); and higher therefore plays a key role in treatment planning. proportion for palliative care in elderly (24.2% vs. The size of primary tumor, the lymph node 18.9%). Unfortunately, after statistic analyses, status, and the presence of distant metastases the rate of surgery for early stage breast cancer determine breast cancer stage. Early-stage did not differ significantly (p = 0.257); and so did breast cancer is generally defined as stage I or II, the rate of palliative for metastatic breast cancer locally advanced as stage III, and metastatic as (p = 0.528). stage IV. In our study, older Balinese women are Several large studies on breast cancer not more likely to present in a later stage than demonstrates that elderly women receive less- younger women. Elderly which diagnosed with aggressive primary therapy11,12,13 including lower early stage was count for 26.1%, compared to overall surgical rates, fewer axillary dissections, 23.1% for younger patients. Locally advanced higher rates of not receiving postoperative stage present slightly higher for older patients radiation or chemotherapy, and higher rates of compared to the other group (49.3% vs. 48.5%). adjuvant hormonal therapy used alone. In our Surprisingly, younger group showed more study, older women also have lower rates metastatic stage compared to their older adjuvant chemotherapy (33.3% vs. 48.0%) and counterpart (28.4% vs. 24.6%). However; the radiotherapy (0% vs. 6.1%) after primary surgery stadium at diagnosis did not differ significantly treatment. As many large reviews have reported, between both groups (p = 0.581). treatment selection does correlate strongly with Stages I, II, or III is considered curable with 5-year survival, in which patients who receive optimal therapy, and according to Surveillance the least aggressive therapy have the worst Epidemiology and End Results (SEER) database, prognosis. One large study reported that five- 5-year overall survival for women of all ages is year overall survival was 46% for women 94% for Stage I and 80% for Stage II and III receiving no therapy, 51% for tamoxifen alone, together.8 Furthermore, SEER database 82% for mastectomy, and 90% for breast- demonstrates that average 5-year survival for conserving surgery with adjuvant therapy.14 elderly patients is lower in each stage and It is difficult to discern the reasons behind the decreases with advancing age. Age-specific 5- observed under-treatment among the elderly in year overall survival for patients with Stage I our study, whether it was the physician bias, cancer to be 88% for those aged 67 to 74,84% for patient preference, or co-morbidity limiting the those aged 75 to 84, and 50% for those aged options of treatment. Since our study is an 85and older, and for subjects with Stage II observational study that based on hospital cancer, to be 79% for those aged 67 to 74, 62% registry, there is potential for residual for those aged 75 to 84, and35% for those aged confounding factors for which we do not have 85 and older.9 However, we could not determine data, such as performance status, social support, the overall survival of these women since data educational background, and economic status about the survival is still lacking in our registry. which contribute to determine the choice of Primary therapy for early-stage breast cancer in therapy. We suggest that access to health care is elderly people should include surgery unless the one of the most important determining factors patient has an absolute contraindication. to this under-treatment. Majority of the elderly Standard therapy for early-stage breast cancer in Bali still have low awareness to breast cancer involves local therapy (surgical mastectomy or screening due to low education level and lumpectomy with or without radiation) followed therefore making them having more advance by adjuvant systemic therapy. Adjuvant therapy disease at diagnosis and less likely to receive is therapy given after a definitive surgical more aggressive treatment. Their lower procedure to reduce the risk of future socioeconomic status also plays an important recurrence. This reduction in risk is accomplished role since screening and treatment to breast with systemic therapy by destroying potentially cancer is still considered costly. Lack of family metastatic tumors that may have escaped the support may also affect decision to treatment. breast and lodged as microscopic niduses at Even when the elderly admitted to hospital to distant sites.9 Schonberg et al. showed that receive treatment, they are sometimes not women age ≥80 years have breast cancer eligible to undergo surgery as the majority of characteristics similar to those of younger operative risk results from underlying co- women yet receive less aggressive treatment and morbidity and the effects of anesthesia on their

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Heading To Good Surgery dysfunctional organ systems. However, this issue 5. Ries LAG, Melbert D, Krapcho M, editors. SEER cancer can be addressed by optimizing preoperative statistics review, 1975–2004. Bethesda: National Cancer Institute. care of underlying disease and individualization 6. Zeeneldin AA, Ramadan M, Gaber AA, Taha FM. Clinico- of anesthetic technique (general, local, or spinal pathological features of breast carcinoma in elderly anesthesia) to minimize operative risk.15 Egyptian patients: a comparison with the non-eldery However, there are several limitations to our using population-based data. Journal of the Egyptian NNational Cancer Institute 2013; 25: 5-11. study. This study is a a hospital-based cross 7. Downey L, Livingston R, Stopack A. Diagnosing and sectional study with the number of sample treating breast cancer in elderly women: a call for within the elderly group is far smaller than the improved understanding. JAGS 2007; 55: 1636-1644. non-elderly group. This makes it rather difficult 8. McCarthy EP, Burns RB, Freund KM et al. Mammography use, breast cancerstage at diagnosis and survival among to make an exact correlation between age and older women. J Am GeriatrSoc 2000;48:1226-33. stage at presentation or kinds of treatment 9. Biganzoli L, Wildiers H, Oakman C et al. Management of received. We are also not sure of how many elderly patients with breast cancer: updated percent of Balinese population are covered in recommendations of the International Society of Geriatric Oncology (SIOG) and European Society of Breast our registry since our registry is a hospital Cancer Specialists (EUSOMA). Lancet Oncol 2012; 13: registry that rely its data source solely from the e148-60. admitted patients. Thus, Balinese women with 10. Schonberg MA, Marcantonio ER, Li D et al. Breast cancer breast cancer that are not admitted to Sanglah among the oldest old: tumor characteristic, treatment choices, and survival. Journal of Clinical Oncology 2010; General Hospital will not be included in our 28: 2038-45. registry. This will make the generalization of our 11. Wanebo HJ, Cole B, Chung M et al. Is surgical results to the population rather difficult. Further management compromised inelderly patients with studies with larger sample are needed to further breast cancer? Ann Surg 1997;225:579-89. 12. August DA, Rea T, Sondak VK et al. Age related enrich the understanding of breast cancer in differences in breast cancertreatment. Ann SurgOncol elderly women. 1994;1:45-52. CONCLUSION 13. Kessler HJ, Seton JZ. The treatment of operable breast In accordance to the global trend of breast cancer in the elderly female. Am J Surg 1978;135:664-66. 14. Bouchardy C, Rapiti E, Fioretta G et al. Undertreatment cancer in elderly, there is a tendency for older strongly decreasesprognosis of breast cancer in elderly women in Bali to receive less surgical treatment women. J ClinOncol 2003;21:3580-87. as the primary therapy than their younger 15. Samain E, Schauvliege F, Deval B et al. Anesthesia for counterparts. However, our result did not find breast cancer surgery inthe elderly. Crit Rev OncolHematol 2003;46:115-20. any significant differ between younger and older Balinese women in trend of diagnosis and PODE005. Biologic Characteristics Of Breast treatment for breast cancer. Future study Cancer In Balinese Elderly Women involving a larger number of elderly diagnosed Pande K. A. Prayudi1, Yulan Permatasari1, with breast cancer is needed to further Hendra P. Setiawan1, Putu Anda Tusta Adiputra2 understand the exact correlation between age 1Faculty of Medicine, Udayana University, Bali, and breast cancer characteristics among the Indonesia. elderly of Balinese population. 2Division of Surgical Oncology, Surgery REFERENCES Department, Sanglah General Hospital, Bali, 1. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. GLOBOCAN 2008 v1.2, Cancer Incidence and Indonesia. Mortality Worldwide: IARC Cancer Base No. 10. Lyon, ABSTRACT France: International Agency for Research on Cancer Introduction: Histology and expression of [online], specific protein markers are important http://www.globocan.iarc.fr/factsheets/cancers/breast.a sp; 2010 [accessed on 15.06.2014]. prognostic determinant of breast cancer. 2. Holmes CE, Muss HB. Diagnosis and Treatment of Breast However, biologic characteristics of breast Cancer in the Elderly. CA Cancer J Clin 2003;53:227–244. cancer among Balinese elderly have not been 3. Clough-Gorr KM, Stuck AE, Thwin SS, Silliman RA. Older extensively studied. Breast Cancer Survivors: Geriatric Assessment Domains Are Associated With Poor Tolerance of Treatment Objectives: The aim of this study is to evaluate Adverse Effects and Predict Mortality Over 7 Years of the biologic characteristics of breast cancer in Follow-Up. J Clin Oncol 2010; 28:380-386. older Balinese women (age ≥60 years). 4. Dinas Kesehatan Nasional. Data penderita kanker Methods: This is a hospital-based analytic cross- payudara di Indonesia. http://www.depkes.go.id/index.php/berita/press- sectional study. Data are obtained from the release/1060-jikatidak-dikendalikan-26-juta-orang-di- breast cancer registry of admitted patients in dunia-menderita-kanker-.html. 2007. [accessed on Sanglah General Hospital. 15.06.2014]. Results: A total of 1,045 cases of breast cancer among Balinese women were recorded during

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Heading To Good Surgery the period of 1997-2013, of which 134 (12.8%) patients in clinical trials is an important factor were diagnosed in elderly. Infiltrating ductal contributing to this limited knowledge.4 In spite carcinoma (IDC) was the most common histologic of the paucity of data, age is considered to be an type (75.4%), followed by infiltrating lobular important determinant of therapy, and the carcinoma (ILC, 4.3%), invasive carcinoma of no pattern of care of breast cancer patients differs special type (4.2%), mucinous carcinoma (1.9%), depending on age.5,6,7 More information about medullary carcinoma (0.9%), and malignant the biology and clinical features of breast cancer phylloides tumor (0.8%). There was a significant is needed to support the different approaches to difference in the rate of IDC (76.7% vs. 75.4%, therapy in elderly patients. Several large reviews p=0.018) and invasive carcinoma of no special have reported that the biology of breast cancer type (3.7% vs. 7.5%, p=0.045), but not for ILC, differs according to age, with the elderly tend to mucinous carcinoma, medullary carcinoma, and have more favorable tumor biology.8,9 However, malignant phylloides tumor. The rate for ER- little is known about the biology of breast cancer positive, PR-positive, p53-positive, and HER2- among older Indonesian women, particularly of positive, as well as the rate of Luminal A, Luminal Balinese ethnicity. B, over-expressed HER2, and Triple Negative The aim of this study is to evaluate the biologic breast cancer also did not differ significantly characteristics of breast cancer among older between younger and older patients. Balinese women. Conclusions: The biologic characteristics of METHODS breast cancer differ between younger and older We use the breast cancer registry of Sanglah Balinese women in terms of histologic type but General Hospital as the source of our data. The not for the expression of hormone receptors. registry is the largest hospital registry in Bali INTRODUCTION covering Balinese population in nine districts, Breast cancer is the most common cancer among including Denpasar, Badung, Tabanan, Negara, women in both developed and developing Gianyar, Bangli, Klungkung, Karangasem, and countries. It is also the leading cause of cancer Buleleng. The registry also includes data from death in females. In the United States, there patients that reside outside the island of Bali were more than 200,000 new cases of breast since Sanglah General Hospital is the center of cancer and 40,000 deaths in 2005.1 Currently, referral for East and West Nusa Tenggara region. the incidence of breast cancer in Indonesia is 26 Thus, we exclude patients who reside outside per 100.000 populations.2 Advance age is the Bali. We got 1,045 cases of primary breast cancer most important risk factor for breast cancer. diagnosed between the year of 1997 and 2013. According to Surveillance Epidemiology and End Only 160 cases presented with hormone Results (SEER) databases, 43% of breast cancer receptor status (ER, PR, HER2) and 128 cases patients are aged 65 and older at diagnosis, and presented with p53 staining since 58% aged 65 and older at the time of breast immunohistochemistry analysis was applied cancer-related death.1 since 2004 and it was costly and not covered in The general population of Indonesia is now insurance, so not every patient could afford the aging. According to the data published by the examination. Only tumor with histologic type of Indonesian Ministry of Health, with the increase infiltrating ductal carcinoma present with of life expectancy, the number of older grading (n=711). We defined elderly as those population will be continuously increasing over who aged 60 years and older. Then, we describe the next decades. In 2000, the life expectancy for the characteristics for histology and grading, Indonesian is 64.5 years with 7.18% of the hormone receptor (ER, PR, HER2, p53), and IHC population are aged 60 years and older. The life classification (Luminal A, B, HER2-type, Triple expectancy increases to 69.43 years in 2010 negative) according to the age group (elderly vs. (elderly population being 7.56% of total non-elderly breast cancer). We compare the rate population) and to 69.55 years in 2011 (elderly for breast cancer characteristics among the population being 7.58% of total population).3 elderly and non-elderly or younger women. We Therefore, elderly will represent an increasing use Statistical Packages for Social Science (SPSS cohort of patients with breast cancer in the ver.16) to aid the statistical analysis. The rates future. for each characteristic within each group of age Although the number of elderly patients with were presented within percentage. Chi-square breast cancer is increasing, knowledge about (χ2) or Fischer-Exact test was used to test for possible differences in the biology and clinical significance between 2 proportions. outcomes of breast cancer according to age is limited. The relative under-enrollment of elderly RESULTS

