Amyand's hernia in neonate: a case report

Amyand's hernia is a condition in which vermiform appendix present in the inguinal hernia sac. It is a rare entity, even so in children and neonates. The presentation is often similar like obstructed or strangulated inguinal hernia in which patient came in with tender, often irreducible inguinal swelling. Pre-operative diagnosis is usually difficult and in majority of patients, the correct diagnosis is only made intra-operatively. The difficult pre-operative diagnosis, however, does not affect the management in most cases as the affected patients are usually posted for emergency hernia repair immediately after presentation. We are presenting a case of an Amyand's hernia that occured in a neonate who presented on day 8 of life with sudden onset of right sided inguinal swelling. He was brought in early by the parents and posted urgently for surgery. Intra-operative finding revealed Amyand hernia with gangrenous appendix which was subjected to herniotomy and appendicectomy

MyPaedSurg: a review of burden and short-term outcome of congenital gastrointestinal surgical conditions in Malaysia

Many congenital anomalies involving gastrointestinal tract which were once considered fatal are now surgically correctable due to advances in perioperative care. However, scarce data are available on outcomes of paediatric surgical care in our setting. Aim: To analyse the burden and short-term outcome of key indicator congenital gastrointestinal anomalies across different regions in Malaysia. Methods: Using the reference study protocol by the Global PaedSurg study group, we conducted a multicentre, 30-day prospective cohort study for children presenting for the first time with any of these conditions i.e. oesophageal atresia (OA), congenital diaphragmatic hernia (CDH), intestinal atresia, gastroschisis, exomphalos, anorectal malformation (ARM) and Hirschsprung’s disease during a consecutive six-months period between October 2021 until April 2022. All 14 public hospitals in Malaysia with specialist paediatric surgery services as of October 2021 were involved and analysed according to regions: the Northern, Central, East Coast and South of Peninsular Malaysia and East Malaysia. Results: 228 patients with 242 study conditions were included in the final analysis. Data were obtained from 14 paediatric surgery centres from 11 states with variable level of experience of the paediatric surgeons. 31.5% of patients contributed by the central region of Malaysia. Antenatal diagnosis were made in 20.6% of patients. 16.2% of patients presented with sepsis while 11.4% and 7.0% presented with hypovolemia and hypothermia respectively. Interventions were carried out in 91.7% of patients. We reported an overall mortality rate of 8.3% with the largest proportion contributed by patients with CDH. Respiratory failure is the leading cause of death with overall rate of 42.9% from all mortalities. Interestingly, no mortality was reported from the East Malaysia i.e. Sabah and Sarawak. Conclusion: Our result showed that overall mortality rate in Malaysia is lower than reported by the Global PaedSurg group for middle income countries at 20.4% while morbidity rate varies

Late-presenting congenital diaphragmatic hernia with tension gastrothorax: a case series

Introduction: Congenital diaphragmatic hernia (CDH) is commonly diagnosed during neonatal period, however they may be detected at a later age with various clinical manifestation. We share 3 cases of tension gastrothorax as a manifestation of late-onset CDH. Case summary: Case 1: A 10-month-old boy presented with worsening respiratory distress requiring intubation. Chest radiograph revealed a huge lucency in the left hemithorax with mediastinal shift which improved after nasogastric tube insertion. CT thorax confirmed the diagnosis of left CDH. Laparotomy revealed 5x6 cm posterolateral defect was seen, content completely reduced and the defect was primarily repaired. Case 2: A 22-month-old baby boy presented with rapid breathing with reduced air entry on the left side. Chest radiograph revealed a lucent left hemithorax causing mediastinal shift. Patient was misdiagnosed as tension pneumothorax and tube thoracostomy was performed in emergency department. CT thorax confirmed presence of CDH and surgical referral was made for primary repair. No stomach injury due to chest tube insertion was seen. Case 3: A 12-month-old boy presented with abdominal pain and intractable crying. Chest X-ray suggestive of CDH. Ultrasound assessment showed a suspicion of left CDH with gastric volvulus. Hence, emergency laparotomy was performed . Content was reduced completely and healthy. Primary repair was performed. Conclusion: Late-onset CDH with a tension gastrothorax must be recognised and managed promptly to relief the mediastinal shift. Misdiagnosis of a tension pneumothorax poses a risk of stomach perforation following tube thoracotomy. Suspicion of gastric volvulus otherwise requires an urgent exploration

Amyand’s hernia complicated with perforated appendicitis in neonates: a case report

Introduction: Inguinal hernia (IH) is a common condition encountered in premature neonates. Amyand’s hernia (AH) is an uncommon form of IH in which the hernia sac contains appendix. Surgical repair of AH is similar to usual IH, however if it contains a perforated and inflammed appendix, the diagnosis and repair can be challenging. Case summary: A premature baby boy was referred to surgical team for a diagnosis of incarcerated right IH. In view of no obstructive symptoms, he was sent to our out-patient clinic. Upon clinic review irreducible right inguinal hernia was seen clinically with erythematous scrotum and tender. Urgent ultrasound confirmed the diagnosis of IH containing mesentry and bowel. He was brought to theatre urgently concerning bowel compromised. Intra-operatively, a IH was found. However, the appendix was enlarged with evidence of perforation at its tip with surrounding pus collection. Appendicectomy was performed via the same incision followed with herniotomy. He recovered well post-operatively and discharged after three days. Conclusion: Incarcerated IH in neonates without symptoms of intestinal obstruction should raise a suspicion of AH. The presence of inflammation should prompt the possibility of appendicitis or even perforated appendicitis as reported in this case

Cavectomy following thrombectomy for Wilms’ Tumour with intracaval tumour thrombus: a case report and literature review

