Gastrointestinal bleeding caused by epitheloid sarcoma: a case report

Epithelioid sarcoma (ES) of the small bowel is a rare gastrointestinal tumour. We report a case of gastrointestinal bleeding secondary to small bowel ES in a 55-year-old gentleman. After gastroscopy and colonoscopy failed to identify the source of bleeding, we proceeded with computed tomography angiogram of the mesentery, which revealed intraluminal blood clot in the distal jejunum with features of obstruction. This is a rare cause of obscure gastrointestinal bleeding and emphasises the need for additional evaluation in the presence of negative endoscopic findings

Idiopathic duodenal varix presenting as a massive upper gastrointestinal bleeding: a case report

Ectopic variceal bleeding is both a diagnostic dilemma and a therapeutic challenge, especially when it is located in the third part of the duodenum. Varix is rare in the absence of cirrhosis or portal hypertension. Because the diagnosis of this condition is usually delayed, treatment is administered late resulting in high morbidity and mortality rate. We report a case of a 61-year-old lady with an idiopathic duodenal varix presenting as an upper gastrointestinal bleeding

Combined laparoscopic and thoracoscopic repair of a large traumatic diaphragmatic hernia: a case report

Traumatic diaphragmatic hernia is a well known complication of blunt trauma to the abdomen and thorax. In the acute setting, laparotomy is mandatory. In this current era, this condition can be managed with minimally invasive surgery. We hereby report a case of delayed large left diaphragmatic hernia that was repaired with a combination of laparoscopic and thoracoscopic approach

Healing of venous ulcers secondary to an ankle arteriovenous fistula

Venous ulcer as a complication of ankle arteriovenous fistula for hemodialysis is rarely reported. It poses a challenge between ulcer healing and fistula preservation. We report our experience in the management of venous ulcers secondary to an ankle arteriovenous fistula in a hemodialysis patient

Axillary accessory breast carcinoma masquerading as axillary abscess: a case report

Accessory breast is a frequently seen developmental breast abnormality, commoner among Asians than Caucasians. This ectopic breast tissue shares many similarities as the normal breast tissue, and although subjected to the same pathological processes, accessory breast carcinoma is rare. As locations of the accessory breast may be variable, detection of pathological lesions through clinical examinations and standard diagnostic tools (i.e., mammogram) can be difficult. Staging and management should be tailored-made according to the location of the accessory breast as well as its known pattern of lymphatic drainage. We report a case of an intra-ductal carcinoma occurring in an axillary accessory breast

Axillary accessory breast carcinoma masquerading as axillary abscess: a case report

Accessory breast is a frequently seen developmental breast abnormality, commoner among Asians than Caucasians. This ectopic breast tissue shares many similarities as the normal breast tissue, and although subjected to the same pathological processes, accessory breast carcinoma is rare. As locations of the accessory breast may be variable, detection of pathological lesions through clinical examinations and standard diagnostic tools (i.e., mammogram) can be difficult. Staging and management should be tailored-made according to the location of the accessory breast as well as its known pattern of lymphatic drainage. We report a case of an intra-ductal carcinoma occurring in an axillary accessory breast

Ano-coccygeal support in the treatment of idiopathic chronic posterior anal fissure: a prospective non-randomised controlled pilot trial

Background: Idiopathic chronic anal fissure is believed to be a consequence of a traumatic acute anodermal tear followed by recurrent inflammation and poor healing due to relative tissue ischaemia secondary to internal sphincter spasm. This pilot trial compared the efficacy of a novel manufactured ano-coccygeal support attached to a standard toilet seat (Colorec) to the standard procedure of lateral internal sphincterotomy (LIS) for chronic anal fissure. Methods: Fifty-three patients with confirmed chronic anal fissures were enrolled and assigned, based on their preference, to the test group and the control group. Each patient was reviewed after therapy, and follow-up was scheduled at 4, 6 and 8 weeks and at 6 months. Results: The fissure healing rate was 100 % in both groups. There were no statistically significant differences between the test group (n = 30, median age 42 years; range 20–71 years) and the control group (n = 22, median age 38 years; range 23–60 years) with regards to resolution of rectal bleeding at defaecation after 4 weeks (86.6 vs 72.7 %, p = 0.698), and by week 6, bleeding had resolved in 100 % of patients in both groups. There was no statistically significant difference between the test group and the control group with regards to pain scores at 4, 6 and 8 weeks (4.30 ± 0.79, 2.03 ± 0.80, 0.43 ± 0.50 vs 3.50 ± 0.74, 1.68 ± 0.56, 0.50 ± 0.51, p = 0.054) and to time until complete healing of fissures (5.60 ± 1.52 weeks vs 5.91 ± 1.57 weeks, p = 0.479). After continuous use of the ano-coccygeal support over 6 months, no patients in the test group had recurrent fissures. No complications were observed during the trial. Conclusions: Results of both methods were comparable and demonstrated that the ano-coccygeal support is at least as effective as LIS, without any short-term complications. Larger and randomised trials on the use of ano-coccygeal support for chronic anal fissures are awaited

Update on the management of peripheral arterial disease (PAD)

There has been much progress made in the management of peripheral arterial disease (PAD) in the past two decades. Progress in the understanding of the endothelial-platelet interaction during health and disease state have resulted in better antiplatelet drugs that can prevent platelet aggregation, activation and thrombosis during angioplasty and stenting. Collaborative effort by different international societies has resulted in a consensus guideline that recommends the modality of intervention in certain disease states. Progress in perioperative care has reduced the morbidity and mortality associated with peripheral vascular reconstruction surgery. Nevertheless, the advances in percutaneous peripheral intervention (PPI) have made a paradigm shift in the current management of patients. The procedure is safe and effective and is emerging as the first choice revascularization procedure