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A total of 1,045 cases of breast cancer among Grade II 310 49.1 39 48.8 0.004 >0.05 Balinese women of various ages were recorded Grade III 264 41.8 33 41.2 0.010 >0.05 ILC 39 4.3 6 4.5 0.011 >0.05 during the period of 1997-2013, of which 134 Invasive ca 34 3.7 10 7.5 4.031 <0.05 (12.8%) cases were attributed to elderly (age ≥60 of no years). The mean age was 44.3±7.9 years among special the younger women and 66.3±5.4 years among type Mucinous 17 1.9 3 2.2 0.086* >0.05 the older women (mean age ± SD). The biologic carcinoma characteristics of all study population were Medullary 8 0.9 2 1.5 0.465* >0.05 presented in Table 1. Infiltrating ductal carcinoma carcinoma (IDC) was the most common histologic Malignant 8 0.9 1 0.7 1.000 >0.05 phylloides type (75.4%), followed by infiltrating lobular tumor carcinoma (ILC, 4.3%), invasive carcinoma of no *Fisher-Exact test. special type (4.2%), mucinous carcinoma (1.9%), Number of sample that presented with grading medullary carcinoma (0.9%), and malignant was 711, 631 in the younger group and 80 in the phylloides tumor (0.8%). Luminal A was the most older group. common type of breast cancer in this study population. Although there was a tendency of the younger Table 1. Breast cancer characteristics of all patients to had a higher rate of positivity for the studypopulation expression of estrogen receptor (ER), n % progesterone receptor (PR), and human Total sample 1,045 Elderly breast cancer (EBC) 134 12.8 epidermal growth factor receptor-2 (HER2), the Non-elderly breast cancer (NEBC) 911 87.2 results did not statistically significant. The rate of Luminal A, Luminal B, over-expressed HER2, and Histology (n=1,045) Triple Negative breast cancer also did not differ IDC 788 75.4 ILC 45 4.3 significantly between older and younger patients Invasive carcinoma of no special type 44 4.2 (Table 3). Mucinous carcinoma 20 1.9 Medullary carcinoma 10 0.9 Table 3. Expression of specific protein markers Malignant phylloides tumor 9 0.8 and IHC profiling of breast cancer according to Hormone receptor (n=160) age group. ER-positive 66 41,2 Age PR-positive 63 39.1 <60 years ≥60 years χ2 p- HER2-positive 51 31.8 old old value No. % No % IHC Classification (n=160) . Luminal A 57 35.6 Hormone 14 15 Luminal B 20 12.5 receptor 5 Luminal C/HER2-type 30 18.8 (n=160) Triple negative 53 33.1 ER-positive 62 42. 4 26. 1.453 >0.0 8 7 5 Elderly had a lower rate of IDC but a higher rate ER-negative 83 57. 11 73. of invasive carcinoma of no special type 2 3 PR-positive 59 40. 4 26. 1.079 >0.0 compared to younger patients (75.4% vs. 76.7%, 4 7 5 7.5% vs. 3.7%, respectively, p<0.05). However, PR-negative 87 59. 11 73. there was no significant difference in the rate of 6 3 ILC, mucinous carcinoma, medullary carcinoma, HER2- 46 31. 3 20. 1.414 >0.0 positive 5 0 5 and malignant phylloides tumor between older HER2- 10 68. 12 80. and younger patients. The rate of high grade IDC negative 0 5 0 also did not differ significantly (Table 2). P53- 34 29. 4 36. 0.262 >0.0 positive 1 4 5 P53- 83 70. 7 63. Table 2. Histologic type of breast cancer negative 9 6 according to age group Age IHC 14 15 <60 years ≥60 years χ2 p- Classificatio 5 old old value n (n=160) No. % No. % Luminal A 53 36. 4 26. 0.579 >0.0 Histology 6 7 5 (n=1,045) Luminal B 18 12. 2 13. 1.000 >0.0 IDC 698 76.7 90 75.4 5.631 <0.05 4 3 * 5 Grade I 57 9.0 8 10.0 0.080 >0.05 Luminal 29 20. 1 6.7 1.576 >0.0 31

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C/HER2- 0 * 5 In a study involving 50,828 and 256,287 women type with invasive breast cancer in the San Antonio Triple 45 31. 8 53. 3.032 >0.0 negative 0 3 * 5 Breast Cancer and SEER (Surveillance, *Fisher-Exact test. Epidemiology, and End Results) databases in Number of sample that presented with p53 United States, biologic characteristics of breast staining was 128, 117 in the younger group and cancer are more favorable in older women 9 11 in the older group. compared with the younger women. In San Antonio database, the rate of positivity for DISCUSSION estrogen receptors increased from 83% in Our results suggest that biologic characteristics patients 55-64 years old to 87% in patients 65-74 of breast cancer in older women are different years old to 90% in patients 75-84 years old to compared with the younger women. We found a 91% in patients ≥85 years old (p<.001). Older statistically significant difference in the rate of women had higher rate of tumors that were certain histologic subtypes. Older women in our diploid, had a low S-phase fraction and normal study had a lower rate of IDC but higher rate for p53, and were negative for epidermal growth invasive carcinoma of no special type. Although factor receptor and c-erbB2 compared with the there was a tendency for higher rate of mucinous younger women. The SEER database also and lobular carcinoma (histologic subtype which supported similar correlations between age and 9 are associated with more indolent growth and biologic characteristics. However, in both San progression) among older women, these results Antonio and SEER databases, they observed no were not statistically significant. For the statistically significant differences in histological expression of certain protein markers (ER, PR, subtype, although there was a trend toward HER2, p53) as well as immunohistochemistry more-lobular and mucinous types (which are profile, we found no statistically significant associated with more-indolent disease). difference between older and younger women. However, many of the large studies investigating Several large epidemiologic studies involving the biologic characteristics among older women thousands of patients in North America and use younger women (age < 60 years) as a control Europe confirmed that the biology of breast group. In our study, the mean age for the cancer in elderly patients appears to be different younger group was 44.3±7.9 years (mean±SD). than in young women, with different molecular Only few that investigates the correlation markers and a slower, more-indolent pattern of between increasing age and the tumor growth and progression. In a study involving characteristics among the very old patients. In a more than 3,200 patients in Europe and 800 study involving 49,616 women from SEER- patients from the Massachusetts General Medicare data set, the investigator examine the Hospital, various prognostic markers were tumor characteristics of women age 80 years or compared according to age.8 They found no older (80-84, 85-89, and ≥90 years) with stage I/II significant association between age and histology breast cancer compared with younger women (ductal vs. lobular) or tumor stage at diagnosis, (age 67-79 years). They reported that tumor although there were significant correlations characteristics (i.e. histology, grade, hormone 10 between age and expression of hormone receptivity) were similar across age groups. receptors. They found that estrogen receptor However, the youngest women in this study (ER) expression, a known biomarker of improved were older than most women included in other prognosis, correlated positively with age. ER studies. This study suggested that it is possible positivity was observed in 40% of patients aged that tumors present with more favorable 40, in 60% of patients aged 60, and in more than characteristics with older age but beyond age 67 10 70% of patients aged 80 (p-value <0.001). HER-2 years, these differences are negligible. Other overexpression, a known poor prognostic studies have also demonstrated that there were indicator, correlated inversely with age, with no correlations between increasing age and 29% positivity in those younger than 40, 17% in hormone receptor positivity among women older 11,12 those aged 40-60, 14% in those aged 60-70, and than 70 years. only 9% in those aged ≥70 years (p-value Our study population was of Balinese ethnicity, <0.001). No significant association between age and therefore are Asians. Asians may have a and markers of angiogenesis or invasion, i.e. different tumor characteristics compared to vascular endothelial growth factor (VEGF), Caucasians or Africans. One study has reported cathepsin D, and uroplasminogen activator. that breast cancer characteristics indeed differ according to race and ethnicity.13 They reported that relative to non-Hispanic white women,

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Asians women (Filipinos, Chinese, Koreans, 2. Dinas Kesehatan Nasional. Data penderita kanker Vietnamese, Indian/Pakistanis) who live in the payudara di Indonesia. http://www.depkes.go.id/index.php/berita/press- United States have a greater risk of presenting release/1060-jikatidak-dikendalikan-26-juta-orang-di- with biologic characteristics that associated with dunia-menderita-kanker-.html. 2007. [Accessed on a poorer prognosis. Asian women had 1.2- to 2.6- August 31, 2014]. fold elevation in the risk of having either ER- 3. Data and Information Center Indonesian Ministry of Health. Gambaran Kesehatan Lanjut Usia di Indonesia. negative or PR-negative tumor. Asian women Buletin Jendela Data dan Informasi Kesehatan. Jakarta: also had 20-70% reductions in the risk of having Bakti Usadha. 2013. pp.1-18. lobular and/or ductal carcinoma (except for 4. Goodwin JS, Hunt WC, Humble CG, Key CR, Samet JM. Indians/Pakistanis). Among Filipino and Chinese Cancer treatment protocols. Who gets chosen? Arch Intern Med 1988;148:2258-60. women, there were even 1.3- to 3.4-fold 5. Bergman L, Kluck HM, van Leeuwen FE, Crommelin MA, increases in risk of mucinous carcinoma.13 In a Dekker G, Hart AA, et al. The influence of age on study involving 280 Chinese women with invasive treatment choice and survival of elderly breast cancer breast cancer, it was reported that the patients in south-eastern Netherlands: a population- based study. Eur J Cancer 1992;1475-80. immunohistochemical typing characteristics of 6. Rijke JM, Schouten LJ, Schouten HC, Jager JJ, Koppejan the elderly and youths were different.14 AG, van den Brandt PA. Age-specific differences in the Therefore, race/ethnicity may play a significant diagnostics and treatment of cancer patients aged 50 role to the expression of certain breast cancer years and older in the province of Limburg, The Netherlands. Ann Oncol 1996;7:677-85. phenotype. The role may be attributed to the 7. Goodwin JS, Hunt WC, Samet JM. Determinants of cancer difference in genetics and lifestyle among the therapy in elderly patients. Cancer 1993;72:594-601. races. 8. Eppenberger-Castori S, Moore DH Jr, Thor AD. Age However, there are several limitations to our associated biomarker profiles of human breast cancer. Int J Biochem Cell Biol 2002;34:1318-1330. study. Our study is a hospital-based cross- 9. Diab SG, Elledge RM, Clark GM. Tumor characteristics sectional study that used data from a hospital and clinical outcome of elderly women with breast registry. The number of elderly breast cancer in cancer. J Natl Cancer Inst 2000;92:550-56. our registry is far smaller than the number of 10. Schonberg MA, Marcantonio ER, Li D, Silliman RA, Ngo L, and McCarthy E. Breast Cancer Among the Oldest Old: non-elderly breast cancer. The number of Tumor Characteristics, Treatment Choices, and Survival. J patients that present with result from Clin Oncol 2010;28:2038-2045. immunohistochemistry analysis is even smaller 11. Gazetas P, Estabrook A, O’Neil J. Importance of adequate since not every patient can afford the staging and of hormone receptors in women older than age 70 with breast cancer. Ann Surg 1992;216:22-26. examination. On the other hand, we are not sure 12. Ferno M, Borg A, Johansson U. Estrogen and of how many percent of Balinese population are progesterone receptor analyses in more than 4,000 covered in our registry since our registry is a human breast cancer samples: A study with special hospital registry that rely its data source solely reference to age at diagnosis and stability of analyses- Southern Swedish Breast Cancer Study Group. Acta from the admitted patients. Thus, Balinese Oncol 1990;29:129-135. women with breast cancer that are not admitted 13. Li CI, Malone KE, Daling JR. Differences in Breast Cancer to Sanglah General Hospital will not be included Hormone Receptor Status and Histology by Race and in our registry. Our study population may be less Ethnicity among Women 50 Years of Age and Older. Cancer Epidemiol Biomarkers Prev 2002;11:601-607. representative to the general population of 14. Ji H, Ai N, Li Q, Zhang K, Di W. Clinical pathologies of women with breast cancer. Further efforts to breast cancer in the elderly and youths and their increase the number of sample are needed in the prognosis. Park J Med Sci 2014;30(3):535-538. future study. CONCLUSIONS PODE009. Giant Lipofibromatosis In A 5 Year The biologic characteristics of breast cancer Old Girl: A Case Report differ between younger and older Balinese Putu Astri Novianti*, Putu Anda Tusta women in terms of histologic type but not for the Adiputra** expression of hormone receptors. Future study *General Surgery Resident, Medical Faculty, involving a larger number of elderly diagnosed Udayana University-Sanglah General Hospital with breast cancer is needed to further ** Subdivision of Surgical Oncology, General understand the exact correlation between age Surgery Department, Medical Faculty, Udayana and breast cancer characteristics among the University-Sanglah General Hospital, Bali- elderly of Balinese population. Indonesia REFERENCES ABSTRACT 1. Surveillance Epidemiology and End Results (SEER) Cancer Introduction: Lipofibromatosis is a rare benign Statistics Review 1975-2002, based on SEER data soft tissue tumor in childhood, slow growing with submission 2004 [on-line]. Available at predilection to involve distal extremities. Only a http://seer.cancer.gov/csr/1975_2002/ Accessed August 31, 2014. few cases have been published in literature.

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Here, we report a case of lipofibromatosis August 2014. Data retrieved from the medical occurring on the lower left leg of a 5 year old girl. records were reviewed then sorted into defined The decision to either amputate or salvage the categories and analyzed. affected limb has been a controversial one, as Result: The population analyzed was composed large amount of muscles, vascular and bones has of 83 patients. The results showed that most of been affected due to its large mass. the patients were male (54.22%), young adult Case presentation: A 5 year old girl presented aged from 19 to 35 years (45.78%). They were with painless enlarging mass in her lower left leg mainly foreigner (89.16%), Australian (22.89%), since she was 3 months old. Mass range in size with insurance coverage (54.22%). The tetanus 24x37x35 cm. MRI showed a soft tissue mass vaccination status was updated in most of our located at lower left leg muscle that has been patients (54.22%). The wounds were largely pressing on the artery which also caused the laceration wounds (85.54%), located at the lower bowing of the tibia and fibula bones. The extremities (51.81%), caused by accident (e.g. controversy lies on the best course of action falling, slipping, swept by wave) and motor taken which would either be limb salvation or vehicle accident (83.13%). Most of the incident amputation. Considering that only a few muscles happened on the month of August (16.87%) and can be saved, we choose to go with amputation. July (14.46%). The length of stay was less than 5 But upon evaluating the vascular, muscles, and days in 90.36% of our patients. There was no 24- bone during wide excision, we ultimately hour post surgery infection found in our study decided to save the extremity. population. Conclusions: Delay in seeking treatment makes Introduction tumor enlarges and causes muscles, bones or Undeniably, wound will affect the quality of life vascular complications. Careful surgical decision of both the patient and their caregiver. is vital in offering the best possible care to the Physically, wound brings changes in the patient. Due to the lack of data about post appearance and how patients perceive operative prognosis, management must be themselves. Wound will bring impairment in the based on patient condition and clinical evolution. functionality and daily activities. Patient needs to bear the pain and restriction that it brings. All of PODH004. Sociodemographic And Clinical these will also bring psychological, social, and Profile Of Patients With Surgical Wound financial impact. Social interactions may be Debridement At BIMC Hospital Nusa Dua: A impaired. Treatment will cost, and lost day at Descriptive Study work will add to the extent. Gst. A. A. Kartika Saraswati*, Putu Anda Tusta Wound debridement plays a crucial role in Adiputra** wound healing. The term debridement comes *General Practitioner, Emergency Department, from the French desbrider, which means to BIMC Hospital, Nusa Dua, Bali-Indonesia. unbridle. It was probably first used as a medical **General Surgeon & Surgical Oncologist, BIMC term by surgeons working several hundred years Hospital, Nusa Dua, Bali-Indonesia. ago in war zones, after realizing that grossly Abstract contaminated soft tissue wounds had a better Introduction: Wound may bring a spectrum of chance of healing (and the soldier surviving) if impact to the bearer, ranging from the physical the affected tissue was surgically removed to pain and burden to emotional impact. Therefore, reveal a healthy bleeding wound surface.1, 2 wound debridement is playing a crucial role in Debridement is the removal of nonviable tissue the treatment of both acute and chronic and foreign matter (i.e. necrotic tissue, exudates, wounds. Sharp debridement has been practiced bacteria, and metabolic waste) from a wound in long in history, and when done surgically, it is the order to improve and accelerate healing process. fastest method to remove devitalized tissue. The Debridement naturally occurs in the wound purpose of this study is to give a picture of repair process, however when overwhelming characteristics of patients who undergone accumulation of damaged tissue is present, the surgical debridement in the operating theatre at natural process alone is insufficient. In this BIMC Hospital Nusa Dua Bali, from process, sharp debridement played a crucial role sociodemographic and clinical view. in speeding the wound healing.3-5 Method: This study is retrospective and Debridement is often classified based on the descriptive, utilizing a quantitative approach. It mechanism of action into autolysis, chemical, involved analysis done upon patients with chief mechanical, biologic, or sharp.3-5 Sharp complaint of wound, who were admitted since debridement is a method of debridement using the opening of the hospital on May 2012 until sterile equipment such as scalpel, scissor, or

