65-year-old Male With Testicular Hernia

You have been asked to perform a preoperative consultation on a 65-year-old male who will be undergoing a testicular hernia repair. Of the following findings, which is of most concern in predicting a cardiac complication in this patient undergoing noncardiac surgery?

a) Age over 60
b) History of myocardial infarction 3.5 years ago
c) Harsh systolic crescendo-decrescendo murmur radiating to the carotids
d) ECG and subsequent telemetry showing up to five PVCs per minute
e) Serum creatinine 2.0 mg/dL

Answer:

34 year-old Man With Intermittent Melena

A 34-year-old man presents to the emergency department(ED) with intermittent melena of 3 days’ duration. He is mildly fatigued but hemodynamically stable and denies any hematemesis or coffee ground emesis. His serum hemoglobin level is 8.2 g/dL. Intravenous (IV) fluids are started. Physical examination is essentially unremarkable. What is the next best step in this patient’s evaluation?

A. Check serum Helicobacter pylori antibody levels
B. Perform a colonoscopy
C. Perform an esophagogastroduodenoscopy(EGD)
D. Start a histamine2 receptor antagonist (H2 blocker)
E. Transfuse 2 U of packed red blood cells

Answer: 

Did You Know ? Surgical Fact #1

Peptic ulcer disease was once being recognized as a complicated disease which can turn out to be life threatening. For more than a century, it was often being treated surgically, with resulting high morbidity and mortality rate.  The perception of the pathophysiology of peptic ulcer disease has totally changed during the 1980s, when Barry J. Marshall and J. Robin Warren discovered the relationship between helicobacter pylori with gastritis and gastric ulcer. Since then, the management of peptic ulcer disease has been shifted towards conservative treatment with various pharmacological therapy being  introduced to inhibit the gastric acid secretions and to eradicate the H.pylori J. Marshall and J. Robin Warren were being awared the 2005 Nobel prize for their contribution.

The Case of the Sickly Scribbler With an Agonizing Belly Ache

The patient was a 59-year-old white male author who complained of severe abdominal pain.

Personal History

The patient was the eldest of 10 children. Two siblings died of typhoid -- one from peritonitis secondary to a perforated intestinal ulcer that had been caused by the disease. His mother died of abdominal cancer at age 44 and his father died at age 82. As an adult, the patient smoked and drank copious amounts of white wine -- often becoming inebriated. He led an irregular life, frequently moving, sometimes eating poorly, and, although he had multiple medical problems, he often failed to comply with medical advice. He had 2 children, a son and a daughter who required frequent hospitalization for attacks of schizophrenia.

Medical History

Throughout adulthood, the patient experienced a number of severe medical conditions. At age 27, he was hospitalized with what was thought to be rheumatic fever, which was followed by attacks of polyarthritis over the course of his life. The patient also suffered from attacks of iritis and glaucoma, which were treated with medications and applications of leeches. He also underwent multiple eye operations. Despite these efforts, his vision gradually deteriorated. In later life, he became blind in his right eye, with limited vision in his left eye. Eventually he could only write using crayons to form large letters, depending on friends to type his manuscripts. Additional health problems included severe dental caries, sciatica, and tonsillitis. Beginning in his twenties, the patient had several attacks of upper abdominal pain, sometimes lasting for a week or more. It was after a final attack that the patient died. Until this last event, his physicians never obtained abdominal x-rays, nor had they succeeded in establishing a definitive diagnosis for the abdominal condition.

Final Illness

His final illness began with "stomach cramps" after an evening meal washed down with copious amounts of white wine. The abdominal pain became so severe that at 4:00 AM the patient called a local physician who administered morphine. Later that day, a surgeon visited the patient and advised hospitalization. The next morning, abdominal x-rays were obtained, and approximately 30 hours after the initial onset of pain, the patient underwent an abdominal operation. For the first several postoperative hours, the patient seemed to be doing well, but he soon weakened. The dLay following surgery, he developed gastrointestinal bleeding and received 2 transfusions. Unfortunately, he soon lapsed into a coma and died on the second postoperative day.^[2] An autopsy was performed.

