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Trocar site incisional hernia (TSIH) is an unpleasant complication of laparoscopic surgery. A 70-year-old male with low rectal carcinoma underwent a laparoscopic abdominoperineal resection after completion of neoadjuvant radiotherapy. The postoperative recovery was smooth; however, he developed abdominal distension and pain over the previous drain site after removal on day 3. In view of diagnostic ambiguity, an imaging tool was requested as an adjunct to further management. Computed tomography of the abdomen showed small bowel obstruction secondary to herniated ileal loops passing through the right iliac fossa anterior abdominal wall defect at the previous drainage site. An exploration was made and the rectus defect was closed using a non-absorbable suture.

Introduction and importance The differential diagnosis of a paediatric abdominal mass can be extensive, as it potentially involves multiple organs including gastrointestinal, genitourinary, endocrine, and gynaecological systems. Hence, a systematic approach to history taking and physical examination is needed to clinch the diagnosis. Specifically, the approach for assessing, investigating, and managing a ballotable left hypochondrial mass in a child can be challenging. Case presentation We report a 10-year-old Dusun girl presenting with left hypochondrial pain and noted a left hypochondrial mass on examination. This report highlights the role of clinical imaging during the pre-operative and post-operative phases. Clinical discussion Ultrasound and CT imaging was useful in determining that the tumor originated from the tail of the pancreas. The presence of a definite capsule with internal solid-cystic components helped narrowed the differential diagnosis to solid pseudopapillary neoplasm (SPN) of the pancreas. MR liver was useful to rule out liver metastasis in this child. Intervention and outcome The patient was scheduled for laparotomy and tumour excision at a regional paediatric centre. Successful excision of the tumor en-mass was performed and the child's subsequent recovery was uneventful. Conclusion Clinical imaging plays a critical role in the diagnosis and management of paediatric solid organ tumours. Other than renal origin, suspicion of pancreatic tail origin should be considered by clinicians when encountering a ballotable left abdominal mass., Highlights • A mass arising from the pancreatic tail can present as a ballotable mass. • Imaging findings for solid pseudopapillary neoplasm and differentials are presented. • The role of imaging in the management of solid pseudopapillary neoplasm is discussed.

Background Tuberculosis (TB) is classified according to the site of disease as pulmonary or extrapulmonary. Extrapulmonary TB is less common than its counterpart in which it can be found anywhere in the body including the liver. Similar to ampullary carcinoma, TB liver can manifest with jaundice and deranged liver function tests, particularly in the obstructed biliary systems. Case presentation A 43-year-old gentleman with locally advanced ampullary carcinoma was noticed to have multiple suspicious liver nodules intraoperatively during curative ampulla resection. The surgery was then abandoned after a biopsy. The histology was consistent with chronic granulomatous inflammation. He was then subjected to a Whipple pancreaticoduodenectomy procedure after initiation of anti-tubercular treatment. He recovered well with no evidence of tumour recurrence and worsening TB. Conclusions A high index of suspicion and quick decision making can help to diagnose a possible extrapulmonary TB masquerading as a malignant disease in a patient with curative intention of ampullary carcinoma.

Traumatic abdominal wall hernia (TAWH) is a rare type of hernia resulting from blunt abdominal trauma. It develops following the inertia of sudden, high-energy blunt trauma or focused low-energy impact. A 22-year-old motorcyclist presented to the emergency department following a collision with an automobile. Clinical examination demonstrated a bulging mass at the lower abdomen, resulting from impact with the motorcycle handlebar. A contrast-enhanced CT scan of the abdomen revealed a disruption of both rectus abdominis muscle and linea alba at the lower abdomen with loops of small bowels and mesentery herniating through the defect, associated with multiple air pockets and pneumoperitoneum. Exploratory laparotomy showed TAWH containing loops of small bowel and mesentery in addition to mesenteric tears. Small bowel resection with primary anastomosis and repair of the anterior abdominal wall defect using interrupted polypropylene sutures was performed. The patient recovered well postoperatively and was discharged home three days later. A follow-up at 1 year showed no evidence of recurrence.

A colo‐appendico‐duodenal fistula is a rare occurrence that results from extrapulmonary tuberculosis (TB) complications, especially in the endemic region.