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Heading To Good Surgery forceps. It can be done conservatively involving larger number of exposures to high risk activity repeated and sequential tissue sparing at the in male such as driving, riding motorcycle, bedside or in the procedure room or surgically in surfing, and extreme sports (e.g. paragliding). the operating theatre, however, either fashion Table 1. Distribution of study population based on must be performed by a skilled, well-trained, and gender qualified health care provider.1, 3, 5 Gender Number Percentage Surgical debridement involves wider excision of Male 45 54.22% devitalized tissue, including the removal of healthy tissue from the wound margins.5 It is Female 38 45.78% best used in cases of contaminated tissue or We divided the study population into five age sepsis where rapid removal is essential. It is also groups: children, adolescent, young adult, adult, best to be performed on large areas. Therefore, and elderly. The result showed young adult age it is ideal for trauma cases, where the wound is group (19-35 years old) was accounted for most contaminated. of the cases (45.78%). People on this age group Because it must be undertaken by a skilled and are productive financially, and their health status trained surgeon or practitioner, hence it is has not deteriorated due to aging. Therefore, outside of the scope of non physician they are the most active and mobile. This will practitioners. As it requires theatre space, it is make them more exposed to high risk activities. related with higher cost. Due to its invasive Given the financial independence and prime manner, anesthesia is often required, which health status, most of the travelers that travel to brings associated risk. The time spent in hospital Bali are within this age group. The financial will also increase.3,5 independence will also ease the access to Being a newly opened hospital located at one recreational high risk sports such as paragliding, popular tourist attraction, BIMC Hospital Nusa skateboarding, and surfing. Dua is exposed to a unique set of patients. The second most prevalent age group was the Therefore, sociodemographic and clinical profile adult age group (36-60 years old). This age group of these patients will provide invaluable has similar characteristics as the young adult information for understanding patient group, which may be accountable for the high characteristics, to carry out required preventive number. measures and improve standard of care in the Children were accounted for 19.28% of the future. cases. This is probably caused by the nature of Method this age group, where they often are exploring This is a retrospective and descriptive study, and playing. Childhood injury should not be utilizing a quantitative approach. The inclusion taken lightly; it is a major public health burden criteria of this study is: patient who was under that requires urgent attention. Unintentional full care of BIMC Hospital Nusa Dua from the injuries are the leading cause of death for time the surgery was done until the patient was children aged 10-19 years.8 Parental supervision discharged, and patient with chief complaint of is an utterly important key in preventing injuries wound that made surgical management in in this age group. operating theatre required. If there was any Table 2. Distribution of study population based on other injury present that served as the main age group reason a surgical approach needed to be done, Age Group Number Percentage the patient was therefore excluded. Data Children 0-12 16 19.28% collection was done through electronic medical Adolescent 13-18 2 2.41% records review and then further compiled. The Young adult 19-35 38 45.78% data tabulation was done with spreadsheet in Adult 36-60 21 25.30% Microsoft Excel and further constructed into Elderly >60 6 7.23% tables. The data interpretation then further analyzed in regard of current literature of the topic under study. The majority of the cause of the wounds was Result accident (36.14%), such as slipping, falling, The study population consisted of 83 patients stumbling, etc. A lot of tourists are involved in who met the inclusion criteria and admitted adventurous activities like trekking, hiking, and since May 2012 until August 2014. Out of 83 outbound games. Naturally, the risk of trauma is patients, 45 patients (45.78%) were male. This increasing. Water sports activities such as was noted on one of the previous study done in swimming also predisposes tourists to certain Brazil as well.7 This finding may be caused by risks, such as slipping in the poolside, hitting the

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Heading To Good Surgery head to the pool side/bottom when diving, and unintentional burn. This finding is concordant swept to the reef by big wave. In two of the with the WHO data on childhood injuries, where cases the causes were boat hit when they were it is stated that injury and violence is a major swimming in the sea. killer of children in the world, and 90% of them Preventive measures for these causes need to be are unintentional.8 taken by the community at large. Preventing Given the magnitude of the problem, prevention adventurous activities during holiday obviously is highly important. Three ‘E’s has been used to will not be accepted, hence, preventing injury describe interventions to prevent unintentional and limiting the extent of injury may be the injuries; they are: education, enforcement, and solution. Hotels, villas, tourist attractions, engineering. Education is important as it can shopping centers, and other public spaces need raise awareness and provide guardians with to adopt ergonomic and safety concepts. Holes proper ways to prevent injuries and give first and uneven surfaces need to be repaired; aids. Children themselves can also be spillage and wet areas need to be marked. Stair advantaged through education by teaching them edges need to be marked to increase visibility. safer way to play. Children needs to understand Lifeguard and beach authorities need to enforce the importance of seatbelt and sports protective the rules and limitation for visitor. Last but not gears. Enforcement by the authorities is least, people also need to be aware of potential important in banning the production and sale of hazard of adventurous activities and they need unsafe products. Children’s environment also to pay attention to recommended safety needs to be modified through engineering for measures. safety. Measures that can be taken are installing The second highest contributor was motor window bars, pools fencing, and covering vehicle accident (MVA). The traffic in Bali is very wells.8,9 crowded. The rules are often unmet; hence it is quite dangerous for inexperienced driver or Table 4. Distribution of study population based on rider. Young tourists are often adventurous and age group and incident cause Childre Adolesce Youn Adul Elderl Tot often seen riding motorcycle – one of the main n nt g t y al transportation modalities in Bali. The difference adult in traffic densities, driving lane, and road culture MVA 0 2 22 4 2 30 might contribute to the high number of MVA Accident 15 0 11 9 4 39 Surfing 0 0 2 5 0 7 (36.14%). Syncope 0 0 0 1 0 1 As Bali is a surfing destination, 8.43% of the Paraglidi 0 0 0 1 0 1 wounds were related to surfing injuries. Being ng done in the sea, surfing itself has its own injury Assault 0 0 1 0 0 1 Animal 0 0 0 1 0 1 risk. Fins of surf board are sharp and this is strike responsible as the cause of wounds in some of Burn 1 0 0 0 0 1 the patient. Animal 0 0 1 0 0 1 Out of the study population, only one was bite Skate 0 0 1 0 0 1 admitted due to chronic wound. The rest was board acute wound caused by trauma. Total 16 2 38 21 6 83 Table 3. Distribution of study population based on the cause of the wounds Motor vehicle accidents or road traffic injuries Cause Number Percentage are the leading cause of death among people MVA 30 36.14% aged 15-19 years, and the second leading cause Accident 39 46.99% among 10-14 years age group. It mostly affects Surfing 7 8.43% 15 and 44 years old.8, 10 This is consistent with Syncope 1 1.20% our findings where MVA is the leading cause of Paragliding 1 1.20% injury in the adolescent and young adult group. Assault 1 1.20% MVA make up a significant portion of the Animal 1 1.20% worldwide health burden. It is the leading cause Burn 1 1.20% of death by injury and the tenth-leading cause of Bite 1 1.20% all death throughout the world. It is estimated Skateboarding 1 1.20% that in a year, 50 million people are injured because of MVA, occupying 30% to 70% of If we cross the data of the cause of injury and orthopedic beds in developing countries hospital. age group, in children, 15 out of 16 cases were Developing countries endured 85% of annual caused by accidents and 1 case was caused by deaths and 90% of the disability-adjusted life 36

Heading To Good Surgery years (DALYs) lost because of road traffic injury; Travel preparation is essential. Pre-travel hence, it has become a major public health vaccination, prevention of prevalent non problem in low and middle income countries.10, 11 vaccine-preventable disease, emergency contact A public health approach needs to be taken to numbers, nearest health facility location, address this problem, risk factors need to be common traveler’s ailment, and first aid assessed, and a systematic framework needs to measures are essential information that needs to be developed. The World Bank and the World be obtained prior to traveling. Getting a travel Health Organization (WHO) suggest a "systems health insurance is likely to put travelers at ease approach" to road traffic safety that stresses if any medical emergency happens. involvement at all levels of the road traffic system, that is, not only involving the road users, Table 5. Distribution of study population based on but also road providers and enforcers (such as residential status vehicle manufacturers, road traffic planners, Residential Status Number Percentage road safety engineers, police, educators, health Indonesian 3 3.61% professionals, and insurers).11, 12 Expatriate 7 8.43% Reducing exposure of road users by providing Foreign travelers 73 87.95% efficient land use and shorter, safer routes can reduce the risk of road traffic injuries. Taking into Australians were accounted for 22.89% of cases. accounts the road function (high speed, rural, This may be related to the popularity of Bali as a transitional between high speed and rural, and tourist attraction in Australia. Given the close residential) in designing road and the safety of distance, Bali is reachable by most Australians. pedestrian and cyclist, has shown to reduce The close distance also reduces cost and accidents significantly. Improving the motorized eliminates the need to adjust to major time vehicle into a more crashworthy and visible one changes. is important as well. Nonetheless, setting road and safety rules, securing compliance, and Table 6. Distribution of study population based on improving transport policy is essential.10, 13 All of nationality these measures can only be achieved through Nationality Number Percentage harmonious and motivated work with policy Indonesian 3 3.61% makers and government. Italian 4 4.82% From health care provider point of view, hospital French 6 7.23% and its human resources need to prepare for the Australian 19 22.89% post-crash care. Increasing the readiness of the American 5 6.02% health facilities will reduce the mortality and Dutch 3 3.61% morbidity rate; this can be achieved through Japanese 5 6.02% continuous and constantly updated education, Czechs 1 1.20% 10, 13 training, and improvement in facilities. A British 3 3.61% rapid response emergency team systems that German 5 6.02% can dispatch ambulance quickly also needs to be Russian 10 12.05% established, since time is invaluable in most of Swedish 1 1.20% the trauma cases. Indian 1 1.20% Most of the patients were foreigners who travel Canadian 1 1.20% to Bali (73 out of 83). Seven out of 83 of the patients were expatriates, and the rest are Norwegian 4 4.82% Indonesian (3 out of 83). The hospital location Belgian 3 3.61% may have influenced this finding. Tourists often New Zealander 1 1.20% involve themselves in relatively unsafe Brazilian 1 1.20% recreational activities such as surfing, Irish 1 1.20% paragliding, hiking, etc; this too may have Swiss 1 1.20% contributed as the cause of high prevalence of Korean 1 1.20% wound in tourists. Foreigners who drive car or Ukrainian 1 1.20% ride motorcycle, even walk as pedestrian, may be Austrian 1 1.20% are not familiar with the traffic rules and Finnish 1 1.20% condition. This predisposes them to higher risk of Argentinian 1 1.20% having motor vehicle accidents. Foreign travelers should do a research before coming to Bali so they can have an image of Bali.

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The largest portion of our patients was covered securing compliance in the community to update by insurance (45 out of 83). Financially secured their vaccination is very important.15 patients are more likely to search for medical assistance, this may be the reason. Most of the Table 9. Distribution of study population based on study population was from developed country tetanus vaccination status (91.57%), usually the awareness and the financial Tetanus vaccination status Number Percentage capability of getting insured is higher. The Updated 45 54.22% majority of the rest was self-paying (36 out of Outdated 26 31.33% 83). The others were covered by private third Unknown 12 14.46% party, this happens when, for example, the patient is injured in hotel facilities and the hotel Forty eight of our patients had single prominent wants to cover the expenses. wound, while the rest (35 patients) had multiple wounds. Table 7. Distribution of study population based on financial coverage Table 10. Distribution of study population based on Financial coverage Number Percentage the number of prominent wound(s) sustained Self-pay 36 43.37% Number of Number Percentage Insurance 45 54.22% prominent wound(s) Private 2 2.41% Single 48 57.83% Multiple 35 42.17%

The causal incident mainly happened in August (16.78%) and July (14.46%). This may be related Most of the patient had wounds on the lower to the volume of tourist coming to Bali at those extremities (43 out of 83) and upper extremities months. Those months are the so called ‘high (33 out of 83). Because some of the patients had season’ with the highest number of visitor, as multiple wounds, the multiple locations were pictured in the trends in the report of foreign also counted. The percentages presented in the tourist numbers based on month by Balai Pusat table 10 below were generated by dividing the Statistik (Statistic Center) of Bali Province.14 number of patient with wound on certain location with the total number of patient (83 Table 8. Distribution of study population based on the patients). month of causal incident occurrence Lower extremities is often uncovered and Month Number Percentage unprotected during activities, especially in Bali, January 4 4.82% as a tropical areas, a lot of people are wearing February 6 7.23% shorter attire. It is also largely involved in March 3 3.61% activities like running, swimming, hiking, and April 9 10.84% trekking. Consistent with the leading cause of May 9 10.84% injury in the study – accidents – slipping, stumbling, and falling, it naturally contributes to June 5 6.02% a significant portion of injuries in the lower July 12 14.46% extremities. Wearing proper protective August 14 16.87% equipment during high risk activities (such as September 6 7.23% outbound games, riding, driving) will reduce the October 10 12.05% chance of injury. November 4 4.82% December 1 1.20% Table 11. Distribution of study population based on the location of wound Forty five of our patients had updated tetanus Location of wound Number Percentage vaccination, while 26 of them had their last Scalp 13 15.66% tetanus vaccination more than 10 years ago. The Face 20 24.10% rest (12 patients) was unsure of their vaccination Lip 1 1.20% status. In all patients with unknown tetanus Tongue 2 2.41% vaccination status, appropriate immunization Trunk 8 9.64% had been administered. The risk of tetanus Upper extremities 33 39.76% increases in case of puncture wounds and Lower extremities 43 51.81% wounds with a significant amount of tissue injury. Since it is a vaccine-preventable disease,

