Contents 29th May 2015 (Friday)

MEET-THE-EXPERTS 1 | Plastic Getting Skin Grafts To Take – Lim Lay Hooi

MEET-THE-EXPERTS 2 Improving Cosmesis In Breast Conservation Surgery – Visnu Lohsiriwat / Suebwong Chuthapisith

PLENARY 1 Optimizing Every Patient’s Outcomes – How To Deliver High – Quality, Accessible Surgery To A Whole Population Phillip Carson

SYMPOSIUM 1 | Surgical Physiology Of Trauma 1.1 Trauma Coagulopathy And Its Management – Philip Iau 1.2 Damage Control Resusitation – Teo Aik Howe 1.3 Understanding The Pathophysiology Of SIRS And 9 Optimizing Outcomes Lum Siew Kheong 1.4 Intensive Care In Polytrauma 9 Lee See Pheng

SYMPOSIUM 2 | Breast 2.1 Hereditary Breast And Ovarian Cancer – The Manchester 10 Experience Gareth Evans 2.2 Dense Breast And Breast Cancer Risk And Management 11 Suebwong Chuthapisith 2.3 Experience In Implant Breast Reconstruction 12 Sarinah Basro 2.4 Sentinel Lymph Node Biopsy – An Update 12 Saladina Jaszle

1 Contents 29th May 2015 (Friday) [cont’d]

PLENARY 2 Research And Registries In Cardiothoracic Surgery 13 John Chan Kok Meng

SYMPOSIUM 3 | Managing Surgical Trauma 3.1 Refining Management Of Head Trauma 14 Dharmendra Ganesan 3.2 Managing Chest Trauma 14 Tan Boon Lee 3.3 Laparoscopy In Intra-Abdominal Injury 15 Mohd Yusof bin Abd Wahab 3.4 Spine Trauma – The Young, The Old And The Mortal 15 Zamyn Zuki bin Mohd Zuki

SYMPOSIUM 4 | Surgical Research 4.1 Essential Elements For A Speedy Ethical Approval – Goh Pik Pin 4.2 What You Need To Know About Animals In Research 16 Ooi Peck Toung 4.3 My Experience Initiating Research In District Hospitals – Kalaiarasu Peariasamy 4.4 My Experience In Research In Upper Gastrointestinal – Surgery Mahadevan Deva Tata

SYMPOSIUM 5 | Urology – Urolithiasis 5.1 Approach To Management Of Ureteric Colic 16 Murali Mohan 5.2 Medical Therapy For Urolithiasis – Does It Work? 17 Leong Wing Seng 5.3 Endoscopic Management Of Stones – Rohan Malek

2 Contents 29th May 2015 (Friday) [cont’d]

SYMPOSIUM 6 | Vascular Access Outcomes 6.1 Salvaging Thrombosed AV Fistula 17 Tan Kia Lean 6.2 Vascular Access Planning 18 Ashraf Md Razi 6.3 Recognising And Managing Access Failure And Common 18 Complications Benjamin Leong Dak Keung

3 Contents 30th May 2015 (Saturday)

MEET-THE-EXPERTS 3 | Vascular Management Of Acute Limb Ischaemia –

MEET-THE-EXPERTS 4 | Trauma A Century Of Trauma Resuscitation Advances – Ronald V Maier

MEET-THE-EXPERTS 5 Single Port Laparoscopic Surgery – Chin Kin Fah

PLENARY 3 Modern Management Of Chronic Venous Disease – Benjamin Chua Soo Yeng

SYMPOSIUM 7 | Managing Surgical Trauma 7.1 Managing Soft Tissue Trauma – Lim Lay Hooi 7.2 Managing Disasters And Mass Events 19 Oliver Hautmann 7.3 Managing Trauma In A District Hospital – Phillip Carson 7.4 Inter-Hospital Transfer Of Trauma Patients – Andrew Gunn

SYMPOSIUM 8 | Endocrine Surgery 8.1 The Role Of Ultrasound In Thyroid Diseases 19 Shahrun Niza Abdullah Suhaimi 8.2 Hypercalcemia: Treatment And Management Update 20 Imisairi Abd Hadi 8.3 Robotic Thyroidectomy In Malaysia: Is It The Future? 20 Hakim Nor Azham 8.4 Adrenal Incidentaloma: Do We Need To Remove? 21 Normayah Kitan

4 Contents 30th May 2015 (Saturday) [cont’d]

PLENARY 4 Practice And Training Of Oncoplastic Breast Surgery In Asia – Visnu Lohsiriwat

PLENARY 5 The Impact Of ERAS On Colorectal Practice – Mike Lavelle-Jones

SYMPOSIUM 9 | RCS Edinburgh 9.1 The Current Status Of Training/Assessment In The UK – Mike Lavelle-Jones 9.2 Non-Technical Skills For Surgeons (NOTSS) – Simon Paterson-Brown 9.3 Surgical Competence And Curriculum Design – David Pitts 9.4 Postgraduate Training: Why Should We Change? – Simon Frostick

5 Contents 31st May 2015 (Sunday)

MEET-THE-EXPERTS 6 | Urology – Renal Trauma Diagnosis, Imaging And Staging 21 Khor Tze Wei Management Issues; Non-Surgical And Surgical – Hamid Ghazali Follow-Up And Management Of Late Complications Of 22 Renal Trauma Teoh Boon Wee

MEET-THE-EXPERTS 7 | Bariatric Revisional Bariatric Surgery: Why, When And What To Do – Nik Kosai

MEET-THE-EXPERTS 8 | Colorectal Solving Matters The Colorectal Way – Ismail Sagap / April Roslani

SYMPOSIUM 10 | Colorectal 10.1 How Can We Lower The Number Of Deaths From 22 Colorectal Cancer In Malaysia? Lim Kean Ghee 10.2 Clinical Practice Guidelines For Colorectal Cancer – Nil Amri Mohamed Kamil 10.3 Revisiting Colorectal Surgery Training And Research – In Malaysia Fitjerald Henry

SYMPOSIUM 11 | Vascular 11.1 Optimizing Patency Of Vascular Access – New Strategy – Liew Ngoh Chin 11.2 Optimizing Outcomes In Vascular Trauma – Naresh Govindarajanthran 11.3 Optimizing Outcomes In RAAA Through Early Diagnosis – Kevin Moissinac

6 Contents 31st May 2015 (Sunday) [cont’d]

PLENARY 6 | Upper GI The KLASS Trial In Laparoscopic Gastrectomy – Sang-Uk Han

SYMPOSIUM 12 | Surgical Education 12.1 Entry To Surgical Training In Malaysia – Ismail Sagap 12.2 Formative Assessment Of A Masters Candidate 23 April Roslani 12.3 Summative Assessment Of A Masters Candidate – Hanafiah Harunarashid 12.4 Continued Post Graduate Development In the Post-National – Specialist Register Era P Kandasami

SYMPOSIUM 13 | Upper GI & Hepatobiliary 13.1 The Management Of A Giant Para-Oesophageal Hiatus Hernia – Simon Paterson-Brown 13.2 Minimally Invasive Oesophagectomy – Chin Kin Fah 13.3 Reconstruction Techniques In Lap Gastrectomy – Sang-Uk Han 13.4 Laparoscopic Repair For Perforated Peptic Ulcer – Ramesh Gurunathan

HOW I DO IT SESSION Crash Trauma Laparotomy – Philip Iau Continuous Intra-Operative Nerve Monitoring (Thyroidectomy) 23 Rohaizak Muhammad Laser Haemorrhoidoplasty – April Roslani

7 Contents

Ethicon Prize Presentations 24 – 28

FREE PAPER PRESENTATION 1 29 – 34

FREE PAPER PRESENTATION 2 35 – 42

OFFICIAL POSTER PRESENTATIONS 43 – 181

8 Symposium 1 Surgical Physiology Of Trauma

Understanding the Pathophysiology of SIRS and Optimizing Outcomes Lum Siew Kheong International Medical University Clinical School, Seremban, Negeri Sembilan, Malaysia

SIRS is a systemic inflammatory state arising after an infectious or a non infectious insult to the body. It is believed that the insult which results in SIRS causes an over exuberant compensatory anti-inflammatory response (CARS) which leads to immunosuppression, sepsis and multi organ dysfunction. The components of SIRS are temperature (T <36°C or > 38°C) , pulse rate (>90/min), respiratory rate (>20/min or pCO2 <32mmHg ), white cell count (<4000/mm3 or >12,000/mm3 or increase in immature neutrophils > 10%). SIRS is said to be present when 2 out of 4 of these criteria are present.

When SIRS is present with acute organ dysfunction without infection, it is termed SEVERE SIRS. When SIRS is present with suspected or documented infection, it is termed SEPSIS. When sepsis is present with acute organ dysfunction it is termed SEVERE SEPSIS. When sepsis and shock are present (+/- organ dysfunction), SEPTIC SHOCK is said to be present.

To optimise clinical outcomes in patients with SIRS, the following principles should be borne in mind. A. Treat the underlying cause and early aggressive sepsis management – eg treat shock or hypovolaemia with fluid replacement, treat pancreatitis with fluid therapy, treat anaphylaxis with adrenaline and antihistamine, treat sepsis by early prophylactic antibiotics and removal of infected mesh. B. Avoid harmful practices – eg avoid starch for fluid resuscitation and limit the use of RBC transfusion5. C. Early enteral feeding is superior to parenteral feeding (Arginine, Glutamine) D. Early ventilation E. Anti-inflammatory – Omega 3 fatty acid eg ecosapentaenoic acid, F. Antioxidants – Selenium, Vitamin E G. Tranexamic acid – beneficial in CRASH 2 trial due to ? antifibrinolytic effect in reducing bleeding or ? immunomodulatory effect. H. On going trials8 – statins, immunonutrition and targeting neutrophil function.

Symposium 1 Surgical Physiology Of Trauma

Intensive care in Polytrauma Lee See Pheng Hospital Tengku Ampuan Rahimah Klang (HTAR), Klang, Selangor, Malaysia

Care of the polytrauma patient does not end in the operating room or emergency bay.

ICU physicians must be prepared to receive patients at any point along the continuum of care, and must be adept at assessing the patient’s physiologic status and addressing ongoing needs in a prompt fashion. As the patient stabilizes, the ICU physician must then change the focus of care to longer term considerations such as infectious and thromboembolic complications, organ support, nutrition requirement and the need for planned re-exploration and staged definitive repair.

9 Symposium 2 Breast

Hereditary Breast and Ovarian Cancer – The Manchester Experience D Gareth R Evans Department of Genomic Medicine, St Mary’s Hospital, Manchester, United Kingdom and Manchester Breast Centre, The Christie, Manchester, United Kingdom

Summary Breast cancer is the commonest cancer in women worldwide and its incidence is increasing at all ages and especially in the Asian subcontinent. Around 5% of breast cancer is due to inheriting mutations in single high risk genes such as BRCA1, BRCA2 and TP53, but overall around 30% of breast cancer has a substantial heritable component. BRCA1 and BRCA2 account for the vast majority of the strong inherited link between breast ad ovarian cancer and negative testing for BRCA1 and BRCA2 in the UK in a breast cancer family eliminates any increased risk of ovarian cancer. NICE guidance in the UK recently confirmed that high-risk thresholds for high risk were a ≥30% Lifetime breast cancer risk and in moderate risk (≥17% Lifetime). Women at moderate or greater risk are eligible for annual mammography screening in their forties in the UK. These guidelines also for the first time recommended offering tamoxifen or raloxifene for breast cancer prevention to high risk women and considering chemoprevention in moderate risk. Long term follow up of tamoxifen in the IBIS1 trial shows a continued risk reduction of around 35% 10 years after ceasing treatment. However in Manchester uptake to tamoxifen is only just over 10%. In IBIS2 there was an even greater 50% short term risk reduction with the aromatase inhibitor anastrazole. Thresholds for MRI screening can be as low as a 20% lifetime risk in the USA to being as high as only offering MRI to gene carriers and those with a very high chance (≥30% of BRCA1/2 or TP53). Most countries in Western Europe, Australasia and North America will offer genetic testing to those with at least a 10% chance of an underlying mutation. We have recently shown a significant reduction in mortality from breast cancer in women undergoing MRI with 10 year survival in excess of 90%.

The likelihood of a high-risk mutation increases the chances of further primary breast cancer particularly in the contralateral breast, but also ovarian cancer. Around 2-3% of breast cancer in outbred populations are due to mutations in BRCA1 or BRCA2. Contralateral risks increase to around 2% annually (60% at 30 years), although this can be reduced by endocrine therapy and oophorectomy. In some Western populations (including Manchester) uptake of contralateral mastectomy is around 50% in those that know their mutation at time of primary diagnosis and has now been confirmed to improve survival. Annual mammography is recommended in the UK for women after primary breast cancer until 50 years of age and continued to 70 years in very high risk women such as gene carriers. MRI is also recommended in gene carriers to 50 years of age. Bilateral mastectomy as prevention is now quite commonplace in the UK and other Western countries and we have recently shown that risk reducing mastectomy alongside oophorectomy in an unaffected gene carrier increases life expectancy. This effect is driven to a large extent by oophorectomy. We have shown that ovarian screening with ultrasound and CA125 is ineffective in detecting ovarian cancer early and that 10 year survival is only 35% in mutation carriers with ovarian cancer found whilst undergoing screening.

10 Symposium 2 Breast

Dense breast and breast cancer risk and management Suebwong Chuthapisit Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand

Mammographic breast density is currently an interesting issue in screening for breast cancer. In the United State, recently 20 states now require radiologist to notify women who undergone mammography for their breast density, as well as any information for further supplement screening modality.

According to ACR-BIRADS classification (5th edition), published in 2013, mammographic breast density can be classified into 4 categories:

Category A: The breasts are almost entirely fatty

Category B: There are scattered areas of fibroglan¬dular density (an optional description of a few or moderate scattered areas of density can be included in a second sentence

Category C: The breasts are heterogeneously dense, which may obscure small masses (if the dense tissue is localized to one area of the breast, the location of the dense tissue can be included in a second sentence: “The dense tissue is located anteriorly in both breasts, and the posterior por¬tions are mostly fatty” or “Primarily dense tissue is located in the upper outer quadrants of both breasts; scattered areas of fibroglandular tissue are present in the remainder of the breasts”)

Category D: The breasts are extremely dense, which lowers the sensitivity of mammography

Dense breast is related to increase risk of breast cancer with a relative risk of 2.1 in extremely dense breast tissue. This is possibly due to masking effect and perhaps other factors. However, this risk is much less than other previously known factors eg. family history or previous other high risk pathology in the breast. There are many debates in the use of additional other radiological modalities to improve the diagnosis of breast cancer in women with dense breast tissue. So far, the use of ultrasonography seems to show benefit in many recent publications. However, the problem of high false positive rate is highly concerns; and that leads to consideration in term of cost- effectiveness. As well, the use of automated ultrasonography by well trained breast imaging technician may be able to detect more breast cancer in the dense breast women.

Other modalities for screening of breast cancer in women with dense breast tissue include digital breast tomosynthesis and breast MRI. However, again, findings from further researches are still required before any conclusions for appropriate use of these modalities are established.

11 Symposium 2 Breast

Experience in Implant Breast Reconstruction Sarinah Basro Department of Breast & Endocrine Surgery, Hospital Putrajaya, Putrajaya, Malaysia

The local management of breast cancer has undergone continuous advances in the last two decades. Since Toth and Lappert introduced the skin-sparing mastectomy (SSM) in 1991, immediate breast reconstruction IBR (autologus or implant-based reconstruction) is increasingly accepted as a method of treatment. Numeorus studies reported the oncology safety and the excellent asthetic outcome of SSM and IBR. More recently, nipple-sparing mastectomies (NSM) have also been proposed in selected cases.

Implant-based reconstruction is relatively simple and does not greatly prolong the surgery. However, the use of the prosthesis may give rise to complications which may increase the number of corrective interventions, possibly even leading to removal of the implant. After SSM, the combination of abundance of breast skin envelope and the anatomical shaped of prostheses facilitate the use of a definitive implant in IBR. The implant is placed in a submuscular position superiorly and in a subfascial pocket inferiorly. Preservation of the infra- mammary fold (IMF) further enhanced the cosmetic results.

In Hospital Putrajaya, we performed 58 implant-based reconstructions between January 2007 to December 2014. Majority of them (80%) were immediate one-stage reconstruction using adjustable implant (Becker) following SSM. Based on our experiences, we conclude that implant-based IBR offers an acceptable cosmetic outcome without compromising the oncology safety. Proper selection of patients is very important and is a basic element of the procedure. Patient with high risk of post operative radiotherapy preferably should go for autologus IBR or delayed reconstruction.

Symposium 2 Breast

Sentinel Lymph Node biopsy – An Update Saladina Jaszle Jasmin Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

Axillary surgery in patients with breast cancer serve; two main purposes.

Firstly, to stage the axilla. This determine the prognosis and assign additional treatment/s required and to clear the axilla of any cancer that may be present.

Despite the known morbidity and the lack of added survival benefit in Early Breast Cancer it remained standard treatment for the axilla.

Since Its Introduction in 1991, sentinel LN biopsy has gained popularity among the breast surgeons as the preferred surgical option in axillary surgery for early breast cancer. SLNB not only provides adequate staging with added advantage of reduced morbidity as compared to conventional axillary dissection. The results from Z11 trial and AMAROS trial further challenge the role of axillary dissection in the treatment for early breast cancer. An Update on Sentinel LN biopsy and the latest evidence will be highlighted in this presentation.

12 Plenary 2

RESEARCH AND REGISTRIES IN CARDIOTHORACIC SURGERY John Chan Kok Meng Sarawak General Hospital Heart Centre, Kuching, Sarawak, Malaysia Royal College of Surgeons of England, London, England, United Kingdom

The importance of research in surgery is increasingly being recognised as a means to provide the evidence to better guide surgical decision-making. In addition to providing evidence for the need for surgical interventions, evaluation of new surgical techniques, procedures and approaches, and the long term outcomes from surgical interventions can be studied. Research in surgery has predominantly been based on observational studies. For many years, surgeons have been criticised for the low quality of surgical research studies. To strengthen the quality of surgical research studies, propensity matching has been used in an attempt to more equally balance the baseline characteristics of study patients. However, propensity analysis can never fully eliminate all confounding factors in treatment groups.

The highest class of evidence comes from prospective randomised controlled trials (RCT). However, such RCT are difficult to do in surgery, particularly in major surgery such as cardiothoracic surgery. The difficulty arises both from recruiting study patients and also from surgeons. Patients often decline to take part in surgical RCT because they do not want their choice of treatment to be decided by chance, which is what would happen in a RCT; many patients prefer to make the decision on their treatment themselves, while others prefer their surgeon to make this decision for them. There is also a lack of equipoise amongst surgeons for many of the treatments that need to be evaluated by RCTs. Advocates of a new surgical procedure may already feel that it is the better treatment and hence would not want patients randomised to the older more established treatment. Finding sufficient numbers of patients to meet the required sample size as determined by power calculations is also often difficult in surgical trials. Unlike trials involving medications where large numbers of patients can usually be easily recruited, surgery involves smaller numbers of patients but the required number of patients, which are needed to detect a difference in outcomes, remains the same. Many surgical studies are underpowered and this can result in misleading results and conclusions. Most trials in surgery therefore need to be multicentre to recruit sufficient numbers of patients. However, this brings another problem, that of standardisation of surgical techniques. To truly evaluate a new surgical technique or procedure, or to compare different surgical techniques, it is important that there is at least some standardisation of the technique in the studies. This can be difficult if the study is being conducted in different centres and countries. Surgeons taking part in clinical trials should also have passed the learning curve of the surgery being studied and should preferably be experts in performing the surgery concerned. A strict inclusion and exclusion criteria is also important to ensure only patients who are likely to benefit from the surgery being studied are recruited.

Despite the many difficulties in performing surgical randomised controlled trials, many such trials have now been performed, particularly in Cardiothoracic Surgery. Many of these are large multicentre trials and have been published in the best and highest impact journals. Many of these trials have led to a profound change in clinical practice. Unfortunately, many poorly designed large randomised controlled trials have also raised more questions than answers, and some have in fact given misleading results and conclusions. Although randomised controlled trials provide the highest level of evidence, it is important that it is well designed and done properly particularly in surgery. Surgery, after all, is more an art than a science, although it is an art based on scientific principles.

A useful tool for research, particularly suited to surgery, is the registry, which can be disease or procedure based. Registries not only provide a rich source of data for research, but more importantly, it provides information about surgical activity levels and can be used as a tool to measure and compare outcomes amongst surgeons and centres. Benchmarking of surgical quality and outcomes can also be performed with setting of minimum standards. Cardiothoracic Surgery has led the way amongst surgical specialties in setting up registries and detailed data analysis of outcomes has been performed with risk stratification of results in many countries. However, when measuring outcomes, even with risk stratification, care has to be taken to ensure that surgeons are not unfairly penalised for operating on high risk or complex cases. Such patients may benefit in the longer term, although the risk during the perioperative period will undoubtedly be higher. If not done well, risk adverse practice can occur whereby surgeons only operate on the more straightforward lower risk cases in order to make their results look good. This would be to the detriment of some patients who need complex higher risk operations. Outcomes reporting and benchmarking must therefore be done carefully and using the right tools and methods. Moreover, it is important to appreciate that the surgeon is only one person in a team responsible for the care and outcome of the patient. Although the surgeon is ultimately responsible for the patient, it is important to recognise that surgical factors are often not the only cause for an unfavourable patient outcome. Complications can and do happen but it is the ability to recognise and deal with these complications which distinguishes the centres of excellence from the average centre.

The National Cardiovascular and Thoracic Surgical database is now in place and Cardiothoracic Surgeons throughout the country have been entering details of their patients, operations and outcomes into this database. It is planned that reports will be produced yearly, which initially will be on activity levels only, providing useful information on the burden of disease and help in the planning of resources, amongst others.

13 Symposium 3 Managing Surgical Trauma

REFINING MANAGEMENT OF HEAD TRAUMA Dharmendra Ganesan Division of Neurosurgery, University of Malaya, Kuala Lumpur, Malaysia

Head injury traditionally can be divided into either mild, moderate and severe based on the presenting Glasgow Coma Scale (GCS).

Mild head injury patients have neurocognitive impairment of various degrees. The patients with complicated mild head injury seem to have more pronounced cognitive deficits. The deficits need to be identified early and rehabilitative therapy need to be initiated to limit socioeconomic problems.

Severe head injury needs sound intensive care management. The insertion of intracranial pressure (ICP) monitoring device would be standard of care in many centres. The ICP and cerebral perfusion pressure (CPP) driven therapy forms the guide for head trauma management. If ICP is elevated and there is no surgical lesion, then either barbiturate coma or decompressive craniectomy is the options available.

Research in neurotrauma has begun to define the benefits of monitoring brain tissue oxygen, lactate/pyruvate ratio and pH etc. Substantial work on MRI imaging of the brain with specific sequences eg. FLAIR, DTI etc. to further define anatomical injury to the brain in neurotrauma. There are volumetric assessment of lesions and brain regions. The use of genomics to predict the potential for functional recovery eg. apolipoprotein E4 (APOE4), brain derived neurotrophic factor (BDNF) etc.. More recently, several serum biomarkers (proteomics) have been described to be elevated in head injury.

Symposium 3 Managing Surgical Trauma

Managing Chest Trauma Tan Boon Lee Putra Medical Centre, Alor Setar, Kedah, Malaysia

Chest cavity contains vital organs most essential for life namely heart, lung and great vessels. 20% of traumatic death linked directly to chest injuries, up to 50% may indirectly related to chest injuries; however many of these can be prevented with prompt identification and treatment. Less than 10% blunt chest trauma and less than 30% penetrating chest trauma require operative treatment, most of these patient require only a simple procedure such as a tube thoracostomy for live saving. Physician caring for the trauma patients need to be familiar with spectrum of chest trauma, emergent life saving procedure and identified the subgroup require operating room procedure as a continuance of patient resuscitation and management in order to reduce morbidity and mortality.

14 Symposium 3 Managing Surgical Trauma

Laparoscopy in Intra-abdominal injury Muhammad Yusof Abd Wahab Hospital Tengku Ampuan Rahimah, Klang, Selangor, Malaysia

The gold standard for intervention in patients with definite and suspected intra-abdominal injury is laparotomy. However an outcome of negative and non-therapeutic laparotomy is undesirable. The reported rate of negative or non-therapeutic laparotomy is in the range of 15-30%1.

In haemodynamically stable patients with suspected intra-abdominal injury, the current approach to confirm the diagnosis is by active observation and/or use of imaging modalities such as ultrasound or CT scan. These modalities however, are limited by varying rates of false positive and false negative results, and hence is unable to reduce negative or non-therapeutic laparotomy.2,3

In haemodynamically stable patients with suspected intra-abdominal injury, laparoscopy can be used as a diagnostic tool and in selected cases, as a therapeutic tool. Laparoscopic surgery also has the added benefit of allowing the surgeon to make ‘targeted’ incisions in some patients who require conversion to open surgery.

The number of laparoscopic surgeries done by the Surgical Department of Hospital Tengku Ampuan Rahimah, Klang in both elective and emergency settings, has seen a steady increase from 130 cases in 2006, to 374 cases in 2014. Audit of our data over the last 2 years showed that we managed 44 patients with intra-abdominal injuries laparoscopically. 10 patients (22%) were converted to open surgery, 1 patient (2%) died following complications of injuries to his chest.

In conclusion, laparoscopy is a safe option for intra-abdominal injury in patients who are haemodynamically stable.

References 1. Trauma Registry Report, Hospital Sultanah Aminah, 2012 - 2013 2. Stengel D, Bauwens K, Sehouli J, Porzsolt F, Rademacher G, Mutze S, et al. Systemic review and meta-analysis of emergency ultrasonography for blunt abdominal trauma. Br J Surg 2001; 88(7):901-12 3. Salim A, Sangthong B, Martin M, et al. Use of computed tomography in anterior abdominal stab wounds. Arch Surg 2006; 141: 745-752

Symposium 3 Managing Surgical Trauma

SPINE TRAUMA – The Young, The Old And The Mortal Zamyn Zuki Bin Mohd Zuki Orthopedics and Traumatology Department, Hospital Sungai Buloh, Selangor, Malaysia

Introduction Traumatic spinal injury usually causes morbidity and mortality especially injury to the upper cervical spine. The primary causes of traumatic spine injury are mostly motor vehicles accident, falls and sports. Due to complex anatomical and biomechanical features of the spine, types and severity of the injury will differs from immature bone, matured bone and diseased bone.

Spine trauma in Pediatric Spinal injuries in children are very challenging in terms of diagnosis and subsequent care as their bone is still developing. Especially, the phenomenon of spinal cord injury without radiographic abnormality (SCIWORA), is unique to pediatic age group.

Spine trauma in adult Most of the traumatic spinal injury occurs between age 18-35 years old. Spinal injuries carry a double threat: damage to the vertebral column and damage to the neural tissue. Neurological involvement in adult are most likely due to fracture or dislocation of vertebrae rather than prolapsed of intervertebral disc.

Spine trauma among Geriatric Due to degenerative changes of vertebrea and disc in elderly, even minor trauma can results in spinal injury. Traumatic disc herniation is also common among the geriatric patient.

Spine trauma that is highly mortal Upper cervical injury often fatal , as well as fracture dislocation of the thoracic region with associate chest injury

15 Symposium 4 Surgical Research

What you need to know about animals in research Ooi Peck Toung Department of Veterinary Clinical Studies, Faculty of Veterinary Medicine, Universiti Putra Malaysia, Serdang, Selangor, Malaysia

The use of animals for research, teaching and testing program has increase dramatically since the early 1980s. For research involving animals, the first and most important step is to establish a protocol. The protocol must describe the operative procedure and state the rationale of animal used. The proposal also must justify the animal species selected, number of animals used and degree of invasive that involved. Procedures that may cause pain or distress should be performed with appropriate sedation, analgesia, or anesthesia. The protocol need to be review and approve by the relevant Institutional Animal Care and Use Committee (IACUC) or Animal Ethic Committee. Next, is to select the appropriate animal. Rat and mice are the most common animals used for medical research and make up to 90%. Another 10% will be mammals such as guinea pigs, rabbits, hamsters, pigs and sheep. Researchers need to choose the species that best parallels the biology of what they want to study. It is important to acclimate the animals to the facility prior to the procedure to reduce stress. A thorough health check is needed to make sure that the animals are not affected by any condition. General or partial anesthetic might be required depend on the procedure. During the procedure, researcher need to keep the animals warms and monitored the vital organ function. Post-operative care is important for survival procedure. For non-survival/non-recovery procedure, animals need to be euthanized and proper dispose.

Symposium 5 Urology – Urolithiasis

APPROACH TO MANAGEMENT OF URETERIC COLIC Murali Mohan Kedah Medical Centre, Alor Setar, Kedah, Malaysia

Urinary stone disease is increasingly prevalent, with a lifetime risk of about 12% in men and 6% in women.1 Age of onset of a first stone episode for men rises from their 20s and peaks at age 40-60 years, with an incidence of three cases per 1000 population per year. In the local setting it accounts for almost two thirds of the work load for a urologist both in the public and private sector.

The approach to management of ureteric colic involves clinical evaluation, differential diagnosis, investigations with special emphasis on appropriate imaging modality and definitive management. The management of ureteric colic has changed significantly over the past three decades. Factors such as stone size, location, composition as well as patient and surgeon preference influence the management decision. Recent work has looked at the expansion of the role of medical therapy beyond symptomatic control to attempt to target some of the reversible factors in stone retention and thereby improve the likelihood of spontaneous stone expulsion. Technological advances in shock wave lithotripsy and ureteroscopy offer patients highly effective, minimally invasive options for stone clearance that can often be performed on a day care basis .

All the above stated issues will be discussed in detail during the lecture.

16 Symposium 5 Urology – Urolithiasis

Medical Therapy for Urolithiasis – Does it Work? Leong Wing Seng Lam Wah Ee Hospital, Penang, Malysia

Over a lifetime urolithiasis can affect up to 10-15% of the population. After passage of a first stone, the risk of recurrence is 40% at 5years & 75% at 20years.

Recurrent stone disease cause not only pain and distress to the patient, but also imposes significant economic burden for lost working days and associated healthcare costs. Minimally invasive surgery has revolutionized stone management, but it has not reduced recurrence rates.

This metabolic investigations and medical treatment are important elements in clinical management of urolithiasis in term of reducing the rates of stone recurrence.

The lecture intend to provide a summary of medical therapies available for urolithiasis, which includes general medical advice, prophylactic medications dissolution therapy and medical expulsive therapy. Hence, a management strategy for all physicians who treat urolithiasis medically.

Symposium 6 Vascular Access Outcomes

Salvaging Thrombosed AV Fistula Tan Kia Lean Serdang Hospital, Selangor, Malaysia

With the prevalence of End Stage renal Failure (ESRF) patient approaching thirty thousand in Malaysia, the number of patient undergoing haemodialysis has been on uprising trend. Hence the work on AV fistula creation and surveillance also increase proportionally. However the work on salvaging thrombosed AV fistula is still minimal in our country.

The work of Salvaging thrombosed AV fistula is normally carried out at secondary or tertiary center. It can be either repaired by open method or Endovascular method. Open repair involves thrombectomy with patch plasty of stenotic or occluded vein segment. On top of that, it is not uncommon that the diseased vein segment is replaced with an autogenous or prosthetic graft. On the other hand Endovascular repair involves percutaneous pharmacological or mechanical thrombectomy followed by fistuloplasty to correct the underlying pathology . Both aiming at returning the thrombosed AV fistula back to function.

A hybrid procedure on salvaging thrombosed fistula allowed us to reduce the cost of procedure and at the same time improve the outcome and durability of functioning AV fistula. This will improve the outcome of AV fistula salvaging.

17 Symposium 6 Vascular Access Outcomes

Vascular Access Planning Ashraf Md Razi KPJ Penang Specialist Hospital, Penang, Malaysia

Creation of an arterio venous fistula (AV fistula, AVF) for future dialysis access is crucial in helping the haemodialysis- dependant patient. Preoperative patient demography may differ but few criteria may require consideration when planning for creation of a new AV fistula. Planning for a new vascular access is important in order to optimize the chance of success and reducing the morbidity from the procedure.

The presentation will briefly cover the natural history of an AV fistula, preoperative patient selection, various operative options that are available, preoperative work-up and tools required for a successful creation of an AV fistula. Common pitfalls in fistula failure and reasons will also be discuss as these will help to ensure the success rate of fistula creation improved.

Various types of vascular access available for the haemodialysis patient will be mentioned and which one is more suitable in a given situation. USG imaging is of utmost importance during the preoperative work up and in this day and age, creating an AV fistula without proper preoperative vein mapping and arterial tree evaluation should be a thing of the past. Few simple USG parameters that will help in making a correct decision and choice of AV fistula creation will be presented.

Even though the creation of an arterio-venous anastomosis is fairly simple and straightforward, the skills required for a good anastomosis will improve over time but planning criteria remains the same. Taking a bit more time in preoperative planning may help create a longer lasting, functioning and low morbidity fistula for the patient.

Symposium 6 Vascular Access Outcomes

Recognising and Managing Access Failure and Common Complications Benjamin Leong Dak Keung Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia

End stage renal failure(ESRF) is a common disease with significant disease burden and the incidence is on the rise globally. In Malaysia, the number of prevalent dialysis patients has increased almost three-fold from 7837 in 2000 to almost 23,000 in 2010. The need to create an arterio-venous fistula that matures well at appropriate time frame and, as well as, the effort to maximize the longevity of the fistula of each patient cannot be over emphasized.

Pre- and post-operative duplex scan assessments with careful patient selection and meticulous surgical creation of a fistula are important in preventing primary access failure. Subsequently, proper fistula usage and care with regular fistula assessment of complications are important steps to prevent late access failure.

AVFs are associated with numerous complications. Common and important complications include infection, pseudoaneurysm, limb swelling secondary to central venous stenosis or occlusion and digital hypoperfusion ischaemic syndrome. It is important for these problems to be recognised early and be managed accordingly as they may lead on to fistula failure and, more seriously, life and limb threatening events.

In general, a failing AVF and other complications can be managed either by surgical or endovascular intervention. Endovascular intervention is gaining much popularity because it is less invasive but it is not suitable to manage all types of complication. In certain conditions, such as a thrombosed fistula, a hybrid of surgical and endovascular approach can offer the best outcome. Management of complications has to be tailored to the specific complication, patient’s condition and the availability of facilities in the respective centre.

18 Symposium 7 Managing Surgical Trauma

Managing Disasters and Mass Events Oliver Hautmann University Malaya Medical Centre, Kuala Lumpur, Malaysia

Disasters and mass casualties occur randomly, worldwide, regardless of a countries or mass events infrastructure or the on call health professionals capabilities. Prevention and foresight is to date still the most powerful factor influencing the outcome of such scenarios.

There is no specific training program for doctors in disaster care, other than disaster and evacuation training in their respective health care facilities. As the occurence is rare and happens predominantely in underprivilidged health care environments, genuine available expertise in the moment of a strike or medical meltdown is rare to be found. In this respect an awful lot of people walk our streets who consider themselves disaster experts without ever having seen or experienced one.

This presentation wants to offer a comprehensive but realistic strategy into disaster and mass casualty care for anyone who has a chance of beeing exposed to one. At the same time, it wants to identify high risk scenarios and their respective needs. In addition it wants to give guidelines on how to make a big difference by using the resources available to their very limit but not overexhaust them.

Symposium 8 Endocrine Surgery

The Role Of Ultrasound In Thyroid Diseases Shahrun Niza b Abdullah Suhaimi Endocrine and Breast Surgery Unit, Department of Surgery, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia

Ultrasonography (US) is an important tool in the evaluation of thyroid nodules. The revised American Thyroid Association (ATA) guidelines for the management of thyroid cancer recommend US before neck exploration in these patients. In most scenarios, a pre-consultation US would be performed by a non- surgical personnel and these studies often failed to mention important features and findings critical for surgical recommendation and operative planning. The US report should mention nodule features, location, if local invasion and extension is present and whether central or lateral cervical compartment lymph nodes are abnormal. Suspicious features of a thyroid nodule include irregularity, hypoechogenicity, taller than width, calcification, halo sign and intranodular vascularity. Furthermore, for indeterminate fine needle cytology (FNAC) results, US may be able to predict malignancy as in a presence of two or more adverse features, the likelihood of thyroid cancer increases. Moreover in multinodular goiter, US study would be able to see detailed features of each nodule and thus enable an US guided FNAC for any suspicious nodule found on US. A dominant nodule of an MNG does not necessarily harbors malignant cells.

Recently with the wider availability of portable ultrasound units, many endocrine surgeons have rapidly acquired the knowledge and skills to become excellent ultrasonographers in thyroid diseases. A clinic based surgeon-performed US (SUS) for thyroid nodules may alter the decision making on the management of thyroid diseases. Furthermore SUS can fast track these patients in an outpatient clinic and making it cost effective.

19 Symposium 8 Endocrine Surgery

HYPERCALCEMIA: TREATMENT and MANAGEMENT UPDATE Imi Sairi Ab Hadi Malaysia

Hypercalcemia is a disorder commonly encountered by primary care physicians. Hypercalcemia is a condition in which the calcium level in your blood is above normal. It can be an asymptomatic laboratory finding, but because an elevated calcium level is often indicative of other diseases. Among all causes of hypercalcemia, primary hyperparathyroidism and malignancy are the most common, accounting for greater than 90 percent of cases. Therefore, the diagnostic approach to hypercalcemia typically involves distinguishing between the two.

Parathyroid hormone (PTH), 1,25-dihydroxyvitamin D3 (calcitriol), and calcitonin control calcium homeostasis in the body. Increased bone resorption, increased gastrointestinal absorption of calcium, and decreased renal excretion of calcium cause hypercalcemia.

Saline infusion reduces hypercalcemia in most patients but will not restore normocalcemia in individuals with severe hypercalcemia. Loop diuretics are often combined with isotonic saline infusion. They block calcium re-absorption in the ascending limb of the loop of Henle, inducing calciuresis. Bisphosphonate therapy is highly effective in lowering calcium levels in hypercalcemia of malignancy. However, their efficacy and safety in hypercalcemia resulting from other causes is less clear. They are superior to other modes of treatment, including volume repletion, loop diuretics, and the combination of glucocorticoids and Calcitonin.

In cases of resistant, life-threatening hypercalcemia, hemodialysis against a low-calcium dialysate is more effective than peritoneal dialysis in lowering serum calcium levels. In cases of hypercalcemic crisis resulting from primary hyperparathyroidism, urgent parathyroidectomy is potentially curative.

Symposium 8 Endocrine Surgery

Robotic Thyroidectomy In Malaysia: Is It The Future? Hakim Nor Azham Breast & Endocrine Surgery Unit, Department of Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

A century on since Kocher’s introduction of modern thyroid surgery technique, thyroidectomy has been refined to near perfection. These days open thyroidectomy is the standard of care in surgical intervention of thyroid diseases particularly for thyroid malignancies. Advancement in laparoscopic surgical technique led to exploration in endoscopic thyroidectomy in an effort to improve results. This led to an evolution of the endoscopic thyroid surgery by incorporating the use of robotic surgical system. In 2007, Chung and his team successfully performed the first robotic thyroidectomy using transaxillary approach. After more than 3000 cases, this technique has been shown to be safe and comparable to open thyroidectomy, with superior cosmetic results. However, there is a steep learning curve and one needs to be intimately knowledgeable in thyroid anatomy and thyroidectomy technique. Currently, robotic thyroidectomy is popular in the far east, particularly Korea, and amongst European thyroid surgeons. The first robotic thyroidectomy in Malaysia was performed in Hospital Kuala Lumpur in early 2013. To date almost 30 cases has been performed with good results and minimal morbidity. Patient satisfaction has generally been superior to open surgery. Compared to endoscopic approach, robotic thyroidectomy is easier to the surgeon due to its inherently stable platform, excellent range of motion, high- definition 3D visual input and overall better ergonomics. There is however a downside to this. System availability is very limited due to the overwhelmingly expensive initial investment coupled with high running costs, particularly in Malaysia. It has to be incorporated into a multispecialty robotic surgical unit to make such investment worthwhile. Current robotic surgical system may be good enough for abdominal or pelvis surgeries. However, further technological advancements are needed before the system can be fully optimized for thyroid surgery. In short, does robotic thyroidectomy has a future in Malaysia? Yes it does and should be given a future in our country, but perhaps limited to specialized centers with access to robotic surgical systems. Is robotic thyroidectomy the future of thyroid surgery in Malaysia? Depending on how far in the future we are looking at. Robotic thyroidectomy will not replace open surgery in the near future, but perhaps 20 or 30 years from now?

20 Symposium 8 Endocrine Surgery

Adrenal Incidentaloma : Do We Need To Remove? Normayah Kitan Putrajaya Hospital, Putrajaya, Malaysia

Adrenal incidentaloma refers to incidentally discovered adrenal mass in patients undergoing imaging modalities mainly CT-scan and magnetic resonance imaging (MRI) for other clinical indications. The aim of management of adrenal incidentaloma is to remove functioning and malignant lesions without performing unnecessary adrenalectomy. In non-functioning incidentaloma the management is often a challenge because imaging characteristics and guided needle biopsy do not always distinguish benign from malignant pathology.

When an adrenal incidentaloma is detected, it is important to exclude phaeochromocytoma and subclinical cortisol or aldosterone secreting lesion. CT scan phenotype indicating malignancy includes attenuation value higher than 10 HU, a contrast agent washout lesser than 50%, tumour size bigger than 6 cm, irregular shape, central necrosis, vena cava thrombosis and distant metastases.

In non-funtioning lesion, generally accepted recommendation is to excise lesions that are larger than 6 cm because the risk of malignancy is 25%. Lesions less than 4 cm and appear to be benign on imaging criteria are generally not resected. For lesions between 4 and 6 cm, either close followup or adrenalectomy is considered a reasonable approach. Follow up may not be necessary in patients with stable tumour size on two imaging studies carried out at least 6 months apart and do not exhibit hormonal hypersecretion over 4 years.

Meet-The-Experts 6 Urology – Renal Trauma

Diagnosis, Imaging and Staging Khor Tze Wei Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia

Renal traumas account for 1-5% of all traumas and in 10% of all intra-abdominal injuries. The goal of treatment is to accurately diagnose and to grade the injury in order to decide on the treatment. Detailed history of the incident (rapid deceleration injury) and known renal abnormalities with a focus physical examination (haematuria and hypotension) should be sought. Contrast enhanced computed tomography scan in haemodynamically stable patient is preferred. The renal injury severity scale (Grade 1 to 5) is adapted from the American Association for the Surgery of Trauma (AAST).

21 Meet-The-Experts 6 Urology – Renal Trauma

Follow-up And Management of Late Complications of Renal Trauma Teoh Boon Wei Hospital Pulau Pinang, Penang, Malaysia

Late Complications of Renal Trauma include • Bleeding • Urinoma • Arterio-venous fistula (AVF) • Abscess • Pseudoaneurysm • Hypertension • Hydronephrosis

Follow-up within 3 months of major renal injury with • Physical examination • Urinalysis • Serial blood pressure measurement • Individualized radiological investigation • Renal profile

Management of complications • Bleeding, AVF or pseudoaneurysm – angiographic embolization • Urinoma, abscess &/or hydronephrosis – antibiotics, percutaneous/surgical drainage &/or ureteric stenting • Hypertension – medical antihypertensive treatment, evacuation of perinephric haematoma/scar, vascular reconstruction or nephrectomy

Symposium 10 Colorectal

How Can We Lower The Number Of Deaths From Colorectal Cancer In Malaysia? Lim Kean Ghee Department of Surgery, International Medical University, Kuala Lumpur, Malaysia

There are about 3,000 new cases of colorectal cancer a year in Malaysia. A Malaysian man has a lifetime risk of 1:38 to develop colorectal cancer; a woman 1:50. Several reported series on the stage of disease of colorectal cancer patients in Malaysia indicate that they tend to present later than patients in developed countries. As such the overall survival of colorectal cancer patients is Malaysia ranges from about 33-40%, compared to above 50% in Europe and nearly 60% in the United States. In addition to late presentation reported survival rates of colorectal cancer for each stage of disease the disease appears to also be lower in Malaysia than in the West.

The data we have show a that the need for earlier detection of colorectal cancer in Malaysia is great. Studies show Malaysians are largely ignorant of the symptoms and risk factors of colorectal cancer. In addition, they tend to perceive colorectal cancer as not a severe disease. The tools for screening and knowledge on reducing risk factors are available need to be applied.

22 Symposium 12 Surgical Education

Formative Assessment of a Masters Candidate April Camilla Roslani Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia University Malaya Medical Centre, Kuala Lumpur, Malaysia University Malaya Cancer Research Institute, Kuala Lumpur, Malaysia

The evolution of the Malaysian Clinical Master of Surgery programmes, in line with Medical Educational principles, has necessitated a critical review of assessment methods. High attrition rates at the summative assessments have highlighted the importance of structured training and formative assessments, with scheduled, regular feedback, and mechanisms for timely remediation.

Formulating and implementing such valid and reliable formative assessment methods is even more challenging than for summative ones. While methods from more established overseas programmes may serve as templates, they are not necessarily fit for purpose, and should not be implemented without scrutinizing their applicability in the local context.

Training and availability of assessors in sufficient numbers are further limitations, as additional skills and experience are required for formative assessment. Yet, the pool of such trainers and assessors is subject to constant attrition, with little recognition of the contributions of those remaining, in any tangible sense. In the long run, continued haemorrhage of human resource is likely to lead to a dilution of training and deterioration of surgical standards.

It is crucial, therefore, that all stakeholders recognize the need to strengthen this component of assessment, if we are to achieve the objectives of surgical training in Malaysia.

How I Do It Session

Continuous Intra-Operative Nerve Monitoring (Thyroidectomy) Rohaizak Muhammad Breast and Endocrine Surgical Unit, Department of Surgery, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

Thyroid surgery is a common procedure in surgical practice. It is not without complication and the most devastating complication is an injury to the recurrent laryngeal nerve or external laryngeal nerve, leading to poor quality of the voice. In order to avoid injuring the nerve, less than total thyroidectomy like subtotal thyroidectomy or near total thyroidectomy had been performed for benign condition but unfortunately the risk is still significant if performed by junior surgeon with less experience. Routine identification of the recurrent laryngeal is mandatory but again not all cases seem to be easy to identify especially when dealing with large goiter, recurrent disease or malignancy. Intra-operative is not new in head and neck surgery and been used to identify other nerves. Intermittent intra- operative nerve monitoring allows the surgeon to identify or map the nerve before seeing it and will be useful for less experience surgeon. But this does not prevent the inadvertent injury to the nerve either by direct injury or traction injury. Continuous intra-operative nerve monitoring will combine the ability to map the nerve as well as to give the continuous status of the nerve during the procedure. At the end of the operation, an intact vagal stimulation will be an indication of a functioning undamaged nerve. This video session will illustrate how the procedure will be performed.

23 ETHICON PRIZE PRESENTATIONS 30th May 2015 (Saturday)

EP 01 Use Of Rockall Risk Score In Predicting 30-Days Non-Variceal Upper 25 Gastrointestinal Rebleeding - A Malaysian Single Centre Retrospective Study Henry Tan Chor Lip1, Heah Hsin Tak1, Sarojah Arulanantham1, Premaa S2 1General Surgery Department, Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia 2Clnical Research Centre, Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia

EP 02 Impact Of Day Care Ureteral Stent Placement Under Local 26 Anaesthesia Versus Local Anaesthesia And Oral Paracetamol On Pain Experience. A Randomized Control Study Vikneswaren Wera Singgam1, Praveen2, Datesh Danawar1, Zulkifli Zainuddin2 1Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia 2Hospital Univerisiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

EP 03 Ultrasonographic Features Of Malignant Thyroid Nodule: 27 Comparison Between Ultrasonographic Performed By Surgeon And Radiologist Rashidah Khalid1, Shahrun Niza2, Sharifah Majidahs2 1University Kebangsaan Malaysia, Kuala Lumpur, Malaysia 2Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

EP 04 Evaluating The Effect Of Compression Stocking On Venous 28 Hemodynamic In Chronic Venous Insufficiency Using Air Plethysmography Nurul Rauf1, Zainal Ariffin Azizi1, M Azim Idris2 1Hospital Kuala Lumpur, Kuala Lumpur, Malaysia 2Hospital Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

24 EP 01

Use Of Rockall Risk Score In Predicting 30-days Non-variceal Upper Gastrointestinal Rebleeding - A Malaysian Single Centre Retrospective Study Henry Tan Chor Lip1, Heah Hsin Tak1, Sarojah Arulanantham1, Premaa S2 1General Surgery Department, Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia 2Clnical Research Centre, Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia

Introduction Rebleeding in Upper Gastrointestinal Bleed(UGIB) has a high mortality rate of 16%. The Complete Rockall Risk(CRS) score is commonly used to stratify patients into high, moderate and low risk of mortality and rebleeding. The aim of this study is to determine the usefulness of the CRS in predicting outcomes of 30days rebleeding, mortality and need for surgery.

Methods This is a retrospective cohort study of all emergency endoscopy performed in Hospital Sultan Ismail from January2009 to October2014 for indications of UGIB. Data was extracted from the Total-Hospital-Information- System(THIS) and only non-variceal bleeds were included. CRS were calculated and outcomes of 30days rebleeding, mortality and need for surgery after first intervention endoscopy were recorded. For each outcome, calibration was done using the Goodness-of-fit tests and discriminative ability of scoring system was reflected by area under receiver operating curve(AUROC).

Results A total of 1323 patients were included with male a preponderance of 847(64%). The overall rates of rebleeding were 11.2%(148), mortality 8.7%(115) and surgery 2%(26). Low AUROC values of rebleeding(0.63), mortality(0.58) and surgery(0.67) showed poor discriminative ability of CRS. The Goodness-of-fit test also revealed that the Rockall score were poorly calibrated in outcomes of rebleeding(p <0.001), mortality(p = 0.001) and surgery(p = 0.038) with p-value ≤0.05. However, patients with high risk(score≥ 8) displayed highest rebleeding and mortality rates of 20% respectively in comparison to the moderate(score 3-7) and low(score ≤ 2) risks groups. The high risk group had an odds ratio of 4.02(95% CI: 1.51, 10.66) at rebleeding in comparison to the moderate and low risk groups.

Conclusion Rockall risk score had a very low quality in predicting all three outcomes. However with increasing scores, there were an increased risk which serves as a simple numerical guide to clinicians in regards to severity of rebleeding and mortality in individual patients.

25 EP 02

Impact Of Day Care Ureteral Stent Placement Under Local Anaesthesia Versus Local Anaesthesia And Oral Paracetamol On Pain Experience. A Randomized Control Study Vikneswaren Wera Singgam1, Praveen2, Datesh Danawar1, Zulkifli Zainuddin2 1Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia 2Hospital Univerisiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

Introduction Modern cystoscopic Double J ureteric stent insertion was first described and done in 1978 and the procedure is commonly performed under general anaesthesia.

Objective The primary objective of this study was to assess the pain score of Double J stenting using visual analog scale ( VAS ) and vital sign changes ( pulse rate , systolic and diastolic blood pressure ) before and after the procedure.

Methods A prospective randomized control trial conducted in the Urology Department, Hospital Sultanah Bahiyah, Alor Setar from June 2014 until November 2014. A total of 62 patients were recruited and was block randomized into two groups consisting of 31 patients each, either receiving local lignocaine gel (Group A) and combination of local lignocaine gel and oral paracetamol (Group B) prior to local ureteric stenting. They would be assessed for pain score post procedure based on the Visual Analogue Pain Score Chart and also assessing the pre and post procedure systolic and diastolic blood pressure and pulse rate.

Results In Group A final analysis, we found that the majority of the patients experienced moderate pain scores consisting of 22 patients (71%) followed by 6 patients with severe pain score (19.4%) and 3 patients experiencing mild pain (9.7%).In Group B, 24 of its patients experienced mild pain (77.4%), 6 patients experienced moderate pain (19.4%) and 1 patient experienced severe pain (3.2%). There was significant difference between group A and Group B in terms of change of systolic and diastolic blood pressure and change in pulse rate pre and post procedure , p value 0.001(p<0.05) for all 3 variables.

Conclusion Combination of Oral Paracetamol and local lignocaine gel is more effective than only local lignocaine gel in terms of pain score perception when performing local ureteric DJ stent insertion.

26 EP 03

Ultrasonographic Features Of Malignant Thyroid Nodule: Comparison Between Ultrasonographic Performed By Surgeon And Radiologist Rashidah Khalid1, Shahrun Niza2, Sharifah Majidahs2 1University Kebangsaan Malaysia, Kuala Lumpur, Malaysia 2Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

Background Thyroid ultrasound is a proven, useful tool in the evaluation of patients with thyroid nodules because 97.2% of nodules diagnosed as malignant on USG were also pathologically confirmed as thyroid carcinoma. Now a day, there is an increased number of non-radiologists mainly endocrine surgeons who perform thyroid ultrasonography. However, the question is how accurate the surgeon performed ultrasound compared with radiologist.

Methodology A prospective observational study was carried out for patients who underwent thyroidectomy at Hospital University Kebangsaan Malaysia from April 2013 until September 2014. 75 thyroid nodules from total of 54 patients were included in this study. Patients who were enrolled into the study was examined with ultrasound twice, first by a surgeon and then by a radiologist. Ultrasound scan done by surgeon was compared to radiologists. The ultrasound findings were done by surgeon and radiologist was compared with the HPE results and the sensitivity, specificity, positive and negative predictive values was calculated. Each characteristic from ultrasound was evaluated in correlation with risk of malignancy. Statistical analysis was performed using the Chi squre test and fisher’s exact test. Probability value of less than 0.05 was considered significant. (p ≤ 0.05)

Results A total of 75 thyroid nodules from 54 patients were recruited for this study. Eleven thyroid nodules confirm malignant from histophathology result. SUS shows more sensitive and specific compaired to RUS. The sensitivity, the specificity, positive predictive value and negative predictive value of US-HPE for thyroid cancer for the endocrine surgeons was 90.9 %, 93.8 %, 71.4% and 98.4% respectively, whereas that for the radiologist was 72.7 %, 75 %, 33.3% and 94.1 % respectively. Oval shape, presence of microcalcification, hypoechogenicity and presence of suspicious lymph nodes are associated with malignancy with P value < 0.05 for each both SUS and RUS group.

Conclusion Surgeon doing Ultrasonography had a comparable finding as a radiologist. Instead the sensitivity, specificity and accuracy were higher in surgeon group. Oval shape, presence of microcalcification, hypoechogenicity and presence of suspicious lymph nodes are associated with malignancy for both SUS and RUS.

27 EP 04

Evaluating The Effect Of Compression Stocking On Venous Hemodynamic In Chronic Venous Insufficiency Using Air Plethysmography Nurul Rauf1, Zainal Ariffin Azizi1, M Azim Idris2 1Hospital Kuala Lumpur, Kuala Lumpur, Malaysia 2Hospital Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

Objective To evaluate effect of class 2 compression stockings on venous hemodynamic in grade 2 and 3 chronic venous insufficiency at baseline and at 6 weeks by using air plethysmography.

Methods 46 limbs in 29 patients (15 women and 14 men) with mean age of 55 years old with were evaluated. Duplex examination scanning was done to rule any deep vein reflux or thrombosis. From this, 18 limbs were classified into CEAP 2 and 28 limbs CEAP 3. Assessment using air plethysmography were taken at 3 moment; before wearing stocking (T0), after 6 weeks using stocking (T1) and 1 hour removal of stocking (T2). Patient symptoms were evaluated using venous score scoring system (VCSS) before and after 6 week wearing stocking A paired T-test and Wilcoxon Rank T were used for statistical analysis with P <0.05 is considered significant

Result Class 2 compression stocking improved venous hemodynamic efficiently. Venous volume was decreased from 157.42ml at T0 to 126.41ml at T1 (p <0.05). Venous flow index reduced from 2.8 ml/s to 2.2ml/s at T0 and T1 respectively. Compression stocking potentiate the ejection fraction from 44.05% (T0) to 49.12% (T1). Residual volume also were decrease from 49.98 %to 43,04% but not statistically significant

Conclusion Class 2 Compression stocking improve venous hemodynamic in patients with venous insufficiency after 6 weeks usage. The result showed the benefit of compression only upon wearing them.

28 Free Paper PRESENTATIONS 1 30th May 2015 (Saturday)

FP 1.1 Acute Post-Operative Pain Difference Between Two Mesh-Fixat 30 On Technique In Laparoscopic Total Extraperitoneal (TEP) Inguinal Hernioplasty In Long-Standing Hernia: A Prospective Randomized Clinial Trial Asma’ R1, T Nur T M1, Kalsom A1, Hairol O2 1Department of Surgery, Hospital Sultanah Aminah Johor Bahru, Johor, Malaysia 2Department of Surgery, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

FP 1.2 Retrospective Study: Outcome Of Endovenous Radio-Frequency 30 Ablation (RFA) Therapy For Lower Limb Varicose Veins In Hospital Kuala Lumpur Hadi M A1, Ismazizi Z2, Naresh G2, Zainal A A2 1Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

FP 1.3 Titrating Calcium Infusion After Parathyroid Surgery Made Easy: 31 A New Modified Calcium Infusion Regime Jih Huei Tan, A Sarojah Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia

FP 1.4 Emergency Air Transfer To Neurosurgical Tertiary Centre – 31 Experience from General Surgical Department of Hospital Tawau Z L Lim, Othman M Z Surgical Department, Tawau General Hospital, Sabah, Malaysia

FP 1.5 Sentinel Lymph Node Frozen Section Service In UKMMC 32 Norlia Abdullah1, Saladina Jaszle Jasmin1, Rossnita Marzuki1, Fazarina Mohammed2 1Department of Surgery, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia 2Department of Pathology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

FP 1.6 Impact Of Calcium Replacement Protocol On Achieving Stable 32 Calcium Level After Total Parathyroidectomy In Renal Hyperparathyroidism Kugan R, Normayah K, Sarinah B, Daphne A Breast and Endocrine Department, Hospital Putrajaya, Putrajaya, Malaysia

FP 1.7 clinical Predictors Of Diabetic Remission After Bariatric Surgery 33 R Hassan1, N Q Pang2, Z Y Yan2, A Shabbir2, D Lomanto2, So J B2 1RCSI Surgical Training & Research, Penang Medical College, Penang, Malaysia 2Department of General Surgery, National University Hospital, Singapore

FP 1.8 Is Pre Operative Ultrasound Localisation In Renal Hyperparathyroidism 33-34 By Endocrine Surgeon Reliable? Nor Faezan A R1, Nani M L2, Shahrun N A S2, Rohaizak M2 1Department of Surgery, Universiti Technology MARA, Shah Alam, Selangor, Malaysia 2Department of Surgery, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

FP 1.9 A Retrospective Study On “The Effect Of Bariatric Surgery In 34 Resolution Of Comorbidities”- Hospital Taiping Suriakanthan Bala Krishnan, Rajkumar Vinayak, Umasangar Ramasamy, Yap Choon Fong, Leong Keen Wai Hospital Taiping, Perak, Malaysia

29 FP 1.1 FP 1.1

Acute Post-operative Pain Difference performed in multi-ethnics male (median age, Between Two Mesh-fixation 50 years;range 20-78 years). Randomization done into two groups; glue (GG) and tacks (TG) with 40 patients Technique In Laparoscopic Total in each group. Median duration of symptoms was Extraperitoneal (TEP) Inguinal 7-months with 18(22.5%) patients had pre-operative Hernioplasty In Long-standing pain. Median size of hernia was 3.0cm. One patient in each GG and TG had conversion of surgery to open Hernia: A Prospective Randomized repair. A significant difference was observed between Clinial Trial two groups in median duration of surgery (glue 45 vs Asma’ R1, T Nur T M1, Kalsom A1, Hairol O2 tacks 39 minutes; p=0.020), post-operative pain score 1 at 1-hour (glue 4 vs tacks 5; p=0.006),and 6-hours Department of Surgery, Hospital Sultanah Aminah (glue 3 vs tacks 4; p=0.012). At 1-week follow-up, Johor Bahru, Johor, Malaysia incidence of seroma formation is significantly higher 2 Department of Surgery, Universiti Kebangsaan in GG, 8(10.0%) vs 2(2.5); p=0.043, whereas urinary Malaysia Medical Centre, Kuala Lumpur, Malaysia incontinence was higher in TG, 9(11.3%) vs 1(1.3%); p=0.007. No significant difference seen in terms Introduction of duration of symptoms, hernia size, rescue drug Inguinal hernia repair surgery has evolved and is requirement, post- operative hematoma or recurrence aiming towards better outcome with regards to post- rate. 1 patient in GG had hernia recurrence at 6-weeks operative pain, early return to normal activities, and follow-up. 1 patient in TG reported to have chronic low recurrence rate. pain up to 6-months post-operatively. No incidence of post-operative surgical site infection reported. Return Objectives time to normal activities was significantly faster in A prospective randomized trial between March 2013 GG, 1-week vs 2-weeks in TG, p=0.001. to May 2014, researching outcome differences in post-operative pain, seroma, haematoma, and early Conclusions recurrence between two mesh fixation methods in Mesh fixation with tissue glue in laparoscopic TEP laparoscopic TEP inguinal hernioplasty. hernioplasty was superior to tacks in terms of lower acute post- operative pain score, less incidence of Results post-op urinary incontinence, and early return to 82 laparoscopic TEP inguinal hernioplasties were normal daily activities.

FP 1.2 FP 1.2

Retrospective Study: Outcome Methods of Endovenous Radio-Frequency A retrospective study was conducted on patients Ablation (RFA) Therapy For Lower whom underwent endovenous RFA therapy with multiple stab avulsion performed in the same settings Limb Varicose Veins In Hospital for lower limb varicosities, from January to December Kuala Lumpur 2014. All patients were generally monitored during Hadi M A1, Ismazizi Z2, Naresh G2, Zainal A A2 1st month and 3rd month post-operative. Inclusion criteria based on CEAP 2-6 with saphenofemoral and/ 1Hospital Kuala Lumpur, Kuala Lumpur, Malaysia or saphenopopliteal junction incompetency by clinical and Doppler examination. Introduction Endovenous radio-frequency ablation therapy Results for lower limb varicose veins has been regularly Total of 90% (18 patients) underwent endovenous RFA performed on patients in Hospital Kuala Lumpur along therapy, 10% (2 patients) cancelled due to unfit for with mechanicochemical endovenous ablation and the surgery, 70% (14 patients) had pain relieved, reduction more conventional method of high saphenous vein of oedema, and return quality of life, 15% (3 patients) ligation. had persistent pain, 5% (1 patient) had healed ulcer and 15% (3 patients) had persistent venous ulcer, 5% Objective (1 patient) had recurrent varicose vein. No patient To analyze the outcome of RFA therapy for lower sustained DVT, burn marks, hematoma, paraesthesia, limb varicose veins, primarily in terms of pain relief, or ecchymoses. reduction in oedema, healing of ulcer, recurrent varicose veins, deep vein thrombosis and return of Conclusion quality of life in general. Post-operative complications Endovenous RFA therapy has been shown to be such as hematoma, ecchymoses, burn marks secondary efficient, safe and beneficial in treating lower limb to thermal injury and paraesthesia also reviewed in varicose veins. Comparison need to be made with follow up records. other methods eg. MOCA and conventional HSVL to determine the advantages of RFA in future studies.

30 FP 1.3 FP 1.3

Titrating Calcium Infusion After endocrine surgical unit, Hospital Sultan Ismail, JB Parathyroid Surgery Made Easy: from year 2013 to 2014. In 2013, calcium infusion was titrated based on surgeon experience. Since April 2014, A New Modified Calcium Infusion our post-operative calcium infusion protocol had Regime changed. We modified the calcium regime published Jih Huei Tan, A Sarojah by Loke SC with add on immediate post-operative Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia calcium infusion at the rate of 4.5ml/hour. Data including demographics, extent of surgery, duration Introduction of intravenous calcium requirement and length of hospital stay were recorded. Postoperative hypocalcemia is profound after parathyroid surgery done for renal Results hyperparathyroidism patients. Calcium infusion has Sixty four patients with 23 male and 41 female been used post-operatively to prevent symptomatic were included. 45 patients underwent total hypocalcemia. Titrating infusion was done based on parathyroidectomy and 19 patients had subtotal. individual clinician’s experience. Recent study created Forty one patients were given old calcium infusion a new regime for calcium infusion but with some regime and 23 patients given new regime. There pitfalls. We had modified and used the regime in our were 29 patients (70.7%) with old regime required clinical practice. calcium infusion more than 3 days when compared to Objective 8 patients (34.8%) with new regime. This is statistical significant with p=0.005. Objective of the study is to explore the usefulness of a new modified calcium regime post parathyroid Conclusion surgery. Our new modified calcium regime can reduce duration Methods of infusion requirement after parathyroid surgery. Patients underwent total or subtotal parathyroidectomy for renal hyperparathyroidism were included in the study. Study was conducted in

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Emergency Air Transfer To and 6.25% (82) respectively from 2012 to 2014. Cases Neurosurgical Tertiary Centre – requiring further neurosurgical investigations and interventions in Kota Kinabalu such as brain tumors Experience from General Surgical are sent via road or air-transport, escorted or by self, Department of Hospital Tawau nearly every other week. Land transfer may take up to Z L Lim, Othman M Z 10 hours, whilst bed-bound flight transfer application Surgical Department, Tawau General Hospital, Sabah, requires 3 working days of processing by a certain Malaysia airline company. Thus, urgent neurosurgical transfers such as aneurysmal bleed requiring vascular clipping Introduction are sent immediately via air-MEDEVAC. Since 2012, 6 out of 10 air-MEDEVAC patients transferred from The Air Retrieval Unit (ARU) under the Emergency Tawau are neurosurgical-related cases; there were 3 Retrieval Unit (ERU) service of Sabah Health cases in 2015 alone. Each MEDEVAC air-transfer costs Department has flown over 800 patients statewide approximately RM25,000 to the Sabah State Health since its introduction by Likas Women and Children’s Department. Hospital in 2012. Being a vast state endowed with difficult terrain, this service plays an important role in Conclusion Sabah’s Medical Emergency Evacuation (MEDEVAC) of It remains a huge logistical challenge to transport patients from peripheral health centres and hospitals emergency neurosurgical cases to tertiary centres in to Kota Kinabalu via air, in aircraft-access cooperation Sabah, owing to its topography and great vastness. with Sabah Air and also with the Royal Malaysian Air-MEDEVAC is an imperative retrieval option albeit Police, Navy, and Fire & Rescue Department. a costly one. Perhaps, due consideration to have a Air-MEDEVAC Transfer in Tawau resident neurosurgeon in Tawau once the supportive facilities are established is the next step forward. Tawau Surgical Department operates as a generalist, with concomitant visiting subspecialty clinics and OT scheduled at regular periods. Neurosurgical operative case-load of total major surgical OT cases are increasing yearly, registering 3.9% (70 cases), 5.0% (91) 31 FP 1.5 FP 1.5

Sentinel Lymph Node Frozen Section dissection. The intraoperative results were compared Service in UKMMC with those analyzed on the paraffin block 3-4 weeks post-operatively. Norlia Abdullah1, Saladina Jaszle Jasmin1, Rossnita Marzuki1, Fazarina Mohammed2 Results 1Department of Surgery, Universiti Kebangsaan Malaysia A total of 39 patients underwent SLNFS with the ages Medical Centre, Kuala Lumpur, Malaysia ranging from 35 to 78 years. The total number of 2Department of Pathology, Universiti Kebangsaan lymph nodes sent per patient varied from 1 to 4 with Malaysia Medical Centre, Kuala Lumpur, Malaysia a total of 81 lymph nodes. One patient needed axillary dissection at a later date as 1 out of 81 lymph nodes Introduction was a false negative. UKMMC was the first centre to start Sentinel Lymph Node Biopsy in Malaysia. In 2005 the dye alone Discussion method was used followed by the combined method of Both the negative predictive value and accuracy were radioisotope and dye in 2008. Routine intraoperative 0.99. sentinel lymph node frozen section (SLNFS) service Conclusion was started in 2013. The SLNFS service in UKMMC is highly reliable and Objective saves a second admission and general anaesthetic for The data has been collected to analyse the number of the patient. cases performed and safety of the method.

