Residen Bedah FK Unand

CARCINOMA RECTI

2008-09-08T12:58:00.000+07:00

Tuti lestari, asril zahari, ahmad luthfi
Bagian Bedah Fakultas Kedokteran Universitas Andalas
/ RS Dr. M. Djamil Padang

Latar belakang : Carcinoma kolorektal merupakan keganasan ketiga terbanyak di dunia dan penyebab kematian kedua terbanyak di Amerika dan merupakan 10 penyakit tersering di Indonesia.

Metode : Dilaporkan satu kasus di RS. Dr. M. Djamil Padang, seorang anak perempuan berumur 11 tahun dengan keluhan tidak buang air besar sejak 2 hari sebelum masuk RS. Pemeriksaan fisik pada abdomen terlihat benjolan di perut kanan bawah, teraba massa ukuran 6x5x3 cm,konsistensi padat, permukaan tak rata dan terfixir. Pada rectal toucher ditemukan massa 2 cm dari AKL, sirkuler dengan konsistensi keras.Dilakukan laparotomy dengan temuan intra operative seeding tumor pada semua organ intra peritonium.Dilakukan iliostomy dan biopsi.

Hasil : Hasil patologi anatomi berupa Signet ring cell

Kesimpulan : Kunci utama keberhasilan penanganan karsinoma kolorektal adalah ditemukannya karsinoma dalam stadium dini sehingga terapi dapat dilaksanakan secara bedah kuratif.

2008-08-30T12:17:00.001+07:00

KELUARGA BESAR RESIDEN BEDAH FK UNAND/RS DR M DJAMIL PADANG MENGUCAPKAN

SELAMAT MENUNAIKAN IBADAH PUASA

FREKWENSI DAN DISTRIBUSI HIRSCSPRUNG DISEASE DI RS DR.M.DJAMIL PADANG MEI 2003 – APRIL 2008

2008-08-30T12:02:00.003+07:00

Ismail Muhammad, Yusirwan Yusuf

Bagian Bedah Fakultas Kedokteran Universitas Andalas / RS Dr.M.Djamil Padang

ABSTRAK

Latar belakang :

Hirschsprung disease merupakan kasus bedah anak yang banyak dijumpai dalam masyarakat dan menjadi problem tersendiri bagi penderita dan keluarganya. Permasalahan yang ditimbulkan cukup komplek sehingga memerlukan penatalaksanaan yang tepat karena kegagalan dalam penatalaksanaan anak akan mengalami komplikasi serius dalam kehidupannya.

Bahan dan Metode :

Merupakan penelitian Retrospektif dengan mengumpulkan data-data dari catatan medis pasien yang dirawat dibangsal bedah anak dan bagian kesehatan anak RS.DR.M.Djamil Padang mulai dari bulan Mei 2003 s/d April 2008.

Tujuan :

Melihat distribusi frekuensi penderita Hirschsprung disease di RSUP Dr.M.Djamil berdasarkan, jenis kelamin, umur diagnostik, gambaran klinis, Tipe Hirschsprung disease berdasarkan barium enema, penatalaksanaan tahap awal dan keadaan pasien post kolostomi

lengkapnya

“POSSUM Scoring System” to Predicted Morbidity and Mortality in Carcinoma Anorectal at M Djamil Hospital Padang

2008-08-07T09:24:00.002+07:00

Rixendo, Asril Zahari. Achmad Luthfi

Sub Bagian Bedah Digestif FK Unand/ RS dr M Djamil Padang

Abstrak

Penelitian prospektif terhadap pasien Ca Anorectal yang di rawat di bangsal Bedah RS dr M Djamil Padang periode Januari-April 2008, yang di lakukan penilaian dengan Sistem skoring POSSUM sewaktu pre operatif dengan semua resiko yang terdapat selama preoperasi dan operasi.

Pada penelitian ini semua pasien di diagnosa dengan Ca anorectal yang memerlukan tindakan operasi, kemudian di observasi dan di follow up paska operasi untuk mengetahui angka morbiditas dan mortalitasnya.

Hasil penelitian di dapatkan, angka morbiditas post operasi kurang dari 4 %. dan angka mortalitas post operasi kurang dari 7% dengan infeksi luka operasi, demam paska operasi dan nyeri paska operasi merupakan yang terbanyak.