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Based on international guidelines for the care of Infection 4 4.82% pressure ulcer (NPUAP-EPUAP 2009), surgical Foreign body 1 1.20% debridement in the operating theatre is 3, 13 recommended in the following cases: The majority of our patients (90.36%) stayed in - Presence of advancing cellulitis hospital for less than 5 days. Most of them - Wound related sepsis stayed for 2 days (42.17%), usually this was the - Extensive necrotic tissue case if they come at the day of the incident and - Inability to establish degree of undermining undergone the surgery straightaway, then and tunneling discharged on the next day after 24-hour - Infected bone or hardware that may need to observation, follow up, and once the pain is be removed tolerable with oral painkiller. In patients who We observed several main reasons in our study stayed for 5 days or longer, a more complicated population that played role in the decision case was usually present. One of the cases was making of whether patients will undergo surgical involving a chronic wound that required skin debridement or not. Forty seven (56.63%) of our graft, while other cases had associated injuries patient underwent surgical debridement because that made them stayed longer. Associated of the complexity of the wound. Complexity in injuries noted were related to head injuries, such the shape and nature (e.g. irregular, jagged as subarachnoid hemorrhage, dizziness, and edges, flapping, deeply contaminated, through headache. Headache and dizziness were and through, presence of necrotic tissues), and impairing the patient’s ability to mobilize, which depth (i.e. involvement of deeper structures such was one of the discharge criteria. Other factor as galea aponeurotica, muscles, vessels, exposed was pain tolerance; certain patient had lower bones, etc) made it difficult for optimal bedside pain tolerance and requires more time to adjust. wound debridement. Fifteen of the patients During the hospital stay, there was no post- were having wounds that either multiple or surgery infection found. involving an extensive area (for example when a patient is having wide deep contaminated Table 13. Distribution of study population based on excoriation wounds). Four out of 83 patients had hospital length of stay an advancing infection that needs to be debrided Length of stay in number of day(s) Number Percentage urgently. One of the patients had a foreign body 1 14 16.87% (gravel) in the wound that required exploration 2 35 42.17% and extraction. 3 16 19.28% Health care provider must familiarize themselves 4 10 12.05% with wound healing process and appropriate 5 4 4.82% wound care, to ensure proper treatment for 6 2 2.41% patients. Health care provider needs to be 7 1 1.20% trained to recognize impending infection and 9 1 1.20% able to dispose accurate antibiotic. Comprehensive and appropriate patient Conclusion education is also necessary, as patient is their The population analyzed was composed of 83 own caretaker at home. They also need to be patients. The results showed that most of the motivated to perform good wound care and to patients were male (54.22%), young adult aged comply with treatment plan. from 19 to 35 years (45.78%). They were mainly On the other hand, sixteen (19.28%) of our foreigner (89.16%), Australian (22.89%), with patients were undergoing surgical debridement insurance coverage (54.22%). The tetanus in the operating theatre because of the need of vaccination status was updated in most of our anesthesia. This group is either composed of patients (54.22%). The wounds were largely uncooperative children or patients that could not laceration wounds (85.54%) and located at the tolerate the pain during debridement in the lower extremities (51.81%), which needed to be procedure room. debrided surgically due to the complexity (56.63%). Most wounds were caused by accident Table 12. Distribution of study population based on (e.g. falling, slipping, swept by wave), followed the main reason of performing surgical debridement by motor vehicle accident (83.13%). Most of the Reason Number Percentage incident happened on the month of August Extensive 15 18.07% (16.87%) and July (14.46%). The length of stay Complexity 47 56.63% was less than 5 days in 90.36% of our patients. Need of anesthesia 16 19.28%

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There was no 24-hour post surgery infection ulcers: quick reference guide. Washington DC: National found in our study population. Pressure Ulcer Advisory Panel; 2009. 17. Banyaknya wisatawan mancanegara yang datang Prevention – primary, secondary, or tertiary – is langsung ke bali per bulan tahun 2009 - 2013 [Internet]. very important to decrease the burden of 2014 [updated 2014 Apr 12; cited 2014 Aug 25]. disease. Specific primary preventive measures Available from: directed to specific cause of injury needs to be http://bali.bps.go.id/tabel_detail.php?ed=611001&od=1 1&id=11 systematically done. Education to patients and 18. Tiwari TSP. Manual for the surveillance of vaccine- community at large to take care of their wounds preventable diseases [Internet]. 2014 [updated 2014 Apr well, hence preventing complications (such as 1; cited 2014 Aug 25]. Available from: infection or dehiscence) is also essential. http://www.cdc.gov/vaccines/pubs/surv- manual/chpt16-tetanus.html Nonetheless, rehabilitation to prevent future disability also needs to be reinforced. PODJ001. Shark Bite On Surfers In Bali: A Serial Health care provider need to continuously Cases Report improving their standard of care to cater the I Gusti Ngurah Gde Dwi Aryanata*, Putu Anda needs of the population. Human resources Tusta Adiputra**, Made Bramantya Karna*** improvement through training, facilities *Emergency Department, BIMC Hospital, Kuta, upgrading, and communication with policy Bali-Indonesia. maker must take place in harmony in order to **General Surgeon & Surgical Oncologist, BIMC answer the growing challenge. Hospital, Kuta, Bali-Indonesia. References ***Orthopedics Surgeon, BIMC Hospital, Kuta, 1. Leaper D. Sharp technique for wound debridement [Internet]. 2002 [updated 2002 Dec; cited 2014 Aug 25]. Bali-Indonesia. Available from: Abstract http://www.worldwidewounds.com/2002/december/ Introduction: Shark attack on humans annually 2. Leaper/Sharp-Debridement.html averaging 50–75 unprovoked incidents and 3. Stuart E, Harding K. Wound bed preparation: the science behind the removal of barriers to healing [Internet]. resulting in about 5–10 deaths.The main victims 2003[updated 2003; cited 2014 Aug 25]. Available from: have been surfers and swimmers who crossed http://www.medscape.com/viewarticle/459733_6. over the natural barrier reefs running along the 4. Ramundo JM. Wound debridement. In: Bryant RA, Nix seashore. Shark bite cases in Bali have never DP, editors. Acute & chronic wounds current. 5. management concepts. 4th ed. Missouri. Elsevier; 2012. been reported in scientific meeting or journal. 6. Ayello EA, Baranoski S, Cuddigan J, Sibbald KG. Wound Our hospital recorded 3 shark bite cases since debridement. In: Baranoski S, Ayello EA, editors. Wound 2011. nd care essentials practice principles. 2 ed. Pennsylvania. Case Presentation: A 30 year old British male, Lippincott Williams & Wilkins; 2008. 7. Gray D, Acton C, Chadwick P, Fumarola S, Leaper D, present with open wound on his right forearm Morris C, Stang D, Vowden K, Vowden P, Young T. from shark bite during surfing. He had ruptured Consensus guidance for the use of debridement of Extensor muscles and tendon Abductor techniques in the UK. Wounds UK. 2010;6(4). pollicis, Extensor pollicis and Extensor 8. Steed DL, Donohoe D, Webster MW, Lindsley L. Effect of extensive debridement and treatment on the healing of digitorumcommunis. The second, an 18 year diabetic foot ulcers. Diabetic Ulcer Study Group. J Am oldAustralian male, present with open wound in Coll Surg. 1996;183(1):61-4. his right hand from Shark bite. He had multiple 9. Oliveira BGRB, Lima FFdS. The sociodemographic and bite marks with normal fingers movement. Last, clinical profile of clients with cutaneous wounds. Online Brazilian Journal of Nursing. 2007;6(0). 36 year old South African male, present with 10. Peden M, Oyegbite K, Ozanne-Smith J, Hyder AA, open wound on the right foot from shark bite. He Branche C, Rahman AKMF, Rivara F, Bartolomeos K, had multiple bite marks without suspicion of editors. World report on child injury prevention. tendon ruptured. Switzerland: World Health Organization; 2008. 11. Protect the ones you love: child injuries are preventable Discussion: The management is depend on the [Internet]. 2012 [updated 2012 Apr 12; cited 2014 Aug severity of injuries. The goals of therapy are to 25]. Available from: http://www.cdc.gov/SafeChild/Falls/ prevent or treat infection and minimize soft 12. Worley H. Road traffic accidents increase dramatically tissue damage.Tetanus prophylaxis is very worldwide [Internet]. 2006 [cited 2014 Aug 25]. Available from: important considerations. Radiological studies http://www.prb.org/Publications/Articles/2006/Road are obtained to identify fractures, air inside joint, 13. TrafficAccidentsIncreaseDramaticallyWorldwide.aspx piece of broken tooth or a foreign body in the 14. Nantulya VM. The neglected epidemic: road traffic wound.Empiric choice of antibiotics for an actual injuries in developing countries. BMJ 2002;324:1139. 15. Mohan D, Tiwari G, Meleckidzedeck K, Nafukho FM, wound infection will depend on the predicted editors. Road traffic injury prevention training manual. inciting organisms. India: World Health Organization; 2006. Introduction 16. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Treatment of pressure

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As a number of people increase, the number of the Thumb. Generally, he looked in mild to travelers increase as well, including traveling to moderate pain, vital signs is stable. beach or sea for recreation. This condition also Investigation: increase the number of people who going to Radiograph did not show fractures or foreign swimming, diving, surfing, snorkeling, and scuba bodies. diving and will increase their risk to have interaction with marine animals, especially sharks. Over the last decade, more and more tourists have been going to places where there are sharks, and the local communities are not prepared for the number of people going into the water.[1] Shark attack on humans is not a recent phenomenon, annually averaging 50–75 unprovoked incidents and resulting in about 5– 10 deaths. In more recent years, despite the Fig. 1. Open wound on the dorsal side. impact of fishing pressure on shark populations, the worldwide trend towards more intense recreational use of marine waters has increased the chances of shark-human interactions, resulting in an increase in the total number of attacks.Most attacks are recorded in waters of the United States (primarily in Florida and California), South Africa, and Australia. [2,3] Attacks by sharks have resulted in fewer than

400 fatal victims around the world since records Fig. 2. Flapping wound with some ruptured tendons. first started being kept in the early 1900s. However, from 1992 to 2009 in Recife, Brazil, sharks bite 53 people, of whom 20 died as a result of bleeding. The main victims have been surfers and swimmers who crossed over the natural barrier reefs running along the seashore.[3] Shark bite cases in Bali has never been reported in a scientific meeting or journal. Our hospital recorded 3 shark bite cases since 2011, all of the Fig. 3. Exposing the ruptured tendons. victim was bitten when they were surfing in 3 different sites in Bali. In this chance we would like to report all the 3 cases of shark bite, how we manage these victims and how is the outcome. Case Presentation 1 A 30 year old male, British nationality present in Emergency Department BIMC hospital with open wound on his right forearm from shark bite 2 hours priorly when he was surfing. Visual Fig. 4. Multiple bite mark on the ventral side. examination showed flapping wound on the Treatment dorsal side of the forearm, 20 cm length, 8 cm An IV line was inserted with 2000 ml NaCl 0.9% width, 5 cm depth with bowing rough edge. bolus in 2 hours and then maintained with 2000 Inside the wound showed some ruptured tendon ml for 24 hours. A 50 mcg Fentanyl was and active bleeding. On the ventral side of the administered for the pain by bolus and continue forearm, described as multiple bite mark with 300 mcg Fentanyl finished in 24 hours on (morethan 15 wounds) and actively bleeding (fig. syringe pump. Antibiotic Ciprofloxacine 400 mg 1,2,3,4). He could not do extention on the injection was given every 12 hours considering Metacarpophalangeal (MCP) joint on all fingers, sea water contamination covering Vibrio spp. unable to do extention and flexion on the MCP of Tetanus vaccination was up to date. A surgery

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Heading To Good Surgery conducted by Orthopedics for wound debridement, tendon and wound repair under general anesthesia. On exploration found ruptur of Extensor Muscles (Abductor Pollicis et Extensor Pollicis) to the thumb and Extensor Digitorum Communis.

Fig. 9.

Fig. 5. Exploring muscle and tendon ruptures.

Fig. 10.

Fig. 6. Ruptured tendon of abductor pollicis and extensor pollicis has been repaired.

Fig. 11.

Fig. 7. Repairing ruptured muscle of extensor digitorum communis.

Fig. 12.

Fig. 8.

Fig. 13. Fig. 8-13. Repairing the flapping skin and inserting draining tube.

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A surgery conducted by General Surgeon for debridement and wound repair under General Anesthesia. A broad spectrum antibiotic Cephazolinewas administered withCiprofloxacine prior surgery. Tetanus Toxoid was injected along with Tetanus Imunoglobulin (Tetagam). The surgery was well conducted. No ruptured tendon was found upon exploration. He was observed in the recovery room for 6 hours before discharged. Fig. 14. Multiple bitemark on the ventral side has been repaired. Outcome and Follow Up He was continuing treatment as outpatient with Antibiotic Cefixime and Ciprofloxacine. He was followed up every 3 days since after without any complication. Case Presentation3 A 30 year old male, South African, present in Emergency Department with open wound on the right foot since 3 hours ago when he was surfing. On visualexamination found multiple laceration Fig. 15. Procedure finished. wound described as bite mark, morethan15 After the surgery his arm was stabilized on wounds, round shape on the medial part of the Lumbrical Position Cast and Dynamic Splint on foot and the plantar part, bleeding has stopped, the Thumb. no tendon exposure, he still able to move the Outcome And Follow Up toes normally. He was continuing treatment at the hospital for another 3 days, 3 different antibiotic was administered which was Netilmycine 100 mg (Hypobac) IV every 12 hours, Ceftriaxone 1 gram IV every 12 hours and Ciprofloxacine 400 mg IV every 12 hours. Painkiller was maintained for 2 days after surgery with Fentanyl 300 mcg IV drip finished in 24 hours. Post operative treatment was uneventfull and he recovered well. He was follow up 1 week after surgery, there was no complication found and then the next follow up was conducted in his home country. Case Presentation 2 Fig. 16. Bitemark on the medial side of the right foot. An 18 year old male Australian present in Emergency Department BIMC Hospital with open wound on his right hand from shark bite 2 hours priorly when he was surfing. On visual examination he had multiple laceration wound on the right hand, vary in size, the biggest was on the thumb base 5 cm length 2 cm width and 1 cm depth, bleeding actively, no visible ruptured tendon and finger movement was normal. On the other of thumb area and interphalangeal II and III, multiple laceration wound, 2 cm in length, 1 cm width and 0.5 cm depth averagely, it was also bleeds actively. Investigation Fig. 17. Bitemark on the plantar side of the right foot. X-ray study showed no fractures or foreign Investigation bodies. X-ray of right pedisreveal no fracture, neither Treatment foreign bodies. Treatment

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An IV line was inserted with NaCl 0.9%. Antibiotic provoked attacks, four interactions involving a Ceftriaxone 2 gram with Ciprofloxacine 400 mg shark biting a motorized or non-motorized vessel has given by IV injection, tetanus toxoid and ("boat attack"), six incidents regarded as not tetanus imunoglobuline was also administered involving a shark ("doubtful"), two cases intramuscularly. Fentanyl was administered for involving sinking ships or downed aircraft ("air- the pain by IV bolus.A surgery conducted by sea disaster"), two incidents involving post- General surgeon for debridement and wound mortem bites ("scavenge"), and 11 cases in repair under Spinal Anesthesia. Upon which data is not yet available to determine if an exploration, there was no ruptured tendon, no unprovoked shark attack occurred major vascular or nerve damage, no foreign ("insufficientevidence"). bodies. The 2013 yearly total of 72 unprovoked attacks was lower than the 81 recorded in 2012 and represents the lowest global total since 67 in 2009. In general, however, the number of worldwide unprovoked shark attacks has grown at a steady pace since 1900, with each decade having more attacks than the previous. The numerical growth in shark interactions does not necessarily mean there is an increase in the rate of shark attacks; rather, it most likely reflects the ever-increasing amount of time spent in the sea by humans, which increases the opportunities for interaction between the two affected parties.