Materials and Method From September 2013 to February 2015, suitable patients were offered intraoperative SLNFS services. Breast surgery was performed while the results were awaited. The patients with positive results immediately went on to have Level 2 axillary

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Impact Of Calcium Replacement The patients were treated with calcium to induce Protocol On Achieving Stable hypercalcemia in the preoperative period. The regime was adjusted post operatively, where the patients Calcium Level After Total were “loaded” with calcium based predicted elemental Parathyroidectomy In Renal calcium requirement. Duration taken to stabilize the Hyperparathyroidism calcium between these two groups were analyzed.

Kugan R, Normayah K, Sarinah B, Daphne A Results Breast and Endocrine Department, Thirty six patients were treated according to the Hospital Putrajaya, Putrajaya, Malaysia calcium replacement protocol and forty four patients without it. Duration for calcium stabilization after Background the surgery was reduced from a median of 5 days Hungry bone syndrome following parathyroidectomy (Interquartile Range = 24) to 3 days (Interquartile in renal hyperparathyroidism often necessitates Range = 3) after introduction of the protocol as a result prolonged treatment with high doses of calcium.This of better calcium balance (P < 0·001). study assessed the impact of calcium replacement protocol with predicted elemental calcium Conclusion requirement in achieving stable serum calcium post A standardized calcium replacement protocol with total parathyroidectomy. predicted postoperative calcium requirements can achieve earlier calcium stabilization, hence achieve Methods early discharge rates after total parathyroidectomy. This cross sectional study included all patients who underwent total parathyroidectomy from December 2011 until December 2014. From December 2011 until November 2013, oral and intravenous calcium infusions were started postoperatively based on serum calcium levels to achieve a stable calcium level. From December 2013 until December 2014, a standard calcium replacement protocol was introduced. 32 Fp 1.7 Fp 1.7

Clinical Predictors of Diabetic Results Remission after Bariatric Surgery 76 obese patients with underlying T2DM were included in this study. 30 (39.4%) Malay, 23 (30%) Chinese and 1 2 2 2 R Hassan , N Q Pang , Z Y Yan , A Shabbir , 23 (30%) Indian patients underwent BS. Mean pre- D Lomanto2, So J B2 operative BMI and HbA1c level were 42.9kg/m2 and 1RCSI Surgical Training & Research, Penang Medical 8.2% (±1.2) respectively. 47 (62%) sleeve gastrectomy College, Penang, Malaysia (SG) and 29 (38%) roux-en-Y gastric bypass (RYGB) 2Department of General Surgery, National University were performed. At 1 year post-op, 29 (38%) patients Hospital, Singapore achieved complete T2DM remission, 3 (4%) had partial T2DM remission, 26 (34%) had improvements in Introduction glycaemic status, 7 (9%) reported no change in their Although bariatric surgery (BS) was shown to glycaemic status while the remaining 11 (15%) are yet induce remission of type 2 diabetes mellitus (T2DM) to be assessed. Indians formed the highest proportion glycaemic status in the morbidly obese, little is known of remitters while Malays were the highest non- about the glycaemic outcomes and clinical predictors remitters. Duration of T2DM, pre-operative insulin use of response to BS in the multiethnic Southeast Asian and higher HbA1c levels were found to be significant population. factors for T2DM remission in all races (p<0.05). In Malays, pre-operative hyperlipidemia predicts non- Aim remission (p<0.05). To review one-year outcome of BS on the glycaemic status of diabetic obese Singaporeans. Conclusion Bariatric surgery improves glycaemic control in the Methods diabetic obese Singaporeans. Clinical predictors of This is a prospective cohort study involving morbidly non-remission discovered may help clinicians select obese (BMI ≥35.0kg/m2) patients with underlying patients for BS and counsel patients to modify their T2DM who underwent BS from August 2008 and expectations regarding post-operative glycaemic December 2013 at the National University Hospital outcomes. (NUH), Singapore.

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Is pre operative ultrasound Methodology localisation in renal Study was conducted in a tertiary referral centre hyperparathyroidism by endocrine at Universiti Kebangsaan Malaysia Medical Centre from January till November 2013. All patients who surgeon reliable? underwent bilateral neck exploration for renal Nor Faezan A R1, Nani M L2, Shahrun N A S2, hyperparathyroidism had a neck ultrasonography Rohaizak M2 using 7.5MHz linear array probe (GE) done one day prior 1Department of Surgery, Universiti Technology MARA, to surgery. Size (in mm), exact location in relation to Shah Alam, Selangor, Malaysia upper or lower pole of the thyroid gland, unidentified 2Department of Surgery, Universiti Kebangsaan gland and histopathological results were recorded. Malaysia, Kuala Lumpur, Malaysia Results Introduction Twenty-four patients comprising of 9 females and 15 males were included in this study. In 2 patients Pre operative localization using ultrasound is now the indication was for recurrent hyperparathyroidism becoming popular among endocrine surgeons. Most due to a residual hyperfunctioning gland. The localization is being used for parathyroid adenoma, mean volume for accurately identified gland was however in the era of surgeon-performing ultrasound, 1085mm3 whilst the mean volume for unidentified parathyroid hyperplasia can also be localized pre gland preoperatively was 918mm3; however the operatively as it is cheap, easily reproducible and non difference observed was not statistically significant. invasive. Real-time interpretation and knowledge The sensitivity and specificity of surgeon-performed on anatomy give the surgeons an extra advantage in sonography was 84.9% and 60.6% respectively. The interpreting the findings1. We sought to determine the positive predictive value for this procedure was 94.5% accuracy of parathyroid ultrasonography at our centre with an accuracy of 81.8%. by the two available endocrine surgeons. Conclusion Objective Preoperative parathyroid sonography performed by To detect sensitivity and specificity of pre operative an endocrine surgeon serves as a good guide with ultrasound localization by endocrine surgeons in our centre. 33 FP 1.8 FP 1.9 acceptable accuracy. The low specificity was largely A Retrospective Study On “The Effect due to the presence of concomittant nodular goitres Of Bariatric Surgery In Resolution which can be improved by enhancing the surgeon’s experience in performing this procedure. Of Comorbidities”- Hospital Taiping Suriakanthan Bala Krishnan, Rajkumar Vinayak, Umasangar Ramasamy, Yap Choon Fong, Leong Keen Wai Hospital Taiping, Perak, Malaysia

Aim Of Study To determine the effects of bariatric surgery on the resolution of selected comorbidities – 1)diabetes,2) hypertension, 3)dyslipidemia,4) OSA,5)Polycystic Ovarian Syndrome (PCOS).

Methodology A retrospective data collection done on all patients who underwent bariatric surgery from 2009 to 2015 in Hospital Taiping. A total of 100 patients selected as all required data available in these patients. Data was collected pre-operatively as well as 1 month, 3 months, 6 months, 9 months and 1 year post-operatively. Targeted parameters were obstructive sleep apnea (OSA) symptoms, blood pressure- reduction/cessation of antihypertensive medication, HbA1c/ reduction or cessation in oral hypoglycemic agent (OHA) or insulin medications, LDL level, review of PCOS symptoms (infertility).

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Results Bariatric surgery showed positive outcomes in the reduction of symptoms of OSA (100%), optimization of blood pressure (88%), diabetes (86%), dyslipidemia (88%) and resolution of infertility/ PCOS symptoms (100%). This is in addition to the positive effects of the surgery on lowering body mass index (BMI), and a mere reduction of 15% in excess body weight has shown to grossly alleviate symptoms of arthritis, OSA and PCOS. Apart from resolution of comorbidities, bariatric surgery has shown to have positive influence on patient’s lifestyle.

Conclusion A very favourable outcome has been shown in the resolution of comorbidities and improvement of metabolic syndrome in patients who underwent bariatric surgery.

34 Free Paper PRESENTATIONS 2 30th May 2015 (Saturday)

FP 2.1 Laparoscopic Modified Sugiura Procedure - A Surgical Modality 37 In The Acute Management Of Bleeding Gastroesophageal Varices Sabrina B1, Sivaneswaran L1, Vinayak R1, Premnath N2 1Hospital Taiping, Taiping, Perak, Malaysia 2Penang Medical College, Pulau Pinang, Penang, Malaysia

FP 2.2 Clinical Outcome Of Surgical Therapy In Renal Hyperparathyroidism 37 Haekal K, Kugan R, Sarinah B, Normayah K Breast & Endocrine Unit, Department of Surgery, Hospital Putrajaya, Putrajaya, Malaysia

FP 2.3 Wound Infection Following Stoma Reversal: A Prospective 38 Comparative Study Between Primary Closure And Partial Closure With Intervening Silver Dressings J Y Soo1, N H Zubaidah2, K W Ong3, T Gee4 1Department of Surgery, Universiti Putra Malaysia, Serdang, Selangor, Malaysia 2Hospital Serdang, Selangor, Malaysia 3Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

FP 2.4 Low Pressure Laparoscopy With Deep Neuromuscular Bloackade 38-39 Versus Convetional High Pressure Laparoscopy In Sleeve Gastrectomy: A Randomized Clinical Trial S Y Lim1, N H Zubaidah1, T Gee1, E F F Chew2 1Department of Surgery, Universiti Putra Malaysia, Serdang, Selangor, Malaysia 2Department of Anaesthesia, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

FP 2.5 Laparoscopic Sleeve Gastrectomy Versus Laparoscopic Banded 39 Gastric Plication: A Combined University Hospital Experience A T Hizami1, R Reynu1, N R Kosai1, M T Mustafa1, G Tikfu2 1Minimally Invasive, Upper Gastrointestinal and Bariatric Surgery Unit, Department of Surgery, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia 2Upper Gastrointestinal and Bariatric Surgery Unit, Department of Surgery, Universiti Putra Malaysia, Kuala Lumpur, Malaysia

FP 2.6 Incidence Of Hypocalcemia In Post Thyroidectomy Patients And 40 Its Relation To Parathyroid Hormone And Vitamin D Level H P Nadzlee, B Sarinah, K Normayah, B Anita, M Nor Hisham Hospital Putrajaya, Putrajaya, Malaysia

FP 2.7 Evaluating The Effect Of Compression Stocking On Venous 40 Hemodynamic In Chronic Venous Insufficiency Using Air Plethysmography Nurul Rauf1, Zainal Ariffin Azizi1, M Azim Idris2 1Hospital Kuala Lumpur, Kuala Lumpur, Malaysia 2Hospital Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

FP 2.8 comparison Between Laparoscopic Sleeve Gastrectomy And 41 Laparoscopic Roux-En-Y Gastric Bypass in Predicting The Remission Of Type 2 Diabetes Mellitus in Morbidly Obese Population A Haniffa1, R Reynu, N R Kosai 1Department of General Surgery, Hospital Selayang, Selangor, Malaysia 2Minimally Invasive, Upper GI and Bariatric Surgery Unit, Department of General Surgery, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

35 Free Paper PRESENTATIONS 2 30th May 2015 (Saturday) [cont’d)

FP 2.9 Is Laparoscopic Repair Of Incarcerated Or Obstructed Ventral 41-42 Hernias Feasible In The Emergency Setting? A Retrospective Comparative Study Of Emergency Laproscopic Versus Open Ventral Hernia Repair K Y Low, Kanesh Kumaran, P C Lau, E H Pok Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

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Laparoscopic Modified Sugiura This emergency surgical procedure which successfully Procedure - A Surgical Modality In controls gastroesophageal variceal bleeding while conferring the benefits of a laparoscopic surgery, is The Acute Management Of Bleeding not widely documented. We provide evidence on the Gastroesophageal Varices effectiveness in achieving hemostasis, significantly Sabrina B1, Sivaneswaran L1, Vinayak R1, reducing perioperative mortality and risk of rebleed. Premnath N2 1Hospital Taiping, Taiping, Perak, Malaysia 2Penang Medical College, Pulau Pinang, Penang, Malaysia

The current gold standard in the management of acute gastroesophageal variceal bleeding is a combination of pharmacological and endoscopic therapy followed by Transjugular Intrahepatic Portosystemic Shunt (TIPS) as a rescue therapy when the former fails to establish hemostasis. However, TIPS facility is not readily available in our country. Laparoscopic Esophagogastric Devascularization (Modified Sugiura) has gained interest as a treatment modality for patients who have failed conventional therapy.

We report a case of a Modified Sugiura without oesophageal transection, performed laparoscopically in a cirrhotic patient with an uncontrolled bleed from a fundal varix. Splenectomy was not performed to reduce perioperative morbidity risk associated with prolonged surgery. His recovery was uneventful and was discharged well nine days after the surgery.

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Clinical Outcome Of Surgical up and completed this study. The mean age of our Therapy In Renal patients was 43.7 (25-68). All patients were on regular hemodialysis with an average duration of dialysis of Hyperparathyroidism 6.5 years (1-15). Majority of patients had underlying Haekal K, Kugan R, Sarinah B, Normayah K hypertension (85%), diabetes (24%) and heart disease Breast & Endocrine Unit, Department of Surgery, (20%). 33 patients (80%) presented with bone pain. Hospital Putrajaya, Putrajaya, Malaysia All patients had elevated alkaline phosphatase (ALP) an average of 335 U/L (59-2408) and parathyroid Introduction hormone (iPTH) an average of 198 pmol/L (21-738). All Secondary hyperparathyroidism, which is common patients had undergone successful removal of four sequelae of chronic kidney disease, is a consequence of parathyroid glands and confirmed by histology. 12 a disturbed calcium and mineral metabolism. It leads patients (28%) developed perioperative complications; to severe bone disease and serious cardiovascular three neck hematomas, four line related infections, events. Surgical therapy is necessary to those resistant two nosocomial infections and two cardiac events to medical therapy. We examine clinical outcome of where one passed away. At three months after surgery, parathyroidectomy in renal hyperparathyroidism in almost all patients with bone pain showed resolution our center. of symptoms and marked improvement in ALP level. Serum iPTH also was normalized in all patients. Method Conclusion We prospectively studied 64 patients who underwent total parathyroidectomy for renal hyperparathyroidism Surgical therapy in renal hyperparathyroidism results from January 2013 to December 2014. Their clinical and in a prompt clinical improvement and provides a biochemical features, perioperative complications good quality of life to the patient. However special and clinical improvement in three months after measures should be taken perioperatively as it may parathyroid surgery were reviewed. carry a significant mortality and morbidity.

Result Only 42 patients managed to comply for follow 37 FP 2.3 FP 2.3

Wound Infection following Stoma Methods Reversal: A Prospective Comparative A randomized prospective study was conducted Study between Primary Closure and incorporating two groups of patients comparing primary closure and partial closure with intervening Partial Closure with Intervening silver dressings. A total of 41 patients who underwent Silver Dressings reversal of stoma in UPM surgical unit between 2011 J Y Soo1, N H Zubaidah2, K W Ong3, T Gee4 and 2015 were enrolled in the study. As of March 2015, primary closure was performed in 24 patients and 1Department of Surgery, Universiti Putra Malaysia, Serdang, Selangor, Malaysia a total of 17 patients underwent partial closure with 2Hospital Serdang, Selangor, Malaysia intervening silver dressings as the method of closure. 3Hospital Kuala Lumpur, Kuala Lumpur, Malaysia They are followed up and the post-operative SSI were analyzed. Background Results Closure of gastrointestinal tract stoma has been Complication rate was low in both groups (7.7%). SSI regarded as a clean contaminated surgery that is often occurred more frequently in primary closure group complicated by infection. Various techniques have (5.1%) in comparison to the partial closure with been postulated to aid in the reduction of surgical intervening silver dressing group (2.6%). Although site infection (SSI) as alternatives to primary skin there is no statistical difference of SSI between the 2 closure. Studies have shown that silver impregnated groups, there is a clinically significant difference in the dressing has effective antimicrobial properties as well reduction of SSI in the test group. All wounds healed by as being a good buffer for wound exudate, thereby, 6 weeks post operatively except one which heal after promoting faster wound healing. Therefore, the study reopening and daily dressing. is conducted to compare the rate of surgical site infection of two methods of wound closure following *This is a preliminary results because the study is still stoma reversal: primary closure versus partial closure ongoing. with intervening silver containing Hydrofiber dressing (Aquacel® Ag).

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Conclusion Low Pressure Laparoscopy With In conclusion, reversal of stoma via partial primary Deep Neuromuscular Bloackade closure with intervening silver dressings is a feasible versus Convetional High Pressure method. Larger studies are required to confirm its efficacy. Laparoscopy in Sleeve Gastrectomy: A Randomized Clinical Trial S Y Lim1, N H Zubaidah1, T Gee1, E F F Chew2 1Department of Surgery, Universiti Putra Malaysia, Serdang, Selangor, Malaysia 2Department of Anaesthesia, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

Background Laparoscopy is currently the gold standard approach in most types of abdominal surgery including bariatric surgery. Carbon dioxide insufflation is the commonest gas employed in laparoscopic surgery and the pressure used to create pneumoperitoneum is typically in the range of 10 to 15mmHg. This is essential for the creation of an optimal working surgical space. However high insufflation pressures are frequently associated with complications related to hypercarbia and high intra-abdominal pressure. Deep neuromuscular blockade facilitates a lower insufflation pressure to obtain the same pneumoperitoneal volume seen in higher pressure laparoscopy.

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Methods Laparoscopic Sleeve Gastrectomy A single centre study performed between January 2014 versus Laparoscopic Banded Gastric till December 2014. Eighty patients between the ages of 25 to 53 years were randomized into two groups Plication: A Combined University (A and B), those receiving a deep neuromuscular Hospital Experience blockade and low pressure (8mmHg) laparoscopy (A) A T Hizami1, R Reynu1, N R Kosai1, M T Mustafa1, and those receiving conventional muscle relaxants and 2 high pressure (15mmHg) laparoscopy (B). Train-of-four G Tikfu responses and post tetanic count were documented 1Minimally Invasive, Upper Gastrointestinal and Bariatric throughout surgery. Primary outcome is the surgical Surgery Unit, Department of Surgery, space condition during surgery documented using a Universiti Kebangsaan Malaysia Medical Centre, numeric rating scale and a four-step scale. Secondary Kuala Lumpur, Malaysia end points include operating time, shoulder tip pain 2Upper Gastrointestinal and Bariatric Surgery Unit, and post operative complications. Department of Surgery, Universiti Putra Malaysia, Kuala Lumpur, Malaysia Results A total of 76 patients were included in the study, A = 37 Introduction and B = 39. Four patients were excluded from the study. Obesity is fast becoming a global pandemic. In There is no significant difference in the working surgical Malaysia, obesity rate has trebled from 4.4% to space between the low pressure group (A) and the high involve 14% of the overall adult population. The pressure group (B). There is a significant difference in the shoulder tip pain between the 2 groups. negative impact on economic growth and financial burden on our national health care system is a serious Conclusion issue. Bariatric surgery compared to medical therapy Low pressure laparoscopy with deep neuromuscular has been proven effective in sustained weight blockade provides an optimal working space reduction, decreasing obesity related morbidity and comparable with conventional high pressure mortality. Laparoscopic sleeve gastrectomy (LSG) laparoscopy and is associated with less post operative and laparoscopic banded gastric plication (LBGP) are complications and shoulder tip pain in laparoscopic examples of restrictive bariatric procedures that are sleeve gastrectomy. used for this purpose.

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Objective Conclusion The aim of this study is to compare post-operative Although LBGP rivals LSG in weight reduction, the weight reduction between morbidly obese patients cost, associated morbidity, and prolonged hospital undergoing LSG versus LBGP. Operative time, hospital stay makes it a less favourable option in our setting. stay and associated morbidities between the two groups were also analysed.

Method This is a comparative observational study performed in Universiti Kebangsaan Malaysia Medical Centre and Kuala Lumpur General Hospital from February 2012 to November 2013. Morbidly obese patients planned for LSG and LBGP were consecutively recruited. Perioperative data was collected and analysed using SPSS version 20. Power was set at 80% with p value of 5% (<0.05) considered statistically significant.

Results A total of 55 and 32 patients underwent LSG and LBGP respectively. Mean BMI in both groups prior to surgery, at 6-months and 12-months post procedure was compared. Significant weight reduction was evident in the LBGP group (p=0.008). Mean operative time was longer in the LBGP group (p = <0.0005), while mean duration of hospitalization was shorter in the LSG group (p = <0.0005). One gastric perforation in the LBGP group required urgent re-laparotomy while another radiological leak in the LSG group was treated conservatively with success. 39 FP 2.6 FP 2.6

Incidence Of Hypocalcemia In Post factors such as thyroid function status, weight of Thyroidectomy Patients And Its thyroid gland, presence of retrosternal extension, number of parathyroid glands identified and final Relation To Parathyroid Hormone histology were also analyzed And Vitamin D Level H P Nadzlee, B Sarinah, K Normayah, B Anita, Results M Nor Hisham 102 patients were accrued for this study. Results showed a total of 54 patients (53%) with low pre Hospital Putrajaya, Putrajaya, Malaysia operative Vitamin D level and 32 patients (31%) had low early post-operative iPTH level. Only 42 patients (40%) Objective had temporary hypocalcemia. Hypocalcemia were Thyroidectomy carries a significant risk of observed in patients with low early post operative hypocalcaemia which may lead to life-threatening iPTH (p:0.007), low Vitamin D (p:0.591), presence complications, therefore patients usually require of retrosternal extension (p:0.341), lesser number inpatient calcium monitoring prior to discharge. of parathyroid identified at surgery (p:0.466) and We aim to evaluate the factors that can predict the hyperthyroid (p:0.499). incidence of post operative hypocalcemia particularly with regards to the intact parathyroid hormone (iPTH) Conclusion and vitamin D level. Low early post operative iPTH may predict the incidence of hypocalcaemia post thyroidectomy. Methods Pre-existing low vitamin D also contributes We performed a prospective study for patients significantly to temporary hypocalcaemia. undergoing total thyroidectomy for presume benign goitre from June 2013 to December 2014 in Hospital Putrajaya. Vitamin D level is taken preoperatively. Then post operative serum calcium and iPTH at 8 pm, followed by daily serum calcium level as required. Serum calcium is repeated at 6 weeks, 3 months and 6 months, with iPTH at 6 months follow-up. Other

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Evaluating The Effect Of stocking A paired T-test and Wilcoxon Rank T were Compression Stocking On used for statistical analysis with P <0.05 is considered significant Venous Hemodynamic In Chronic Venous Insufficiency Using Air Result Plethysmography Class 2 compression stocking improved venous hemodynamic efficiently. Venous volume was Nurul Rauf1, Zainal Ariffin Azizi1, M Azim Idris2 decreased from 157.42ml at T0 to 126.41ml at T1 (p 1Hospital Kuala Lumpur, Kuala Lumpur, Malaysia <0.05). Venous flow index reduced from 2.8 ml/s 2Hospital Universiti Kebangsaan Malaysia, to 2.2ml/s at T0 and T1 respectively. Compression Kuala Lumpur, Malaysia stocking potentiate the ejection fraction from 44.05% (T0) to 49.12% (T1). Residual volume also were decrease Objective from 49.98 %to 43,04% but not statistically significant To evaluate effect of class 2 compression stockings on venous hemodynamic in grade 2 and 3 chronic venous Conclusion insufficiency at baseline and at 6 weeks by using air Class 2 Compression stocking improve venous plethysmography. hemodynamic in patients with venous insufficiency after 6 weeks usage. The result showed the benefit of Methods compression only upon wearing them. 46 limbs in 29 patients (15 women and 14 men) with mean age of 55 years old with were evaluated. Duplex examination scanning was done to rule any deep vein reflux or thrombosis. From this, 18 limbs were classified into CEAP 2 and 28 limbs CEAP 3. Assessment using air plethysmography were taken at 3 moment; before wearing stocking (T0), after 6 weeks using stocking (T1) and 1 hour removal of stocking (T2). Patient symptoms were evaluated using venous score scoring system (VCSS) before and after 6 week wearing 40 FP 2.8 FP 2.8

Comparison Between Laparoscopic Method Sleeve Gastrectomy and This is a cross-sectional observational study conducted in a single centre (UKMMC) between January 2012 and Laparoscopic Roux-En-Y Gastric March 2014. Morbidly obese patients with underlying Bypass in Predicting The Remission Of T2DM were consecutive recruited during admition for Type 2 Diabetes Mellitus in Morbidly bariatric surgery. Diabetic status and weight loss was Obese Population reviewed at 6 months and 12 months following surgery. A Haniffa1, R Reynu, N R Kosai Results 1Department of General Surgery, Hospital Selayang, Of the 106 patients that underwent surgery during Selangor, Malaysia that time frame, only 41 patients with diabetes were 2Minimally Invasive, Upper GI and Bariatric Surgery Unit, recruited. 21 underwent LSG while the remaining 20 had LRYGB. Complete remission of diabetes at 6 Department of General Surgery, Universiti Kebangsaan months was notably higher in the LRYGB group (35% vs Malaysia Medical Centre, Kuala Lumpur, Malaysia 28.6%). At 12 months however, the LSG group showed a much higher rate of complete diabetic remission Introduction (57.2% vs 40%). The remission of diabetes was more Obesity is a known trigger for development of type 2 prominent in patients with diabetic surgery score Diabetes Mellitus (T2DM). Bariatric surgery has been (DSS) of more than 6 in both groups. increasingly recognized as an effective treatment modality for morbid obesity due to its ability to Conclusion provide a more sustainable weight loss, and better Previously regarded as a purely restrictive procedure, control as well as complete remission of T2DM. LSG has been increasingly recognized as a mixed procedure. The high-pressured tubular stomach Objective shortens gastric emptying time (Poiseuille Law) which leads to food reaching the hind gut faster. This in-turn To compare the diabetic remission rates between stimulates release of GLP-1, a hormone responsible laparoscopic sleeve gastrectomy (LSG) and laparoscopic for pancreatic stimulation and good glycemic control. Roux-en-Y gastric bypass (LRYGB) in morbid obesity. To We believe this to be the reason behind a higher rate analyse the association between the diabetic surgery of complete diabetic remission in the LSG group at scoring system (DSS) and remission of diabetes. 12 months.

FP 2.9 FP 2.9

Is Laparoscopic Repair of Methodology Incarcerated or Obstructed A retrospective cohort of 45 consecutive patients Ventral Hernias Feasible in the who underwent emergency ventral hernia repair at University Malaya Medical Center (UMMC) from Emergency Setting? A Retrospective 2009 to 2014 was included. All ventral hernias that Comparative Study of Emergency were either diagnosed as incarcerated, obstructed or Laproscopic versus Open Ventral strangulated were included. Hernia Repair Data analyzed using SPSS version 22. The outcomes K Y Low, Kanesh Kumaran, P C Lau, E H Pok were compared using the Mann Whitney U test for Department of Surgery, Faculty of Medicine, non-parametric data and Chi square test and Fisher- University of Malaya, Kuala Lumpur, Malaysia Exact test.

Introduction Result The benefits of laparoscopic ventral hernia repair During that period, 12 patient underwent an emergency (LVHR) has been well documented and it’s role well LVHR while another 33 patients had an OVHR, with a established. However, in the emergency setting when median follow-up period of 12 months (1-48 months). the hernia is incarcerated or even strangulated, most surgeons would prefer an open approach. The role of There was no significant difference in demographics laparoscopic repair in this scenario is still a debate and between to 2 groups. Compared with OVHR, LVHR poorly documented. had a shorter median length of stay (3 days vs 4 days, p=0.04) and lesser incidence of surgical site infection Objective (SSI) (21.2% vs 0%, p=0.18). LVHR was also associated To compare the outcomes of laparoscopic ventral with less overall complications (25% vs 31%, p=0.71). hernia repair versus open ventral hernia repair (OVHR) There was 1 recurrence in the LVHR group but none for in an emergency setting. the OVHR group.

41 FP 2.9

Conclusion We managed to demonstrate that LVHR is safe and feasible in the emergency setting. The benefits of LVHR include shorter hospital stay and lesser incidence of SSI. Although the results of the outcomes like SSI and overall complications are not statistically significant, clinically it is a favorable and significant outcome. Further prospective studies on the role emergency LVHR with larger number are suggested to consolidate our current findings.

42 Poster PRESENTATIONS

PP 01 Isolated Necrotizing Fasciitis of Anterior Abdominal Wall After 68 Prostate Biopsy: A Case Report Mohamed Muhshin Mohamed Sickandar, Khairuzi Salekan Department of Surgery, Hospital Sultanah Nora Ismail, Batu Pahat, Johor, Malaysia

PP 02 Management of Malignant Gastric Outlet Obstruction – A Case Series 68 Lily L Y Wong, K C Soon Department of General Surgery, Hospital Miri, Sawarak, Malaysia

PP 03 Rare Presentation of A Femoral Hernia: Case of De Garengeot Hernia 69 Adrian Gerard1, Ganendra Paramasvaran1, Kumaresan Supramaniam2 1Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia 2Surgery Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

PP 04 Anterior Abdominal Wall Abscess as a Complication Of 69 Appendicular Mass In Elderly: A Case Report C A Shahidah1, S M Ikhwan2, Norzila Abu Bakar2, Z Zaidi2 1Department of Surgery, International Islamic University Malaysia, Kuantan, Pahang, Malaysia 2Department of Surgery, Universiti Sains Malaysia, Penang, Malaysia

PP 05 Who Is The Culprit: Trauma Or H.Pylori? Case Report: Perforated 69-70 Duodenal Ulcer In A Teenage Girl Thiru V Raau, Sivapiragas S, Davaraj Balasingh, Rudyanto Saripan Department of Surgery, Hospital Tuanku Ampuan Najihah, Kuala Pilah, Negeri Sembilan, Malaysia

PP 06 Metastatic Liver Liposarcoma, Pleomorphic Subtype With Unknown 70 Primary – A Case Report Lily L Y Wong, K C Soon Department of General Surgery, Hospital Miri, Sarawak, Malaysia

PP 07 Intestinal Obstruction With Perforated Gastric Ulcer Secondary 70-71 To Ingested Foreign Bodies – A Case Report Lily L Y Wong, K C Soon Department of General Surgery, Hospital Miri, Sarawak, Malaysia

PP 08 gastric Rupture After Blunt Abdominal Trauma 71 Adrian Gerard1, Rajiev Raja Sakaran2, Chong Hoong Weng2, Yan Yang Wai2 1Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia 2Surgery Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

PP 09 Bowel Injury Post Blunt Abdominal Trauma with Normal CT 71 Findings Fitgerald H, Pavin K, Aizat T Department of General Surgery, Hospital Selayang, Selangor, Malaysia

PP 10 Awareness Of Testicular Cancer And The Practice Of Testicular 71-72 Self-Examination Among Male University Students S K Wong, M Mokhtar, H N A Majid Universiti Kuala Lumpur RCMP, Ipoh, Perak, Malaysia

43 Poster PRESENTATIONS [cont’d)

PP 11 Unusual Presentation Of Dermoid Cyst of the Spermatic Cord In 72 An Adult Patient Mimaking Incarcerated Irreducible Inguinal Hernia. A Case Report With Review Of Literature Sarmukh Singh1,Tan Yee Ling1, Ramesh Thangaratnam1, Chew Loon Guan1, Zaidi Zakaria2 1HospitalSerdang, Selangor, Malaysia 2Universiti Sains Malaysia, Malaysia

PP 12 The Umbilical Nodule: Sign Of A Hidden Pathology 72-73 Karthikeyan M, Thiagarajan G, Gunaseelan D, Ros’aini Paijan Department of Surgery, Hospital Pakar Sultanah Fatimah, Muar, Johor, Malaysia

PP 13 choledochal Cyst In Teenage: Missed In Childhood. Case Report: 73 Choledochal Cyst Theebanraja Ramalingam, Sivapiragas S, Davaraj Balasingh, Rudyanto Saripan Department of Surgery, Hospital Tuanku Ampuan Najihah, Kuala Pilah, Negeri Sembilan, Malaysia

PP 14 A Case Of Lipomatous Tumor Of Thyroid Gland : A Rare Entity 73 F Idris1, N Amjad1, E Mahno1, S Murad2 1International Islamic University Malaysia, Kuantan, Pahang, Malaysia 2Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia

PP 15 A Rare Benign Neck Tumor: Cervical Ganglioneuroma 74 A H Junaidi1, W M Atman2, H Singh2 1Department of Surgery, Kulliyah of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia 2Department of Surgery, Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia

PP 16 Life-threatening Hemorrhagic Pericardial Tamponade: A Rare 74 Intrathoracic Complication in Severe Acute Pancreatitis A H Junaidi1, Zalikha K2, H Singh2 1Department of Surgery, Kulliyah of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia 2Department of Surgery, Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia

PP 17 Reno-Colic Fistula – A Rare Case Report 74 Wilson Liew, S B Lee, J R Sathiyanathan, Hemanth Kumar Ramasamy Department of Urology, Penang General Hospital, Penang, Malaysia

PP 18 granulomatous Mastitis In West Coast And Interior Sabah 74-75 F Y Chai1, A Y P Tan2, Z S Siti2, J A Chuah2 1Department of Surgery, Hospital Keningau, Sabah, Malaysia 2Department of Surgery, Hospital Queen Elizabeth, Kota Kinabalu, Sabah, Malaysia

PP 19 Primary Hyperparathyroidism Presenting With Pathological 75 Fracture of Long Bone K S Khoo1, Vivek Singh2, S S Chong1, K L Ng1 1Department of Surgery 2Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

PP 20 case Report : Chilaiditi’s Syndrome – The Odd Cause Of 75-76 Pseudopneumoperitoneum F Shah, A Wafi, G Y Lo, T Clement Hospital Tuanku Fauziah, Kangar, Perlis, Malaysia 44 Poster PRESENTATIONS [cont’d)

PP 21 Retrospective Study: Outcome of Endovenous Radio-Frequency 76 Ablation (RFA) Therapy For Lower Limb Varicose Veins In Hospital Kuala Lumpur Hadi M A1, Ismazizi Z2, Naresh G2, Zainal A A2 1Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

PP 22 Injury Trends And Risk Factors Of Trauma Mortality In A Geriatric 76-77 Population Henry Tan Chor Lip, Tan Jih Huei, Sarojah Arulanantham General Surgery Department, Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia

PP 23 Rectal Foreign Objects, Does The Care Ends After Removal? 77 - A Case Report And Literature Review Henry Tan Chor Lip, Seniyah Md Sikin General Surgery Department, Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia

PP 24 Mono Or Dual Therapy, Are We Following The Standard? An Audit 77-78 Of Upper Gastrointestinal Bleeding Henry Tan Chor Lip1, Nur Fitriyani Afiqah2 1General Surgery Department, Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia 2Newcastle University Medicine Malaysia, Johor Bahru, Johor, Malaysia

PP 25 colopleural Fistula with Faecopneumothorax From A Non Traumatic 78 Splenic Flexure Perforation: A Case Report Mohd Firdaus R, George John K T G, Zainal Ariffin A Thoracic Surgery Unit, Department of General Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

PP 26 Emphysematous Pyelonephritis : A Case Report 78-79 Mohd Johari1, Khair Syamimi2, Hasnizal Nording3, Chen Hong Lim4 1, 2Medical Officer, Department of Surgery, Hospital Segamat, Johor, Malaysia 3Surgeon, Department of Surgery, Hospital Segamat, Johor, Malaysia 4Head of Deparment and Surgeon, Deparment of Surgery, Hospital Segamat, Johor, Malaysia

PP 27 case Report on Umbilical Metastatic Lesion from Endometrioid 79 Ovarian Carcinoma Mimicking Incarcerated Umbilical Hernia To General Surgeon Sarmukh Singh1, Putera Mas Piah1, Ramesh Thangaratnam1, Chew Loon Guan1, Zaidi Zakaria2 1Hospital Serdang, Selangor, Malaysia 2Universiti Sains Malaysia, Penang, Malaysia

PP 28 gangrenous Bowel Survivors - A Case Series 79 Mohammad Alif Y, Sekkapan T, Wan Athman W M, Jiffre Din Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia

PP 29 How Much Do We Know About Chest Trauma In Malaysia? Chest 80 Injury Pattern and Outcome Jih Huei Tan, Yue Yi Cheah, Rahmat Othman, Henry Tan Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia

45 Poster PRESENTATIONS [cont’d)

PP 30 case Report: Large Wild Banana Seeds Phytobezoar In The Rectum 80 H S L Sophia, Y E Tan, S M D Asilah, F Y Chai Department of Surgery, Hospital Keningau, Sabah, Malaysia

PP 31 Popliteal Artery Pseudoaneurysm Successfully Treated With 80-81 Amplatzer Vascular Plug Liew K W, Leong B D K, Selvarajoo G Hospital Queen Elizabeth II, Kota Kinabalu, Sabah, Malaysia

PP 32 First Endovascular Management Of Axillary Artery Pseudoaneurysm 81 In Sabah: A Case Report And Review Of The Literature Selvarajoo G, Leong B D K, Valan A, Liew K W Vascular Unit, Surgical Department, Hospital Queen Elizabeth II, Kota Kinabalu, Sabah, Malaysia

PP 33 Trends in ESBL-Production And Susceptibility For Intraabdominal 81-82 Infections Isolates In Hospital Sultanah Aminah Johor Bahru: SMART 2009-2013 Ganeswrie Rajasekaram1, W Y Tay2 1Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia 2Merck Sharpe & Dohme, Petaling Jaya, Selangor, Malaysia

PP 34 A Giant Fibroadenoma Turns Out To Be Phylloid Tumour 82 Thiagarajan Gobal, Karthikeyan Marthay, Gunaseelan D, Ros’aini Paijan Department of Surgery, Hospital Pakar Sultanah Fatimah, Muar, Johor, Malaysia

PP 35 Rare Yet Aggressive – Angiosarcoma Of The Breast : A Case Report 82-83 Thomas F1, Nor Aishah MA1, Rosmalinda K1, Ganapaty S2 1Department of General Surgery, Hospital Ampang, Selangor, Malaysia 2Department of Pathology, Hospital Serdang, Selangor, Malaysia

PP 36 Malignant Mediastinal Germ Cell Tumour With Intra Pulmonary 83 Infiltration: A Case Report Atifah A, George John K T G, Zainal Ariffin A Thoracic Surgery Unit, Department of General Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

PP 37 chest Wall Reconstruction With Free Transverse Rectus Abdominis 83-84 (TRAM) And Pedicled Latissimus Dorsi Flap In A Case Of Malignant Phyllodes Tumour Of The Breast Invading Into The Ribs: A Case Report Syafiq Idris, Suniza J, See M H, Ridwan Mirza, Alizan Khalil, Taib N A University of Malaya, Kuala Lumpur, Malaysia

PP 38 Hepatic Angiosarcoma: A Rare Primary Liver Malignancy 84 Nur Zawani Z, Friman H, Ikhwan S M, S Hassan, Z Zaidi Department of Surgery, Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia

PP 39 A Case Series Of Neuroendocrine Carcinoma Of The Breast In 84 Penang General Hospital And Its Literature Review S Y Loi, M S Teoh, Y T Cheong Hopsital Pulau Pinang, Penang, Malaysia

46 Poster PRESENTATIONS [cont’d)

PP 40 A 5-Year Retrospective Review Of Pelvic Exanteration In 85 Hospital Selayang Prathaban, Mark S G, Tan X Y, Kavitha M D, Gerald H Colorectal Unit, Department of General Surgery, Hospital Selayang, Selangor, Malaysia

PP 41 A Short-Term Outcome Analysis Of Laser Hemorrhoid Surgery In 85 Hospital Selayang Sivakumaran J, Prathaban T, Mark S G, Gerald H Department of Surgery, Hospital Selayang, Selayang, Selangor, Malaysia

PP 42 jejunal Diverticulosis : A Rare Cause of Obscure Gastrointestinal 86 Bleeding Shafhawi M A, Elina S, Fitjerald H

PP 43 Wandering Intrauterine Contraceptive Device : An Unusual Travel 86 To The Sigmoid Colon Kumarappan Al, Karthikeyan M Gunaseelan D, Ros’aini Hospital Pakar Sultanah Fatimah, Muar, Johor, Malaysia

PP 44 An Unusual Presentation Of The Rare Primary Pleomorphic Sarcoma 87 Of The Liver Suriaraj K, Devanraj S, Premjeet S, Suraj P B Department Of General Surgery, Miri General Hospital, Sarawak, Malaysia

PP 45 Incidental Finding Of An Anorectal Malformation In A 58 Year Old 87 Premjeet S, Zulkifli M Z, Suriaraj K, Nursheila Izrin A Z General Surgery Department, Hospital Miri, Sarawak, Malaysia

PP 46 Undifferentiated Embryonal Sarcoma Of The Liver: A Case Report 88 And Literature Review H L Sha, Aminnur H M, M Hardin, A Ali General Surgery Department, Sarawak General Hospital, Kuching, Sarawak, Malaysia

PP 47 Perforated Gastric Ulcer In A Child 88 Nursheila Izrin A Z, Suraj P B, Premjeet S, Suriaraj K General Surgery Department, Hospital Miri, Sarawak, Malaysia

PP 48 gastric Plasmacytoma: A Rare Malignancy Of The Stomach 89 Devanraj S, Suriaraj K, Zulkifli M Z, Suraj P B Hospital Miri, Sarawak, Malaysia

PP 49 video-Assisted Thoracoscopic Surgery For Empysematous Lung Bullae 89 Phrabakaran Rajehgopal1, Nurfareha Mohd Hatta2, Poh K S2, Yusof Wahab2 1Department of Surgery, Hospital Tengku Ampuan Rahimah, Klang, Selangor, Malaysia

PP 50 An Uncommon Adrenal Tumour 90 S L Raymond Yii, S S Chong, K L Ng Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

47 Poster PRESENTATIONS [cont’d)

PP 51 Ascariasis Causing Small Bowel Volvulus – The Deeper Perils Of 90 Being A Stateless Child In Malaysia Z L Lim, Maung K L, Othman M Z, S S M Fadzil Surgical Department, Tawau General Hospital, Sabah, Malaysia

PP 52 Huge Gluteal Well-differentiated Liposarcoma 91 P S Law, R S Lam Hospital Kulim, Kedah, Malaysia

PP 53 Accuracy Of Surgeon-Performed Ultrasound-Guided Core-Needle 91 Biopsy Of Breast Lesions Nasir S, M S Teoh, Sunil S P, Azra S Hospital Pulau Pinang, Pulau Pinang, Penang, Malaysia

PP 54 Parathyroid Carcinoma In Primary Hyperparathyroidism: A Rare 92 Occurrence Deborah Ding Y S, Kirubakaran M, Y W Yan Department of General Surgery, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

PP 55 Parathyroid Surgery: A Case Series In Hospital Raja Permaisuri 92 Bainun, Ipoh Deborah Ding Y S, Ooi G K, Kirubakaran M, Yan Y W Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

PP 56 Delayed Diagnosis of Traumatic Diaphragmatic Hernia: A Case Report 93 Deborah Ding Y S, Basel E, Yan Y W Department of General Surgery, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

PP 57 Minimising Minimal Invasive Surgery: “ Two 5mm Ports & Puppetry 93 Traction Laparoscopic Cholecystectomy” Single Surgeon & Single Centre Experience Tang Y M1, Salina A Y2, Mutyala Vinod Kumar1, Lai C K1, et al 1Hospital Duchess of Kent, Sandakan, East Sabah, Malaysia 2Hospital Sultanah Nur Zahirah, Kuala Terengganu, Terengganu, Malaysia

PP 58 A Case Report: Nipple Areola Sparing Subcutaneous Mastectomy, 94 Axillary Clearance And Immediate Breast Reconstruction With Tram (Transverse Rectus Abdominis Myocutaneous) Flap For A Young Patient With Breast Carcinoma M Sohail1, Aini Farizan Binti Ibrahim1, Khairunnisa C G2, J Ranjit3 1Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak (UNIMAS), Sarawak, Malaysia 2Department of Surgery, Hospital Umum, Sarawak, Malaysia 3Department of Plastic Surgery, Hospital Umum, Sarawak, Malaysia

PP 59 Resuscitative Thoracotomy In Penetrating Thoracic Injury; 94-95 Case Series Khair Syamimi B, Mohd Johari, Hasnizal Nording, Chen Hong Lim Surgery Department, Hospital Segamat, Johor, Malaysia

48 Poster PRESENTATIONS [cont’d)

PP 60 Low Rectal Cancer Presenting With Perforated Sigmoid Volvulus : 95 A Case Report L L Sivamoorthy, Chong Chaw Jong, Adnan Zafar, S Saidah, Sazalene D H, Othman M Z Department of General Surgery, Tawau Hospital, Sabah, Malaysia

PP 61 Multiple Small Bowel Diverticuli 95-96 Su Kim Peng, Dyg Zahratul Hamrak, Rizal Irwan Syah, Rashide Yaacob Surgical Department, Hospital Sultan Abdul Halim, Sungai Petani, Kedah, Malaysia

PP 62 giant Benign Prostate Hyperplasia Successfully Removed By 96-97 Suprapubic Prostatectomy Rizal Irwan Syah, Nur Amira, Su Kim Peng, Hari Dass Govindasamy Surgical Department, Hospital Sultan Abdul Halim, Sungai Petani, Kedah, Malaysia

PP 63 case Report: Blunt Cerebrovascular Injuries (BCVI) - An 97 Underdiagnosed Condition In Trauma Patients W S Pang, Yuzaidi M, Rizal I A, Farouk A Trauma Unit, Department of General Surgery, Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia

PP 64 case Report: A Rare Case Of Adult Multiple Small Bowel 97-98 Intussusceptions Due To Metastatic Sarcomatoid Carcinoma W S Pang1, K K Chan1, R Abd Rashid2, S M Devan2 1General Surgery Department, Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia 2Pathology Department, Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia

PP 65 Factors Associated With Clearance Of Renal Stones Treated With 98 Extracorporeal Shockwave Lithotripsy Senthil Vasan Kanthasamy, Khaidir Abu Bakar University of Malaya, Kuala Lumpur, Malaysia

PP 66 Acute Appendicitis In Leptospirosis: A Case Report 98-99 Rosliza G1, Rosmalinda K2, Nor Aishah M A2 1Faculty of Medicine and Health Science, Islamic Science University of Malaysia (USIM), Selangor, Malaysia 2Department of Surgery, Ampang Hospital, Selangor, Malaysia

PP 67 Does Serum Intact Parathyroid Hormone (iPTH) Decline 6 Hours 99 After Total Thyroidectomy Can Predict Post Operative Hypocalcaemia ? Norashikin M N1, Aina E N1, Nor Shafini2, Shahrun Niza3 1Breast and Endocrine Unit, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia 2Department of Pathology, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia 3Endocrine and Breast Unit

PP 68 A Retrospective Study On “The Effect Of Bariatric Surgery In 99-100 Resolution Of Comorbidities”- Hospital Taiping Suriakanthan Bala Krishnan, Rajkumar Vinayak, Umasangar Ramasamy, Yap Choon Fong, Leong Keen Wai Hospital Taiping, Perak, Malaysia

49 Poster PRESENTATIONS [cont’d)

PP 69 Post-Operative Vomiting Proves Fatal : A Rare Case Of 100 Boerhaave’s Syndrome Arivarni K1, Sivaneswaran L1, C Rajkumar Vinayak1, Umasangar R1, Premnanth N2 1Department of Surgery, Hospital Taiping, Taiping, Perak, Malaysia 2Penang Medical College, Penang, Malaysia

PP 70 Outcome Of Inter-Hospital Transfers For Major Trauma Victims: 100-101 A Preliminary Audit J C Y Gan, Y Mohammed, Rizal I A, A K B Gunn Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia

PP 71 Pneumoperitoneum, Pneumoretroperitoneum, Tension Pneumothorax 101 And Diffuse Subcutaneous Emphysema Secondary To Caecal Perforation Post Colonic Stenting : A Case Report H S Boo, Fadliyazi A R, Prabhu Ramasamy Penang General Hospital, Penang, Malaysia

PP 72 When The Stomach Flips Over On Itself 101 R Hassan1, Tay K V2, A Shabbir2 1Department of Surgery, Penang Medical College, Penang, Malaysia 2Department of General Surgery, National University Hospital, Singapore

PP 73 gastrointestinal Amyloidosis: Rare Disease With Common 102 Presentation Causes Dilemma in Diagnosis Humaizy A S2, Shamsher S N2, Mohd Naufal R2 , Prathaban M2, N Haron1, Fitzjerald H2 1Discipline of General Surgery, Faculty of Medicine, Universiti Teknologi MARA (UiTM), Shah Alam, Selangor, Malaysia 2Department of Surgery, Hospital Selayang, Selangor, Malaysia

PP 74 Breast Cancer Audit in Sarawak General Hospital, A 7-Year Review 102-103 L W Wong, K S Chai, C H Chea, J Rokayah Sarawak General Hospital, Kuching, Sarawak, Malaysia

PP 75 Diagnostic Dilemma In Primary Breast Neuroendocrine Tumour: 103 Sarawak General Hospital Experience Khairunnisa C G1, Aini I1,2, Nik Azim N A1 1Sarawak General Hospital, Kuching, Sarawak, Malaysia 2Universiti Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia

PP 76 gastrointestinal Bleed Caused By Epitheloid Sarcoma : 103-104 A Case Report F Y Lee, L Limi, T Gee Surgical Department, Universiti Putra Malaysia, Hospital Serdang, Serdang, Selangor, Malaysia

PP 77 Simulating Laparoscopic Cholecystectomy Using Ex Vivo Sheep 104 Gallbladder And Liver N S Elina, N Haron, M A Yahya General Surgery Discipline, Faculty of Medicine, Universiti Teknologi MARA (UiTM), Shah Alam, Selangor, Malaysia

50 Poster PRESENTATIONS [cont’d)

PP 78 Synchronous Bilateral Breast Cancer 104-105 L W H Lai, A K N Kwan, Mohan, Lewellyn Hospital Teluk Intan, Perak, Malaysia

PP 79 Metaplastic Breast Carcinoma: A Rare Histopathological Subtype 105 Firdaus M G, Siti Rahmah H I M, Ikhwan S M, Zaidi Z, Syed Hassan Department of Surgery, School of Medical Science, Universiti Sains Malaysia Health Campus, Kubang Kerian, Kelantan, Malaysia

PP 80 Per Rectal Bleed in Pregnancy: How Aggressive Should We 105 Investigate? Anuradha Valan, Edwin See, Krishnan Sriram, Siti Zubaidah, Chuah Jitt Aun Surgical Department, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia

PP 81 Undifferentiated Small Bowel Sarcoma with Lung Metastasis: 106 A Rare Diagnostic Entity Akmal Hisham, Akbar Bahari, Nor Aishah M A Department of Surgery, Hospital Ampang, Selangor, Malaysia

PP 82 Endoscopic Retrograde Cholangiopancreatography On Common 106 Bile Duct Stones In A Tertiary Hospital Compared To The Gold Standard By The Joint Advisory Group On Gastrointestinal Endoscopy (JAG) : An Audit Louis Ling1, L E Teng2, H W Sim2, S N Yeoh2 1Department of General Surgery, Hospital Sultanah Aminah Johor Bahru, Johor, Malaysia 2Jeffrey Cheah School of Medicine and Health Sciences, Monash University, Johor Bahru, Johor, Malaysia

PP 83 Two Rare Cases of Large Cystic Adrenal Teratomas: A Malaysian 107 Experience A R Izad1, M N Hisham2, B Anita2, B Sarinah2, K Normayah2, A N Hisham2, A Asmiati3 1Department of General Surgery, Hospital Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia 2Department of Breast and Endocrine Surgery, Hospital Putrajaya, Putrajaya, Malaysia 3Department of Pathology, Hospital Putrajaya, Putrajaya, Malaysia

PP 84 Trauma In General Surgical Unit: Epidemiology And Predictors Of 107-108 Mortality Jih Huei Tan, Henry Tan, A Sarojah Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia

PP 85 gastrointestinal Tuberculosis (TB GUT) Still A Menace In Sandakan 108 Tang Y M, Sridar S, Lai C K, Mutyala Vinod Kumar, et. al General Surgery Department, Hospital Duchess of Kent, Sandakan, Sabah, Malaysia

PP 86 challenges In Managing Medullary Thyroid Carcinoma Associated 108-109 With Carcinoid Syndrome Suhairil B1, Chan A C2, Sarinah B1 1Breast & Endocrine Unit, Department of General Surgery, Hospital Putrajaya, Putrajaya, Malaysia 2Department of General Surgery, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

51 Poster PRESENTATIONS [cont’d)

PP 87 A Rare Case Of Jejunal Adenocarcinoma With Krukenberg 109 Ovarian Tumour A K N Kwan, L W H Lai, Lewellyn, Mohan Hospital Teluk Intan, Perak, Malaysia

PP 88 Huge 3.6kg Suprafascial Anterior Chest Wall Myxofibrosarcoma: 109-110 A Case Report A K N Kwan, L W H Lai, Lewellyn, Mohan Hospital Teluk Intan, Perak, Malaysia

PP 89 challenges In Diagnose Adult Intussusceptions With Unspecific 110 Presentation: 3 Cases Reports A K N Kwan, L W H Lai, Lewellyn, Mohan Hospital Teluk Intan, Perak, Malaysia

PP 90 Breast Cancer In Young Women. The Penang GH Experience 110-111 Michael A, Sunil S P, M S Teoh, W J Tan Hospital Pulau Pinang, Pulau Pinang, Penang, Malaysia

PP 91 Fulminant Necrotizing Amoebic Colitis: A Diagnostic Conundrum 111 Michael A, Jasjit S N Hospital Pulau Pinang, Pulau Pinang, Penang, Malaysia

PP 92 Endogenous Endophthalmitis: An Unusual Presentation Of 111-112 Perforated Gastric Ulcer Aminnur H M, H L Sha, M Hardin, S L Siow Department of Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia

PP 93 Wilkie’s Syndrome - Management Dilemma On The Implementation 112 Of The Nutrition And Surgical Approach Aminnur H M, A Ali, Rokayah J, Azim N A N Department of Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia

PP 94 A Retrospective Analysis Of Chemo-port Complications In Adults 112 With Malignancy Manoj B N, Mathew T, Sarojah A Department of Surgery, Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia

PP 95 De Garengeot’s Hernia: Case Report Of Appendicitis Within 113 An Incarcerated Femoral Hernia Manoj B N, Heah H T, Sarojah A Department of Surgery, Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia

PP 96 gastrointestinal Neurofibromatosis Causing Gastrointestinal 113 Obstruction: A Case Series Manoj B N, Mathew T, Sarojah A Department of Surgery, Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia

52 Poster PRESENTATIONS [cont’d)

PP 97 Plummer’s Disease With Intolerance Towards Carbimazole And 114 Propylthiouracil: A Case Report Of A Rare Phenomenon Manoj B N, Maizatul R, Sarojah A Department of Surgery, Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia

PP 98 Perforated Meckel’s Diverticulum Following Blunt Abdominal 114 Trauma: A Case Report Tuang G J, Goo Z Q, Kandasami P International Medical University

PP 99 The Masquerading Mass: Breast Tuberculosis 115 N Kumar, C H Chan, L Sivaneswaran, R Umasanga Department of General Surgery, Hospital Taiping, Taiping, Perak, Malaysia

PP 100 Testicular Tuberculosis Presenting As Complex Hydrocele 115 N Kumar, C H Chan, AH Hasslinda, L Sivaneswaran Department of General Surgery, Hospital Taiping, Taiping, Perak, Malaysia

PP 101 giant Leiomyoma Of Oesophagus: A Case Report 116 Y W Choo, H Syakirah A R, Zuraimi Z, Nshukri N Y Department of surgery, Hospital Raja Perempuan Zainab II, Kota Bharu, Kelantan, Malaysia

PP 102 A Case Report: Primary Tuberculosis Of Thyroid 116 Juan B A1, Chan A C2, Anita B3 1Department of Surgical Oncology, National Cancer Institute, Putrajaya, Malaysia 2Department of Surgical, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia 3Department of Breast of Endocrine Surgery, Hospital Putrajaya, Putrajaya, Malaysia

PP 103 Dissecting Aortic Aneurysm Presented With Acute Limb Ischaemia 117 In A Healthy Young Adult Male Muhammad Za’im, Nur Amira, Rizal Irwan Syah, Norhashimah Abdul Kadir Surgical Department, Hospital Sultan Abdul Halim, Sungai Petani, Kedah, Malaysia

PP 104 Multi-Organ Infarcts With Evidence Of Auto Amputation Secondary 117 To Arterial Thrombus (Thoracic Aorta) In A Normal-Appearing Aorta In An Asymptomatic Patient Muhammad Za’im, Awatif, Su K P, Norhashimah Abdul Kadir Surgical Department, Hospital Sultan Abdul Halim, Sungai Petani, Kedah, Malaysia

PP 105 case Report : Gastric Schwannoma - A Rare Gastric Tumour 118 W J Wong, J A Chuah, R Palaniappan, E See, R K Sriram Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia

PP 106 Pioneering Vascular Service In Sabah: An Audit Of Arteriovenous 118 Fistulas Valan A, Leong B, Selvarajoo G, Wong W J Vascular Unit, General Surgery Department, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia

53 Poster PRESENTATIONS [cont’d)

PP 107 A Single Tertiary Vascular Center Report On Outcome Of EVAR: 119 Hospital Serdang’s 5 Years Experience J Y Eng, Y L Tan, L G Chew, B L Ee, P Kayalvilli Hospital Serdang, Selangor, Malaysia

PP 108 Small Bowel Arteriovenous Malformation; An Unusual Suspect 119 In Lower Gastrointestinal Bleeding Karthik K, Buveinthiran B, David Ong, H Singh Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia

PP 109 Multiple Magnet Ingestion: A Rare Cause Of Bowel Perforation 120 Jothinathan M, Razali M, Muthu A, Andrew G Pediatric Surgery Department, Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia

PP 110 Laparoscopic Repair Of Acquired Abdominal Intercostal Hernia: 120 A Case Report And Literature Review C K Seak1, K L Seng2, S L Siow1, Mark Hardin1 1Sarawak General Hospital, Sarawak, Malaysia 2Sibu General Hospital, Sarawak, Malaysia

PP 111 A One-Year Study of Bacteriology In Skin & Soft Tissue Infection 121 With Underlying Diabetes Mellitus Patients In Department Of Surgery, Hospital Seberang Jaya Sumaraj A1, Nasheef1, Fitreena A2, Imran A K1 1Hospital Seberang Jaya, Penang, Malaysia 2Institut Perubatan Dan Pergigian Termaju, Universiti Sains Malaysia, Penang, Malaysia

PP 112 Audit On Adult Inguinal Hernia Surgery In Hospital Seberang Jaya: 121 Have We Done Enough? C W Yong, C T Ooi, Sumaraj A, Imran Khalid Hospital Seberang Jaya, Penang, Malaysia

PP 113 Neuroendocrine Tumor In Sarawak General Hospital 122 N R Nordin, A Ali, N A Nik Abdullah Hospital Umum Sarawak, Kuching, Sarawak, Malaysia

PP 114 The Enemy Under Cover: Retroperitoneal Inflammatory 122 Myofibroblastic Tumour With Locally Aggressive Behaviour B C Chang, Ngo Choon Woon Department of General Surgery, Hospital Sultanah Nur Zahirah, Kuala Terengganu, Terengganu, Malaysia

PP 115 Skeletal Muscle Metastases Of Gastric Carcinoma – A Case Report 123 Neehad Baharuddin, Noraishah Mohd Arif Hospital Ampang, Selangor, Malaysia

PP 116 Outcome Of Peripheral Vascular Injury In A Trauma Surgery Unit: 123 HSAJB Experience Yuzaidi M, W S Pang, Asma’ R, Rizal I A Surgical Trauma Unit, Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia

54 Poster PRESENTATIONS [cont’d)

PP 117 A Case Report: Primary Omental Torsion Mimicking Acute 123-124 Appedicitis Y S Lee, P S Koh, J K Koong, B K Yoong University of Malaya, Kuala Lumpur, Malaysia

PP 118 Neuroendocrine Tumours – Primary Lesion From Common To 124 Extremely Rare Locations With Different Presentation: Hospital Temerloh’s Experience Sabrina K, Tham S Y, Salleh M S, Azmi H Hospital Sultan Haji Ahmad Shah, Temerloh, Pahang, Malaysia

PP 119 chronic Cholecystitis: An Unsusal Causes Of Duodenal Obstruction 124-125 Tham S Y, Sabrina K, Salleh M S, Azmi H Hospital Sultan Haji Ahmad Shah, Temerloh, Pahang, Malaysia

PP 120 Primary Diffuse Large B-Cell Lymphoma of the Breast 125 Harjeet S S1, Thevarasan G1, Salleh M S1, Azlina A R2 1Hospital Sultan Haji Ahmad Shah, Temerloh, Pahang, Malaysia 2Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia

PP 121 colonoscopy With Clipping Of Bleeding Diverticulum Of The Colon. 125 Another Tool In The Armentarium. A Case Report Ragu Ramasamy, Loh Soo Kang Hospital Selayang, Selangor, Malaysia

PP 122 Successful T-tube Assisted Primary Duodenal Repair In A Grade 3 126 Duodenal Injury: A District Hospital Experience A Choke, N Rosly, D M Dualim, S H Saifuddin, W M Abuzeid Department of Surgery, Hospital Bintulu, Sarawak, Malaysia

PP 123 caecal Volvulus: An Unsuspecting Cause Of Intestinal Obstruction 126 N Rosly, D M Dualim, A Choke, S H Saifuddin, W M Abuzeid Department of Surgery, Hospital Bintulu, Sarawak, Malaysia

PP 124 Etiology And Epidemiology Perspectives Of Lower Gastrointestinal 127 Bleeding (LGIB) Diagnosed By Colonoscopy At A Periphery Hospital Thiru V Raau, Sivapiragas S, Rudyanto Saripan, Davaraj Balasingh Department of Surgery, Hospital Tuanku Ampuan Najihah, Kuala Pilah, Negeri Sembilan, Malaysia

PP 125 Breast Lump Extrapulmonary Tuberculosis: A Case Report 127 N D Mohamed Khairi, K Supramaniam, A Gerard Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

PP 126 Simultaneous Rupture Of Diaphragm And Uterus Post Blunt Trauma: 127-128 A Case Report N D Mohamed Khairi, K Supramaniam, A Gerard Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

55 Poster PRESENTATIONS [cont’d)

PP 127 Polytetrafluoroethylene Mesh With Filler Methyl Methacrylate 128 Sandwich Graft Reconstruction Following Resection Of Ewing Sarcoma Of Ribs - A Case Report Yuganeswary S, Rahmat Othman Department of Surgery, Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia

PP 128 Hyperamylasemia : The Unusual Suspect 128-129 A Wafi, S Fairuz, H Rezqa Department of General Surgery, Hospital Tuanku Fauziah, Perlis, Malaysia

PP 129 Infected GIST Of Lesser Sac 129 Maung K L, Z L Lim, Othman M Z, S S M Fadzil Surgical Department, Tawau General Hospital, Sabah, Malaysia

PP 130 case Report: Bleeding Kissing Duodenal Ulcers In Child With 129-130 Henoch-Schonlein Purpura (HSP) T S Chang, S L Lim, Hakem S, K J Chung, Waleid M Department of General Surgery, Hospital Bintulu, Sawarak, Malaysia

PP 131 Tracheobronchial Injury – A Case Report 130 Bhuwaneswaran V, Yuganeswary S, Rahmat Othman Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia

PP 132 Spermatic Cord Teratoma Presented As Inguinal Hernia 130-131 Mohd Fahmi Ismail, Fatahurrahman Aminuddin, Mohd Azren Hashim, Wan Mohd Hanif Wan Yusof, Normah Ismail, Mohamed Muhshin Mohamed Sickandar Department of Surgery, Hospital Sultanah Nora Ismail, Batu Pahat, Johor, Malaysia

PP 133 complication Of Meckel’s diverticulum. Case Series 131 Fadya Nabiha A S, Mohamed Muhshin, M S Khairuzi S, Normah I Department of Surgery, Hospital Sultanah Nora Ismail, Batu Pahat, Johor, Malaysia

PP 134 genitourinary Tuberculosis In Bladder 131-132 Husna Haji Harun, Nur Amira, Dalilah Diyana, Rashide Yaacob Surgical Department, Hospital Sultan Abdul Halim, Sungai Petani, Kedah, Malaysia

PP 135 Association Of Choledochal Cyst And Biliary Atresia 132 Shanthya Devi, I Mohan Nallusamy Paediatric Surgery Department, Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia

PP 136 Primary Angiosarcoma Of Breast: A Case Report 132 Balakumaran B P, Kirubakaran M R, Elaine Ng, Y W Yan Hospital Raja Pemaisuri Bainun, Ipoh, Perak, Malaysia

PP 137 case Report : Extramammary Pagets Disease Of The Scrotum 133 With Skeletal Metastases Vilashini Aruna A, Arivarni K, Sivaneswaran L, Umasangar R Department of Surgery, Hospital Taiping, Perak, Malaysia

56 Poster PRESENTATIONS [cont’d)

PP 138 An Audit Of Nephrectomies In Hospital Taiping : ‘ The Role Of 133 General Surgeons’ Vilashini Aruna A, Arivarni K, Sivaneswaran L, C R Vinayak, Umasangar R Department of Surgery, Hospital Taiping, Perak, Malaysia

PP 139 A Peculiar Chest Wall Swelling In A Diabetic Man 133-134 A Choke, N Rosly, S H Saifudin, W M Abuzeid Department of General Surgery, Hospital Bintulu, Sarawak, Malaysia

PP 140 cT Phenotype Analysis in Adrenal Incidentaloma 134 Saiyidah M A, Normayah K Breast and Endocrine Department, Hospital Putrajaya, Putrajaya, Malaysia

PP 141 Malignant Melanoma of the Rectum: A Case Report 134 Norly Salleh, Muhammad Hilmi Hashim, Nor Saadah Idris, Karthikeyan Marthay Department of Surgery, Hospital Pakar Sultanah Fatimah, Muar, Johor, Malaysia

PP 142 Early Laparoscopic Hepatectomy Experience In University Malaya 135 Medical Centre Jun Kit Koong, Hiong Chin Lim, Peng Soon Koh, Boon Koon Yoong University of Malaya, Kuala Lumpur, Malaysia

PP 143 Burst Colon From Compressed Air Injury: A Case Report And 135 Literature Review W C Pui, Thinesh Raja, Shehab C W Phung, Nik Azim N A Sarawak General Hospital, Kuching, Sarawak, Malaysia

PP 144 A Rare Association Of Breast Carcinoma and Dermatomyositis: 136 A Case Report And Literature Review Ragnild R1, H L Sha1, Aini I2, Rokayah J1 1Sarawak General Hospital, Kuching, Sarawak, Malaysia 2Universiti Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia

PP 145 A Safety Review Of Laparoscopic Cholecystectomy In Hospital 136 Tengku Ampuan Rahimah, Klang from 2008 - 2014 Kamal Barathi N Barathilingam1, Phrabakaran Rajehgopal2, Thamilannal Subramanian2, Yusof Wahab2 1Department of Surgery, Hospital Tengku Ampuan Rahimah, Klang, Selangor, Malaysia

PP 146 Intraabdominal Actinomycosis Post Lichtenstein Hernia Repair; 137 A Hybrid Surgical Approach Michael A1, Pavitratha P2, Jasjit S N1 1Department of Surgery, Hospital Pulau Pinang, Pulau Pinang, Penang, Malaysia 2Department of Pathology, Hospital Pulau Pinang, Pulau Pinang, Penang, Malaysia

PP 147 One-Year Surgical Audit Of General Thoracic Unit Hospital Sultan 137 Ismail, Johor Bahru Yuganeswary S, Aishah R, Rahmat Othman Department of Surgery, Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia

57 Poster PRESENTATIONS [cont’d)

PP 148 video-Assisted Thoracoscopic Resection Of A Giant Bulla 138 Mimicking A Pneumothorax With Tension Pneumothorax – A Diagnostic Challenge A Case Report George John K T G, Zainal Ariffin Thoracic Surgery Unit, Department of General Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