Frekuensi Osteosarkoma di Laboratorium Patologi Anatomi Rumah Sakit Achmad Moechtar Bukittinggi Periode Januari 2002-Desember 2006

2008-08-07T09:15:00.001+07:00

Dr. Ari Oktavenra, Dr. Delsi Hidayat,SpBOT

Latar Belakang: Osteosarkoma merupakan keganasan tulang primer paling sering ditemukan. Kangker ini bersifat sangat ganas, progresif dan destruktif terhadap tulang dan jaringan sekitarnya, serta cepat bermetastasis. Osteosarkoma lebih sering terjadi pada usia dekade II dan sering ditemukan pada laki-laki.

Materi dan Metode: Dilakukan penelitian dengan metode deskriptif retrospektif berdasarkan rekam medis mengenai frekuensi osteosarkoma pada Laboratorium Patologi Anatomi Rumah Sakit Achmad Moechtar Bukittinggi periode Januari 2002- Desember 2006.

Hasil: Dalam penelitian ini didapatkan 7 kasus osteosarkoma (63,63%) dari 11 kasus kanker tulang (57,13%), diantaranya pada umur dekade II. Perbandingan laki-laki dan perempuan 1,3 : 1 dan lokasi paling sering pada tibia proksimal (42,84%) dengan tipe histopatologi yang paling sering tipe osteoblastik (57,14%).

Kesimpulan: Dari hasil penelitian ini dapat disimpulkan bahwa osteosarkoma banyak ditemukan pada usia dekade II, jenis kelamin laki-laki, lokasi tumor di tibia proksimal dan tipe histopatologinya osteoblastik.

CARCINOMA RECTI

2008-08-07T09:12:00.001+07:00

Tuti lestari, Asril Zahari
sub Bagian Bedah Digestif RS dr M Djamil/FK Unand
Padang

Latar belakang : Carcinoma kolorektal merupakan keganasan ketiga terbanyak di dunia dan penyebab kematian kedua terbanyak di Amerika dan merupakan 10 penyakit tersering di Indonesia.

Metode : Dilaporkan satu kasus di RS. Dr. M. Djamil Padang, seorang anak perempuan berumur 11 tahun dengan keluhan tidak buang air besar sejak 2 hari sebelum masuk RS. Pemeriksaan fisik pada abdomen terlihat benjolan di perut kanan bawah, teraba massa ukuran 6x5x3 cm,konsistensi padat, permukaan tak rata dan terfixir. Pada rectal toucher ditemukan massa 2 cm dari AKL, sirkuler dengan konsistensi keras.Dilakukan laparotomy dengan temuan intra operative seeding tumor pada semua organ intra peritonium.Dilakukan iliostomy dan biopsi.

Hasil : Hasil patologi anatomi berupa Signet ring cell

Kesimpulan : Kunci utama keberhasilan penanganan karsinoma kolorektal adalah ditemukannya karsinoma dalam stadium dini sehingga terapi dapat dilaksanakan secara bedah kuratif.

The Anal Fistula Plug versus the mucosal advancement flap for the treatment of Anorectal Fistula (PLUG trial)

2008-07-03T20:10:00.000+07:00

Abstract (provisional)

Background

Low transsphincteric fistulas less than 1/3 of the sphincter complex are easy to treat by fistulotomy with a high success rate. High transsphincteric fistulas remain a surgical challenge. Various surgical procedures are available, but recurrence rates of these techniques are disappointingly high. The mucosal flap advancement is considered the gold standard for the treatment of high perianal fistula of cryptoglandular origin by most colorectal surgeons. In the literature a recurrence rate between 0 and 63% is reported for the mucosal flap advancement. Recently Armstrong and colleagues reported on a new biologic anal fistula plug, a bioabsorbable xenograft made of lyophilized porcine intestinal submucosa. Their prospective series of 15 patients with high perianal fistula treated with the anal fistula plug showed promising results. The anal fistula plug trial is designed to compare the anal fistula plug with the mucosal flap advancement in the treatment of high perianal fistula in terms of success rate, continence, postoperative pain, and quality of life. Methods/ design: The PLUG trial is a randomized controlled multicenter trial. Sixty patients with high perianal fistulas of cryptoglandular origin will be randomized to either the fistula plug or the mucosal advancement flap. Study parameters will be anorectal fistula closure-rate, continence, post-operative pain, and quality of life. Patients will be followed-up at two weeks, four weeks, and 16 weeks. At the final follow-up closure rate is determined by clinical examination by a surgeon blinded for the intervention.