Fig 19. Post operation wound appearance. Outcome and follow up Patient was observed in the hospital for 24 hours after the surgery, the pain was maintained with 400 mcg Fentanyl on IV drip (Syringe pump) for 24 hours. It was unevenfull, he was discharged from the hospital with antibiotic Cefixime 200 mg every 12 hours and Ciprofloxacine 500 mg every 12 hours for 5 days. Follow up was scheduled every 2 days after discharged. Discussion The International Shark Attack File investigated 125 incidents of alleged shark-human interaction occurring worldwide in 2013. Upon review, 72 of these incidents represented confirmed cases of unprovokedsharkattacks on humans. "Unprovoked attacks" are defined as incidents where an attack on a live human by a shark occurs in its natural habitat without human provocation of the shark. Incidents involving sharks and divers in public aquaria or research Positive identification of attacking sharks is very holding-pens, shark-inflicted scavenge damage to difficult since victims rarely make adequate already dead humans (most often drowning observations of the attacker during the "heat" of victims), attacks on boats, and other incidents the interaction. Tooth remains are seldom found involving provocation by humans occurring in or in wounds and diagnostic characters for many out of the water are not considered unprovoked requiem sharks (family Carcharhinidae) are attacks. "Provoked attacks" usually occur when difficult to discern even by trained professionals. a human initiates physical contact with a shark, That said, this list must be used with caution e.g. a diver bitten after grabbing a shark, attacks because attacks involving easily identified on spearfishers and those feeding sharks, bites species, such as white, tiger, sandtiger, occurring while unhooking or removing a shark hammerhead and nurse sharks, nearly always from a fishing net, etc. The 53 incidents not identify the attacking species, while cases accorded unprovoked status in 2013 included 28 involving difficult to identify species, such as

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requiem sharks of the genus Carcharhinus, Carcharias spp., lamnifor 0 2 2 seldom correctly identify the attacker. Thus the m list is skewed to readily identified species. A Carcharodoncarchari white 201 78 279 number of requiem sharks in the as, genus Carcharhinus likely are involved in many Galeocerdocuvier, tiger 73 28 101 more attacks than they are credited in this list and, if the list could reflect that Galeorhinusgaleus tope 1 0 1 reality, Carcharhinus bites would push such Ginglymostomacirrat nurse 10 0 10 species as the sandtiger, hammerhead and nurse um, sharks towards the bottom of the list. Heterodontisportusja port 1 0 1 Nonetheless, the white, tiger and bull sharks are cksoni, jackson the "Big Three" in the shark attack world because Cookiecut Isistiusbrasiliensis, 1 0 1 they are large species that are capable of ter inflicting serious injuries to a victim, are Shortfinm Isurusoxyrinchus, 9 1 10 commonly found in areas where humans enter ako the water, and have teeth designed to shear rather than hold. Realistically, almost any shark Isurus spp., mako 8 0 8 in the right size range, roughly six feet (1.8 Lamnanasus, porbeagle 2 0 2 meters) or greater, is a potential threat to Negaprionbrevirostri lemon 10 0 10 humans because, even if a bite is not intended as s, a directed feeding attempt on a human, the Notorhynchuscepedi sevengill 5 0 5 power of the jaw and tooth morphology can lead anus, to injury.7 spotted Table 1. Species of shark implicated in confirmed Orectolobusmacalatu wobbego 4 0 4 unprovoked attacks around the world, 1580 – 2013. s, ng Non- Fatal Orectolobus spp., Wobbego Common fatal Tot 19 0 19 Species Unprovo ng Name Unprovo al ked ked Prionaceglauca blue 9 4 13 Carcharhinusamblyrh grey reef 7 1 8 Rhinobatos spp., guitarfish 1 0 1 ynchos, Hammerh Carcharhinusbrachyu bronze Sphyrna spp., 17 0 17 19 1 20 ead rus, whaler whitetip Carcharhinusbrevipin Triaenodonobesus, 5 0 5 spinner 16 0 16 reef na, Triakissemifasciata, leopard 1 0 1 Carcharhinusfalcifor silky 3 0 3 Trygonorrhinafasciat southern mis, 1 0 1

a fiddler Carcharhinusgalapag Galapago 0 1 1 34+ ensis, s TOTALS 614 153 767 species Carcharhinusleucas, bull 67 26 93 Last updated: March 19, 2014. © International Shark Carcharhinuslimbatu blacktip 28 0 28 Attack File, Florida Museum of Natural History, s, University of Florida. Carcharhinuslongima oceanic People utilize marine habitats in a broad range of 7 3 10 nus, whitetip recreational and professional activities, thus Carcharhinusmelano blacktip shark attacks occur in a variety of circumstances. 11 0 11 pterus, reef Victim activities assemble into four main Carcharhinusobscuru categories; those on top of, in, under, or entering dusky 1 1 2 s, and exiting the water. "Surface recreationists" include those victims atop a body of water Caribbea Carcharhinusperezi, 4 0 4 n reef through the use of a board or flotation device. These victims were engaged in activities such as Carcharhinusplumbe sandbar 5 0 5 us, surfing, water skiing, windsurfing, boogie boarding, rafting, or floating on inflatables at the Carcharhinus spp., requiem 39 7 46 time of attack. Immersed in the water are the Carchariastaurus, sand tiger 29 0 29 "swimmers and bathers" who may be treading water, snorkeling, playing in the shallows, or

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Heading To Good Surgery wading at the time of attack. "Divers" are all injury. Application of an ice pack may aid in pain victims underwater. This division includes mostly relief and decrease swelling. [4] SCUBA divers, but also includes hookah and free Meticulous cleaning with saline irrigation should divers. The fourth activity category is those occur, as the wound should always be entering or exiting the water. These attacks can considered contaminated. Saline lavage with a occur as someone is climbing a ladder into a boat 30-ml syringe and 18-gauge intravenous catheter or immediately after jumping off a platform for is recommended, with volumes up to 150 ml for example. Below are graphs showing each group's wounds less than 3 cm. When necessary, foreign shark attack frequency individually over several body removal and debridement of dirt and decades.8 nonviable tissue can occur after irrigation is complete. Tetanus prophylaxis is very important considerations when managing a bite wound. Every patient with a bite injury that seeks medical care should have their tetanus status checked, with appropriate immunization as needed. Tetanus booster should be given if the victim received a primary series, but no booster within the last 5 years. If tetanus status is unknown, or if the vaccine series was not completed, then both tetanus vaccine and Management tetanus immune globulin (in the arm opposite Most of the management guidelines for the the vaccine) should be administered. [4] treatment of bite infections are based on expert Radiological studies are often obtained after any opinion. The goals of therapy are to prevent or 'mauling' injuries, any extensive wounds, as well treat infection, as well as minimize soft tissue as on closed-fist injuries and other bites to the damage. In general, a number of therapies may hand. In addition to identifying fractures, be undertaken for all bite wounds.The radiographs may reveal air in a joint, or may be management is depend on the severity of used to determine if a piece of broken tooth or a injuries. Whether it minor, serious, or severe foreign body is in the wound. Radiographs are injuries. That required suture or even also used to look for evidence of osteomyelitis in amputations.[4] a chronic wound infection. If there is evidence of A laceration should be evaluated and the purulence in the wound, aerobic and anaerobic bleeding controlled using direct pressure. A cultures should be obtained. [4] careful exploration of the laceration should be Sharks are the most reported marine animal to performed to determine severity and whether it bite humans, although there have been reports involves muscle, tendons, nerves, blood vessels, of bites from fish such as barracuda and eels. or bone. Suturing is the preferred technique for Infecting organisms are usually specific to the laceration repair. Absorbable sutures, such as marine environment, and therapy should be polyglactin 910 (Vicryl), polyglycolic acid (Dexon), tailored to the organism. The most common and poliglecaprone 25 (Monocryl), are used to organisms associated with these bites were close deep, multiple-layer lacerations. Although Vibrio spp. (especially Vibrio vulnificus, Vibrio these sutures absorb at varying rates, they all parahaemolyticus and Vibrio alginolyticus) and usually absorb within four to eight weeks. Nylon, contamination often led to soft tissue infection monofilament nonabsorbable sutures and necrosis. Buck et al.looked at cultures of (polypropylene) must eventually be removed. [5] great white shark teeth and, in addition, to Smaller wounds should be flushed with large theVibrio, Pseudomonas, Staphylococcus,Citroba amounts of cool clean water. A mild soap may be cterand Micrococcus species were isolated. [4] gently used to cleanse the area, and may have Empiric choice of antibiotics for an actual wound some prophylactic effects against rabies. The infection will depend on the predicted inciting WHO recommends thorough flushing and organisms. Marine animals, coverage washing of bite wounds for a minimum of 15 min forVibrio species with a tetracycline or with soap and water, detergent or povidone fluoroquinolone is necessary. [4] iodine.Soaking the injury is not recommended as The decision to use parenteral versus oral this may introduce infection into the wound. antibiotics as well as length of therapy will Alcohol or peroxide is also not recommended depend on location and extent of infection. Soft because of the potential for further tissue tissue infections usually only require 7–14 days

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Heading To Good Surgery of therapy after appropriate wound care is University-Sanglah General Hospital, Bali- accomplished, whereas septic arthritis or Indonesia. osteomyelitis may require longer treatment Abstract regimens, with courses from 3 to 6 weeks. Introduction: Cutaneous squamous cell Ultimately, duration and route of antibiotic carcinoma (SCC) is the second most common should be individualized, based on the infected form of skin cancer and accounts for 20% of site, culture and sensitivity results, and response cutaneous malignancies. Patients usually come to therapy. [4] with a large tumor > 5 cm in diameter, this is due Finally, adequate follow-up and education are to lack of knowledge about the disease. It is crucial. Patients should be taught wound care as often mistaken with common infection well as the signs of infection. A follow-up wound processes. Thus, this large tumor can cause a check should take place in 24-48 hours (sooner if round shaped defect which is difficult to close there are signs of infection). Also, if indicated, primarily. The round shaped defect often be the bite should be reported to local health or law closed with a local flap, one of those is the enforcement agencies. [4 double rotational flap, which is easy to perform References without special instruments. 1. West, J G. Changing Patterns of Shark Attacks in Case Report: We report two cases of scalp SCC. Australian Waters. Marine and Freshwater Research. First case is male 43 years old with occipital SCC, 2011, 62, 744-754. 2. Hazin F H V, Burgess G H, Carvalho F C. A Shark Attack 7x8 cm in diameter. The second case is female 52 Outbreak Off Recife, Pernambuco, Brazil: 1992-2006. years old with parietal SCC, 5x6 cm in diameter. 2008. Bulletin of Marine Science, 82(2): 199-212. Both patient have undergone wide excision with 3. McCoskerJ E, LeaR N. White Shark Attacks Upon Humans safety margin 1 cm from the tumor. The base of in California and Oregon, 1993-2003. 2006. Proceedings of The California Academy of Sciences.Fourth Series, excision was calvaria, without infiltration of the Volume 57, No. 17, 479-501. tumor to calvaria. The round shaped defect was 4. Thomas N, Brook I. Microbiology and Treatment. Expert corrected with a double rotational flap. Post Rev Anti Infect Ther. 2011;9(2):215- operative care was 2 weeks. The pathological 226.http://www.medscape.com/viewarticle/739023_13. 5. Abrahamian F M, Goldstein E J. Microbiology of Animal report identifies squamous cell carcinoma with Bite Wound Infections. 2011. Clin. Microbiol. Rev. 2011, tumor free incision margin. 24(2):231. Conclusion: Squamous cell carcinoma is the 6. Burgess G H.ISAF 2013 Worldwide Shark Attack second most common form of skin cancer. Wide Summary. International Shark Attack File, Florida Program for Shark Research, Florida Museum of Natural excision can cause a round shaped defect which History, University of Florida. can be difficult to correct primarily. Double https://www.flmnh.ufl.edu/fish/sharks/isaf/2013Summa rotational flap is the method of choice to correct ry.html the defect. 7. Burgess G H.ISAF Statistics on Attacking Species of Shark, Species of Shark Implicated in Confirmed Unprovoked INTRODUCTION Attacks Around The World 1580 – 2013. International Cutaneous squamous cell carcinoma (SCC) is the Shark Attack File, Florida Program for Shark Research, second most common form of skin cancer and Florida Museum of Natural History, University of accounts for 20% of cutaneous malignancies. The Florida.https://www.flmnh.ufl.edu/fish/sharks/statistics/ species3.html. increasing incidence is likely multifactorial; the 8. Victim’s Activity during unprovoked shark attack speculated causes for the rise include an aging worldwide 1900-2009.International Shark Attack File, population, improved detection, and Florida Program for Shark Research, Florida Museum of environmental factors, such as depletion of the Natural History, University ofFlorida.https://www.flmnh.ufl.edu/fish/sharks/statistic ozone layer. Although cutaneous SCC is not often s/Act.html fatal, it can cause significant morbidity. Most SCC are located in the head and neck Poster Presentation region, where surgery for advanced-stage disease can be disfiguring. Localized SCC of the POSE004. Squamous Cell Carcinoma of SCALP - skin is a highly curable disease. There are a Reconstruction with Double Rotational Flap: variety of treatment approaches to localized SCC, Serial Case Reports including excision, radiation therapy, Lidya Kurniawan*, Putu Anda Tusta Adiputra** cryosurgery, and electrodessication and * General Surgery Resident, Medical Faculty, curettage. Excision is probably the most common Udayana University-Sanglah General Hospital. therapy for SCC. This surgical treatment usually ** Subdivision of Surgical Oncology, Surgery relies on surgical margin ranging from 4 mm to Department, Medical Faculty, Udayana 10 mm, depending on the diameter of the tumor and degree of differentiation.