PP 149 Ascaris Lumbricoides: A Rare Cause of Intestinal Perforation 138 H C Lim, Sandip Kumar Department of Surgery, University of Malaya, Kuala Lumpur, Malaysia

PP 150 Outcome Of Treatment For Breast Cancer Patient In A Breast 138-139 Centre Without Resident Oncologist Annisaa A S, Sarinah B, Normayah K Hospital Putrajaya, Putrajaya, Malaysia

PP 151 Tolerance of a High Protein Clear Liquid Formula Versus 139 Conventional Clear Fluid Diet After Bariatric Surgery: A Randomized Clinical Trial A Z Ahmad Al-Hafeez, S Y Lim, N H Zubaidah, T Gee Department of Surgery, Universiti Putra Malaysia, Serdang, Selangor, Malaysia

PP 152 Down to the WIRE 139-140 Hidayati Z, Nik Hafinni N H, Kiran K, Yusof Wahab Department of General Surgery, Hospital Tengku Ampuan Rahimah (HTAR), Klang, Selangor, Malaysia

PP 153 Indirect Laryngoscope; Do Or Don’t In The Benign Thyroid Surgery 140 C T Ooi, C W Yong, Imran Abdul Khalid Hospital Seberang Jaya, Pulau Pinang, Penang, Malaysia

PP 154 video-Assisted Thoracic Surgery (VATS) For Iatrogenic Thoracic 140-141 Injury; A Case Series Kishore Kumaar, Yusof Wahab Department of Surgery, Hospital Tengku Ampuan Rahimah, Klang, Selangor, Malaysia

PP 155 Managing Superior Mesenteric Artery Syndrome: Two Successful 141 Cases of Laparoscopic Duodenojejunostomy S C Tee, S L Siow, C M Wong Hospital Umum Sarawak, Kuching, Sarawak, Malaysia

PP 156 Rare Emergence Of Abdominal Tuberculosis 141-142 G Dhayalan, T Sekkapan , K Karthik , H Singh Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia

PP 157 Patent Vitello Intestinal Duct ; A Rare Cause of Umbilical Discharge 142 G Dhayalan, M Alia, K Karthik, G Samuel Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia

PP 158 Clinical Experience In Managing Medullary Thyroid Carcinoma in 142-143 Putrajaya Hospital – A 15-Year Evaluation Suhairil B, M N Hisham, Sarinah B, Normayah K Breast and Endocrine Unit, Department of General Surgery, Putrajaya Hospital, Putrajaya, Malaysia

58 Poster PRESENTATIONS [cont’d)

PP 159 Prospective Study: The Pattern And Early Treatment Outcome 143 Of Abdominal Injury In Hospital Pakar Sultanah Fatimah, Muar Norly Salleh, Mohd Hamidi Osman, Muhammad Hilmi Hashim, Thiagarajan Gobal Department of Surgery, Hospital Pakar Sultanah Fatimah, Muar, Johor, Malaysia

PP 160 A Rare Presentation Of Small Bowel Lymphoma 143-144 Hidayah M S, Zuraimi A Z, Hafizullah M, Wan Omar, Luqman H Hospital Raja Perempuan Zainah II, Kota Bharu, Kelantan, Malaysia

PP 161 Audit On Drain Use For Breast Cancer Surgery In Hospital Raja 144 Permaisuri Bainun, Ipoh And Patient’s Perception On Ambulatory Post-Operative Drain Care M F Madzlan, M A Abdul Manan, G K Ooi, N D Mohamed Khairi, C A Muttaqin, A Gerrad, E H B Ng, Y W Yan General Surgical Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

PP 162 Small Bowel Lymphoma as Lead Point For Adult Lleo-Ileal 145 Intussusception: A Case Report M A Zairul, Y L Quek, I H Dina, I Sagap Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

PP 163 Post-Laparoscopic Sleeve Gastrectomy Narrowing – Stricture Or 145 Normal Variant of Gastric Remnant? K Yugasaravanan, G Prem Kumar, A Sivananthan, Andrea Se En Ooi 94 Terendak Army Hospital, Melaka, Malaysia

PP 164 A Young Girl With An Absent Right Thyroid Lobe: A Case Report 146 And Literature Review H M Firdaus, M Suziah, N A Hakim, E N Aina Department of Surgery, Breast and Endocrine Unit, General Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

PP 165 Spontaneous Haemo-Pneumothorax: A Rare, Life Threatening Entity 146 Yogessvaran Krishnan1, Thinesh Raja1, Noorharisman I2, Nik Azim N A1 1Sarawak General Hospital, Kuching, Sarawak, Malaysia 2Melaka General Hospital, Melaka, Malaysia

PP 166 An Innovative Method Of Managing Early Buried Bumper Syndrome 147 N R Kosai, H S Gendeh, M T Mustafa , R Reynu Upper GI, Bariatric and Minimally Invasive Surgery Unit, Department of Surgery, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

PP 167 Intussusception Due To Meckel’s Diverticulum : A Case Report 147 Mohd Johari, Ahmad Akram, Hasnizal Nording, C H Lim Deparment of Surgery, Hospital Segamat, Johor, Malaysia

PP 168 Endoscopic Double Stenting In The Management Of 148 Tracheo-Oesophageal Fistula: A Case Report J H Asraf, N H Zubaidah, A H Shaker, T Gee Department of Surgery, Universiti Putra Malaysia Hospital Serdang, Selangor, Malaysia

59 Poster PRESENTATIONS [cont’d)

PP 169 Breast-Esophagus Syndrome: Esophageal Metastasis From 148 Invasive Ductal Carcinoma Of Breast R Reynu1, N R Kosai1, M T Mustafa1, K W Chan2 1Minimally Invasive, Upper GI and Bariatric Surgery Unit, Department of Surgery, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia 2Department of Surgery, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia

PP 170 A Rare Case Of Ischaemic Colitis Precipitating Ruptured 149 Abdominal Aortic Aneurysm C K Seak1, Richard Hardin1, T L Luk2 1Sarawak General Hospital, Sarawak, Malaysia 2Borneo Medical Centre, Sarawak, Malaysia

PP 171 Spontaneous Mesenteric Hematoma: Uncommon Yet Fearful 149 Complication In Patient On Anticoagulant Therapy K L Seng1, C K Seak2, L M 1Sibu Hospital, Sarawak, Malaysia 2Sarawak General Hospital, Sarawak, Malaysia

PP 172 Laparoendoscopic Transgastric Enucleation Of A Peri-Cardial 150 Gastrointestinal Stomal Tumour (GIST) Elsa R1, Reynu R1, Kosai N R1, Yugasaravanan K2 1Minimally Invasive, Upper Gastrointestinal and Bariatric Surgery Unit, Department of Surgery, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia 2Department of Surgery, Hospital Angkatan Tentera, Kem Terendak, Melaka, Malaysia

PP 173 Anterior Laparoscopic Approach In The Management Of A 150 Para-Pancreatic Ectopic Adrenal Adenoma S Y Lim, N H Zubaidah, J Y Soo, T Gee Department of Surgery, Universiti Putra Malaysia, Serdang, Selangor, Malaysia

PP 174 case Report: Congenital Mesoblastic Nephroma 151 (Aggressive Cellular Variant) Elango Thambusamy, Umasangar Ramasamy, Herbert Leslie Department of General Surgery, Hospital Taiping, Taiping, Perak, Malaysia

PP 175 chemoport Insertion: Comparison Between The Open And Closed 151 Method With Their Related Complications Among Oncology Patients Juan B A1, Abdul Fattah1, Anita B2, Sarinah B2 1Department of Surgical Oncology, National Cancer Institute, Putrajaya, Malaysia 2Department of Breast of Endocrine Surgery, Hospital Putrajaya, Putrajaya, Malaysia

PP 176 Intestinal Obstruction And Lower Gastrointestinal Bleed In Behcet’s 152 Disease: A Rare Presentation C A M Firdaus, R Reynu, N R Nik, S A Salauddin, M T Mustafa Minimally Invasive, Upper GI and Bariatric Surgery Unit, Department of General Surgery, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

60 Poster PRESENTATIONS [cont’d)

PP 177 Bariatric Surgery In Malaysia: An Update On Volume Of Bariatric 152 Procedures Performed In The Last 5 Years (2009-2014) N R Kosai, R Reynu, M T Mustafa Minimally Invasive, Upper GI and Bariatric Surgery Unit, Department of General Surgery, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

PP 178 The Morel Lavallee Lesion : Hospital Kuala Lumpur Early Experience 153 R Rosnelifaizur1, M K Azuddin2, Hussein Hanif3, Ariffin Azizi Zainal3 1Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia 2Hospital Tengku Ampuan Rahimah, Klang, Selangor, Malaysia 3Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

PP 179 Outcomes of Early Versus Delayed Cholecystectomy In Patients 153 With Mild To Moderate Acute Biliary Pancreatitis – A Randomized Prospective Study S L Jee1, K F Lim1, K Raman1, R Jarmin2 1Hospital Selayang, Selangor, Malaysia 2Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

PP 180 Predictors Of Occult Nipple Involvement In Breast Cancer Patients 153-154 With Grossly Normal Nipples Z Sofina, K Normayah, B Sarinah, A Asmiati Breast & Endocrine Unit, Department of Surgery, Hospital Putrajaya, Putrajaya, Malaysia

PP 181 Acute Pancreatitis In Hospital Taiping, Perak: A One-Year Audit 154 Pravin P1, Sivaneswaran L1, Umasangar R1, Premnath N2 1Department of surgery, Hospital Taiping, Perak, Malaysia 2Penang Medical College, Penang, Malaysia

PP 182 Trisegmentectomy Surgical Option For Invasive Aspergillosis 154-155 Shafiz 1,2Z , George John2 1Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia 2Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

PP 183 Immediate Breast Reconstruction Post Mastectomy And Axillary 155 Clearance - Autologous Or Prosthetic? Weng Jun Tang, Arman Zaharil Mat Saad Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia

PP 184 Midgut Volvulus: Mislooked Differential In Adult Patients 155-156 Ashok Marappan, Kandasami P, Mahadevan D Tata Department of Surgery, Hospital Tuanku Ja’afar Seremban, Negeri Sembilan, Malaysia

PP 185 “I Lost Weight, But I Don’t Want Big Breasts”: Combination Of 156 Bilateral Mastopexy And Reverse Abdominoplasty Chai Siew Cheng, Wan Azman Wan Sulaiman, Arman Zaharil Mat Saad Reconstructive Science Unit, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia

PP 186 Successful Pregnancy “During” Pedicled Transverse Rectus Abdominis 156 Musculocutaneous Flap For Breast Reconstruction With Normal Vaginal Delivery Chai Siew Cheng, Umayaal Shahlini, Arman Zaharil Mat Saad Reconstructive Science Unit, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia

61 Poster PRESENTATIONS [cont’d)

PP 187 A Rare Cause Of Gastrointestinal Haemorrhage: Bleeding Jejunal 157 Diverticula L Wong, I Aini, N A Nik Azim Sarawak General Hospital, Sarawak, Malaysia

PP 188 Preoperative Tattooing Improved Lymph Nodes Retrieval Rate 157 In Laparoscopic Colorectal Surgery W K Kong, H S Boo, Prabhu R Department of General Surgery, Penang General Hospital, Penang, Malaysia

PP 189 ‘The Little Old Lady’s Hernia’: A Rare Case of Obstructed 158 Obturator Hernia L Y Teoh, Suniza J, M H See Surgical Department, University Malaya Medical Centre, Kuala Lumpur, Malaysia

PP 190 Right Posterior Segmental Duct: Role Of Intraoperative 158 Cholangiogram To Prevent Extrahepatic Biliary Duct Injuries Ikhwan Sani Mohmad1, Hairol Othman2, Razman Jarmin2, Zamri Zuhdi2, Affirul Chairil3 1Department of Surgery, Universiti Sains Malaysia 2Hepatobiliary Unit, Department of Surgery, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia 3Department of Surgery, Universiti Sains Islam Malaysia, Nilai, Negeri Sembilan, Malaysia

PP 191 Transverse Testicular Ectopia; A Rare Clinical Phenomenon 159 Sivapiragas S, Davaraj Balasingh, Rudyanto Saripan Department of Surgery, Hospital Tuanku Ampuan Najihah, Kuala Pilah, Negeri Sembilan, Malaysia

PP 192 Laparoscopic Management Of Paraesophageal Hiatal Hernia 159 With Intrathoracic Mesentericoaxial Type of Gastric Volvulus S L Siow1,2, S C Tee1, C M Wong1,2 1Department of Surgery, Jalan Hospital, Kuching, Sarawak, Malaysia 2Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Kota Samarahan, Kuching, Sarawak, Malaysia

PP 193 Hartmann’s Procedure : Penang Hospital Experience 160 H S Boo, Fadliyazid A R, Prabhu R Department of General Surgery, Penang General Hospital, Penang, Malaysia

PP 194 Urachal Sinus Tuberculosis As A Component Of Abdominal 160 Tuberculosis In An Adolescent H L Sha, S C Tee, C M Wong, S L Siow General Surgery Department, Sarawak General Hospital, Kuching, Sarawak, Malaysia

PP 195 A Case Series – TB Breast, Diagnostic Dilemma 161 Mohamed Arif H S1, Siti Zubaidah M S2 1Department of General Surgery, Queen Elizabeth Hospital Kota Kinabalu, Sabah, Malaysia 2Breast & Endocrine Unit, Department of General Surgery Queen Elizabath Hospital, Kota Kinabalu, Sabah, Malaysia

62 Poster PRESENTATIONS [cont’d)

PP 196 Primary Necrotising Fasciitis of Breast: Fatal When Missed 161 Atifah A, Raflis R A, Hakim N A, Aina E N Breast and Endocrine Surgical Unit, Department of General Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

PP 197 A Case Report – Laparoscopic Modified Sugiura Procedure – 162 A Surgical Modality in the Acute Management of Bleeding Gastroesophageal Varices L Sivaneswaran1, B Sabrina1, C R Vinayak1, N Premnath2 1Hospital Taiping, Perak, Malaysia 2Penang Medical College, Pulau Pinang, Penang, Malaysia

PP 198 Fish Bone And Ischiorectal Abscess 162 Sumaraj A, Syafiq, Khoo H Y, Imran A K Hospital Seberang Jaya, Penang, Malaysia

PP 199 Managing Traumatic Thoracic Duct Injury: A Case Report 163 Tai C H, Chan K W, Rohamini S Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia

PP 200 Primary Breast Diffuse Large B-Cell Lymphoma Rare Presentation 163 Of Breast Cancer: A Case Report H Syakirah A R, M Azihan Z, W Omar W D, A H Imisairi Unit of Breast Endocrine Surgery, Department of Surgery, Hospital Raja Perempuan Zainab II, Kota Bharu, Kelantan, Malaysia

PP 201 The Effectiveness Of Peer Tutoring On Basic Surgical Knowledge 164 For Preclinical Students Y Z Ho, I H E Heng, M Sundaran, A Kumarasamy IMU Surgical Society International Medical University Clinical School, Negeri Sembilan, Malaysia

PP 202 Radical Resection Of Primary Leiomyosarcoma Of Inferior Vena Cava 164 Sivabalan Nadarajan1, Ikhwan Sani Mohamad2, Razman Jarmin1, Zamri Zuhdi1, Hairol Azrin Othman1, Azim Idris3, Affirul Chairil4 1Hepatopancreaticobiliary Unit, Department of Surgery, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia 2Department of Surgery, Universiti Sains Malaysia 3Vascular Unit, Department of Surgery, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia 4Department of Surgery, Universiti Sains Islam Malaysia, Nilai, Negeri Sembilan, Malaysia

PP 203 Wide Local Excision For Recurrent Chronic Granulomatous Mastitis 165 Nor Safariny A, Siti Hartinie M, Hussain M Breast & Endocrine Unit, Surgical Department, Hospital Sultanah Nur Zahirah, Terengganu, Malaysia

PP 204 New Hemostatic Alternative To Massive Presacral Bleeding 165 K N Tan1, A C Roslani1, N A Aziz1, M K Nil Amri2, W Khamizar2 1University Malaya Medical Centre, Kuala Lumpur, Malaysia 2Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia

63 Poster PRESENTATIONS [cont’d)

PP 205 giantic Malignant Phylloides: Management Dilemma 166 K N Tan1, H L Hoo2 1University Malaya Medical Centre, Kuala Lumpur, Malaysia 2Hospital Enche’ Besar Hajjah Khalsom, Kluang, Johor, Malaysia

PP 206 Relationship Between Stone Density On CT And Outcomes Of 166 Percutaneous Nephrolithotomy B T Y Lim, W L Yam, S K Lim, F C Ng Department of Urology, Changi General Hospital, Singapore

PP 207 Traumatic Abdominal Wall Hernia: A Case Report Of A Rare Entity 167 Z Ramli, E T Geng Ju, M F Madzlan, Y Y Wai Department of Surgery, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

PP 208 conservative Management Of A Traumatic Chylothorax After 167 Blunt Chest Trauma: A Case Report M A Manan, G K Ooi, M H Sidik, M F Mazlan, N D Khairi, Y Y Wai Department of General Surgery, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia

PP 209 A Rare Case Of A Perforated Jejunal Diverticulum In An Elderly Patient 168 Syahrul Hadi K, V M Leow, Vasupillai, M Manisekar Department of Surgery, Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia

PP 210 Bilateral Necrotizing Fasciitis Of The Breast: A Case Report 168 Faizul A A R1, Hafiez N 2F , Salleh M S2 1Hospital Tg Ampuan Afzan, Kuantan, Pahang, Malaysia 2Hospital Sultan Hj Ahmad Shah, Temerloh, Pahang, Malaysia

PP 211 A Young Girl With Oesophageal, Rectal And Porta Varices : 168-169 A Case Report Nor Safariny A, Zaharul Azran Z, Siti Hartinie M, Hussain M Surgical Department, Hospital Sultanah Nur Zahirah, Terengganu, Malaysia

PP 212 cystic Mass Of Bowel In Origin As A Rare Presentation Of 169 Abdominal Tuberculosis: A Case Report Faizul A A R1, Faiz I2, Singh H1 1Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia 2International Islamic University Malaysia, Kuantan, Pahang, Malaysia

PP 213 Upper Gastrointestinal Bleeding Audit In Hospital Sarikei, One-Year 169-170 Review – A District Challenge Yen Zhir Tay1, Ahmad Zahier Bin Ramli2, Kavinya Diana T Nadesalingam2, Tarek Seddik2 1Hospital Umum Sarawak, Kuching, Sarawak, Malaysia 2Hospital Sarikei, Sarikei, Sarawak, Malaysia

PP 214 A Comparison Study Of The Imrie’s Scoring System And 170 Determinant Based Classification In Assessing The Outcome And Prognosis Of Acute Pancreatitis In Local Population Mohanraj T1, Thiagaraj V, Kandasami P, Mahadevan D Tata Hospital Tuanku Ja’afar, Seremban, Negeri Sembilan, Malaysia

64 Poster PRESENTATIONS [cont’d)

PP 215 Tooth Picking After Meal: An Unusual Cause Of Small Bowel 170-171 Perforation V K Vikinesan, Nora, H Y Chong, April C R University of Malaya, Kuala Lumpur, Malaysia

PP 216 Posterior Retroperitoneoscopic Adrenalectomy: Penang General 171 Hospital’s Experience Alexander Z Y Lim, Sunil S P, M S Teoh, Y T Cheong Hospital Pulau Pinang, Pulau Pinang, Penang, Malaysia

PP 217 gastrointestinal Bleed Secondary To Gastric Lipoma: A Case Report 171-172 K Y Low, H C Lim, E H Pok, P C Lau University of Malaya, Kuala Lumpur, Malaysia

PP 218 Hirshsprung’s Disease In Adult; A Rare Case Report 172 Deven Aragena1, Komalah Subramaniam2, Lai Chung Kiet1, Falah Akmal1 1Department of Surgery, Hospital Duchess of Kent, Sandakan, Sabah, Malaysia 2Department of Radiology, Hospital Duchess of Kent, Sandakan, Sabah, Malaysia

PP 219 Right Ureterocele 26-Years Post Nephrectomy: A Rare Presentation 172-173 Deven Aragena1, V M Kumar1, Komalah2 1Department of Surgery Hospital Duchess of Kent, Sandakan, Sabah, Malaysia 2Radiology department Hospital Duchess of Kent, Sandakan Sabah, Malaysia

PP 220 The Impact Of FDG-PET/CT In The Management Of Recurrent 173 Colorectal Cancer C W James Khaw, A C Roslani, H C Eugene Wong University Malaya Medical Centre, Kuala Lumpur, Malaysia

PP 221 comparison Of Colorectal Screening Strategies Using Qualitative 173-174 And Quantitative Faecal Immunochemistry Test To Prioritise Urgency Of Colonoscopy Referral-Interim Results Ee Shuan Lim1, April Camilla Roslani2, Chee-Wei Law1, Ausama A Malik1, Hoong-Yin Chong, Ida Normiha Hilmi2, Chirk -Jenn Ng3, Tin-Tin Su4 1Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia 2Department of Internal Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia 3Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia 4Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

PP 222 Does Pre-Operative Hand Ball Exercise Result In Functional 174 Arterio-Venous Fistulaes? C K Seak, Yogessvaran K, Richard Hardin, T L Luk Sarawak General Hospital, Kuching, Sarawak, Malaysia

PP 223 Endovascular Approach In Post-Traumatic Popliteal Artery 175 Pseudoaneurysm: A Case Report M Fairuz Anisa, Firdaus H, R Rosnelifaizur, Zainal A A

65 Poster PRESENTATIONS [cont’d)

PP 224 Study On Post-Operative Pain Scores Based On Dermatomal 175 Distribution In Surgical Wards In Penang General Hospital Alyson Tan S Y, Alexander Z Y Lim, Lim S Y Hospital Pulau Pinang, Pulau Pinang, Penang, Malaysia

PP 225 Endoscopic Component Separation Technique For Repair Of 176 Large Complicated Ventral Hernia – Report Of Two Cases And Literature Review C K Seak, S C Tee, M Hardin, S L Siow Sarawak General Hospital, Kuching, Sarawak, Malaysia

PP 226 comparison Between Open And Laparoscopic Repair Of Perforated 176 Peptic Ulcer: A Retrospective Study Kugan V, Mahadevan D Tata Department of Surgery, Tuanku Ja’afar Seremban, Seremban, Negeri Sembilan, Malaysia

PP 227 Effect of Sleeve Gastrectomy In Type-2 DM In Morbidly Obese 177 Patients Azahar S1, Hazimi R2, M N Hisham2, Normayah K2 1Institut Kanser Negara, Putrajaya, Malaysia 2Breast and Endocrine Unit, Department of Surgery, Hospital Putrajaya, Putrajaya, Malaysia

PP 228 A Rare Entity Of A Common Disease: A Case Report Of Metaplastic 177 Squamous Cell Breast Carcinoma Nor Safariny A, Chang B C, Siti Hartinie M, Hussain M Breast & Endocrine Unit, Surgical Department, Hospital Sultanah Nur Zahirah, Terengganu, Malaysia

PP 229 Laparoscopic Repair Of Acquired Abdominal Intercostal Hernia (AAIH) 177 Ashok Marappan, Thanabalan Fonseka, Mahadevan Tata Hospital Tuanku Jaafar Seremban, Seremban, Negeri Sembilan, Malaysia

PP 230 Pregnancy Associated Breast Cancer: Retrospective Review 178 Nor Safariny A1, Azhani Chik2, Siti Hartinie M1, Hussain M1 1Breast& Endocrine Unit, Surgical Department, Hospital Sultanah Nur Zahirah, Terengganu, Malaysia 2Kulliyyah of Medicine, International Islamic University of Malaysia, Kuantan, Pahang, Malaysia, and Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia

PP 231 Perforated Ileoceacal Intussusception Following Open 178 Appendectomy discovered Non-Hodgkin’s Lymphoma: A Case Report Fon Sheng Sei1, A Rahman, Ainilhayat1, Ming Yen Lee2 1Department of Surgery, Hospital Enche’ Besar Hajjah Khalsom, Kluang, Johor, Malaysia 2Department of Pathology, Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia

PP 232 Hurthle Cell Thyroiditis: Diagnosis And Surgical Options: A Case 179 Report C C Sim, Ainilhayat A R, Mohd Shariman M S Hospital Enche’ Besar Hajjah Khalsom, Kluang, Johor, Malaysia

66 Poster PRESENTATIONS [cont’d)

PP 233 colon Carcinoma With Inferior Mesenteric Vein Tumor Thrombosis: 179 A Poor Prognosis Indicator? J Jazree, K N Tan, A C Roslani University Malaya Medical Centre, Kuala Lumpur, Malaysia

PP 234 Adherence To Hormonal Therapy Amongst Breast Cancer Patients 179-180 Attending Public Hospitals In Malaysia Mastura Mujar1, 3, M Dahlui1, E N Aina4, I Sairi4, Ang L P4, A Sarojah4, Chea C H4, Taib N A2, On behalf of the Breast Chapter, College of Surgeons of Malaysia 1Centre of Population Health, Department of Social & Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia 2Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia 3Cluster of Healthy Lifestyle, Advanced Medical and Dental Institute (AMDI), University Science of Malaysia, Pulau Pinang, Penang, Malaysia 4Ministry of Health Malaysia

PP 235 can Laparoscopic Appendicectomy Replace Open Appendicectomy? 180 Cheng Y H1, Ho Y T1, Lim K K1, Siman A M1, Vivian C W Y1, Kandasami P1, Mahadevan D Tata2 1International Medical University, Negeri Sembilan, Malaysia 2Department of Surgery, Tuanku Ja’afar Hospital, Seremban, Negeri Sembilan, Malaysia

PP 236 challenges In Managing Esophageal Perforations – A Case Report 181 Thiagaraj V, Alvin Lum W K, Azrina A B, Jasiah Z, Mahadevan D T Department of Surgery, Hospital Tuanku Jaafar, Seremban, Negeri Sembilan, Malaysia

PP 237 A Rare Case Of Duodenal Brunner Adenoma Causing Gastric Outlet 181 Obstruction K N Tan1, H L Hoo2, A C Roslani1 1University Malaya Medical Centre, Kuala Lumpur, Malaysia 2Hospital Enche’ Besar Hajjah Khalsom, Kluang, Johor, Malaysia

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Isolated Necrotizing Fasciitis of Post-operatively, a CT scan showed evidence of NF at Anterior Abdominal Wall After anterior abdominal wall with lesions in the prostate that may represent as haematoma or early abscess Prostate Biopsy: A Case Report with locally infiltrative tumour. The prostate biopsy Mohamed Muhshin Mohamed Sickandar, revealed prostate adenocarcinoma and culture showed Khairuzi Salekan multi-resistant Escherichia coli. Unfortunately patient Department of Surgery, Hospital Sultanah Nora Ismail, Batu passed away because of severe sepsis with multi- Pahat, Johor, Malaysia organ failure

Introduction Conclusion Fournier’s gangrene is a reported complication of Necrotizing fasciitis of anterior abdominal wall with trans-rectal prostate biopsy that may progress up to Fournier’s gangrene is a reported complication after anterior abdominal wall. However, we reported a case, a trans-rectal biopsy. However, isolated NF of anterior where a patient with history of trans-rectal prostate abdominal wall without Fournier’s gangrene is not a biopsy who presented with bleeding duodenal ulcer known complication and not being reported. This is and necrotizing fasciitis (NF) of anterior abdominal probably because prostate encapsulated with tough wall without Fournier’s gangrene. fibrous capsule. However this patient had an extension of the fasciitis from retro pubic space of Retzius which Case Report is located in between pubic symphysis and prostate. 67 years old gentleman with underlying hypertension The history of prostate biopsy and imaging evidence and benign prostatic hyperplasia who undergone of infective prostate with locally infiltrative tumour trans-rectal biopsy of prostate eight days prior, probably suggest the infection spread from prostate presented with bleeding duodenal ulcer with 1 week to retro pubic space due to breach in fibrous capsule history of fever, left iliac fossa pain and leucocytosis. anteriorly by the tumour. However progression to Exploratory laparotomy revealed incidental finding sepsis may be due to antibiotic resistance. of pus collection in between anterior abdominal muscles at lower abdomen that originated from retro pubic space but no intraperitoneal extension.

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Management of Malignant Gastric done for staging. Preoperatively, all patients were Outlet Obstruction – A Case Series optimized with peripheral parenteral nutrition for 3 to 5 days. Surgical treatment performed consist of 4 Lily L Y Wong, K C Soon gastrojejunostomy, 5 subtotal gastrectomy and 1total Department of General Surgery, Hospital Miri, Sawarak, gastrectomy. Postoperatively, parenteral nutrition Malaysia was continued with oral intake introduced gradually. Intensive chest physiotherapy with incentive Objective spirometry, DVT stocking and early ambulation Gastric carcinoma is a common cause of malignant were enforced to prevent pneumonia and deep vein gastric outlet obstruction, accounting for 35% of thrombosis. No perioperative complications were all the gastric outlet obstruction. Management are observed. All patients were discharged well except challenging as most of the patients are of advanced one patient, 77 years old female who underwent age with multiple comorbids and are nutritionally gastrojejunostomy, passed away on day 14 post depleted. We presented 10 cases of malignant gastric operation due to cardiac event. Mean duration of outlet obstruction secondary to gastric carcinoma and hospital stay were 9 days post operatively (range discuss about its management. 7 - 16). Patients were then referred for adjuvant chemotherapy and radiotherapy. Methods All patients with malignant gastric outlet obstruction Conclusions secondary to gastric carcinoma from January 2014 till Surgical management for malignant gastric outlet December 2014 were included. obstruction is relatively safe, be it resection or bypass. Preoperative optimization is important as well as Results proactive postoperative care. A total of 10 cases were identified during the study period. 7 were male and 3 were female, with a mean age of 72 years (range 53 - 92). All the patients presented with typical symptoms of gastric outlet obstruction. Upper endoscopy with biopsy were performed to confirm the diagnosis and computed tomography 68 PP 03 PP 04

Rare Presentation of A Femoral Anterior Abdominal Wall Abscess Hernia: Case of De Garengeot Hernia as a Complication of Appendicular Adrian Gerard1, Ganendra Paramasvaran1, Mass in Elderly: A Case Report Kumaresan Supramaniam2 C A Shahidah1, S M Ikhwan2, Norzila Abu Bakar2, 1Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia Z Zaidi2 2 Surgery Department, Hospital Raja Permaisuri Bainun, Ipoh, 1Department of Surgery, International Islamic University Perak, Malaysia Malaysia, Kuantan, Pahang, Malaysia 2Department of Surgery, Universiti Sains Malaysia, Penang, An unusual content in a femoral hernia is the presence Malaysia of the vermiform appendix, known as De Garengeot hernia, named after the French surgeon who first Appendicitis in the elderly continues to be a described it 1731. The operating surgeon is usually challenging surgical problem. Patients continued to caught by surprise intra-operatively by this entity. A present late with atypical presentations. The diagnosis 56 years old lady presented with painful right groin of appendicitis is often difficult to establish. Elderly swelling which was tender and erythematous and she patients usually presented as appendicitis with underwent emergency hernia repair. However, intra- complications and tend to undergo more complicated operatively, the presence of a strangulated appendix operative procedures. within the femoral hernia sac prompted us to proceed to a lower midline laparotomy. Appendicectomy and We reported a case of a 84 year-old Chinese male, primary femoral hernia repair was performed. Various presented with a painful right iliac fossa swelling surgical options are available for patients with this for 4 days. Clinically, there was a well-defined, firm entity depending on the surgeon’s preference and 6x4cm irreducible tender mass at right iliac fossa intra-operative findings extending to the right inguinal region. The skin over the lump was normal. An urgent ultrasound abdomen reported as right Spigelian hernia. He underwent an emergency exploration over right groin area which revealed an abscess with 100cc of pus draining from

PP 04 PP 05 intraperitoneal cavity. The procedure was converted Who Is The Culprit: Trauma or to lower midline laparotomy. The groin abscess was H.Pylori? Case Report: Perforated originated from an appendicular abscess that eroded the anterior abdominal wall. Appendicectomy and Duodenal Ulcer In A Teenage Girl thorough peritoneal lavage were perfomed. Thiru V Raau, Sivapiragas S, Davaraj Balasingh, Rudyanto Saripan To be certain of the diagnosis based on right iliac Department of Surgery, Hospital Tuanku Ampuan Najihah, fossa mass is sometimes quite difficult especially in Kuala Pilah, Negeri Sembilan, Malaysia elderly. Complicated appendicitis such as extension of appendiceal abscess needs to be considered in the Introduction differential diagnosis of all patients with right iliac Perforated peptic ulcers continue to be one of surgical fossa mass. emergencies, which require immediate surgical intervention. However perforated peptic ulcers among teenagers are relatively rare and perforation of pre- exiting peptic ulcer following a trauma is an extremely rare phenomenon.

Case Presentation We present a 19 years old girl with underlying dyspeptic symptoms for 2 years who alleged a low velocity motor vehicle accident (MVA) and was treated for abrasions over abdomen at an outpatient department. Two weeks post trauma patient presented with progressively worsening abdomen pain with fever. Upon examination, abdomen was tender and guarded. An erect CXR revealed air under diaphragm. Patient underwent an emergency diagnostic laparoscopy which revealed a perforated duodenal ulcer. Due to 69 PP 05 PP 06 gross contamination, operation was converted to Metastatic Liver Liposarcoma, laparotomy, and simple closure with omental patch Pleomorphic Subtype with Unknown was performed. The perforation measured 0.5 X 0.5cm at D1 and the surrounding mucosa was smooth. Primary – A Case Report Patient was discharge well with PPI. HPE of ulcer edge Lily L Y Wong, K C Soon showed necrotic tissue with neutrophilic infiltration Department of General Surgery, Hospital Miri, Sarawak, and muscular disruption, suggestive of chronic Malaysia inflammation, associated with H.Pylori activity. Introduction Discussion Liposarcoma is an uncommon malignant mesenchymal Peptic ulcer perforation among teenagers is tumour, accounts for 15% of all sarcomas. There are uncommon. Pre-existing peptic ulcer disease in this few subtypes of liposarcomas, with pleomorphic patient is confirmed with history of dyspepsia prior liposarcoma being the rarest subtype. It usually to trauma and HPE results which shows presence developed in lower extremities and retroperitoneal of chronic ulceration. However the role of trauma space. Metastatic spread of liposarcoma to liver is rare, which suspected as the cause of the perforation is occurs in only 10% of cases. still doubtful. Signs of peritonitis which develop after the MVA and site of trauma which correlate with the Case Report intraoperative findings are supportive factors to label A 65 years old Chinese gentleman with no significant the trauma as culprit. past medical or surgical history, presented with abdominal mass for 2 months duration, associated Conclusion with loss of weight and loss of appetite. He is otherwise Perforation of peptic ulcer requires an emergency asymptomatic. Clinically, there was a huge mass surgical intervention to avoid mortality. However in palpable at the epigastrium. Computed tomography younger patients proper follow-up with intensive scan reported as mass in between left lobe of liver investigation is required to identify the etiology and and transverse colon with mixed soft tissue and fat to provide a systematic management. attenuation, likely omental liposarcoma. He was then proceeded with laparotomy and tumour excision. Intra-

PP 06 PP 07 operatively, there was a huge mass, approximately Intestinal Obstruction with 15 cm x 15 cm, arising from undersurface of segment Perforated Gastric Ulcer Secondary III liver. Otherwise, the rest of the liver was grossly normal. There was no ascites noted. Microscopically, to Ingested Foreign Bodies – A Case the tumour showed the picture of pleomorphic Report liposarcoma, with the presence of pleomorphic Lily L Y Wong, K C Soon malignant cells, epitheloid cells and central necrosis Department of General Surgery, Hospital Miri, Sarawak, (about 25% of tumour mass). Resection margin was Malaysia clear. Postoperative course was uneventful and he was discharged well on the third postoperative day. No Introduction evidence of primary liposarcoma was found on further Foreign body ingestion occurs frequently, and most history and subsequent investigations. of it will pass through the gastrointestinal tract uneventfully. Complications due to ingested foreign Conclusions bodies, like intestinal perforation and obstruction are Pleomorphic liposarcoma is a rarest subtype of rare, occuring in less than 1% of patients. We presented liposarcomas that frequently metastasizes, most a case of intestinal obstruction with perforated gastric commonly to the lungs. Metastatic spread to the liver ulcer secondary to ingested foreign bodies. is rare. Clinical course and optimal management of metastatic liver liposarcoma remain uncertain. Case Report A 44 years old gentleman, with no known medical illness, presented with generalized abdominal pain of 1 day duration, associated with nausea and vomiting. Prior to that, he ingested multiple rambutans with seed. On physical examination, the abdomen is distended with generalized tenderness and guarding. Erect chest x-ray and abdominal x-ray revealed presence of air under diaphragm with dilated loops of small bowel. Emergency exploratory laparotomy 70 PP 07 PP 08 was done. Intraoperatively noted grossly distended Gastric Rupture After Blunt stomach, small bowel and large bowel till the splenic Abdominal Trauma flexure with multiple rambutan seeds impacted in the transverse colon. Perforated prepyloric ulcer was also Adrian Gerard1, Rajiev Raja Sakaran2, found with moderate contamination. The perforated Chong Hoong Weng2, Yan Yang Wai2 prepyloric ulcer was repaired with omentoplasty 1Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia and transverse colostomy was done for removal of 2Surgery Department, Hospital Raja Permaisuri Bainun, Ipoh, rambutan seeds. Total of 42 rambutan seeds were Perak, Malaysia retrieved from the large bowel. Postoperative course was uneventful and he was discharged well. Gastric rupture after blunt abdominal trauma is a rare occurrence with cited incidence between Conclusion 0.02% and 1.7%. We report a case of a 15 year old Foreign body ingestion is common, and occasionally boy, referred from a district hospital due to a tender results in intestinal perforation or obstruction. Foreign abdomen after a motor vehicle accident. An urgent body ingestion in this case, probably cause a stress to computed tomography (CT) scan of the abdomen the patient and indirectly result in perforated gastric and pelvis revealed gross pneumoperitoneum and ulcer. free intraperitoneal fluid. An emergency exploratory laparotomy revealed a 7cm long full thickness rupture of the stomach with splenic injury. Primary gastric closure was performed and splenic injury was treated conservatively. Although rare, urgent surgical exploration is necessary in these patients to reduce mortality and morbidity.

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Bowel Injury Post Blunt Abdominal Awareness Of Testicular Cancer Trauma with Normal CT findings And The Practice Of Testicular Self- Fitgerald H, Pavin K, Aizat T examination Among Male University Department of General Surgery, Hospital Selayang, Selangor, Students Malaysia S K Wong, M Mokhtar, H N A Majid Motor Vehicle Accidents remain the 3rd leading cause Universiti Kuala Lumpur RCMP, Ipoh, Perak, Malaysia of death in Malaysia. The incidence of bowel injury post abdominal trauma is as low as 0.3-1.1%. The Introduction rate of mortality increases with time to operative intervention. Bowel injury may vary from minor Testicular cancer commonly affects men aged hematomas to perforations and can be classified between 15-35 years. It accounts for only 1-1.5% of as partial or full thickness bowel injuries. The lack male neoplasms but early detection may result in a of definitive diagnostic method leads to an elusive cure rate of >95%. The awareness of this disease and diagnosis hence increases the morbidity and mortality. the practice of testicular self-examination may play Although the Computed Tomography is the most an important role in detecting this cancer at an early widely used modality, it may not be the most sensitive stage. diagnostic tool. The CT findings suggestive of bowel injury are pneumoperitoneum, thickened bowel Objective wall, extraluminal contrast material and bowel wall heamatoma. We report 2 cases of bowel injury involved The objectives of our study were to assess the in motor vehicle accidents whereby the CT scan failed awareness of testicular cancer and the practice of to detect bowel injury in these patients. This lead to a testicular self-examination among a group of male delay in diagnosis causing mortality in 1 of the cases. university students. Unlike solid organ injuries where there is a role for conservative management, bowel injury warrants Method an early surgical intervention. The monitoring of a A descriptive cross sectional study was used in our suspected bowel injury is more clnical than imaging survey. The survey was carried in a local private based even in haemodynamically stable patients. university which allowed us to conduct the survey. The The early diagnosis and treatment remains the most essential part of the management. classes were randomly selected and questionnaires 71 PP 10 PP 11 were distributed among the male students of the Unusual Presentation of Dermoid selected classes. Cyst of the Spermatic Cord Result in an Adult Patient Mimaking A total of 263 students were recruited in this survey. Incarcerated Irreducible Inguinal Although 55.9% of them have heard of testicular Hernia. A Case Report With Review Of cancer, most of them did not know that the cancer Literature afflicts young men (87.1%) or the common signs and 1 1 symptoms of the cancer (81.7%). Sarmukh Singh ,Tan Yee Ling , Ramesh Thangaratnam1, Chew Loon Guan1, 85.6% of the respondents had never heard of Zaidi Zakaria2 testicular self-examination and not surprisingly, 98.1% 1HospitalSerdang, Selangor, Malaysia had never performed testicular self-examination. The 2Universiti Sains Malaysia, Malaysia main reason given for not practising testicular self- examination was: not knowing how to perform it. We Background: Dermoid cyst of the spermatic cord is found that there was a significant correlation between a very rare clinical entity with only 6 cases reported the awareness of testicular cancer with the practice of in the literature so far [1]. We hereby describe an testicular self-examination (p-value<0.001). extremely rare case of a large dermoid cyst of the right spermatic cord measuring 6cm x 5cm x 5cm in Conclusion an elderly patient who approached us with clinical These young men who are better educated than the manifestations of an incarcerated irreducible inguinal general population lacked awareness of testicular hernia. The final histopathological analysis established cancer and hence did not practice testicular self- the diagnosis of a dermoid cyst. Dermoid cyst of the examination even though they fall within the high risk spermatic cord mimicking incarcerated irreducible age group. A good awareness of the disease may lead hernia is rare but possible entity. to an increased practice of testicular self-examination. Case Report A 58 year old malay gentleman came to our emergency department with complains of swelling over the right

PP 11 PP 12 inguinal scrotal region for the past two days which The Umbilical Nodule: Sign of was progressively increasing in size associated with a Hidden Pathology irreducibility. Per abdominal soft, not distended, non tender. Our initial diagnosis was right incarcerated Karthikeyan M, Thiagarajan G, Gunaseelan D, irreducible inguinal hernia. Proceeded with open Ros’aini Paijan hernioplasty. Histopathologic feature impression was Department of Surgery, Hospital Pakar Sultanah Fatimah, dermoid cyst of the spermatic cord. Muar, Johor, Malaysia

Conclusion INTRODUCTION We have presented a rare case of a dermoid cyst of Umbilical tumours are relatively rare and consist the spermatic cord in an adult patient mimaking of both benign and malignant conditions. The term incarcerated irreducible inguinal hernia. Uncommon Sister Joseph’s nodule is a clinical sign associated with diagnosis as such prompted the need for a literature advanced metastasizing intra-abdominal cancer. Here search along with a case report for the best surgical two cases of different pathology are discussed. treatment. Following a complete surgical excision. The common practice of concurrent tension free mesh CASE 1 repair is recommended. A 33 year old Indonesian male with no past medical history presented with umbilical swelling for two weeks measuring 2cm x 2cm with altered bowel habit for a month and on and off per rectal bleeding. A wedge biopsy of the umbilical mass revealed metastatic poorly differentiated carcinoma with primary tumour is uncertain.Staging showed multiple large heterogeneous lobulated peritoneal & intraperitoneal omental masses with liver, nodal, & lungs metastasis.

CASE 2 A 39 year old Malay female presented with a umbilical swelling measuring 0.5 cm x 1 cm for the past seven 72 PP 12 PP 13 years which is progressively increasing in size with on Choledochal Cyst in teenage: and off bleeding on scratching and intermittent pain Missed in childhood. Case Report: during menstruation. The excision biopsy consistent with endometriosis. Choledochal Cyst Theebanraja Ramalingam, Sivapiragas S, DISCUSSION Davaraj Balasingh, Rudyanto Saripan Umbilical nodules are easy to identify on physical Department of Surgery, Hospital Tuanku Ampuan Najihah, examination and provide clinicians a site where biopsy Kuala Pilah, Negeri Sembilan, Malaysia can be easily performed. Although current advanced technology can easily diagnose malignancies, Sister Introduction Joseph’s nodule nevertheless remains an important Choledochal cyst is a congenital cystic dilatation of clinical sign. However a primary tumour or non- biliary tract. Incidence of choledochal cyst is 1:150,000 neoplastic conditions such as endometriosis need to and 80% of cases are diagnosed in childhood. be excluded and histopathological examination may Choledochal cyst among teenagers and adult is a rare assist in diagnosis. clinical entity.

Case Presentation A 17 years old malay girl with no known medical illness, presented with 2 weeks history of progressively worsening upper abdomen pain with jaundice. Clinically patient was icteric and per abdomen examination revealed grossly enlarged liver with tenderness at right hypochondrium. Laboratory investigation revealed elevated liver enzymes and total bilirubin with predominantly increase in direct component. Ultrasonography showed large cystic lesion at right hypochondrium. Subsequent CT and MRCP revealed fusiform dilation of the common

PP 13 PP 14 bile duct measuring 14.2x13x13 cm. Patient was A Case Of Lipomatous Tumor Of then referred to hepatobiliary centre in Hospital Thyroid Gland: A Rare Entity Selayang and underwent excision of cyst and biliary reconstruction. Intraoperatively it was Todani Type 1 F Idris1, N Amjad1, E Mahno1, S Murad2 choledochal cyst. Postoperatively patient discharged 1International Islamic University Malaysia, Kuantan, Pahang, well. Malaysia 2Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia Discussion Choledochal cyst was first described by Alonso Lej Sarcomas encountered in head and neck region and modified by Todani in 1977 which is currently the show wide variety of histo-morphological types common used classification. Most choledochal cyst are and grades. Liposarcoma of the head and neck diagnosed in childhood. Low incidence rate ,non specific represents approximately 1% of head and neck presentation and absence of classical clinical triad sarcomas. Amongst the group are well differentiated leads to missed diagnosis of choledochal cyst in adult. liposarcomas / atypical lipomatous tumors (WDL/ALT). Ultrasound is the best initial investigation followed by Here we report a case of an atypical lipomatous tumor CT and MRCP which can provide detailed description of a thyroid gland in a 59 year-old Ibanese gentleman concerning relationship between cyst and adjacent from the island of Borneo, Malaysia. This presentation structure. Treatment is always surgery which involves of a lipomatous tumor is a rare entity as it arises from excision of the cyst with or without hepatobiliary the thyroid gland. We here discuss the classification of reconstruction.Recurrent cholangitis, pancreatitis, ALT/WDL, the histological diagnosis of this tumor and abcess, calculi and malignancy potential are recognised the imaging modalities. complications of untreated choledochal cyst.

Conclusion Choledochal cyst even though rare in adult, it is important to include as the differential diagnosis to prevent misdiagnosis and to avoid possible complications.

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A Rare Benign Neck Tumor: Cervical Life-threatening Hemorrhagic Ganglioneuroma Pericardial Tamponade: A Rare A H Junaidi1, W M Atman2, H Singh2 Intrathoracic Complication in 1Department of Surgery, Kulliyah of Medicine, Severe Acute Pancreatitis International Islamic University Malaysia, Kuantan, A H Junaidi1, Zalikha K2, H Singh2 Pahang, Malaysia 1 2Department of Surgery, Hospital Tengku Ampuan Afzan, Department of Surgery, Kulliyah of Medicine, Kuantan, Pahang, Malaysia International Islamic University Malaysia, Kuantan, Pahang, Malaysia 2Department of Surgery, Hospital Tengku Ampuan Afzan, Anterior neck swelling is usually associated with Kuantan, Pahang, Malaysia thyroid pathology with a common differential diagnosis of branchial, thyroglossal or parapharyngeal Acute pancreatitis is an acute inflammatory process cyst. However, when clinical and radiological of the pancreas. In its severe form, it is complicated assessment of the swelling does not meet the criteria with systemic complications or multi-organ for the common diagnoses, it warrants a surgical dysfunction syndrome which associated with poor exploration and excision with a histopathology outcome. Hemorrhagic pericardial tamponade is one report to confirm the diagnosis. We report a case of the rare intrathoracic complications in severe acute of cervical ganglioneuroma, in which its rarity pancreatitis, which can be fatal if left undetected posed an assessment and diagnosis difficulty. It and untreated. However, this condition is reversible is later confirmed after surgical exploration and following an appropriate management. We report a histopathological examination. case of severe acute pancreatitis, in which clinical deterioration resulted from this remote complication.

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Reno-colic Fistula - A Rare Case GRANULOMATOUS MASTITIS IN WEST Report COAST AND INTERIOR SABAH Wilson Liew, S B Lee, J R Sathiyanathan, F Y Chai1, A Y P Tan2, Z S Siti2, J A Chuah2 Hemanth Kumar Ramasamy 1Department of Surgery, Hospital Keningau, Sabah, Malaysia 2 Department of Urology, Penang General Hospital, Penang, Department of Surgery, Hospital Queen Elizabeth, Malaysia Kota Kinabalu, Sabah, Malaysia

Reno-colic fistula is a rare entity and only about BACKGROUND 100 cases have been reported in the literature. Granulomatous Mastitis (GM) is a rare benign Occurrence of reno-colic fistula was first described inflammatory breast condition that mimics carcinoma. in 460 B.C. by Hippocrates. We report a case of reno- Its optimal treatment remains controversial leading to colic fistula in a 46 year old lady, presented to us with frequent recurrence and morbidity. right staghorn calculus with obstructive uropathy. OBJECTIVES She was nephrostomised at the referring hospital To review our experience with GM among Borneo and subsequently underwent ureteral stenting population. at our center. Prior to the planned percutaneous nephrolithotomy, retrograde pyelogram revealed METHODOLOGY extravasation of contrast from the right kidney into We retrospectively reviewed patients with GM the adjacent colon hence diagnosis of reno-colic diagnosed histologically from March 2010 to December fistula was made. She was then planned for trial of 2013. Characteristics of patients with resolved lesion conservative treatment by means of ureteric stenting. during data collection (Group A) were compared with However a repeat retrograde pyelogram after 3 months patients with active lesion (Group B). showed persistent reno-colic fistula. Subsequently, she underwent right nephrectomy, fistulectomy and RESULTS wedge resection of ascending colon with primary Thirty-six cases were reviewed. The mean age was closure. We would like to highlight this rare case of 35.3±7.40 years. Dusun was the largest ethnic group reno-colic fistula and discuss the management of this (n=12, 33.3%). Majority of patients (n=32, 94.4%) were uncommon condition. 74 PP 18 PP 19 married while 3 (8.3%) were pregnant and 21 (58.3%) Primary Hyperparathyroidism were lactating. Thirty-four (94.4%) presented with Presenting with Pathological breast lump (mean size 4.27±2.49 cm) and pain (n=21, 58.3%) was the major associated symptom. There Fracture of Long Bone were 23 core biopsies, 11 FNACs and 2 excisions done. K S Khoo1, Vivek Singh2, S S Chong1, K L Ng1 Twenty-three (63.8%) patients had antibiotics with the 1Department of Surgery 2Department of Orthopaedic average duration of 2.57± 2.31 weeks. Only 13 patients Surgery, Faculty of Medicine, University of Malaya, (36.1%) had received pre-surgical oral prednisolone Kuala Lumpur, Malaysia with 9 patients had disease resolution (9 vs 4, p=1). The mean duration of prednisolone therapy was 7.54 ±5.80 We report a case of a 17-year old Indian man weeks. The most commonly prescribed initial dosage was 20 mg 3 times/day. In bivariate analysis, Group presenting with pathological fracture secondary to B has more pus discharging lesions (4/12 vs 0/24, primary hyperparathyroidism due to a parathyroid p=0.009), shorter antibiotic duration (1.38 ± 0.74 weeks adenoma. The patient who was previously well, vs 3.20 ± 2.62 weeks, p=0.022) and shorter follow up presented with a closed right distal femur fracture (5.52± 6.16 months vs 12.55 ± 9.42 months, p=0.026). after a minor fall. As his injury did not tally with the degree of trauma, further investigations were CONCLUSIONS performed as a pathological fracture was suspected. Both FNAC and Core biopsy can provide accurate Initial investigations showed hypercalcaemia diagnosis of GM. The initial treatment for pus (3.16mmol/L) with normal phosphate levels. 24-hour discharging lesions should be incision & drainage urinary calcium and intact parathyroid hormone with antibiotics. Otherwise, high initial dose of (iPTH) levels were both elevated at 12.7 mmol/24H corticosteroid followed by tapering regime should and 37.6pmol/L respectively. Core needle biopsy of be the preferred therapy. Surgical excision should be the fracture showed fibrous dysplasia and skeletal reserved for complicated and steroid resistant cases. survey was inconclusive. In view of the high iPTH Long term follow up is required to observe disease levels, ultrasonography of the neck was performed and resolution. showed right parathyroid gland enlargement. A Single KEYWORDS photon emission computed tomography (SPECT-CT) Granulomatous Mastitis, Breast Carcinoma, Borneo, scan showed increased uptake by the right parathyroid Sabah

PP 19 PP 20 glands. The diagnosis of primary hyperparathyroidism Case Report : Chilaiditi’s Syndrome was made and right parathyroidectomy was – The Odd Cause Of subsequently performed. Intra-operatively, the right superior and inferior parathyroid glands appeared Pseudopneumoperitoneum to be enlarged and merged. Both glands were F Shah, A Wafi, G Y Lo, T Clement removed. Post-operative recovery was uneventful Hospital Tuanku Fauziah, Kangar, Perlis, Malaysia and the patient’s serum calcium and iPTH levels gradually normalised. The histology was consistent Introduction with parathyroid adenoma. This case illustrates that This rare but otherwise important condition, was pathological fractures should be investigated to first reported over a century ago by the radiologist exclude the possibility of hyperparathyroidism as a Demetrius Chilaiditi in 1910, after an incidental causative factor. This will help prevent recurrence of radiological findings of colonic interposition between fractures and future complications. liver and diaphragm, in a series of patients. It is a rare anomaly and documented to account about 0.025-0.28% cases, mostly asymptomatic and was discovered incidentally. This paper describes the important of indentifying and diagnosing this condition, as a differential diagnosis of more serious cause of pneumoperitoneum.

Case Report We present a case of 61 years old patient who presented with history of severe epigastric pain and vomiting, which was initially treated as Perforated Gastric Ulcer and undergone emergency exploratory laparotomy. Intraoperatively noted normal intraabdominal organs, and patient was then diagnosed as Chilaiditi’s Syndrome. 75 PP 20 PP 21

Discussions Retrospective Study: Outcome of Chilaiditi’s Sign or also known as Colonic Interposition Endovenous Radio-Frequency is usually asymptomatic, incidental radiological Ablation (RFA) Therapy For Lower finding in population. On the other hand, it can present with spectrum of symptoms, known as Chilaiditi’s Limb Varicose Veins In Hospital Syndrome. The exact etiology is unkown, but it was Kuala Lumpur thought to be due to various anatomical variations Hadi M A1, Ismazizi Z2, Naresh G2, Zainal A A2 present. The most popular theories that contribute 1Hospital Kuala Lumpur, Kuala Lumpur, Malaysia to the pathogenesis of Chilaiditi’s Syndrome is due to abnormalities ( ie absence, laxity or elongation) Introduction of the suspensory ligament of the transverse colon. Endovenous radio-frequency ablation therapy . Diagnosing Chilaiditi’s Sign is important as it may for lower limb varicose veins has been regularly lead to complication such as volvulus, bowel gangrene performed on patients in Hospital Kuala Lumpur along and perforation. Treatment is usually conservative with mechanicochemical endovenous ablation and the (symptomatic) and surgery is rarely indicated unless more conventional method of high saphenous vein the complication, such as bowel ischaemic and volvulus ligation. developed, or failure of conservative management Objective To analyze the outcome of RFA therapy for lower limb varicose veins, primarily in terms of pain relief, reduction in oedema, healing of ulcer, recurrent varicose veins, deep vein thrombosis and return of quality of life in general. Post-operative complications such as hematoma, ecchymoses, burn marks secondary to thermal injury and paraesthesia also reviewed in follow up records.

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Methods Injury Trends And Risk Factors Of A retrospective study was conducted on patients Trauma Mortality In A Geriatric whom underwent endovenous RFA therapy with population multiple stab avulsion performed in the same settings for lower limb varicosities, from January to December Henry Tan Chor Lip, Tan Jih Huei, 2014. All patients were generally monitored during Sarojah Arulanantham 1st month and 3rd month post-operative. Inclusion General Surgery Department, Hospital Sultan Ismail, criteria based on CEAP 2-6 with saphenofemoral and/ Johor Bahru, Johor, Malaysia or saphenopopliteal junction incompetency by clinical and Doppler examination. Introduction Mortality rate and injury trends amongst the geriatric Results population has not been established in many centres. Total of 90% (18 patients) underwent endovenous RFA This study aims to examine the injury mechanisms and therapy, 10% (2 patients) cancelled due to unfit for identify risk factors of mortality in trauma patients surgery, 70% (14 patients) had pain relieved, reduction aged more than 65 in a tertiary centre without a of oedema, and return quality of life, 15% (3 patients) specialized surgical trauma team. had persistent pain, 5% (1 patient) had healed ulcer and 15% (3 patients) had persistent venous ulcer, 5% Methods (1 patient) had recurrent varicose vein. No patient This is a retrospective study of all geriatric trauma sustained DVT, burn marks, hematoma, paraesthesia, patients aged 65 and above admitted to Hospital or ecchymoses. Sultan Ismail(HSI) surgical unit from January 2013 to February 2014. Patients were audited retrospectively Conclusion by retrieving data from HSI electronic database. Endovenous RFA therapy has been shown to be Demographics, mechanism of injury, nature of injury, efficient, safe and beneficial in treating lower limb operative or non-operative management, operating varicose veins. Comparison need to be made with time, organ involved, revised trauma score and other methods eg. MOCA and conventional HSVL to mortality data was collected. Data was analyzed with determine the advantages of RFA in future studies. SPSS version 16. 76 PP 22 PP 23

Results Rectal Foreign Objects, Does The Forty one trauma patients aged more than 65 years Care Ends After Removal? - A Case were included with male preponderance of 70.7%(29). Report And Literature Review The overall mortality rate was 22%(9). 56.1%(23) patients were involved in road traffic accidents(RTA) Henry Tan Chor Lip, Seniyah Md Sikin and 24.4% sustain injuries from a fall ≥2 meters. General Surgery Department, Hospital Sultan Ismail, Majority of injuries sustained were head trauma Johor Bahru, Johor, Malaysia 22(53.7%) followed by chest trauma 34.1%(14)patients and abdominal trauma 7.3%(3) patients. Mortalities Introduction from head and abdominal trauma were 37.5% and Insertion of rectal foreign body for purposes of 33.3% respectively with no deaths from chest trauma. sexual pervertism, self gratification, accidentally or Mode of injury showed no significant statistical voluntarily has been described since the 16th century. association with deaths. Head trauma in geriatric The true incidence rate in our population is unknown population had adjusted odds ratio of 2 for mortality. as many cases goes unreported due to the nature of Mean length of stay was 5.59 ± 9.2days. the condition .

Conclusions Objective In our centre, higher incidence of geriatric population A case presentation and literature review on was involved in road traffic accidents. From our study, management of retained rectal foreign bodies. head and abdominal trauma had poorer outcome in comparison to chest traumas. More research is Case Presentation required to understand the risk factors of mortality in A 48 years old male with no previous medical history this increasing geriatric population. was presented with constipation and abdominal pain for 3 days. History revealed that he had inserted a sex device into his anus for sexual satisfaction but was unable to remove it.

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Discussion Mono Or Dual Therapy, Are We An abdominal radiograph was performed and revealed Following The Standard? An Audit a foreign body shaped oval longitudinal in the rectum. Of Upper Gastrointestinal Bleeding Attempts at removing it manually via per rectal and colonoscopy failed. He was taken to operation theatre Henry Tan Chor Lip1, Nur Fitriyani Afiqah2 and successfully removed with muscle relaxant 1General Surgery Department, Hospital Sultan Ismail, subsequently with suprapubic pressure. Johor Bahru, Johor, Malaysia 2Newcastle University Medicine Malaysia, Johor Bahru, Conclusion Johor, Malaysia Rectal foreign bodies is easily diagnosed with a plain radiograph. Its management varies on individual Introduction presenting symptoms and clinical assessment. A Acute upper gastrointestinal bleeding(UGIB) is a successful removal is not complete without post common surgical emergency with a 10% mortality. It removal care selective colonoscopy and a referral is one of the main cause for hospitalization worldwide. to the physiatrist for treatment of such abnormal behavior. Methods This is a retrospective cohort study conducted in Hospital Sultan Ismail over 2 months from August to October 2014. All patients with signs of UGIB and emergency endoscopy performed were included. Electronic clinical notes from the Total Hospital Information System were reviewed and analysed to obtain details of endoscopic treatment given to patients. The objective of this study is to audit the adherence of endoscopy therapy and usage of PPI in treatment of acute non-variceal UGIB in accordance to National Institute for Health Excellence(NICE) 2012 UGIB guidelines.

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Results Colopleural Fistula with A total of 78 patients were included with male to Faecopneumothorax From female ratio 3:2 and mean age of 58.5 years. Only A Non Traumatic Splenic Flexure 29%(24) required endoscopy interventions of mono or dual therapy whereas the remaining patients only Perforation: A Case Report diagnostic endoscopy were performed. 78.3%(19) had Mohd Firdaus R, George John K T G, Zainal Ariffin A dual or triple therapy of adrenaline added with another Thoracic Surgery Unit, Department of General Surgery, modality for hemostatsis, whereas 21%(5) received Hospital Kuala Lumpur, Kuala Lumpur, Malaysia only monotherapy. 93.6% of the patients was started on a single form of proton pump inhibitor(PPI’s) prior Introduction to endoscopy whereas 97.4% of patients was started Fistulous communication between the organs in on PPI’s after endoscopy. the abdominal cavity and pleural space is extremely rare as described barely in a handful of articles. It is Discussion associated with a high morbidity and mortality if not Ulcer risk is the main reason for using monotherapy recognized early. We describe a case of colopleural intervention. Forrest classification of 2C or 3 in peptic fistula with faecopneumothorax post perforated ulcer disease indicates low risk of re-bleeding and thus gastric ulcer repair. single modality of endoscopy or PPI treatment might be sufficient to treat the ulcer. Studies also show Case Presentation that low risk stigmata do not benefit from endoscopy A 41 year old gentleman, with an underlying Hepatitis therapy and should not be treated endoscopically. C, presented with a history of high grade fever and shortness of breath, two weeks after undergoing a Conclusion laparotomy for perforated gastric ulcer. Diagnosis In our centre, majority of patients received dual of left empyema thoracis was established by clinical therapy as per the international guidelines. However, examination and a CXR . Initial management of the decision for method of endoscopic hemostasis draining the empyema was carried out via a chest still depends on ulcer risk and on the experience of the drain insertion as well as starting antibiotics. Culture endoscopist. and gram stain of the pleural fluid grew E.coli. A

PP 25 PP 26 lower GI contrast study with CT Abdomen and Thorax Emphysematous Pyelonephritis : confirmed a fistulous communication between splenic A Case Report flexure of colon and the left pleural cavity . Patient underwent laparotomy,primary large bowel resection, Mohd Johari1, Khair Syamimi2, Hasnizal Nording3, fistulectomy with double barrel stoma followed by Chen Hong Lim4 Left VATS and pleural cavity washout. Left pleural 1, 2Medical Officer, Department of Surgery, Hospital Segamat, cavity was filled with faecal debris and thickened Johor, Malaysia pleura causing trapped lung. In view of on going 3Surgeon, Department of Surgery, Hospital Segamat, Johor, sepsis, left thoracotomy and decortications was done. Malaysia 4 Patient’s condition dramatically improved after the Head of Deparment and Surgeon, Deparment of Surgery, Hospital Segamat, Johor, Malaysia thoracotomy and was discharged well after 2 weeks. Colostomy was reversed after 2 months . He developed Emphysematous pyelonephritis (EPN) is an uncommon a transient colocutaneous fistula which was treated infection characterized by severe, acute necrotizing conservatively and ultimately closed after 6 weeks renal parenchymal and perirenal infection with duration. Patient is well as seen during the last clinic formation of gas. EPN is common in persons with follow up. diabetes, and its presentation is similar to that of Conclusion acute pyelonephritis. However, the clinical course of Colopleural fistula are rare but is a life-threatening EPN can be severe and life-threatening if the disease complication after an abdominal surgery. It present not recognized and treated promptly. It is rapidly a diagnostic challenge to a surgeon, especially when progressive, requiring appropriate therapy to salvage patient presents with no abdominal symptoms. It the infected kidney. Emphysematous pyelonephritis should be suspected when there is a presence of predominantly affects females with uncontrolled colonic flora in the pleural fluid. Failure to recognize diabetes and can occur in insulin-dependent as it early will lead to complications requiring complex well as non-insulin dependent patients. Computed management with escalation of hospitalization cost Tomography (CT) scan is the modality of choice for and increases morbidity. Surgery is mandatory once the staging of the parenchymal gas and to rule out diagnosis is established. obstruction. We present a case of 67 years old female with underlying diabetes mellitus and hypertension 78 PP 26 PP 27 who presented with complaint of left loin to groin Case Report on Umbilical Metastatic pain in the emergency department. An abdominal Lesion from Endometrioid Ovarian radiograph disclosed gas distributed over region where left kidney located and left para-lumbosacral Carcinoma Mimicking Incarcerated area. CT scan revealed extensive left emphysematous Umbilical Hernia to General pyelonephritis with possible abscess collection, Surgeon retoperitoneum as well as pneumoperitoneum. Sarmukh Singh1, Putera Mas Piah1, She was treated successfully by antibiotics and 1 1 percutaneous drainage. Early goal directed therapy Ramesh Thangaratnam , Chew Loon Guan , 2 with intravenous fluids and antibiotics followed Zaidi Zakaria 1 by less invasive urologic interventions such as Hospital Serdang, Selangor, Malaysia 2 percutaneous drainage can provide viable alternatives Universiti Sains Malaysia, Penang, Malaysia to nephrectomy in early stages of emphysematous pyelonephritis, thereby attempting to salvage kidneys. Background Skin metastasis from endometrioid ovarian carcinomas is a rare condition and conveys a poor prognosis. Endometrioid ovarian carcinomas comprise about 10-25% of all the primary ovarian carcinoma. To our knowledge an umbilical metastatic lesion from endometrioid ovarian carcinoma mimicking an incarcerated umbilical hernia has not been reported yet and very rare condition.

Case Report A 53 year old Indian lady came to our surgical clinic with the complaint of abdominal pain and distention since past 1 month which worsened for the past 2 weeks, associated with bloody and foul smelling discharge from her umbilical region. Proceeded with

PP 27 PP 28 open hernia repair. Postoperative impression was an Gangrenous Bowel Survivors - umbilical endometrioma. Histopathology confirmed A Case Series endometrioid ovarian carcinomas which have metastasis to skin and omentum. Mohammad Alif Y, Sekkapan T, Wan Athman W M, Jiffre Din Conclusion Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia Cutaneous or umbilical metastasis of endometrioid ovarian carcinomas is rare. It can cause a diagnostic Bowel gangrene has high mortality rate up to 50% of challenge to the general surgeon evaluating an cases and mesenteric insufficiency is the commonest umbilical hernia. The incision should be closed primary cause of bowel gangrene, accounting up to 74% of its repair with no mesh repair as studies have shown that mortality. It requires rapid surgical treatment upon relationship between inflammation and peritoneal diagnosis. metastasis, chronic stimulus of mesh plugs and peritoneal trauma caused peritoneal metastasis at We report 3 rare cases related to this problem which the mesh repair sites. As in this case the cutaneous involved in young aged patients. All the patients were involvement is a late complication and gives a poor diagnosed clinically with prompt laparotomy showed prognosis. A proper counseling whether for debulking frank bowel gangrene with intra abdominal sepsis. 2 of surgery should be carried out. Computed tomography the patients underwent bowel resections and creation and MRI can be useful and can give accuracy of of stoma and had post operative complications of preoperative diagnosis. gangrenous stoma, requring second laparotomy. The other patient in contrary, underwent bowel resection and end to end bowel anastomosis, had faster recovery. All of them were discharged home after a mean of 25 days hospitalization.

