Reply on comments on ‘a lesson to learn in an Iatrogenic Perforation of Sigmoid Volvulus after Endoscopic Derotation’

Acute sigmoid volvulus is a surgical emergency, in which the initial treatment is endoscopic derotation in uncomplicated cases. Flatus tube dislodge is one of the common condition after endoscopic intervention. By performing a technique against the term of reference, management of a patient can skew towards a guarded outcome. I reply to comments on a paper concerning on iatrogenic bowel perforation after a successful endoscopic derotation of acute sigmoid volvulus

An Observation on the Effect of Semi-Elemental Oral Nutritional Supplements on the Reduction of Small Bowel Ostomy Output

Semi-elemental oral nutritional supplements are also referred to the oligomeric, hydrolysed or peptide formula, the nitrogen source of the formulas derived from hydrolyzed oligopeptide of shorter lengths such as the dipeptides and tripeptides. The ingredient of casein and lactaalbumin hydrolysates in this formula are believed to be capable of stimulating the jejunal absorption of water and electrolytes. The postulated stimulation of improves absorption increased our curiosity on its effect on those patient with high output ostomy. We understand that this formula is more costly compared to the other polymeric formula available in the market. We would like to share an observation of two ostomies output that are managed conservatively along with the supplementation of a semi-elemental formula. We retrospectively review the case notes of two patients with small bowel ostomies and graphs were plotted to demonstrate the relationship between the output and the intake of the semi-elemental formula. We observed an interesting pattern of the ostomy output in relationship to intake volume. The ostomy output decreases as the patients increase the intake of the semi-elemental formula. From our observation, we concluded that semi-elemental formula improved clinical nutrition outcome and also quality of life in terms of stoma output reduction, making the stoma care more manageable. However, we hope that through our observation case studies, we would encourage more researchers to conduct a larger prospective and clinical study to explore the true clinical effects and also cost-effectiveness of this formula

Rectal Foreign Bodies: Sexual Gratification Turned Misery

Receiving referrals for a retained foreign body in the lower gastrointestinal tract is not something rare these days. Foreign body insertion can be classified as voluntary or involuntary which might present to the emergency department for assistance with removal. We describe a 25-year-old lady with abdominal pain and per-rectal bleeding after a retained foreign body in the rectum. She denied any peculiar activities but confessed after pelvic radiograph suggested a foreign body likely represents a self-inserted material in the rectum. Patients may present with a wide variety of symptoms but typically the history will be misleading fearing of prejudice and discrimination from the mainstream treatment. We highlight our surgical intervention and its literature review

Breast Cancer with Isolated Metastatic Temporomandibular Joint: A Surgeon’s Challenge

Breast cancer is the number one malignancy in women worldwide. It tends to metastasize distantly via lymphatic and haematogenous route. Skeletal metastases are frequent with more than three quarter of cases in all malignant bone tumours. Breast cancer can infiltrate the axial bone especially spine, but rarely affect the temporomandibular joint. In view of its rarity and the significance of early detection, the diagnosis is always challenging and shall be considered in the differential diagnosis. We endeavour to highlight this unfortunate 37-year-old lady who had just undergone left mastectomy and axillary dissection but was complicated with left temporomandibular joint metastasis

Vanek’s tumor causing ileoileal intussusception in a middle-aged man

Intestinal obstruction is a common surgical emergency requiring urgent intervention. Small bowel obstruction secondary to intussusception is rarely encountered especially when inf lammatory fibroid polyp (IFP) is the lead point. A 41-year-old gentleman with intestinal intussusception secondary to IFP presented to us with a classic symptom of intestinal obstruction. Computed tomography revealed a target or sausage-shaped soft tissue mass with a layering effect, which was confirmed by intraoperative findings. Histopathology was consistent with IFP and supported by immunoreactivity of CD34 and negative immunostaining for CD117. He recovered without any surgical complication or recurrence. Even intussusception can be managed via non-surgical technique in children; surgery is the mainstay of treatment in adults

Perforated Gastric Ulcer Masquerading as Anterior Abdominal Wall Necrotizing Fasciitis