Vitiligo is one of the dermatomes affecting the melanocytes resulting in their destruction and subsequent patchy depigmentation of the skin. It is postulated to occur due to an autoimmune problem. Despite being a disease with limited systemic involvement and lack of mortality, it has a severe psychological impact. It may have a powerfully negative effect on a patient's quality of life. The relationship between vitiligo and pregnancy is not widely acknowledged. It may be associated with adverse pregnancy outcomes such as recurrent miscarriage, prematurity, intrauterine growth retardation and pre-eclampsia. Herein, this review describes the disease's adverse effects on pregnancy outcomes and the influence of pregnancy itself on the clinical evolution and prognosis of vitiligo., Highlights • Vitiligo may be associated with adverse pregnancy outcomes such as recurrent miscarriage, prematurity and pre-eclampsia. • In this review, a comprehensive literature search has been taken to outline the disease’s adverse effects on pregnancy. • This review also includes a literature search on the effects of pregnancy on the clinical progress of vitiligo.

Background Adult intussusception is a relatively rare clinical entity. The majority of cases of intussusception in adults are due to a pathologic condition that serves as a lead point and requires surgery. Small bowel intussusception is usually caused by benign or malignant neoplasms appearing at the head of the invagination. Inflammatory fibroid polyp (IFP) of the small bowel is an unusual benign neoplastic lesion that has been rarely reported to cause intussusception, especially in the jejunum. Case presentation We present a rare case of adult intussusception who presented with a triad of intestinal obstruction. Computed tomography revealed small bowel intussusception with bowel ischemia. Intraoperatively, she required resection of the small bowel and primary anastomosis. Macroscopic examination revealed a single pedunculated polyp, which is the lead point of intestinal obstruction and confirmed histologically. Conclusion Inflammatory fibroid polyp should be considered as a cause of intussusception among adults with small bowel obstruction., Highlights • IFP must be considered among adults with small bowel intussusception. • Surgery is the mainstay of treatment in obstructed small bowel intussusception. • Histological examination with immunohistochemistry is warranted to establish the final diagnosis.

Introduction Adrenal myelolipoma is a rare, non-functional, benign neoplasm which is constituted of mature haematopoietic elements and adipose tissues in various proportions. It is diagnosed accidentally and frequently with the widespread use of imaging modalities. Presentation of case We report a 63-year-old lady with incidental findings of adrenal tumour on computed tomography (CT) scan during a routine medical check-up. She underwent tumour resection in view of a large tumour of 7 cm in size. Discussion CT scan is sensitive to diagnose adrenal myelolipoma in view of its fat-laden property and useful to monitor the tumour progress. Even previously she opted for conservative management; the decision for surgery was made in view of enlarging tumour and risk of surrounding tissue compression. Conclusion With increased awareness, the detection rate of this tumour is improving, hence able to prevent the complications of a large tumour such as compression, bleeding and tumour necrosis.

Colorectal cancer (CRC) is a major public health threat. Therefore, CRC screening uptake has been a focus with the established precancerous lesion and the strong association of early detection with staging and survival of the disease. However, CRC screening is relatively low in many countries. This article briefly discussed the current situation of CRC, recommendations, and current uptake of CRC screening in various countries. Besides that, this article also highlights the potential factors that help to predict the CRC screening uptake worldwide. Identification of those factors could guide policymakers to develop an effective strategy to improve the CRC screening uptake and ultimately improve the health outcome of the population.

Introduction:type 2 diabetes mellitus has become a global public health crisis. The increment in the cases has contributed significantly to the parallel increase in the prevalence of overweight and obesity. This paper aimed to analyse the relationship between lipid profile, waist circumference and body mass index (BMI) with the glycaemic control of the diabetes patients in Kedah. Methods:a cross-sectional study was conducted, using the Kedah audit samples data extracted from the National Diabetes Registry (NDR) from the year 2014 to 2018. A total of 25,062 registered type 2 diabetes mellitus patients were selected using the inclusion and exclusion criteria from the registry. Only patients with complete data on their HbA1C, lipid profile, waist circumference and BMI were analysed using SPSS version 21. Results:the means for the age, BMI and waist circumference of the samples were 61.5 (±10.85) years, 27.3 (±5.05) kg/m2and 89.46 (±13.58) cm, respectively. Poor glycaemic control (HbA1c>6.5%) was observed in 72.7% of the patients, with females having poorer glycaemic control. The BMI and waist circumference were found to be significantly associated with glycaemic control (P