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How Much Do We Know About Chest Results Trauma In Malaysia? Chest Injury There were 152 patients range from 9 to 78 years of Pattern and Outcome age included. Majority (89.5%) are male patients. Most common chest injury was ribs fracture (63.2%), Jih Huei Tan, Yue Yi Cheah, Rahmat Othman, followed by pneumothorax (24.3%), lung contusion Henry Tan (23.7%), hemothorax (14.5%) & flail chest (3.9%). Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia Other rarer injuries include 3 cardiac contusions with sternal fracture & 2 diaphragmatic rupture. Introduction Associated common injuries include head (23%), Chest traumas are common cause of admission in long bone fractures (21.7%), clavicle fracture (19.7%), general surgical ward. Most chest injuries can be intra-abdominal injury (13.2%) & pelvic injury (5.3%). managed with chest drain insertion, rarely it require Mean length of hospital stay was 5 days. Overall emergency thoracotomy. Injury trends and outcome mortality rate was 3.9% (6 patients). Three mortalities of chest trauma in developed countries are frequently had associated head injuries; two had associated seen in the literature. In developing country with high abdominal organ injuries. Emergency thoracotomies trauma load, data are still underreported. were performed in 2 patients and both survived. And 2 patients with diaphragmatic rupture were repaired via Objective laparotomy with good outcome. Study objective is to describe injury pattern and outcome of chest trauma in Malaysian setting. Conclusion In a Malaysian setting, patients with chest trauma Methods have good outcome but it can be fatal especially when Study conducted in general surgical unit, Hospital associated with abdominal and head trauma. Sultan Ismail, Johor Bahru. All chest trauma patients fits the criteria for admission are included. Data including demographics, type& mechanism of injury, operative intervention, associated injury, mortality and length of hospital stay are included.

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Case Report: Large Wild Banana Popliteal Artery Pseudoaneurysm Seeds Phytobezoar In The Rectum Successfully Treated with H S L Sophia, Y E Tan, S M D Asilah, F Y Chai Amplatzer Vascular Plug Department of Surgery, Hospital Keningau, Sabah, Malaysia Liew K W, Leong B D K, Selvarajoo G Hospital Queen Elizabeth II, Kota Kinabalu, Sabah, Malaysia Wild banana seeds phytobezoar causing fecal impaction in adults are extremely rare. Here, we report Popliteal artery pseudoaneurysm is uncommon. They a 75 year-old male with dementia who presented to usually result from penetrating or blunt trauma, us with lower abdominal pain, per rectal bleeding arterial reconstructive surgery and invasive diagnostic and overflow fecal incontinence. Our investigations or surgical orthopedic procedures. They can cause revealed a large wild banana seeds phytobezoar arterial thrombosis limb ischemia. We report a 53 impacted in the rectum causing obstruction, mucosal year old Chinese gentleman with popliteal artery erosion and fecal overflow incontinence. In this article, pseudoaneurysm who presented with right lower limb we discussed the patient’s clinical findings, imaging numbness and paralysis in toes extension. He gave a and management. The culprit fruit was identified and history of acupuncture treatment around the popliteal is depicted. Public consumption of these wild bananas fossa of the affected limb. Clinical examination should be curtailed, and the risks of ingesting large revealed a pulsatile mass in the popliteal fossa. quantities leading to fecal impaction should be made Computed tomography angiography showed a large, 5 known. cm, pseudoaneurysm to be arising from the popliteal artery. A diagnostic angiogram was performed and revealed that there is no run off from the popliteal artery and the tibial vessels were reconstructed from collaterals. Endovascular intervention was carried out with an Amplatzer Vascular Plug to embolise the pseudoaneurysm. The pseudoaneurysm was successfully excluded and post-op follow up reveals no more pulsatile mass and improving lower limb 80 PP 31 PP 32 function. To the best of our knowledge this is first First Endovascular Management of reported case of pseudoaneurysm of the popliteal Axillary Artery Pseudoaneurysm in artery secondary to acupuncture in Malaysia. Sabah: A Case Report and Review of Keywords the Literature Pseudoaneurysm, popliteal artery, acupuncture, Selvarajoo G, Leong B D K, Valan A, Liew K W endovascular intervention, amplatzer Vascular Unit, Surgical Department, Hospital Queen Elizabeth II, Kota Kinabalu, Sabah, Malaysia

Pseudoaneurysm is characterized by focal defect in the arterial wall, with hemorrhage controlled by surrounding tissues. The majority of cases are due to penetrating or blunt trauma. Surgical resection with end-to-end anastomosis or a bypass is the conventional treatment. There is an emerging rise in the adoption of endovascular intervention in the treatment of pseudoaneurysm where it is less invasive, safe and have less significant complications, cost-effective and cosmetically acceptable. This case is first endovascular repair of axillary artery pseudo aneurysm in Sabah. An 18-year-old male was referred for right infra-clavicular and shoulder swelling associated with weakness and paraesthesia of his right upper limb post arthrotomy for traumatic right shoulder penetrating injury with brachial plexus injury. CT Angiogram showed right axillary artery pseudo aneurysm with active slow bleed into the surrounding hematoma. Diagnostic angiogram was obtained via

PP 32 PP 33 the right brachial artery cut down approach and Trends in ESBL-Production and confirmed a right axillary artery pseudo aneurysm. Susceptibility for Intraabdominal A 7F access sheath was used. Stenting was done using 7mm x 38mm Advanta V12 stent with balloon Infections Isolates in Hospital angioplasty. The pseudoaneurysm was successfully Sultanah Aminah Johor Bahru: excluded. Post stenting day 5, evacuation of clots SMART 2009-2013 was done. Post-op follow-ups showed a successfully Ganeswrie Rajasekaram1, W Y Tay2 treated pseudoaneurysm with preservation of distal 1Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia circulation and good improvement in upper limb 2Merck Sharpe & Dohme, Petaling Jaya, Selangor, Malaysia function. Axillary artery aneurysm is a rare disorder and endovascular management is an evolving Objectives option. Endovascular therapy is a minimally invasive The Study for Monitoring Antimicrobial Resistance technique, an effective and safe therapeutic approach Trends (SMART) has monitored the in vitro and advantage of shortening the hospital stay. In susceptibility of organisms isolated from conclusion, with its higher technical success rate and Intraabdominal Infections (IAI) since late 2009. This lower mortality and morbidity rates, it is superior to report summarizes pathogen distribution in IAIs, open surgical therapy. trends in extended-spectrum β-lactamase (ESBL) Keywords production and susceptibility of the two most common pathogens of IAI from 2009 to 2013 in Pseudo aneurysm, Axillary artery, Endovascular Hospital Sultanah Aminah Johor Bahru (HSAJB). intervention Methods 438 isolates were collected from IAI by HSAJB in 2009- 2013. MICs and ESBL phenotypes were determined by CLSI broth microdilution, and interpreted using CLSI guidelines. Distribution of IAI pathogens and trend of ESBL producing Escherichia coli and Klebsiella pneumonia were calculated using proportion. 81 PP 33 PP 34

Results A Giant Fibroadenoma Turns Out To The 5 most common pathogens for IAI were: E.coli Be Phylloid Tumour (37%, n=148); K.pneumonia (29%, n=116); P. aeruginosa (16%, n=64); A. baumanni (5%, n=22); P.mirabilis (5%, Thiagarajan Gobal, Karthikeyan Marthay, n=22), others (8%, n=33). For the 2 most common Gunaseelan D, Ros’aini Paijan pathogens, the prevalence of ESBL is increasing. Department of Surgery, Hospital Pakar Sultanah Fatimah, ESBL prevalence for E. coli increased from 7% (2/29) Muar, Johor, Malaysia in 2009 to 23% (6/26) in 2013. ESBL prevalence for K.pneumonia increased from 24% (6/25) in 2009 Introduction to 27%(6/22) in 2013. Susceptibility for ESBL was The term giant breast tumor is given to rapidly growing low for cephalosporins (generally ~60% or less), masses with diameters exceeding 5cm or weight more fluoroquinolones (<45%) and ampicillin sulbactam than 500g. After carcinoma, fibroadenoma is the (<30%). Antimicrobials demonstrating susceptibility common breast lesion in adolescent women and is very ~90% and higher for ESBL E.coli were amikacin (100%), rare in the elderly aged women. However, a phylloid ertapenem(100%), piperacillin-tazobactam (95%), tumour should be at consideration when dealing with cefoxitime (95%) and imipenem (100%). Whereas for an elderly aged women with rapidly growing benign ESBL K.pneumonia only ertapenem and imipenem looking breast tumour. demonstrated susceptibility of more than 90% (95%). Case Report Conclusion A 70 year old Malay lady presented with left breast This report shows increasing trend of ESBL in the 2 most lump for 3 years, progressively increasing in size for common pathogens for IAI in HSAJB. Even though the the past 6 months and becoming hard, associated sample size is small, this finding resonates with HSAJB with 2 years history of taking oral contraception and existing microbiology data. Susceptibility to ampicillin strong family history of breast cancer. Clinically the sulbactam, cepholosporins and fluoroquinolones were left breast lump measures 30x30cm,hard, fixed but low, limiting therapeutic options for IAI in HSAJB. no cervical lymph node palpable. Mammogram unable to exclude malignancy features due to large breast mass preventing adequate compression. However

PP 34 PP 35 trucut bioposy revealed usual ductal hyperplasia and Rare Yet Aggressive – Angiosarcoma no evidence of malignancy. The patient underwent left Of The Breast : A Case Report mastectomy and axillary clearance. Gross specimen dissected showed a huge left breast lump 30x 15cm Thomas F1, Nor Aishah MA1, Rosmalinda K1, not fused to pectoralis muscle and multiple well Ganapaty S2 capsulated axillary lymph node. Histopathological 1Department of General Surgery, Hospital Ampang, Selangor, report turn out to be phylloid tumour. Malaysia 2Department of Pathology, Hospital Serdang, Selangor, Conclusion Malaysia Phyllodes tumours are clinically similar to fibroadenomas and difficult to diagnose at first Angiosarcoma of the breast is a rare tumour arising attempt using fine needle aspiration cytology or from the vascular endothelium. It accounts to only trucut biopsy. Clinically significant breast masses 0.04% of all malignant breast tumours. Angiosarcoma especially those causing discomfort and arousing can be divided into a primary angiosarcoma or malignant suspicion necessitate mastectomy. Triple secondary angiosarcoma which usually arises assessments have been the primary approach to all following radiation to the breast. We report a case of breast lump regardless of age to confirm the exact primary angiosarcoma in a 36 year old lady. Her initial pathology of the tumor. core biopsy was mistakenly diagnosed as capillary haemangioma. However, during excision, the lesion was suspiciously noted to be highly infiltrative in nature. Close histopathological study of the excised lump finally confirms mammary angiosarcoma of low grade. As the surgical margins were involved and the histopathological grading is no longer thought to be of prognostic significance in this type of tumour, the patient subsequently underwent a total mastectomy. The patient is currently undergoing radiotherapy but refuses chemotherapy. Clinical

82 PP 35 PP 36 presentation, diagnostic challenges and treatment Malignant Mediastinal Germ Cell of this uncommon yet aggressive breast tumour is Tumour with Intra Pulmonary further discussed in this report. In conclusion, despite the diagnostic difficulties of mammary angiosarcoma, Infiltration: A Case Report once confirmed this rare yet aggressive tumour Atifah A, George John K T G, Zainal Ariffin A needs to be treated in an equally aggressive manner. Thoracic Surgery Unit, Department of General Surgery, Excision with wide surgical margins or mastectomy is Hospital Kuala Lumpur, Kuala Lumpur, Malaysia recommended in all cases. The benefits of adjuvant therapy, even though widely practised, still remains Introduction unproven. A proper follow up and disease surveillance Primary mediastinal germ cell tumor (GCT) is a rare must be establish in each patient ,in view of the nature neoplasm, constituting < 5% of all germ cell tumors of this disease for having high local recurrence and and < 1% of all mediastinal tumors. Any anterior also earlier metastasis. MRI is the prefered imaging mediastinal mass especially in young male must raise modality to monitor for local recurrences. the suspicion of germ cell tumor because despite its rarity, it is a potentially curable condition. We present a case of non seminomatous germ cell tumor with Intra pulmonary infiltration.

Case Presentation A 26 years old male presented with 1 month history of cough and exertional dyspnea. Chest x ray showed left pleural effusion and widened mediastinum. The pleural fluid was exudative in nature. He was initially treated empirically with anti- tuberculosis. Tuberculosis workout came back negative. All 3 tumor markers; AFP, HCG and LDH were markedly raised. Ultrasound guided biopsy then revealed seminomatous germ cell tumor. CT Thorax confirmed germ cell tumor with huge mass

PP 36 PP 37 occupying the whole lung and possible involvement Chest Wall Reconstruction With of pericardium, thoracic wall and left hemidiaphragm. Free Transverse Rectus Abdominis He completed 6 cycles of neo-adjuvant chemotherapy with subsequent pronounced drop in all of the tumor (TRAM) And Pedicled Latissimus markers and reduction in the tumor size with clear Dorsi Flap In A Case Of Malignant demarcation from the previously involved adjacent Phyllodes Tumour Of The Breast structures based on the repeated CT. He then Invading Into The Ribs: A Case Report underwent left thoracotomy, bronchoscopy, en bloc resection of mediastinal GCT and pneumonectomy. Syafiq Idris, Suniza J, See M H, Ridwan Mirza, HPE reported as malignant teratoma. Alizan Khalil, Taib N A University of Malaya, Kuala Lumpur, Malaysia Conclusion Mediastinum as the primary site of germ cell tumor INTRODUCTION is uncommon. It should be suspected in young male Phyllodes tumour of the breast is a rare type of who came with respiratory symptoms and suspicious tumour. Malignant phyllodes tumour represents 10 chest radiograph. It is potentially curable with early to 30% of all phyllodes tumour. Surgery has been the detection and commencement of therapy. mainstay of treatment. Due to recent advances in oncoplastic techniques, reconstruction of the breast is often offered to patients. Ribs resection and chest wall reconstruction may be needed if the tumour invades into the chest wall.

PRESENTATION OF CASE We present a case of a 45-year-old lady who came with 3-year-history of left breast mass. It measured about 30x30 cm and was seen invading into the left 5th and 6th ribs on CT scan. Three differential diagnoses were obtained from core biopsy namely

83 PP 37 PP 38 malignant Phyllodes tumour, metaplastic carcinoma HEPATIC ANGIOSARCOMA: A RARE and sarcoma. Multidisciplinary discussion between the PRIMARY LIVER MALIGNANCY breast, plastic and oncology team decided on surgery and postoperative radiotherapy. Patient underwent Nur Zawani Z, Friman H, Ikhwan S M, S Hassan, left mastectomy and left 5th and 6th ribs resection Z Zaidi with chest wall reconstruction using titanium mesh Department of Surgery, Hospital Universiti Sains Malaysia, implant, free transverse rectus abdominis (TRAM) and Kubang Kerian, Kelantan, Malaysia pedicled latissimus dorsi flaps. The final pathology Angiosarcoma is a rare primary liver malignancy in report confirmed malignant phyllodes tumour with which the tumour arises from endothelium, blood or clear margin. She was discharged 3 weeks after surgery lymphatic system. It is difficult to diagnose as it has and due to undergo radiotherapy. vague presentations with non specific symptoms, therefore most cases presented at advanced stage. DISCUSSION Furthermore, the computed tomography(CT) scan has The interesting parts about the management were the its own limitation to diagnose this lesion. Liver biopsy pathological diagnosis on initial core biopsy and the with immunohistological stains will help in diagnostic use of double flaps for the chest wall reconstruction. evaluation but the procedure may carry risks of There was an inconclusive core biopsy result leading to bleeding and mortality. multidisciplinary discussion between different teams. We reported a case of a young lady who initially Double flaps were used in order to cover the big defect presented with history of upper abdominal pain which after the mastectomy and also to prevent thinning of was initially treated as dyspepsia. The condition flaps, which may cause exposure to the titanium mesh worsened when she developed hematemesis and underneath. subsequently being subjected for upper endoscopy and 4 phases CT scan of liver. Ultrasound guided CONCLUSION biopsy was performed based on suspicious findings of The aim of treatment for the malignant Phyllodes multiple liver lesions with lung and bone metastases. tumour of the breast is to achieve good margin of Histopathological examination confirmed the diagnosis clearance to prevent recurrence. In this case, without of Primary Hepatic Angiosarcoma. The standard compromising the tumour clearance, the surgery has management of this malignancy is still liver resection also achieved cosmetic acceptability for the patient. as the tumour has poor response to chemoradiation.

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A Case Series Of Neuroendocrine Results Carcinoma Of The Breast In Penang 3 tumors fully satisfied the neuroendocrine breast General Hospital And Its Literature carcinoma criteria established by WHO (2003) were collected over 6 years , recording an incidence of Review 0.38%.All patients are female, one premenopausal and S Y Loi, M S Teoh, Y T Cheong two with history of oral contraceptive use.The age of Hopsital Pulau Pinang, Penang, Malaysia patients ranged from 39 to 78 years (median: 72).All cases are grade 1 or 2 solid neuroendocrine carcinoma Background/purpose showing positive for ER and PR immunize activity. Neuroendocrine carcinoma ( NEC ) of the breast is a Summary rare type of breast carcinoma that has not been well studied and recognized.To gain more insight into NEC is a rare but aggressive type of mammary mammary NEC , we present the clinicopathological carcinoma.To date , the optimal treatment modality findings of 3 cases of primary NEC of the breast and is not clear.Radical mastectomy with neoadjuvant/ review the pertinent literature. adjuvant chemotherapy , adjuvant radiotherapy appears as viable options. Novel therapeutic Methods approaches should be explored for this uniquely We retrospectively searched the General Surgery clinical entity. Online ( GSO ) Database, surgical outpatient clinic and histopathological lab files of all patients with breast carcinomas treated in Penang General Hospital between January 2010 and 2015 to identify patients with primary NEC of the breast.We analyzed patient demographics ,clinicopathological findings , disease stage and treatment effects , in 3 cases of primary NEC of the breast.

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A 5-year retrospective review of Results Pelvic Exanteration in Hospital A total of 23 patients were included in this study which Selayang comprised of 11 (48%) males and 12 (52%) females. Thirteen patients (57%) underwent bladder- sparing Prathaban, Mark S G, Tan X Y, Kavitha M D, PE, 8 (35%) underwent total PE while 2 (8%) patients Gerald H were found to be inoperable on table due to frozen Colorectal Unit, Department of General Surgery, Hospital pelvis. Twenty one patients were operated upon; 20 Selayang, Selangor, Malaysia patients (95%) for primary (locally advanced) rectal cancer and 1 (5%) for recurrent rectal cancer. There was Introduction a single case of post- operative mortality due to post Pelvic exenteration (PE), though an extensive surgical operative lung complications and one patient who modality for primary and recurrent rectal cancers, succumbed due to advanced disease one year after remains as the only method to achieve curative aim. surgery. There were no recurrences among patients Procuring margin free specimens in locally advanced who underwent total and bladder- sparing PE. and recurrent cases is always challenging. While total PE is an extensive surgical procedure, bladder- sparing Conclusion PE is an acceptable alternative. It is associated with Bladder- sparing PE offers oncological outcome lower morbidity, better quality of life and recurrence comparable to total PE. In addition to comparable rates comparable to total PE. outcome, quality of life and morbidity can be significantly improved Aim To evaluate the outcome of patients subjected to total Keywords and bladder- sparing pelvic exenteration in Colorectal Bladder- sparing, pelvic exenteration, rectal cancer Unit in Hospital Selayang.

Methods All patients who underwent pelvic exenteration from January 2010 to December 2014 in Colorectal Unit, Hospital Selayang were retrospectively analyzed.

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A Short-Term Outcome Analysis Result of Laser Hemorrhoid Surgery in A total of 35 patients were recruited in this study. Hospital Selayang Twenty six (74%) cases were newly diagnosed cases while 9 (26%) had previously undergone various Sivakumaran J, Prathaban T, Mark S G, Gerald H procedures such as banding, stapler hemorrhoidopexy Department of Surgery, Hospital Selayang, Selayang, and open hemorrhoidectomy. There were 2 (6%) cases Selangor, Malaysia of intra- operative bleeding while 33 (94%) were uneventful. There was one case of recurrence and no Introduction reported cases of stenosis, incontinence or secondary Surgery for hemorrhoids underwent a series of bleeding in our study sample during first, third and changes over the years. What was once a surgery sixth month follow up associated with significant morbidity, loss of sphincter function and even mortality, is now a safe and Conclusion common procedure. The concept of minimally invasive Review from our study shows laser hemorrhoid surgery is also being incorporated in the realms of surgery to be safe procedure with low recurrence hemorrhoidal surgery in the form of Laser Hemorrhoid rates. Though it is not suitable for large prolapsed Surgery. The advantages of laser hemorrhoid surgery hemorrhoids, it is an ideal method for treating grade 2 include minimal bleeding, less pain experienced by and grade 3 hemorrhoids. the patient and a faster recovery which makes it a favorable modality among surgeons and patients. Keywords Laser Hemorrhoid surgery, Hemorrhoids, Objective hemorrhoidopexy To analyze the short term outcome of laser hemorrhoid surgery in Hospital Selayang

Method All patients who underwent laser hemorrhoid surgery from September 2014 to March 2015 were reviewed retrospectively 85 PP 42 PP 42

Jejunal Diverticulosis : A Rare primary anastomosis was performed and the patient Cause of Obscure Gastrointestinal recovered well post operatively with no further bleeding episodes. Histopathology results confirms Bleeding small bowel diverticula evidenced by ‘invagination Shafhawi M A, Elina S, Fitjerald H of mucosa of variable depth, through the muscularis propria muscle. The diverticulums are surrounded Obscure gastrointestinal bleeding (OGIB) are notorious by multiple markedly dilated and congested blood for posing a diagnostic and therapeutic dilemma. We vessels’. report a rare cause of OGIB due to bleeding jejunal diverticulum. Although rare, complications from this Jejunal diverticulum is usually an incidental finding condition can lead to significant morbidity or even during surgery, radiological investigations or autopsies. mortality. It is almost always, associated with diverticulum in other parts of the gastrointestinal tract. Majority of An elderly male was referred to us from another these patients are asymptomatic. The major acute hospital with recurrent gastrointestinal bleeding. He complications of a jejunal diverticulum include had undergone an open exploratory laparotomy which inflammation, obstruction or bleeding. Awareness of found right colonic diverticula, and therefore right jejunal diverticulum and possible bleeding from it, as hemicolectomy was performed for presumed bleeding a cause of gastrointestinal bleeding, is helpful in the diverticulum. In our hospital, he continued to pass diagnosis and management of patients. malaena with blood clots per rectum. After an initial period of work-up with repeat colonoscopies and CT The importance of a ‘thorough run’ of the small angiogram of mesenteric vessels, which revealed bowel during exploratory laparotomy could not be no obvious bleeding point, he underwent a second emphasized more as it would pick up the jejunal exploratory laparatomy. Intraoperative findings, abnormality and avoid potential morbidity or mortality. assisted with an on-table endoscopic examination showed fresh blood clots within the small bowel and multiple jejunal diverticulum at 25cm from the DJ flexure to about 80cm. Small bowel resection with

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Wandering intrauterine usually encountered are bleeding and pain that usually contraceptive device : an unusual co-exist, pelvic infection, expulsion and perforation. Investigations should be based on clinical suspicion, travel to the sigmoid colon starting from abdominal radiograph, if needed to Kumarappan Al, Karthikeyan M Gunaseelan D, proceed with ultrasonography, computed tomography Ros’aini and localization prior to operation allows good Hospital Pakar Sultanah Fatimah, Muar, Johor, Malaysia preoperative planning. Surgical method of removal depends on available expertise whereby laparoscopy Intrauterine contraceptive device (IUCD) is common would be preferred compared to laparotomy in case choice for contraception, 14.3 % women of childbearing of intra abdominal migration and intraluminal large age, worldwide uses them. Migration of IUCD is one bowel migration would favour endoscopic removal. of the complications that are encountered. Possible Migrated IUCD in symptomatic patients should areas that they can end up are peritoneal cavity, colon, be surgically removed whereas, asymptomatic rectum, appendix, bladder. Here we report a case of patients can be managed conservatively under IUCD migration to the sigmoid colon. A 39 -year-old certain circumstances. However in the presence of a Malay lady had a copper T type of IUCD inserted two concurrent pathology that requires exploration then months after childbirth and noted missing thread retrieval of the migrated IUCD should be undertaken. during a routine pap smear examination two months later. After failed examination under anaesthesia and hysteroscopy, abdominal ultrasound detected it in the left lower quadrant of abdomen. She then underwent diagnostic laparoscopy where the device was found to be embedded in the sigmoid colon. Technical difficulty necessitated conversion to mini laparotomy and sigmoidotomy performed to remove the IUCD and the bowel closed primarily. IUCD is a relatively simple and safe contraceptive procedure that is being used since 1965. Complications that are 86 PP 44 PP 44

An Unusual Presentation of the Rare sarcoma of the liver. In view of the advanced disease Primary Pleomorphic Sarcoma of at time of presentation and the multifocal lesion of the liver it was not amenable for surgical resection. the Liver Palliative radiotherapy was done for the buccal Suriaraj K, Devanraj S, Premjeet S, Suraj P B mucosa mass to alleviate the gum bleeding and pain. Department Of General Surgery, Miri General Hospital, Unfortunately patient succumbed 5 months after time Sarawak, Malaysia of diagnosis.

Primary liver sarcoma is very rare accounting for Primary liver sarcomas should be considered as a only 1-2% of all malignant liver neoplasms. Among differential when dealing with liver neoplasms and one the primary liver sarcoma, the pleomorphic type is should be wary of its atypical presentations as shown the rarest subtype and has the highest metastatic in our case report. The experience of dealing with this potential. disease is limited due to its rarity; be it the natural course of the disease or the most suitable treatment We report a case of a 62-year-old gentleman with modality. primary pleomorphic liver sarcoma who presented initially to our centre with complaints of gum bleeding and pain. There were no other associated complaints. Examination revealed bleeding from a malignant looking mass arising from the right lower buccal mucosa. Biopsy taken from this mass revealed a metastatic sarcoma arising from a primary tumour in the liver. Subsequent ultrasonography and computed tomography (CT) examination of the abdomen showed multifocal mixed density lesions of the liver with no other tumour elsewhere. CT guided biopsy of the liver mass was performed. Histopathological examination of this sample reported high grade pleomorphic

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Incidental finding of an Anorectal She was counseled and given the option for corrective Malformation in a 58 year old surgery or referral to a higher centre but she refused and was discharged. Premjeet S, Zulkifli M Z, Suriaraj K, Nursheila Izrin A Z General Surgery Department, Hospital Miri, Sarawak, The fact that this kind of extremely rare case is still Malaysia being encountered especially in the rural areas or Sarawak enlightens us to consider corrective surgeries A child with anorectal malformation is almost like PSARP which has only been performed in pediatric never missed in today’s era of advanced and easily age groups to be performed in adults as well. The assessable health care service even with a very low management of a case of this nature is a challenge and incidence of only 2 -2.5 in 10000 live births. Hence, has not been clearly delineated due to its rarity. when this 58 year old lady, Para 6, was referred to us by the gynecology team, it was indeed interesting and we were surprised at what we found.

This is a case report of a 58 year old Iban lady, married, Para 6 with 6 living children, all delivered via SVD, presenting with UV prolapse during which a rectovaginal fistula was incidentally found. She was initially referred by Klinik Kesihatan for mass pervaginum to our gynaecology team. She gave history of bowel incontinence as well for many years. External genitalia examination revealed an absent anus and an opening at the posterior wall of the vagina. Colonoscopy was performed and noted an opening to the rectum within the vaginal vault, with the rest of the colon being normal. We investigated further for associated anomalies (VACTERL association) and found no other anomalies. 87 PP 46 PP 46

Undifferentiated Embryonal excision of the tumour. Histopathological examination Sarcoma of the Liver: A Case Report of the tumour was consistent with undifferentiated embryonal sarcoma of the liver. and Literature Review H L Sha, Aminnur H M, M Hardin, A Ali Conclusion General Surgery Department, Sarawak General Hospital, Although rare, UESL should be considered as a Kuching, Sarawak, Malaysia differential diagnosis in paediatric patients presenting with a solid-cystic liver lesion on CT scan. For Objective resectable lesions, primary surgical resection remains Undifferentiated embryonal sarcoma of the liver the diagnostic and therapeutic procedure of choice. (UESL) is a malignant mesenchymal tumour that is UESL is an aggressive disease, however, the recent use believed to arise from malignant transformation of of multimodal therapy has produced longer disease mesenchymal harmatomas. Primary liver malignancies free median periods. represent about 1% of paediatric malignancies. UESL represents about 9-13% of paediatric hepatic tumors. Keywords We intend to present what we believe to be the first Liver cyst; undifferentiated embryonal sarcoma of the reported case of UESL in Sarawak and discuss the liver; UESL. current evidence available in the literature.

Case Presentation A previously well 15-year-old girl presented to us with progressive abdominal distension and pain over three months. Clinically, she had a distended abdomen with a vague central abdominal mass. Initial investigations with computed tomography (CT) scan revealed a complex cystic liver lesion arising from the liver. Liver function tests and tumour markers were within normal ranges. She underwent laparotomy with

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Perforated Gastric Ulcer In A Child This case represents a rare entity in paediatric emergency. With only a few etiologies of peptic ulcer Nursheila Izrin A Z, Suraj P B, Premjeet S, Suriaraj K disease in this age group it is important to consider General Surgery Department, Hospital Miri, Sarawak, Helicobacter pylori infection with concurrent Zollinger Malaysia Ellison syndrome in this patient.

Perforated gastric ulcer is unusual in children. We report a case in a boy presenting with acute abdomen with an unexpected evolution.

Case report A 13 year old boy presented with 5 days abdominal pain which worsened on admission. On examination he was in sepsis with evidence of peritonitis. His total white count was 15000. Erect chest x-ray showed right pneumoperitoneum. Patient underwent laparotomy primary repair of perforated ulcer in the first part of duodenum.

Oesophagoduodenoscopy 6weeks later showed no ulcer and biopsy culture was positive for Helicobacter Pylori. Serum Gastrin level showed significant increase, however contrast enhanced computed tomography of the abdomen showed no focal lesion in pancreas or duodenum. Helicobacter pylori eradication therapy was given and he was started on regular proton pump inhibitor. During follow up he was asymptomatic and had no more abdominal pain.

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Gastric Plasmacytoma: A Rare curvature gastric mass was also noted to be adhered Malignancy Of The Stomach anteriorly to the transverse colon. She then underwent a subtotal gastrectomy with Billroth II reconstruction, Devanraj S, Suriaraj K, Zulkifli M Z, Suraj P B along with an extended right hemicolectomy. Hospital Miri, Sarawak, Malaysia The whole stomach specimen showed diffuse Plasmacytoma of the stomach is an unusual infiltration of plasma cells which was in-keeping with presentation of monoclonal gammopathy, plasma cell myeloma. A whole body skeletal survey which may or may not be systemically involved. revealed no lytic lesion. Subsequently, a bone marrow Gastrointestinal involvement is seen in less than 5% aspiration and trephine biopsy was performed along of all extramedullary plasmacytoma, while the latter with additional investigations such as serum and urine accounts for only 2% of multiple myeloma. We report a protein electrophoreses which the results upon date, rare case of gastric plasmacytoma presenting with an are pending. abdominal mass. Gastric plasmacytoma, which clinically may simulate A 57-year-old lady presented with a 3-month history very much like an adenocarcinoma, should be of abdominal pain and constitutional symptoms. The appreciated as a different entity altogether as the only significant physical finding was a mass at the subsequent treatment and management differ. epigastric region while her blood profiles showed no abnormality in the renal function, liver function and serum calcium levels. An upper GI endoscopy revealed a fungating growth at the greater curvature with central ulceration, which was supported with a CT scan that further revealed the absence of any distant metastases. Initial histo-pathological examination from the biopsy taken surprisingly demonstrated it to be a diffuse-type of a poorly differentiated adenocarcinoma. Hence, she was planned for a curative surgery and intra-operatively, the greater-

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Video-Assisted Thoracoscopic pneumothorax with large right lower lobe lung bullae, Surgery for Empysematous Lung thus VATS was performed. Intraoperatively, there was right lung collapse with large bullae noted at the lower Bullae lobe. Bullae resection was done. Post operatively, she Phrabakaran Rajehgopal1, Nurfareha Mohd Hatta2, recovered well. Both chest tubes were removed on post Poh K S2, Yusof Wahab2 op day 2 and day 5 respectively. She was discharged on 1Department of Surgery, Hospital Tengku Ampuan Rahimah, post op day 5. Klang, Selangor, Malaysia Conclusion Introduction VATS replaces the conventional thoracotomy in Video-assisted thoracoscopic surgery (VATS) is a diagnosing bullous disease of the lung. Bullae minimally invasive approach that has been widely resection can be performed in VATS as it is safe and used to diagnose and treat in cardiothoracic effective. surgery. It gradually replaces the traditional open approach method, such as thoracotomy. With a rapid development of VATS, the management of lung diseases such as emphysematous lung bullae has improved tremendously. Hence, bullectomy can be performed effectively.

Case History A 24-year-old lady with no underlying medical illness consulted our centre with a 1-day history of right chest pain and dyspnea. Chest X-ray at that time showed large right pneumothorax without mediastinal shift. Chest tube was inserted. Chest X-ray post chest tube insertion day 3 showed resolving right pneumothorax. CT Thorax revealed very minimal residual right 89 PP 50 PP 50

An Uncommon Adrenal Tumour due to its rarity and to demonstrate the hormonally active presentation of adrenal cortical carcinoma. S L Raymond Yii, S S Chong, K L Ng Department of Surgery, Faculty of Medicine, University of Key words Malaya, Kuala Lumpur, Malaysia Adrenal tumour, Cushing’s syndrome, Adrenal cortical carcinoma Adrenal cortical carcinoma (ACC) is a rare and aggressive malignancy of the adrenal gland with heterogenous presentation and generally poor prognosis. We report a case of a 67-year-old lady who was incidentally discovered to have an adrenal tumour with undiagnosed Cushing’s syndrome. The patient, with a past history of Type II diabetes mellitus, initially presented with left lower limb radicular pain to the orthopaedic unit. A Magnetic Resonance Imaging (MRI) scan of the spine was performed and an incidental finding of a left adrenal tumour was made. She was subsequently referred to the endocrine surgery unit. Further investigations revealed elevated levels of cortisol and testosterone with high normal levels of aldosterone. The patient was hypokalaemic on presentation and required potassium supplementation. Screening for phaeochromocytoma was negative. The diagnosis of a functioning adrenal cortical tumour was made. An open left adrenalectomy was performed and post-operative recovery was uneventful. Histology was reported as adrenal cortical carcinoma and the patient was referred to the oncologist for adjuvant therapy. This case is presented

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Ascariasis Causing Small Bowel electrolyte imbalance. Despite worsening condition, Volvulus – The deeper perils of being the child’s parents only consented for surgery on day four of admission due to financial constraints. a stateless child in Malaysia Laparotomy revealed gangrenous small bowel volvulus Z L Lim, Maung K L, Othman M Z, S S M Fadzil with perforation at its fundus. Live ascariasis were Surgical Department, Tawau General Hospital, Sabah, seen within the resected segment of small bowel and Malaysia also the proximal loops. There was delay in initiating parenteral nutrition as the parents struggled to afford Introduction payment. Post-operative period was complicated with Ascaris lumbricoides is the commonest cause of anastomotic leak warranting a relaparotomy, bowel helminthic infection in humans. Nearly a quarter resection and anastomosis. Child was later discharged of the world’s population is infected at any given well after three weeks of admission. time. It is prevalent in the subtropical and tropical developing nations, causing serious intra-abdominal Conclusion complications. Clinical presentations vary according Children residing in areas of socio-economic to the stage of its life-cycle. deprivation and at-risk of malnutrition, should be considered for early structured deworming program Case Report to prevent Ascariasis’ fatal complications. With the A 3 year old non-Malaysian Bajau Laut boy was new non-Malaysian hospital charges introduced in admitted for progressive abdominal distension, 2015, this compounds further the vulnerability of fever, bilious vomiting and constipation of one being a stateless Bajau Laut, bereft of their rights, week duration. At presentation, child appeared as individuals and as a minority, seeking affordable weak, malnourished, tachypnoeic and tachycardic. healthcare services in this part of the world. Abdomen was distended and tense. Live ascariasis was noted upon vomiting. On abdominal X-ray, multiple curvilinear soft-tissue density cords with generalised bowel dilatation were seen. Blood counts revealed anaemia with leucocytosis of 17,900/mm3 and 90 PP 52 PP 52

Huge Gluteal Well-differentiated Discussion Liposarcoma Liposarcoma is classified into 4 subtypes: well- differentiated liposarcoma, myxoid liposarcoma, P S Law, R S Lam pleomorphic liposarcoma and dedifferentiated Hospital Kulim, Kedah, Malaysia liposarcoma. The prognosis and risks of distant metastasis related to the low grade or high grade Introduction tumour. Well-differentiated liposarcoma(WDL), also Liposarcoma is one of the most common type of soft known as atypical lipomatous tumour is the most tissue sarcoma in adult,composing 10-15%. It mostly common subtype of liposarcoma, account for about arises from deep soft tissue or retroperitoneally. Males 30-40% of all liposarcoma. It usually initial as low at fifth and sixth decade are more common affected grade tumour. It’s commonly found at the limbs and than females. retroperitoneum. WDL usually arising from deep seated and well-vascularized tissue. The lesion Case Report usually painless unless it’s large enough to caused A 73year-old man with no comorbidity presented with dysfunctions. The treatment for this tumour is wide left gluteal swelling for 6 months. It’s painless but excision. Local recurrence rate is high, about 23-43% progressively increasing in size. MRI revealed a well- in the limbs and 90-100% in the retroperitoneum. defined multilobulated and septated lesion involving The gold standard method in diagnosing subtypes of the left gluteal muscles with intrapelvic extension. sarcoma is biopsy either by FNAC or excisional biopsy. Patient underwent complete excision of the lesion. On gross appearance revealed a mass sized 18cm X Conclusion 16cm X 95cm, lobulated pale yellowish with fibrous The gold key in treating liposarcoma is wide excision septations and solid central mass weighing 1.15kg. It with negative margins. By surgical complete excision, was reported as a well differentiated liposarcoma in it reduces risks of recurrence and metastasis. the histopathology report.

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Accuracy Of Surgeon-Performed Results Ultrasound-Guided Core-Needle Adequate sample were obtained in all 58 cases. Biopsy Of Breast Lesions Malignancy was present in 32 of 58 (55.2%), 1 (1.72%) with atypical features, benign lesions 25(43.1%). Nasir S, M S Teoh, Sunil S P, Azra S Among the patients with cancerous or atypical core- Hospital Pulau Pinang, Pulau Pinang, Penang, Malaysia biopsies, 23 proceeded with surgery and all cases were confirmed to have malignancy. Among the non- Introduction cancerous specimens, 7 patients proceeded with Triple assessment is the cornerstone of the initial excision, of which 1 was found to be malignant. The management of breast lesions. Ultrasound-guided case that was reported to have atypical features is an core-needle biopsies have a higher sensitivity if atypical papillomatous lesion and the histopathological compared to palpation based biopsies and is frequently result from excision was invasive papillary cancer. In performed by radiologists. this study the sensitivity of ultrasound guided core- needle biopsy was 95.8% and the specificity was 100%. Objective To determine the diagnostic accuracy of specimens Conclusion obtained by trained surgeons performing office-based Surgeon performed office based ultrasound guided ultrasound-guided core biopsy of suspicious breast biopsy has comparable diagnostic success to that lesions of radiologist-performed ultrasound guided biopsy and is associated with a high accuracy. It is an Methods effective diagnostic tool, convenient to both patients This is a prospective study of surgeon-performed and surgeons and is a valuable skill in a surgeon’s ultrasound-guided core biopsy of suspicious breast armamentarium. lesions from November 2014 till February 2015 in Surgical Out-Patient Department at Hospital Pulau Pinang. Core-biopsies were performed on 58 women, and specimens were sent for histopathological examinations. All data were recorded in Microsoft Excel 2010 and subsequently analysed. 91 PP 54 PP 54

Parathyroid Carcinoma In Primary diagnosis of primary HPT was made at the time. He Hyperparathyroidism: A Rare underwent a left hemithyroidectomy and left inferior parathyroidectomy, which revealed an enlarged left Occurrence inferior parathyroid gland with no clear plane of Deborah Ding Y S, Kirubakaran M, Y W Yan demarcation from the left thyroid lobe with no lymph Department of General Surgery, Hospital Raja Permaisuri node enlargement. Bainun, Ipoh, Perak, Malaysia Histopathology would later report this as parathyroid Overactivity of the parathyroid gland(s) in primary carcinoma. Further disease staging by CT imaging hyperparathyroidism(HPT) results in excess production showed no evidence of distant metastases. of parathyroid hormone (PTH), causing hypercalcemia and hyperphosphatemia. The condition that follows In light of the paucity of its occurrence, here we is associated with calculus formation, osteoporosis, describe the onset, diagnosis and features of peptic ulcers, pancreatitis and depression. In nearly parathyroid carcinoma with literature review. 90% of cases, primary HPT is caused by a single parathyroid adenoma; multigland disease is seen in about 10% of patients. Primary HPT caused by parathyroid carcinoma is extremely rare and accounts for <1% of cases.

We report the case of a 51 year-old Malay man, with a history of chronic kidney disease and renal calculi, who was seen by the endocrinologist for evaluation of his increasingly high calcium levels. Ultrasonography and Tc-99m sestamibi scintigraphy showed features of a left solitary thyroid nodule, and a single hyperfunctioning parathyroid adenoma in the left inferior thyroid pole respectively. A

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Parathyroid Surgery: A Case Series hemithyroidectomy. For each patient, preoperative In Hospital Raja Permaisuri Bainun, workup with baseline serum calcium, phosphate and iPTH levels, echocardiography, assessment of the vocal Ipoh cords by ENT, and ultrasound neck was performed. Deborah Ding Y S, Ooi G K, Kirubakaran M, Yan Y W Intraoperative frozen sections were sent in each case. Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia RESULTS INTRODUCTION Currently no patients have displayed evidence of Overproduction of parathyroid hormone (PTH) in recurrent disease, or hypoparathyroidism post- hyperparathyroidism (HPT) causes hypercalcemia due surgery. Histopathology for 12 patients was reported to various mechanisms. In primary HPT, PTH levels as nodular hyperplasia of the parathyroid glands. are abnormally high, in spite of the negative feedback Of note, histopathology for 1 patient was reported mechanism which suppresses PTH release in response as parathyroid carcinoma, and in another as thyroid to increased serum calcium. Secondary HPT occurs carcinoma with nodular parathyroid hyperplasia. where PTH levels are elevated secondary to a chronic CONCLUSION condition, most commonly renal failure. Tertiary HPT occurs with autonomous secretion of PTH, typically Parathyroid surgery remains an effective means after longstanding secondary HPT. Parathyroidectomy of palliation in renal failure patients resistant is the mainstay of treatment in these conditions. Being to medical therapy. It is interesting to see in the the newest Endocrine unit in KKM we reviewed the long-term, with growing patient data, the rate of patients who underwent parathyroid surgery in the recurrence and prevalence of malignant disease in past 6 months. hyperparathyroidism in our setting.

METHOD From September 2014 – February 2015, 12 patients were referred to us by the nephrologist - 10 of whom underwent total parathyroidectomy, while 2 underwent subtotal parathyroidectomy with 92 PP 56 PP 56

Delayed Diagnosis of Traumatic was gradual but progressive and he was discharged 2 Diaphragmatic Hernia: A Case Report weeks later. Deborah Ding Y S, Basel E, Yan Y W Here we discuss the incidence of the delayed Department of General Surgery, Hospital Raja Permaisuri diagnosis of traumatic diaphragmatic hernias and its Bainun, Ipoh, Perak, Malaysia management with literature review.

Traumatic diaphragmatic hernias can occur as a result of severe blunt trauma or penetrating thoracoabdominal injuries. Making an early diagnosis can be difficult; delayed diagnoses of this condition have been reported, where patients may present with chronic abdominal and/or chest symptoms, or symptoms of acute intestinal obstruction.

We report the case of a 50 year-old man who, giving no recent history of trauma, presented to casualty in respiratory distress. In the week leading up to his admission he had complained of worsening dyspnoea and epigastric pain. Computed tomography showed a deficient left posterior diaphragm, with herniation of the stomach and spleen.

An emergency laparotomy was performed once the patient was stabilized - intraoperative findings revealed a ruptured left posterolateral wall of the diaphragm. Further history taken revealed that he was involved in a motor vehicle accident more than a year ago. Postoperative recovery for this patient

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MINIMISING MINIMAL INVASIVE Minimising the number of ports to perform SURGERY: “ TWO 5MM PORTS & laparoscopic cholecystectectomy can reduce the number of incisions, improve post operative pain PUPPETRY TRACTION LAPAROSCOPIC control, rapid return to the activity and work, patient CHOLECYSTECTOMY” SINGLE SURGEON & satisfaction and cosmetic result. SINGLE CENTRE EXPERIENCE We report several cases of two 5mm ports and Tang Y M1, Salina A Y2, Mutyala Vinod Kumar1, “Puppetry Traction” for laparoscopic cholecystectomy 1 Lai C K , et al done by a single surgeon at a district hospital in the 1 Hospital Duchess of Kent, Sandakan, East Sabah, Malaysia east coast of Sabah, Malaysia. 2Hospital Sultanah Nur Zahirah, Kuala Terengganu, Terengganu, Malaysia

Minimally invasive surgery has been great changes over the last few years. In the world of laparoscopy there were a lot of innovations to further minimise the incision.

New approach comes with increased demand on technical skills, a need for training technique and the potential for new possible complications and adverse outcome.

The introduction of an innovative “ Puppetry Traction” not only allow the operating surgeon to be fully in control of the procedure but reduce the number of assistants. This offers the opportunity for the surgeon to progress and improve his or her technical capabilities. 93 PP 58 PP 58

A Case report: Nipple areola Case Report sparing subcutaneous mastectomy, A 3o-year-old lady presented with painless left breast axillary clearance and immediate lump of 3 months duration. She had menarche at 11 year of age. She was married and breast fed her child breast reconstruction with TRAM for 6 months. There was no family history of breast (Transverse Rectus Abdominis cancer. On examination she had 3 x 2 cm firm spherical Myocutaneous) flap for a young mobile lump at upper inner quadrant of left breast patient with breast carcinoma with no palpable axillary lymph nodes. Ultrasound breast showed two hypoechoic lesions (1.2cm x1.7cm 1 1 M Sohail , Aini Farizan Binti Ibrahim , and 0.7cm x1 cm) at upper inner quadrant of left Khairunnisa C G2, J Ranjit3 breast with irregular margins and foci of calcifications. 1Department of Surgery, Faculty of Medicine and Health Ultrasound guided core biopsy was taken from larger Sciences, Universiti Malaysia Sarawak (UNIMAS), Sarawak, lesion. HPE report showed invasive ductal carcinoma Malaysia with focal DCIS component. 2Department of Surgery, Hospital Umum, Sarawak, Malaysia 3 Department of Plastic Surgery, Hospital Umum, Sarawak, After counselling, patient and husband agreed for Malaysia mastectomy, axillary clearance and immediate breast reconstruction. Nipple areola sparing subcutaneous Introduction mastectomy and level 2 axillary clearance was Mastectomy is one of the common procedures performed through laterally placed incision over the performed for breast carcinoma patients. left breast. Immediate breast reconstruction was done Unfortunately most of the patients are not offered with de-epithelized TRAM flap. Patient’s recovery was breast reconstruction either due to lack of awareness uneventful and she was happy with the outcome. or due to lack of expertise. We present a case of young lady who underwent mastectomy, axillary clearance HPE and immediate breast reconstruction. Invasive ductal carcinoma (T2N0Mx), ER: Positive, PR: Positive, HER2: 1+. All margins were clear.

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Discussion Resuscitative Thoracotomy Breast cancer is currently one of the most curable in Penetrating Thoracic Injury; forms of cancer. Survival without restoration however Case Series has negative impact on self- image and lifestyle. Breast reconstruction either immediate or delayed should be Khair Syamimi B, Mohd Johari, Hasnizal Nording, offered to all patients who undergo mastectomy. Chen Hong Lim Surgery Department, Hospital Segamat, Johor, Malaysia Key words Breast CA, breast reconstruction, nipple-sparing Introduction mastectomy Emergency resuscitative thoracotomy is performed immediately as part of initial resuscitation either at scene, emergency department or in operating theatre. The common indications include penetrating and blunt injury to the chest with cardiac arrest, shock or persistent thoracic hemorrhage. We aimed to review our experience and outcome of resuscitative thoracotomy in penetrating thoracic injury.

Materials and Methods Our data were from records of three patients who underwent emergency thoracotomy in Hospital Segamat from January 2012 to March 2015.

Results All cases presented with penetrating chest injury were in hypovolemic shock with massive haemothorax. The first patient, 26-year-old man accidentally stabbed his left chest with a sickle that created a 12cm wound. 94 PP 59 PP 60

Resuscitative thoracotomy revealed a diaphragmatic LOW RECTAL CANCER PRESENTING WITH ruptured with spleen eviscerated into pleural cavity PERFORATED SIGMOID VOLVULUS : A CASE and a transected left kidney. Splenectomy, left nephrectomy and left hemidiaphragm repair were REPORT done. For the second case, 58-year-old man developed L L Sivamoorthy, Chong Chaw Jong, Adnan Zafar, massive haemothorax after a CT guided lung biopsy. S Saidah, Sazalene D H, Othman M Z He arrested for 10 minutes. Resuscitative thoracotomy Department of General Surgery, Tawau Hospital, Sabah, revealed a 1.5cm laceration wound on the right lung Malaysia parenchyma which was primary closed. The third patient, 31-year-old man was stabbed over the left INTRODUCTION chest during an assault. Resuscitative thoracotomy A case report on a patient with concurrent sigmoid revealed a penetrating lung parenchymal injury with volvulus and rectal carcinoma. adjacent penetrating injury into the left ventricle. Pledgeted repair of myocardium and primary repair of CASE REPORT the lung done. Post operatively all patients survived A 72-year-old gentleman, presented with a 2-week and fully recovered. history of intestinal obstruction symptoms and constipation for 3 months. Clinically patient was septic Conclusion and peritonitic. Per rectally an obstructing tumour 4 Emergency resuscitative thoracotomy is a lifesaving cm from anal verge was felt. Abdominal X-ray showed procedure that usually performed by trauma or coffee bean sign. Patient underwent emergency cardiothoracic surgeons. However, in a center without laparotomy and intraoperatively noted to have faecal these subspecialties, the general surgeons have a role peritonitis secondary to perforated sigmoid volvulus, in performing the live saving procedure. We attribute with the rectal tumour extending above the peritoneal the good outcomes to initial aggressive resuscitation reflection. Sigmoidectomy, double barrel stoma and and rapid decision for resuscitative thoracotomy. abdominal washout was done. Punch biopsy of rectal mass reported adenocarcinoma. CT staging showed no distant metastasis, only local infiltration and regional lymphadenopathy. He recovered well post operatively.

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DISCUSSION Multiple small bowel diverticuli Sigmoid volvulus causes 5% of large bowel obstruction Su Kim Peng, Dyg Zahratul Hamrak, Rizal Irwan in Western nations and is 10 times higher in Africa and Asia; most likely attributed to the high fibre diet in Syah, Rashide Yaacob these populations. Chronic constipation and faecal Surgical Department, Hospital Sultan Abdul Halim, Sungai Petani, Kedah, Malaysia loading causes torsion on a narrow sigmoid mesentery pedicle creating a closed loop obstruction, which leads to infarction, perforation and faecal peritonitis, like Background our patient. However, it is rare for a rectal cancer to Diverticula of small bowel, excluding Meckel’s, cause acute dilatation and elongation of the colon is uncommon and usually asymptomatic. It may leading to volvulus. On literature review, there were occur at duodenum, jejunum or ileum. Small-bowel 6 cases reported in which the tumour causes the diverticulosis is a rare entity that can be discovered volvulus, there is only 1 previous case reporting a incidentally during laparotomy, endoscopy, or concurrent rectal tumour with sigmoid volvulus. Our radiographic imaging studies. However, when case is similar to the last case report. In view of the complications do occur, such diverticula may cause obstructing rectal mass and peritonitis in our case, inflammation, intestinal obstruction, gastrointestinal urgent bowel decompression, resection and washout hemorrhage, perforation, abscess formation and was done. Definitive management in regards to fistula formation. the rectal carcinoma was planned after adequate optimization. At this moment, there is no consensus concerning its treatment, although laparotomies are common in the acute setting. In this case report, we report two cases of incidental findings of small bowel diverticuli during laparotomies for acute abdomen, which we treated conservatively for asymptomatic small bowel diverticuli.

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Case report Conclusion Case 1: 65-year-old Malay gentleman with no known The symptomatology of small bowel diverticulum underlying medical illness presented with lower is unspecific, therefore preoperative diagnosis abdominal pain and fever. Physical examination is difficult. The low incidence of complications revealed peritonitis and exploratory laparotomy associated with small bowel diverticulum justifies was performed. Intra-operatively noted perforated a nonoperative approach. However, more studies appendicitis and multiple small bowel diverticuli ; should be done to find out the benefits of resection 18cm from terminal ileum up to 20cm from DJ junction of multiple small bowel diverticuli versus conservative (approximately 100cm), all non-complicated with management for small bowel diverticuli. broad based neck , largest 2x2cm with broad neck 1cm. Appendicectomy was done and small bowel diverticuli were treated conservatively.

Case 2 57-year-old Malay woman with previous surgical history of open paraumbilical hernia repair in 1997, presented with generalized abdominal pain for 3 days, associated with abdominal distension and vomiting. Physical examination revealed abdominal distension and tenderness over paraumbilical area. Computed Tomography of Abdomen was done which showed small bowel dilatation secondary to adhesion with ascites. Exploratory laparotomy was performed. Intra- operatively, noted internal herniation of loop of small bowel by omental band and multiple small bowel diverticuli, all non-complicated with broad based neck, largest measuring about 5x5cm with broad neck about 1cm. Adhesion of omental band was released and small bowel diverticuli were not resected.

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Giant Benign prostate Hyperplasia rectal examination was found to be normal, but the successfully removed by suprapubic prostate was very large with a rubbery consistency and no palpable hard nodules. The upper border of prostatectomy the prostate could not be reached. Renal function Rizal Irwan Syah, Nur Amira, Su Kim Peng, test was deranged with urea and creatinine of a Hari Dass Govindasamy value of 13.0 and 136 respectively. Hemoglobin on Surgical Department, Hospital Sultan Abdul Halim, presentation was 8.4g/dl and PSA level was 26ng/ml. Sungai Petani, Kedah, Malaysia Flexible cystoureteroscopy revealed kissing prostate with blood clots in the bladder. Ultrasound KUB Background suggestive of prostatic mass, thickened bladder wall A benign prostatic hyperplasia (BPH) weighing more due to chronic bladder outlet obstruction, bilateral than 200 g is a rare entity. This case report concerns renal parenchymal disease. He was planned for a patient with a BPH weighing 320 g which was Transurethral Resection of Prostate , however unable successfully removed by suprapubic prostatectomy. to proceed as cystocope unable to pass through The unusual case described here presented in an thus proceed with suprapubic prostatectomy. The 89-year-old man with significant lower urinary tract estimated blood loss was about 1,800 mL throughout obstructive symptoms, an episode of hematuria, surgery and six units of blood were transfused during retention and a high prostate specific antigen (PSA) surgery. The urine was clear after 4 days postoperative. value of 26ng/ml. The surgical specimen measured 7.5 The urethral catheter was removed after 2 weeks and x 60 x 5.5 cm. The patient’s postoperative period was patient was able to void without difficulty. The excised uneventful. Pathologic examination revealed nodular specimen measured 75 x 60 x 55 mm, and weighed 320 hyperplasia with no evidence of malignancy. g and submitted for histopathological examination. The external surface of the prostate is smooth. There Case presentation are multiple variably sized nodules, grossly consistent We report a case of 89-year-old man who had a long with benign prostatic hyperplasia with no evidence of history of day and night frequency which progressively prostatitis or malignancy. worsened and lead to acute urinary retention. He was on urinary catheter for the past 3 years. On digital 96 PP 62 PP 63

Conclusion Case Report: Blunt Cerebrovascular Prostate weighing more than 200g is an extremely Injuries (BCVI) - An Underdiagnosed rare entity. In this patient, a transvesical open Condition In Trauma Patients prostatectomy was performed and nodular hyperplasia was removed in one piece successfully. Large benign W S Pang, Yuzaidi M, Rizal I A, Farouk A prostatic hyperplasia is a very rare condition and Trauma Unit, Department of General Surgery, open surgery techniques still appear to be the safest Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia methods for treatment. Introduction Blunt cerebrovascular injuries represent a group of blunt injuries to the carotids and the vertebral arteries, presenting as vessel wall hematoma, dissection, pseudoaneurysm, vessel transection or occlusion. BCVIs are uncommon, but can carry significant morbidity and mortality.

Case Report We describe a case of a 19 year old female college student who was involved in a high impact car collision. She sustained a moderate head injury, right pneumothorax, grade 2 liver injury and a right humeral shaft fracture. After regaining consciousness she complained of bilateral upper extremity weakness with preservation of lower extremity motor function. CT scan of the spine showed that she did not have any fractures and further MRI did not show any central cord lesion. Although she had a compound fracture of her right humerus, the radial nerve was noted to be

PP 63 PP 64 intact during debridement of the fracture site. These Case report: A Rare Case Of facts did not explain her upper limb weakness. Upon Adult Multiple Small Bowel further scrutiny of the MRI, it was noted that she had ischemic changes in the cortex of her brain, worse on Intussusceptions Due To Metastatic the right side. Investigations proceeded to a CTA of the Sarcomatoid Carcinoma brain and neck vessels whereupon a dissection in the W S Pang1, K K Chan1, R Abd Rashid2, S M Devan2 right carotid artery and a pseudoaneurysm of the left 1General Surgery Department, Hospital Sultanah Aminah, carotid artery was revealed. Johor Bahru, Johor, Malaysia 2Pathology Department, Hospital Sultanah Aminah, Conclusion Johor Bahru, Johor, Malaysia BCVI is oftentimes missed. Depending on grade and location of the lesion, BCVI may be treated Introduction with antiplatelets or may require intervention. CT Adult small bowel intussusceptions triggered by angiogram of the cervical vessels should be carried small bowel polyps are rare. Metastatic sarcomatoid out in trauma patients with risk factors for screening carcinoma forming multiple polyps in small bowel is of BCVI. This should be done before the onset of almost unheard of. Less than 20 cases have so far been neurological symptoms. reported in literature.

Case Report We describe a case in a 64 year old Chinese man presenting with small bowel intussusceptions, identified through abdominal sonography and CT scan. Intraoperatively there were two small bowel intussusceptions identified with numerous small bowel polyps located from proximal till distal jejunum. We resected the whole affected segment with primary anastomosis. Pathology revealed metastatic high grade sarcomatoid carcinoma, supported by immunohistochecmical staining. 97 PP 64 PP 65

Conclusion Factors Associated With Clearance Sarcomatoid carcinoma is an aggressive and Of Renal Stones Treated With fortunately very rare disease, leading to very poor Extracorporeal Shockwave prognosis. Patients typically present in an advanced stage of the disease with distant metastasis. In Lithotripsy the small bowel it may present as gastrointestinal Senthil Vasan Kanthasamy, Khaidir Abu Bakar bleeding, mechanical obstruction, perforation or and University of Malaya, Kuala Lumpur, Malaysia as in this case, intussusception. Treatment is largely by surgical resection, and both chemotherapy and Extracorporeal shock wave lithotripsy (ESWL) is the radiotherapy generate poor response and neither preferred treatment modality for patients suffering affects survival rates. Seventy percent of patients with from urinary stones sized <20 mm. But there is sarcomatoid carcinoma die within 3 months to 2 years. much uncertainty with the use of this technological Due to its aggressive nature, sarcomatoid carcinoma intervention as the stones cannot always be should be considered as one of the causes of small fragmented. The objective of this study was to bowel polyps. determine the patient and stone characteristics that were associated with clearance of renal stones treated with ESWL. We retrospectively evaluated 100 patients who underwent ESWL with solitary, radio-opaque kidney stones measuring 6–20 mm. Patients were evaluated with computed tomography urogram prior to the first ESWL and x-ray/ultrasound after the last ESWL session. All patients were treated using Dornier Lithotripter S. Patients with stone fragments ≤5mm were categorised as stone-free and those with stones >5mm underwent further ESWL sessions to a maximum of three sessions. Univariate and multivariate logistic regression were performed between patient and stone characteristics and ESWL outcome (success or failure).

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Two receiver operating characteristic (ROC) curves Acute Appendicitis in Leptospirosis: were plotted to determine the optimum stone density A Case Report and size for a successful ESWL. 35 patients (35%) were stone-free and 65 patients (65%) were grouped as Rosliza G1, Rosmalinda K2, Nor Aishah M A2 unsuccessful ESWL. Stone density and stone size were 1Faculty of Medicine and Health Science, Islamic Science important predictors of ESWL in fragmenting renal University of Malaysia (USIM), Selangor, Malaysia 2 stones. Probability of ESWL success can be calculated Department of Surgery, Ampang Hospital, Selangor, Malaysia using the formula P(ESWL success) = 2.718z/1+2.718z, where z=12.11–0.011X–0.169Y, 12.111=constant, X=stone density and Y=stone size. ROC curve demonstrated Leptospirosis is a common zoonotic disease. a stone density cut off value of 982.5HU with 81.5% The infection is not uncommon but its clinical sensitivity and 60% specificity. We concluded that manifestation is non-specific with different rare the probability of a successful ESWL in fragmenting presentations. renal stones can be predicted if stone size and density We report a case of an uncommon presentation of is known. ESWL is not recommended for stones with leptospirosis as an acute abdomen in 35-year-old density >982.50HU. lady. She presented with sudden onset of right-sided abdominal pain associated with high-grade fever of one-day duration. On arrival, she was in septic shock with tender and guarded right abdomen. Laboratory test showed neutropenia with normal range of renal profile and liver function test. Ultrasonagraphy demonstrated some free fluid mainly at pelvic region. She underwent an emergency surgery for an indication of perforated appendicitis. However, intraoperative finding revealed ascitic fluid at the pelvic region, engorged and inflamed appendix with multiple mesenteric lymphadenopathy. Histopathological examination (HPE) described features of acute 98 PP 66 Pp 67 appendicitis with enlarged mesenteric lymph nodes. Does Serum Intact Parathyroid Septic screening was performed in which serology test Hormone ( iPTH) Decline 6 Hours for leptospirosis was positive. After Total Thyroidectomy A rare presentation of leptospirosis with acute Can Predict Post Operative pancreatitis and acute acalculous cholecystitis has Hypocalcaemia ? been described in the past. However, to date, no Norashikin M N1, Aina E N1, Nor Shafini2, presentation of this disease as an acute appendicitis 3 has been reported. Her clinical presentation of Shahrun Niza 1 septic shock was not correlated with the operative Breast and Endocrine Unit, Hospital Kuala Lumpur, finding, thus clinical suspicion for an acute febrile Kuala Lumpur, Malaysia 2Department of Pathology, Hospital Kuala Lumpur, illness of tropical country was raised. High index of Kuala Lumpur, Malaysia clinical suspicion is crucial so that the appropriate 3Endocrine and Breast Unit investigations and early intervention can be carried out to reduce the morbidity and mortality. Leptospirosis is INTRODUCTION probably an etiology of acute appendicitis. Hence, it is The level of serum iPTH has been useful in the important to be aware of uncommon manifestations prediction of post thyroidectomy hypocalcemia. of this disease. Analysis of the decrease between preoperative and postoperative iPTH levels reported to be more accurate. Key words Leptospirosis, acute acalculous cholecystis, acute OBJECTIVES appendicitis To determine whether serum iPTH decline 6 hours after total thyroidectomy can predict post operative hypocalcaemia

MATERIALS AND METHODS A prospective study of 49 consecutive patients who underwent total thyroidectomy was performed. Serum iPTH level was measured preoperatively and

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A Retrospective Study On “The Effect 6 hours postoperatively . The sensitivity, specificity, for the relative iPTH decline was estimated by confidence Of Bariatric Surgery In Resolution interval from thresholds determined by ROC curve Of Comorbidities”- Hospital Taiping analysis Suriakanthan Bala Krishnan, Rajkumar Vinayak, Umasangar Ramasamy, Yap Choon Fong, RESULTS Leong Keen Wai Fifteen patients developed hypocalcemia . 11(22%) were asymptomatic, and 4 (8%) were Hospital Taiping, Perak, Malaysia symptomatic . Majority 39 patients (69%) of patient were normocalcemia within 16 hours post total Aim Of Study thyroidectomy. The thresholds enabling prediction of To determine the effects of bariatric surgery on the hypocalcemia obtained with ROC curves were 70.1% resolution of selected comorbidities – 1)diabetes,2) for relative iPTH decline. This study showed high hypertension, 3)dyslipidemia,4) OSA,5)Polycystic sensitivity which was 93.3%.However , specificity Ovarian Syndrome (PCOS). was only 50%.The threshold value of 82.2% relative Methodology iPTH decline was determined to distinguish patients presenting with symptomatic hypocalcemia from A retrospective data collection done on all patients those with asymptomatic hypocalcemia. Sensitivity who underwent bariatric surgery from 2009 to 2015 and specificity values were 100% and 36.3 %. in Hospital Taiping. A total of 100 patients selected as all required data available in these patients. Data was CONCLUSION collected pre-operatively as well as 1 month, 3 months, The decline in serum intact parathyroid hormone 6 6 months, 9 months and 1 year post-operatively. hours post total thyroidectomy is a sensitive indicator Targeted parameters were obstructive sleep apnea of hypocalcaemia. However due to high false positive (OSA) symptoms, blood pressure- reduction/cessation , results in decreased both in accuracy and specificity. of antihypertensive medication, HbA1c/ reduction or In this study, false positive results were mainly due to cessation in oral hypoglycemic agent (OHA) or insulin the timing of serum calcium taking postoperatively medications, LDL level, review of PCOS symptoms in which too early for detection of hypocalcaemia (infertility). symptoms. In such ,serum iPTH is not a good predictor. 99 PP 68 PP 69

Results Post-Operative Vomiting Proves Bariatric surgery showed positive outcomes in the Fatal : A Rare Case of Boerhaave’s reduction of symptoms of OSA (100%), optimization Syndrome of blood pressure (88%), diabetes (86%), dyslipidemia (88%) and resolution of infertility/ PCOS symptoms Arivarni K1, Sivaneswaran L1, C Rajkumar Vinayak1, (100%). This is in addition to the positive effects of Umasangar R1, Premnanth N2 the surgery on lowering body mass index (BMI), and 1Department of Surgery, Hospital Taiping, Taiping, Perak, a mere reduction of 15% in excess body weight has Malaysia shown to grossly alleviate symptoms of arthritis, OSA 2Penang Medical College, Penang, Malaysia and PCOS. Apart from resolution of comorbidities, bariatric surgery has shown to have positive influence Nausea and vomiting after an operation is a common on patient’s lifestyle. symptom which may result from a wide range of anesthetic, surgical or patient factors. However it Conclusion rarely causes fatal complications. One such rarity is A very favourable outcome has been shown in the perforation of the esophagus secondary to forceful resolution of comorbidities and improvement of vomiting, known as Boerhaave’s Syndrome. metabolic syndrome in patients who underwent bariatric surgery. We report this rare presentation in an elderly gentleman, who had developed persistent nausea and vomiting after an uneventful right hemicolectomy for an ascending colon tumor. Though symptoms subsided with antiemetics, he subsequently developed shortness of breath which was attributed to his history of Chronic Obstructive Airway Disease. Immediate post-operative chest x-ray was unremarkable, however a repeated chest X-ray on post-operative day three revealed bilateral pneumothorax. After insertion of bilateral chest tube, brownish purulent material

PP 69 PP 70 was drained. An urgent CT scan of the thorax revealed Outcome of Inter-hospital minimal pneumomediastinum and possible empyema Transfers for Major Trauma thoracis. He was treated conservatively with broad spectrum antibiotics. Four days later he underwent an Victims: A Preliminary Audit Oesophago-gastro-duodenoscopy (OGDS) in suspicion J C Y Gan, Y Mohammed, Rizal I A, A K B Gunn of upper gastro intestinal bleeding, when a lower Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia third esophageal perforation was incidentally noted. Despite successfully stenting the perforated segment, Objectives patient succumbed to multiorgan failure secondary to The management of trauma patient in hospitals the sepsis a month later. without full resources can be challenging. We reviewed the survival outcome of major trauma patients who Due to the diagnostic dilemma from an unusual were first managed by other hospitals within the state presentation, the delay in management proved to be of Johor and subsequently referred to tertiary hospital fatal in this patient. Though Boerhaave’s syndrome with trauma care service. secondary to post-operative vomiting is rare, with our case being only the fifth of such reported cases Method in literature, there should still be a high index of The database of Hospital Sultanah Aminah Johor suspicion as early treatment is known to significantly Bahru (HSAJB) trauma registry was analyzed from May reduce the risk of mortality. 2011 to April 2013. The number of district referrals of Southern Johor for major trauma was identified. The time taken for inter-hospital transfer, mechanism and severity of injury, ICU admission, cause of death and survival rate was observed.