Discussion

Before broadly implementing the anal fistula plug results of randomized trials using the plug should be awaited. This randomized controlled trial comparing the anal fistula plug and the mucosal advancement flap should provide evidence regarding the effectiveness of the anal fistula plug in the treatment of high perianal fistulas. ISRCTN: 97376902

link

Thorakotomi dan Dekortikasi pada Emphyema Thoraks

2008-06-27T15:59:00.003+07:00

Kurniady, Juli Ismail

Bagian Bedah Fakultas Kedokteran Universitas Andalas/RS dr M Djamil Padang

Pendahuluan : Prinsip dasar pengobatan empyema thorak tidak berubah sejak dari masa hipocrates. Dekortikasi dari paru dipopulerkan oleh George Fowler tahun 1893. Empyema thorak adalah suatu penumpukan cairan purulen, debris dan pus dalam rongga pleura. Pada kebanyakan empyema hasil dari suatu efusi pleura yang berhubungan dengan pneumonia (parapneupmonic effusion). .

Tujuan penulisan : Dilakukan penelitian sederhana untuk mempelajari hal ini terhadap 20 orang yang dirawat di RSUP M Djamil Padang selama 3 tahun terakhir dari Januari 2005 s/d Januari 2008.

Metode : Data diperoleh dari medical record pasien yang didiagnosa empyema thorak.

Hasil : Telah dilakukan 32 kasus thorakotomi non Kardial, 12 kasus anak dan 20 dewasa. 10 anak dengan empyema dan 7 diantaranya dilakukan dekortikasi. Sedangkan 2 orang anak lagi hanya diterapi konservatif,

Kesimpulan : Kuman penyebab terbanyak adalah stafilokokkus (50%), pada pasien yang dilakukan thorakotomi dan dekortikasi lama perawatan rata-rata 10 hari. Pada pasien yang diterapi konservatif, lama perawatan rata-rata 28 hari. Keuntungan thorakotomi dan dekortikasi dini adalah memperpendek waktu perawatan, mengurangi mortalitas dan mencegah terjadinya komplikasi.

Bladder Exstrophy

2008-06-27T15:44:00.003+07:00

Marwazi Syofyan, Yusirwan Yusuf
Bagian Bedah FK Unand/ RS dr M Djamil Padang

Latar belakang : Bladder Extrophy merupakan suatu kelainan kongenital dimana buli-buli atau vesica urinaria terletak pada bagian luar dari dinding abdomen dengan permukaan bagian dalam dinding posterior buli-buli berada pada bagian tengah dinding abdomen bagian bawah dengan pinggir mukosa yang bersatu dengan kulit. Uretra dan genitalia biasanya tidak terbentuk secara komplit (epispadia), anus dan vagina terletak lebih ke anterior dari yang seharusnya dan ditemukan juga jarak tulang pelvis yang berjauhan (diastasis). Bladder exstrophy-Epispadia Complex merupakan kasus yang sangat jarang terjadi, insidennya diperkirakan antara 1: 30.000 - 1 : 50.000 kelahiran hidup.Insiden lebih banyak pada anak laki-laki dibanding perempuan dengan perbandingan 2 : 1, kemudian bila salah satu orang tunya menderita bladder extrophy maka anak kedua akan menderita berkisar 1 : 100. Menurut data dari International Clearinghouse for Births Defects monitoring system,insidennya sekitar 3,3 kasus dari 100.000 kelahiran hidup.

Metode : Dilaporkan satu kasus di RS.Dr.M. Djamil Padang, seorang anak laki-laki umur 2 tahun 8 bulan, Bladder Extrophy yang telah dilakukan tindakan penutupan defek anterior, osteotomy posterior,uretroplasty dan rekonstruksi buli-buli.

Hasil : Evaluasi pasca bedah tidak dijumpai keluhan dan luka operasi baik.