What is your diagnosis?

1. Intestinal obstruction
2. Ruptured peptic ulcer
3. Ruptured aortic aneurysm
4. Mallory-Weiss syndrome 

1st Surgical Meeting: A Step Onto The Surgical Ladder

I want to be a surgeon. Yes, I really do. I want to start my plans and be prepared for the path ahead of me. But, then again , I don't have a clue of the surgical training in Malaysia. MRCS ? Masters in Surgery ?  If I succeeded in being a surgeon , what would life be after that? 

Have you ever pondered upon the pathway to become a surgeon , how you should go about it , what are the requirements and how life as a surgeon is? 

Well , I do. I bet some of you do too! 

You are in luck ! 

IMU Surgical Society will be having our 1st Surgical Meeting on the 16th of June 2012, Saturday ! The main objectives of this Surgical Meeting is to clear your doubts and answer the inquiries that you have about Surgical Training in Malaysia and life as a surgeon. 

We have invited speakers to enlighten us on the path before us. There will also be clinical anatomy workshops. This will definitely be a treat! Also , for those who have excellent suture techniques , here's your chance to shine as a Suture Competition will be held ! 

It will be held in IMU Clinical School Seremban 9.00am - 5.00pm. 

Early bird registration fee : RM 20 ( before 31st May ) 

So what are you waiting for ?! Download the form and register quick !

You can download the Surgical Meeting details, program sheet and registration form from here :

Do check out and join our Facebook group and Facebook event page to keep up with the latest updates !
Cheers !

77 year-old Lady With Left Iliac Fossa Pain

Madam LGY,77 years old presented with left iliac fossa pain for the past 3 weeks radiating to the whole abdomen and constant. The pain has been there for the past 5 years but has increased in intensity in the past 3 weeks. She has tenesmus also for 3 weeks. She has altered bowel habits for the past 5 years where she passes 4-5times each day. There was no blood in the stools.She has associated dizziness and tiredness. She has loss of appetite and loss of weight and sleep is also disturbed.Patient was discharged while awaiting appointment for MRI.

On examination, the patient was comfortable and not in obvious pain.Her pulse rate was 52bpm and regular. There was pallor under her conjunctiva. On examination,her abdomen was distended but umbilicus was inverted. It was soft on palpation with slight guarding and tenderness at the left iliac fossa.

INVESTIGATION
Ultrasound:Bowel mass noted.
Colonoscope:Mass found at sigmoid colon,scope was unable to pass through.

FBC

RBC: 3.0X10¹² /L

Hb    :11g/dL

1. What are your differential diagnosis and provisional diagnosis?

2. How do we manage the patient ?

"Wait And See"

"Wait and See" Instead of Surgery an Option in Rectal Cancer

November 9, 2011 — Surgery is usually the preferred option for rectal cancer, but it can have a hugely detrimental effect on quality of life. Now there are data to suggest that for some patients with rectal cancer, a "wait-and-see" policy after chemoradiotherapy appears to be feasible and safe. A study published online November 7 in the Journal of Clinical Oncology shows that patients who achieve a clinical complete response after neoadjuvant chemoradiotherapy had outcomes similar to those who underwent surgery.

Of the 21 patients treated with neoadjuvant chemoradiotherapy, 20 remain alive, without disease, after a mean follow-up of 25 ± 19 months. One patient developed a small local recurrence without nodal recurrence after 22 months of follow-up. 

The control group consisted of 20 patients who achieved a pathologic complete response after chemoradiotherapy and a total mesorectal excision. Mean follow-up was 35 ± 23 months. In this group, 2 patients died — one from metastatic disease and the other from surgical complications associated with colostomy closure. None of the patients experienced a local recurrence. 

"A wait-and-see policy for clinical complete responses after chemoradiotherapy for rectal cancer with strict selection criteria and follow-up with up-to-date imaging techniques is feasible and safe," write the authors, led by Geerard L. Beets, MD, PhD, from Maastricht University Medical Center, the Netherlands. "Outcome is at least comparable with that of patients with a pathologic complete response after surgery." 