Results Our trauma registry database recorded 780 major trauma (ISS >15) admissions within 2 years in which 368 (47.2%) were district referrals from Hospital 100 PP 70 PP 71

Pontian (73), Hospital Kulai (108), Hospital Batu Pahat Pneumoperitoneum, (16), Hospital Kluang (74), Hospital Kota Tinggi (18), pneumoretroperitoneum, Hospital Mersing (12), Hospital Segamat (15), Hospital Muar (17), Hospital Ledang (1), Hospital Sultan Ismail tension pneumothorax and (21), other hospitals (13). The median duration for inter- diffuse subcutaneous emphysema hospital transfer was 5 hours 30mins (IQR 5 hours secondary to caecal perforation 15 mins). Majority were victims of blunt trauma (354 post colonic stenting : A case cases) whereas 14 cases were victims of penetrating report injury. The mean ISS was 32 and systolic blood pressure on presentation to HSAJB was 120 (SD ± 25) mmHg. Two H S Boo, Fadliyazi A R ,Prabhu Ramasamy hundred fifty patients required ICU admission. Eighty Penang General Hospital, Penang, Malaysia two patients died and the cause of death were head injury (28), multiorgan failure syndrome (6), bleeding Colonic stenting is a relatively safe procedure for and coagulopathy (8), sepsis (32) and others (8). There palliation and acute decompression of colonic is no statistical difference between the survival of obstruction. The incidence of intraperitoneal major trauma victims referred from district hospital, colonic perforation post colonic stenting ranged 77.7% (286), and that of direct admission, 80.8% (333). from 3.7%-4.5%1. However,combination of intraperitoneal and extraperitoneal perforation with Conclusions pneumoretroperitoneum, tension pneumothorax and In general the survival of trauma patients transferred diffuse subcutaneous emphysema is an extremely rare from district hospital has equal outcome of survival and lethal complication. We report a case of a 87-year- compared with direct admissions. However, this data old women with underlying sigmoid colon carcinoma represents non-stratified injury severity. Future audits who underwent palliative colonic stenting and are planned to address this deficiency. complicated by caecal perforation and extraperitoneal perforation. This case may raise the awareness on the likelihood of these serious complications after colonic stenting.

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When The Stomach Flips Over on Discussion and Conclusion Itself MGV is a rare diagnosis with various possible presenting symptoms, which makes the diagnosis 1 2 2 R Hassan , Tay K V , A Shabbir challenging Although it usually presents with 1 Department of Surgery, Penang Medical College, Penang, Borchardt’s triad of upper abdominal pain, non- Malaysia productive retching and inability to pass an NG tube 2Department of General Surgery, National University down the stomach, none of our patients exhibited the Hospital, Singapore latter two symptoms. Prompt diagnosis with clinical and imaging findings is paramount to intervene Introduction early, as delay in diagnosis will cause catastrophic Gastric volvulus is the abnormal rotation of the consequences such as extensive gastric ischemia, stomach of more than 180° in its short or long necrosis and perforation with generalized peritonism. 3 axis. There are only about 300 cases of gastric X-ray and CT scan are routine investigations in tertiary volvulus reported to date since 1886 in the adults. centre for patients presenting with acute abdomen. Mesenteroaxial gastric volvulus (MGV), a rotational Once the diagnosis is made, NG tube decompression variant where the stomach rotated abnormally along and surgical intervention are performed. its short axis, comprises of about one-third the cases of all gastric volvulus in adults. MGV is associated with 3 Sevcik, William E., and Ivan P. Steiner. “Acute gastric volvulus: case high mortality due to the acuteness of presentation report and review of the literature.” Cjem 1.3 (1999): 200-203. and delay in diagnosis.

Case Presentation 3 three elderly gentlemen presented acutely with primary MGV. All patients were treated with emergency nasogastric (NG) tube decompression and laparoscopic gastropexy in the acute setting. One patient developed haemoperitoneum due to a splenic subcapsular tear which was secured by haemostasis. All patients were alive upon discharge. 101 PP 73 PP 73

Gastrointestinal Amyloidosis: Rare with friable and oedematous mucosa. She underwent Disease With Common Presentation CT scan demonstrating obstruction at mid small bowel and suspicious of pyloric stenosis. She had laparotomy Causes Dilemma in Diagnosis for her non resolving obstruction, revealing dilated Humaizy A S2, Shamsher S N2, Mohd Naufal R2 , edematous and inflamed small bowels with no obvious Prathaban M2, N Haron1, Fitzjerald H2 transitional point with multiple mesenteric lymph 1Discipline of General Surgery, Faculty of Medicine, nodes. Bowel decompression was performed via Universiti Teknologi MARA (UiTM), Shah Alam, Selangor, appendix stump and the appendix sent for histology Malaysia which eventually confirms the diagnosis. 2Department of Surgery, Hospital Selayang, Selangor, Malaysia Discussion Amyloidosis is an uncommon condition usually Introduction affecting the renal and cardiac symptoms. Other Amyloidosis is a rare disorder of protein folding in typical presentations includes hepatomegaly and which normally soluble proteins are deposited as sensorineural peripheral neuropathy. Gastrointestinal abnormal, insoluble fibrils causing disruption of amyloidosis is not common but usually presents with organ function. Commonly affected organs includes myriad of symptoms which includes gastrointestinal renal and cardiac system. Amyloidosis of the bleeding, pseudoobstruction, macroglossia including gastrointestinal tract is rare, may be limited to gut or fatigue and weight loss. Its vital to have low threshold part of systemic disease, with most presenting with of suspicion in patients with multiple symptoms. upper gastrointestinal bleeding (UGIB). Clinician might be investigating other disorders including invasive procedures prior to considering A 62 year old lady presented with abdominal distension amyloidosis. Gold standard for confirmation of and malaena for six weeks with tender epigastrium diagnosis is biopsy of organ involved with “Congo and distended abdomen. She denies any constitutional Red” stain. Literatures has suggested biopsy of distant or alarming symptoms and no significant family or sites including abdominal fat, rectum, bone marrow or medical history. She underwent multiple gastroscopy minor salivary glands with positive results. due to persistent UGIB, revealing a large antral ulcer

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Conclusion Breast Cancer Audit in Sarawak Amyloidosis is a rare condition presenting with General Hospital, A 7-Year Review bewildering symptoms and mimic other common presentation. It is frequently not the first line of L W Wong, K S Chai, C H Chea, J Rokayah differential diagnosis and always unaccounted, but Sarawak General Hospital, Kuching, Sarawak, Malaysia should be considered when approaching a patient with chronic gastrointestinal dysmotility and recurrent OBJECTIVE UGIB. Breast cancer is a major cause of death worldwide and locally in women. There is still relative scarcity of data on breast cancer in the Sarawakian population, hence the creation of our audit.

METHODS Breast cancer cases detected in Sarawak General Hospital were collected from July 2007 – December 2014. Demographics, history, clinical, operative and histopathological data were collected.

RESULTS We evaluated 706 patients with age ranging from 17 – 91-year-old and a peak age group of 41 – 55-year-old. Malay women make up about 35% of our patients, Chinese women made up of 37% of our patients. Although the majority of Sarawak population is Dayak, their women made up only about 23.3% of our patients.

Most of our patients presented with a lump(98.5%). Unfortunately, only 331 patients seek medical

102 PP 74 PP 75 attention within 6 months after noticing the lump Diagnostic Dilemma In Primary (46.8%) Breast Neuroendocrine Tumour: CONCLUSION Sarawak General Hospital Sarawakian women are becoming more aware of Experience breast cancer however there is still a number of Khairunnisa C G1, Aini I1,2, Nik Azim N A1 women who presented late in the disease. More 1Sarawak General Hospital, Kuching, Sarawak, Malaysia awareness programmes should be organised because 2Universiti Malaysia Sarawak, Kota Samarahan, Sarawak, early detection saves life. Patients should be educated Malaysia to present early in the disease. Background

Primary breast neuroendocrine tumour (NET) is a rare tumour that is still largely under diagnosed and treated. The essence of this tumour is still controversial and, if acknowledged, it would account for less than 1% of primary breast cancer. We present three different cases of primary breast NET diagnosed in our local hospital setting.

Method Case 1 56-year-old lady, presented with painless right breast lump. MMG showed BIRADS 5 lesion, while FNAC of the lump showed category 5 (highly suspicious of malignancy). She underwent right mastectomy and axillary clearance. Unfortunately, four weeks later she developed bilateral leg weakness secondary to cord compression. Urgent spinal decompression and

PP 75 PP 76 posterior instrumentation done. Vertebral bone biopsy Gastrointestinal Bleed Caused By revealed metastatic breast neuroendocrine tumour. Epitheloid Sarcoma : A Case Report She underwent chemotherapy successfully and on regular surgical clinic follow-up. F Y Lee, L Limi, T Gee Surgical Department, Universiti Putra Malaysia, Hospital Case 2 Serdang, Serdang, Selangor, Malaysia 72-year-old lady, complaint of painful right breast lump for two months duration. USG guided biopsy showed Introduction invasive ductal carcinoma, Bloom & Richardson Grade Epithelioid sarcoma is a rare soft tissue neoplasm , 3. MMG and USG of breast showed highly suspicious comprising less than 1% of sarcoma. In this case, we of malignancy. She underwent wide local excision and report a rare cause of bleeding from the small bowel. axillary clearance of right breast. However, formal HPE revealed well differentiated neuroendocrine tumour Case presentation grade 1. Subsequently, she underwent completion A 55 year old Chinese man presented with symptomatic mastectomy and subjected for chemotherapy. anemia and partial intestinal obstruction symptoms. Fecal occult blood tests were positive, but gastroscopy Case 3 and colonoscopy did not demonstrate any lesion that 50-year-old lady with underlying cervical cancer stage could explain the rapid fall of hemoglobin level. We IA, presented with rapidly enlarging right breast mass. proceeded with CT angiogram of mesentery which USG and MMG showed right breast BIRADS 3. USG revealed suspicious intraluminal blood clot in the guided core biopsy reported as poorly differentiated distal jejunum, however there is no evidence of active neuroendocrine tumour grade 3 (small cell type). bleeding during the scan. Exploratory laparotomy She is currently planned for staging and surgical revealed multiple intraluminal and extraluminal intervention. tumors along the small bowel with largest obstructing tumor located 180cm from duodenojejunal junction. Conclusion Gross examination showed circumferential fungating These three cases illustrated the different tumor infiltrating the mucosa up to subserosal presentation of breast NET and impose diagnostic layer. The tumor composed of malignant cells with challenges in their treatment. 103 PP 76 PP 77 pleomorphic and large vesicular nuclei, prominent Simulating Laparoscopic nucleoli and ample of eosinophilic cytoplasm. The Cholecystectomy Using Ex Vivo surface of tumor is ulcerated and large areas of necrosis is present with lymphovascular invasion. Sheep Gallbladder And Liver Immunohistochemical staining demonstrate positive N S Elina, N Haron, M A Yahya for Vimentin (diffuse), CKAE1/ AE3, EMA and CK7. This General Surgery Discipline, Faculty of Medicine, supported the diagnosis of epithelioid sarcoma. Universiti Teknologi MARA (UiTM), Shah Alam, Selangor, Malaysia Conclusion Epithelioid sarcoma of the small bowel is very rare. We report the use of ex vivo sheep gallbladder and liver, To date, only a handful of cases been reported and in Malaysia, to simulate laparoscopic cholecystectomy, commonly presents with symptomatic anemia and during our basic laparoscopic skills workshop. gastrointestinal bleed. This is a rapidly progress disease and it is very aggressive with a huge propensity The pursuit of simulating surgical procedures is for widespread dissemination with poor prognosis. especially relevant with laparoscopic cholecystectomy as this is a ‘gold standard’ procedure offered to patients with symptomatic cholelithiasis and takes up a significant proportion of a general surgeon’s workload. However, the main ‘bane’ to this procedure is injury to the common bile duct (CBD), as this would render the patient morbid, for life. Hence, it is vital to improve the ability of surgeons to perform this surgery safely.

Using ex vivo animal tissues is one form of simulation in surgical skills training. We used sheep gallbladder and liver, and found that the tissues closely simulate human tissues and provided approximate haptic

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(tactile sensations) feedback. This allowed the trainees SYNCHRONOUS BILATERAL BREAST to understand the principles of the procedure better. CANCER The tissues were able to withstand caudolateral and caudomedial retraction, or ‘flagging’, of the L W H Lai, A K N Kwan, Mohan, Lewellyn gallbladder infundibulum. It also mimics human Hospital Teluk Intan, Perak, Malaysia tissues in the way that the peritoneal coverings and areolar tissues envelopes the Calot’s triangle. This Introduction allowed participants to appreciate the dissection of Synchronous breast cancers represent 0.2% to 3.2% of Calot’s triangle and complete clearance of the areolar all newly diagnosed breast cancers. Its incidence has tissue, which is a key step in achieving the critical view. been reported to be as high as 12%.

We recommend the use of this tissue as a simulation Case Report for laparoscopic cholecystectomy, as the price of sheep A 74-year-old Indian lady with underlying diabetes, innards is relatively low compared to other animal hypertension and history of stroke presented to us tissue, is easily available around the country and avoids with right breast lump of 6 months’ history. There cultural/religious taboos that may surround the use of were no constitutional symptoms or family history other animal tissues. The cost of this type of training, of carcinoma. On examination, there were two in some aspects, is relatively low again in comparison lumps palpable on both breasts with a palpable right to live animal training or ‘in theatre’ training. axillary lymph node. Mammogram showed BIRADS 4 on both breast lesions. Tissue biopsy of right breast We hope to accrue data in subsequent workshops showed intraductal papillary neoplasms while the to confirm that the use of this simulation model left showed infiltrating ductal carcinoma. CT staging improves outcomes in clinical performance. showed no distant metastasis. She underwent bilateral mastectomy and level II axillary clearance. The histopathology report showed right intracystic papillary carcinoma and left showed infiltrating ductal carcinoma.

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Discussion Metaplastic Breast Carcinoma: Synchronism is ambiguous in the literature used A rare histopathological subtype to describe synchronous breast cancers. A widely accepted definition for synchronous bilateral breast Firdaus M G, Siti Rahmah H I M, Ikhwan S M, cancer (SBBC) is when a tumour diagnosed within 90 Zaidi Z, Syed Hassan days of first tumour. They have poorer survival rate and Department of Surgery, School of Medical Science, prognosis in comparison to unilateral breast cancers. Universiti Sains Malaysia Health Campus, Kubang Kerian, The mainstay of approach remains the same as any Kelantan, Malaysia breast lumps where triple assessment is mandatory. Assessment of risk factors is vital, especially family Metaplastic breast carcinoma is a rare subtype of breast history as SBBC is closely associated with genetic neoplasm which contains mixture of carcinomatous predisposition. Treatment for patients with SBBC (epithelial) and sarcomatous (mesenchymal) elements will be based on the basis of tumour biological in variable proportion. The epithelial component characteristics, type of tumour, hormonal status, is usually ductal carcinoma but may include other the number of lymph node metastases or distant variants of breast carcinomas such as squamous, metastases. Neoadjuvant chemotherapy has shown spindle, osseous or chondrosarcoma. We report a a pathological complete response in certain cases of 52-year-old lady who presented with unresolved left SBBC based on its tumour biology and subtype. breast abscess. Biopsy showed extensive squamous metaplasia with a focus of intraductal carcinoma. Conclusion Vimentin, CKAE1 & AE3 was strongly positive but Early detection remains the cornerstone of effective negative for ER, PR and C-erb B2. breast cancer management. Usage of gene expression profiling may provide avenue for future research in investigation of SBBC.

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Per Rectal Bleed in Pregnancy: How was reviewed at our clinic, she had a palpable lower Aggressive Should We Investigate? abdominal mass. Colonoscopy revealed fungating tumour at the sigmoid colon causing luminal Anuradha Valan, Edwin See, Krishnan Sriram, obstruction. Urgent CT abdomen revealed sigmoid Siti Zubaidah, Chuah Jitt Aun colon tumour causing near total occlusion with local Surgical Department, Queen Elizabeth Hospital, invasion and peritoneal metastasis. She was subjected Kota Kinabalu, Sabah, Malaysia to diagnostic laparoscopy and transverse colostomy. Intraoperatively, there were multiple nodules on the Introduction peritoneum and omentum with frozen abdomen. The incidence of colorectal cancer has been increasing Histopathology of the colonoscopic sigmoid biopsies worldwide. Although many countries have national and intraoperative omental biopsies were consistent guidelines on the approach to diagnose colorectal with metastatic sigmoid adenocarcinoma. She was cancer however, there are no particular guidelines referred to oncology for palliative chemotherapy. pertaining to symptomatic pregnant ladies. Here we present a case of advance colorectal cancer in a Conclusion postpartum lady. Up to date there are no guidelines for the approach to per rectal bleed in pregnancy. The lack of national Case report consensus and guidelines makes it difficult to A 31 year old lady, para 3, post partum 10 months outline the management for such cases because presented with per rectal bleed for the past 1 year. under management leads to late diagnosis and She developed per rectal bleed during pregnancy, over management leads to pregnancy related which was associated with chronic constipation and complications. mucous in stool. She presented herself to a district clinic several times whereby she was treated for internal haemorrhoids. She subsequently delivered her child via elective lower segment caesarian section in a tertiary hospital where her symptoms were picked up once again and referred to us. When she

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Undifferentiated Small Bowel cocoon-like-mass with widespread bowel necrosis Sarcoma with Lung Metastasis: and perforation. This patient died with a severe intra- abdominal sepsis, 50 days after the initial operation. A Rare Diagnostic Entity A complex immunohistochemical study was finally Akmal Hisham, Akbar Bahari, Nor Aishah M A completed after he has passed away, confirming the Department of Surgery, Hospital Ampang, Selangor, Malaysia diagnosis of a high-grade, undifferentiated primary SBS. INTRODUCTION DISCUSSION Undifferentiated small bowel sarcoma (SBS) is an extremely rare form of small bowel malignancy. Whilst The pathogenesis of undifferentiated SBS has not 2% out of all gastrointestinal malignancies occur in been clarified. Discussions of SBS from the literature the small bowel (SB), only 10% are SBS. Of these, the are largely centered towards the more common and undifferentiated type is even rarer. To our knowledge, well-differentiated subtype. The standard practice reported cases of undifferentiated SBS with distant of wide surgical resection remains the mainstay of metastasis are exceedingly scarce. the surgical treatment. Adjuvant therapy has limited outcome and is reserved for those with metastasis or CASE PRESENTATION high-grade tumour. A previously healthy 61-year old gentleman was CONCLUSION admitted with an acute intestinal obstruction. Abdominal computed tomography (CT) scan showed a Undifferentiated SBS is an extremely rare neoplasm large SB mass with multiple enlarged lymph nodes and with a fulminant biological behavior and poor small pneumoperitoneum. Laparotomy was performed prognosis as demonstrated by this present case. with SB resection followed by an end-to-end Further studies are needed to determine the optimal anastomosis. However, the tumour was incompletely treatment for undifferentiated SBS. resected due to its close proximity to the superior mesenteric artery. Postoperatively, he developed an entero-cutaneous fistulae and a burst abdomen. Second laparotomy was performed revealing a

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Endoscopic Retrograde CBD stones who underwent ERCP from 1st January Cholangiopancreatography On 2013 t0 31st December 2013. A total of 123 ERCPs were performed during the study period. Relevant Common Bile Duct Stones In A informations of the ERCP reports and medical records Tertiary Hospital Compared To were obtained by the audit team in the Endoscopy The Gold Standard By The Joint Suite and Records Department. The results were Advisory Group On Gastrointestinal compared to the gold standard set by the JAG.

Endoscopy (JAG) : An Audit Results Louis Ling1, L E Teng2, H W Sim2, S N Yeoh2 Successful cannulation rate was 87%. 49.6% of 1Department of General Surgery, Hospital Sultanah Aminah total ERCPs performed resulted in complete stone Johor Bahru, Johor, Malaysia clearance. Commonest complication in HSAJB was 2 Jeffrey Cheah School of Medicine and Health Sciences, haemorrhage (12.2%). Post ERCP cholangitis was seen Monash University, Johor Bahru, Johor, Malaysia in 3.2% and pancreatitis in 0.8%.

Introduction Discussion ERCP is often recommended as a therapeutic tool for Twenty five patients presented with acute cholangitis common bile duct stones. However, ERCP is technically based on the 2013 Tokyo guidelines. Limitation of this difficult and is associated with various complications study is it is of a retrospective audit. with an incidence of 4-30%. Conclusion Objective ERCPs performed for the treatment of CBD stones in The aim of this audit is to examine the effectiveness HSAJB is both effective and safe according to the gold and safety of ERCP on the treatment of CBD stones in standard set by the JAG. Hospital Sultanah Aminah, Johor Bahru.

Materials and Methods The clinical audit was conducted retrospectively in HSAJB by identifying patients confirmed to have 106 PP 83 PP 83

Two Rare Cases of Large Cystic a well encapsulated heterogenous mass from the left Adrenal Teratomas: A Malaysian suprarenal region 14x12x19cm with mixed density consisting of calcifications, fatty components. She Experience underwent an open left adrenelectomy; 2kgs left A R Izad1, M N Hisham2, B Anita2, B Sarinah2, suprarenal encapsulated mass found. K Normayah2, A N Hisham2, A Asmiati3 1Department of General Surgery, Hospital Universiti Histologically, showed a cyst devoid of epithelial lining, Kebangsaan Malaysia, Kuala Lumpur, Malaysia lined by keratinising stratified squamous epithelium 2Department of Breast and Endocrine Surgery, with underlying sebaceous glands, sweat ducts, hair Hospital Putrajaya, Putrajaya, Malaysia follicles, mature adipose tissue, bone marrow and 3Department of Pathology, Hospital Putrajaya, Putrajaya, muscle fibres. Adrenal gland tissues are also noted at Malaysia the periphery.

Introduction Case 2 A teratoma is a rare germ-cell tumour, composed from A 45 year old Malay lady, referred from a private germ-cell layers which can mimic other lipomatous institution after menorrhagia, an incidental tumours. 10.8x12.8cm heterogenous lipomatous right adrenal mass with calcifications was found on CT, with a Methodology 4x5cm uterus fibroid. A malignant liposarcoma needed To describe a case series of two very rare adrenal to be ruled out. Intraoperatively, a 7x7cm 285g pale teratomas in two adult Malay women, in a tertiary unilocular cystic right retroperitoneal adrenal mass endocrine referral centre. found, containing a group of hair and bones, with a 5.5x4.3x2.5cm solid protuberance. Histologically, Result a mature cystic teratoma is noted, composed of Case 1 skin, hair follicles, sebaceous glands, sweat glands, A 41 year old lady, referred for left sided flank pain peripheral nerve bundle ganglion, bone, and loose radiating to the back for a year, noted a large palpable connective tissues. There are cystic spaces with 15x12cm mass over the left hypochondium. CT showed epithelium, multinucleated giant cells, lymphocytes and lipophages.

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Discussion Trauma in General Surgical Unit: Adrenal teratomas are rare, with few recorded in Epidemiology and Predictors of literatures. It can occur in any body region, giving rise Mortality to tissue like skin, muscles, and even teeth. Jih Huei Tan, Henry Tan, A Sarojah Conclusion Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia A mature cystic adrenal teratoma should be considered when dealing with a patient with a large adrenal Introduction tumour. Trauma represents a neglected epidemic in developing countries. In Malaysia, trauma loads are high but numbers are underreported. Most life threatening traumatic injuries in Malaysia are managed by General Surgeon without trauma team support. It represents a major burden to such general surgical unit. Injury patterns and predictors of mortality in such unit are not clear.

Objective Therefore, we intend to identify the predictors of mortality and describe injury trends of trauma patients in general surgical unit.

Methods This is a retrospective cross sectional study of all trauma patients admitted to surgical unit, Hospital Sultan Ismail (HSI), Johor Bahru in year 2013. Demographics, mode of transport, vehicles involved in trauma, mechanism of injury, nature of injury, 107 PP 84 PP 85 operative or non-operative management, operating GASTROINTESTINAL TUBERCULOSIS (TB time, organ involved, revised trauma score and GUT) STILL A MENACE IN SANDAKAN mortality data were collected. Data was analysed with SPSS version 15. Tang Y M, Sridar S, Lai C K, Mutyala Vinod Kumar, et. al Results General Surgery Department, Hospital Duchess of Kent, Six hundred and one patients was included with male Sandakan, Sabah, Malaysia predominance of 502(83.6 %) with mean age of 33 ± 17 years. Major cause of trauma was due to road traffic Introduction accident (63.4%), fall (11.6%) & physical assault (10%). Tuberculosis relentlessly marauds Sabah; almost one Body regions involved are head (n=296, 49.3%), chest third of Malaysia’s total cases in 2014 were reported (n=165, 27.5%) and abdomen (n= 64, 10.6%). Abdominal from the land below the wind. Mycobacterium- organs injured were liver (n=34, 53.1%), spleen (n=26, tuberculosis reaches the gastrointestinal tract via 40.6%), kidney (n=9, 14.1%), and bowel (n=14, 21.9%). haematogenous spread, ingestion of infected sputum, Overall mortality rate was 5.5% (33/601). Patients or direct spread from infected contiguous lymph with abdominal injury had an odds ratio of 4.86(2.234 nodes and fallopian tubes. Here we discussed the -10.567), p<0.001 for mortality. Other significant various presentations of TB GUT in Sandakan. predictors of mortality was age >60yrs with odds ratio of 5.45(2.432-12.194) p<0.001. Discussion Over the course of 2 years from 2013-2015, TB GUT Conclusion has taught us a great deal of lesson in our approach In conclusion, age >60years and patients presented towards a patient with abdominal symptoms. We have with abdominal trauma are the significant predictors encountered a lady where the initial dilemma was of mortality. between ovarian or colonic cancer, but it turned out to be tuberculosis of the ovaries. Next, a gentleman whose pleural effusion was being investigated for almost a year, and repeated sputum of acid-fast- bacili ( AFB) yield negatives samples, presented with

PP 85 PP 86 a left sided reducible indirect inguinal hernia. As the Challenges in Managing Medullary grainy character of the hernia sac, raised suspicion of Thyroid Carcinoma associated with chronic infection, tuberculosis of the peritoneum was clinched once the biopsy report returned. Then there Carcinoid Syndrome were two patients with mobile right iliac fossa mass Suhairil B1, Chan A C2, Sarinah B1 for months, where initial computed tomography was 1Breast & Endocrine Unit, Department of General Surgery, inconclusive, subsequently had colonoscopy where Hospital Putrajaya, Putrajaya, Malaysia smeared biopsies yielded AFB positive. 2Department of General Surgery, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia Other TB GUT presentations were, colo-vesical fistulas, TB peritoneum with ascites and hyperplastic ileacaecal Introduction tuberculosis presenting as appendicular mass. Medullary thyroid carcinoma (MTC) associated with carcinoid syndrome is a rare clinical occurrence. We Conclusion report our challenges in diagnosing and managing There are various presentations of gastrointestinal MTC associated with carcinoid syndrome. tuberculosis, and it is imperative to clinch the diagnosis so that anti-TB therapy can be commenced Case report to prevent complications of the disease. A 43 years old Indian gentleman presented with left thyroid nodule for six months. The nodule was firm Major operations involving bowel resection can be in consistency and measuring 4x3 cm. On CT-scan the avoided, as a high index of suspicion would allow the left thyroid nodule was heterogeneous with presence clinician to obtain tissue biopsies, laparoscopically or of enlarged ipsilateral cervical lymph nodes. Fine colonoscopy from which a diagnosis can be made. needle aspiration reported as follicular neoplasm. He underwent surgery for possibility of follicular thyroid carcinoma. Unfortunately, after induction he developed persistent severe tachycardia and hypotension. The operation was abandoned and he was subjected for further work-up.

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Further history revealed that he had diarrhoea three A Rare Case Of Jejunal to four times per day. He also experienced palpitation Adenocarcinoma With Krukenberg and facial flushing during defecation. His 24 hours urine catecholamine was normal. The serum calcitonin Ovarian Tumour and CEA were markedly raised. However the urine A K N Kwan, L W H Lai, Lewellyn, Mohan 5HIAA was normal. Ultrasound-guided biopsy of Hospital Teluk Intan, Perak, Malaysia the thyroid nodule confirmed as MTC. The diagnosis of MTC with carcinoid syndrome was established Introduction and he was prepared for surgery again. Despite pre- Cancerous tumours in the small bowel are very operative administration of octreotide for 3 days, he uncommon, occurring in fewer than 2 of 100,000 still developed severe tachycardia and hypotension populations each year. Histologically, adenocarcinoma intra-operatively. Fortunately his condition improved is the most common type of small bowel malignancy. with aggressive administration of octreotide and phenylephrine. His vital signs became more stable Case report upon removal of the tumour and we proceeded with A 34-year-old lady, with no known medical illness, bilateral modified neck dissection. His post-operative presented with 1 week history of lower abdominal pain recovery was uneventful. At 3 months follow up his associated with loss of weight, loss of appetite and symptoms disappeared and serum calcitonin and CEA fever. Clinically, there was a pelvic mass palpable. CT were normalised. abdomen and pelvis revealed a large heterogeneous pelvic mass extending to lower abdomen measuring Conclusion 12.4 x 14.7 x 15.2cm, which may represent right As like other neuroendocrine tumours, MTC may tubo-ovarian abscess or malignant ovarian tumour. present as carcinoid syndrome. Undiagnosed carcinoid Tumour markers CEA and CA-125 were raised. She syndrome may cause catastrophic event during underwent TAHBSO for huge right ovarian tumour surgery. A multidisciplinary teamwork is crucial and intra-operatively noted gross dilated small bowel for optimal treatment strategies. An aggressive with constricting jejunal tumour about 40cm from perioperative administration of octreotide enabled the duodenojejunal junction. Besides that, there were surgery to be performed successfully. multiple tumour deposits at the entire small bowel up

PP 87 PP 88 to terminal ileum. Thus, jejunal resection with end-to- Huge 3.6kg Suprafascial Anterior end anastomosis and omentectomy were conducted. Chest Wall Myxofibrosarcoma: Macroscopically, right ovarian tumour, measured 130 x 115 x 28mm, subtotally effaced by a solid whitish A Case Report mass with ill-defined border and yellowish areas of A K N Kwan, L W H Lai, Lewellyn, Mohan necrosis. Exophytic and endophytic tumour of jejunum Hospital Teluk Intan, Perak, Malaysia extends transmurally involved the serosal surface and mesenteric fat. Histopathologically, it was a well- Introduction to-moderate differentiated adenocarcinoma of the Majority of primary malignant chest wall lesions are jejunum with right krukenberg ovarian tumour. soft tissue sarcomas. Myxofibrosarcoma is one of the most common fibroblastic sarcomas in the older The tumour cells of both right ovary and jejunum are patient. positive for CEA and focally positive for both CK7 and CK20. Case Report A 70-year-old man, with no known surgical and medical Conclusion illness, presented with huge painless left anterior Small bowel malignancy is rare, accounting for chest wall swelling which was rapidly growing in size. approximately 2% of gastrointestinal tumours. CT thorax showed a large heterogenous lobulated Diagnosis is often delayed due to lack of specific mass in the left supra-clavicular region. Surgical presentation and no effective screening methods. excision of large suprafascial anterior chest wall mass Surgery is the mainstay of treatment for both locally measuring 290 x 170 x 115mm and weighing3634gm advanced and localized disease. Subsequently follow was performed. The histopathology showed large by adjuvant chemotherapy, with or without radiation. suprafascial myxofibrosarcoma, FNCLCC III, with invasion through the fascia. The tumour had focally infiltrative margin involving the adjacent subcutaneous tissue but well-demarcated from the adjacent skeletal muscle by thick fascia while the dermis and epidermis were free from tumour involvement. 109 PP 88 PP 89

Conclusion Challenges In Diagnose Adult Combinations of wide resection of chest wall Intussusceptions With Unspecific myxofibrosarcoma with radiotherapy for a positive Presentation: 3 Cases Reports surgical margin case contribute to more effective local control. Frequent close follow up plan with A K N Kwan, L W H Lai, Lewellyn, Mohan the attenuation of the symptom of local or distant Hospital Teluk Intan, Perak, Malaysia recurrences, and thorough physical examination for early detection of recurrences are recommended. Introduction Unlike children with the classical triad of presentations, adult intussusceptions presentation tends to be unspecific which is challenging for diagnosis.

Case 1 21-year-old lady presented with severe epigastric pain for 2 days associated with persistent vomiting but no per-rectal bleeding. There was a palpable mass over right iliac fossa. Ultrasound abdomen showed intussusception. She underwent limited right hemicolectomy for ileo-colic intussusceptions. A polypoidal intra-luminal gastric heterotropias growth with a 4.5cm stalk seen 11cm from ileal margin.

Case 2 42-year-old male, history of chronic NSAIDS ingestion for gouty arthritis, presented with per-rectal bleeding associated with vomiting for 1 day and intermittent right hypochondrium pain for 1 week. OGDS and colonoscopy were normal. Until day 5 of

PP 89 PP 90 hospitalization, there was palpable right iliac fossa Breast Cancer In Young Women. mass. He underwent small bowel resection with end- The Penang GH Experience to-end anastomosis for ileo-ileal intussusceptions 250mm in length 20cm from ileo-cecal junction. Michael A, Sunil S P, M S Teoh, W J Tan A small pedunculated polyp was found as a leading Hospital Pulau Pinang, Pulau Pinang, Penang, Malaysia point. Introduction Case 3 One in 19 Malaysian women are at risk of developing 51-year-old lady presented with 3 days para- breast cancer in their lifetime. If detected early, cure umbilical pain associated with abdominal distension, rates for stage I and II are as high as 80%. A literature vomiting and unable to pass motion. Abdominal x-ray review shows that just 7% of all breast cancer occurs in showed dilated small bowel. CT abdomen revealed women below 40 years of age. intussuception. She underwent small bowel resection with end-to-end anastomosis and found an intra- Objectives luminal, polypoidal small bowel leiomyosarcoma. This retrospective study aims to identify the epidemiology of young breast cancer patients (<40 Conclusion years old) in Penang General Hospital (GH). Adult intussusceptions tend to be unspecific with intermittent abdominal pain associated with Methods obstructive symptoms, per-rectal bleeding or palpable A review of breast cancer patients in Penang GH from abdominal mass. High clinical suspicion is needed and January 2010 till December 2014 was conducted using aided by imaging for early establish of the diagnosis. the General Surgery Online (GSO) database and review of histopathology reports.

Results A total of 731 women were diagnosed with breast cancer during this period, and 8% (63) of them were less than 40 years of age. Median age of those affected

110 PP 90 PP 91 was 36 years. Racial distribution comprised of Malays Fulminant Necrotizing Amoebic 43% (27), Chinese 33% (21) and Indians 13% (8) while Colitis: A Diagnostic Conundrum foreigners made up 11% (7). 9% of patients presented at stage I, 49% stage II, 31% stage III and 11% stage IV. Michael A, Jasjit S N Histopathology reports demonstrated 60% (38) had Hospital Pulau Pinang, Pulau Pinang, Penang, Malaysia infiltrating ductal carcinoma (IDC). A total of 30% of patients were ER/PR negative, and 22% HER2 negative. Introduction Only 28% of patients underwent breast-conserving Entamoeba histolytica is one of the most common surgery (BCS). parasitic infections worldwide, infecting about 50 million people. The World Health Organization Conclusion suggests that this pathogen is responsible for 70,000 This retrospective study demonstrated that most deaths annually, second only to malaria as the leading young breast cancer patients presented between cause of death from a parasitic infection worldwide. stage II and stage III and had subtypes with poor prognostic features. As less than a third of these Case Report patients underwent BCS, further studies should be A 41 year old Burmese national presented with conducted as to the reasons why radical surgery was decompensated heart failure and atrial fibrillation preferred. In view of the stage of presentation, further with underlying pneumonia. He was managed efforts for breast cancer awareness among the young in the cardiology unit but subsequently referred should be conducted in the community. to the surgical team for an acute abdomen with hematochezia. Clinically he appeared dehydrated, cachexic and had a temperature of 38.4°C. His abdomen was tender and guarded with generalized peritonitis. A contrast enhanced CT scan of the abdomen and pelvis, showed pneumoperitoneum and pneumoretroperitoneum suggestive of second part of duodenum perforation and a liver cyst. An emergency laparotomy revealed multiple perforations along

PP 91 PP 92 the colon with gross necrotic contamination of the Endogenous Endophthalmitis: An abdominal cavity. He underwent a subtotal colectomy Unusual Presentation of Perforated with an end ileostomy. Histopathological examination confirmed fulminant necrotic amoebic colitis with Gastric Ulcer perforation. He was treated with metronidazole and Aminnur H M, H L Sha, M Hardin, S L Siow discharged home well. Department of Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia Conclusion Fulminant necrotizing amoebic colitis is extremely Objective rare, and is a life threatening condition requiring Endogenous endophthalmitis (EE) is an uncommon immediate intervention. One should always keep but devastating, severe vision threatening occular in mind this diagnosis after factoring in the social infection caused by the hematogenous dissemination history and clinical presentation of patients. In of microorganisms from an extraoccular infective Malaysia, with such a large migrant workforce, focus. It is commonly associated with underlying diseases not previously seen will eventually present immunosuppression. Commonly reported sources itself after mimicking a variety of other illnesses. It is of endogenous endophthalmitis include meningitis, important to ensure appropriate history taking to aid endocarditis, urinary tract infection and hepatobiliary in the diagnosis and prompt intervention to reduce tract infection. We would like to report a rare case morbidity and mortality of such illnesses. of endogenous endophthalmitis resulting from a perforated gastric ulcer.

Case report A 69-year-old Chinese gentleman with underlying diabetes mellitus presented to the emergency department with an acute deterioration of vision, pain and redness in the right eye. Systemic and clinical examination only showed hyperpyrexia. Eye examination noted hypopyon in the right eye. Vitreous 111 PP 92 PP 93 tap obtained turbid intravitreal fluid. He was started Wilkie’s Syndrome - Management on intravenous and intravitreal antibiotics and Dilemma on the Implementation subsequently investigated for possible extraoccular sources of infection. Abdominal ultrasonography of the Nutrition and Surgical revealed a normal liver with minimal subhepatic Approach collection. Chest radiograph demonstrated free air Aminnur H M, A Ali, Rokayah J, Azim N A N under diaphragm. A diagnosis of perforated viscus was Department of Surgery, Sarawak General Hospital, Kuching, made. Exploratory laparotomy found a perforated pre- Sarawak, Malaysia pyloric ulcer. Intravitreal fluid and blood cultures grew Klebsiella pneumoniae. The post operative recovery Wilkie’s syndrome (WS) is a rare but potentially life was uneventful and he was discharged home well. threatening gastrointestinal disorder that was initially described by Von Rokitansky in 1861. This syndrome Conclusion is characterized by acute angulation of superior This case report illustrates a perforated gastric ulcer mesenteric artery (SMA) causes compression of the presenting atypically as EE without any abdominal third, or transverse portion of the duodenum between signs or symptoms. In our literature review, the aorta and SMA resulting in chronic, intermittent, perforated gastric ulcer has never been reported as or acute complete or partial duodenal obstruction. The an extraoccular focus of infection in patients with patient often presents with chronic upper abdominal EE. Due to the catastrophic consequences of EE, a symptoms such as epigastric pain, nausea, eructation, thorough systemic review should be undertaken to early satiety, voluminous vomiting and post-prandial discomfort. We report two case series on WS that look for occult or rare sites of extraoccular infection. occurred in younger age groups (16 & 18 year old girl) Prompt appropriate treatment should be tailored who are having similar clinical presentation (gastric towards both the infective focus and EE. outlet obstruction) with different severity (severe & mild). Different nutritional implementation and Keywords surgical approaches are discussed. Endogenous endophthalmitis, perforated gastric ulcer Keywords Wilkie’s syndrome, superior mesenteric artery syndrome

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A Retrospective Analysis of via cephalic vein or subclavian vein. Two catheters Chemo-port Complications in needed readjustments as the tip was too deep causing tachycardia. Migration occurred in 2(1.7%) cases. Adults with Malignancy These ports were successfully removed by cardiac Manoj B N, Mathew T, Sarojah A catheterization. Hematoma occurred in 3(2.5%) cases. Department of Surgery, Hospital Sultan Ismail, Johor Bahru, Insertions were done blindly and more than one Johor, Malaysia attempt was made for each case. One patient was on warfarin treatment. Thrombosis occurred in 3(2.5%) Cancer patients require repeated venous punctures. cases. No pneumothorax was reported. Chemo-port(CP) insertion have facilitated the problem of vascular access. However, CP has inevitable CP should be inserted prior to chemotherapy as the problems such as insertion-related and long-term chances of SSI in the already immunocompromised complications despite providing benefits to patients. cancer patient would be higher if chemotherapy was started first. Although our center do not routinely We retrospectively analyzed 120 patients(74 females practice image guided CP insertion, our results are and 46 males, mean age: 53 years(17-76 years)with comparable to other studies. However, it is optimal malignancy, that had CP implanted from January 2009 to perform CP insertion under image guidance to to December 2014 at our institute. All patients had CP minimize complications such as hematoma and inserted as a daycare procedure, under local anesthesia. malposition. Most cases were performed using closed technique, and not guided by any imaging modalities. Chest x-ray was performed after the procedure. The complication rate was 20%. Surgical site infection(SSI) occurred in 11(9%) cases. All patients had chemotherapy prior to CP insertion. Malposition occurred in 5(4.2%) cases. No image guiding modalities were used in all cases. Three patients needed adjustments of the catheter as the tip was in the jugular vein from an insertion site

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De Garengeot’s Hernia: Case raised. Incarcerated femoral hernia was suspected and Report of Appendicitis within an a decision for exploration and hernia repair was made. Intraoperatively, the herniated sac looked gangrenous. Incarcerated Femoral Hernia Contents were unable to be assessed as it was Manoj B N, Heah H T, Sarojah A spontaneously reduced during exploration. McVay’s Department of Surgery, Hospital Sultan Ismail, Johor Bahru, repair of the femoral hernia performed. Subsequent, Johor, Malaysia laparoscopic examination and appendicectomy performed as the appendix was found lying next to Appendix within a femoral hernia (De Garengeot’s hernia orifice looking purplish with a constricting hernia) is a unique surgical pathology with a repoerted mark across its mid-body. Post operatively, patient incidence of 0.5%. Appendicitis occurring in this rare was discharged well without any sign of surgical site clinical setting represents a challenge in diagnosis infection. Histopathological report of the appendix and management. Most cases are incidental finding showed serositis/ periappendicitis which did coincide during surgery. The sequence of development of with the intraoperative finding and suspicion. appendicitis in a femoral hernia was most likely due to an extraluminal obstruction at the hernial neck A prompt diagnosis and appropriate management for rather than the more usual cause of an intraluminal a patient presenting with De Garengeot’s hernia it is obstruction. CT scan has been established to be vital to limit morbidity and mortality. highly sensitive recently, but an evident incarcerated or strangulated femoral hernia leaves little room for radiological investigations.

Here we report a case of a 71 year old man whom presented with painful irreducible right groin swelling for 3 days duration. The patient was afebrile, there was a swelling over the right groin, the swelling was below and medial to the pubic tubercle, 5x4cm, tender, erythematous and warm. White cell count was not

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Gastrointestinal was palpable over that region. None of the patients Neurofibromatosis Causing showed signs of peritonism, and hence imaging was performed. CT abdomen of the 18year old girl Gastrointestinal Obstruction: showed bowel wall thickening with intussusception. A Case Series Laparotomy and right hemocolectomy was performed. Manoj B N, Mathew T, Sarojah A Gastrograffin study was done for the 49year old Department of Surgery, Hospital Sultan Ismail, Johor Bahru, man. It showed no progression of contrast beyond Johor, Malaysia mid-ileum after 24hours and hence laparotomy, small bowel resection and end-to-end anastomosis Neurofibromatosis type1(NF-1) is an autosomal performed. CT scan of the 61year old patient showed dominant disorder known to be associated with clumping of small bowel with hypodense lesions gastrointestinal neoplasms in 2-25% of patients. causing obstruction. Intraoperatively for these two The most frequent gastrointestinal complications patients, there were clumping of small bowels with are ulceration, bleeding, and obstruction. Rarely tumor deposits at the small bowel. The affected bowel intussusception and perforation can occur. 5% of the was resected. Histopathology report of all three of gastrointestinal manifestations of NF-1 will require the resected bowel segments did show features of surgical treatment. neurofibromatosis. In addition, findings of ischemic changes compatible with intussusception were Here we report three cases of gastrointestinal present in the 18year old girl. neurofibromatosis causing gastrointestinal obstruction. They were 18, 49 and 61years old and were Due to its rarity, a high degree of suspicion for known to have neurofibromatosis on presentation. gastrointestinal tumor in patients with NF-1 is needed All three presented with the classical small bowel for timely diagnosis and management. obstructive symptoms i.e. abdominal distension, abdominal pain, vomiting and constipation. Per abdomen examination noted distension, tenderness and hyperactive bowel sounds. The 18year old girl had more tenderness over the right iliac fossa. A mass 113 PP 97 PP 97

Plummer’s Disease with intolerance were demonstrated biochemically suggestive of towards carbimazole and allergic reaction component. In view of that, PTU was discontinued followed by urgent radioactive iodine propylthiouracil: A case report of a therapy. rare phenomenon Manoj B.N, Maizatul R, Sarojah A To our knowledge, this is the first case of allergic reaction towards both carbimazole and Department of Surgery, Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia propylthiouracil to be reported. The prompt recovery of patient’s symptoms upon withdrawal of the drugs and Thyrotoxicosis is a common disorder especially in laboratory abnormalities support this phenomenon. women. Thionamides have been commonly used as the Apart from medical therapy as described, surgery can first line of treatment. In Malaysia, Propylthiouracil also be considered. However, surgical intervention is (PTU) and Carbimazole are the most widely used anti- associated with high risk of developing thyroid storm thyroid drugs. Side effects related to Thionamides in the thyrotoxic patient which can be potentially include transient granulocytopenia, pruritus, urticaria, lethal. arthralgia, myalgia, fever, generalized maculopapular and papular purpuric rashes. Even fatal cases have been reported.

We report a case of a teenage girl whom was referred for the management of toxic multinodular goiter. Initial high loading dose of Carbimazole was commenced. However, she developed pruritus and urticaria. Hence, carbimazole was withheld and replaced with Propylthiouracil as an alternative since she was in a thyrotoxic state. Unfortunately, she also developed similar side-effect reaction requiring admission. Leukocytosis with absolute eosinophilia

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Perforated Meckel’s diverticulum laparotomy, a perforated Meckel’s diverticulum following blunt abdominal was found with other organs intact. Meckel’s diverticulotomy and appendectomy were performed. trauma: a case report Postoperatively, he developed right lung atelectasis Tuang G J, Goo Z Q, Kandasami P the day after surgery but has since recovered and was International Medical University subsequently discharged on postoperative day 8.

Introduction Conclusion Meckel’s diverticulum, being the commonest Blunt abdominal trauma should be evaluated promptly congenital gastrointestinal abnormality, was first to minimize or avoid preventable morbidity and described in detail by Johann Friedrich Meckel and mortality. Perforation of Meckel’s diverticulum as bears his name. It is a remnant of the omphalo- a consequence of blunt injury, although unusual, mesenteric duct and a true diverticulum. The should not be dismissed. This case report highlights manifestation of Meckel’s diverticulum varies the importance of careful evaluation of the bowel greatly. It can present as an incidental intraoperative during exploratory laparotomy in suspected bowel finding or undergo mechanical complications, such as perforation. obstruction and intussusception, culminating in an acute abdomen. Perforation of Meckel’s diverticulum due to blunt abdominal trauma however, represents an extremely unusual presentation.

Case presentation We describe the case of a 15 year-old boy, who presented with severe right abdominal pain following blunt abdominal trauma during a road traffic accident. On examination, features of peritonism were noted in the right iliac fossa. A provisional diagnosis of peritonitis due to perforated viscus was made. During 114 PP 99 PP 99

The Masquerading Mass: Breast axillary clearance was done. Intra operatively, the lump Tuberculosis was centrally located, adherent to pectoralis major, measuring 5 x 5cm with multiple matted axillary N Kumar, C H Chan, L Sivaneswaran, lymph nodes. Her recovery period was uneventful. R Umasanga Histopathological analysis of the resected specimen Department of General Surgery, Hospital Taiping, Taiping, revealed central caseating necrosis and acid fast bacilli Perak, Malaysia staining positive with Ziehl-Neelsen, consistent with tuberculosis. Subsequently, she was started on anti- Introduction tubercular therapy and was symptom free with no Breast tuberculosis is a rare disease, accounting evidence of recurrence during follow ups at 6 and 12 for less than 0.1% for all breast lesions in developed months. countries and 4% developing nations. It can present as an abscess or carcinoma, posing a diagnostic challenge Discussion to the clinician. We report a case of breast tuberculosis Breast tuberculosis usually affects the younger age presenting as breast mass. group, which manifests as breast abscess while in the older population it tends to mimic carcinoma. Case Report Recognized modes of spread include direct, A 70 year old Malay lady presented with 8 months hematogenous and lymphatic. The bacilli most often history of painless breast lump. Upon examination, infect the ducts and spare the lobules. Treatment the lump was centrally located with areas of necrosis options include anti tubercular therapy alone or in and ulceration along with nipple retraction. There combination with limited excision of diseased breast were also palpable ipsilateral axillary lymph nodes. tissue, with the latter being a preferred approach as it (Clinical staging- cT4aN1Mx)Imaging showed a right has lower rate of recurrence. breast mass suggestive of malignancy with axillary lymphadenopathy. Attempts at obtaining tissue diagnosis were unsuccessful as the samples were unsatisfactory for evaluation. In view of the clinical and radiological findings, right mastectomy and

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Testicular Tuberculosis Presenting testis which was biopsied. Both testes appeared viable As Complex Hydrocele with no suspicious lesions. Histopathological study of the specimen revealed caseating granulomatous N Kumar, C H Chan, AH Hasslinda, L Sivaneswaran inflammation with acid fast bacilli suggestive of Department of General Surgery, Hospital Taiping, Taiping, tuberculous infection. Subsequently patient was Perak, Malaysia commenced on anti-tubercular therapy. He showed good response, as the wound healed well with no Introduction recurrence during follow up visits. Genitourinary tract is the commonest site for extrapulmonary tuberculosis. It often affects the Discussion lower urinary tract but testicular involvement is rare. Tuberculosis of lower urinary tract frequently involves Testicular tuberculosis lacks classical presentation, the epididymis rather than the testis. Hence testicular making the diagnosis a daunting task. We report a case involvement is usually due to local spread or retrograde of such nature. seeding from epididymis and rarely hematogenous spread. Classically, genitourinary TB is diagnosed by Case Report identification of Mycobacterium Tuberculosis in the A 42 year old Chinese gentleman with no known urine through various methods namely TB culture, illnesses presented with bilateral painless scrotal TB- PCR and nucleic acid amplification. Diagnosis swelling of 4 months duration. Examination noted proves to be difficult due to its atypical presentation, bilateral scrotal enlargement, both of which were firm, frequently simulating testicular neoplasm. A high non tender and non erythematous. Furthermore, the index of suspicion is vital for accurate diagnosis of right scrotum had a few pustules. Ultrasound showed this condition, as it responds well to anti tubercular bilateral hydrocele with internal septations, scrotal therapy without the need for surgical excision. skin thickening with normal testicular vascularity on both sides. No focal testicular lesion was visualised. Tumour markers were normal. Bilateral scrotal exploration was performed. Intra operatively, the pustular lesion over right scrotum extended into the

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Giant Leiomyoma of oesophagus: DISCUSSION A Case Report Leiomyoma is slow growing tumour and lesion >5cm will produce symptoms2. Giant leiyomyoma usually Y W Choo, H Syakirah A R, Zuraimi Z, Nshukri N Y presented late and the symptoms can mimic cancer. Department of surgery, Hospital Raja Perempuan Zainab II, An oesophagoscopy, endoscopic ultrasound and Kota Bharu, Kelantan, Malaysia CT scan are mandatory procedures to establish the diagnosis. The need of endoscopic punch biopsy is INTRODUCTION controversial as it often yields an inconclusive result Benign oesophageal tumours are rare with the due to overlying mucosa. Furthermore, oesophageal incidence of 1%1. It has indolent clinical course and perforation and scarring will hamper the future the presentations may mimic oesophageal cancer. enucleation surgery. Making a correct diagnosis is important before the definite surgical treatment. We report a case of giant CONCLUSION leiomyoma of distal oesophagus. Leiomyomas of oesophagus is rare and should be differentiated from malignant tumours. There is no CASE REPORT literature regarding enucleation of giant leiomyoma. A 25 year-old girl presented with progressive Perhaps, trial of enucleation in giant leiomyoma dysphagia and regurgitation for 6 years. She was thin should be our future challenge. and short stature with BMI of 10.9. Oesophagoscopy showed a dilated oesophagus with mass in lower oesophagus while barium swallow suggested a chronic distension of oesophagus with ineffective peristalsis. CT scan revealed an obstructing mass at gastro- oesophageal junction. An Ivor Lewis procedure was performed. There was a 10cmx20cm encapsulated lesion at oesophago-gastic junction with dilated proximal oesophagus. She recovered and tolerating solid diet post-operatively. The final histopathological examination confirmed the diagnosis of leiomyoma.

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A Case Report: Primary Tuberculosis lymphadenopathies for a duration of 2 years. Clinically, of thyroid she was euthyroid, without airway compromise or dysphagia. There were also no fever or constitutional Juan B A1, Chan A C2, Anita B3 symptoms. CT neck and thorax suggested a malignant 1Department of Surgical Oncology, National Cancer Institute, thyroid mass with multiple cervical, mediastinal, right Putrajaya, Malaysia axillary and right parotid lymph node metastasis. 2 Department of Surgical, Hospital Raja Permaisuri Bainun, CXR and Breast Ultrasound were normal. FNAC of the Ipoh, Perak, Malaysia thyroid nodule revealed follicular neoplasia, where else 3Department of Breast of Endocrine Surgery, Hospital Putrajaya, Putrajaya, Malaysia FNAC of the upper cervical mass and axillary lymph nodes revealed necrotic lymphoid tissue. Her TFT and other blood test were normal. She underwent total Introduction thyroidectomy, right modified radical neck dissection Tuberculosis (TB) of the thyroid gland is an uncommon and excision biopsy of an axillary node. Histopathology entity even in the countries where tuberculosis is an reported chronic granulomatous thyroiditis and endemic. The prevalence varies from 0.1% to 0.6%. lymphadenitis, consistent with tuberculosis. She then The reason of the rarity remains unknown. Among received anti tuberculosis treatment, and recovered the rare cases of thyroid tuberculosis, secondary is uneventfully. more common than primary etiology. Initial clinical diagnosis is often difficult as history-taking and early Conclusion physical presentations are non-specific and vary. Although seldom encountered, TB should be kept in Patient may be asymptomatic or the presentation mind in any patient with thyroid mass. Several simple may mimic advanced thyroid carcinoma, as in this tests like Mantoux test, lymph node excision biopsy case report. Having high index of suspicion is key to and detection of acid fast bacilli in the FNAC of the accurate diagnosis and avoidance of unnecessary thyroid nodule, may be helpful in doubtful cases. surgery It is vital to differentiate TB thyroid from thyroid malignancy, as to avoid unnecessary surgery. Case summary A 29 year old lady presented with a right solitary thyroid nodule and worsening cervical and axillary 116 PP 103 PP 103

Dissecting Aortic Aneurysm using Doppler US. We proceeded with right lower Presented With Acute Limb Ischaemia limb embolectomy, however, no blood clot seen intra- operatively. Post-operative CTA of Thorax, Abdomen in a Healthy Young Adult Male and bilateral Lower Limbs showed right lower limb Muhammad Za’im, Nur Amira, Rizal Irwan Syah, peripheral vascular disease with dissecting aortic Norhashimah Abdul Kadir aneurysm from aortic root until proximal descending Surgical Department, Hospital Sultan Abdul Halim, aorta. Urgent referral to cardiothoracic center was Sungai Petani, Kedah, Malaysia done and patient later underwent emergency Bentall Operation. Background Conclusion Thoracic aortic aneurysm is a condition which more commonly affects male, aged greater than 65 Possible for fatal condition such as dissecting aortic years old, occurring in about 5 to 10 within 100,000 aneurysm to present with rare symptoms, thus, a high populations. Most of the patients are asymptomatic, index of suspicious is required in diagnosing, especially however, they may present with dissecting features in in a healthy adult as in this case. which majority of cases have sudden onset of severe, sharp pain in the chest, neck or back. On the other hand, in our case, we would like to describe a rare presentation of dissecting aortic aneurysm involving a healthy young adult male.

Case presentation We report a case of a 29 years old, healthy young adult, who presented with one day history of right lower limb pain and numbness associated with vague epigastric pain and vomiting. Abdomen was soft but there was clinical evidence of right acute lower limb ischaemia which was further supported by radiological method,

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Multi-Organ Infarcts with Evidence soft. Esophagogastroduodenoscopy revealed a of Auto Amputation Secondary to malignant looking ulcer at lesser curvature, however serial biopsy came back as benign. He was well with Arterial Thrombus (Thoracic Aorta) proton pump inhibitor. We proceeded with Computed in a Normal-Appearing Aorta in an Topography of Thorax, Abdomen and Pelvis which Asymptomatic Patient showed mural thrombus at descending thoracic aorta until coeliac axis with extension into the coeliac Muhammad Za’im, Awatif, Su K P, artery causing total occlusion. He was then started Norhashimah Abdul Kadir on anticoagulant and referred to vascular team, Surgical Department, Hospital Sultan Abdul Halim, however he defaulted. Repeated scan one year later Sungai Petani, Kedah, Malaysia revealed absent gallbladder, spleen and pancreatic tail with reperfusion of segment VIII liver infarct and Background significant resolution of extensive mural thrombus of Arterial thromboembolism has a substantially the descending thoracic and upper abdominal aorta. negative impact on morbidity and mortality rates. It is Patient is still under our follow up and he is well with challenging to detect early and to treat. Approximately monitored anticoagulant. 85% of all arterial thrombi arise from cardiac causes, such as atrial fibrillation, valvular abnormalities, and Conclusion myocardial infarction. 5% of thrombi are found in Multi-organ infarcts secondary to arterial thrombus the aorta, usually in the presence of atherosclerosis occlusion particularly in apparently normal aortas is or aneurysm. Our patient’s case is notable because, an uncommon diagnosis and it is rare for a patient despite having severe arterial thrombus in a normal- to present asymptomatically such as in this patient. appearing aorta causing multiple visceral infractions, Multiple factors guide the management strategy, he remains asymptomatic. including the characteristics of the thrombus, the patient’s comorbidities and symptoms, and the risk Case presentation factors for thrombus formation. We report a case of 55 years old active smoker Indian gentleman, who presented with PUD features. Clinically patient was well built and abdomen was 117 PP 105 PP 105

Case Report : Gastric Schwannoma - curve of stomach, suggestive of GIST. Biopsies of the A Rare Gastric Tumour mass during endoscopy only showed chronic atrophic gastritis. W J Wong, J A Chuah, R Palaniappan, E See, R K Sriram She subsequently underwent a laparascopic-assisted Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia wide local excision of the tumour, requiring complete resection of the antrum to achieve satisfactory Gastric schwannoma is a rare differential to resection margins. End-to-end anastamosis of the consider when approaching a gastric mass. Gastric stomach was done. She recovered uneventfully. schwannomas represent only 0.2% of all gastric neoplasms, and are usually benign. Identification is Histopathological examination revealed a benign via histopathological examination, showing positive tumour with spindle cell proliferation, arranged in staining for vimentin and S-100, and negative for actin, palisades. The cells stained positive for vimentin and c-kit and CD34. s-100, and negative for actin and CD34. This supports the diagnosis of gastric schwannoma. We report a case of submucosal gastric mass. A 37 year old lady presented with intermittent epigastric The long-term follow up for gastric schwannoma pain since 2012. She described it as localized, sharp, remains uncertain due to the paucity of these occasionally debilitating, with no loss of weight or tumours. As such, there has been no large study or appetite. She had no significant family history. Past consensus regarding the prognosis and follow up of medical history was only significant for a caesaerean these patients. Further studies are required. section done 3 months prior to presentation in February 2015. Ultrasound showed a well-defined hypoechoic lesion at the lesser curve of the stomach measuring 4.7x3.9cm, with minimal vascularity. OGDS showed a large smooth mass, 3x4cm at the lesser curve with central puckering. A CT showed a heterogenous lobulated mass at the antrum and lesser

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PIONEERING VASCULAR SERVICE IN of end stage renal failure and haemodialysis were SABAH: AN AUDIT OF ARTERIOVENOUS 2.8 years respectively. 48% of patients had diabetes mellitus. 72% of the patients had previous venous FISTULAS access, 82% had central venous cannulation and 5.6% Valan A, Leong B, Selvarajoo G, Wong W J had peritoneal dialysis. All patients were assessed Vascular Unit, General Surgery Department, with duplex scan for suitable vein and artery for Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia AVF creation. 90% of patients were discharged for cannulation with a functioning AVF. Primary failure Introduction was 7%. 1 patient developed pseudoaneurysm (1.4%) Permanent vascular surgical service in Sabah started and required ligation of fistula. Another patient in July, 2014. Prior to this, vascular service was in developed brachial artery emboli and required ligation. the form of monthly visiting basis initiated in 2006. 2 patients developed limb swelling post operatively. Arteriovenous fistula (AVF) creation is the commonest Central venogram revealed central venous stenosis procedure performed in vascular surgery. AVF is thus central venoplasty was done. also the commonest permanent vascular access for heamodialysis in Malaysia. We performed an audit on Discussion and Conclusion the outcomes of all AVFs done under our unit over one There is a huge demand for vascular access creation year period. in Sabah. We believe in pre-operative assessment with duplex scan. Appropriate patient and, as well as, Method procedure selection coupled with meticulous surgical Subjects are all patients with AVFs created from July technique maximize success rate of AVF creation. 2013 to June 2014. Data of patients were collected retrospectively from medical records at our clinic.

Results A total of 70 AVFs were created. Patients originate from different parts of Sabah. The average age of patients were 53 years and the average duration

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A Single Tertiary Vascular Results Center Report on Outcome of Sixteen cases had successful elective endovascular EVAR: Hospital Serdang’s 5 years repair (n=16) out of which fifteen cases were infrarenal aneurysms and one case was thoracoabdominal Experience aneurysm. Patients were predominantly male (14:2) J Y Eng, Y L Tan, L G Chew, B L Ee, P Kayalvilli with mean age of 72.3 ± 5.9. Mean size of aneurysm at Hospital Serdang, Selangor, Malaysia time of repair was 6.1±1.6cm. All cases were repaired using Endurant® II AAA Stent Graft (Medtronic). Introduction Average duration of hospital stay was 6.8±2.9days. All Elective repair for AAA had significantly reduced the patients had CT angiography surveillance at 6 month mortality associated with its rupture, dissection and and 12 months after the procedure and annually the morbidity risks associated in emergency surgery. thereafter. No mortality was observed in this case The improved patients outcome with endovascular series. The single case of thoraco-abdominal aneurysm aneurysm repair (EVAR) in comparison to open repair in this case series had type 1b endoleak reported within was well established in European and Dutch studies i.e. 6 month from repair. EVAR 1 and DREAM trial. In Malaysia, Hospital Serdang Conclusion functioned as one of the main vascular tertiary centers available for such treatment. We had since performed Elective EVAR in Hospital Serdang has produced a significant numbers of cases with low number of favourable short and long term outcomes in patients complications since the hospital establishment as with aortic aneurysms. This is consistent with results a tertiary vascular center. We report our success in from other centers worldwide. treating abdominal aortic aneurysm by endovascular repair over the period of 5 years.

Method A retrospective, descriptive analysis on elective EVAR performed in Hospital Serdang from January 2010 to December 2014.

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Small Bowel Arteriovenous Arteriovenous malformation of the small bowel is an Malformation; An Unusual Suspect unusual cause of lower gastrointestinal bleeding and it is paramount that the diagnosis is made prompt in Lower Gastrointestinal Bleeding and accurately, as these patients tend to present Karthik K, Buveinthiran B, David Ong, H Singh with massive bleeding and more often than not are Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia haemodynamically unstable. Given the nature of the disease, early surgical intervention is recommended. A 27 year-old Malay woman with no prior history of gastrointestinal bleeding presented with a massive lower gastrointestinal bleed. She complained of severe abdominal pain, passed out copious amounts of haematochezia and presented in hypovolemic shock. Her initial Haemoglobin was noted to be 7.7, and she was resuscitated adequately. Once stabilized she was pushed for an emergency CT Angiogram which showed contrast blush which was a feature of active bleed as there was extravasation of contrast within the small bowel loops at the left iliac fossa adjacent to the distal descending colon. In lieu of the findings she was pushed for an emergency exploratory laparotomy and was noted to have a bleeding jejunal polyp measuring 1x1cm about 60cm from the duodenojejunal junction and 120cm from the ileocaecal valve. She underwent a small bowel resection and functional end to end anastomosis. Post operatively, she recovered well and was subsequently discharged. Her Histopathology report came back as an ateriovenous malformation.