Necrotizing fasciitis (NF) is a deadly soft tissue infection causing a significant morbidity and mortality. Abdominal and chest wall NF are unusual. We describe a 49-year-old male with anterior abdominal wall NF secondary to perforated gastric ulcer (PGU). He was admitted in septic shock presenting an abdominal wall NF with severe metabolic acidosis requiring dialysis and admission to the intensive care unit. There was a patch of gangrene with surrounding skin discoloration at lower quadrant of the abdominal wall. Local debridement was done without a preoperative computed tomography that was performed after surgery. Adequate source control was not achieved after the second surgery and the patient had worsened resulting to death. We describe this rare presentation of NF and discuss the issues learnt from this unfortunate event

Wandering Spleen as a Cause of Acute Abdomen: A Surgical Conundrum from Acute Appendicitis to Splenic Torsion and Ischemic Small Bowel Volvulus

Wandering spleen is renowned as a surgical enigma due to its diverse presentations. Due to lack of its attaching ligaments which would usually place it at the left hypochondrium region, the spleen ‘wanders’ and may be located anywhere within the abdominal cavity. This condition has been associated with many complications such as splenic torsion, pancreatitis and portal hypertension. We report a case of a wandering spleen presenting as acute appendicitis in an 18-year-old young active sportsman. The patient developed post-operative ileus and later intestinal obstruction which necessitated exploratory laparatomy onto which the final diagnosis of splenic and small bowel infarct due to splenic torsion with small bowel volvulus was made. Splenectomy, small bowel resection and primary anastomosis were performed and the patient made a full recovery

A Diagnostic Conundrum in a Localized Ascending Aortic Aneurysm

Aortic dissection (AD) is an uncommon life-threatening emergency. Its development is usually subtle and easily missed. On the other hand, an aneurysm nearly always requires immediate surgical intervention. Both interventions are technically different and pose their own challenges. We experienced a distinct case of AD of the ascending aorta in a 65-year-old lady, who presented with a sudden onset of severe chest pain and shortness of breath. Thoracic aortic aneurysm was suspected as computed tomography revealed a saccular aneurysm of the proximal ascending aorta with no involvement of the valve and aortic branches. Surgery was decided after considering the risk of rupture and mortality. However, a diagnosis of localized aortic dissection was discovered and repaired accordingly. We discuss the pitfalls of diagnostic modalities and the techniques of surgical repair

Brain Metastasis from Breast Cancer in a Male Patient

Male breast cancer is a rare disease and has contributed to <1% of all cancers in the male population. Delay in diagnosis is common, due to its rarity and lack of awareness of the disease among the male patient and physicians. Most cases were detected at an advanced stage and up to 30% of them were diagnosed with metastasis on the initial presentation. The authors presented a case of a 60-yearold man who presented with seizure and right hemiparesis. In addition, he also has left breast mass for one year. Computed tomography of the brain showed a left frontal intra-axial brain lesion and biopsy of the breast lesion confirmed triple-negative invasive breast cancer. He was planned for whole-brain radiotherapy, however, he succumbed prior to the treatment

Intestinal knot in acute Meckel’s diverticulitis

A 47-year-old man, with no past surgical history presented to the emergency department with colicky abdominal pain since 2 days prior to the admission. It was associated with abdominal distension, vomiting and no bowel output. The pain became worsened which resulted in his immediate hospital visit. On examination, the abdomen was peritonitic. The blood investigations showed marked leucocytosis. There were signs of small blood obstruction on abdominal radiograph but no free gas on erect chest radiograph. He was immediately rushed to the emergency operation theatre and exploratory laparotomy was performed. Upon entry, there was gangrenous small bowel caused by an ileo-ileal knot with Meckel’s diverticulitis, which was adjacent to the caecum. We had to proceed with limited right hemicolectomy and functional end-to-end anastomosis using linear stapler. The recovery process was uneventful. Patient was discharged home after a week. On follow-up at 3 months, he was well with no complications. The histopathological examination was consistent with ischaemic bowel