De Garengeot hernia is a rare finding of the vermiform appendix inside a femoral hernia sac. We report this occurrence in a 73-year-old woman who presented in the acute setting. There are no standardised surgical approaches and many different techniques have been described in case reports in the literature. We conducted a literature review of and found a total of 113 cases with addition of our case 114 unique cases were included for analysis. Inguinal incision was most cited (n=89). Concomitant laparotomy was needed in 13 patients, however, the association between type of incision and additional laparotomy was not significant (p>0.05). Laparoscopic surgery alone was performed in eight patients. Nine patients had hybrid surgery. The most common hernia repair was through suture technique with non-absorbable material (n=31). Mesh repair was used in 28 cases. More laparoscopic surgeries were done when the disease was diagnosed preoperatively (7/39, p

Spigelian hernia (SH) occurs due to the protrusion through a congenital or acquired defect or weakness in the Spigelian aponeurosis. SH accounts for only 0.1–0.4% of occurrence and a 17–24% risk of strangulation. We hereby report a case of a 34-year-old gentleman presented with concomitant incarceration of the omentum with small intestine and testis in Spigelian hernia sac. We have successfully operated on this patient via a transperitoneal approach with a small incision over the hernia site. This incision could be an alternative to midline laparotomy as a safe and effective method in managing incarcerated SH in an emergency setting.

A 51-year-old man with multiple comorbidities of hypertension, chronic kidney disease, dyslipidaemia and a history of stroke was presented to the emergency department with a 1 day epigastric pain. He was subsequently diagnosed with hypertensive emergency and inferior myocardial infarction. Despite

Traumatic testicular dislocation (TTD) is a rare consequence of blunt scrotal trauma. A 21-year old gentleman presented with inguinal pain following a motorcycle accident and physical examination revealed absence of both testes within a well-formed scrotal sac with bilateral inguinal swellings. Ultrasonography confirmed viability and location of the testes at the superficial inguinal pouch. He underwent emergent surgical reduction with orchidopexy and was discharged the next day. No evidence of testicular dysfunction or atrophy was noted at follow-up. We reviewed reports of TTDs reported in English over the last two centuries and discuss its occurrence, evolution and management.

Interleukin 6 (IL-6) is one of the markers of immune system activation indicating existent infection and inflammation. We present here a case of a 55-year-old male COVID-19 patient with an unusual high level of interleukin 6 (IL-6). Further investigation revealed he had hepatocellular carcinoma (HCC) with underlying hepatitis B. He did not present with respiratory symptoms although a baseline chest x-ray showed changes, and the patient was categorized as Class 3A of COVID-19. Routine investigations proceeded with high-resolution computed tomography and IL-6 to monitor for progression to severe COVID-19. Notably, there was a high IL-6 level but other parameters did not show he was in severe COVID-19. In this report, we conclude that elevated IL-6 level in a COVID-19 patient is not necessarily associated with severe COVID-19.

BACKGROUND: Gallstone ileus is a misnomer of intestinal obstruction. This rare entity of gallstone disease happens after episodes of acute cholecystitis, Mirizzi’s syndrome, or even after endoscopic intervention. CASE REPORT: A 17-year-old lady with acute cholecystitis, hepatolithiasis, and choledocholithiasis was endoscopically managed through endoscopic retrograde cholangiopancreatography. She was initially well but complicated with intestinal obstruction the next day. The abdominal radiograph and computed tomography showed a dilated small bowel secondary to gallstone ileus. An emergency laparotomy was performed to relieve the obstruction. CONCLUSION: Gallstone ileus is a rare cause of intestinal obstruction. It must be suspected in a patient with underlying gallstone disease, especially after an endoscopic biliary intervention. Emergency enterotomy and stone extraction are the imperative surgical intervention if the stone is not able to pass out spontaneously.

Suprapubic catheterization (SPC) is a temporary measure to relieve acute urinary retention (AUR). Despite being effective, it can lead to complications such as colon perforation, haematuria, and bladder wall spasm. We present a 52-year-old lady with cystofix for underlying urethral stricture presented with AUR. A new SPC was inserted to drain the urine. However, the SPC had looped and entangled with her cystofix, and laparoscopic removal of cystofix and insertion of a new SPC was done. In conclusion, trapped cystofix to the SPC tube is a potential complication during SPC insertion that can be avoided with appropriate care.