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Multiple Magnet Ingestion: A Rare were tightly adherent to one another causing necrosis Cause Of Bowel Perforation and perforation at the site of contact. In the post- operative period he was managed in pediatric intensive Jothinathan M, Razali M, Muthu A, Andrew G care unit (PICU) for septic shock and post-operative Pediatric Surgery Department, Hospital Sultanah Aminah, ileus. He gradually improved and progressed well. Johor Bahru, Johor, Malaysia DISCUSSION INTRODUCTION Magnet ingestion requires special attention especially Foreign body ingestion among children is common when two or more magnets are swallowed. When presentation to hospital. Rarely morbidity is associated multiple magnets move in different part of intestinal with foreign body ingestion. We report a rare case of a tract, magnetic attraction between different parts of child who presented with intestinal obstruction and intestinal tract can be potentially catastrophic. This perforation following magnet ingestion. may lead to intestinal obstruction, fistula, ulceration, local bowel necrosis and perforation. CASE REPORT A 3 year old boy presented with acute abdominal pain CONCLUSION and obstructive symptoms. He was initially treated Multiple magnet ingestion should not be taken for acute gastroenteritis with dehydration. Pediatric lightly. Magnet ingestion can cause catastrophic surgical team was consulted when he had symptoms gastrointestinal morbidity. Therefore, early diagnosis suggestive of intestinal obstruction. He was clinically and intervention significantly changes the outcome. dehydrated with large amount of bilious Ryle’s tube Intervention when dealing with cases of magnet aspirate. His abdomen was distended and tense with ingestion would go more in the line of surgical or sluggish bowel sound. Plain abdominal radiograph endoscopic technique rather than conservative showed dilated small bowel and multiple opacities, management. which were overlooked as artifacts. Laparotomy revealed fecal contamination and small bowel was grossly dilated and two magnets were caught in between two segments of bowel loop. The magnets

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Laparoscopic Repair Of Acquired subsequently. She recovered well postoperatively and Abdominal Intercostal Hernia: was asymptomatic on review 6 months later. A Case Report And Literature Review Discussion C K Seak1, K L Seng2, S L Siow1, Mark Hardin1 Laparoscopic repair with placement of prosthetic 1Sarawak General Hospital, Sarawak, Malaysia mesh as an underlay to bridge a hernia defect is our 2Sibu General Hospital, Sarawak, Malaysia method of choice as it obeys the concepts of tension- free repair, confers the benefits of minimally invasive Introduction surgery and provides a superior view of the abdominal Abdominal intercostal hernia (AIH) occurs rarely and wall defect, allowing for an adequate mesh overlap. has so far been reported sporadically in literature with less than 30 cases to date. It occurs mainly secondary Conclusion to trauma when disruption of thoracoabdominal wall Laparoscopic repair of AIH is highly feasible and musculature resulting in an acquired herniation of beneficial and thus should be the preferred method of fascia layer between adjacent ribs. Surgical repair is the surgical repair when the surgical expertise is available. recommended choice of treatment as there are risks of incarceration or strangulation of visceral organs if left untreated. However, the choice of appropriate surgical treatment remains a challenge.

Presentation of Case A 51-year-old lady with no previous history of surgery presented with a painless left intercostal swelling for 2 years following a history of high velocity motor vehicle accident. Computed tomography scan of thorax and abdomen showed a left anterolateral intercostal hernia between the 9th and 10th rib and a mesh repair was carried out via laparoscopic approach 120 PP 111 PP 111

A One-Year Study of Bacteriology cultures were Staphylococcus aureus (67.7%), followed In Skin & Soft Tissue Infection by Klebsiella Pneumonia (14.2 %), Escherichia Coli (7.1%), Proteus (3.5%) and Methicilin-resistant With Underlying Diabetes Mellitus Staphylococcus Aureus, Group B Streptococcus, Patients In Department of Surgery, Coagulase Negative Staphylococcus, Enterobacter had Hospital Seberang Jaya 1.7% each. The Staphylococcus aureus cultures were all sensitive to Cloxacilin. Sumaraj A1, Nasheef1, Fitreena A2, Imran A K1 1 Hospital Seberang Jaya, Penang, Malaysia Conclusion 2Institut Perubatan Dan Pergigian Termaju, Universiti Sains Malaysia, Penang, Malaysia The majority of culture-positive SSTIs were caused by Staphylococcus Aureus and sensitive to Cloxacilin Introduction even though in Diabetes Mellitus patient. Diabetes Mellitus associated with high risk of Skin and Soft Tissue Infection.

Methods A retrospective review of bacteriology in SSTI with underlying Diabetes Mellitus from 1st January 2014 till 31 December 2014.

Results A total of 118 patients were diagnosed with SSTI and hospitalized in our hospital, in which 66.1% of them were diabetic patients. And out of these diabetic patients, 71.7% had positive culture isolates. About 39.3% of these diabetic patients that had positive culture aspirate were reported to have SSTI anatomically at the back. Most of the positive

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Audit on Adult Inguinal Hernia to 77 years), and direct inguinal hernia was 45 years Surgery in Hospital Seberang Jaya: (18 years to 72 years). 64% of patients underwent elective herniotomy and mesh repair under day care Have We Done Enough? surgery. 60 patients (25%) underwent elective hernia C W Yong, C T Ooi, Sumaraj A, Imran Khalid repair under spinal anaesthesia. General anaesthesia Hospital Seberang Jaya, Penang, Malaysia only performed in 10% of patients. Techniques used in hernia repair including open method (90%) and Objective laparoscopic method (10%). Complication rate was This study is intended to describe our own experiences 19%, and pain at operation site (50%) account for half in the surgical management of inguinal hernias. of complications, others are scrotal swelling (23%), erythema (13%), and wound breakdown (13%). The Method median length of hospital stay for hernia surgery This is a prospective study conducted in Hospital under spinal/general anaesthesia was 3.5 days (2 days Seberang Jaya from January 2014 to January 2015. to 5 days). Mortality rate was 0%.

Result Conclusion A total of 103 patients with inguinal hernias were Under local anesthesia the hernia surgery is feasible enrolled in the study. The median age of patients and cost saving. was 44.5 years (range 12 years to 77 years). Males outnumbered females by a ratio of 24:1. Right side (47%) was more than left side (40%), ratio of 2:1. 15 (14%) patients had bilateral inguinal hernias. At presentation, 38 (36%) patients had reducible hernia, 60 (58%) had irreducible hernia, 5 (6%) patients had obstructed hernias. 35 (33%) patients had indirect hernia, 66 (64%) had direct hernia and 4 (3%) had both indirect and direct types (pantaloon hernia). Median age of indirect hernia patients was 44.5 years (12 years 121 PP 113 PP 113

Neuroendocrine Tumor In thyroid. Age of presentation ranges from 14 years old Sarawak General Hospital to 68 years old. None of the patients presented with carcinoid symptoms. 75% of patients NET were not N R Nordin, A Ali, N A Nik Abdullah the first diagnosis. 1 patient presented with distant Hospital Umum Sarawak, Kuching, Sarawak, Malaysia metastases.

Introduction and Objective Discussion Neuroendocrine tumor is a rare tumor that arises The commonest NETs seen in our hospital include from cells that releases hormones into the blood in carcinoid tumor and NET of the breast, and they response to a signal from the nervous system. It has occurred at any age. NET has diverse mode of a wide range of presentation. Early diagnosis and presentation. Unfortunately one of our patient had prompt treatment is needed for favorable outcome. metastatic insulinoma which is rare presentation for insulinoma. The diagnosis of NET can be very Material and Method challenging, and the gold standard of diagnosis is a This is a retrospective review from SGH Multi- complete immunohistochemical analysis. disciplinary Team NET registry for all patients admitted/ referred to Surgical Department SGH with Conclusions the tissue diagnosis of neuroendocrine tumor from The diverse presentations of NET makes it difficult August 2014 until 15 March 2015. Demographics, to diagnose as such on first presentation. Thus cancer history, initial symptoms, first diagnosis, high index of suspicious is required and proper pathology, treatment administered and surgical immunohistochemical analysis is mandatory. procedure were recorded. Total of 7 patients were analysed during this study period.

Results 2 of the patients are diagnosed with carcinoid tumor, 3 patient is diagnosed with NET of breast, 1 patient is diagnosed with NET of pancreas, and 1 patient NET of

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The Enemy under Cover: Laparotomy revealed retroperitoneal mass with Retroperitoneal Inflammatory adhesions with no clear plane to the adjacent structures; including hepatic flexure, duodenum Myofibroblastic Tumour with and gall bladder. Extended right hemicolectomy, Locally Aggressive Behaviour cholecystectomy and stenting of right kidney were B C Chang, Ngo Choon Woon performed. Complete resection of tumour was Department of General Surgery, Hospital Sultanah Nur inaccessible. She was well after 7 days post-operatively Zahirah, Kuala Terengganu, Terengganu, Malaysia and discharged home. Histopathology finding revealed mixture of spindled and dispersed pleomorphic cells Inflammatory myofibroblastic tumours (IMT) are that were haphazardly arranged. It was consistent rare mesenchymal solid tumours usually that is with IMT of aggressive behavior. documented in children and young adult. It has been reported in various locations, which usually in lungs. Three months thereafter, she came back with episodes We report the case with unusual presentation. of upper gastrointestinal bleeding. OGDS showed huge duodenal tumour obstructing the lumen with active This is a 52-year-old lady presented with 6-month bleeding. Repeated CT scan confirmed aggressive history of right upper abdominal lump, associated progression of tumour. Then she was successfully with constitutional symptoms, constipation and managed by embolization. Currently she is undergoing flatulence. Clinically there was a vague mass in the radiotherapy. right hypochondrium. Complete resection of IMT is the mainstay treatment. Oesophageogastroduodenoscopy(OGDS) revealed However, it was unattainable for the case as there was external compression over the duodenum without any no clear plane of the tumour. The optimal management obstruction. Computed tomography (CT scan) showed of locally aggressive and recurrent tumours remains a peri-ampullary mass with moderate hydronephrosis controversial. of the right kidney. Blood investigations including tumour markers were unremarkable.

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Skeletal Muscle Metastases of Outcome of Peripheral Vascular Gastric Carcinoma – A Case Report Injury in a Trauma Surgery Unit: Neehad Baharuddin, Noraishah Mohd Arif HSAJB experience Hospital Ampang, Selangor, Malaysia Yuzaidi M, W S Pang, Asma’ R, Rizal I A Surgical Trauma Unit,Hospital Sultanah Aminah Johor Bahru, Skeletal muscle metastases of gastric carcinoma is Johor, Malaysia very uncommon; the more typical sites of metastases being the liver, lung, lymph nodes and peritoneum. Due to the rarity of this presentation, our literature INTRODUCTION review is limited to case reports. Furthermore, it is difficult to differentiate a primary soft tissue sarcoma Peripheral vascular injuries resulting from penetrating from a skeletal muscle metastases at presentation. or blunt trauma to the extremities, if not recognized Previous history of carcinoma, clinical examination and treated rapidly, may have disastrous consequences and magnetic resonance imagining all aid in diagnosis, resulting in loss of limb. We analyzed the outcome of however pathological examination expressing peripheral vascular injury encountered in our unit. patterns of cytokeratin 7 and 20 are valuable in determining the primary site. We present a case of a 41 METHODS year old Burmese gentleman with a history of gastric carcinoma and also a past history of gastrointestinal The Trauma Surgery Registry was retrospectively tuberculosis. He presented to our hospital with a 6 queried from May 2011 to Feb 2015, for patient month history of right iliac fossa fullness, associated with vascular injuries that require surgery. Surgical with severe pain radiating down the right thigh. A procedures performed were either primary repair or contrasted CT showed an enlarged right iliacus muscle vein grafts. Patients with unsalvageable extremity with a lobulated, multiseptated heterogenous cystic injury requiring primary amputation were excluded. collection within. Our initial impression was a cold abscess; however a core biopsy of the mass revealed RESULTS atypical cells with signet ring appearance as well as A total of 41 patients were identified. The median age positive immunohistochemical stains for CKAE1/ was 26 years, 87.8% were male. Twenty-two (53.7%) AE3 and CK20. Hence a diagnosis of metastastic adenocarcinoma was made and the patient were admitted directly to our ED and 19(46.3%) were subsequently received palliative chemotherapy. from other hospitals. Median duration of presentation

PP 116 PP 117 was 9.20hours following injury. Thirty-two (78%) A Case Report: Primary Omental sustained blunt and 9(22%) had penetrating injuries. Torsion Mimicking Acute Appedicitis Median ISS score was 13. No different in rates of amputations between blunt and penetrating injuries Y S Lee, P S Koh, J K Koong, B K Yoong (9.4% vs. 11.1%, p>0.05). The most common injured University of Malaya, Kuala Lumpur, Malaysia artery was brachial 18(43.9%), followed by popliteal artery 10(24.4%). The limb salvage rate was 37(90.2%). Introduction Although successful revascularization was higher Primary omental torsion is uncommon and usually when the presentation is less than 12-hours (73.0% present as an acute abdomen. It can often be mistaken vs. 27%), but the difference was not statistically for other types of acute abdomen such as an acute significant(p>0.05). Among ICU admissions, majority appendicitis. were successfully re-vascularized than those who require amputation, (75% vs. 25%, p<0.037). Successful Methodology re-vascularization was not associated with Injury We report a case of omental torsion mimicking an Severity Score(ISS), mechanism, duration of injury and acute appendicitis. source of referral. Result CONCLUSION A 45 year-old man presented with right-sided Based on our experience, patient can be treated abdominal pain associated with fever and anorexia. successfully if the surgeon is trained to manage He was initially diagnosed with acute appendicitis vascular trauma. Decision to re-vascularize injured and underwent laparoscopic appendicectomy. Intra- limbs were based on clinical judgement by the surgeon, operatively, the appendix was normal and conversion not solely on time elapsed since injury. Decisive and to open laparotomy revealed an omental torsion rapid intervention based on holistic assessment of the which appeared gangrenous. An omentectomy was injured limb appears to support limb salvage. performed. Patient recovered well post-operatively and discharged home on third post-operative day.

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Discussions Neuroendocrine Tumours – Primary Omental torsion is a rare condition where the Lesion from Common to Extremely omentum is twisted in its long axis causing ischaemia Rare Locations with Different and infarction. Its presentation is usually non-specific, which can mimic other acute abdomen. Pre-operative Presentation: Hospital Temerloh’s imaging such as ultrasound or computed tomography Experience are commonly employed in acute abdomen but the Sabrina K, Tham S Y, Salleh M S, Azmi H ability to diagnose omental torsion using these Hospital Sultan Haji Ahmad Shah, Temerloh, Pahang, modalities remained low at 0.6% to 4.8%. Diagnosis Malaysia is often made during surgery and the mainstay of treatment is surgical resection. Neuroendocrine tumous(NETs) are a group of rare neoplasm with variable histories and biological Conclusions behaviours. Nearly 70% of NETs develop in Although uncommon, omental torsion should be the gastroinstestinal, and another 25% in the considered a differential diagnosis in the management bronchopulmonary system, while testicular and of an acute abdomen. A careful inspection of omentum primary retroperitoneal NETs are exceedingly rare. in a “negative laparoscopy” is strongly recommended. Resection remained the mainstay of cure. We would like to report our three cases of NETs with different presentation in our healthcare setting Key words between the year of 2012 to 2014. The ages of the Omentum, torsion , acute abdomen, appendictis patients are between 50 to 69 years old. The first patient was referred for intestinal obstruction after being investigated for anaemia and menorrhagia by obstetric and gynaecology team. She underwent exploratory laparotomy which revealed small bowel tumour with secondary in the liver. Small bowel resection and primary anastomosis was done and histopathological analysis revealed NET

PP 118 PP 119 of small bowel. The next patient presented with Chronic Cholecystitis: An Unsusal progressively enlargement of right testes and left Causes of Duodenal Obstruction inguinal lymph nodes. A CT scan demonstrated a right testicular mass with lobulated, multiple left inguinal Tham S Y, Sabrina K, Salleh M S, Azmi H lymphadenopathies. Right orchidectomy with left Hospital Sultan Haji Ahmad Shah, Temerloh, Pahang, inguinal nodes dissection was done and histological Malaysia analysis showed compatible with right testicular NET. The third case was referred for chronic anaemia Duodenal obstruction, which may be partial or with upper abdominal mass. A CT scan revealed complete, may occur in adults and infants, each for upper abdominal mass most likely bowel in origin. a different set of reasons. The etiology in adults is She underwent exploratory laparotomy and found usually as result of repeated cycle of injury of peptic huge friable retroperitoneal tumour. Biopsy of the ulcer which cause scarring and narrowing of passage tumor revealed primary NET of retroperitoneum. Two way. There were also case report stated that the patients were given sandostasin LAR. obstruction can be due to external compression such as in Wilke’s syndrome, pancreatic tumour or cyst. In conclusion, NETs varies in presentations depending We are reporting a rare case of duodenal obstruction on the tumour location and usually patients present secondary to compression from an inflamed and at advanced stage. NET can occur in any anatomical distended gall bladder. locations. Thus, one should consider NETs as one of differential diagnosis in working up cause of any A 72 year old Malay lady presented with chronic tumor although it is rare. vomiting for almost 2 years and two weeks history of right hypochondriac pain. On examination, she was malnourished and dehydrated. The abdomen was fullness at epigastric region. An Abdominal X-Ray showed dilated stomach. The patient was subjected with an OGDS and subsequently a CT abdomen which revealed duodenal obstruction secondary to adjacent distended and stone containing gallbladder. We

124 PP 119 PP 120 proceeded with exploratory laparotomy and noted a Primary Diffuse Large B-Cell thickened gall bladder wall with cholelithiasis which Lymphoma of the Breast was severely adherent to and compressing the first part of duodenum. This caused the duodenal lumen Harjeet S S1, Thevarasan G1, Salleh M S1, Azlina A R2 narrowed at this level. Cholecystectomy and followed 1Hospital Sultan Haji Ahmad Shah, Temerloh, Pahang, by gastrojejunostomy and jejunojejunostomy was Malaysia 2 done, the procedure was uneventful. Patient recovered Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia well post-operatively. Primary breast lymphoma is an extremely rare disease and represents 0.38-0.7 percent of all non- Hodgkin type of lymphoma and comprises 1 to 2% of all extranodal lymphoma and less than 0.04 to 0.5 percent of all breast malignancies. Most cases are high-grade and from B-cell origin , mainly large cell and Burkitt type . Breast lymphoma is presented as single or multiple unilateral or bilateral breast masses not distinguishable from breast carcinoma in clinical presentation. Diagnosis is based on histopathological findings and managements differs from other forms of breast cancer.We would like to report a case of Primary Diffuse Large B-Cell Lymphoma of the breast that was diagnosed at our centre.

A 66 years old nulliparous and menopaused Malay lady presented with a two months duration of progressive increasing mass at right axillary .During physical examination the mass was three centimeters in diameter with firm consistency and non-tender. There was no other significant breast changes on

PP 120 PP 121 examination. A mammogram was done which showed Colonoscopy with clipping of a large multilobulated mass at right breast tail bleeding diverticulum of the colon. without any findings suggestive of malignant tumor. Further diagnostic investigation with trucut biopsy Another tool in the armentarium. was reported as Diffuse Large B-Cell Lymphoma. This A case report patient has been referred and has since been started Ragu Ramasamy, Loh Soo Kang on chemotherapy and bone marrow aspiration was Hospital Selayang, Selangor, Malaysia done. Patient is currently showing good response to treatment clinically. Diverticular bleeding is the most common cause in severe lower gastrointestinal bleeding (LGIB). Currently there are no single standardize approaches in managing the diverticular bleeding. Colonoscopy remains the first and outmost important tool in the armentarium of technology available. However the most challenging step is identifying the bleeding diverticulum and what treatment method to apply when it is identified. Clipping (Resolution clip) has been used as a technique with success rate of rebleeding prevention, if deployed correctly, approaching 100%. We present a case of patient with severe diverticular bleeding who was treated with colonoscopic clipping. Brief literature reviews of diverticular bleeding complement the case report, with an emphasis on colonoscopy with clipping in bleeding diverticulum.

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Successful T-tube Assisted Primary small liver contusion and pneumoperitoneum around Duodenal Repair in a Grade 3 the proximal duodenum. Subsequent laparotomy revealed a near-total disruption (>75% circumference) Duodenal Injury : A District Hospital of the duodenum at the D2 and D3 junction. After Experience adequate washout, the T-tube was placed anteriorly A Choke, N Rosly, D M Dualim, S H Saifuddin, and primary duodenal repair performed with W M Abuzeid interrupted Polydioxenone (PDS) 3/0 suture along both edges. Pyloric exclusion was performed, followed by Department of Surgery, Hospital Bintulu, Sarawak, Malaysia gastrojejunostomy with nasojejunal tube insertion for early feeding. Intravenous antibiotics, parenteral Introduction nutrition and subcutaneous Octreotide injection was Traumatic duodenal injuries are rarely encountered given. The T- tube was kept on low pressure suction for and technically challenging to general surgeons. The 8 days and clamped after initiation of enteral feeding. ideal repair should weigh the hemodynamic stability There was no immediate complication and tube was of the patient, degree of injury and experience of the removed at 6 weeks, he remains well on out-patient surgeon. Previously reported methods for complex review at 3 months. duodenal repair include pyloric exclusion, triple ostomies, or pancreacticoduodenectomy, but all does Conclusion not eliminate the possibility of duodenal leak. We The use of a biliary T-tube as a controlled fistula assists describe a case of successful duodenal repair by the in duodenal decompression, reduces suture tension, use of a biliary T-tube in a traumatic Grade 3 duodenal and allows time for healing. In this case, we had the injury. advantage of time as there was no concomitant bleeding or severe contamination. In a district setting, Case Presentation this method can be a safe, easily performed and A 40-year-old gentleman was admitted following a reliable alternative for complex duodenal injury when road traffic accident, he sustained blunt impact of resources for subspecialties are limited. the abdomen by the steering wheel. On arrival, he was hemodynamically stable with a guarded abdomen. Abdominal Computed Tomography (CT) revealed a

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Caecal Volvulus: An Unsuspecting peritoneal attachment of the right sided colon and Cause of Intestinal Obstruction underdeveloped greater and lesser omentum. An extended right hemicolectomy and ileotransverse N Rosly, D M Dualim, A Choke, S H Saifuddin, anastamosis was performed. Post-operative he had W M Abuzeid an uneventful recovery. In this case, the mobile and Department of Surgery, Hospital Bintulu, Sarawak, Malaysia redundant caecum with lack of peritoneal attachment served as a lead point for twisting to occur, and with Caecal volvulus is rare and accounts for 1% of causes chronic constipation this eventually precipitated of intestinal obstruction in adults and 25-40% of volvulus. We highlight the importance in considering all colonic volvulus. It is characterized by the axial caecal volvulus as an unusual yet possible differential twisting of bowel involving the caecum, terminal diagnosis for large bowel obstruction. ileum and ascending colon.We report a case of a 31 years old laborer who presented with 3 days history of generalized colicky abdominal pain, distension and vomiting. There was no previous surgical history. At presentation, he was dehydrated and unwell, with a grossly distended abdomen, no external hernias were noted. He has a Haemoglobin level of 16g/ dL, leukocytosis of 16150 cell/mm3, and a normal electrolyte profile. Abdominal X-Ray showed isolated small bowel dilatation, and subsequent Computed Tomography of abdomen revealed dilated large bowel loop and ‘whirling of mesenteric vessels’ at the central abdomen, suggesting the findings of caecal volvulus. The patient underwent emergency laparotomy, and we found a grossly dilated, twisted and gangrenous caecum at central part of abdomen, with largest diameter up to 8cm. We also noted deficient 126 PP 124 PP 124

Etiology And Epidemiology ranged from 15 to 79 with median age of 47.0. Five Perspectives Of Lower patients had normal colonoscopy findings. Among the patients with positive findings 58% (n=58) patients Gastrointestinal Bleeding (LGIB) were male and 42% (n=42) were female. Malays had Diagnosed By Colonoscopy At A highest incidence of LGIB, 83% (n=83), followed by Periphery Hospital Chinese, 13% (n=13), Indians 3% (n=3) and Orang Asli 1% (n=1). The most common cause of LGIB detected by Thiru V Raau, Sivapiragas S, Rudyanto Saripan, colonoscopy were Hemorrhoids 28% (n=28), followed Davaraj Balasingh by diverticular disease 19% (n=19), colonic polyps 18% Department of Surgery, Hospital Tuanku Ampuan Najihah, (n=18), colon carcinoma 13% (n=13), colitis 12% (n=12) Kuala Pilah, Negeri Sembilan, Malaysia and solitary rectal ulcers 10% (n=10). Each of above the causes were further analyzed with reference to age, Objective race and sex. To detect frequency of most common causes of LGIB diagnosed by colonoscopy with special reference to Discussion and Conclusion age, race and sex distribution in a periphery hospital. LGIB is the most common symptoms that may reflect serious pathology in the colon. Colonoscopy is a good Methodology method in examination of large intestinal lesion. Retrospective data of 105 patients who presented with Most common causes of LGIB in our set-up were at least one episode of LGIB were identified through hemorrhoids, followed by diverticulum and colonic endoscopy records from January 2013 to December polyps. Early diagnosis in LGIB patients is important 2014. Colonoscopy was performed on all patients. for an aggressive and symptomatic management to The causes and epidemiology data was recorded and save patients’ life. analyzed using SPSS Statistics Software Windows Version 17.0.

Results A total of 105 patients with LGIB had colonoscopy between January 2013 and December 2014. Their age

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Breast Lump Extrapulmonary Simultaneous Rupture Of Diaphragm Tuberculosis: A Case Report And Uterus Post Blunt Trauma: N D Mohamed Khairi, K Supramaniam, A Gerard A Case Report Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia N D Mohamed Khairi, K Supramaniam, A Gerard Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia Breast tuberculosis is a rare manifestation of extra- pulmonary localization of the disease, with an Traumatic diaphragmatic injury is usually occult and incidence of less than 0.1% of all breast lesions in can easily be missed. Blunt diaphragmatic rupture Western countries and 3–4% in tuberculosis endemic occurs in up to 5% trauma patients admitted to regions, such as India and Africa. It appears mostly in hospital. Uterine rupture occurs in less than 1% of women of reproductive age, multiparous, lactating, patients suffering blunt abdominal trauma. It is although it may also be reported in prepubescent associated with a maternal mortality of approximately males, or in elderly women. We report a case of a 10% but with a fetal mortality approaching 100%. 44 year old lady who presented with a left breast lump, We report a case of a 24 year old primigravida at 18 noted for the past 5 months. Clinical examination weeks period of gestation, who was a pillion rider on revealed palpable lump in the upper outer quadrant, no a motorbike which collided with a car. She presented palpable axillary lymph nodes. Fine needle aspiration with abdominal pain, in Class II hypovolemic shock, cytology showed granulomatous inflammation. with intrauterine fetal death due to suspected uterine Mammogram showed no evidence of malignancy. She rupture. Urgent laparotomy revealed dissected uterus subsequently underwent wide local excision of the with anterior and posterior tears. Intraoperatively left breast lesion. Pathology report was positive for patient was referred to surgical team after it was Tuberculous infection. Breast tuberculosis represents noted that there were tears of the diaphragm, a rare disease that should always be suspected measuring 6x3cm bilaterally, exposing lung when evaluating cases of breast abscesses, fistulae parenchyma. Blunt diaphragmatic rupture is rare and or nodules. Clinicians should consider this clinical represents a challenge to diagnosis and management, entity, often mimicking breast cancer, and may be particularly when imaging modalities are limited in misdiagnosed as either breast carcinoma or abscess. view of pregnancy. One must maintain a high index 127 PP 126 PP 127 of suspicion based on the mechanism of injury. Once Polytetrafluoroethylene Mesh diagnosed, management focuses on ventilatory With Filler Methyl Methacrylate support, treatment of associated injuries and surgical repair of the diaphragmatic tear. Sandwich Graft Reconstruction Following Resection Of Ewing Sarcoma Of Ribs - A Case Report Yuganeswary S, Rahmat Othman Department of Surgery, Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia

Management of patients requiring chest wall resection and reconstruction is ongoing challenge for thoracic surgeons, despite significant improvement in surgical techniques. Whether the indication be neoplastic or nonneoplastic, approach with reconstructive surgery remain essential in obtaining good results. Reconstruction provides maintenance of thoracic contents to optimize respiration post thoracic surgery.

Many literature have showed that sandwich of two layers, polytetrafluoroethylene mesh with filler methyl methacrylate gives good combination and was widely accepted by thoracic surgeons as it gives excellent physiologic and asthetic results.

Here we have a case report of reconstruction surgery with polytetrafluoroethylene mesh with filler methyl methacrylate post resection of Ewing sarcoma of ribs.

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14 years old girl who presented with right lateral chest Hyperamylasemia : The Unusual wall swelling and was diagnosed as Ewing sarcoma of Suspect ribs. She was started on neoadjuvant chemotherapy by oncologist and proceed with excision by thoracic team. A Wafi, S Fairuz, H Rezqa Department of General Surgery , Hospital Tuanku Fauziah, Patient underwent right thoracotomy with wide Perlis, Malaysia excision of Ewing sarcoma of ribs and chest wall reconstruction. Intraoperatively noted huge tumor Acute pancreatitis and GI perforations carries different involving inner aspect of 8th rib, in view of oncologic spectrum of management.In acute pancreatitis, aims clearance 6th to 9th rib was excised together with of management are directed towards supportive and tumor. The large defect was then reconstructed using managing SIRS complications.While in GI perforations, Polytetrafluoroethylene mesh with filler methyl urgent surgical intervention is always needed.In acute methacrylate sandwich graft. Post operatively patient patient presented with shared similarities between recovered well .Post operative chest radiograph these two pathology, making a direct impression need showed fully expended lungs with no chest wall extensive reassessment of clinical and laboratomy deformity. informations.

Based on literature published, it shows chest wall We presented a case of 72 year old lady with acute tumor resection followed by immediate reconstruction onset of generalized abdominal pain with significant using polytetrafluoroethylene mesh with filler methyl raise of serum amylase, therapy was initially directed methcrylate is safe one staged procedure besides towards acute pancreatitis however GI perforation shows good outcomes. was suspected in view of her abdominal findings and worsening condition .CT abdomen done at day 2 of admission and revealed abundant intraperitoneal free fluid that may suggest GI perforation.Urgent exploratory laparotomy done and revealed first part duodenal perforation measuring 1.5x1.5 cm with 2 litres of purulent peritoneal fluid.She recovered well

128 PP 128 PP 129 from her acute condition and was discharge home for Infected GIST of Lesser Sac rehabilitation on day 10 post duodenal perforation repair. Maung K L, Z L Lim, Othman M Z, S S M Fadzil Surgical Department, Tawau General Hospital, Sabah, Although an abnormal raise in serum amylase is Malaysia accepted clinically as usually indicative of acute pancreatits, it is also proven that such a rise may occur INTRODUCTION in other pathology especially in GI perforations.. Most Gastro-Intestinal Stromal Tumours are the accepted explanation is that GI perforation spill of most common mesenchymal neoplasms of the gastric juice into peritoneum and causing peritonitis, gastrointestinal tract. The prognosis depends on the later this amylase-rich gastric juice absorbed through tumour size, mitotic figures and location. Surgical peritoneal surface and result in lymphatic pick up and resection remains the mainstay of treatment for raise in peripheral serum amylase. localised and operable GIST.

Clinicians should put wide range of differential CASE REPORT diagnosis in mind in acute abdominal cases that has A 60 year old lady presented to us with epigastric pain significant raise of serum amylase.Judgement for and constitutional symptoms for one year. Clinically additional imaging such as CT abdomen or peritoneal there was an epigastric mass measuring 8 X 10 cm. aspiration should be done if in doubt. CT scan revealed a large irregular mass in upper abdomen measuring 10 X 11 cm with displacement of surrounding organs, possibly arising from the stomach fundus or body of pancreas. OGDS showed slight external compression and a clinical diagnosis of GIST was made. She subsequently deteriorated with worsening pain associated with rapid enlargement of the mass in two weeks. Exploratory laparotomy revealed a large cystic mass containing almost 3 L of seropurulent fluid with solid components arising from

PP 129 PP 130 the lesser sac and invading the left hemidiaphragm Case Report: Bleeding Kissing and anterior abdominal wall. The stomach was Duodenal Ulcers in Child with spared. The tumour was resected en-bloc with a post- op diagnosis of liposarcoma of the lesser sac. Her Henoch-Schonlein Purpura (HSP) recovery was complicated with burst abdomen before T S Chang, S L Lim, Hakem S, K J Chung, Waleid M she was discharged almost a month later. HPE revealed Department of General Surgery, Hospital Bintulu, Sawarak, it to be a low grade GIST of lesser sac. Malaysia

DISCUSSION Henoch-Schonlein Purpura (HSP) is common systemic This patient shows an abnormal presentation and vasculitis in childhood, characterized by a triad of progress of a Gastro-Intestinal Stromal Tumour, palpable purpura, abdominal pain, and arthritis with where it was thought to arise from the stomach and or without renal involvement. We are reporting a 5 subsequently rapidly increased in size secondary to years old boy presented with perforated and bleeding an infection, as reflected by her clinical deterioration duodenal ulcers (kissing ulcer) with underlying HSP. with intra-operative findings. The planned total This child previously well, presented with acute gastrectomy changed to en-bloc resection as the abdomen associated with haemetemesis and melaena, tumour was found to not arise from the stomach but preceded by bilateral lower limbs papular rashes posterior abdominal peritoneal wall. Despite the size for 2 days, off and on epigastric pain for 2 weeks and invasion to the diaphragm, HPE revealed a low duration. Clinically child had signs of peritonism; CT grade tumour, suggesting the infection could alter the abdomen suggestives of perforated appendicitis with tumour’s growth and progress. pneumoperitoneum at right subdiaphragmatic region. Exploratory laparotomy through transverse incision revealed periappendicitis, perforated duodenal ulcer at superior anterior D1, sealed with blood clot, primary repair and appendicectomy performed. Post-operative day 1, child developed massive haemetemesis and melaena, emergency oesophagogastroduodenoscopy showed large clot with minimal oozing at D1 posterior

129 PP 130 PP 131 wall. Second laparotomy through midline incision Tracheobronchial Injury – A Case found kissing ulcer from anterior to posterior duodenal Report wall, bleeding at ulcer base from gastroduodenal artery and under-running was done. Post operatively, Bhuwaneswaran V, Yuganeswary S, child recovered and was workout for HSP. Skin biopsy Rahmat Othman consistent with diagnosis of HSP and discharging Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia home well. Gastrointestinal involvement in HSP covers the spectrum from trivial to severe. Gastrointestinal Tracheobronchial injuries (TBI) are defined as injuries bleeding occurs in one-third of cases and may be involving the trachea and /or bronchi from the level overt, with hematemesis, melaena, or bloody stools as of the cricoid cartilage possibly extending up to the occurred in this child. These could be fatal if prompt division of the lobar bronchi. TBIs affect approximately intervention was not taken. Most gastrointestinal 3% of all patients who sustain blunt chest trauma. manifestations and complications of patients with 80% of intrathoracic TBIs are within 2.5 cm of the HSP are self-limiting and has overall good prognosis carina, most commonly involving the proximal right which can usually be managed conservatively, however main stem bronchus. surgical intervention may sometimes needed to prevent fatal outcome. The most frequent symptoms are dyspnea whilst the common clinical signs are subcutaneous emphysema and hemoptysis. Radiography shows pneumomediastinum and pneumothorax in up to 60% and 70% cases respectively. Computed Tomography (CT) is indicated for the evaluation of associated injuries while significant air leak and a suspicion of tracheal rupture mandate a bronchoscopy.

We report a case of a 21 year old gentleman following blunt trauma resulting from a road accident. He was haemodynamically stable but was tachypneic

PP 131 PP 132 in the casualty. He had no other injuries except Spermatic Cord Teratoma Presented for radiographic evidence of pneumothorax and As Inguinal Hernia subcutaneous emphysema and was later intubated for respiratory failure. Chest tubes were inserted Mohd Fahmi Ismail, Fatahurrahman Aminuddin, bilaterally and he was ventilated at the ICU. Mohd Azren Hashim, Wan Mohd Hanif Wan Yusof, Normah Ismail, Mohamed Muhshin Mohamed Sickandar He was treated conservatively as there was no Department of Surgery, Hospital Sultanah Nora Ismail, progression of symptoms nor difficulty in ventilation. Batu Pahat, Johor, Malaysia However, he later showed signs of increasing sepsis and a neck CT scan revealed tracheal tear at C6 level. Introduction Primary paratesticular tumors are rare, 7-10% of all An oesophagoscopy was performed to exclude intrascrotal tumors, commonly grouped into location oesophageal injury prior to neck exploration. ; testicular tunica, epididymis or spermatic cord. Intraoperatively, he had two third circumferential Mostly benign lipomas, however approximately 25% disruption of cervical trachea with muscle necrosis are malignant tumors.. Spermatic cord tumors are the and pus. A tracheal resection and anastomosis was most common tumor of the paratesticular region. In performed. adults, more than 75% arise from spermatic cord. SCT usually unilateral, hard, firm, slow growing masses of Post operatively, he was gradually weaned off the inguinal canal or scrotum hence tumor can easily be ventilation and discharged. Although TBI is rare mistaken for inguinal hernia. phenomenon, a high clinical suspicion leads to prompt diagnosis and intervention which in this case proved Case Report to be life saving. 68 years old gentlemen presented with painless, slow growing left inguinoscrotal swelling for two years. Otherwise no intestinal obstruction or other constitutional symptoms. Upon examination, noted huge, non tender, irreducible left inguinoscrotal mass. Ultrasound scrotum revealed collective appearance of 130 PP 132 PP 133 mesenteric fat less likely scrotal tumor and CT scan Complication Of Meckel’s showed collective features of large left inguinal hernia diverticulum. Case Series with predominantly mesenteric content. Densities seen within may represent testis with chronic Fadya Nabiha A S, Mohamed Muhshin, changes and less likely fatty mass with malignant M S Khairuzi S, Normah I transformation. Elective open left hernioplasty was Department of Surgery, Hospital Sultanah Nora Ismail, done with findings of huge scattered masses which Batu Pahat, Johor, Malaysia tracks along the spermatic cord into the scrotum. Operation was converted to excisional biopsy and left Introduction orchidectomy. Postoperative histopatology showed Meckel’s diverticulum (MD) is the most common spermatic cord tumor (monodermal teratoma with congenital anomaly of the gastrointestinal tract. In sarcomatous changes), well differentiated liposarcoma any patient with a MD, there is approximately a 4% risk and atypical chondrocytes. Case subsequently referred of developing complications. to oncology team for further management. Methods Conclusion We reported 2 cases of MD complications happen in It is recommended that ultrasound, CT or MRI used our hospital. The first case is an unusual case of small to evaluate masses before surgery. Incidental finding bowel infarction as a result of strangulation by an of spermatic cord tumor during open hernioplasty inflamed MD. The second case is intestinal obstruction were rarely reported. With limitations, frozen section caused by internal herniation of perforated.MD.We would be helpful to determine malignancy in order to also discuss about the epidemiology of MD, the ensure adequate resection intraoperatively. Curative atypical presentation in our patient, the post operative treatment of choice is radical orchidectomy with high complication and the role of CT scan in diagnosingMD. cord ligation and wide excision of surrounding tissue within the inguinal canal. If inadequately resected Results should undergo reoperative procedure for wide First case inguinal resection. Adjuvant treatments shown little A 29 year-old Vietnamese male came severe epigastric efficacy. pain.He was noted to have generalized board- like

PP 133 PP 134 rigidity and guarding. White cell count was increase. Genitourinary Tuberculosis In Exploratory laparotomy was done. A segment of small Bladder bowel appeared gangrenous and twisted through an inflamed MD that formed a loop with small bowel. Husna Haji Harun, Nur Amira, Dalilah Diyana, Limited right hemicolectomy with resection of the Rashide Yaacob gangrenous bowel with primary anastomosis were Surgical Department, Hospital Sultan Abdul Halim, Sungai done. He discharged well 5 days post surgery. Petani, Kedah, Malaysia

Second case Background A 44 year old Chinese lady came with intestinal Genitourinary Tuberculosis (GUTB) is one of the obstruction . CECT abdomen was done. It showed small extrapulmonary TB that can be asymptomatic in bowel dilatation with transitional zone at the distal the initial presentation and usually diagnosed after ileum. Laparotomy was done. A perforated MD was bladder perforation. In the GUTB the kidneys are the found forming a loop. A loop of small bowel herniated most common sites of infection and are infected into the the loop. The small bowel was released and the through hematogenous spread of the bacilli, which perforated MD was excised. She discharged well day 8 then spread through the renal and genital tract. As in post surgery. our presented case, diagnosis was only obtained after biopsy taken from cystoscopy procedure. Conclusion Complications of MD are uncommon and can be Case presentation difficult to diagnose. CT abdomen can be used in We report a case of a 65 year-old gentleman who emergency setting but the correct diagnosis of MD has no urinary symptoms but accidentally noted to could only be made during surgery. MD should be kept have multiple focal thickening of bladder wall from in mind in patients with atypical presentations. ultrasound KUB which was done after noticing his Serum Creatinine level deranged. Cystoscopy was done and noted irregular thickening of bladder mucosa and hence, biopsy was obtained and microscopically revealed presence of epithelioid granulomas in the

131 PP 134 PP 135 lamina propria. No acid-fast bacilli on ZN. Further Association of choledochal cyst investigations found acid-fast bacilli and positive and biliary atresia mycobacterium tuberculosis in sputum and left middle zone haziness from chest Xray. Patient was Shanthya Devi, I Mohan Nallusamy treated for Genitourinary TB with pulmonary TB and Paediatric Surgery Department, Hospital Sultanah Bahiyah, is on treatment. Alor Setar, Kedah, Malaysia

Conclusion This is a case report of an infant who presented with Diagnosis of GUTB is often delayed due to its clinical features of prolonged jaundice due to neonatal nonspecific presentation and more commonly cholestasis. Clinically the patient was suspected to have mimicked by other diseases. Diagnosing correctly is biliary atresia and this was supported by ultrasound crucial even for cases with the slightest significant imaging. The patient subsequently underwent Kasai presentation because any delay with proper treatment portoenterostomy. Intraoperatively, it was noted will increase rate of morbidity and mortality. that there was an area on the supraduodenal portion of the common bile duct (CBD) which had a deposit of some inspissated greenish material which may represent a possible ruptured cholodochal cyst. Post- operatively the jaundice cleared. It is important to differentiate between biliary atresia and choledochal cyst in the early newborn period as the operative management and prognosis differs. However, this case lends a support to the theory that choledochal cyst presenting as conjugated hyperbilirubinaemia in the early newborn period is a separate entity from that presenting later in life, and may actually be part of the spectrum of biliary atresia.

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Primary Angiosarcoma of Breast: is of non-specific findings. Treatment of choice would A Case Report be mastectomy, as margins are difficult to attain in a wide local excision. Radiotherapy and chemotherapy Balakumaran B P, Kirubakaran M R, Elaine Ng, have no proven role so far. Y W Yan Hospital Raja Pemaisuri Bainun, Ipoh, Perak, Malaysia

Background Primary breast angiosarcoma is a very rare mammary malignancy, making up only 0.04% of all breast malignancies. A combination of rarity, occurrence in primarily younger age and initial benign appearance makes it a difficult diagnosis at initial presentation.

Case This is a case report of a 28 year old mother of two who had presented with a right breast lump attributed to trivial trauma. Initial clinical, aided with cytology, diagnosis was of an infected heamatoma. Pathology after surgery reported intermediate grade angiosarcoma. She subsequently underwent wide local excision, and finally a mastectomy.

Conclusion Primary angiosarcoma is a rare entity, often masquerading as a benign lesion. A high level of suspicion is required to make an accurate initial diagnosis. Classical imaging for mammary malignancy 132 PP 137 PP 138

Case Report : Extramammary An Audit of Nephrectomies In Pagets Disease Of The Scrotum With Hospital Taiping : ‘ The Role of Skeletal Metastases General Surgeons’ Vilashini Aruna A, Arivarni K, Sivaneswaran L, Vilashini Aruna A, Arivarni K, Sivaneswaran L, Umasangar R C R Vinayak, Umasangar R Department of Surgery, Hospital Taiping, Perak, Malaysia Department of Surgery, Hospital Taiping, Perak, Malaysia

Extramammary Pagets disease is a rare condition and Objective guidelines in management of this disease is limited. To analyse and critically examine nephrectomies The clinical manifestation is varied and is often performed by general surgeons in Hospital Taiping associated with internal malignancies. Method An 80 year old man presented with nodular scrotal skin A retrospective study of nephrectomies performed swelling that has been progressively increasing in size by general surgeons in Hospital Taiping over a 5 year over few years. Wedge biopsy of the lesion revealed ( January 2010 until December 2014) period was done. adenocarcinoma of the scrotal skin. He underwent computed tomographic scan of thorax, abdomen and Results pelvis which revealed multiple lytic and sclerotic bony A total of 28 nephrectomies were performed during lesions involving the thoracic and lumbosacral spine. the 5 years period. The male to female ratio was 3: All other investigations to determine a spread from an 4. The most common indication for nephrectomy underlying internal malignancy came back negative. was malignancy of which 26% were primary renal Hence we proceeded with a wide local excision of the malignancy. Of the 28 cases, 1 case was a performed lesion by a paediatric surgeon and the rest was performed by 2 general surgeons. Perioperative morbidity rate is We report this case because of its rarity. about 23 % and the perioperative mortality rate is 7%

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Conclusion A Peculiar Chest Wall Swelling in There is still a role for nephrectomies to be performed a Diabetic Man by a general surgeon. The complexity of the case done depends on the experience, skills and resources A Choke, N Rosly, S H Saifudin, W M Abuzeid available to the surgeon. Department of General Surgery, Hospital Bintulu, Sarawak, Malaysia

Meliodosis is a tropical infectious disease caused by the gram negative bacterium Burkholderia pseudomallei. It has a variable clinical presentation ranging from acute septicemia to latent disease, and is characterized by abscess formation in any parts of the body. We present a case of a 55 years old Diabetic man who presented to the surgical clinic with an anterior chest wall swelling of two months. He described some weight loss but is otherwise well. On examination, there is a large protruding right sided anterior chest wall swelling with an overlying tattoo, measuring about 10x8cm, it is firm and fixed beneath, and is neither warm nor tender, the skin overlying is intact. An initial suspicion of a soft tissue tumor was denied after a Computed Tomography of Thorax revealed a multilobulated collection with underlying lung and pleural consolidation and splenic collection. An incision and drainage of the swelling followed, draining 200cc of ‘yellow-grey’ pus. The pus culture and sensitivity revealed Burkholderia pseudomallei sensitive to Ceftazidime and Augmentin. He was started on high

133 PP 139 PP 140 dose intravenous Ceftazidime for two weeks with CT Phenotype Analysis in Adrenal strict diabetic control, followed by oral Doxycycline for Incidentaloma 6 weeks. We later found out a history of non-traumatic extradural empyema with cranium osteomyelitis 3 Saiyidah M A, Normayah K years ago which required open neurosurgical drainage, Breast and Endocrine Department, Hospital Putrajaya, during which he was treated empirically for Meliodosis Putrajaya, Malaysia but subsequently defaulted follow up on discharge. This case depicts an unusual, latent musculoskeletal Introduction manifestation of Meliodosis and befits the disease Adrenal incidentaloma (AI) is applied to adrenal mass familiarity as a ‘Great Mimicker’. It also highlights the that discovered during abdominal imaging performed importance of strict antibiotics compliance to ensure to investigate other pathology not related to adrenal complete disease eradication and relapse prevention. disease. Distinctive characteristic of adrenal mass on CT scan might be helpful in differentiating benign or malignant pathology

Objective The objective of our study is to evaluate the accuracy of CT phenotype in predicting the adrenal pathology.

Method The study was conducted between January 2010 until December 2014 in Hospital Putrajaya. All patient with adrenal incidentaloma and underwent adrenal surgery were included in this study. The CT phenotype analysis and final histopathology were analysed. CT phenotype includes the size of the tumour, heterogeneity, margin, calcification, necrosis and distant metastasis.

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Result Malignant Melanoma of the There were 181 patients underwent adrenal surgery. Rectum: A Case Report Thirty three patients (18%) identified as adrenal incidentaloma. Majority was female (21 patients; 64%). Norly Salleh, Muhammad Hilmi Hashim, Median age was 50 (ranges 22- 76). Malignancy was Nor Saadah Idris, Karthikeyan Marthay found in 4 patients (12%): 2 adrenocortical carcinoma Department of Surgery, Hospital Pakar Sultanah Fatimah, and 2 sarcoma. There were 5 patients with tumour Muar, Johor, Malaysia size less than 4 cm and all were benign. However the prevalence of malignancy in adrenal mass >4cm were Malignant melanoma is a deadly form of cancer. only 14 % (4/28). Heterogeneity presence in both Malignant anorectal melanoma is rare but highly benign (82%) and malignant (18%) and all homogenous aggressive and it shows worse prognosis compared adrenal incidentaloma were benign (100%). For to cutaneous melanoma with median survival of 24 irregular margin the prevalence of malignancy was 33% months and a 5-year survival of 10%. Anorectum is the (2/6). The presence of calcification was demonstrated 3rd most common anatomic location for malignant in 9 patients (27%) and only 1 patient (11%) was positive melanoma after skin and retina. for malignancy. There were 5 patients with tumour necrosis but only 40% (2/5) were malignant. One We report a 84-years old lady who presented to us with patient had other organ involvement and the final one week history of rectal pain and altered bowel habit histology showed malignant adrenal tumour. of unknown duration. Colonoscopy revealed a large fungating rectal mass from 3 to 5 cm from the anal Conclusion verge which proved to be rectal malignant melanoma from histopathological examination. In conclusion, size, margin, presence of calcification and necrosis are not reliable indicator to determine Surgery is the main management for the disease. We malignancy in AI. However in our study, tumour <4cm discuss regarding surgical approach for excision of and all homogenous tumour were benign. The only the tumour and relevant literature review regarding predictor of malignancy is distant metastasis. the treatment and prognosis of malignant anorectal melanoma.

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Early Laparoscopic Hepatectomy Results Experience in University Malaya The commonest indication for liver resection was Medical Centre colorectal liver metastasis. All resections were for malignant conditions. One out of the surgery was Jun Kit Koong, Hiong Chin Lim, Peng Soon Koh, Boon converted to open. The mean age of the patients Koon Yoong was 53.1 years (28-74). They were mostly ASA 2. The University of Malaya, Kuala Lumpur, Malaysia average operating time was 3 hours 47 minutes (range 2 hours 10 minutes to 4 hours 30 minutes). The mean Introduction estimated blood loss was 400mls (200-700mls). The Laparoscopic liver resection for malignant conditions average hospital stay was 4.2 days post operatively. is a well-established technique worldwide. However, There were no major morbidity recorded and there local experience and data on its outcome is lacking. were no deaths. Cessation of parenteral analgesia, Our early experience with laparoscopic liver surgery in return to diet and full mobility were 2.25 days, 2.8 days a single tertiary unit is described. and 2.8 days respectively.

Objectives Discussion To investigate on the feasibility and safety of The average operating time and blood loss were laparoscopic liver surgery in malignancy. comparable to other studies published. Postoperative analgesia requirement, hospital stay and recovery Materials and Methods after surgery is acceptable. A review of demographics, profiles, pathology, surgery and recovery was performed on six patients between Conclusion April 2014 and March 2015. Data were collected and Laparoscopic liver resection is a safe option in analyzed retrospectively from medical records on a selected groups of patients including malignancies. pre-designed datasheet. The technique results in shorter hospital stays, earlier return to normal diet and mobility. It is also associated with minimal morbidity and mortality.

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Burst Colon From Compressed Air intubation. An urgent peritoneocentesis relieved Injury: A Case Report And Literature the tension pneumoperitoneum. Subsequently, he underwent a laparotomy to repair multiple colonic and Review rectal tears and there was a single transverse colon W C Pui, Thinesh Raja, Shehab C W Phung, perforation which was brought out as loop colostomy. Nik Azim N A He went home a week later. Sarawak General Hospital, Kuching, Sarawak, Malaysia Conclusion Background Pneumatic injury causing rupture of colon is rare and unique. It is associated with severe morbidity and even High pressure compressed air is widely used in current mortality. Prompt surgical intervention especially industrial and manufacturing setting. Pneumatic decompression of pneumoperitoneum and stoma devices can easily deliver pressurized air at 141L/ creation is warranted. min which is a hundred fold above the safety limit of colonoscopy air flow at 1.46 L /min. In 1904, Stone reported the first colonic rupture from compressed air into the rectum. Ever since then, there have been numerous reports of colorectal injury from either compressed air or hydrostatic pressure pump through the anal orifice due to playful insufflation, accidental or purposely self-inflicted.

Case report A 17 year old factory worker presented with sudden abdominal distension, severe abdominal pain and breathlessness after a coworker played a prank by spraying compressed air jet near the victim’s anus. He had tension pneumoperitoneum, respiratory distress and abdominal compartment syndrome which required 135 PP 144 PP 144

A Rare Association of Breast and myopathy before she underwent an elective MAC. Carcinoma and Dermatomyositis: One month post surgery, both her skin manifestation and myopathy resolved with the use of low dose A Case Report and Literature Review steroid therapy which was gradually tapered off. She Ragnild R1, H L Sha1, Aini I2, Rokayah J1 subsequently underwent adjuvant chemotherapy for 1Sarawak General Hospital, Kuching, Sarawak, Malaysia the breast carcinoma. 2Universiti Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia Conclusion DM is a type of paraneoplastic syndrome, which Introduction indicates the presence of tumour. The association Dermatomyositis (DM) is a type of idiopathic of DM and breast carcinoma is exceptionally rare. inflammatory myopathy with typical cutaneous The pathophysiology between these 2 conditions manifestation. On its own, DM is a rare disease and are still poorly understood. Thus, clinician should be its association with breast cancer is infrequently seen. aware about the strong association between DM and We present a case report of primary breast carcinoma malignancy, and if patient is diagnosed with DM first, associated with DM from our hospital setting. thorough screening tests should be carried out to exclude possible underlying malignancy. Medications Materials and Method are able to control the dermatological and muscular A 43-year-old lady presented with painless right manifestations, but the mainstay treatment is the breast lump for one month duration. Triple removal of the primary malignancy. assessment performed were consistent with right breast carcinoma and she is subjected for right Keywords mastectomy and axillary clearance (MAC). While Breast carcinoma, Dermatomyositis awaiting for surgery, she developed extensive poikiloderma over the sun exposed areas and also proximal muscle weakness. Laboratory investigations and skin biopsy were suggestive of DM. A pulse steroid therapy gradually improved the skin manifestation

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A Safety Review of Laparoscopic converted were included in this study. The procedure Cholecystectomy in Hospital was carried out by standard four port technique. Clinical examination, investigations, operative time, Tengku Ampuan Rahimah, Klang post-operative complications, reasons for conversion from 2008 - 2014 and hospital stay were recorded. Kamal Barathi N Barathilingam1, Results Phrabakaran Rajehgopal2, The average age was 48.48 years while male to Thamilannal Subramanian2, Yusof Wahab2 female ratio is 1:2. Main complications observed were 1Department of Surgery, Hospital Tengku Ampuan Rahimah, haemorrhage in 2.12% cases, bile duct injury in 0.14%, Klang, Selangor, Malaysia retained CBD stones in 0.42%, bile leakage in 0.28% and gut injury in 0.14% cases. Minor complications Objective included gallbladder perforation during procedure This study was carried out to see the incidence in 4.96% and surgical site infection in 1.13% cases. of various complications of laparoscopic Overall conversion rate was 4.14% cholecystectomy. Conclusion Study Design The morbidity and mortality of laparoscopic It was an observational case series study. cholecystectomy are remarkably low compared to the incidence in open cholecystectomy. This makes this Place and duration procedure safe and effective. This study was conducted at Hospital Tengku Ampuan Rahimah, Klang from January 2008 to December 2014

Patients and Methods This study comprised of 705 cases. All patients had routine investigations, liver function tests and ultrasound abdomen. The patients who underwent laparoscopic cholecystectomy whether successful or 136 PP 146 PP 146

Intraabdominal Actinomycosis showed a heterogeneous lesion in the lower anterior Post Lichtenstein Hernia Repair; abdominal wall, the uterus was displaced antero- superiorly and appeared to adhere to the underlying A Hybrid Surgical Approach peritoneum at the same region. On day 5 the swelling Michael A1, Pavitratha P2, Jasjit S N1 discharged foul smelling pus. She was subject to 1Department of Surgery, Hospital Pulau Pinang, immediate wound debridement and diagnostic Pulau Pinang, Penang, Malaysia laparoscopy. Intraoperatively, there was a large 2Department of Pathology, Hospital Pulau Pinang, abscess in the right lower abdomen encroaching the Pulau Pinang, Penang, Malaysia midline and breaching the fascial layer. Intraperitoneal examination revealed a mass involving a migrated Introduction propylene mesh eroding into small bowel and adhered Intraabdominal Actinomycosis is rare. It can present to the uterus. The mesh was removed en-bloc with as either an abdomino-pelvic mass mimicking the bowel segment and shaved off the uterine serosa malignancy or as suppurative infection. We aim to with primary bowel anastomosis and repair of the demonstrate the importance of the hybrid approach; fascial layer. Histopathology examination confirmed diagnostic laparoscopy during conventional surgery to Actinomycosis of the affected mass. improve diagnostic sensitivity of complex presenting lesions. Conclusion Intraabdominal Actinomycosis is rarely diagnosed Case Report preoperatively but almost always from a histological A 47 year old female with poorly controlled diabetes or microbiological examination. Management entails mellitus and a history of 3 previous uneventful surgery and prolonged antibiotic therapy. This case caesarean sections, tubal ligation and a recent highlights the benefits of the hybrid approach in Lichtenstein right inguinal hernia repair presented diagnosing and managing potentially life threatening with a painful swelling in the right iliac fossa for Actinomycosis complications. 3 weeks . Initial blood work was unremarkable. A colonoscopy and complimentary gynaecological examination was normal. A CECT Abdomen/Pelvis

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One-Year Surgical Audit Of General chest wall reconstruction, 5 cases of video assisted Thoracic Unit Hospital Sultan thoracoscopic surgery and 1 tracheal resection. There were no life threatening complications directly related Ismail, Johor Bahru to the operation, which lead to death. 3 deaths from Yuganeswary S, Aishah R, Rahmat Othman 25 cases were generally patients with poor prognosis. Department of Surgery, Hospital Sultan Ismail, Johor Bahru, Johor, Malaysia Our new thoracic unit was only able to perform 25 cases for the year 2014. Procedures like median General Thoracic Surgery is a major surgical specialty sternotomy and mediastinoscopy was not performed. service provided by the Ministry of Health Hospitals, These are mainly due to lack of equipment and which still remains a challenging surgical field. facilities. Even though the number of cases handled Increasing prevalence of lung carcinomas, pulmonary were few, outcomes were good which signifies success tuberculosis and thoracic traumas requiring surgical of our unit. Consequently, access to more equipments intervention increases the demand for this service. and facilities is likely to enable us to perform more There are only few functioning general thoracic units thoracic cases in the future. in Ministry of Health Hospitals. In a hospital without general thoracic unit, the service is provided by Cardiothoracic unit.

General Thoracic Surgery is a newly established unit in Hospital Sultan Ismail, Johor Bharu, since 2014, run by a thoracic surgeon. This audit is meant to demonstrate the quantity and variety of cases performed in the past year. Thoracic surgical cases which was operated in Hospital Sultan Ismail, Johor Bharu in 2014 was collected retrospectively.

A total of 25 cases, subdivided into 19 cases of open thoracotomy, out of which one constituted a 137 PP 148 PP 148

Video-Assisted Thoracoscopic Thorax was ordered as left pneumothorax persisted Resection Of A Giant Bulla with continuous bubbling on the chest drain despite being on low grade suction for almost 2 weeks. CT Mimicking A Pneumothorax With Thorax revealed a large left upper lobe bulla with Tension Pneumothorax – A bronchopleural fistula suggestive of possibility of Diagnostic Challenge A Case Report congenital cystic adenomatoid malformation. Patient successfully underwent Left VATS resection of bulla . George John K T G, Zainal Ariffin No complications occured in post-operative period and Thoracic Surgery Unit, Department of General Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia patient was discharged well on day 6 post operative with one month follow up to review the HPE. Introduction Conclusion A pneumothorax is an abnormal collection of air or gas Differentiation between a Giant bulla from in the pleural space which leads to lung collapse or in pneumothorax remains a diagnostic challenge as worse case scenario, mediastinal shift due to tension chest drain insertion into a bulla can lead to occurance pneumothorax, a medical emergency. Giant bulla is of a bronchopleural fistula and sometimes surgical also known as vanishing lung syndrome as most of emphysema too. Understanding that these conditions the space is occupied with air filled cavity without any may be present can lead to proper treatment and lung parenchyma seen.The main diagnostic challenge avoidance of morbidity from unnecessary chest drain is to differentiate a giant bulla from a pneumothorax insertion. Surgery remains the treatment of choice whereby chest drain insertion leads to bronchpleural and in these era, VATS resection of bulla remains the fistula formation. preferred ,viable and safe technique. Case Presentation We report a case of a young gentleman who was referred by a pulmonologist with history of recurrent left sided pleuritic chest pain with shortness of breath. CXR showed a left sided pneumothorax with lung collapse for which a chest drain was inserted. CT

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Ascaris Lumbricoides: A Rare Cause Outcome Of Treatment For Breast of Intestinal Perforation Cancer Patient In A Breast Centre H C Lim, Sandip Kumar Without Resident Oncologist Department of Surgery, University of Malaya, Kuala Lumpur, Annisaa A S, Sarinah B, Normayah K Malaysia Hospital Putrajaya, Putrajaya, Malaysia Introduction Introduction Ascaris Lumbricoides is a common parasitic infestation in the under-developed and developing countries. We Chemotherapy treatment for breast cancer in Hospital present a rare case of intestinal perforation caused by Putrajaya was commenced from 2008 until 2013. Ascaris Lumbricoides. During that period there was only visiting oncologist every month and the treatment was given by the Case report surgical team. A 25 year-old man, presented to us complaining of generalized abdominal pain with haemotochezia. Methods & Material Clinical assessment revealed an acute abdomen and We retrospectively reviewed 287 patients who erect chest radiograph revealed pneumoperitoneum. were diagnosed with breast cancer and received Emergency laparotomy was performed and revealed a chemotherapy in Hospital Putrajaya from January small intestine perforation, with multiple worms seen 2008 to December 2013 were included in this study. protruding from the perforation site. Their clinicopathological features, treatment and outcomes were analysed. Conclusion Ascariasis has a wide range of clinical manifestation. Results It can be completely asymptomatic, or it may lead to The mean age of our patient was 49 years (range 23- severe complications which can be potentially fatal. 75 years). Majority of patients were Malays (84%). Intestinal obstruction is the commonest complication of Ascariasis. Although intestinal perforation is a rare Seven patients (2.4%) presented with TNM stage 1, complication and presentation of Ascariasis, it should 128(44.6%) with stage II, 89 (31%) with stage III and be considered in patients presenting with peritonitis, 63 (22%) with stage IV. Patients with ER/PR negative especially in under-develop and developing countries. 138 PP 150 PP 151 was 104 patients (36.2%), 191(66.6%) had ER and/or PR Tolerance of a High Protein positive. Clear Liquid Formula versus Out of 224 patients with stage I-III disease, 211 Conventional Clear Fluid Diet After patients completed treatment. Majority 148(70.1%) Bariatric Surgery: A Randomized had mastectomy. One hundred seventy-one patients Clinical Trial (81%) received adjuvant chemotherapy and 40 A Z Ahmad Al-Hafeez, S Y Lim, N H Zubaidah, T Gee patients (19%) had neo-adjuvant. One hundred twenty nine patients (61.1%) received anthracycline- Department of Surgery, Universiti Putra Malaysia, Serdang, Selangor, Malaysia based chemotherapy and 61(28.9%) had sequential anthracycline and docetaxel. One hundred sixty-eight Background patients (79.6%) had post-operative radiotherapy and 143(67.8%) patients had hormonal therapy. Feeding after surgery is frequently complicated by post operative vomiting. In bariatric surgery, oral At a median follow up of 41 months (range 4-132 intake is further restricted by the newly created months), 40 patients (19%) had recurrence ; 1 of 7 in smaller stomach pouch. Generally clear liquids are stage I, 14 of 120 in stage II and 25 of 84 in stage 3. recommended in the first 48 hours after surgery. Thirty-four patients died from breast cancer. 2 years However such clear liquids lack nutritional value and survival rate for stage II was 96.4% and stage III was electrolytes except for the providence of fluids and 80.7%. simple carbohydrates. The purpose of this study is to study the tolerance of a high protein clear fluid Conclusions formula (RESOURCE Fruit Beverage) as compared Majority of patient presented at late stage. The to conventional clear fluids in the immediate post outcome of treatment is comparable to breast centre bariatric surgery period (first 48 hours). with resident oncology. Methods This is a single centre study performed between January 2014 to October 2014. Ninety-two patients were randomized into two groups (A and B), those

PP 151 Pp 152 receiving oral RESOURCE Fruit Beverage and clear Down to the WIRE liquids(A) and those receiving clear liquid diets only(B). The primary end-point is the tolerance of feeds. Other Hidayati Z, Nik Hafinni N H, Kiran K, Yusof Wahab secondary end-points include post operative nausea Department of General Surgery, Hospital Tengku Ampuan Rahimah (HTAR), Klang, Selangor, Malaysia and vomiting (PONV), numeric satisfaction scale, blood glucose levels , serum electrolytes and length of hospital stay. Background The widespread use of screening mammography and Results increased awareness has resulted in an increase in the A total of 87 patients were included in the study. Five number of nonpalpable breast lesions. The purpose of patients who were not compliant to the post operative this study was to evaluate the outcome of Hook Wire feeding protocol were excluded from the study. There Localization biopsy, to assess the correlation between were no statistically significant difference in feeding the preoperative assessment and final diagnosis to tolerance and vomiting among the 2 groups but a determine the usefulness of this procedure. statistical difference was seen in the satisfaction score between them. Methods This was a descriptive retrospective study conducted Conclusion at HTAR, Klang involving all patients who underwent Oral RESOURCE Fruit Beverage is well tolerated after Hook Wire Localization biopsy from January 2011 bariatric surgery with patients feeling more satisfied. to December 2013. Patients were categorized using BIRADS assessment categories. The percentages of benign, pre-malignant and malignant lesions were determined by histopathological examination of the surgically removed specimens.

Results A total of 40 Hook Wire Localization biopsies were carried out throughout the study period. Of the 40 biopsies, 7 (17.5%) turned out to be malignant, 9 139 Pp 152 PP 153

(22.5%) were pre-malignant and the remaining 24 Indirect Laryngoscope; Do Or Don’t (60%) were benign lesions. The malignancy rate was In The Benign Thyroid Surgery 28.6% for benign lesions and 71.4% for malignant lesions, respectively. The Hook Wire Localization C T Ooi, C W Yong, Imran Abdul Khalid procedure was warranted in 40% of our patients who Hospital Seberang Jaya, Pulau Pinang, Penang, Malaysia had a final diagnosis of malignant and pre-malignant lesions. Background According to some authors, routine laryngoscope Conclusion should be the standard of care in all patients undergoing Hook Wire Localization offers an opportunity for thyroid surgery. The rationale for this approach is accurate excision and diagnosis of nonpalpable breast the risk that a patient may have preoperative vocal lesions. Overall, the malignancy rate in our study was cord palsy without symptoms. However, there is 17.5%. Previous studies have reported malignancy some literature review show preoperative vocal cord rates of between 19-32% with Hook Wire Localization palsy is rare in patient with benign thyroid disease. biopsy. In January 2015, HTAR has implemented the use Thus, the study of the incidence of the preoperative of screening guidelines as well as single physician care asymptomatic vocal palsy in benign thyroid disease is for proper patient selection in order to improve our important. malignancy rates. Methods Medical records of total 75 patients who underwent benign thyroid surgery from 2013-2014 were retrospectively review for patient voice complaints, surgeon documented voice quality and result of laryngoscopy. We exclude the thyroid malignancy case in this study.