Introduction: Wilms’t tumour is the commonest renal tumour in children. With a predisposition of forming tumour thrombus in blood vessels, tumour extension into renal veins and inferior vena cava (IVC) has been reported in up to 10% of cases. Neoadjuvant chemotherapy has been shown to promote intracaval tumour regression, however in cases of persistent thrombus, thrombectomy is required along with the radical nephrectomy via cavotomy. We shared a rare complication of thrombectomy which required a cavectomy. Case Summary: A 7-year-old girl was diagnosed with right Wilms’ tumour with tumour extension into IVC. After three courses of neoadjuvant chemotherapy, she developed duodenal obstruction caused by the tumour and the repeat imaging showed non-regression of the intracaval tumour thrombus. She underwent right radical nephrectomy with thrombectomy. However, Doppler assessment after the surgery revealed the IVC was filled with clots which persisted despite the administration of anticoagulant. With the concern of pulmonary embolism, she was subjected to another surgery to remove the clots. Intraoperatively, the IVC was found completely blocked at the level of intrahepatic IVC, thus decision was made for cavectomy without reconstruction. Post-operative recovery was uneventful. She was continued on chemotherapy and radiotherapy. Up until 18 months after surgery at the time of report, she remains well with no evidence of venous congestion and disease recurrent. Conclusion: Surgical excision of Wilms’ tumour with intravascular invasion is challenging. IVC wall injury following thrombectomy may end up with cavectomy. Cavectomy in children is otherwise safe and no major sequelae has been reported

The study on range of motion of hip and knee in prayer by adult Muslim males. A preliminary report

Introduction: Praying represents a fundamental activity of daily living in Muslim community. Muslims need to adopt several postures that require deep flexion of the knee and hip to perform this daily obligation. This is a preliminary report of the study on hip and knee range of motion conducted to obtain normative passive and functional range of flexion data during Muslim prayers in both weight-bearing joints of normal Muslim adults. Methods: A cohort of Malay men aged between 20 to 30 years was recruited in this cross-sectional study. Passive range of motion and flexion angles of the joints in various postures during prayer were measured using a standard goniometer. The difference against existing normative range of motion database available and the influence of various factors were analysed. Factors analysed include body mass index and other anthropometric measurements. Results: Sixty participants recruited for the preliminary phase of this study. The mean (SD) of passive hip and knee flexions were higher compared to other existing normative range of motion database. A unit increase in body mass index will have 0.782 units lower of knee range of motion. The hip and knee flexion arc were from 74.1° to 119.0° and from 3.3° to 119.7° respectively. Conclusion: The range of motion involved for prayers was more for the knee but less for the hip as compared to the measured passive range of motion. Body mass index has a significant linear negative relationship with the passive range of motion of the knee, but not the hip

SARS-CoV-2 infection and venous thromboembolism after surgery: an international prospective cohort study

SARS-CoV-2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri-operative or prior SARS-CoV-2 were at further increased risk of venous thromboembolism. We conducted a planned sub-study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS-CoV-2 diagnosis was defined as peri-operative (7 days before to 30 days after surgery); recent (1–6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre-operative anti-coagulation for baseline comorbidities was not available. Postoperative venous thromboembolism rate was 0.5% (666/123,591) in patients without SARS-CoV-2; 2.2% (50/2317) in patients with peri-operative SARS- CoV-2; 1.6% (15/953) in patients with recent SARS-CoV-2; and 1.0% (11/1148) in patients with previous SARS- CoV-2. After adjustment for confounding factors, patients with peri-operative (adjusted odds ratio 1.5 (95%CI 1.1–2.0)) and recent SARS-CoV-2 (1.9 (95%CI 1.2–3.3)) remained at higher risk of venous thromboembolism, with a borderline finding in previous SARS-CoV-2 (1.7 (95%CI 0.9–3.0)). Overall, venous thromboembolism was independently associated with 30-day mortality (5.4 (95%CI 4.3–6.7)). In patients with SARS-CoV-2, mortality without venous thromboembolism was 7.4% (319/4342) and with venous thromboembolism was 40.8% (31/76). Patients undergoing surgery with peri-operative or recent SARS-CoV-2 appear to be at increased risk of postoperative venous thromboembolism compared with patients with no history of SARS-CoV-2 infection. Optimal venous thromboembolism prophylaxis and treatment are unknown in this cohort of patients, and these data should be interpreted accordingly

SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18–49, 50–69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population

Blue toe syndrome: a rare presentation of atrial myxoma

Blue toe syndrome is a condition in which patient presented with cyanotic toe caused by fibrino-platelet micro-emboli occlusion of the small digital arteries while atrial myxoma is the most common primary cardiac tumour. Most patients with atrial myxoma present with emboli to blood vessel of the brain causing ischaemic stroke. We report a case of a 37 year old gentleman who presented with blue toe syndrome affecting right second and fourth toes without any symptoms and signs of cardiac insufficiency or other embolus elsewhere. Further investigation and echocardiography revealed a mass over the left atrium that lead to the provisional diagnosis of atrial myxoma. He underwent excision of the left atrial myxoma with repair of interatrial septum within the same admission. Surgery was uneventful and he was discharged home well

Total colorectal duplication in an infant presenting with fecaluria as the initial symptom

An 11-month old boy presented with 2 months history of progressive abdominal distension. The current presentation was preceded by an initial presentation of fecaluria during the neonatal period. Digital rectal examination revealed a firm mass anterior to the rectum. Computed tomography (CT) of the abdomen and pelvis showed a long tubular structure adjacent to the native colon and rectum filled with fecal material. He underwent fenestration of the tubular colorectal duplication and recovered well. We report a case of duplicated colon and rectum with a unique initial presentation of fecaluria during the neonatal period