Kesimpulan : Terapi pembedahan pada bladder exstrophy memerlukan beberapa tahap operasi meliputi penutupan buli-buli, uretra posterior dan dinding abdomen (dengan atau tanpa osteotomy), epispadia repair, rekonstruksi buli-buli.

Deltopektoral Flap pada kasus Squamous Cell Carcinoma di Wajah ( Laporan Kasus )

2008-06-27T15:40:00.001+07:00

Edwar Martin¹, Azamris², Wirsma Arif Harap³, Daan Khambri³.

Bagian Bedah Fakultas Kedokteran Universitas Andalas/RS Dr M Djamil Padang

ABSTRAK

Latar belakang :

Penutupan defek setelah dilakukan wide eksisi, dapat dilakukan dengan berbagai cara. Beberapa teknik bedah rekonstruksi diantaranya skin graft, Flap lokal, free flap dan tissue expansion. Untuk defek yang luas sering digunakan flap deltopektoral.

Metode :

Penelitian ini meninjau 2 kasus squamous cell carcinoma pada wajah di RS dr. M. Djamil Padang yang dilakukan wide eksisi dan dilanjutkan dengan penutupan defek memakai flap deltopektoral.

Hasil :

Dilaporkan 2 kasus squamous cell karsinoma pada wajah yang dilakukan wide eksisi dan dilanjutkan dengan penutupan defek menggunakan flap deltopektoral. Kasus pertama seorang wanita 70 tahun dengan lessi pada wajah kanan. Dilakukan wide eksisi dan penutupan defek dengan flap deltopektoral. Kasus kedua seorang wanita 40 tahun dengan squamous cell karsinoma rekuren. Telah dilakukan wide eksisi dan enukleasi bola mata kanan. Setelah 4 tahun timbul rekuren. Dilakukan kembali wide eksisi dan penutupan dengan flap deltopektoral. Flap dipotong pada hari ke 21. Dilanjutkan dengan radioterapi

Kesimpulan :

Defek setelah wide eksisi dapat di tutup dengan flap deltopektoral

Profil penderita Ca Thyroid di RS dr M Djamil Padang

2008-06-27T15:17:00.004+07:00

Rixendo, Azamris, Wirsma Arif

Bagian Ilmu bedah FKUA/ RS dr M Djamil Padang

A. Pendahuluan

Pada saat sekarang pola penyakit telah bergeser dari penyakit infeksi ke pola penyakit degeneratif dan neoplasma. Insiden ditiap tempat berbeda. Keganasan endokrin merupakan salah satu keganasan yang jarang ditemukan, yang paling banyak berupa keganasan thyroid. Ada beberapa masalah yang ditimbulkan oleh gejala klinis penyakit tersebut di antaranya, penderita biasanya datang dengan keluhan benjolan dileher, setelah adanya rasa tidak nyaman di daerah leher yang merupakan gejala utama, untuk stadium lanjut bisa berupa gejala penekanan ke daerah sekitarnya dan gejala metastase jauh.

Dengan kemajuan ilmu yang berkembang , pengobatan penyakit mulai dari diagnosa dini dan pentalaksanaan yang efektif dapat menjadikan kualitas hidup yang lebih baik.

B. Epidemiologi

Kanker thyroid adalah keganasan endokrin yang lazim ditemui. Perkiraan angka kematian dari kanker thyroid pada tahun 2002 adalah 1300 kasus atau 7 % dari seluruh kasus baru kanker thyroid. Di antara tahun 1973 sampai tahun 1997, insiden kanker thyroid meningkat 24 %, sebaliknya kematian akibat kenker ini menurun sekitar 24 %.

Angka rata-rata untuk kanker thyroid yang ditemukan pada otopsi sebanyak 5%-10 %, kecuali di Hawai dan Jepang, dimana angka itu bisa mencapai 28 %. Kebanyakan otopsi tidak berhubungan dengan insiden klinis.

Insiden nodul thyroid pada masyarakat umum adalah 4%-6%, lebih banyak ditemukan pada wanita dibandingkan dengan pria. Rata-rata kanker thyroid pada nodul soliter atau multinodular thyroid adalah 10%-20%, meningkat seiring dengan adanya riwayat radiasi di daerah leher. Insidenya lebih tinggi didaerah dengan struma endemik.