Results Of total 75 patients, only 4% (3 patients) had abnormal laryngoscopy findings including 1 asymptomatic

PP 153 PP 154 vocal cord paralysis (1.2%). Preoperatively, 24% Video-Assisted Thoracic Surgery of patient’s complaint of voice changes, but only (VATS) for Iatrogenic Thoracic 3 patients had a corresponding abnormality on laryngoscopy examination. Only 4% of patients had Injury; A Case Series a surgeon documented voice abnormality with 100% Kishore Kumaar, Yusof Wahab corresponding abnormality on laryngoscopy. Department of Surgery, Hospital Tengku Ampuan Rahimah, Klang, Selangor, Malaysia Conclusion The incidence of preoperative asymptomatic vocal Introduction cord palsy is low in benign thyroid surgery. Thus Video-Assisted Thoracoscopic Surgery (VATS) has an selective rather than routine use of preoperative established role in elective thoracic surgery. However, laryngoscope is acceptable. We recommended its role in emergency thoracic is still uncommon. We surgeon documented voice abnormality as criteria for would like to share our experience performing VATS in preoperative laryngoscopy. emergency thoracic surgery.

Case Presentation This report presents three cases which were seen at our center from 2013 till 2014. All three cases were referred to the Surgical Department for iatrogenic thoracic injury; One patient developed tension haemothorax after needle thoracocentesis, the second patient developed haemothorax after chest tube insertion, while the third patient developed haemothorax after internal jugular vein catheterisation. We selected these cases to highlight how VATS can be used to manage patients requiring emergency thoracic surgery.

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Conclusion Managing Superior Mesenteric VATS is a safe and acceptable option for emergency Artery Syndrome: Two Successful thoracoscopic surgery with an appropriately Cases of Laparoscopic resuscitated patient, proper equipment and an experienced/ trained surgeon. Duodenojejunostomy S C Tee, S L Siow, C M Wong Hospital Umum Sarawak, Kuching, Sarawak, Malaysia

Introduction Superior mesentery artery (SMA) syndrome is a rare cause of mechanical duodenal obstruction. The popular pathogenesis of SMA syndrome is loss of mesenteric fat pad which surrounds the SMA. Loss of intervening fat leads to entrapment of third part of the duodenum when it passes between the SMA and the aorta, results in proximal duodenal obstruction. Its incidence is unknown, estimated to be 0.3% from upper gastrointestinal contrast series.

Case presentation We report 2 cases of SMA syndrome in young females. They presented with typical history of postprandrial epigastric pain, vomiting and weight loss. A barium meal study showed an abrupt cut off at the third part of the duodenum. Computed tomography confirmed the diagnosis by demonstrating a narrowed aorto-mesenteric angle and distance. The initial management focused on supporting their nutritional

PP 155 PP 156 needs. Subsequently, we performed laparoscopic Rare Emergence of Abdominal duodenojejunostomy. On follow up, they regained Tuberculosis weight gradually and their symptoms improved. G Dhayalan, T Sekkapan , K Karthik , H Singh Conclusion Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia Diagnosis of SMA syndrome is often not pursued as the symptoms are non-specific. Hence, high index This is a rare presentation of a 27 year old gentleman of suspicion is required if routine management fails. with no known co-morbids. Presented with lethargy, There are various surgical methods which are employed abdominal pain and bloating, giddiness, vomiting, after failed medical management. Traditionally, open diarrhoea, loss of appetite and loss of about 5 approach duodenojejunostomy is favoured as the kilograms in the past 2 months. On initial examination, results are excellent. Currently laparoscopic approach patient was thin and frail, abdomen was grossly has replaced it as recovery is faster. Laparoscopic distended and patient was anaemic. duodenojejunostomy is safe, effective and easily reproducible method in managing SMA syndrome. Initial impression was complex abdominal cystic mass ergo patient was planned for an urgent CT abdomen and pelvis and for both oesophagogastrod uodenoscopy(OGDS) and colonoscopy. OGDS findings was pangastritis with reflux oesophagitis and from colonoscopy he was queried to have a bleeding gastrointestinal stromal tumour and was admitted to ward.

CT abdomen/pelvis was done and was noted there was a huge intraperitoneal complex cyst with air and fluid within occupying the whole abdominal cavity. Impression was a huge intraperitoneal contained complex fluid with large air within is very suggestive

141 PP 156 PP 157 or perforated viscus with underlying presence of Patent Vitello Intestinal Duct ; capsulated (or pseudo capsulated) complex peritoneal A Rare Cause of Umbilical Discharge cyst and bilateral moderate hydronephrosis. G Dhayalan, M Alia, K Karthik, G Samuel As it was still uncertain the nature of the disease or Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia causative factor, patient was opted for a surgery and underwent an exploratory laparotomy. Intra This is a case of a 2 year old boy who from history has operatively the cyst was turbid, blackish, foul smelling been having discharge from his umbilicus since birth. and contaminated with feces. Diagnosis was still He has been brought to multiple practitioners prior to uncertain then and was pending for the HPE report. this and has been treated as umbilical sepsis and been given courses of antibiotics, when he first presented The HPE result with Ziehl-Neelsen stain for acid fast to us, there was a small 2x2 swelling over the umbilical bacilli was positive. Patient was then started on anti- region. It was erythematous with healthy mucosa. He TB medication was managed in the ward. was treated as umbilical granuloma and was given a date for a laparoscopic examination. Abdominal TB usually presents with almost similar complaints but presentations will be hematochezia, Laparoscopic examination showed a Patent Vitello bowel obstruction, and fever amongst others and CT Intestinal Duct (PVID) and hence it was converted to an scans will usually show peritoneal lymphadenopathies. open laparotomy and resection of the Vitello Intestinal With this poster presentation, this rare presentation Duct with primary anastomosis. Patient recovered well can be further exposed and brought to attention and and there was no discharge or active complaint post- thus be a differential when a patient presents with surgery. signs and symptoms such as this patient Differentials for patients who present with similar swelling are umbilical adenoma, umbilical sepsis, patent urachus and patent VID. The latter two would require surgical intervention hence is important to be identified from the primary setting and for early

PP 157 PP 158 surgical referral to prevent mismanagement and Clinical Experience in Managing prompt intervention. Mortality rate can increase Medullary Thyroid Carcinoma detrimentally especially in the event of a prolapse. in Putrajaya Hospital – a 15-year Patients will usually present with persistent discharge Evaluation from the umbilicus, swelling over the umbilical region, Suhairil B, M N Hisham, Sarinah B, Normayah K and with complications; bleeding, and obstructive Breast and Endocrine Unit, Department of General Surgery, symptoms. This poster is hoped to be beneficial in Putrajaya Hospital, Putrajaya, Malaysia exposing amongst the presentation and differentials of such a case. A laparoscopic examination would Medullary thyroid carcinoma(MTC) is a tumour of the be able to delineate the differentials and aid in the parafollicular C cells. It accounts for approximately 4% definitive management. of thyroid carcinomas. The most common presentation is solitary thyroid nodule in 75 to 95% of patients. Approximately 50% have clinically detectable cervical lymph node metastasis and about 5% have distant metastatic disease.

We report a total of 12 cases of MTC managed in Putrajaya Hospital from January 2000 to December 2014. The gender distribution revealed a male preponderance with male:female ratio of 1.4:1. The mean age at diagnosis was 44.8 years, SD(12.74). The racial distribution showed an equal preference to Malay and Indian races, Malay:Indian:Chinese 2.5:2.5:1. All of the patients came with anterior neck swelling at first presentation. Only one of the patients had associated carcinoid syndrome which proved to be a challenge to manage. 142 PP 158 PP 159

Preoperative tissue biopsies were performed in all Prospective Study: The Pattern patients, six of which(50%) were diagnosed as MTC. and Early Treatment Outcome of Preoperative serum Calcitonin was elevated in six cases(50%), whereas one had a normal level, one had Abdominal Injury in Hospital Pakar a lysed sample and the rest were not done as they Sultanah Fatimah, Muar were not diagnosed as MTC preoperatively. Neck nodal Norly Salleh, Mohd Hamidi Osman, metastases were present in 10 patients(83.3%), whilst Muhammad Hilmi Hashim, Thiagarajan Gobal MTC recurrence was present in 8 patients(66.7%). Department of Surgery, Hospital Pakar Sultanah Fatimah, Muar, Johor, Malaysia Majority of the cases(nine patients) were sporadic MTC, while three patients with familial MTC; one of Objective which with MEN Type 2A. During a period 0.4 - 10.0 Trauma is the leading cause of death under the age of years follow-up, nine are still alive, one lost to follow- forty and of all traumatic deaths abdominal trauma up, and two succumbed to death. In conclusion, the is responsible for approximately 10%. The objective preliminary data suggests that MTC cases managed is to study the demography data, pattern and early in Putrajaya Hospital has following characteristics: treatment outcome of abdominal injury in surgical (1) male preference, (2) mostly sporadic MTCs, (3) neck unit HPSF, Muar. nodal metastasis is common, (4) MTC with carcinoid syndrome is plausible but very rare. Method A prospective, descriptive and observational study of abdominal injury patients from the day of admission to final outcome of management at discharge or death, presenting to surgical unit HPSF, Muar, from June 2014 to February 2015. The data were analyzed using SPSS software.

Results A total of 29 patients with abdominal trauma managed

PP 159 PP 160 in the surgical department during the study period A Rare Presentation Of Small Bowel were enrolled. Males were 23 and females were 6 Lymphoma with the male to female ratio of 3.8:1. The age range was 11 to 78 years with the mean age of 37.8 years. 10 Hidayah M S, Zuraimi A Z, Hafizullah M, Wan Omar, patients (34.5%) were in the age group of <20 years. Luqman H Occupational wise student were most involved in Hospital Raja Perempuan Zainah II, Kota Bharu, Kelantan, accident constituting 31% (9 patients) of all cases. All Malaysia abdominal injuries were caused by blunt trauma and 89.6% (26 patients) were involved in MVA. 18 patients Introduction (62.1%) with intra abdominal solid organ injuries were Lymphoma of the small bowel is the most common managed non-operatively. During the study period, 4 small bowel malignancy, accounting for 25% of complications and 4 death were recorded in which all all primary small bowel malignancies. Clinical death are related to MVA. The average length of stay presentation can be either abdominal mass, for abdominal injury patients ranged from 3 to 23 days. gastrointestinal bleeding, perforation or intestinal obstruction. Conclusion Blunt abdominal trauma was the commonest type of A Case Report abdominal injuries in HPSF, Muar and vast majority A 29 years old gentleman, with generalized colicky were treated non-operatively. Early diagnosis and abdominal pain for 1 month, persistent vomiting appropriate treatment contribute greatly to reduce and significant weight loss. He presented to us with the mortality and morbidity rate. worsening abdominal pain and intestinal obstruction. Clinically, there was visible peristalsis. Supine abdominal x-ray showed dilated jejunum.

Intra-operatively, revealed small bowel tumour, located 130 cm from duodenojejunal junction, with only pinpoint lumen, ulcerated mucosa and infiltrating into sigmoid colon. The proximal small bowel was

143 PP 160 PP 161 grossly dilated. There were multiple mesenteric AUDIT ON DRAIN USE FOR BREAST lymph nodes. We did en-bloc resection of small bowel CANCER SURGERY IN HOSPITAL RAJA together with sigmoid colon. PERMAISURI BAINUN, IPOH AND HPE came back as Diffuse Large B-cell Lymphoma. No PATIENT’S PERCEPTION ON AMBULATORY neoplastic changes seen in all lymph nodes. POST-OPERATIVE DRAIN CARE

Discussion M F Madzlan, M A Abdul Manan, G K Ooi, Despite the extensive involvement, small bowel N D Mohamed Khairi, C A Muttaqin, A Gerrad, obstruction is uncommon because of lack of E H B Ng, Y W Yan desmoplastic reaction and perforation is also rare. General Surgical Department, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia The outcome depends on the histology and stage of disease. With ‘curative’ resection for and subsequent OBJECTIVE chemotherapy, the survival rate is usually favourable. Vacuum drains are routinely used for breast cancer surgery and contribute to prolonged hospital stay as patients are only routinely discharged after all drains are removed. We conducted a 1-year audit on drain use for breast cancer surgery HRPB Ipoh. Patients’ perceptions on early discharge with drains were assessed to aim for future daycare breast cancer surgery.

METHODS We conducted a retrospective review of 101 patients who underwent breast cancer surgery in HRPB Ipoh in 2014. Each patient had 1 suction drain in the axillary (A) and breast bed (B) post-operatively. Patients, who were

PP 161 PP 161 discharged home with drains, were given adequate CONCLUSION instruction regarding drain care and quantification. Patients were generally happy with the concept of Comparison was made between the group who discharging home post-breast cancer surgery with discharged with drain and those who discharged after drains which suggests feasibility of daycare breast drain removal. They were interviewed regarding the cancer surgery with adequate education and drain care concept of early discharge with drain. support.

RESULTS Only 63 out of 101 patients had sufficient documentation for analysis. 8 patients were successfully discharged home with drains.

Patients who were discharged with drains had an average output of 50cc/day from drain B and 60cc/day from drain A and were discharged on POD 2. B drain was removed after an average of 3 days, and A after 5 days. Average daily B drain collection was 30cc and A was 50cc prior to removal. Only 1 patient had seroma.

The other 55 patients were discharged after all drains removed. In average, drain B was 52.6cc/day and A 77.16cc. Mean removal of B drain was 2.3 days and A 5.2 days. Mean length of hospital stay was 5.4 days. 30 patients developed complications upon discharge.

Feedbacks from both groups of patients were assessed with a questionnaire.

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Small Bowel Lymphoma as ill-defined para-umbilical mass was palpable. Digital Lead Point for Adult lleo-ileal rectal examination revealed normal findings. Intussusception: A Case Report Contrast enhanced computed tomography (CT) M A Zairul, Y L Quek, I H Dina, I Sagap scan of the abdomen and pelvis revealed enhancing Universiti Kebangsaan Malaysia Medical Centre, lobulated para-aortic mass which represents matted Kuala Lumpur, Malaysia lymph nodes, strongly suggestive of abdominal lymphoma. There was ileal thickening at the pelvis Introduction which demonstrated concentric layers, suspicious of Intussusception of the bowel is defined as intussusception. the telescoping of a proximal segment of the gastrointestinal tract (intussusceptum) within the We proceeded with a diagnostic laparoscopy and lumen of the adjacent segment (intussuscipient). Adult found an ileo-ileal intussusception with multiple intussusception is an uncommon cause of intestinal lymphadenopathy at the mesentery of the small obstruction, thus posing a diagnostic challenge to bowel. Segmental resection and primary anastomosis the surgeon. The majority of intusussception in was performed through a lower midline incision. adults is due to a secondary cause – adhesion, polyps, Histopathological report confirmed small bowel lymphoma and metastases. Burkitts Lymphoma.

Case Report Conclusion We report a case of a 71-year old male with left-sided Adult intussusception is uncommon and poses a hemiparesis, on percutaneous gastrostomy tube diagnostic challenge. CT scan of the abdomen plays feeding following a cerebrovascular accident four an important diagnostic role – localising the site of years ago, who presented with a one-week history of intussusception and the presence of a lead point. bilious vomiting, colicky abdominal pain and abdominal Surgical resection remains the main treatment distension. On examination, he was haemodynamically modality in adult intusussception. stable. The abdomen was distended. There was no peritonism and hernial orifices were intact. A diffuse,

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Post-Laparoscopic Sleeve ease towards the antrum. A serial gastrograffin Gastrectomy Narrowing – Stricture study on POD1 and POD5 showed a very tight acute stricture proximal to the incisura which subsequently or Normal Variant of Gastric improved on the 2nd study. She was started on fluids Remnant? and and discharged. At post operative 3 months, K Yugasaravanan, G Prem Kumar, A Sivananthan, barium swallow showed persistent narrowing with Andrea Se En Ooi smooth flow of contrast. She has been asymptomatic of any reflux symptoms throughout her postoperative 94 Terendak Army Hospital, Melaka, Malaysia course. Her excess weight loss is 55% at 6 months now and is tolerating normal diet. Introduction Laparoscopic Sleeve Gastrectomy(LSG) has gained Conclusion popularity in last few years as a weight loss procedure. Few studies have evaluated the post LSG gastric LSG is a relatively easier procedure in comparison to remnant radiological anatomy. These have shown the well established laparoscopic Roux-en-Y gastric that shapes other than the expected tubular gastric bypass(LRYB). However, its complication such as remnant could possibly be a normal variant. More leaks and strictures are rather challenging to manage. studies are needed in this area to correlate this with We present a case of post LSG narrowing in an stricture rates and long term patient outcomes. asymptomatic patient.

Case Presentation A 38 year old lady with a BMI of 50.1 underwent a LSG in Aug 2014. The surgery was done using a 5 port technique in supine position. Sequential stapling was started at 4 cm proximal to the pylorus guided by a 36F gastric calibration tube. Post procedure intra-operatively, there appeared to be an apparent narrowing of the lower 3rd of the gastric tube. However, the calibration tube was reinserted with 145 PP 164 PP 164

A Young Girl with an Absent Right lobe. Cytology revealed nodular hyperplasia with Thyroid Lobe: A Case Report and thyroiditis. CT scan showed an aberrant left thyroid lobe and presence of a lingual thyroid tissue, confirmed Literature Review by the subsequent thyroid scan with Tc-99m. H M Firdaus, M Suziah, N A Hakim, E N Aina Following medical therapy, her anterior neck swelling Department of Surgery, Breast and Endocrine Unit, reduced in size, there was no obstructive symptoms General Hospital Kuala Lumpur, Kuala Lumpur, Malaysia from her lingual thyroid, and she remained clinically and biochemically euthyroid. Lingual thyroid is a rare congenital condition results from lack of normal caudal migration of the thyroid Conclusion gland. We report a case of a young girl diagnosed with Lingual thyroid is the most frequent ectopic location lingual thyroid who presented with an anterior neck of the thyroid gland although the prevalence varies swelling. The literatures on this rare condition are between 1:100000 to 1:300000. It occurs more reviewed and its management discussed. frequently in female. About 33-62% of patients showed subclinical hypothyroidism. Differential Case Report diagnosis includes thyroglossal, epidermal, dermoid An 18 year old Malay female presented to us in or sebaceous cyst and lipoma. Management is December 2010 with an anterior neck swelling since controversial and no treatment is required when age 9. She was clinically euthyroid and had neither lingual thyroid is asymptomatic and patient is constitutional nor compressive symptoms. Physical examination revealed no evidence of hyperthyroidism euthyroid. or hypothyroidism. She has a 4 x 4 cm swelling lateral to the thyroid cartilage on the left. Her blood tests revealed a high TSH and low free T4 levels. Microsomal antibody was detected. She was started on L-thyroxine 100 mcg daily.

Ultrasound showed a superiorly located diffusely enlarged left thyroid lobe with absence of the right

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Spontaneous Haemo- 9g/dl, requiring aggressive resuscitation and blood Pneumothorax: A Rare, Life products transfusion. Chest X-ray revealed a right hydropneumothorax with possible lung collapse. Tube Threatening Entity thoracostomy was done and drained 2.6 litres of blood Yogessvaran Krishnan1, Thinesh Raja1, over 4 hours. Cardiothoracic team was consulted and Noorharisman I2, Nik Azim N A1 in view of hypovolemic shock with drainage of more 1Sarawak General Hospital, Kuching, Sarawak, Malaysia than 600mls/hour for 4hours, patient was planned 2Melaka General Hospital, Melaka, Malaysia for urgent surgery. Video Assisted Thoracic Surgery (VATS) was done and intraoperatively found a spurting Introduction vessel over the apical region due to torn adhesion band Spontaneous haemo-pneumothorax (SHP) is a between an apical right lung bullae and the parietal rare clinical disorder, complicating 2 to 7.3% of pleura. The tear was due to a collapse following patients with spontaneous pneumothorax and is spontaneous rupture of the apical lung bullae. potentially life threatening due to massive bleeding. Hemostasis was secured with endoscopic ligaclips and SHP occurs commonly in young male patients with bullectomy was performed with endoscopic staplers. a 30:1 predominance, following collapsed lung Patient had a complete recovery postoperatively. from pneumothorax with haemorrhage from torn Conclusion congenital aberrant vessel, bleeding from torn adhesions between parietal and visceral pleurae or We are reporting this case to emphasize: (i) unique bleeding from ruptured bullae. mechanism of SHP (ii) importance of early surgical intervention which has led to uncomplicated and Case report complete recovery. We report a case of a 24 years old man, presented with 1 day history of right sided chest pain and breathlessness, with no history of trauma. He was a smoker but had no significant medical history. Upon presentation, patient was hemodynamically unstable due to hypovolemia with drop in Hb from 12.8 to 146 PP 166 PP 166

AN INNOVATIVE METHOD OF MANAGING through the external tube, acting as a guide for bumper EARLY BURIED BUMPER SYNDROME readjustment. Gentle manipulation with rotational movements enables the bumper to be re-introduced N R Kosai, H S Gendeh, M T Mustafa , R Reynu into the stoma cavity . Upper GI, Bariatric and Minimally Invasive Surgery Unit, Department of Surgery, Universiti Kebangsaan Malaysia Results Medical Centre, Kuala Lumpur, Malaysia The endoscope provides real-time imaging for guidance, thereby ensuring patient safety by Introduction preventing mucosal trauma through ‘blind’ Buried Bumper Syndrome (BBS) is a known long term manipulation. Moreover, the procedure is carried out complication of PEG tube insertion. Although, many in the outpatient setting, avoiding invasive surgical precautions being taken for the long term care and intervention. sustaining the durability of the tube from the moment of its insertion, many precipitating factors that Discussion may speed up the occurrence of this complication, An extra space is allowed between the bumper and rendering the tube non-functional. This often results gastric wall and the external bolster and skin in order in the removal of the tube or even warranting an to achieve a better or solid maturation of the tube exploratory laparotomy. tract. A simple act of pushing internally and rotating the tube by a 5mm distance on each adjustments will Objectives prevent BBS and increase the durability of the PEG To illustrate a new innovative method that may safe tube especially among patients whom are in risk. the patient with BBS from unnecessary invasive endoscopic intervention of even emergency Conclusion laparotomy . Endoscopic guided PEG tube readjustment is an innovative, cost effective and surgically feasible Method technique for the treatment of early BBS. A12mm endosscope assess the patency of the tract in the gastric mucosa. Then, a 9mm nasoendoscope is inserted through the existing PEG tube to pass

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Intussusception due to Meckel’s We diagnosed an acute small bowel obstruction Diverticulum : A Case Report and performed emergency laparatomy. The intra operative findings were distension of the small bowel Mohd Johari, Ahmad Akram, Hasnizal Nording, and intussusception of ileum due to an adhesion of C H Lim inverted Meckel’s diverticulum. Adhesiolysis with Deparment of Surgery, Hospital Segamat, Johor, Malaysia wedge resection of Meckel’s diverticulum and hand- sewn anastomosis was performed. Histopathology Adult intussusception due to Meckel’s diverticulum is examination distinguished Meckel’s diverticulum an uncommon cause of intestinal obstruction. Adult and no sign of malignancy seen. Post operatively, the intussusception itself occurs infrequently and differs patient made an uneventful recovery. from childhood intussusception in its presentation, aetiology, and treatment. Diagnosis can be delayed because of its longstanding, intermittent, and non- specific symptoms and most cases are diagnosed at emergency laparatomy. With more frequent use of computed tomography in the evaluation of patients with abdominal pain, the condition can be diagnosed more reliably. We experienced a case of intussusception due to Meckel’s diverticulum which caused intestinal obstruction. A 16 year old boy presented with complaint of generalized abdominal pain associated with multiple episodes of vomiting. Patient had history of similar symptoms last year but never investigated. An abdominal radiograph showed small bowel loop dilated. Subsequently, computed tomography was done and findings of small bowel obstruction with transition point seen at the ileum and incidental finding of intussusception. 147 PP 168 PP 168

Endoscopic Double Stenting in from the incisors communicating into the trachea. the Management of Tracheo- The denture was then removed endoscopically and a naso-gastric tube inserted for feeding purposes. Oesophageal Fistula: A Case Report A”Y” stent was inserted into the trachea via rigid J H Asraf, N H Zubaidah, A H Shaker, T Gee bronchoscopy and followed by an endoscopic insertion Department of Surgery, Universiti Putra Malaysia of an esophageal stent. There were no adverse events Hospital Serdang, Selangor, Malaysia following the endoscopic procedures. The nasogastric tube was removed and he was allowed orally. The Introduction stents were then removed with no residual fistulation Acquired tracheo-oesophageal fistula (TOF) is a rare demonstrated. condition. Locally invasive cancers are the major causes of TOF. Benign causes are less common and Conclusion the aetiology includes swallowed or aspirated foreign Benign acquired tracheo-oesophageal fistula (TOF) can bodies. be effectively managed with endoscopic procedures.

Case Description A 62 year old gentleman presented to the surgery outpatient department with a 6 month history of chronic cough and 2 month history of dysphagia with associated choking upon ingesting solid food. Although he had significant weight loss, physical examination did not reveal any abnormalities. CT thorax and abdomen showed a tracheoesophageal fistula at level T3 with foreign body seen. Subsequent bronchoscopy showed an embedded foreign body covered with granulating tissue 1cm above the carinii. This was followed by OGDS which revealed dentures causing a large chronic fistula in the oesophagus 26cm

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Breast-Esophagus Syndrome: investigating “benign-looking” esophageal strictures Esophageal Metastasis from Invasive in the background of breast cancer. Ductal Carcinoma of Breast Methodology and Result (case report) R Reynu1, N R Kosai1, M T Mustafa1, K W Chan2 A 50-year-old woman who was treated for invasive 1Minimally Invasive, Upper GI and Bariatric Surgery Unit, ductal carcinoma of the left breast 10 years earlier, Department of Surgery, Universiti Kebangsaan Malaysia presented to the surgical clinic with complaint Medical Centre, Kuala Lumpur, Malaysia of progressive dysphagia. Narrowing of lower 2Department of Surgery, Queen Elizabeth Hospital, esophagus with normal musoca was seen on Kota Kinabalu, Sabah, Malaysia oesophagoduodenoscopy. Initial biopsy of the stricture was inconclusive. Endoscopic ultrasonography (EUS) Introduction guided tissue biopsy confirmed the diagnosis of metastatic breast carcinoma with positive ER and PR Breast cancer remains the most prevalent cancer status. Staging CT was negative for distant metastasis. among women, with metastatic spread seen commonly Endoscopic stenting was performed to alleviate her to the liver, bone and brain. Esophageal metastasis symptoms before being referred to oncology for is relatively uncommon, favors a delayed occurrence palliative chemoradiotherapy. following initial breast cancer treatment and is often mistaken as benign. Largely asymptomatic, onset Discussion and Conclusion of clinical manifestation such as dysphagia denotes disease progression and confers poorer prognosis. A “breast-esophagus” syndrome can be described based Metastatic spread to the distal esophagus occurs via on history of breast cancer, worsening dysphagia, false lymphatic channels and affects the outer layer while negative tissue biopsy and normal esophageal mucosa. sparing the mucosa. EUS is popularly used to assess depth of tumor infiltration. EUS guided biopsy facilitates targeted Objective sampling under direct vision, thus reducing false negative results and need for endoscopic submucosal We aim to highlight a rare case of metastatic dissection. Diagnostic confirmation is achieved esophageal disease in a patient who was earlier through application of immunohistochemical analysis treated for invasive ductal carcinoma of the breast. on the biopsy specimens. Treatment strategy is often Awareness of this clinical entity will prompt surgeons palliative and aimed to alleviate symptoms. to adopt a higher index of clinical suspicion when 148 PP 170 PP 170

A Rare Case Of Ischaemic Colitis with loose stool and fever. The pain then become Precipitating Ruptured Abdominal generalised with increasing severity and radiating to the back. Clinical examination shows a generalised Aortic Aneurysm tender and guarded abdomen and abdominal C K Seak1, Richard Hardin1, T L Luk2 computed tomography scan was arranged which 1Sarawak General Hospital, Sarawak, Malaysia demonstrated a ruptured infrarenal fusiform AAA. 2Borneo Medical Centre, Sarawak, Malaysia Open surgery subsequently revealed a concomittant ischaemic caecal collitis with rupture AAA. Introduction Abdominal aortic aneurysm (AAA) occurs as Conclusion degeneration of tunica media leading to loss of A review of literature suggests that the inflammatory structural integrity. Old age, Caucasian, male gender, response from sepsis or peritonitis upregulates level with smoking history and underlying artherosclerotic of matrix metalloproteinases which can degrade aortic disease are well-recognised risk factors associated wall elastin and collagen leading to expansion and with AAA development. Progressive dilatation and rupture of AAA. expansion of the aorta may eventually lead to rupture of the aneurysm. Recent literatures postulate that mechanical force may not be solely responsible for an acute aneurysm rupture, as inflammatory activity may also precipitate it owing to the enzymatic effect of matrix metalloproteinases.

Presentation of Case Here we present a rare case of ischaemic caecal colitis precipitating the rupture of an abdominal aortic aneurysm. A 71 year old Caucasian gentleman with a previous history of cerebrovascular event presented to us with right iliac fossa pain for 1 week associated

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Spontaneous Mesenteric Patient was noted to be hypotensive with rapid Hematoma: Uncommon Yet Fearful drop of hemoglobin count. Coagulation profile was deranged with INR of 4.66. Computed Tomography Complication In Patient On (CT) angiography of abdomen confirmed the diagnosis Anticoagulant Therapy of mesenteric hematoma with active extravasation. K L Seng1, C K Seak2, L M Following resuscitation and correction of the 1Sibu Hospital, Sarawak, Malaysia abnormally prolonged INR, there was no evidence of 2Sarawak General Hospital, Sarawak, Malaysia further bleeding. Patient was discharged uneventfully after 4 days of hospitalization. Oral warfarin was Introduction reintroduced on subsequent follow up with no further Spontaneous mesenteric hematoma is uncommon complication. with variable aetiologies. It is potentially life- Conclusion threatening if not duly recognized and promptly treated. In comparison with gastrointestinal Patient on anticoagulant therapy with abnormally haemorrhage and hematuria, spontaneous mesenteric prolonged INR and abdominal symptoms should hematoma is a rare complication of anticoagulant prompt the suspicion of spontaneous mesenteric therapy. With advent use of anticoagulant therapy hematoma. Imaging should be done immediately to worldwide, incidence of occurrence may be on confirm the diagnosis. CT remains the modality of the rise. Here we describe a case of spontaneous choice as it provides the benefits of localizing the mesenteric haematoma occurring as a complication of site of bleeding, visualizing active extravasation and anticoagulant therapy leading to hemorrhagic shock. identifying any vascular malformation. Accurate diagnosis followed by prompt treatment ensure Case Presentation a favourable outcome in spontaneous mesenteric A 63-year-old man with hypertension and atrial hematoma. fribillation on warfarin, presented with sudden onset left iliac fossa pain and abdominal distension without other significant history. Clinically, a 5X7cm tender mass was palpable over left iliac fossa. 149 PP 172 PP 172

LAPAROENDOSCOPIC TRANSGASTRIC lumen. Pneumoperitoneum was created and a ENUCLEATION OF A PERI-CARDIAL laparoscope inserted through a 10mm trocar at the umbilicus. Two 5-mm trocars were inserted GASTROINTESTINAL STOMAL TUMOUR through the gastric wall and into the lumen under (GIST) laparoscopic and endoscopic vision. Dilute epinephrine

1 1 1 2 was injected endoscopically beneath the tumor to Elsa R , Reynu R , Kosai N R , Yugasaravanan K create a tumescent effect. The tumor was retracted 1 Minimally Invasive, Upper Gastrointestinal and Bariatric by laparoscopic graspers and enucleated using Surgery Unit, Department of Surgery, Universiti Kebangsaan Harmonics Ultracision (UltraCision Ethicon Endo- Malaysia Medical Centre, Kuala Lumpur, Malaysia 2 Surgery, Cincinnati, Ohio). The submucosal defect was Department of Surgery, Hospital Angkatan Tentera, promptly approximated. The excised tumor was placed Kem Terendak, Melaka, Malaysia into an endopouch and removed through the umbilical incision upon closure of all gastrotomy sites. Introduction In the modern era of surgery, minimally invasive Results surgery is increasingly applied for excision of Histopathology confirmed the excised specimen gastrointestinal stromal tumors. Site, size and tumor to be a benign GIST. There were no post-operative location are important factors that affect the surgical complications and patient was discharged well on day approach and excision. Staple resections of peri- cardial tumors have been associated with stenosis and two. On follow up six months later, the patient denied gastro-esophageal reflux symptoms. having gastro-esophageal reflux symptoms and was able to tolerate orally well. Surveillance OGDS was also Objective negative for tumor recurrence. We report a technique of enucleating a well- circumscribed peri-cardial GIST using Harmonics Conclusion Ultracision (UltraCision Ethicon Endo-Surgery, Peri-cardial GIST can be enucleated safely by this Cincinnati, Ohio). method. The avoidance of surgical staplers is not only cost effective, but also reduces the risk of associated Methods complications. A gastroscope was performed to distend the gastric

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Anterior Laparoscopic Approach time, a right adrenalectomy was performed since the in the Management of a Para- ectopic was adjacent to it and there was a large feeder vessel originating from the adrenal gland. The post- Pancreatic Ectopic Adrenal operative period was uneventful and the patient was Adenoma discharged 2 days after the surgery. A 6 month follow S Y Lim, N H Zubaidah, J Y Soo, T Gee up revealed that the patient has a complete resolution Department of Surgery, Universiti Putra Malaysia, Serdang, of hypertension and hypokalemia. Selangor, Malaysia Discussion Background Anterior laparoscopic approach is employed in the Conn’s syndrome refers to primary aldosteronism management of ectopic adenomas which are more cause by an aldosterone-secreting benign adrenal “anteriorly” located. Simultaneous adrenalectomy adenoma. It is one of the causes of secondary could also be performed using the same approach. hypertension which is refractory to medical treatment. Diagnosis of Conn’s is usually made by measuring plasma aldosterone/plasma renin activity ratio as well as a presence of an adrenal adenoma in the CT scan.

Case Description A 39 year-old woman presented with hypertension and hypokalemia which was retractable to medical management. The endocrinologist further investigated with blood tests and a CT scan which revealed normal looking adrenals with an ectopic adenoma seen adjacent to the right adrenal gland and superior to the 2nd part of duodenum and the head of pancreas. An anterior laparoscopic approach was employed during the excision of the ectopic adenoma and at the same 150 PP 174 PP 174

Case Report: Congenital Mesoblastic of left renal tumor well circumcised heterogeneously Nephroma (Aggressive Cellular enchancing mass. Therefore underwent left nephrectomy at 1month of life. Histopathological Variant) report revealed complete specimen consistent with Elango Thambusamy, Umasangar Ramasamy, cellular mesoblastic nephroma. However at 3month of Herbert Leslie life presented with right sided pleural effusion which Department of General Surgery, Hospital Taiping, Taiping, suggestive of lung metastasis.Thus given given trial Perak, Malaysia of chemotherapy VAC regime (vincristine,actinomycin and cyclophosphamide).In view good response Introduction completed 9cycles of VAC regime. At 1yr of age Congenital Mesoblastic Nephroma (CMN) is a rare repeated CT abdomen and thorax not suggestive of pediatric renal tumor. However the most common recurrence. renal tumor in neonates.It comprises two histological Discussion subtypes, namely classic and cellular. It remains a diagnostic challenge for pathologists due to its CMN should always be considered in the differential similarity with other more frequent pediatric kidney diagnosis of hypertension in neonatal period .In neoplasms. contrast to classical CMN histological variants may exhibit aggressive behavior, tumor recurrence and Case presentation metastasis very rare except in atypical mesoblastic Baby girl born at 37 weeks and 5 days of gestation born nephroma (aggressive cellular variant).otherwise CMN to a 27 yr old mother G3P2with Gestational diabetes. generally benign and only warrants adjuvant therapy Antenataly no documented polyhydroamnios. in rare cases.

Post-delivery noted to have abdominal distension with palpable left abdominal mass; associated with persistent high BP reading which requiring nifidipine suspension 0.25mg/kg tds dosing.Computer tomography(CT) of abdomen confirmed the presence

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Chemoport Insertion: Comparison Result Between the Open and Closed Of those patients, 24 were male and 245 were Method with Their Related female, with mean age of 49.4 years. 229 cases (85.1%) were performed under local anesthesia complications Among Oncology while other 40 patients (14.9%) underwent general Patients anesthesia. Indications for insertions were for Juan B A1, Abdul Fattah1, Anita B2, Sarinah B2 chemotherapy commencement (96.6%), intravenous 1Department of Surgical Oncology, National Cancer Institute, fluid access (2.6%), antibiotic administration (0.4%), Putrajaya, Malaysia and parenteral feeding (0.4%). A total of 17 out of 2Department of Breast of Endocrine Surgery, 94 patients (18.1%) who underwent Open method Hospital Putrajaya, Putrajaya, Malaysia and 50 out of 175 patients (28.6%) where Closed method performed, developed complications of Oncology patients undergoing complex chemotherapy post-procedural hematoma or bleeding - 3.2% and generally require a long-term venous access. 2.3% (p = 0.698), venous thrombosis - 4.3% and 1.7% Repetitive intravenous (IV) cannulations or central (p = 0.243), infection - 4.3% and 8.0% (p = 0.241), port line (CVL) insertions may cause venous thrombosis, malposition and migration - 5.3% and 4.0% (p = 0.617), peripheral veins damage and extravasation of arterial puncture - 1.1% and 8.6% (p = 0.013), and drugs, leading to tissue necrosis. To overcome this, pneumothorax - nil and 2.3% (p = 0.301), respectively. chemoport - a tunneled vascular access device, are At least 8 patients (3.0%) required readjustment and 16 routinely implanted using either an Open method or patients (5.9%) needed their ports removed. Closed method. This study is to evaluate and compare the complications between the two techniques. Conclusion Based on our study, chemoport insertion can be Method performed safely within an acceptable risk of A 5 years retrospective analysis on 269 patients complications. However, one should always keep who underwent chemoport insertions by Breast and in mind of a higher risk of arterial puncture while Endocrine Surgeons in our two centres, Putrajaya performing the closed method technique. Hospital and Institut Kanser Negara, from January 2009 to December 2014 were studied. 151 PP 176 PP 176

Intestinal Obstruction and Lower Methodology (case report) Gastrointestinal Bleed in Behcet’s A 35-year-old lady presented with complaints of oro- Disease: A Rare Presentation genital ulcers, rash and fever for the past 2 weeks. She also had abdominal distension, intermittent C A M Firdaus, R Reynu, N R Nik, S A Salauddin, abdominal pain and bloody diarrhoea for the past 3 M T Mustafa days. There was generalised abdominal distension with Minimally Invasive, Upper GI and Bariatric Surgery Unit, hyperactive bowels sounds. Abdominal radiograph Department of General Surgery, Universiti Kebangsaan demonstrated dilated loops of small bowel. There was Malaysia Medical Centre, Kuala Lumpur, Malaysia no previous surgical history. Emergency laparotomy was performed the same day. Introduction Behcets Disease (BD) is a rare, multisystem inflammatory Results disease that affects the eye, oral cavity, and genitalia. Intraoperatively, a stricture was noted 10cm from Highest prevalence has been reported in Turkey, young ileo-caecal junction as well as deep mucosal ulcers East Asian women and Middle Eastern men. Intestinal at the ascending colon. Right hemicolectomy was BD is seen in 10-15% of BD patients. These subsets of performed with functional end-to-end anastomosis. BD patients share similar characteristics as those with Post-operative recovery was unremarkable and she inflammatory bowel disease (IBD). The blurred line of was discharged well 5 days later. HPE of the resected differentiation between the two clinical entities often specimen showed severe enterocolitis with vasculitis poses a diagnostic challenge. With no confirmatory changes. laboratory test, diagnosis often rests on the shoulders of the attending physician. Conclusion Intestinal BD is a rare subset of BD. The multisystem Objective disease can eventually lead to multi organ failure. We aim to describe a case of intestinal BDin a young Surgical resection followed by systemic control of female who presented with symptoms of chronic disease by use of steroids or immune modulators intestinal obstruction and lower gastrointestinal may be beneficial to prevent further recurrence and bleeding. progression of the disease.

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Bariatric Surgery in Malaysia: with bariatric services in Malaysia. The participating An Update on Volume of Bariatric hospitals were required to provide an estimate of volume, type of surgeries performed and number of Procedures Performed in the Last surgeons who performed those procedures. 5 Years (2009-2014) Results N R Kosai, R Reynu, M T Mustafa 9 government hospitals and 6 private medical centers Minimally Invasive, Upper GI and Bariatric Surgery Unit, participated in this survey. Since the first bariatric Department of General Surgery, Universiti Kebangsaan procedure in Malaysia 20 years ago, only 1221 cases Malaysia Medical Centre, Kuala Lumpur, Malaysia have been performed to date. However, in the past 5 years, 987 bariatric procedures were performed with Introduction 730 executed by 14 government sector surgeons and The first open vertical gastroplasty was performed in 257 procedures by 8 private sector surgeons. On Malaysia in 1996 while the first LRYGB performed in average, each surgeon performed 44 procedures in year 2000. However, being the fourth country in Asia five years, or 8 cases per year. This number is still a far to embark on bariatric surgery, we have not caught up cry from the average number of procedures per-Asian with our neighbors in terms of case volume. A global bariatric surgeon reported in previous studies. comparative study proclaimed Malaysia to be the most obese nation in South East Asia and possibly Asia Conclusion overtaking South Korea and China with 45.3% of its The increase in obesity rates has prompted several population identified to be obese. game changing national healthcare policies including a stricter implementation of the existing national Objective CPG on obesity management, and nationwide health We aim to highlight the updated volume and trend campaigns. There has also been a more robust of bariatric surgery in Malaysia from 2009 to 2014 discussion among policy makers to recognise bariatric and discuss the way forward for bariatric surgery in surgery as an effective form of treatment for obesity Malaysia. and T2DM.

Methodology A questionnaire was distributed by e-mail to government hospitals and private medical centers 152 PP 178 PP 179

The Morel Lavallee Lesion : Hospital Outcomes of Early Versus Delayed Kuala Lumpur Early Experience Cholecystectomy In Patients With R Rosnelifaizur1, M K Azuddin2, Hussein Hanif3, Mild To Moderate Acute Biliary Ariffin Azizi Zainal3 Pancreatitis – A Randomized 1Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia Prospective Study 2 Hospital Tengku Ampuan Rahimah, Klang, Selangor, 1 1 1 2 Malaysia S L Jee , K F Lim , K Raman , R Jarmin 1 3Hospital Kuala Lumpur, Kuala Lumpur, Malaysia Hospital Selayang, Selangor, Malaysia 2Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia Morel-Lavallee lesions are rarely diagnosed posttraumatic sequelae that firstly described by the Introduction French physician Maurice Morel-Lavallee in 1853. It In patients with ABP, cholecystectomy is mandatory to follow closed degloving injuries due to accumulation prevent further biliary events, but the precise timing of blood and debris in the subcutaneous plane in of cholecystectomy for mild to moderate disease association with pelvic and acetabular fractures, but it remain a subject of ongoing debate. The aim of this can also occur from low velocity crush injury. Though study is to assess the morbidity and effectiveness of they are not uncommon, they are rarely diagnosed early versus delayed cholecystectomy. We hypothesize which results in delay in their treatment. Diagnosis that early cholecystectomy as compared to delayed is through a combination of clinical examination, cholecystectomy reduces recurrent biliary events history, and imaging studies. Missed diagnosis can without a higher peri-operative complication rate. lead to delayed presentation or death. Different Methods treatments have been used for their management like compression therapy, sclerosant injection, pulse Patients with mild to moderate ABP were prospectively lavage, and open debridement. Treatments resulted in randomized to either an early cholecystectomy varying degree of success. Here we reported 2 cases (within the same index admission) versus a delayed from our recent experienced in managing this cases in cholecystectomy group (performed after discharge our centre. Multidiciplinary approach is essential for a from index admission). Recurrent biliary events, peri- good results. operative complications, conversion rate, length of

PP 179 PP 180 surgery and total hospital length of stay between the Predictors Of Occult Nipple two groups were evaluated. The study was designed Involvement In Breast Cancer to enroll 120 patients with an interim analysis midway through the study. Patients with Grossly Normal Nipples Results Z Sofina, K Normayah, B Sarinah, A Asmiati A total of 72 patients of multiracial population were Breast & Endocrine Unit, Department of Surgery, enrolled at a single public hospital. Of them, 38 were Hospital Putrajaya, Putrajaya, Malaysia randomized to the early group and 34 patients to the delayed group. There were no baseline differences Introduction between groups with regards to demographics. Breast conserving surgery (BCS) with nipple –areolar There were no differences regarding peri-operative complex (NAC) sparing is a preferred treatment for complications (7.78% vs 11.76%; P = 0.700), conversion early breast cancer patients. We aim to predict the rate to open surgery (10.53% vs 11.76%; P = 1.000) and occult nipple involvement in grossly normal nipples to duration of surgery performed (80 vs 85 minutes, guide a safe nipple sparing surgery. P = 0.752). Nevertheless, a greater rate of recurrent biliary events was found in the delayed group (44.12% Methods vs 0%; P = < 0.0001) and the hospital length of stay was We retrospectively analysed mastectomy specimens longer in the delayed group (9 vs 8 days, P = 0.002). with grossly normal nipples from 2013 until 2014 in our centre. The occult nipple involvement is compared Conclusion with respect to the tumour size and tumour – nipple In mild to moderate ABP, laparoscopic cholecystectomy - distance (TND) obtained from Electronic Medical performed within the same index admission reduces Record (EMR). the risk of recurrent biliary events without an increase in operative difficulty or perioperative morbidity. Results A total of 67 mastectomy specimens with grossly normal nipples were analysed for this study. 8 specimens showed occult nipple malignancy (12%). 153 PP 180 PP 181

Median age of patient was 35 years old (27 -84 years Acute pancreatitis in Hospital old). There were 54 specimens in TND≥ 20 mm, and Taiping, Perak: a one-year audit out of these, 5 specimens (9%) showed occult nipple involvement. In the group of TND ≥ 20 mm, the Pravin P1, Sivaneswaran L1, Umasangar R1, mean tumour size for specimens with occult nipple Premnath N2 involvement was 51 mm (12 – 125 mm), whereas 1Department of surgery, Hospital Taiping, Perak, Malaysia the mean size of specimens without occult nipple 2Penang Medical College, Penang, Malaysia involvement was 35 mm (6 – 120 mm). As for TND ≤ 20 mm, there were 13 specimens and 3 specimens (23%), BACKGROUND the nipples were involved. In these group, the mean Acute pancreatitis has various precipitants; the most size of tumour with nipple involvement was 85 mm common are gallstone and alcoholism. It causes (range 45 – 125 mm). The mean size of tumour without morbidity and mortality depending on its severity nipple involvement was 39 mm (6 – 90 mm). Out of 8 which ranges from mild, moderate to severe. We patients with occult nipple involvement, only 4 (50%) studied patients who were admitted to determine were associated with multifocality. the primary aetiology of pancreatitis and outcome in treating acute pancreatitis. Conclusion Tumour nipple distance is unreliable to predict DESIGN occult nipple involvement. Preoperative MRI and Retrospective audit of medical records intraoperative frozen section are required to detect occult nipple involvement prior to nipple sparing METHODS surgery. The medical records of patients admitted to hospital Taiping Perak with diagnosis of acute pancreatitis from 20th March 2014 to 20th March 2015.

RESULTS Forty four patients were admitted with a diagnosis of acute pancreatitis where by the median age group was

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51 years old, with a 59%(26) male predominance. Out of TRISEGMENTECTOMY SURGICAL OPTION all the admissions 54.5 %( 24) were of Malay ethnicity, FOR INVASIVE ASPERGILLOSIS 36.3 %( 16) Indians and 8.2 %( 4) Chinese. Atlanta classification was used to diagnose acute pancreatitis, Shafiz 1,2Z , George John2 whereby, the most common aetiology was gallstone 1Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia 61.4%(27), followed by chronic alcoholism 15.9%(7), 2Hospital Kuala Lumpur, Kuala Lumpur, Malaysia dyslipidaemia 6.8%(3), 2.2%(1) post ERCP, 2.2%(1) secondary to steroid use and 11.4%(5) unidentified Introduction cause(not investigated). The Modified Ransons Aspergillosis is as uncommon lung pathology criteria was used to determine the severity of acute commonly affecting immunocompromised patients pancreatitis, whereby 22.7 %( 10) of the patient and few reported case of concomitant tuberculosis suffered severe pancreatitis, 9.1 %( 4) moderate and infection. One of severe manifestation are invasive 68.2 %( 30) mild. There was a high percentage of death aspergillosis. in severe pancreatitis (30%, three patients). Seven of the severe acute pancreatitis received ICU care upon Case summary admission. Three others were admitted to general Our case is 34 year old lady presented with wards. nonresolving hemoptysis. Previosly known case of TB completed therapy 10 years ago. CONCLUSION The aetiology of pancreatitis in our centre by hierarchy Serial CT was done show cavitation with fungal ball is gallstones, chronic alcoholism and dyslipidaemia. formation. Subsequent CT show increasing left fungal High mortality rates of severe pancreatitis patients in ball. this centre should be addressed with multidisciplinary teams such as the surgical, intensive care and radiology She was referred to thoracic HKL for intervention. to improve outcome. Her lung function was FEV1 was 26%. CPET was arranged. Left upper zone Lobectomy was plan. Trisegmentectomy was done. Her follow up showed improvement in symptoms.

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Conclusion Immediate Breast Reconstruction Invasive aspergillosis planned for lobectomy however Post Mastectomy And Axillary in our case trisegmentectomy was done instead for Clearance - Autologous Or preservation in lung function in a poor lung status. Prosthetic? Weng Jun Tang, Arman Zaharil Mat Saad Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia

Breast carcinoma is the number one life threatening cancer and leading cause of death in the women population in Malaysia. Some women are avoiding the ultimate treatment which is mastectomy as the loss of a single breast will reduced their confidence and hallmark as a woman. Therefore introduction of immediate breast reconstruction either by autologous or synthetic breast reconstruction has been offered to the women in Malaysia to improve their psychosocial well being and confidence as a woman after mastectomy. Throughout the years, there has always been a debate on which type of breast reconstruction is the ideal most in a long term run - Autologous or prosthetic breast reconstruction?

A case report of a breast reconstruction that was performed in University Sains Malaysia using an autologous tissue - deep inferior epigastric perforator (DIEP) flap immediately post mastectomy and axillary clearance for a 31 years old Malay lady. She presented

PP 183 PP 184 to us with a right breast carcinoma (T3 N1 Mx). Initially MIDGUT VOLVULUS: MISLOOKED she refused for surgery intervention and defaulted DIFFERENTIAL IN ADULT PATIENTS her follow up despite knowing the consequences. Her main concern was her appearance after mastectomy. Ashok Marappan, Kandasami P, Mahadevan D Tata Her breasts are of a cup C size. After the offer of Department of Surgery, Hospital Tuanku Ja’afar Seremban, breast reconstruction immediately post mastectomy, Negeri Sembilan, Malaysia she agreed and opted for a more natural looking breast using autologous tissue. Postoperatively Background she progressed well and the flap was well perfused One of the most common complication will be midgut without any flap necrosis. She was discharged home volvulus. This manifestation is usually seen in the in less than a week. The size of the newly mould breast peadiatric age group and is quite rare in adults. was of adequate size compared to the left breast. We present a case of a 29 year old male who presented to us with abdomen pain and vomiting for about 3 years. He had a BMI of only 17 on presentation. He was initially treated at various hospitals for chronic abdomen pain. He presented to us with worsening abdomen pain and vomiting. Upper endoscope showed grossly dilated stomach and duodenum. Bile retention seen in the duodenum beyond D2. CT abdomen to reveal mid gut volvulus with possible malrotation. Intraoperatively, the stomach and duodenum was dilated till the 3rd part of duodenum. The superior mesenteric artery pedicle were running anterior to the duodenum at the 4th part of duodenum. Small bowel appeared twisted the superior mesenteric artery pedicle causing obstruction and dilatation.

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Conclusion “I lost weight, but I don’t want The diagnosis in this patient was delayed may be due big breasts”: Combination of to possibility of midgut rotation in adult is a rare bilateral mastopexy and reverse entity. High index of suspicion should be practiced in adults with chronic abdomen pain. abdominoplasty Chai Siew Cheng, Wan Azman Wan Sulaiman, Arman Zaharil Mat Saad Reconstructive Science Unit, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia

Introduction Obesity has become a national and worldwide health epidemic. With the increasing popularity of bariatric surgery for morbidly obese patients, the number of massive weight loss patients who seek consultation from plastic surgeons for body contour deformities is in increasing trend.

Case report “I lost weight, but I don’t want big breasts… I look like a female!” was the chief complaint of a 20-year-old gentleman when he first presented to clinic. He had bilateral severe pseudogynaecomastia with redundant soft tissue over the lateral chest wall and abdomen after losing 48 kg of weight. Combination of bilateral mastopexy based on inferior dermoglandular pedicle and reverse abdominoplasty were done. Postoperative, evaluation of satisfaction of new chest wall contour was satisfactory.

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Discussion Successful Pregnancy “During” Massive weight loss patients will have various body Pedicled Transverse Rectus contour deformities due to the laxity of redundant Abdominis Musculocutaneous Flap skin and fat deposition. Pseudogynaecomastia and gynaecomastia in male may lead to psychological for Breast Reconstruction with stress. The goal of chest contouring surgery is to Normal Vaginal Delivery obtain ideal chest wall contour in male and ideal Chai Siew Cheng, Umayaal Shahlini, nipple-areola complex position. Various techniques Arman Zaharil Mat Saad have been described with their advantages and Reconstructive Science Unit, Universiti Sains Malaysia, disadvantages. Therefore, pre-operative assessment Kubang Kerian, Kelantan, Malaysia of chest aesthetic unit of chest including lateral chest wall and upper abdomen is important. A Transverse Rectus Abdominis Myocutaneous (TRAM) flap is a popular choice for breast reconstruction. Conclusion Pregnancies in women following a TRAM flap present Combination of bilateral mastopexy with inferiorly concerns regarding both safety and the integrity of based dermoglandular pedicle and reverse the abdominal wall. We report a case of a patient who abdominoplasty was reliable, safe and achieve was pregnant during immediate breast reconstruction satisfactory results as in our patient. with pedicled TRAM flap and had a successful spontaneous vaginal delivery. We also conducted a literature review using Pubmed on pregnancy post TRAM flap, type of reconstruction, timing of pregnancy after TRAM flap, complication and mode of delivery, which are summarized in this report. We concluded that patients may have safe pregnancies and normal deliveries following TRAM flap breast reconstruction regardless of the time frame of pregnancy after the procedure. Therefore TRAM flaps can continue to be a reconstruction option, even in women of childbearing age. 156 PP 187 PP 187

A Rare Cause of Gastrointestinal resected. After close monitoring in the intensive Haemorrhage: Bleeding Jejunal care unit, patient was discharged to the ward and subsequently discharged well from the hospital after Diverticula 6 days. L Wong, I Aini, N A Nik Azim Sarawak General Hospital, Sarawak, Malaysia Conclusion Gastrointestinal haemorrhage is a common surgical Background disease and requires quick management. Although Jejunal diverticula is a rare condition that is usually jejunal diverticula is uncommon, it is an important found incidentally during postmortem examination. differential when the cause of gastrointestinal Isolated bleeding from jejunal diverticulum is a rare haemorrhage could not be identified through entity but nevertheless could still present as a massive endoscopy. gastrointestinal bleeding.

Method The study design was an observational study. We reported a rare case of gastrointestinal haemorrhage from multiple jejunal diverticulum.

Results A 66 year old gentleman had presented with fresh per rectal bleeding that is large in amount with symptoms of anemia. Further examination showed that patient was pale and per rectal examination showed melenic stool with blood clots. Oesophagogastroduodenoscopy and colonoscopy showed only blood clots in the lumen. Exploratory laparotomy done revealed multiple diverticulum over the jejunum, 80 cm of the jejunum

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Preoperative Tattooing Improved Hence, we conclude that preoperative endoscopic Lymph Nodes Retrieval Rate In tattooing improve the lymph nodes retrieval rate and it can be implement as a standard procedure in Laparoscopic Colorectal Surgery laparoscopic colorectal surgery. W K Kong, H S Boo, Prabhu R Department of General Surgery, Penang General Hospital, Penang, Malaysia

Laparoscopic surgery is currently the gold standard for resection of colorectal malignancies. However, the lack of tactile sensation may possess challenges to the surgeons in localizing the tumour for resection and lymphadenectomy. Previous studies have shown that preoperative endoscopic tattooing of malignant lesion may increase the lymph node yield from pathology specimens removed with subsequent surgery.

From our local experience on going trial, we postulate that preoperative endoscopic tattooing may produce a clear lymphatic mapping and facilitate the lymph nodes retrieval rate during laparoscopic surgery.

82% cases in the tattooed subject achieved the benchmark of > 12 lymph nodes retrieved as compared to 56 % in standard non tattoo cases. The mean total lymph nodes count in the tattoo group was shown to be superior to the non tattoo group, 20 lymph nodes and 14 respectively.

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‘The Little Old Lady’s Hernia’: A Rare Outcome Case of Obstructed Obturator Patient developed postoperative ileus but Hernia subsequently was discharged well after 12 days. L Y Teoh, Suniza J, M H See Discussion Surgical Department, University Malaya Medical Centre, High index of clinical suspicion is needed especially in Kuala Lumpur, Malaysia elderly ladies with no obvious cause of obstruction. Eliciting the Howship-Ronberg sign is helpful in the Introduction diagnosis. More commonly, the diagnosis is made Obturator hernia is a rare cause of intestinal through a CT scan. A midline incision is preferable in obstruction and the diagnosis can be a great challenge the emergency setting especially if bowel ischaemia is in the surgical practice. It is more common among thin suspected. elderly ladies especially in the Asian population. Conclusion Case report Early detection by CT scan and management of the We hereby present a case of a 94-year-old lady who obstructed obturator hernia may reduce the morbidity was admitted for persistent vomiting and abdominal and mortality risk. Simple closure of the hernia sac distension in a geriatric ward and the diagnostic using a purse string especially when contamination challenge that we faced. Exploratory laparotomy via was present showed an acceptable good outcome. midline incision was done after the diagnosis made by CT scan, one week after admission. Intraoperatively, Keywords there was a loop small bowel which was adhered to Obturator hernia, intestinal obstruction, purse string the neck of the hernia and small bowel resection with closure. functional end-to-end anastomosis was done. In view of a shallow hernia sac and presence of contamination, a purse string closure of the neck of hernia was performed.

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RIGHT POSTERIOR SEGMENTAL We discovered the presence of right posterior DUCT: ROLE OF INTRAOPERATIVE segmental duct (RPSD) which was reported as one of the rare variants which accounts for only 0.5% CHOLANGIOGRAM TO PREVENT to 2.8 % . The cystic duct drains directly to the right EXTRAHEPATIC BILIARY DUCT INJURIES posterior segmental ducts (RPSD) . Because of its Ikhwan Sani Mohmad1, Hairol Othman2, proximity to the cystohepatic angle formed by the Razman Jarmin2, Zamri Zuhdi2, Affirul Chairil3 cystic duct laterally, the right hepatic lobe above, and the common hepatic duct medially, this accessory 1Department of Surgery, Universiti Sains Malaysia 2Hepatobiliary Unit, Department of Surgery, duct may be accidentally transected or ligated during Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia cholecystectomy, and therefore, complications, such 3Department of Surgery, Universiti Sains Islam Malaysia, as the formation of a biliary fistula and biloma. When Nilai, Negeri Sembilan, Malaysia cholecystectomy is performed in patients with this variation, the cystic duct must be ligated between the Extrahepatic bile ducts constitute a significant gallbladder and the point at which the cystic duct joins anatomic site for surgeons when performing the right posterior segmental duct. hepatobiliary operations from minor procedure such as cholecystectomy to major operation such as hepatectomy. The challenges for surgeon in performing such cases increase when congenital variance of biliary tree occurs which may lead to unintentional bile duct injuries.

We reported a case of a young lady who presented with obstructive jaundice secondary to huge distal common bile duct stone. The presence of right posterior segmental hepatic duct which rarely occur was discovered during intraoperative cholangiogram before common bile duct exploration. The operation was successful without incidence of biliary duct injury. 158 PP 191 PP 191

Transverse Testicular Ectopia; carefully and herniotomy was performed. Left testis A Rare Clinical Phenomenon was secured at left hemiscortum. Right testis was fixed at right subdartos pouch trough a transeptal Sivapiragas S, Davaraj Balasingh, window. Rudyanto Saripan Department of Surgery, Hospital Tuanku Ampuan Najihah, Discussion Kuala Pilah, Negeri Sembilan, Malaysia TTE was first reported by Von Lenhossck in 1886. Up to 2011, 148 cases have been reported in journals. Introduction Incidence of TTE is about 1 in 4 million. The mean Transverse Testicular Ectopia (TTE) is an uncommon age at presentation is 9.3 years. TTE is associated congenital abnormality in which both testes with inguinal hernia, cryptorchidism or hypospadius migrate towards the same hemiscrotum.TTE also and the correct diagnosis usually made during known as crossed testicular ectopia, testicular surgery. Management for TTE is either transeptal or pseudoduplication and unilateral double testes.Our extraperitoneal transposition orchidopexy with search case report describes this rare phenomenon which was for mullerian remnants and other anomalies. Long diagnosed intraoperatively in a periphery hospital. term follow up is required as infertility and risk of malignancy are known complications of TTE. Case Presentation Five years old Malay boy presented with reducible left Conclusion inguinal swelling since infancy. Clinically there was a TTE with ipsilateral inguinal hernia and contralateral left inguinal swelling with positive cough impulse. Left undescended testis is a rare anomaly. Surgeons who testis was palpable in left scrotum.Patient diagnosed frequently repair inguinal hernia among children with left inguinal hernia and planned for herniotomy. should be aware of appropriate surgical management Intraoperatively both testes were unexpectedly options available when this condition is unexpectedly delivered from left side. Each testis had separate identified during inguinal exploration. epididymis,vasdeferans and testicular vessels. Both spermatic cords followed into the left deep inguinal ring and entered the abdomen. Hernial sac separated

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Laparoscopic Management Of herniated stomach into the abdomen; (2) Resection of Paraesophageal Hiatal Hernia With mediastinal part of the hernial sac; (3) Circumferential oesophageal dissection; (4) A lateral releasing incision Intrathoracic Mesentericoaxial made adjacent to the right crus; (5) Primary closure of Type of Gastric Volvulus the crural defect; (5) Placement of the composite mesh S L Siow1,2, S C Tee1, C M Wong1,2 over the diaphragmatic defect and the hiatal closure; 1Department of Surgery, Jalan Hospital, Kuching, Sarawak, and (6) Toupet fundoplication. Malaysia 2Department of Surgery, Faculty of Medicine and Health Result Sciences, Universiti Malaysia Sarawak, Kota Samarahan, She made an uneventful recovery and was Kuching, Sarawak, Malaysia asymptomatic at six-month follow-up assessment.

Objectives Conclusion Paraesophageal hernia with intrathoracic Laparoscopic repair of such a condition can be mesentericoaxial type of gastric volvulus is a rare accomplished successfully and safely when it is clinical entity. Here, we report the case of a patient performed with meticulous attention to the details of with such a condition who underwent successful the surgical technique. laparoscopic surgery. A literature search revealed that this is the first case report from Southeast Asia.

Method A55-year-old lady presented with symptoms suggestive of gastric outlet obstruction for one year duration. Computed tomography scan and barium swallow study demonstrated the presence of a type III paraesophageal hernia with intrathoracic upside-down stomach. Laparoscopic approach followed several key technical steps: (1) Reduction of

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Hartmann’s procedure : was 6 days. We conclude that hartmann’s procedure Penang Hospital Experience has a definite place in the management of complicated diverticular disease and colorectal malignancy H S Boo, Fadliyazid A R, Prabhu R under emergency setting. The restoration of bowel Department of General Surgery, Penang General Hospital, continuity is a safe procedure with proper timing and Penang, Malaysia patient’s optimization.

The purpose of this retrospective cohort study is to evaluate the indication and outcomes of Hartmann’s procedure performed in Penang General Hospital from Year 2012 to year 2014.A total of 50 Hartmann’s procedures were performed under emergency setting. There were 30 male and 20 female patients. The majority had either complicated diverticular disease (14) or colorectal carcinoma (28). 43 patients were discharged home and 7 patients passed away within 30days of surgery (14 %). Of the 22 cases for benign disease 10 proceeded to reversal with no mortality. Of the 28 patients who had complicated colorectal cancer only 6 had their stoma closed. The mean time from the primary operation to the reconstruction was 7.3 months ( 3- 13 months ) in benign cases and 11.4months ( 8 – 15 months) for malignant cases. 12 patients underwent open reversal of Hartmann’s procedure and 4 patients underwent laparoscopic reversal of Hartmann’s procedure.14 anastomoses were stapled and 2 anastomoses were hand sewn. Average duration of hospital stay for patient who underwent reversal

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Urachal Sinus Tuberculosis as diagnosis of an urachal abscess. An incision and a Component of Abdominal drainage procedure was performed followed by a course of antibiotics. An elective diagnostic laparoscopy done Tuberculosis in an Adolescent later showed a more sinister dilemma. Histopathology H L Sha, S C Tee, C M Wong, S L Siow examination of the resected urachal sinus, peritoneal General Surgery Department, Sarawak General Hospital, nodules and falciform ligament were consistent with Kuching, Sarawak, Malaysia TB infection. He recovered fully after completing 6 months of anti-tuberculous therapy. Introduction Abdominal tuberculosis (TB) is uncommon and can Conclusion be caused by lympho-haematogenous spread after Although rare, we should suspect TB when presented primary infection in the lung or by ingestion of with an infection of the urachus in endemic areas. The infected sputum. It has a nonspecific and protean clinical diagnosis of abdominal TB is challenging and presentation as it can affect any component of the we advocate the use of laparoscopy in achieving the abdomen. TB of the urachus is a rare entity with diagnosis in such cases. only two reported cases previously published in the literature. We report a case of a concurrent subclinical Keywords pulmonary and abdominal TB that presented as an Tuberculosis, Urachus, Urachal Sinus. infection of the urachal sinus.

Case Presentation A 14-year-old boy presented to our institution with peri-umbilical swelling and purulent discharge from his umbilicus for 2 weeks duration. There were no radiological, microbiological or clinical evidences of TB in the initial presentation, though he had close social contact with someone who had TB. A computed tomography scan of the abdomen confirmed the 160 PP 195 PP 195

A Case Series – TB Breast, diagnostic Tubercular lymphadenitis of a single group may be dilemma unilateral in 85% of the cases. It usually presents as slowly increasing swelling which is painless5. Mohamed Arif H S1, Siti Zubaidah M S2 Sometimes it possess challenge in diagnosis and 1Department of General Surgery, Queen Elizabeth Hospital therapy when it mimicks or coexists with carcinoma Kota Kinabalu, Sabah, Malaysia breast1, 6. Diagnosis is confirmed by histopathological 2 Breast & Endocrine Unit, Department of General Surgery examination. The role of FNAC or Core Biopsy in Queen Elizabath Hospital, Kota Kinabalu, Sabah, Malaysia early diagnosis cannot be overemphasized. In our case series, we will be discussing on the different Tuberculous infection is highly prevalent in South presentation of TB Breast to an extent of mimicking East Asia country. However Tuberculosis of the breast breast cancer. is an uncommon disease with non-specific clinical, radiological and histological findings. Misdiagnosis References is common as biopsy specimens are pauci-bacillary 1. Nwagbara VI, Asuquo ME, Ebughe G, Agbor C,Akpan S et al.; and investigations such as microscopy and culture Tuberculous lymphadenitis of the neck: Case series. International Journal ofMedicine, 2013; 1(1): 4-8. are frequently negative. Isolated axillary tuberculous 2. Yang CM, Hsu CH, Hsieh CM, Chen MY; 18 FFDG-PET in a clinical lymphadenopathy is also rare and described in unsuspected axillarytuberculosis lymphadenitis mimicking patients without evidence of previous or ongoing malignancy.Ann Nucl Med Sci., 2003; 16(2): 107-110. 3. Culpinar K, Erpulat Ozis S, Ozdemir S, Korkmaz A; Primary breast tuberculosis anywhere in the body. Tuberculosis (TB) is tuberculosis: Report of a case. Surgical Science, 2013; 4: 68-71. a cause of a large volume disease and involves about 4. Fontanilla JM, Barnes A, von Reyn CF; Current diagnosis and one third of the world population with maximum management of peripheral tuberculous lymphadenitis. Clin Infect 1 Dis., 2011;53: 555- 562. number of patients belong to developing countries . 5. Mohapatra PR, Janmeja AK; Tuberculous lymphadenitis. J Assoc Extra pulmonary TB constitutes 7-30% of TB cases Physicians India, 2009; 57:585-590. and lymphadenitis cases are 17 43% of total TB cases. 6. Bem C, Patil PS, Bharucha H, Namaambo K, Luo N; Importance of human immunodeficiency virusassociated lymphadenopathy and Cervical lymph nodes are the most commonly involved tuberculous lymphadenitis in patients undergoing lymph node site and axillary lymph nodes are affected in 3.8-20.3% biopsy in Zambia. Br J Surg., 1996; 83(1): 75-78. cases1, 2. But tubercular axillary lymph nodes occurring in patients who were not suffering from active tubercular disease elsewhere are rarely reported3, 4.