Constrictive pericarditis is a disabling disease of the heart, which causes cardiac diastolic dysfunction. We present a case of a 44-year-old gentleman with a history of blunt chest trauma who presented with constrictive pericarditis with right-sided heart failure. Imaging studies revealed a calcified pericardium. He underwent an uneventful pericardiectomy. Calcification is common yet rare if it involves the pericardium. It normally occurs following fibrosis and adhesion which are associated with the chronicity of the disease, hence creating more challenge to the operating surgeon in the pericardiectomy procedure.

Retroperitoneal cystic mass is a rare surgical condition that is often misdiagnosed preoperatively. Here, we report a case of a 56-year-old woman who presented with abdominal swelling for a 1-year duration, which was associated with lower abdominal pain for 6 months. Her abdominal radiograph showed a huge radiopaque lesion, and contrast-enhanced computed tomography scan of the abdomen reported it as a left ovarian serous cystadenoma causing local mass effect to the left ureter leading to mild left hydronephrosis. She underwent exploratory laparotomy and noted there was a huge retroperitoneal cystic mass. The histopathological assessment finding was consistent with a benign retroperitoneal cyst. This case report aims to share the rare case of primary retroperitoneal lesions, which can cause a diagnostic challenge preoperatively to all clinicians despite advanced achievement in medical imaging.

Intestinal obstruction is a common surgical emergency requiring urgent intervention. Small bowel obstruction secondary to intussusception is rarely encountered especially when inflammatory 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.

Purpose: To evaluate the expression of estrogen receptor (ER)-beta and Ki67 in prostate cancer and study their relationship. Materials and Methods: We analyzed 101 cases of prostate adenocarcinoma diagnosed from January 2011 to June 2015 in 100 patients. Immunohistochemical staining of ER-beta and Ki67 was analyzed according to Gleason score categorized into prognostic groups of 1 to 5. Double-immunofluorescent staining of ER-beta and Ki67 was performed in a total of 20 cases to study the co-expression and the relationship between these markers within the same tumor. Results: A total of 53 of 101 cases (52.5%) were positive for ER-beta expression. There was a positive correlation whereby a high percentage of ER-beta expression was seen in the higher prognostic groups (groups 4 and 5; p=0.007). High Ki67 expression was observed in the higher prognostic group, whereas low Ki67 or negative expression was found in the lower prognostic group (p

Acute pancreatitis is a common surgical emergency with a variety of aetiologies. Hypertriglyceridaemia is considered as one of the causes, especially in elevated triglyceride levels in the absence of other culprits. However, it rarely occurs in combination with oral contraceptives. We present a case of a 35-year-old woman with acute pancreatitis caused by oral contraceptive-induced hypertriglyceridaemia. This case report highlights the importance of considering rare side effects of oral contraceptives, which are commonly used by women at childbearing age. Proper clinical history and evaluation with measurements of fasting serum lipid profile in high-risk patients will help explain the aetiology of pancreatitis to avoid further morbidity in the future.

The Coronavirus Disease 2019 (COVID-19) pandemic has taken the world into turmoil by surprise. The rapid spreading of this virus has led to an exponential increase in the number of cases. It has created a public health disaster, causing a collapse of the health system in every part of the world. Many sectors in the health area are affected, including histopathology services. The challenges and risk of viral transmission can come from various aspects and levels. For COVID-19 tests, there are even cases of no direct contact with the specimens; the specimens received infection from individuals of unknown status. The fixatives used for histopathology specimens are believed to be inactivated viruses, which can be an inactivate coronavirus. Even so, precautions have to be put in place to prevent the spread of infection to laboratory personnel, especially to those handling underfixed and fresh frozen cytology samples. Precautions must also be taken when dealing with histopathology services, by wearing full personal protective equipment and by executing other standard safety measures. The purpose of this review is to highlight the challenges faced in managing histopathology services in our centre during the COVID-19 pandemic.

Preputial calculus is a relative surgical rarity. It usually happens in elderly men with poor hygiene and uncircumcised penis complicated with phimosis. In the paediatric group, it is usually secondary to phimosis and other urologic and/or neurologic anomalies. Surgical treatment is the mainstay of treatment. Herein, we report a 27-year-old gentleman with preputial stone presented with obstructive uropathy and was successfully treated with surgical intervention. To the best of our knowledge, this is the first reported case of the largest preputial stone in Malaysia.