Ca thyroid bisa di dapat pada segala usia. Kebanyakan pasien diantara usia 25 dan 65 tahun pada saat diagnosa Ca thyroid.

baca lengkap tumor tyroid

Transverse laparostomy is feasible and effective in the treatment of abdominal compartment syndrome in severe acute pancreatitis

2008-06-05T12:44:00.000+07:00

Abstract

Background

Only recently has the important role of abdominal compartment syndrome (ACS) been recognized as a contributing factor to the multiple organ failure commonly seen in severe acute pancreatitis (SAP). Decompressive laparostomy for ACS is a life-saving procedure usually performed through a midline incision followed by a negative pressure wound dressing. High risk of intestinal fistulas and frequent inability to close the fascia with ensuing planned ventral hernia has prompted the search for alternative techniques. Subcutaneous fasciotomy may be effective in early and less severe cases of ACS but it is always accompanied with a ventral hernia.

Case report

A patient with SAP developed manifest ACS and was treated with bilateral subcostal laparostomy. Immediately after decompression, the intra-abdominal pressure dropped from 23 mmHg to 10 mmHg, and the respiratory, cardiovascular and renal functions improved markedly leading to full recovery. The abdominal incision including the fascia and the skin was closed gradually over 4 relaparotomies, and during the 6 months' follow up there are no signs of ventral hernia or other wound complications.

Discussion

Transverse subcostal laparostomy is a promising alternative decompression technique for ACS in SAP. It is feasible, effective and might provide a chance of early fascial closure. Comparative studies are needed to define its role as a decompressive technique for ACS.

link wjes

Postoperative gastric dilatation causing abdominal compartment syndrome

2008-06-05T12:43:00.000+07:00

Abstract

Objective

To study the effect of postoperative gastric dilatation on intra-abdominal pressure (IAP).

Design and setting

Single case report from a primary teaching hospital.

Patients and methods

A 72-year-old woman demonstrated a sudden respiratory and cardiovascular collapse following resection of a retroperitoneal sarcoma. This collapse was caused by abdominal compartment syndrome due to gastric dilatation.

Results

The patient was re-explored, an enormously distended stomach was found with the nasogastric tube situated in a small sliding hernia which prevented drainage of the distended stomach. Re-positioning of the nasogastric tube, allowed the decompression of the stomach and the patient's condition immediately improved.

Conclusion

Acute abdominal distention following major abdominal surgery may result from acute gastric dilatation, leading to oliguria and increased airway pressures. Untreated gastric dilatation can cause abdominal compartment syndrome.

link wjes

Splenic rupture after colonoscopy: Report of a case and review of literature

2008-06-05T12:42:00.000+07:00

Abstract

Splenic rupture is a rare complication of colonoscopy. For this reason the diagnosis could be delayed and the outcome dismal. Fifty-four cases of splenic rupture after colonoscopy have been described in the literature. The majority of the cases required emergent or delayed splenectomy, 13 of these cases were treated conservatively. The main feature that stands out from the review of the literature is the "surprise" of this unexpected complication. This factor explains the elevated mortality (2 out of 54 cases), likely due to the delay in diagnosis. The case here described is probably among the most complex published in the literature; in fact the presence of dense intra-abdominal adhesions not only contributed to the complication itself, but also explain the confinement of the hemoperitoneum to the left supra-mesocolic space and the delayed presentation (13 days from the time of the trauma).

link wjes

Acute gallbladder torsion: an unexpected intraoperative finding

2008-06-05T12:41:00.000+07:00

Abstract

Gallbladder torsion is an uncommon clinical entity and a difficult condition to diagnose preoperatively. Since its first description in 1898 by Wendel there have been over 500 documented cases in the literature. It is known to occur when there is rotation of the gallbladder along the axis of the cystic duct and vascular pedicle. Except for isolated cases reported in childhood, this disease is more frequently encountered in the elderly with 85% of the cases reported between the ages of 60 and 80 years. There is a female preponderance with a female to male ratio of 3:1. Gallbladder torsion typically presents as an acute abdomen requiring emergency surgery but preoperative diagnosis of gallbladder torsion is difficult and most cases are found as a surprise at surgery.

We report a case of acute gallbladder torsion in an elderly lady and review the clinical aspect of the disease.

link wjes

Pelvic radiography in ATLS algorithms: A diminishing role?