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Primary Necrotising Fasciitis of severe sepsis requiring admission to intensive care Breast: Fatal When Missed unit and inotropic support. Rapid progression of the necrotising fasciitis led to gangrenous of the whole Atifah A, Raflis R A, Hakim N A, Aina E N breast tissue. She was finally referred to our centre Breast and Endocrine Surgical Unit, Department of General where vigorous resuscitation, intravenous antibiotics Surgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia and emergency mastectomy were performed. Her condition gradually improved with resolution of the Introduction sepsis. The wound is still requiring daily dressing with Primary necrotising fasciitis of the breast is a rare intermittent surgical debridement. but potentially fatal condition characterized by a widespread subcutaneous tissue and fascial necrosis Conclusion with associated septicaemic shock. It is usually Necrotizing fasciitis of breast may masquerade as a misdiagnosed as a simple breast abscess or mastitis in simple breast abscess. Early detection and surgical lactating women which leads to delay in diagnosis and intervention is a paramount importance for breast treatment. We report a case of a young, non-lactating preservation. lady who was initially treated as a breast abscess instead went into severe sepsis with gangrenous of the whole breast requiring intravenous antibiotics, intensive care treatment, inotropic support and emergency simple mastectomy.

Case Presentation A 27 year old lady presented to a private hospital with a 2 week history of progressive right breast swelling and pain with gangrenous of overlying skin and pus discharge. She was diagnosed as a right breast abscess and subsequently, underwent incision and drainage. Post operatively, she deteriorated and went into

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A CASE REPORT – Laparoscopic was uneventful and was discharged well nine days Modified Sugiura Procedure after the surgery. – a Surgical Modality in the This emergency surgical procedure which successfully Acute Management of Bleeding controls gastroesophageal variceal bleeding while Gastroesophageal Varices conferring the benefits of a laparoscopic surgery, is not widely documented. We provide evidence on the L Sivaneswaran1, B Sabrina1, C R Vinayak1, effectiveness in achieving hemostasis, significantly 2 N Premnath reducing perioperative mortality and risk of rebleed. 1Hospital Taiping, Perak, Malaysia 2Penang Medical College, Pulau Pinang, Penang, Malaysia

The current gold standard in the management of acute gastroesophageal variceal bleeding is a combination of pharmacological and endoscopic therapy followed by Transjugular Intrahepatic Portosystemic Shunt (TIPS) as a rescue therapy when the former fails to establish hemostasis. However, TIPS facility is not readily available in our country. Laparoscopic Esophagogastric Devascularization (Modified Sugiura) has gained interest as a treatment modality for patients who have failed conventional therapy.

We report a case with video presentation, of a Modified Sugiura without oesophageal transection, performed laparoscopically in a cirrhotic patient with an uncontrolled bleed from a fundal varix. Splenectomy was not performed to reduce perioperative morbidity risk associated with prolonged surgery. His recovery

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Fish Bone And Ischiorectal Abscess is a rare cause. The cause of such condition may be that suggested in previous case report by Alawi et al. Sumaraj A, Syafiq, Khoo H Y, Imran A K (2001). The ingested fish bone passed through almost Hospital Seberang Jaya, Penang, Malaysia the whole gastro-intestinal tract and reached the anal canal. However, the high sphincter pressure at anal Introduction canal during defecation forced the sharp fish bone An ingested foreign body often passes the through the anal wall into the ischio-rectal fossa, gastrointestinal tract without any complications. resulting in abscess formation. Besides that factor this Foreign bodies, such as fish bones, chicken bones and incidence can also occur due to anterior angulation of toothpicks, have been known to cause perforation of the rectum which causes the fish bone to lodge at the the gastrointestinal. This case report presents a case mid rectum and during defecation the fish bone passes of rare cause of Ischiorectal Abscess by ingestion of a through the rectum in to the ischiorectal fossa. fish bone.

Case Report 59-year-old male who ingested a fish bone 1 month ago, presented with left buttock painful swelling for 1 week associated with fever. Prior to buttock swelling patient had pain during defecation as though something was piercing through the gut above his anal. Physical examination revealed a fish bone protruding out around 6cm from the anal opening at the left buttock. Patient underwent removal of the fish bone.

Discussion Literature review revealed several case reports on perianal abscess or fistula-in-ano associated with fish bone. Fish bone ingested causing perianal abscess 162 PP 199 PP 199

Managing Traumatic Thoracic Duct performed where oesophagus was repaired using Injury: A Case Report sternocleidomastoid flap but failed to identify thoracic duct at cervical level. A neck drain was inserted draining Tai C H, Chan K W, Rohamini S up to 2L lymph per day while chylothorax resolved. Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia Conservative trial for 2 weeks by keeping patient nil per oral, octreotide, drainage tubes, and later fat Introduction free liquid diet was ineffective in controlling lymph Injury to the thoracic duct is infrequent, but can losses. Surgical management was warranted when cause significant morbidity in cases of persistent neck drain was blocked, causing chylous leak into the chylous leakage. There are various means of trachea resulting in aspiration pneumonia. Mini upper conservative management, failing which surgical midline laparotomy was performed. Thoracic duct was approach is warranted, including direct ligation, identified anterior to the lumbar vertebra and ligated. VATS, percutaneous embolization, biological glue, and Dramatic result was evident by immediate cessation of microscopic repair. lymph leakage from the newly inserted neck drain and abdominal drain. Drains were removed and patient was Case Description discharged home well. We report a case of successful management of traumatic thoracic duct injury by ligation via Conclusion abdominal approach. Identification of thoracic duct poses major challenge in managing thoracic duct injury. Definite approach A 34 year old gentleman with acute psychotic should be tailored according to patient’s condition suicidal intent allegedly stabbed himself in the neck and availability of modalities. In this case, abdominal and abdomen, sustaining small bowel perforation, approach was preferred over thoracoscopy due to tracheal and oesophageal laceration, and recurrent patient’s lung condition. The authors may consider laryngeal nerve injury. Primary repair of small bowel laparoscopic approach in future depending on and tracheostomy was performed. He then developed feasibility. left chylothorax and tracheo-esohageal fistula within first week of trauma. A second surgery was

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Primary Breast Diffuse Large B-cell probably low Non-Hodgkin Lymphoma. Then, she Lymphoma rare Presentation of proceeded with trucut biopsy. Finding revealed Diffuse Large B cell Lymphoma. Patient was started on Breast cancer: A case report chemotherapy. H Syakirah A R, M Azihan Z, W Omar W D, A H Imisairi Discussion Unit of Breast Endocrine Surgery, Department of Surgery, PBL is a rare disease. The clinical presentation is Hospital Raja Perempuan Zainab II, Kota Bharu, Kelantan, usually not different with the other breast cancer. Malaysia Tissue biopsy is mandatory to diagnose PBL. Even though, Diffuse Large B-cell lymphoma is the Introduction commonest type, however, there have been shown Lymphoma is rare presented as primary breast tumor. to be of a non-germinal centre B-cell phenotype Primary breast lymphoma (PBL) accounts for 0.4% of with a high proliferation index and are thought to breast malignancies1. Diffuse Large B-cell lymphoma be associated with a poor outcome2. There is no I the commonest histological diagnosis2. We report a consensus on the question of how to best treat PBL. case of Primary breast Diffuse Large B-cell Lymphoma Mastectomy offers no benefit in the treatment of PBL. in HRPZ II. The combined therapy approach, with chemotherapy and radiotherapy, is the most successful treatment3. Case Report A 30year old malay lady, presented with right breast lump for 1 year, which increase in size gradually, painless and no nipple discharge. She had no family history cancer and no other risk of breast cancer. On examination, there was right breast lump, 6x6cm, nontender, multilobulated and hard mass, mobile, not attached to underlying muscle and skin, no skin changes, no nipple retraction. FNAC done showed features consistent with lymphoproliferative lesion 163 PP 201 PP 201

The Effectiveness of Peer Tutoring Bukit Jalil 2014. A total of 25 respondents from APGHC on Basic Surgical Knowledge for and 26 respondents from BSSW were tested on basic knowledge regarding suturing, sterility and wound Preclinical Students management. Respondents were required to answer Y Z Ho, I H E Heng, M Sundaran, A Kumarasamy 10 one best answer questions for each topic before IMU Surgical Society and after the learning activity. Data was analyzed International Medical University Clinical School, using SPSS. Results were presented for comparison Negeri Sembilan, Malaysia and evaluation.

Introduction Results Peer learning involves the sharing of knowledge; The scores were divided into fail (lower than 50%), experience and ideas between participants, which moderate (51-75%) and good (74-100%). There was would further enhance the learning process. Peer significant improvement in performance of the based teaching trains students to manage their respondents from BSSW.11.5% obtained good scores personal development and to be a better team player, and 11.5% obtained moderate scores in the posttest. a skills necessary in the field of medicine. Results from the APGHC showed no significant improvement in the posttest. 91.4% (n=32) failed the Objectives pre test and no difference was noted in the posttest. 1. To assess the basic knowledge of pre-clinical students in suturing, wound management and Conclusion sterility. Peer tutoring is an excellent platform for both parties to grow academically, but it is not a substitute of 2. To evaluate the effectiveness of peer tutoring, formal learning taught in the universities. However these results could not be extrapolated to the Material and Methods population due to the small sample size. Inclusion criteria were pre clinical students who attended the surgical skill workshop at the Asia Pacific Global Health Conference (APGHC) 2014 and the Basic Surgical Skill Workshop (BSSW) held in IMU

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RADICAL RESECTION OF PRIMARY The goals of surgical management of these tumors LEIOMYOSARCOMA OF INFERIOR VENA in¬clude the achievement of local tumor control, maintenance of caval flow, and the prevention of CAVA recurrence. Complete surgical resection with a tumor- Sivabalan Nadarajan1, Ikhwan Sani Mohamad2, free margin (1 cm) is felt to be the treatment of choice. Razman Jarmin1, Zamri Zuhdi1, There are few reported techniques in dealing with the Hairol Azrin Othman1, Azim Idris3, Affirul Chairil4 IVC following excision including IVC ligation; primary 1Hepatopancreaticobiliary Unit, Department of Surgery, repair of IVC; patching of IVC and interposition Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia grafting with a synthetic conduit. 2Department of Surgery, Universiti Sains Malaysia 3Vascular Unit, Department of Surgery, The 5-year actuarial sur¬vival rate after curative Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia resection is 28% for primary leio¬myosarcoma of 4Department of Surgery, Universiti Sains Islam Malaysia, IVC. The survival rate improved up to 53% in 5 years Nilai, Negeri Sembilan, Malaysia when surgery to the IVC is combined with adjuvant radiotherapy and chemotherapy. Leiomyosarcoma of the Inferior Vena Cava (IVC) is a rare soft tissue tumour which accounts for only 0.5% of all soft tissue sarcomas. The patients usually presented with non specific clinical signs and often diagnosed at advanced stage.

We reported a case of a 58-year-old lady who presented with right sided abdominal pain for about 6 months . CT scan showed large retrohepatic (level II) IVC tumour which encased the right renal vein and abutting the caudate lobe of the liver. She underwent radical resection (Ro resection) of the IVC tumour with the right kidney removed en bloc. Vascular reconstruction was not performed as established collateral veins present. Histopathological Examination results revealed IVC Leiomyosarcoma. 164 PP 203 PP 203

Wide Local Excision For Recurrent Result Chronic Granulomatous Mastitis A total of 5 patients with recurrent CGM had wide local excision. They were treated with multiple courses of Nor Safariny A, Siti Hartinie M, Hussain M antibiotics and oral steroid prior to operation. There Breast & Endocrine Unit, Surgical Department, has been no recurrence in all patients post wide local Hospital Sultanah Nur Zahirah, Terengganu, Malaysia excision.

Introduction Conclusion Chronic granulomatous mastitis (CGM) is a rare The management of recurrent CGM can be challenging. benign disease with unknown aetiology. However, This study showed that wide local excision can prevent the management of CGM can be challenging and the recurrent CGM. However, a larger sample size in the recurrence rate of CGM is as high as 50%. Patients future would be useful to see the best treatment with recurrent CGM have high morbidity due to option in treating recurrent CGM. breast abscess, fistula, ulceration, nipple inversion and breast distortion. Unfortunately, there is no clear clinical guideline regarding the ideal management of recurrent CGM.

Objective To analyze the effectiveness of wide local excision in treating patient with recurrent CGM.

Method All patients with recurrent CGM underwent wide local excision at Hospital Sultanah Nur Zahirah, Terengganu, Malaysia from January 2014 to April 2015 were enrolled in this study. Data were analyzed retrospectively.

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New Hemostatic Alternative To last resort after having failed to achieve hemostasis Massive Presacral Bleeding with all other hemostatic techniques and agents available. Discussion: It is difficult to control massive K N Tan1, A C Roslani1, N A Aziz1, M K Nil Amri2, presacral venous hemorrhage with conventional W Khamizar2 hemostatic measures like diathermy, suture ligation, 1University Malaya Medical Centre, Kuala Lumpur, Malaysia pelvic packing, and hemostatic agents. Several 2Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia alternative hemostatic techniques for controlling this intraoperative emergency have been proposed, such as Introduction the use of thumbtacks, bone wax, balloon tamponade, Massive presacral bleeding is an uncommon but and tissue welding using muscle fragment, epiploic potentially life-threatening complication of pelvic appendices or omental scrap. However, some surgery and remains one of the most challenging techniques fail to arrest the bleeding, resulting intraoperative emergencies to surgeons. The incidence in shock and even death. TachoSil is a absorbable and the mortality have been reported as high as 9.4% fibrin sealant patch consisting of a collagen sponge and 4.3%, respectively. Total mesorectal excision coated with fibrinogen and thrombin. The sponge is was introduced in 1982 and is considered the gold manufactured from horse tendons. TachoSil reacts standard with an acceptable intraoperative risk for upon contact with blood, other body fluids or saline rectal carcinoma. However, massive presacral bleeding to form a fibrin clot that glues it to the tissue surface. remains inevitable, especially in difficult operations. Hemostasis is achieved in a few minutes, and the sponge is absorbed by the body within several weeks. Case Reports We described our experience of using TachoSil as Conclusion an alternative method of hemostasis in 2 patients TachoSil is a safe and highly effective alternative with massive presacral bleeding. First patient was hemostatic adjunct for controlling massive presacral a 58 year-old man with low rectal carcinoma and bleeding from the presacral venous plexus. the second case involved an 80 year-old lady with colonovesical fistula secondary to perforated sigmoid diverticulitis. TachoSil was used in both patients as the

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Giantic Malignant Phylloides: toilet mastectomy and split skin graft (SSG). Specimen Management Dilemma weighted 2.2kg. Histology of the left breast turned out to be malignant phylloides. K N Tan1, H L Hoo2 1University Malaya Medical Centre, Kuala Lumpur, Malaysia Discussion 2Hospital Enche’ Besar Hajjah Khalsom, Kluang, Johor, There is no effective neoadjuvant chemotherapy Malaysia to date to downsize the tumour before surgery. Mastectomy wound coverage for huge breast Introduction: Phylloides tumour is a rare (0.3-0.5%) sarcomatous tumour is always a challenge. Tumour biphasic breast tumour of fibroepithelial origin. It may grow on top of SSG. Latissimus dorsi flap is not can be benign, borderline or malignant (10%) based adequate for big defect. TRAM flap may be feasible. on stromal findings of cellular atypia, anaplasia and Surgery is the primary treatment for phylloides degree of mitotic activity. It can therefore recur tumour. Benign lesions can be treated with local and metastasize hematogenously (12.6%). It is more excision (enucleation) using cosmetic incision. commonly seen in Asian women with peak age 45-49 Borderline or malignant phylloides can be treated with years; rare in adolescent and elderly. wide local excision (simple mastectomy) or re-excision to negative margins as there is tendency to recur with Case Summary incomplete excision. Axillary dissection is usually We report a case of a 39 year-old unmarried lady with not necessary. Adjuvant radiation if wide local spread an exceptionally huge, smelly, ulcerated, and infected of tumour is present and resection margin < 2cm. fungating breast mass with intermittent bleeding. 5-year survival is 90% with benign tumour, 69% with She experienced painless gradual enlargement for borderline tumour, and 61% with malignant tumour. her left breast for 2 years with no family history of malignancy. She was anaemic with Hb 8.08 g/dl. Tissue biopsy revealed phylloides tumour, likely to be benign. Staging computed tomography showed local infiltration into pectoralis muscle & ipsilateral axillary metastasis, no distant metastasis. She underwent left

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Relationship between Stone density, stone free rate decreases. Post op imaging Density on CT and Outcomes of within the first 48 hours revealed overall SFR is lower in the HSD group (53.3% vs 31.1%, p=0.008). There were Percutaneous Nephrolithotomy no significant difference in terms of complication B T Y Lim, W L Yam, S K Lim, F C Ng rates and need for blood transfusion in both groups. Department of Urology, Changi General Hospital, Singapore There is no significant difference between the sizes of residual fragments (RFs) and also subsequent Introduction spontaneous expulsion of RFs in both groups and need We aim to analyze the relationship between stone for secondary treatment. density on CT and outcomes of percutaneous Conclusions nephrolithotomy (PCNL) High stone densities are associated with lower rates of Materials and Methods treatment success and longer operating time in PCNL. We retrospectively examined the records of 183 patients who underwent PCNL in between July 2008 and September 2014. Patients undergoing PCNL were assigned to low stone density (LSD, ≤ 1000HU) vs high stone density(HSD, >1000HU) based on Hounsfield units of primary renal stone. Preoperative characteristics and outcomes were analysed

Results Mean stone size is 30±12mm. Duration of follow up is 25 months. Mean operating time is slightly longer in the HSD group (176 min vs 154 min, p=0.098). Univariate regression analysis reveal a linear relationship between the stone density and the probability of achieving stone free status; with increasing stone 166 PP 207 PP 207

Traumatic Abdominal Wall Hernia: He underwent urgent laparotomy, necessitating small A Case Report Of A Rare Entity bowel resection with anastomosis, with primary repair of the traumatic hernia; the patient later was referred Z Ramli, E T Geng Ju, M F Madzlan, Y Y Wai to a Urology centre for his ureteric injury. Department of Surgery, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia Initial management for all trauma patients remains the same with stabilization based on the ATLS Abdominal wall herniation caused by direct blunt guidelines, though definitive management will trauma is a relatively uncommon entity when be individualized based on the injuries found. compared to the amount of trauma cases seen. It Management of a stable blunt abdominal trauma still is associated with other intra-abdominal injuries in depends on serial assessment, and maybe aided with about 30-60%, with a particular high incidence of imaging by contrast enhanced computed tomography. bowel injury. A high index of suspicion must be maintained so that traumatic anterior abdominal wall herniation and its Diagnosis maybe difficult as the herniation may not be apparent; at times only localized ecchymoses and associated injuries are not missed. tenderness may be present.

We present a case of a traumatic anterior abdominal wall herniation (TAWH) which occurred in a 37 years old man who was involved in a road traffic accident. On initial presentation, he had lower abdominal pain. Examination of the abdomen revealed abrasions over the left iliac fossa, with a reducible tender swelling. He was stable haemodynamically with no overt signs of peritonitis, thus a computed tomography of the abdomen was performed , which revealed small bowel herniation through the fascial layers of the anterior abdominal wall with free gas seen, along with splenic and left ureteric injuries.

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Conservative Management of fractures. Drainage of the right hemothorax led to the a Traumatic Chylothorax After diagnosis of a traumatic chylothorax. The thoracic and lumbar spinous process fractures were treated Blunt Chest Trauma: A case report conservatively and the chylothorax was successfully M A Manan, G K Ooi, M H Sidik, M F Mazlan, treated with drainage and dietary manipulation. N D Khairi, Y Y Wai Conclusion Department of General Surgery, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia In general, traumatic chylothorax should be managed conservatively for at least 4 weeks before surgical Chylothorax is rare following blunt thoracic trauma; intervention is considered. We believe that with the diagnosis is usually delayed until drainage of the triad of RST (re-expansion, starvation diet, TPN), post-traumatic pleural effusion is done. Traumatic conservative treatment will be successful in the chylothorax is usually the result of penetrating trauma majority cases. and disruption of the thoracic duct. We describe an unusual patient with chylothorax from closed chest injury. The patient was successfully treated through a conservative approach with chest drainage and total parenteral nutrition leads to resolution of the condition within 2 weeks.

Case Report A 39 year old male was involved in a motor vehicle accident. He was a motorcyclist and sustained injury while motorbike is skidded. His examination and radiographic work-up revealed fractures over the left transverse process of L1, L2, L3 and right transverse process fracture of T9 and T10. He also sustained bilateral hemothorax secondary to multiple rib 167 PP 209 PP 210

A Rare Case Of A Perforated Jejunal Bilateral Necrotizing Fasciitis of Diverticulum In An Elderly Patient the Breast: A Case Report Syahrul Hadi K, V M Leow, Vasupillai, M Manisekar Faizul A A R1, Hafiez N 2F , Salleh M S2 Department of Surgery, Hospital Sultanah Bahiyah, 1Hospital Tg Ampuan Afzan, Kuantan, Pahang, Malaysia Alor Setar, Kedah, Malaysia 2Hospital Sultan Hj Ahmad Shah, Temerloh, Pahang, Malaysia

We present a case of an elderly gentleman, who Background underwent emergency surgery and segmental jejunal Puerperal breast infections encompass mastitis, resection for perforated jejunal diverticulum. He was abscess, and rarely Necrotizing fasciitis. Necrotizing 87 years old at the time of presentation, and admitted fasciitis (NF) is a rapidly progressive skin, subcutaneous to the ward for signs and symptoms of peritonitis. tissue and underneath fascial infection in which Subsequent laparotomy showed multiple small bowel involvement of the breast is extremely not common. diverticulum from the duodeno-jejunal (DJ) junction, Delay in differentiating NF from puerperal mastitis extending till 150 cm of small bowel length. One of leads to increased morbidity and loss of breast tissue the diverticulum, about 60 cm from the DJ junction to variable extent. We report a case of NF of bilateral had perforated and thus, the segment of affected breast in a lactating young lady which required almost small bowel was resected. Continuity of small bowel subtotal mastectomy in one of the breast. restored via primary anastomosis. Recovery was uneventful with return of bowel motility on day four Case post surgery. A healthy 19 year old lactating mother who had a baby two months prior to admission complaint of bilateral swollen and painful breast one week prior to admission. It was associated with fever and skin discoloration at the most painful area of the breasts. Clinically she was in sepsis and white cell counts were markedly raised. She was posted for incisional and drainage but intra-operatively revealed massive

PP 210 PP 211 necrotic tissue almost occupying the left breast and A Young Girl With Oesophageal, a quadrant of the contralateral breast. Tissue culture Rectal And Porta Varices : A Case grew staphylococcus aureus and she underwent repeated debridement, received a broad spectrum Report antibiotic and expectant wound dressing. She was Nor Safariny A, Zaharul Azran Z, Siti Hartinie M, discharged with a date for secondary suturing for the Hussain M left breast wound. Surgical Department, Hospital Sultanah Nur Zahirah, Terengganu, Malaysia Conclusions Necrotizing fasciitis of the breast is a rare condition Introduction and carries high mortality and morbidity. Early Portal hypertension in children is a rare disorder and diagnosis and prompt intervention save life and are its management is not well described compare to adult vital for preservation of breast tissue. The mainstays of patients. treatments include vigilance resuscitation, aggressive surgical debridement with concurrent broad-spectrum Case Presentation antibiotic therapy. We present a case of 15-year-old lady with history of recurrent upper and lower gastrointestinal bleeding since 11-year-old. She had frequent visits to various clinics and hospitals for her gastrointestinal bleeding but there was no proper investigation done for her.

Oesophagogastroduodenoscopy and colonoscopy performed on her at our centre revealed oesophageal and rectal varices. Ultrasound hepatobiliary found splenomegaly with tortuous vessels at porta hepatis suggestive of varices. She has normal liver echotexture. Computed tomography of the abdomen showed normal portal vein confluence with small 168 PP 211 PP 212 visualized proximal portal vein causing oesophageal, Cystic Mass Of Bowel In Origin As porta and rectal varices. There is no evidence of portal A Rare Presentation Of Abdominal vein thrombosis. Tuberculosis: A Case Report Discussion Faizul A A R1, Faiz I2, Singh H1 Late diagnosis and treatment of portal hypertension 1Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia in children can cause significant morbidity. Morbidity 2International Islamic University Malaysia, Kuantan, Pahang, is mainly related to variceal bleeding, hypersplenism, Malaysia limitation of quality of life, recurrent thrombosis, growth retardation, neurocognitive impairment and Background symptomatic portal biliopathy. Therefore, we must Primary abdominal tuberculosis is a rare condition have a high index of suspicion for portal hypertension that poses different characters and diverse visceral in paediatric patient with recurrent gastrointestinal involvement in which could lead to diagnostic dilemma. bleeding. Most common presentations include recurrent sub- acute intestinal obstruction and abdominal pain. We presented two cases of abdominal tuberculosis presented as acute abdomen with huge cystic bowel mass of each subjected to laparotomy and complicated with high output enterocutaneous fistula.

Case 1 A healthy 24 year old gentleman admitted for painful abdominal distension of one week duration associated with rapid weight loss of 10 kg within one month. Clinically he was in sepsis with tender palpable abdominal mass. White cell count was elevated and CT scan showed enhanced cystic lesion of unknown origin with ascites. In view of worsening of sepsis,

PP 212 PP 213 he was posted for laparotomy. The cystic lesion laid Upper Gastrointestinal Bleeding open and the rest of the abdominal content plastered Audit In Hospital Sarikei, One-Year together by severe adhesion. Post-operative the drain drained high output bilious discharge. Biopsy taken Review – A District Challenge intraoperative biopsy confirmed tuberculosis and Yen Zhir Tay1, Ahmad Zahier Bin Ramli2, anti-tuberculosis commenced. Fistula output reducing Kavinya Diana T Nadesalingam2, Tarek Seddik2 and patient discharged home. 1Hospital Umum Sarawak, Kuching, Sarawak, Malaysia 2Hospital Sarikei, Sarikei, Sarawak, Malaysia Case 2 A 32 year old lady with no co-morbid admitted for Introduction acute abdomen with pelvic mass. She was in severe Upper gastrointestinal bleeding (UGIB) is a life- sepsis and CT scan suggestive of a huge infected threatening emergency and a common cause of mesenteric cyst. She was posted for laparotomy and hospitalization in Sarikei Hospital. it was a cocoon abdomen. The cystic lesion adhered among the loop of bowel and was cut open. She Objective developed high output enterocutaneous fistula and To identify the demographics, the endoscopic findings the sepsis did not resolve even after started with anti- of UGIB and to analyze the provision of emergency tuberculosis as the diagnosis confirmed with biopsy. esophagogastroduodenoscopy (OGDS) services She later succumbed to sepsis. Hospital Sarikei and its outcomes.

Conclusions Methods Gastrointestinal tuberculosis appears sporadically Retrospective review of all the patients who and a great mimicry of other conditions of the bowel underwent emergency OGDS for UGIB from March especially if presented with abdominal mass. A cystic 2014 to March 2015 by collecting the demographics, lesion can be arising from bowel and result in an risk factors, Glasgow-Blatchford Score (GBS) and enterocutaneous fistula particularly following surgery endoscopic findings. Timing to scope, and number of in which is a disturbing complication. Anti-tuberculous blood products used are evaluated. Mortality and re- therapy is mandatory. bleeding are reviewed. 169 PP 213 PP 214

Result A Comparison Study Of The Imrie’s 74 of total 104 patients who underwent emergency Scoring System And Determinant OGDS are male and 30 patients are female. Majority Based Classification In Assessing The (49.0%) were Dayak, followed by Malay (27.9%) and Chinese (23.1%). The peak age group fell within 60- Outcome And Prognosis Of Acute 79 years old, 49 (47.1%) patients. Among 110 ( 95.7%) Pancreatitis In Local Population emergency OGDS were non-variceal bleed. 26.9% are Mohanraj T, Thiagaraj V, Kandasami P, Mahadevan smokers and 20.1% taken aspirin. 12 patients (11.5%) of D Tata 104 are graded with GBS 3 and less. The commonest Hospital Tuanku Ja’afar, Seremban, Negeri Sembilan, OGDS findings are gastric ulcers (34.8%) and Malaysia erosive gastritis (27.0%). 21 (20.2%) patients did not required blood transfusion. 88 (84.6%) patients were Background scoped within 24 hours from the time of admission Acute pancreatitis (AP) is a potentially lethal disease to casualties.10 patients develop re-bleeding. 2 and increasing in incidence. The mortality rate is mortalities documented. influenced by the severity of the disease, and several Discussion prognostic factors have been investigated. All the re-bleeding cases had GBS more than 7 with Aim majority age over 60 years old and scope within 24 To compare the accuracy of the Imrie’s criteria (IC) and hours. UGIB is not the immediate cause of death for Determinant Based classification (DBC) in predicting the mortalities. the outcome and prognosis of AP patients. Conclusion Method Most cases presented with gastric ulcers with high GBS This is a retrospective cross sectional study of all and male predominant. Generally all the emergency patients diagnosed with AP presented to HTJS from Jan OGDS were scoped within 24 hours of admission. 2013- Aug 2014. These patients were re-stratified their Rebleeding and mortality has no relation with timing risk according to the IC and DBC. Data were collected of scope. regarding demographic and clinical characteristics.

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Data was gathered with Microsoft Excel 2010 analysed Tooth Picking After Meal: using Graph Pad software. An Unusual Cause Of Small Bowel Results Perforation Total of 85 patients with AP was taken into this study. V K Vikinesan, Nora, H Y Chong, April C R Their mean ages were 41.6 (Range 24-64 yrs). Ethnic University of Malaya, Kuala Lumpur, Malaysia distribution consists of Malay 23.5%, Chinese 2.4%, Indian 72.9% ,others 1.1%. 69(81.1%) had alcholol- Introduction related pancreatitis, 15(17.6%) gall stone pancreatitis Accidental ingestion of foreign body in adult usually and 3(3.5%) had idiopathic pancreatitis. 74(87%) had does not pose significant problems. Ingested foreign mild AP, and 11(13%) severe AP according to IC. In DBC, bodies usually pass the intestinal tract uneventfully, mild AP 62(72.9%), moderate AP 21(24.7%), severe AP and perforation occurs in less than 1%. 2(2.4%) and 0 (0%) critical AP. The mortality rate was 2.4% (2 patients). Fisher’s exact test between both Case Summary groups shows increased mortality in DBC with severe We report a case of small bowel obstruction with AP (two tailed P value 0.0339). perforation in a 59-year-old male due to the accidental swallowing of a toothpick. He presented with Conclusion persistent colicky lower abdomen pain for 2 week, The DBC has accurately predicted mortality and which was treated as diverticulitis 1 week earlier at a disease progression in our population. DBC should be private Centre. After a day of admission, patient shows recommended as primary tool to assess severity to no clinical improvement. Emergency laparotomy reduce overzealous treatment and use of resources. reveals a 4cm toothpick causing perforation at terminal ileum near ileocaceal valve. Limited right hemicolectomy done. Post-operative recovery was uncomplicated.

Discussion Ingestion of a foreign body is an uncommon 170 PP 215 PP 216 presentation in adult. Previous studies have estimated Posterior Retroperitoneoscopic that the majority of foreign bodies, around 80–90%, Adrenalectomy: Penang General will pass spontaneously. Bowel perforation by sharp or pointed object rarely diagnosed preoperatively Hospital’s Experience because clinical symptoms are nonspecific and can Alexander Z Y Lim, Sunil S P, M S Teoh, Y T Cheong mimic other surgical condition like appendicitis and Hospital Pulau Pinang, Pulau Pinang, Penang, Malaysia diverticulitis , as illustrated in this case. It is important that clinicians maintain an open mind when managing Introduction small bowel obstruction—knowledge of the patient’s Posterior Retroperitoneoscopic Adrenalectomy diet preceding admission may be essential in forming (PRA) has proven to be technically feasible and easy an accurate diagnosis. to perform with short learning curve and minimal complications.

Objective To review the epidemiology and outcome of PRA patients in Penang General Hospital (PGH).

Methods Data of patients with PRA done between March2011 to December2014 were collected from Computerized Operating Theatre Documentation System (COTDS) and General Surgery On Line (GSO). The patients’ demographic data, clinic-pathological results and surgical outcomes were reviewed and analyzed.

Results A total of 30 patients underwent PRA over the 4 years period. The female to male ratio is 1.42:1. The age range

PP 216 PP 217 is between 27 years to 60 years old with a median age Gastrointestinal Bleed Secondary of 43.5 years. Average operative time for PRA in PGH To Gastric Lipoma: A Case Report has been reducing from 123.3minutes in 2011 to 107.3 minutes in 2014. Median duration of hospital stay is 5 K Y Low, H C Lim, E H Pok, P C Lau days ranging from 4 to 12 days. Clinico-pathological University of Malaya, Kuala Lumpur, Malaysia diagnosis showed highest in Conn’s adenoma with 76.66% (23 cases), followed by 3(10%) adrenal Introduction Cushing’s, 2(6.66%) adrenal adenomas, 1(3.33%) Gastrointstinal lipoma is a rare condition. It accounts incidentalomas and 1(3.33%) other tumor. Mean size of for 2% to 3% of all the benign tumour in the stomach tumor removed via PRA was 2.9 cm ranging between and 1% out of all the neoplasms in the stomach. From 1 and 7cm. Among the patients who had PRA done, 2 literature research noted that most gastrointestinal (6.7%) patients developed complications. One patient lipoma are located in the colon (65%-75%). developed subcutaneous emphysema while the other patient had infected retroperitoneal collection. There Followed by small bowel 20%-25%. Due to its rarity, was no conversion rate. gastric lipoma are usually underdiagnosed or often misdiagnosed as GIST. We would like to report a case Discussion of a 75 year old lady who was presented with upper PRA done here is mainly for Conn’s adenoma with gastrointestinal bleeding secondary to suspected mean size of 2.9cm. Average operative time is reducing large cardia GIST. Due to difficult tumour location, and median hospital stay is 5 days. laparoscopic intragastric resection was performed which reveal a large lipoma, thus tumor enucleation Conclusion and primary mucosal closure with sutures performed. PRA is a safe and less invasive method for treatment Essential steps of this unique procedure explained. of small adrenal tumors. As it is a relatively new procedure, a safe learning curve is necessary before Methods one embarks using this approach. 1. Laparoscopic access with CO2 pneumoperitoneum 2. 3 balloon ports inserted into gastric lumen. Intragastric pressure set at 8mmHg 171 PP 217 PP 218

3. Enucleation of the gastric tumor with harmonic Hirshsprung’s Disease In Adult; device with oro-gastric tube in- place as guidance A Rare Case Report to avoid esophageal injury Deven Aragena1, Komalah Subramaniam2, 4. Closure of the mucosal defect with intragastric 1 1 suturing Lai Chung Kiet , Falah Akmal 1Department of Surgery, Hospital Duchess of Kent, 5. Extraction of the tumour with endobag Sandakan, Sabah, Malaysia 2 6. Closure of the gastric access sites with suture or Department of Radiology, Hospital Duchess of Kent, endo-stapler Sandakan, Sabah, Malaysia

Results Objective Post-operatively, she recovered rapidly with oral To study the common and uncommon presenting intake allow the next day and was discharged on POD 3 symptoms of Hirshprung’s disease in adult.

Conclusion To highlight the importance of Hirshprung’s disease Laparoscopic intra-gastric resection is a safe, minimal when dealing with adults with chronic constipation. invasive and function-preserving gastrectomy for benign gastric tumour. Method Clinical presentation and investigation with intraoperative findings will be presented, discussed and supported with literature review.

Result A 25 years old non Malaysian lady, presented with progressively enlarging suprapubic mass for the past six months duration. On further questioning the mass initially appeared almost two years ago, positive history of chronic constipation since her teenage years with frequent use of laxatives and GP visit. She

PP 218 PP 219 was initially referred to gyneacology team to rule Right Ureterocele 26-Years Post out ovarian mass, and after assessment gyneacology Nephrectomy: A Rare Presentation pathology was ruled out. Upon review by surgical team, a decision for colonoscopy was made but the Deven Aragena1, V M Kumar1, Komalah2 procedure was unsuccessful as it was feacal loaded 1Department of Surgery Hospital Duchess of Kent, Sandakan, and narrowed lumen at rectal area. Subsequently Sabah, Malaysia 2 proceeded with CECT of the abdomen with a high Radiology department Hospital Duchess of Kent, Sandakan Sabah, Malaysia index suspicious of tumor as the main pathology, however the finding in CECT abdomen which showed a large dilated loop of rectosigmoid to distal sigmoid Objectives colon with fecal content and transition zone at To highlight the possibility of ureterocele formation midrectum, S2S3 was highly susgetive of adult onset post nephrectomy Hirschsprung’s disease. Due to financial issue as for non Malaysian we proceeded with total colectomy To discuss the prevention of ureterocele formation and ileoanal anastomosis. Review six month post post nephrectomy. operative, patient is keeping well, with good bowel Method opening and occasional passing of loose stools. HPE Clinical presentation, Investigations, U/S and was confirmatory of Hirshprung’s disease. CECT abdomen with intraoperative findings will be Conclusion presented, discussed & supported with literature Despite being a rare entity, Hirshprung’s disease must review. be borne in mind by all health care personnel when Results managing patient with chronic constipation. This 60 years old gentleman, with past history of nephrectomy, presented with lower urinary tract symptoms and right sided abdominal mass for one month. Physical examination showed a huge right side abdominal mass. CECT abdomen was reported as highly suggestive of infected mesenteric cyst or 172 PP 219 PP 220 bowel duplication cyst. Intraoperatively, the cystic The Impact Of FDG-PET/CT In mass was found to be arising from the lower pole of The Management Of Recurrent the right ureter. Cyst was removed completely and the right ureter was ligated distally. HPE consistent Colorectal Cancer with ureterocele. Postoperatively, patient developed C W James Khaw, A C Roslani, H C Eugene Wong leak from the right ureter which needed relaparotomy University Malaya Medical Centre, Kuala Lumpur, Malaysia and religation of the ureter. Subsequently, patient recovered uneventfully. Introduction Colorectal cancer is the 2nd commonest cancer in Conclusion Malaysia. Most patients present in stage III and IV. Formation of ureterocele post nephrectomy is rare, Standard method of detection of recurrences include thus making this an exciting case. Failure to ligate the serial CEA and CT scans. However, CT scans may not be ureter as distally as possible combined with backflow able to detect recurrences early enough. of urine has led to formation of ureterocele in this patient. Objective Any significant impact on management with CT scan only or with PET/CT as adjunct?

Methods Retrospective review of 125 patients with recurrent Colorectal cancer in UMMC from 2007-2013 who had CT and PET/CT done.

Results PET/CT changed the management in nearly 50% of the patients ( p<0.05, odds ratio 2.97, 95% CI 1.06 – 8.31 ). With a PET/CT, there is a statistically significant change in disease staging ( p<0.05, Z = -4.103 ). PET/ CT has a sensitivity of 88.2% and a specificity of 86%.

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Conclusion Comparison Of Colorectal PET scan improves staging accuracy and influence Screening Strategies Using management of patients with recurrent Colorectal Qualitative And Quantitative cancer. Faecal Immunochemistry Test To Prioritise Urgency Of Colonoscopy Referral-Interim Results Ee Shuan Lim1, April Camilla Roslani2, Chee-Wei Law1, Ausama A Malik1, Hoong-Yin Chong, Ida Normiha Hilmi2, Chirk -Jenn Ng3, Tin-Tin Su4 1Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia 2Department of Internal Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia 3Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia 4Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

Background Colorectal cancer is the second commonest cancer in Malaysia.Screening for colorectal cancer is critical for early diagnosis and curative treatment.Primary screening with faecal immunochemistry tests allows selection of those to proceed to secondary screening with colonoscopy.There is a wide variation in the 173 PP 221 PP 221 waiting time for colonoscopic screening in Malaysia. positive,two neoplasia (both benign polyps with faecal Quantitative faecal immunochemistry tests(QT FIT) Hb level of 169 and 402).Time interval from positive allows those tested positive to be categorised to low, test to histological confirmation was 56 to 83days. intermediate and high risk groups, as opposed to qualitative FIT(QL FIT) which only distinguishes the Conclusion positive from negative.There has been no comparison We conclude that QT FIT is better than QL FIT in of these two techniques in risk stratification to priotising screened patients for colonoscopy,resulting prioritise early colonoscopy. in shorter time to diagnosis.

Objective To determine if QT FIT is better than QL FIT in prioritizing screened patientsfor colonoscopy, resulting in shorter time to diagnosis.

Method Participants with an average risk of developing colorectal cancer were randomised to QL and QT arms. Those tested positive underwent colonoscopy with those in the high-risk QT group being expedited.The primary outcome of the interest was time to diagnosis of advanced neoplasm.

Results A total of 509 participants were enrolled.Five out of 236 in the QL arm tested positive, three with neoplasia (two malignant, one benign polyp). The time interval from positive test to histological confirmation was 39 to 239 days .In the QT arm,eight out of 274 tested

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Does Pre-Operative Hand Ball prescribed daily hand ball exercise and reassessed Exercise Result In Functional after 2 weeks. Our aim was to recruit 20 patients but we discontinued recruitment after 8 patients due to Arterio-Venous Fistulaes? poor outcome. C K Seak, Yogessvaran K, Richard Hardin, T L Luk Sarawak General Hospital, Kuching, Sarawak, Malaysia Results Cephalic vein diameter of all 8 patients measured Introduction 2 weeks after hand-ball exercise did not show an Native vein diameter is an important factor in increase in size. Out of the 8 patients, 2 underwent AVF determining the success rate of vascular access creation which failed to mature while the remaining 6 creation. Physicians have routinely subjected end did not proceed with AVF creation. stage renal failure (ESRF) patients to hand-ball Discussion exercise prior to vascular access creation to increase the diameter of native vein and therefore improve the Vein diameter is crucial in creating a functional AVF. success rate of creation. Our study suggests that up to 2 weeks hand ball exercise does not appear to increase the size of the Objectives vein. The two AVFs that were created in the sample Our objectives are to evaluate whether pre operative group were not suitable for haemodialysis. hand-ball exercise will lead to an increase in diameter Conclusion of native veins and subsequently lead to functional arterio-venous fistulaes (AVFs). Pre operative hand ball exercise does not lead to eventual functional AVF. Therefore we do not Materials and methods recommend pre operative hand ball exercise as this ESRF patients requiring haemodialysis were assessed might delay alternative dialysis techniques prior to AVF creation. The diameter of the cepahlic vein in the non-dominant forearm were measured using Duplex Ultrasound. Veins less than 2mm were included in this observational study . The patients were 174 PP 223 PP 223

Endovascular Approach in limbs. A Duplex scan was done to assess the aneurysm Post-Traumatic Popliteal Artery and distal circulation as well as venous patency and plan for the appropriate surgical intervention. She Pseudoaneurysm: A Case Report underwent a Bridging procedure by stenting of the M Fairuz Anisa, Firdaus H, R Rosnelifaizur, distal SFA - posterior tibial artery. Post operatively she Zainal A A had good return of circulation and was discharged well after 7 days. She has recovered well since last seen Introduction during her follow up. Popliteal artery pseudoaneurysms are very rare Conclusion arterial disorders as demonstrated by the limited number of cases reported throughout the years. Most Depending on the involved area, the exact cause commonly, this arterial disorder is of as a result from of a traumatic vascular lesion may be difficult to trauma or after orthopaedic procedures. We report determine, especially when delayed and may even a case of delayed presentation of popliteal artery mimic other conditions. Once the diagnosis is pseudoaneurysm and the endovascular approach confirmed, planning of surgical intervention requires taken under an emergency setting. proper assessment of the distal circulation and run off of the limb. Open surgical repair has always been the Case Report gold standard in repair of distal SFA pseudoaneurysm, A 12 year old girl presented with a progressive swelling however, the endovascular approach undertaken in of her right distal thigh for 6 weeks after she sustained this case had exhibited many benefits in terms of pre- an injury to her right knee during a netball game. Over operative preparation, resolution of pseudoaneurysm time, she begun to develop mild ischaemic pain of her and recovery of distal circulation. right leg. Initial assessment revealed a pulsatile mass at her right distal thigh; distal pulses were weakly palpable but no other abnormalities were detected. Only a posterior thigh soft tissue swelling was seen on radiograph. Diagnosis of distal SFA pseudoaneurysm was confirmed by ultrasound and CTA of her lower

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Study On Post-Operative Pain Scores Results: There were a total of 13 patients included Based On Dermatomal Distribution in the analysis. Under Group 1, there were 3 Lanz, 1 Kocher, 1 transverse incision over transpyloric plane, In Surgical Wards In Penang General and 1 transverse incision over right upper quadrant. Hospital Group 2, there were 3 midline, 1 upper and 1 lower Alyson Tan S Y, Alexander Z Y Lim, Lim S Y midline, 1 right subcostal with upper midline extension Hospital Pulau Pinang, Pulau Pinang, Penang, Malaysia and 1 upper midline incision with left lateral extension. Group 1 consistently resulted in earlier resolution of Introduction pain by an average of 3 days, and had lower initial pain scores with an average of 2.16 versus 4.28 (Group 2). Placement of surgical incisions influences not just Group 2 required hospitalization for analgesia post- cosmetic outcome but also post-operative pain operatively with an average addition of 1 week. Objectives 5 patients (71%) in Group 2 required patient-controlled To demonstrate in a clinical setting if incision wounds analgesia as compared to none in Group 1. over dermatomal distribution (Group 1) would result in reduced pain scores in the immediate post-operative Discussion period as compared to non-dermatomal distribution Group 1 patient shows lower initial pain score with an (Group 2) earlier resolution of pain and shorter hospitalization. Methods Conclusions Patients were selected over a period of 7 weeks Surgical incisions following dermatomal distributions (28/10/14 - 12/12/14) from 3 surgical wards (2 male consistently showed lower absolute pain scores in the and 1 female), and categorized based on incision type post-operative period, with a faster resolution of pain. into groups 1 and 2. They were followed up for 8 days and daily pain scores were assessed from 0-10 with aid of Visual Analogue Scores. Types of analgesia were analyzed.

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Endoscopic Component Separation with large complicated ventral hernia measuring more Technique For Repair Of Large than 10 cm. Pre-operative computed tomography of the abdomen was done to evaluate the structural Complicated Ventral Hernia – defect and further planning of surgery. Both patients Report Of Two Cases And Literature underwent unilateral ECS, followed by open fascial Review closure and further reinforcement with laparoscopic intraperitoneal onlay prosthetic mesh. C K Seak, S C Tee, M Hardin, S L Siow, Sarawak General Hospital, Kuching, Sarawak, Malaysia Discussion Ultrasound guided identification and demarcation Introduction of rectus abdominis was done prior to surgery. Component separation creates a rectus abdominis Intraoperatively, one 10 mm camera port and 5 muscle advancement flap towards the midline mm working port was inserted just lateral to linea that allows for closure of large ventral defect and semilunaris and subcutaneous plane was created with reconstruction of normal abdominal wall physiological gas insufflation. The subcutaneous tissues are bluntly integrity. However, the division of the perforator dissected to expose the external oblique aponeurosis vessels anterior to the rectus abdominus muscle during which was then released longitudinally 2 cm lateral the open technique may result in ischaemia of the to the linea semilunaris from subcostal to inguinal adipocutaneous flap and subsequent necrosis of the area. The ventral defect was closed primarily and overlying skin and fatty tissue. Endoscopic component further reinforced by underlaying a prosthetic mesh of separation (ECS), first introduced in 2000, has a far adequate overlap. lesser risk of flap necrosis as perforator vessels are preserved. Here, we describe our ECS technique in two Conclusion patients with large complicated ventral hernia using ECS is safe and feasible in the repair of large conventional laparoscopic instruments. complicated ventral hernia.

Case report Two patients with previous abdominal midline surgery for benign gynaecological disease presented to us

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Comparison between Open and Results: Total of 50 patients, 31 underwent open repair Laparoscopic Repair of Perforated while 19 underwent laparoscopic repair. The mean age of patient whom underwent open repair was Peptic Ulcer: a retrospective study 45.8 ± 18.6 and the mean age for laparoscopic repair Kugan V, Mahadevan D Tata was 49.1 ± 18.9. There was no significant difference Department of Surgery, Tuanku Ja’afar Seremban, Seremban, between the variables of age, gender, race, size of Negeri Sembilan, Malaysia ulcer and pre-operative days between these two groups. The mean post-operative duration of hospital Background stay for open repair were 6.94 days and laparoscopic Laparoscopic technique of repair of perforated peptic repair being 4.68 days. Open repair was subject to a ulcer (PPU) has emerged as a superior alternative to the significantly higher rate of complications including conventional open repair method. Many studies have intestinal (p<0.05) and surgical site infection. Of the 31 shown that this minimally invasive method shorten patients of open repair, 7 patients developed intestinal hospital stay, less post-operative pain, reduced size complications such as adhesion and intra-abdominal of wound, reduced post-operative complications and collection whereas all 19 patients of laparoscopic mortality. repair did not develop any intestinal complications. Aim Conclusion To compare post-operative outcome between open Laparoscopic repair of perforated peptic ulcer has and laparoscopic repair of perforated peptic ulcer. shown less post-operative complications and shorter Method hospital stay compared to open repair. This was a retrospective study involving all patients who underwent repair of perforated peptic ulcer disease during a 5 year period included in this study. 50 consecutive patients’ records with perforated peptic ulcer were analyzed. Data were collected from operation theatre database and hospital medical records. Chi square and t test were used. Epi info and SPSS were employed. 176 PP 227 PP 227

Effect of Sleeve Gastrectomy in the number of hypoglycaemic agent medications in Type-2 DM in Morbidly Obese Patients morbidly obese T2DM patients who are not adequately controlled with medical therapy Azahar S1, Hazimi R2, M N Hisham2, Normayah K2 1Institut Kanser Negara, Putrajaya, Malaysia Results 2Breast and Endocrine Unit, Department of Surgery, There were remission in 14 patients (63.3%), 5 patients Hospital Putrajaya, Putrajaya, Malaysia (22.7%) showed improvement (22.7%), 2 patient (9.5%) without any changes and 1 patient (4.5%) had to Introduction increase hypoglycaemic agents after 1 year post LSG. Existing evidence has suggested that bariatric surgery produces sustainable weight loss and remission or Conclusion cure of type 2 diabetes mellitus (T2DM). Laparoscopic Our study showed that the LSG is associated with sleeve gastrectomy (LSG) has garnered considerable a high rate of resolution of T2DM and markedly interest as a low morbidity bariatric surgical procedure improved diabetes control at 12-month after surgery that leads to effective weight loss and control of co- in morbidly obese patients with T2DM. morbid disease.1

Objectives The aim of this study is to assess the short- and long- term effects of laparoscopic sleeve gastrectomy (LSG) on body weight and improvement or remission in DM in morbidly obese diabetic patients.

Materials & methods The study was conducted on 22 patients from January 2009 to June 2014 who underwent LSG with T2DM in Hospital Putrajaya, for the evaluation of the short- and long-term effects (three-month, six-month and twelve-month) of LSG on diabetes control by assessing

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A Rare Entity of A Common Disease: Laparoscopic repair of Acquired A Case Report of Metaplastic abdominal intercostal hernia (AAIH) Squamous Cell Breast Carcinoma Ashok Marappan, Thanabalan Fonseka, Nor Safariny A, Chang B C, Siti Hartinie M, Mahadevan Tata Hussain M Hospital Tuanku Jaafar Seremban, Seremban, Breast & Endocrine Unit, Surgical Department, Negeri Sembilan, Malaysia Hospital Sultanah Nur Zahirah, Terengganu, Malaysia Acquired abdominal intercostal hernia (AAIH) is a Metaplastic carcinoma of the breast (MCB) is a rare very rare condition where intra-abdominal contents histological subtype of breast cancer with an incidence protrude out at the intercostal space without any of less than 0.1%–0.5%. MCB is of considerable interest damage to the diaphragm due to its pathological heterogeneity and differences in clinical behavior compared to typical carcinomas. We discuss a case of a 67-year-old female who initially We report a case of MCB in a 61 years old woman who presented to us after a vehicular trauma and had a presented to us with septicemic shock secondary long stay in the hospital. Post trauma she noticed a to infected ulcerating left breast cancer. CT staging swelling over the right hypochondriac region which showed left breast carcinoma with left axillary nodal, was reducible. CT scan revealed defect measuring lung and left adrenal metastasis. She underwent left 11 cm with herniation of small bowel loops, part of mastectomy with axillary clearance. Histopathological the ascending colon and mesentery. She underwent result revealed left breast metaplastic squamous cel laparoscopic hernia repair without any complications. carcinoma with Bloom and Rhichardson Grade 3 and Even though acquired intercostal hernia is a rare event, triple negative phenotype. the diagnosis is easy with the help of CT scan and surgical repair is the best method of treatment. The laparoscopic approach offer s better results and less complications.

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Pregnancy Associated Breast associated breast cancer patient at Hospital Sultanah Cancer: Retrospective review Nur Zahirah, Terengganu, Malaysia. Nor Safariny A1, Azhani Chik2, Siti Hartinie M1, Method Hussain M1 Retrospective study on all pregnancy associated 1Breast& Endocrine Unit, Surgical Department, breast cancer cases at Hospital Sultanah Nur Zahirah, Hospital Sultanah Nur Zahirah, Terengganu, Malaysia Kuala Terengganu, Malaysia for one year duration from 2Kulliyyah of Medicine, International Islamic University of April 2014 to March 2015. Malaysia, Kuantan, Pahang, Malaysia, and Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia Result A total of 5 pregnancy associated breast cancer were Introduction diagnosed in our centre during the one year period. Breast cancer is one of the most common malignancy Mean age of diagnosis is 33.6 (21 to 45 years) and 60% diagnosed during pregnancy. Pregnancy-associated presented in 1st trimester. Most presented in early breast cancer (PABC) occurs in 0.2-3.8% of all pregnant breast cancer, except in 2 patients. All of our patients women, with increasing incidence as more women were managed in multidisciplinary setting which delay childbearing. The goal of treating pregnant involved surgeon, obstetritian, pathologist, radiologist women with breast cancer is the same for non pregnant and paediatritian. 80% of our patients underwent women which include local control of the disease and surgery and only 1 patient received neoadjuvant prevention of systemic metastases. Treatment often chemotherapy. generates problems and distress for the pregnant woman, her family and health care professional due Conclusion to dilemma created between the optimum therapy Pregnancy associated breast cancer is a challenging for the mother and well being of the fetus. Therefore, setting. The approach of management must be all patients should be seen, evaluated and treated in individualized, mainly as a consequence of the multidisciplinary setting. gestational age and the patient’s clinical condition. Further research regarding fetal survival outcome Objective should be considered in the future. To analyse demographic data, tumour characteristic, staging, treatment and outcome of pregnancy

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Perforated Ileoceacal intussusception. Pathologic evaluation revealed a Intussusception Following Open diffuse large B cell non-Hodgkin’s lymphoma of the ileum. As been reported (2), Non-Hodgkin’s lymphoma Appendectomy discovered Non- may masquerading as appendicitis and it also been Hodgkin’s Lymphoma: A Case Report reported presented with ileoceacal intussusception Fon Sheng Sei1, A Rahman, Ainilhayat1, in children (3). Intestinal lymphoma is difficult to Ming Yen Lee2 diagnose as by the non-specific clinical presentation. 1Department of Surgery, Hospital Enche’ Besar Hajjah Key Words Khalsom, Kluang, Johor, Malaysia 2Department of Pathology, Hospital Sultanah Aminah, Non-Hodgkin’s lymphoma (NHL); Intestinal Johor Bahru, Johor, Malaysia Obstruction; Appendicitis; Intussusception; Intestinal lymphoma Incident of non-Hodgkin’s lymphoma (NHL) is increasing which in Malaysia, NHL is the third commonest cancer (7.4%) in male and tenth (2%) in female aged 15-49 years, B-cell lymphoma accounts 80-90% of case (1). The gastrointestinal tract is the most common site of primary extra nodal NHL, accounting for 20%-40% of all extra nodal disease. However, primary diffuse large B cell non-Hodgkin’s lymphoma of the small intestine is rare compare to other intestinal disease. Intussusception due to primary diffuse large B cell non-Hodgkin’s lymphoma in the small intestine is even rarer and is often difficult to diagnose. Case was a 16 years old girl initially operated as appendicitis who presented 3 weeks later with intestinal obstruction and proceeded laparotomy limited right hemi-colectomy for perforated ileoceacal 178 PP 232 PP 233

HURTHLE CELL THYROIDITIS: DIAGNOSIS Colon Carcinoma With Inferior AND SURGICAL OPTIONS: A CASE REPORT Mesenteric Vein Tumor Thrombosis: C C Sim, Ainilhayat A R, Mohd Shariman M S A Poor Prognosis Indicator? Hospital Enche’ Besar Hajjah Khalsom, Kluang, Johor, J Jazree, K N Tan, A C Roslani Malaysia University Malaya Medical Centre, Kuala Lumpur, Malaysia

Hurthle cells (HCs) and HC change, are not infrequently Introduction described on fine-needle aspiration biopsy (FNAB) Colorectal cancer with mesenteric vein tumor reports of thyroid lesions. Clinicians are concern thrombosis has a poor prognosis. However, little is regarding the description of HCs on FNAB reports. The known about the clinicopathological characteristics significance of HCs in thyroid pathology is currently of these patients. Inferior mesenteric venous tumour uncertain. There are many benign thyroid lesions thrombosis is extremely rare entity in colorectal associated with HCs or HC change. It is difficult to carcinoma with only one case reported in the literature diagnose Hurthle cell whether in benign or malignant to date. Case Summary: We describe a case of 71 nature based on histopathology. For now, due to the year-old man who was referred for 6 month history inability to determine the benign or malignant nature of altered bowel habit with significant weight loss. of such neoplasms based on cytology alone, a surgical Colonoscopy and computed tomography (CT) revealed approach is warranted. Surgeons often have dilemma obstructing sigmoid colon tumour with no distant in giving surgical options to patient. It is reported metastasis. CEA was 21.6 ng/ml. He had undergone that in 70-80% of cases, total thyroidectomy was anterior resection with high inferior mesenteric vein done for a benign process. In this report, we describe ligation as there was a large sigmoid colon tumour a case of solitary thyroid nodule which cytology shows with a thrombosed & engorged inferior mesenteric Hurthle cell thyroiditis. Patient was given options vein. Histological examination confirmed poorly between total thyroidectomy and hemithyroidectomy. differentiated adenocarcinoma with intraluminal However, total thyroidectomy was done and reported tumour nodule seen within the thrombosed inferior as nodular hyperplasia. mesenteric vein. He was subsequently discharged well following an uneventful recovery. He had been seen by oncologist and started on adjuvant chemotherapy.

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Discussion ADHERENCE TO HORMONAL THERAPY A search of the relevant literature revealed 9 reports AMONGST BREAST CANCER PATIENTS of similar patients. The patients consisted of 5 females ATTENDING PUBLIC HOSPITALS IN and 6 synchronous cases, with a median age of 70 years. Portal vein thrombosis was observed in 6 patients, MALAYSIA being the most frequent site of thrombosis, other Mastura Mujar1, 3, M Dahlui1, E N Aina4, I Sairi4, patients showed tumour thrombosis of the superior Ang L P4, A Sarojah4, Chea C H4, Taib N A2, On behalf and inferior mesenteric veins. Despite curative of the Breast Chapter, College of Surgeons of resection, 3 patients eventually developed liver Malaysia metastases after the surgery. The median disease-free 1Centre of Population Health, Department of Social & survival of the patients who had undergone curative Preventive Medicine, Faculty of Medicine, University of resection was 300 days, and the overall median Malaya, Kuala Lumpur, Malaysia survival of the patients was 420 days. Conclusion: For 2Department of Surgery, Faculty of Medicine, University of colorectal cancer with mesenteric or portal vein tumor Malaya, Kuala Lumpur, Malaysia thrombosis, we need to adopt adjuvant chemotherapy 3Cluster of Healthy Lifestyle, Advanced Medical and Dental in consideration of the inherent risk for the liver Institute (AMDI), University Science of Malaysia, Pulau metastases. Pinang, Penang, Malaysia 4Ministry of Health Malaysia

Introduction Studies have clearly demonstrated the benefits of hormonal therapy in women with breast cancer. However, there is no standardized practice on measuring the adherence of hormonal therapy in breast cancer in Asia generally and Malaysia specifically. Therefore, this study was done to evaluate the adherence rate to hormonal therapy in the first year of therapy, among breast cancer patients attending public hospitals in Malaysia. 179 PP 234 PP 234

Method Conclusion A retrospective cohort study of 340 newly diagnosed Non-adherence to hormonal therapy was high among breast cancer patients attending public hospitals breast cancer patients in public hospitals in Malaysia. were recruited from six regions in Malaysia. First year This figure is equivalent to 1 in 3 breast cancer patients consumption status was conducted among those discontinue their hormonal medications within the recommended for hormonal therapy through medical first year of hormonal treatment. Further study should record review and phone call. Adherence was defined be done to explore reasons for non-adherence and as those who continue hormonal therapy. Those who to evaluate adherence of hormonal therapy in breast stopped due to medical indications were considered cancer along the 5 year period in Malaysia. as adherent. Non-adherence is when patients refuse to consume or discontinued hormonal therapy due to non-medical reasons. Univariate and multivariate analysis were performed for analysis.

Results A total of 220 patients were recommended for hormonal therapy. Most patients were prescribed Tamoxifen (n=194), and only 12% (n=26) were prescribed aromatase inhibitors. The first year adherence rate of hormonal therapy was 65% (n=144). Majority continued hormonal therapy as recommended and some stopped due to medical indications (n=9). Non-adherence rate for hormonal therapy was 35% (n=76). Marital status, employed status, surgery adherence, type of hospital showed significant associations with non-adherence to hormonal therapy in univariate. After adjustment for covariates by using logistic regression, single women and non-oncology hospital was found to be associated with non-adherence to hormonal therapy.

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Can Laparoscopic Appendicectomy compared to its counterpart in LA (F: M=6:4). On the Replace Open Appendicectomy? contrary, there was more male patients that underwent OA (F: M=1:9) or conversion LO (F: M=3.5:4.5). (p<0.05). Cheng Y H1, Ho Y T1, Lim K K1, Siman A M1, The mean length of hospital stay was 2.77 days in LA Vivian C W Y1, Kandasami P1, Mahadevan D Tata2 compared with 2.54 days in OA (P=0.247). The mean 1International Medical University, Negeri Sembilan, Malaysia duration of surgery was 68.18 minutes in LA and 72.97 2Department of Surgery, Tuanku Ja’afar Hospital, Seremban, minutes in OA (P=0.06). No statistically significant Negeri Sembilan, Malaysia differences between the LA and OA groups with regard to length of hospital stay and duration of surgery. Objectives In LA, there were 6 patients with postoperative To compare benefit and safety of laparoscopic complications and 13 for OA (OR=6.95, CI: 2.60 to appendicectomy (LA) over open appendicectomy (OA). 18.60, P value=0.019). The readmission rate is lower for LA 3.0% (14/484) and OA for 8.9% (25/162) (OR=6.13, Methodology CI: 3.10 to 12.10, P value=0.0004). The accuracy of A cross sectional study was done using the data laparoscopic as diagnostic tool from histopathology from computerized OT documentation system of 773 report was 77.7%. patients who underwent OA and LA from 2012 to 2013; a systematic and comprehensive method database Conclusion (COTDS). Patients’ demographic data, duration of Laparoscopic appendicectomy showed less surgery, length of stay, postoperative complications, postoperative complications and readmission rate re-admission rate, accuracy of diagnosis using over open appedicectomy. laparoscope.

Results A total of 773 patients were included during the study period. Of these, 484 had LA and 162 had OA. The mean age of the patients was 27.93 years for LA, 27.37 years for OA. There was a significant portion of females

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Challenges In Managing Esophageal mediastinal collection. We would like to highlight Perforations – A Case Report the challenges in the management of esophageal perforation in this report. Thiagaraj V, Alvin Lum W K, Azrina A B, Jasiah Z, Mahadevan D T Department of Surgery, Hospital Tuanku Jaafar, Seremban, Negeri Sembilan, Malaysia

Esophageal perforation, whether they are spontaneous or iathrogenic in origin is considered a relatively rare event.

We report a case of iathrogenic esophageal perforation post thyroidectomy. The patient underwent a left hemithyroidectomy at a private centre for multinodular goiter with a complex cyst in the left lobe. In the immediate post operative period, noted the skin over the surgical site was erythematous and minimal food discharge over the edges of the scar. The patient was treated conservatively and discharged home.

After a few days, the patient presented to us with complaints of cough, a discharging sinus over the scar site and chest pain. Imaging showed a huge mediastinal collection.

This is a complex case of esophageal perforation manifesting as a discharging sinus and a large

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A Rare Case Of Duodenal Brunner showed semi-digested fermented food in a dilated Adenoma Causing Gastric Outlet stomach with a swollen and distorted pylorus. Duodenum could not be intubated. Rapid urease Obstruction test was positive and thus, had Helicobacter pylori K N Tan1, H L Hoo2, A C Roslani1 eradicated. Endoscopic biopsy was inconclusive. 1University Malaya Medical Centre, Kuala Lumpur, Malaysia Her symptoms persisted subsequently with same 2Hospital Enche’ Besar Hajjah Khalsom, Kluang, Johor, endoscopic findings. Computed tomography (CT) of Malaysia abdomen was misinterpreted as midgut malrotation resulting in an urgent laparotomy, pyloroplasty, and Introduction excision of duodenal polyp. Histology examination Brunner gland adenoma, also known as Brunneroma or revealed Brunneroma. She had an uneventful recovery polypoidal Hamartoma, is a rare benign, proliferative and complete resolution of symptoms after surgery. lesion from the Brunner’s gland of the duodenum. Discussion: Brunner’s glands consist of submucosal They account for 10.6% of the benign tumours of the mucin-secreting glands located exclusively in the duodenum. The tumours are usually symptomatic duodenum. They secrete an alkaline fluid composed with duodenal/gastric outlet obstruction or with of viscous mucin, whose function appears to haemorrhage. This case report highlights the clinical protect the duodenal epithelium from acid chyme presentation, radiological, pathological features and of the stomach. It is a tumor without malignant therapy. predisposition. Symptomatic Brunner’s gland tumours usually require surgical treatment. When the tumor Case Summary is small or pedunculated, endoscopic polypectomy We describe a case of 39 year-old lady who presented is the treatment of choice. Open surgical excision is with one year history of chronic dyspepsia and reserved for cases where snaring has failed or when intermittent vomiting, which had progressively worsen tumor is too large. In this case, duodenum could not with no apparent predisposing factors. No contributory be intubated due to large size of brunneroma, which medical or family history was identified. Clinically, was covered by a thick intact duodenal mucosa and she was very malnourished with mild tenderness the biopsy was often not deep enough to reach the over her epigastrium. Esophagogastroduodenoscopy submucosal tumour tissue.

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