Impressive Results 

In an accompanying editorial, Joel E. Tepper, MD, and Bert H. O'Neil, MD, from the University of North Carolina Lineberger Comprehensive Cancer Center in Chapel Hill, note that although the follow-up in this study is short, "the results have been impressive, with only 1 local failure to date."

The wait-and-see patients did as well as those who underwent neoadjuvant therapy and who had a pathologic complete response after surgery, they note. "Importantly, this result was achieved with less toxicity and better short-term bowel function in the observed patients, compared with those who underwent surgical resection."

These early results support and enhance previous research, and "raise the possibility that this approach could be generalized to a larger portion of the patient population," the editorialists write. 

They caution that the wait-and-see approach is not one that can be easily evaluated in a randomized controlled trial; it is unlikely that sufficient numbers of patients would consent to being randomized to either surgery or no surgery. 

Well-designed prospective phase 2 studies might be the best way to advance this field, note Drs. Tepper and O'Neil. "This should not be considered a one-size-fits-all approach." 

Similar Survival Outcomes 

Previous research involving a wait-and-see policy demonstrated that patients with low rectal cancer who achieved a clinical complete response after chemoradiotherapy and did not have surgery had impressive results. Five-year overall survival was 93% and disease-free survival was 85% (Ann Surg. 2004;240:711-717; J Gastrointest Surg. 2006;10:1319-1328). 

However, the Dr. Beets and colleagues note that even though the previous results were encouraging, they were viewed with caution by physicians, because of the lack of a sufficiently accurate technique to identify patients with a clinical complete response. In addition, no other study replicated the findings. 

In their trial, Dr. Beets and colleagues hypothesized that for patients without residual tumor on imaging and endoscopy — a clinical complete response — a wait-and-see policy might be considered instead of surgery. 

Of the 21 patients in the wait-and-see cohort, 14 (67%) were male; mean age at diagnosis was 65 years. The authors note that patients who experienced a clinical complete response had a strong preference for the wait-and-see policy over resection, primarily because it offered the possibility of avoiding major surgery or a permanent colostomy. 

In the control group, 9 patients required a definitive colostomy and 11 required a temporary colostomy. Half of the patients experienced no complications after surgery, but 7 patients had major complications, including anastomotic leakage, intraabdominal abscess, and respiratory failure. 

In the wait-and-see group, the cumulative probability for 2-year disease-free survival was 89% (95% confidence interval [CI], 43% to 98%), and the cumulative probability for 2-year overall survival was 100%.

In the control group, the cumulative probability for 2-year disease-free survival was 93% (95% CI, 59% to 99%) and for overall survival was 91% (95% CI, 59% to 99%). The differences were not significantly different between the 2 study groups. 

The authors note that there are several limitations to the study, including the fact that the sample size is small and follow-up short. 

The authors and editorialists have disclosed no relevant financial relationships. 

Source : 

J Clin Oncol. Published online November 7, 2011.

http://www.medscape.com/viewarticle/753204 

Case Based Discussion 001

Hey friends ! This is it ! Our first Case-Based Discussion will be held on the 10th of May , next Thursday ! Here's the case we will be discussing . 

Remember to prepare yourselves and read up before coming ! It will definitely benefit you in many ways . You can know more about CBD from here.

Do approach any of the committee members if you have any inquiries about the case-based discussion .

Sem 9 rep : Goh Chon Han Robin gch_1988@hotmail.com 010-2215270 
Sem 8 rep : Koh Pei Fern kohpeifern@yahoo.com 012-3872812
Sem 7 rep : Lee Wei Rong e.alvin_wrlee@hotmail.com 017-5557125

See you all there ! Cheers !

Evolution of Surgery

Interested in surgery? 

Have you ever wondered how surgery has evolved over the centuries . 

This is a fascinating video clip by Catherine Mohr ( Surgeon and Inventor ) , revealing to us the history of surgery , its present state and robotic future .