Efficacy of low residue enteral formula versus clear liquid diet during bowel preparation for colonoscopy: a randomised controlled pilot trial

Objectives: Conventional bowel preparation for colonoscopy confines patient to clear liquid diet the day before and such non-nutritive dietary regimen often caused discomfort and hunger. The purpose of this study is to determine the feasibility of feeding patient with low-residue, lactose-free semi-elemental enteral formula (PEPTAMEN®) compare to conventional clear liquid diet during bowel preparation before colonoscopy. Methods: This was a randomised, endoscopist-blinded study. Patients were randomised into two groups, those receiving oral PEPTAMEN® and mechanical bowel preparation (A) and those receiving clear liquid while undergoing mechanical bowel preparation (B). Documentation was made with regard to the type of bowel cleansing agents used, completeness of the colonoscopy, cleanliness quality score, and hunger score. Results: A total of 97 patients were included in the study, A=48 and B=49. Eight patients, who were not compliant to the bowel-cleansing agent or had an incomplete colonoscopic examination, were excluded from the study. In terms of the overall cleanliness score, no statistical significant difference was seen (p=0.25) between the two groups, A (fair or poor 37.5%, good or excellent 62.5%) and B (fair or poor 49%, good or excellent 51%) whereas the hunger score showed a significant difference (p=0.016), A (no hunger 41.7%, slight hunger 12.5%, hungry 12.5%) and B (no hunger 24.5%, slight hunger 38.8%, hungry 36.7%). Conclusions: These data suggest that the addition of oral PEPTAMEN® as part of the bowel preparation regimen did not significantly alter the luminal cleanliness score during colonoscopy while alleviating hunger

Combined Laparoscopic and Thoracoscopic Repair of A Large Traumatic Diaphragmatic Hernia: A Case Report

SUMMARY Traumatic diaphragmatic hernia is a well known complication of blunt trauma to the abdomen and thorax. In the acute setting, laparotomy is mandatory. In this current era, this condition can be managed with minimally invasive surgery. We hereby report a case of delayed large left diaphragmatic hernia that was repaired with a combination of laparoscopic and thoracoscopic approach. KEY WORDS: Diaphragmatic hernia, laparoscopic, thoracoscopic, trauma INTRODUCTION Mechanisms of traumatic diaphragmatic hernia have been well described after blunt injury to the chest and abdominal cavity. Diaphragmatic ruptures can occur from 0.8% to 7.0% of blunt abdominal trauma, with left hemi diaphragm involvement the commonest; a ratio of 9:1. 1, 2 Conventionally, laparotomy is indicated in all patients with other associated injuries in the acute setting. However, when the diagnosis is missed during early post trauma period, thoracotomy and repair were recommended. In this present era of minimally invasive surgery, laparoscopy is a useful means to treat diaphragmatic rupture even during the acute phase. 1, 2 Here, we report a case with a delayed large left diaphragmatic hernia that was repaired with a combination of laparoscopy and thoracoscopic approach. CASE REPORT A 30 year old gentleman presented to the emergency department with sudden onset breathlessness on exertion. He had a history of left rib fracture due to motor vehicle accident four years ago, but otherwise asymptomatic prior to current complaint. On examination, the left chest had reduced breath sounds and his abdomen was scaphoid but non tender. Plain chest x-ray showed loops of bowel in the left thorax. Computerized tomography of the thorax and abdomen revealed large left diaphragmatic hernia with bowel occupying almost all the left thorax (figure 1). Elective laparoscopic and thoracoscopic repair of incarcerated diaphragmatic hernia with mesh was performed. He was put in supine position with slightly left sided up. Five trocars were placed; 1x12mm (camera port at infra umbilicus) and 4x5mm (two ports at right upper quadrant, one port at left 4th intercostal space anterior axillary line and another port at the lateral aspect of left upper quadrant). The omentum, small bowel and transverse colon were found densely adhered into the left hemithorax through the left anterolateral diaphragmatic hernia that measured 10x5 cm (figure 2). A combination of blunt and sharp dissection was used to reduce the hernia content to the abdominal cavity. Thoracoscopic approach was used to release the dense adhesion at the upper lobe of the lung to the left lateral thoracic wall. Upon reduction, the hernia defect was then closed with ethibon 2/0. Before placing the mesh, the anaesthetist increased the tidal volume to expand the collapsed left lower lobe of the lung and a chest drain size 28F was placed in the left pleural space. Composite mesh 10x15cm was reinforced with secure strap tackers. Portex drain size 27F was placed at left sub diaphragmatic space. The patient was then transferred to the intensive care unit (ICU) postoperatively. He was extubated on day one in ICU and on postoperative day two, he was transferred out to the general ward. Chest x-ray immediate post-operative showed expansion of the left lung with minimal pleural effusion. He was discharged on post-operative day six. He recovered well and during clinic follow up to six months, there was no evidence of recurrence or infection. DISCUSSION Chronic traumatic diaphragmatic hernia is conventionally repaired using the thoracotomy approach, reduction of intraabdominal content and closure of the defect primarily. Where else in acute cases, a laparotomy is performed to reduce and repair the diaphragmatic hernia defect. In 1976, thoracoscopy was used to evaluate diaphragmatic injuries. Laparoscopy was used in a case series of suspected diaphragmatic injury in 1984