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Radiation therapy is typically used as an adjuvant flap advancement. This can be overcome by to surgery, with primary radiation therapy making incisions perpendicular to the direction typically reserved for patients who are unable to of flap movement. undergo surgical excision.Chemotherapy may be Correct closure with these flaps requires suturing considered as adjuvant therapy in select highest- the aponeurotic layer. Local scalp flaps are risk cases of SCC, or for metastatic SCC. composed of skin, subcutaneous tissue and Epidermal growth factor receptor (EGFR) aponeurosis, intimately connected by fibrous inhibitors may be useful adjuncts to surgical trabeculae. The loose areolar tissue – also known treatment.2 as the subaponeurotic fascia, fascia innominata, Patients usually come with a large tumor > 5 cm and subaponeurotic plane – allows mobility of in diameter, this is due to lack of knowledge the scalp. In this context, the parietal zone is the about the disease. It is often mistaken with most mobile scalp region. The pericranium is common infection processes. Thus, this large intimately adhered to the skull. It must be left tumor can cause a round shaped defect which is intact as far as possible, since free skin grafts can difficult to close primarily, after wide excision. be applied to it – thereby facilitation The round shaped defect often be closed with a reconstruction. local flaps, but unlike in other head and neck There are a number of local flap techniques: areas where local flaps are used to repair large single or multiple, and with or without skin defects, in the region of the scalp the repair of grafting to close the donor defects. Single flaps in even small defects is complicated. Rotation, turn comprise rotation, advancement, advancement and transpositioning scalp flaps transpositioning, bipedicle transpositioning, VY are the reference for reconstructing these advancement and rhomboidal flaps, etc. Multiple defects. One of those, which is easy to perform flaps in turn include the triple-flap technique without special instruments, is the double described by Orticochea, the triple rotation rotational flap.1,2 (pinwheel) flap, double rotation flap, triple The correct design of such flaps includes rhomboid flap, and V-Y-S scalp plasty technique, preservation of the original hairline, acceptable etc. The patients at greatest risk of complications redirectioning of the hair follicles, the after scalp reconstruction are those previously incorporation of large vascular pedicles, and subjected to radiotherapy, patients receiving wound closure without excessive tension. These adjuvant or postoperative chemotherapy, those flaps in turn may require skin grafts to cover the with cerebrospinal fluid fistulas, and patients donor zone. Knowledge of scalp anatomy is with anteriorlylocated defects. essential for preparing these flaps. The skin in CASE REPORT this region is the thickest in the body. It is We report two cases of scalp SCC. First case resistant, very scantly elastic, and is covered with is female 52 years old with parietal SCC, 5x6 cm hair. The subcutaneous tissue in turn contains in diameter. The second case is male 43 years old the blood vessels, nerves and hair follicles. An with occipital SCC, 7x8 cm in diameter. Both exception to this anatomical distribution is the patient have undergone wide excision with location of the superficial temporal artery in the safety margin 1 cm from the tumor. The base of temporoparietal region, which is located in the excision was calvaria, without infiltration of the temporoparietal fascia. tumor to calvaria. The round shaped defect was The main arteries irrigating the scalp are the corrected with a double rotational flap. Post superficial temporal artery, with its frontal and operative care was 2 weeks. The pathological parietal branches, the posterior auricular artery report identifies squamous cell carcinoma with and the occipital artery – all of which are tumor free incision margin. branches of the external carotid artery – and the supraorbital and trochlear arteries (branches of the internal carotid artery). Local flaps must be based on one or two vascular pedicles of the scalp to afford a large rotation angle – thereby facilitating closure of the defect. The aponeurotic layer, also known as the epicranial aponeurosis, is the strongest layer of the scalp, and is anteriorly contiguous to the frontal muscle; posteriorly to the occipital muscles; and laterally to the temporoparietal fascia. As a result of its scant elasticity, the aponeurosis opposes desired

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A A

B B

First case, female, 52 years old, with parietal Second case, male 43 years old, with occipital SCC. SCC. A. Round shaped SCC of the scalp at the parietal A. Round shaped SCC of the scalp at the region ; 5x6 cm. occipital region ; 7 x 8 cm. B. The tumor was excised and double rotational B. Preparation to excise the tumor. flap was performed.

C

C. The defect was perfectly corrected with double rotational flap.

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DISCUSSION Cutaneous squamous cell carcinoma (SCC) is the second most common form of skin cancer and accounts for 20% of cutaneous malignancies. Although cutaneous SCC is not often fatal, it can cause significant morbidity. Most SCC are located in the head and neck region, where surgery for advanced-stage disease can be disfiguring. Localized SCC of the skin is a highly curable disease. C There are a variety of treatment approaches to localized SCC, including excision, radiation therapy, cryosurgery, and electrodessication and curettage. Excision is probably the most common therapy for SCC. Radiation therapy is typically used as an adjuvant to surgery or for patients who are unable to undergo surgical excision.Chemotherapy may be considered as adjuvant therapy in highest-risk cases of SCC, or for metastatic SCC. EGFR inhibitors may be useful adjuncts to surgical treatment.2 Patient often come with large tumor > 5 cm in D diameter. This large tumor can cause a round shaped defect which is difficult to close primarily. There are many options for repairing large scalp C. The tumor was excised, leave the round defects. Rotation, advancement and shaped defect. transpositioning scalp flaps are the reference for D. The defect was perfectly corrected with reconstructing these defects.1,2 double rotational flap. Healing by second intention is a possibility for

repairing scalp defects, though this option is not applicable in the presence of large defects with a lack of pericranium. The use of free skin grafts for reconstruction requires an intact pericranium to supply vascularization to the repaired zone. In addition, careful hemostasis of the receptor bed is necessary, since the formation of hematomas would compromise graft success. In the absence of a pericranium, and if grafting is the only repair option, perforations in the external cortical layer E of the skull allow the formation of granulation tissue that would improve the prognosis ofthe second-step free skin graft. A basic principle in surgery is to first use the most simple technique available. In our case we presented a simple local flap procedure for repairing a large scalp defect that included pericranium. A double rotational flap has been chosen to repair a large round shaped defect, caused by SCC of the scalp after wide excision F procedure. The edges of the wound must be carefully treated, taking care to avoid excessive tension, since localized ischemia with involution of the E. Preparation for posterior neck dissection. hair follicles could result. Prior local anesthetic F. The posterior cervical lymph node was totally infiltration with epinephrine reduces bleeding at excised. the wound edges, and facilitates dissection of the loose areolar plane. Electrocauterization is to

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Heading To Good Surgery be avoided, in order to reduce thermal damage 7. Tan S.T., MacKinnon C.A. Deep Plane Cervicofacial Flap: A to the hair follicles. Useful and Versatile Technique in Head and Neck Surgery. Wiley InterScience. 2005. DOI : The patients at greatest risk of complications 10.1002/hed.20317. after scalp reconstruction are those previously 8. Ransom E.R., Jacono A.A. Double-Opposing Rotation – subjected to radiotherapy, patients receiving Advancement Flaps for Closure of Forehead Defects. Arch adjuvant or postoperative chemotherapy, those Facial Plastic Surg. 2012;14(5): 342-345. with cerebrospinal fluid fistulas, and patients with anteriorly located defects. CONCLUSION Squamous cell carcinoma (SCC) is the second most common form of skin cancer and accounts for 20% of cutaneous malignancies. Most SCC are located in the head and neck region, where surgery for advanced-stage disease can be disfiguring. Localized SCC of the skin is a highly curable disease. There are a variety of treatment approaches to localized SCC, including excision, radiation therapy, cryosurgery, and electrodessication and curettage. Excision is probably the most common therapy for SCC. Patient often come with large tumor > 5 cm in diameter. This large tumor can cause a round shaped defect which is difficult to close primarily. There are many options for repairing large scalp defects. Rotation, advancement and transpositioning scalp flaps are the reference for reconstructing these defects.1,2 A double rotational flap has been chosen to repair a large round shaped defect, caused by SCC of the scalp after wide excision procedure. The patients at greatest risk of complications after scalp reconstruction are those previously subjected to radiotherapy, receiving adjuvant or postoperative chemotherapy, those with cerebrospinal fluid fistulas, and anteriorly located defects. REFFERENCE 1. Monroe M.M., Meyers A.D. Cutaneous Squamous Cell Carcinoma: Overview. American Academy of Otolaryngology – Head and Neck Surgery. 2014; 1965430. 2. Patel K.G., Sykes J.M. Concepts in Local Flap Design and Classification. Operative Technique in Otolaryngology. 2011 ; 22, 13-23. 3. Garcia del Campo J.A., Garcia de Marcos J.A., Del Castillo Pardo de Vera J.L. Local Flap Reconstruction of Large Scalp Defects : Case Report.Medicina Oral Pathology Oral Cir Buccal. 2008; 13(10) : E666-70. 4. Pukar M.M., Shah U.B., Mantro R. Reconstruction of Scalp Defect by Rotation Flap: Case Report. International Journal of Research in Health Sciences [Internet]. 2014 ; 30;2(2):690-2. Available fromhttp://www.ijrhs.com/issues.php?val=Volume2&iss =Issue2. 5. Paver R., Standford D., Storey L., Scalp. Dermatologic Surgery: A Manual of Defect Repair Option.First Edition. 2011. Australia: McGraw-Hill. P.340-352. 6. Thorne C.H, Grabb and Smith Plastic Surgery. Sixth Edition. 2007. Philladelphia: Lippincott Williams & Wilkins. p.1-14.

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INDEX A. Hafid Bajamal ...... 32 Alfarina Herdianti ...... 285 Benjamin Tsang ...... 131, 235 A. Hartono ...... 255 Alfred Sutrisno ...... 57 Benny Issakh ...... 108 A. Prasmono ...... 246 Ali Shodiq ...... 120 Benny Philippi ...... 111 A.A Gd Budhi Kusuma ...... 272 Alvarino ...... 170 Bernardus Parish Budiono ...... 27 Aaron Tigor Sihombing ...... 166 Amandeep Singh Sandhu ...... 64 Bethy S Hernowo ...... 60 Abdul Hafid Bajamal ...... 58 Ambar Mudigdo ...... 94 Boni Irawan ...... 234 Abdus Sjukur ...... 68 Ambarsari Y ...... 232 Bramasta Ogy ...... 91 Abel Jalife-Montaño ...... 27, 55 Amir Saudin Sibarani ...... 137 Bree Stephenson ...... 131, 236 Achmad Fahmi ...... 78 Amritsar ...... 64 Britta Hasemeier ...... 107 Achmad Harijadi ...... 162 Amru Sungkar ...... 112, 113 Budi Irwan ...... 46, 254 Adam Mahendra ...... 152 Amrul Marpaung ...... 210 Bustanul Arifin ...... 232, 238 Adang Bachtiar ...... 76 Anak Agung Gde Oka ..... 226, 251 Bustanul Arifin Nawas ...... 232 Adel F. Ramzy ...... 23, 41 Andi Abdillah ...... 173 Caroline Josephine Simon ...... 87 Adhitya Angga Wardhana .... 252 Andi Dwihantoro ...... 80, 137, 140 Caryl Augustine Johanna ...... 214 Adi K ...... 110 Andi Nugraha Sendjaja ...... 146 Červinka V...... 59 Adi Muradi ...... 234 Andre Saharui ...... 178 Chaidir Arif Mochtar ...... 50 Adi Saputra ...... 178 Andreas. R ...... 259 Chairiandi Siregar ...... 239, 246 Adianto Nugroho ...... 111 Andreasta Ginting ...... 191 Chandra Aquino Tambunan ... 235 Adithya Wardana ...... 273 Andriana Purnama...... 153 Chee-Yin Chai ..... 85, 86, 146, 147 Adityas Sukmadi Karjosukarso Andy Maleachi ...... 67 Chee-YinChai...... 85 ...... 207 Anikin V ...... 66 Chia-LiChung ...... 85 Adrian Tangkilisan ...... 183 Ann-Shung Lieu ...... 85 Chie Yanai ...... 60, 64 Adriansjah R ...... 110 Anton Trihartanto ...... 286 Chieh-Chi Huang ...... 62, 176 Afvan Tri Kurniawan ...... 253 Antonio C. Cabigas ...... 51 Chih-Hong Chiu ...... 62, 176 Agil A ...... 110 Aravinda Chakravarti ...... 80 Chih-Hung Mark Chiu ...... 62 Agoes Wibisono ...... 232 Ardy Santosa ...... 274 Chih-Jen Wang ...... 85 Agung AR Sibuea ...... 176 Argaputra Pradana ...... 141 Chih-Lung Lin ...... 57 Agung B. Sutiono...... 145 Aria Kekalih ...... 273 Chih-Ming Lin ...... 62, 176 Agung Budi Sutiono ...... 146 Ariandi Setiawan ...... 252 Chih-Zen Chang ...... 235 Agung Prasmono...... 56, 255 Ariansah Margaluta...... 89 Chin Li, Tee ...... 131, 235, 236 Agung Wibawanto ...... 120 Arif Budi Satria ...... 112 Ching-Ying Wu ...... 73 Agus Priambodo ...... 111, 175 Arif Kurnia Timur ...... 184, 188 Chohei Sakakura .... 134, 135, 136 Agus Roy R Hamid ...... 194 Arif Zuhan ...... 66 Chouhei Sakakura65, 70, 75, 133, Agus Roy RH Hamid ...... 260 Ario Djatmiko ...... 26 134, 136, 157 Agus Turchan ...... 261 Aris Ramdhani ...... 152 Chris Thompson ...... 130 Ahmad A ...... 170, 244 Asako Takahashi ...... 89, 108 Chrispen Mushaya ...... 69 Ahmad Dimyati Aa ...... 141 Ashish Kapoor ...... 80 Christina NM ...... 154 Ahmad Fahmi ...... 261 Askandar Tjokroprawiro ...... 68 Christopher Chen ...... 49 Ahmad Faried ...... 145, 146 Asra Al Fauzi ...... 23 Chung-ngai Tang ...... 35 Ahmad Kurnia ...... 237 Asri Mashudy ...... 233 Chun-Hsiung Huang ...... 147 Ahmet Gurhan Gurcay ...... 137 Atilla Kazancı ...... 137 Chun-HsiungHuang...... 85 Aij-Lie Kwan .. 25, 80, 85, 86, 146, Atsushi Onodera ...... 88 Cindy E Boom ...... 77 147, 235 Atsushi Shiozaki .. 65, 70, 75, 133, Citra Roshian ...... 164 Akhmad Makhmudi ...... 80 134, 135, 136, 157 D.J. Suta ...... 255 Akihiro Ito ...... 135 Aya Yoshino ...... 64 Daisuke Ichikawa 65, 70, 75, 133, Akihiro Kishida ...... 66 Ayako Miyajima ...... 90 134, 135, 136, 157 Akiko Ohmori ...... 71 Aznan Lelo ...... 32 Dalal P ...... 66 Akiko Omori ...... 70 Azril Okta Ardhiansyah ...... 253 Danarto ...... 170 Akinari Miyazaki ...... 63 B. Gagel ...... 79 Daniel Marthin ...... 156 Akio Kimura ...... 157 B. Prijambodo ...... 48 Daniel Sampepajung ...... 232 Akira Matsuno ...... 36 B. Salem ...... 90 Darwito ...... 264 Akitoshi Yanagihara ...... 63 Bacilius Agung P ...... 170 David H Masjoer ...... 186 Akiyoshi Kanazawa ...... 39 Bajamal, H ...... 145, 262 David H. Masjhoer ...... 175 Akiyoshi Seshimo ...... 88, 91 Bambang AmAm Sulthana ..... 285 David Rimbun Siagian ...... 198 Al Fauzi, A ...... 145, 262 Bambang Rishardana .... 173, 254 Davis RGJ ...... 236 Alan T. Lefor ...... 66 Bambang Suprapto ...... 76 Deasiana Paksi Moeda ...... 129 Alexander Budisectio Asmara 240 Bandara I.M.H.W ...... 130 Dedy Hermansyah ...... 237 Alexander M.E. Nwofor ...... 43 Bannakij Lojanapiwat ...... 20, 30 Dedy Pratama...... 187 Alexandra Bouzouki ...... 130 Barung, S ...... 187 Deny ...... 237