2008-06-05T12:39:00.000+07:00

Abstract

Background

Pelvic x-ray is a routine part of the primary survey of polytraumatized patients according to Advanced Trauma Life Support (ATLS) guidelines. However, pelvic CT is the gold standard imaging technique in the diagnosis of pelvic fractures. This study was conducted to confirm the safety of a modified ATLS algorithm omitting pelvic x-ray in hemodynamically stable polytraumatized patients with clinically stable pelvis in favour of later pelvic examination by CT scan.

Methods

We conducted a retrospective analysis of all polytraumatized patients in our emergency room between 01.07.2004 and 31.01.2006. Inclusion criteria were blunt abdominal trauma, initial hemodynamic stability and a stable pelvis on clinical examination. We excluded patients requiring immediate intervention because of hemodynamic instability.

Results

We reviewed the records of n = 452 polytraumatized patients, of which n = 91 fulfilled inclusion criteria (56% male, mean age = 45 years). The mechanism of trauma included 43% road traffic accidents, 47% falls. In 68/91 (75%) patients, both a pelvic x-ray and a CT examination were performed; the remainder had only pelvic CT. In 6/68 (9%) patients, pelvic fracture was diagnosed by pelvic x-ray. None of these 6 patients was found having a false positive pelvic x-ray, i.e. there was no fracture on pelvic CT scan. In 3/68 (4%) cases a fracture was missed in the pelvic x-ray, but confirmed on CT (false negative on x-ray). None of the diagnosed fractures needed an immediate therapeutic intervention. 5 (56%) were classified type A fractures, and another 4 (44%) B 2.1 in computed tomography (AO classification). One A 2.1 fracture was found in a clinically stable patient who only received CT scan (1/23).

Conclusion

While pelvic x-ray is an integral part of ATLS assessment, this retrospective study suggests that in hemodynamically stable patients with clinically stable pevis, its sensitivity is only 67% and it may safely be omitted in favor of a pelvic CT examination if such is planned in adjunct assessment and available. The results support the safety and utility of our modified ATLS algorithm. A randomized controlled trial using the algorithm can safely be conducted to confirm the results.

link wjes

Colonic perforation following mild abdominal trauma in a patient with Crohn's disease: a case report

2008-06-05T12:38:00.000+07:00

Abstract

Colonic perforation following mild abdominal trauma in patients with Crohn's disease is a rare occurrence. We present a case of a 21 year old Crohn's sufferer, who presented to the emergency department with signs of shock and peritonitis following minor abdominal trauma. A computed tomography (CT) scan revealed ascending colonic perforation and he underwent a subsequent right hemicolectomy. This is the first UK report of a patient with inflammatory bowel disease suffering colonic perforation following minimal trauma.

link wjes

Ileo-anal pouch necrosis secondary to small bowel volvulus: a case report

2008-06-05T12:37:00.000+07:00

Abstract (provisional)

Introduction

Small bowel volvulus is a rare occurrence in the Western world and its occurrence after ileo-anal ouch formation is even rarer.

Case presentation

We report a case of a 26 year old lady who presented with small bowel volvulus and subsequent ischaemia and necrosis of her ileo-anal pouch created 5 years previously.

Conclusion

This case illustrates a rare but potentially devastating complication of ileo-anal pouch formation and as such the diagnosis should be born in mind when patients with pouches present with an acute abdomen.

link wjes

An analysis of 13 patients with perforated gastric carcinoma: A surgeon's nightmare?

2008-06-05T12:35:00.000+07:00

Abstract

Background and Objectives

Perforation is a rare complication of gastric carcinoma and generally not diagnosed preoperatively. To clarify the clinicopathologic characteristics of patients with this condition we reviewed 13 cases of gastric cancer perforation who required emergency surgery.

Methods

A total of 13 patients with gastric cancer perforation were retrospectively reviewed. The clinicopathological features including tumor stage and survival and also the type of treatment were analyzed and compared to literature data.