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Desak G.A. Suprabawati ...... 253 Fahrizal Maradjabessy ...... 144 Hideki Kajiyama ...... 63 Desi Novianti ...... 164 Faisol Darmawan ...... 140 Hideki Katagiri ...... 66 Dewi Aron Listyanti ...... 109 Farhan Syarif...... 239 Hideki Ryo ...... 91 Dewi Prima Chr ...... 265 Farid Nurmantu ...... 76 Hidenori Kamio ...... 76, 106 Dharmawan Mursjid Noor .... 189 Faris Soliman ...... 130 Hidetaka Kitazono ...... 122 Dian Adi S ...... 141 Felicia Tan ...... 18, 26 Hirata K ...... 119 Dian Adi Syahputra ...... 153 Ferry Safriadi ...... 169 Hiroko Tsukada ...... 76, 106 Dicky Fakhri ...... 77 Fikri Hikmasanjaya ...... 181 Hiroshi Kobayashi ...... 63 Dikki Drajat Kusmayadi ...... 238 Firman Nugroho...... 167 Hiroshi Matsuzaki ...... 63, 88 Dimas Aryo Kusumo ...... 111 Francis M. Decangchon ..... 45, 60 Hiroshi Nemoto ...... 151 Dina Perdanasari ...... 238 Frank Bietra Buchari ...... 238, 261 Hiroshi Nishioka ...... 37 Dinar Ayu Pratiwi ...... 211 Frank P. Schulze ...... 25 Hiroshi Niwa ...... 32 Diposarosa Rizki ...... 244 G. Kigawa ...... 73 Hiroshi Tokimura ...... 30 Djanggan Sargowo ...... 68 Gajanthan K ...... 130 Hirotaka Konishi . 65, 70, 75, 133, Djarot Noersasongko ...... 182 Gatot Triwono ...... 194 134, 135, 136, 157 Djohansjah Marzoeki ...... 41 Gede Budhi Setiawan ...... 214 Hiroto Egawa ...... 68, 70, 89 Djoko Handjojo ...... 162 Georgios Tsoulfas ...... 33, 51 Hiroto Tatsumi ...... 64 Djoko Handojo ...... 98 Gst. A. A. Kartika Saraswati ... 113 HirotoEgawa...... 150 Djoko Riadi ...... 24 Gunadi ...... 80 HirotoTatsumi...... 65 Djonny Ferianto...... 232 Gunawan ...... 237 Hisakazu Yamagishi .. 70, 75, 133, Do Yoon Kim ...... 131 Gursimran Kaur...... 64 134, 135, 136 Doddy Efmansyah ...... 170 Guruh Laut Suhartono ...... 167 Hisashi Ikoma ..... 65, 70, 75, 133, Doddy M. Soebadi ...... 29 H. Mizukami ...... 73 134, 135, 136, 157 Douglas Maclean ...... 131, 235 H. Nemoto ...... 73 Hitomi Takaishi ...... 106 Dwi Hantoro Andi ...... 169 H. Schönberger ...... 79 Hitoshi Fujiwara 70, 75, 133, 134, Dwi Hari Susilo ...... 48, 258 H. Soebroto ...... 246 135, 136, 157 Dwi Harry Mulia ...... 238 H.B. Sapan ...... 90 Hitoshi Hujiwara ...... 65 Dwihantoro Andi ...... 189 Hadinata Y ...... 210 Honda Hsu ...... 62, 176 Dyah Ratna Budiani ...... 94, 109 Hafidh Seno ...... 165 Hough S, Beddow ...... 66 E.M.Bothe ...... 79 Haji Ifraddin Pinim ...... 190 Hsing-Lin Lin ...... 71, 72, 73 Eddy Bagus Wasito ...... 252 Hajime Tanaka ...... 63, 88 Hung-Yi Chiou ...... 74 Eddy Herman Tanggo...... 26 Halim Wijaya ...... 138 I Gede Surya Dinata ...... 281 Eddy Sutrisno ...... 238, 261 Hanai T...... 28 I Gede Suwedagatha ...... 191 Edhi Darmana ...... 264 Handoyo Y ...... 240 I Gst Pt Hendra Sanjaya ...... 241 Edi Dharmana ...... 111 Hantoro Ishardyanto ...... 253 I Gusti Ngurah Gde Dwi Aryanata Edmond Rukmana ...... 182 Hari Basuki ...... 251 ...... 122 Edwin Basyar...... 141 Harry Soenaryo ...... 182 I Ketut Subhawa ...... 262 Efman. E. U Manawan ...... 148 Hartanto, Bintoro ...... 149 I Ketut Wiargita ...... 262 Eggo Yonggi ...... 153 Haryo Aribowo ...... 189 I Komang Oka Krishna ...... 226 Eigo Otsuji ... 65, 70, 75, 133, 134, Hasan Sjahrir ...... 32 I Kt Wisudana Yuana ...... 241 135, 136, 157 Hatibie M ...... 177, 179, 180 I Made Darmajaya 202, 221, 223, Eiichiro Noguchi ...... 76, 106 Hatibie, M ...... 182 256 Eka Prasetia Wijaya ...... 239 Havlíček K...... 59 I Made Mulyawan ...... 91 Eko Agus Subagio ...... 251 Heber B.Sapan ...... 147 I Made Sukamartha ...... 202 Eko Prasetyo ...... 142, 144 Heiden S ...... 119 I Made Sukarya ...... 273 EkoAgusSubagio...... 58 Hendra F. Kalitouw ...... 157 I Nyoman Mardika ...... 248 Elias Tam ...... 60 Hendra P. Setiawan ...... 99, 102 I Nyoman Semadi .. 198, 207, 211 Elisa Schipper ...... 107 Hendra Sanjaya ...... 260 I Putu Ari Gunawan ...... 275 Elric Malelak ...... 146 Hendratno J ...... 180 I Wayan Yudiana ...... 226 Emilia R ...... 255 Hendrawijaya JI ...... 255 I.A. Setyawati Sri Krisna Dewi 113 Emoto N ...... 119 Hendri G ...... 154 I.A.Putranti Darma Restuti .... 272 Endang Retnowati...... 253 Hendrik B. Mengga ...... 182 I.B Darma Putra ...... 271, 272 Ening Krisnuhoni ...... 152 Hendro Sudjono Yuwono ...... 40 I.B.Darma Putra ...... 272 Eppy B ...... 170 Herdi Gunanta Syaiful ...... 241 IB Budiarta ...... 262, 273 Erison Sipayung ...... 90 Heri Pratomo ...... 143 Icuk P ...... 155 ErlianoSumarnap ...... 58 Herjuna Hardiyanto ...... 140, 157 Ida Bagus Metria ...... 94 Ernesto G. Acosta ...... 55 Herman Yanto ...... 148 Ida Bagus Oka Widya Putra ... 111 Erwin ...... 98, 173, 184 Heroe Soebroto ...... 255 IGN Wien Aryana ...... 111 Erwin Suryanegara ...... 98 Herry Wibowo ...... 173 Ign. Riwanto ...... 67 Etriyel ...... 170 Hery Purwanto ...... 162 Ignatius Riwanto ...... 150 F.Schneble ...... 79 Hesti Lestari Tandy ...... 179 Indra Mulyawan ...... 162 Fachrul Razi ...... 239 Hidayat Sujuti ...... 68 Inge Kurniawati ...... 94 Fahmi ...... 141 Hidayat, M.Arief ...... 149 Iqbal Pahlevi Nasution ...... 76

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Iqbal R ...... 155 Kenichi Takemoto ...... 133, 134 M.Nazir ...... 168 Irsyad Alamsyah Harahap ..... 163 Kenji Okumura ...... 69 M.R.N.Cassim 110, 120, 121, 185 Irzal Fahrizal ...... 183 Ketting Olivier,Stanley ...... 149 M.Schaffer ...... 79 Ishak L ...... 154 Ketut Putu Yasa ...... 281 Made Bramantya Karna ...... 122 Ishak Lahunduitan ...... 138 Ketut Sudiasa ...... 224 Made Mulyawan ...... 274 Iskandar ...... 239 Ketut Suega ...... 91 Mahadewa. T.G.B ...... 259 Ismono Darmadji...... 286 Ketut Wiargitha ...... 224 Mako Nogami ...... 106 Ivan Hendra Sudarmawan ...... 67 Kevin Fan-Ying Tseng ..... 132, 133 Maman Abdurrahman ...... 164 Ivan Joalsen ...... 175, 186 Khairul I Nasution ...... 32 Mamiko Ubukata ...... 90 Jackson Sihombing ...... 218 Khalikul R ...... 245 Manginte, M ...... 182 Jayarasti K ...... 243 Khosama Y ...... 162 Margarita M. Maramis...... 253 Jimmy Koan ...... 183 Kiki A. Rizky ...... 164 Maria Mayasari ...... 152 Jiro Nagao ...... 89, 108 Kiki Rizki ...... 165 Maria X. Sosa ...... 80 Jiunn-Tat Lee ...... 176 Kiki Rizky ...... 286 Marijata ...... 94 Joan Febrian ...... 175 Kitagawa H ...... 119 Marselus M ...... 157 Joanna Kostoro ...... 85, 86 Kobayashi Takushi ...... 75 Martahadinan ...... 67 Johannes Manurung ...... 251 Koernia Swa Oetomo ...... 68 Masaaki Karino ...... 64, 65 John Karlie ...... 181, 273 Kohar ...... 170, 172 Masaaki Watanabe ...... 65 Johny Syoeib ...... 231 Kohji Tsunematsu ...... 64 Masakazu Yamamoto . 45, 68, 70, Joji Sekine ...... 60, 64 Koichi Hirata ...... 34 71, 89, 150 JojiSekine ...... 65 Koichi Omoto ...... 135 Masaya Yokoyama ...... 63 Joko Siswanto...... 174 Koji Masumori...... 29 Masayoshi Nakanishi.. 65, 70, 75, Jon Efendi ...... 141 Koji Tsunematsu ...... 65 133, 134, 135, 136, 157 Jony Wahyuhadi ...... 269 Kolitha Goonetilleke...... 130 Masumi Nishimura ...... 65, 135 Joon-Khim Loh ...... 85, 235 Kt Putu Yasa ...... 210 Matsuzaki Hiroshi ...... 75 Josua Partogi Saing ...... 165 Kun Semedi Setyadi...... 154 Max Downham ...... 19, 24 Jufriadi Ismy ...... 168 Kuncoro A ...... 244, 270 Maximillian Ch Oley ...... 142 Jufriady I...... 244 Kuncoro Adi ...... 167 Maxmillian Ch. Oley...... 144 Jufriady Ismy ...... 167 Kunihiko Amano ...... 88, 91 MayuShimaguchi ...... 66 Juli Sumadi ...... 275 Kunsemedi S ...... 67 Megu Kikuchi ...... 65 Julius July ...... 78, 79 Kuntoro ...... 68 Melvin Pascamotan Togatrop 238 Jun Kawanishi ...... 135 Kurnia H ...... 240 Mendy H. Oley ...... 142 Junichi Mizuno ...... 22, 57 Kurnia S ...... 138 Mendy Hatibie Oley177, 178, 182 Jun-ichi Tanaka ...... 151 Kusuma Novi ...... 189 Merung M...... 162, 163 Jun-Ichi Tanaka ...... 73 Kwang Wook Suh ...... 131 Merung Marselus ...... 163 Jupiter S...... 171 Kwan-Ming Soo...... 71, 72 Michael Tendean ...... 147 K. Kijima ...... 73 Kyoichi Harada ...... 65, 75, 135 Michio Itabshi ...... 90 K. Sakuraba ...... 73 Kyoko Shikama ...... 91 Mika Habu ...... 38 K. Shinmura ...... 73 L. Stam ...... 59 Mikiko Taneichi ...... 90, 91 K. Yokomizo ...... 73 Lahunduitan IG ...... 139 Mimi Okano ...... 63 K.-H.Dietl ...... 79 Lahunduitan Igl ...... 138 Miradz Hudaya ...... 188 K.Novak ...... 79 Lahunduitan MIG ...... 138 Mirton ...... 155 K.T.D.Kahaduwa ....110, 120, 121, Lampus H ...... 138, 139 Misun Chun...... 131 185 Leise Limpeleh...... 142 Miyazaki Akinari ...... 75 Kai-Chun Chen ...... 132, 133 Leo Rendy ...... 189 Mochammad Arief Tq ..... 81, 112, Kai-Wen Huang ...... 65 Lhora Arie Sandy ...... 137 113 Kamal Basri Siregar ...... 237, 238 Liang-Chi Kuo ...... 71, 72 Mochammad Rasjad Indra ...... 68 Kaneta Yoko ...... 75 Lidya Kurniawan ...... 158 Mohamad Azim Bin Md Idris ... 40 Karmile ...... 244 Limanto D ...... 236 Mohamad Sadikin ...... 152 Kas Mulyadi ...... 244 Limpeleh S ...... 185 Mohammad Reza Nouval ...... 186 Kasun Wanigasooriya ...... 130 Liza Fitria ...... 77 Moheb A. Rashid ...... 40, 52 Katsushi Inoue ...... 136 Lubab I ...... 166 Motohiro Hayashi ...... 88 Kay-Hyun Park...... 56 Luna F. Kusuma ...... 163 Motonobu Sito ...... 91 Kazuha Hatta ...... 90 Luqman Alwi ...... 150 Motowo Nakajima ...... 136 Kazuhiro Nishida ...... 122 Luthfi Gatam ...... 49 Mudatsir ...... 246 Kazuhiro Nisida ...... 69 M Iqbal Rivai ...... 155 Muhaimin ...... 237 Kazuhiro Takabayashi ..... 89, 108 M Robby Cahyadi ...... 221 Muhamad Thohar Arifin ...... 143 Kazuma Okamoto65, 70, 75, 133, M. Istiadjid E.S ...... 142 Muhammad Faris ...... 58 134, 135, 136, 157 M. Jailani ...... 270 Muhammad Jailani ...... 153 Kazuma Sakuraba ...... 151 M. Saiful ...... 232 Muhammad Z. Arifin ...... 146 Kazunari Yoshida ...... 91 M. Thohar Arifin...... 98 Muharriansyah ...... 247 Kazunori Arita ...... 36 M. Z. Arifin ...... 145 Mulyono ...... 67 Ken Mizokami ...... 66 M.I. Ansyori ...... 246 Munawar ...... 153

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Munehiro Sawa ...... 90 Poerwosusanta Hery ...... 240 Rony Rustam ...... 237 Muntadhar ...... 141 Poppy S Roebiono ...... 77 Rosadi Seswandhana ...... 178 Murad Bavbek ...... 137 Prabu Ekalaya U ...... 181 Rousuke Hanaya ...... 261 Muslim Rifki ...... 109 Pradiksa Adhiatsa ...... 162 Rudi Hermanto Sinaga... 140, 157 Mustamsir, Edi ...... 174 Prakoso, Pamungkas Galih .... 142 Ryo Morimura .... 65, 70, 75, 133, Nababan P ...... 172 Pramadika M ...... 168 134, 135, 136, 157 Nadanaka S ...... 119 Pramod SV ...... 168, 260 Ryohei Watanabe ...... 89, 108 Nahan, Adventy ...... 177 Prasmono A ...... 232, 243 Ryota Higuchi ...... 63 Najatullah ...... 179, 181, 182 Priambada D ...... 143, 240 Ryota Otsuka ...... 63, 88 Nakayama K ...... 119 Prima K. Hayuningrat ...... 255 Ryuusuke Yamaguchi ...... 91 Nanda D ...... 171 Pujianto ...... 174 S RustiantoEko ...... 109 Nasrul Haidi ...... 247 Purnomo E ...... 119 S. Kudo ...... 73 Natsume Toshiyuki ...... 75 PuruhitaNiken ...... 109 S. Vijay ...... 168 Nawas Bustanul A ...... 244 Puruhito .... 43, 52, 232, 243, 246, S.I.Liyanage ...... 110, 121, 185 Ndubuisi Eke ...... 50 255 S.M.Wijerathna ...... 110, 121 Ngakan Gede Dwija Hermawan Putra Dananjaya ...... 223 S.M.Wijeyaratne .... 120, 121, 185 ...... 91 Putra R ...... 168, 260 S.Senkyrova ...... 79 Ni Nym Sri Rahayu W M.D .... 144 Putu Anda Tusta Adiputra 94, 99, Safriadi F...... 168 Niam M.S ...... 149 102, 108, 113, 122, 158 Safrizal Rahman ... 174, 175, 233, Niam MS ...... 154 Putu Astri Novianti ...... 108 244, 245, 247 Nico Lumintang ...... 189 Putu Lia Paramita ...... 273 Safrizal Rahman2 ...... 256 Noersasongko D ...... 179 R. Sekine ...... 73 Salamullah ...... 246 Noritoshi Mizuta ...... 69 R. Sjamsuhidajat ...... 58 Salem Billy ...... 163 Norlia Abdullah ...... 18 R.Ivan ...... 254 Samuel Denny Lawanto ...... 260 Nugrahaningsih DAA ...... 119 R.N.Damboragama ...... 110, 120, Samuel J. Haryono ...... 18 Nunik Agustriani ...... 80 121, 185 Sandy Grieve ...... 131, 236 Nurfathonah ...... 112 R.S Bhullar...... 64 Sarup Singh ...... 89 Nurhayat Usman ...... 129, 190 Rachmad M. Putra ...... 256 Satoh Yayoi ...... 75 Nym Putu Riasa ...... 241 Raden Yohana ...... 165 Satoshi Katagiri ... 68, 70, 71, 150 Nyoman Dwi Aussie Hary Rahadian Haryanto ...... 94 Satoshi Ogata ...... 70, 71, 89 Mastika ...... 271 Rajesh C Shah ...... 35 Satosi Ogata ...... 150 Nyoman Dwi Maha Udiyana ... 81 Rama Nusjirwan ...... 56, 183, 188 Satriya W ...... 139 Nyoman Golden ...... 31 Ramana Murthy Tirumularaju Satsuka Tetsutaro ...... 75 Nyoman P.Riasa ...... 260 ...... 130 Sawkar Vijay ...... 165 Oktay Algın ...... 137 Ramses dody ...... 254 Sawkar Vijay P ...... 236 Oktay Gurcan ...... 137 Rantapina Kurnia Sari ...... 81 Sayaka Nagao ...... 89, 108 Oley M ...... 179 Ranti J ...... 163 Sayumi Nakao...... 90 Omer Faruk Turkoğlu ...... 137 Ratna Maruti Manohara ...... 169 Seiji Kondo ...... 64 Otsuka Ryota...... 75 Rayhan Fauzie ...... 94 Selamat B ...... 231 P Tahalele ...... 246 Raymond Adiwicaksana ...... 274 Selamat Budijitno ... 98, 235, 252, P.M.T Mangalindung Rei Morimura ...... 134 270 Ompusunggu ...... 186 Rendy Fitra ...... 287 Sembiring YE ...... 232, 243 P.M.T. Mangalindung ...... 175 Reno Rudiman ...... 156, 285 Senjaya Y ...... 177 Pande K. A. Prayudi ...... 102 Respati Suryanto Dradjat ...... 39 Seung Yeop Oh ...... 131 Pande K. Aditya Prayudi ...... 99 Retno Asti Werdhani ...... 152 Shen-Long Howng...... 85 Pandu Wicaksono ...... 251 Reza Halim ...... 256 Shigeyuki Tahara ...... 37 Panji Utomo ...... 77 Rheno Rachmandita ...... 110 Shingo Kameoka ... 76, 88, 90, 91, Pardamean D ...... 183 Rhonaz Putra Agung ...... 146 106 Parenrengi,M.A ...... 230 Richard Hermawan ...... 111 Shingo Yamashita . 68, 70, 71, 89, Paris B ...... 67 Richard R ...... 157 150 Parish Budiono ...... 76, 150 Richard Romolo ...... 145 Shin-Han Tsai ...... 74 Patrico Rillah ...... 252 Ridwan Mataram ...... 231 Shinpei Ogawa...... 90 Patrik Sebastian Angga Santosa Rifki Muslim ...... 270 Shinya Kusachi ...... 89, 108 ...... 274 Rifta Yustiyardi Sudjoko ...... 258 Shoichi Fujii ...... 28 Paul Tahalele...... 255 Riki Siswandi ...... 152 Shoichiro Hikami ...... 157 Paulina ...... 166 Rio Alfin ...... 238 Shota Aoyama ...... 150 Pei-Chun Chen ...... 132, 133 Rizal Irawan ...... 120 Shu-Chuan Wu ...... 235 Peri handayani ...... 170 Rizal Pohan ...... 48 Shuhei Komatsu .. 65, 70, 75, 133, Perwira Widianto ...... 187 Rochadi ...... 80, 137 134, 135, 136, 157 Peter J. Manoppo ...... 19 Rohadi ...... 230 Shu-Jyuan Chang ...... 85, 86 Peter Robless ...... 51 Romi Saputra ...... 171 Shungo Endo ...... 29 Philemon Okoro ...... 19 Romy Hari ...... 174 Shun-Ichi Ariizumi ...... 70 Po-Chin Liang ...... 65 Roni Khoeroni ...... 190 Shunichi Ito ...... 89

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Heading To Good Surgery

Shunnichi Arizumi ...... 68 Tanaka Hajime ...... 75 Wasisto Dwi Yudisaputro ...... 175 Shu-Wei Wang ...... 62 Tangkilisan A ...... 183, 185 Wayan Niryana ...... 144, 218, 233 Shyunich Ariizumi ...... 71 Tangkilisan Adrian ...... 184 Wayan Sudarsa ...... 275 Sigit Adi Prasetyo ...... 150, 154 Tedy Apriawan ...... 269 Wei-Che Lee ...... 71, 72 Sihombing A T ...... 231 Teguh Aryandono ...... 107 Welman K ...... 66 Sihombing A. T ...... 210 Teguh Dwi Nugroho ...... 233 Welman Pramudyananta .... 270 Sihombing AT ...... 166, 172 Teguh Marfen Djajakusumah Wen-Ta Chiu ...... 74 Šiller J ...... 59 ...... 186, 188 Wesley J ...... 179 Simanjuntak D ...... 231 Tetsuji Wakabayashi ...... 151 Widyanti Soewoto ...... 163 Sirajul Munir ...... 186 Tetsutaro Sazuka ...... 63 Wieko Prayudi ...... 270 Soebandrijo ...... 163 Tetsuya Ohchi ...... 76, 106 Wihasto Suryaningtyas ...... 245 Soebroto H ...... 232, 236, 243 Teuku Yusriadi ...... 139 Wihastyoko, Herman Y.L...... 177 Soedarmo,Suryadi ...... 149 Thomas Erwin CJ Huwaei ...... 173 Winardi Budiwinata ...... 188 Somathilaka SPU ...... 130 Thushara Dissanayake ... 131, 236 Windy Juliandra ...... 156 Soo Khee Chee ...... 51 Till Krech ...... 107 Wiryawan Manusubroto ...... 184 Sou-Hsin Chien ...... 62 Tjahjodjati ...... 166 Wisnu Wardhana, DP .... 145, 262 Sri Maliawan ...... 31 Tjakra W. Manuaba ...... 42 Wuryantoro Soeharto ...... 152 Sri Andreani...... 251 Tjandra F ...... 162 Y.E. Sembiring ...... 255 Sri Maliawan ...... 81, 248 Tjhin Sun Fu ...... 211 Ya-Chun Huang ...... 146, 147 Šťastný K ...... 59 Tjia Jefri ...... 163 Yagi K ...... 119 Steven Christian ...... 273 Tjiptadi V...... 180 Yan E. Sembiring ...... 255 Subagjo ...... 173, 254 Tjokorda G. B. Mahadewa ..... 211 Yan Wisnu Prajoko ...... 47 Subasinghe D ...... 130 Tjokorda GB. Mahadewa ...... 20 Yanagihara Akitoshi ...... 75 Subhash Khanna ...... 74 Tommy Ruchiyat ...... 156 Yao Hui-e ...... 176 Subiyakto ...... 143 Tommy Suharso ...... 182 Yashar A ...... 110, 166 Sudartana. K ...... 259 Tomoichirou Hirosawa ...... 90 Yasutoshi Murayama 70, 75, 133, Sugiharto, Setyo ...... 149 Tomoya Hatakeyama .... 135, 136 134, 135, 136, 157 Suhardi ...... 190, 241, 247 Toru Furukawa ...... 63 Yasutosi Murayama...... 65 Suharto Wijanarko ..81, 109, 112, Toshihiko Nishidate ...... 38 Yataka Takahashi ...... 70 113 Toshihiro Hirai ...... 46 Yati Soenarto ...... 76 Sumadi Lukman Anwar ...... 107 Toshiyuki Enomoto ..... 53, 54, 89, Yayoi Sato ...... 63 Sumangkud, R ...... 187 108 YE. Sembiring ...... 246 Sumantra Chatterjee ...... 80 Toshiyuki kosuga ...... 70 Yefta Moenadjat...... 39, 152 Sumaryono ...... 264 Toshiyuki Kosuga .... 75, 133, 134, Yen-Chang Clark Lai ...... 86 Sunaryo H ...... 179 136 Yeni Puspawani ...... 261 Sungsang...... 172 Toshiyuki Natsume ...... 63, 88 Yenzher T ...... 148 Supomo ...... 188 Tri Wahyu ...... 188 Yevri Zulfiqar ...... 170, 171 Suresh Khanna ...... 86, 87 Tsann-Long Hwang ...... 54 Yi Miao ...... 33 Suroto, NS ...... 145, 262 U.S Dhaliwal ...... 64 Yik-Hong Ho ...... 20, 24, 27 Suryawisesa I.B...... 265 U.Y.Samaratunga . 110, 120, 121, Yoichi Nakamura ...... 89, 108 Susan H Mety ...... 120 185 Yoko Kanada ...... 63 Susan Hendriarini Mety ...... 33 Udayakumara E.A.D ...... 130 Yokoyama Masaya ...... 75 Susilo RH ...... 138 Udayakumara EAD ...... 130 Yopie Afriandi Habibie .. 190, 241, Suyatno ...... 237, 238 Ulrich Lehmann ...... 107 247 Suzanna,Lilys ...... 149 Uncok Andre Pahala S ...... 224 Yoshiaki Kuriu ..... 65, 70, 75, 133, Syahfreadi ...... 151 Untung Alifianto ...... 81 134, 135, 136, 157 Syaifullah Asmiragani ...... 173 Utama Tarigan...... 261 Yoshihisa Saida .... 53, 54, 89, 108 T. Matsubara ...... 73 V. Anikin ...... 53 Yoshihisa Watayo ...... 91 T. Shiozawa ...... 73 Viator Nadeak ...... 285 Yoshihito Kodera...... 89 T. Umemoto ...... 73 Vicky Ferdian ...... 169 Yoshihito Kotera .. 68, 70, 71, 150 T. Wakabayashi ...... 73 Vicky S Budipramana ...... 151 Yoshikazu Sakakima ...... 135 Tadao Kubota ...... 66, 69, 122 Vicky S. Budipramana ...... 47 Yoshiki Nariai ...... 60, 64, 65 Tahalele P ...... 232, 243 Vincent Tjiptadi ...... 177 Yoshiko Banba ...... 90 Takafumi Yoshioka ...... 63 Vita Indria ...... 238 Yoshiko Shirasaki ...... 88 Takahiro Kanno ...... 41, 60, 64, 65 Vita Indriasari ...... 232, 287 Yoshinobu Iwasaki ...... 136 Takako Kamio ...... 76, 106 Vito Mahendra Ekasaputra ...... 98 Yoshioka Takahumi ...... 75 Takashi Maruyama ...... 63, 75, 88 W. Steven Chr ...... 265 Yosua Hardja ...... 165 Takashi Sakamoto ...... 66 W. Sumanti ...... 90 Yosuke Ariyoshi ...... 136 Takehisa Yazawa ...... 63 W.A.L.D. Aruna Prasanna ...... 185 Yosuke kamada ...... 65 Takehito Otsubo ...... 45 W.A.L.D.Aruna Prasanna120, 121 Yosuke Kamada ...... 135 Takeshi Kubota...... 134, 135, 157 W.A.L.D.ArunaPrasanna ...... 110 Yovanka Manuhutu ...... 142 Tan T’zu Jen ...... 86 Wallad C ...... 270 Yu-Hua Huang ...... 80 Tan Yeh Hong ...... 35, 44 Wan-Lin Chen ...... 74 Yuji Yamamoto ...... 63, 75, 88

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Heading To Good Surgery

Yuki Yamashita...... 91 Yuriz Bakhtiar ...... 261 Yutaka Takahasi ...... 68 Yukinori Toyoshima ...... 63 Yusirwan Yusuf ...... 141 Yutaro Takamura ...... 64 Yulan Permatasari ...... 99, 102 Yusuf Hermawan ...... 245 Zainal Muttaqin ...... 44, 261 Yuliono Budi ...... 286 Yutaka Kondo...... 65, 70, 135 Zulfan ...... 170 Yulius Candra Adipurwadi 80, 139 Yutaka Takahashi ...... 71 Zumirda ...... 244

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