Results

There were 13 patients (10 males and 3 females) with a mean age of 59.0 ± 9.56 years. The incidence of perforated gastric cancer was 9.6% among gastric carcinoma and 4.2% of all gastric perforation cases. The perforation was more frequently in stage III–IV (2–10), but one case of stage II (T3N0M0) gastric cancer was also observed. None of the patients had curative resection or radical lymph-node dissection. Six (46%) patients were treated by palliative, local surgery. Emergency gastrectomy were performed in 7 (54%) patients. Overall 30-day mortality rate was % 46. The overall survival time was 128.2 ± 184.8 days for all patients, it was 52.8 ± 52.9 days for locally treated group, and 192.9 ± 235.4 days for patients who underwent resectional surgery. The difference between the treatment groups was not significant

Conclusion

Perforation usually occurs in advanced stages of gastric cancer. These patients had a poor prognosis because of the presence of advanced cancer.

link wjes

Cecal diverticulitis mimicking acute Appendicitis: a report of 4 cases

2008-06-05T12:34:00.000+07:00

Abstract

Diverticulum of the cecum is a rare, benign, generally asymptomatic lesion that manifests itself only following inflammatory or hemorrhagic complications. Most patients with inflammation of a solitary diverticulum of the cecum present with abdominal pain that is indistinguishable from acute appendicitis. The optimal management of this condition is still controversial, ranging from conservative antibiotic treatment to aggressive resection. We describe four cases that presented with symptoms suggestive of appendicitis, but were found at operation to have an inflamed solitary diverticulum.

link wjes

Metastatic Gas gangrene and Colonic Perforation: a case report

2008-06-05T12:26:00.000+07:00

Abstract

Clostridium septicum myonecrosis is associated with diabetes, colorectal and haematological malignancies. We present a case of metastatic myonecrosis in a diabetic patient with a perforated caecal tumour. The literature since 1989 is reviewed and 28 cases of Clostridium septicum myonecrosis are discussed.

Background

Clostridium infection presents as either septicaemia or myonecrosis, and can be classified as traumatic or non-traumatic. Clostridium species are sporulating Gram-positive rods identified by the Nagler reaction, which detects α toxin, a phospholipase [1]. The commonest organisms causing bacteraemia are Clostridium perfringens and Clostridium septicum. Clostridium septicum is found in soil and animal intestines, and is an opportunistic pathogen in humans, unlike Clostridium perfringens, which is part of the normal bowel flora. Infection is characterised by intense pain, a brown discolouration of the skin with violaceous bullae formation, gas in the soft tissues, an odourless discharge and necrosis of the muscles. The patients are unwell and have a low grade fever and tachycardia. Hyperkalaemia and renal failure often prove fatal before diagnosis is made. Clostridium septicum infection occurs most commonly in diabetics, the immunosuppressed, and is associated with intra abdominal and haematological malignancies [2-4].

Case presentation

A fifty eight year old woman, who had well controlled type II diabetes, had been seen in the gynaecology outpatients department with a pelvic mass of unknown origin. She had refused transvaginal examination or ultrasound. She was admitted acutely by her General Practitioner with a short history of increasing abdominal pain.

On admission she was noted to be anaemic and had mildly raised inflammatory markers, white cell count 12 and C – reactive protein 20. Whilst awaiting further investigation her clinical condition rapidly deteriorated. She developed atrial fibrillation (AF) and was reviewed by the acute medical team. Examination at this point revealed a congested, discoloured area of skin over the thenar eminence of her right hand. The combination of a cool hand and AF prompted an acute vascular referral.

On surgical review approximately two hours later, the patient was afebrile, hypotensive, (BP 100/70) and tachycardic, (pulse 120). The discolouration now covered all of the palmar aspect of her hand and extended to the midpoint of her forearm on the flexor surface. It was exquisitely tender to touch and palpation revealed crepitus. Good arterial signals were detected over radial and ulnar arteries with a hand-held Doppler device. A diagnosis of gas gangrene was made, and the plastic surgery team involved. Further examination demonstrated a football sized mass arising from the right pelvis, and local peritonism. An urgent erect chest x-ray showed free gas under her diaphragm.

The patient's transfer to theatre was expedited and the patient given broad-spectrum antibiotics. Surgical exploration demonstrated gangrenous muscles at the antecubital fossa. An above elbow amputation was performed. At laparotomy faecal peritonitis was found to be due to a perforated, but small caecal tumour, which was resected. An end ileostomy and mucus fistula were fashioned. The large pelvic mass appeared to be uterine fibroids.

The patient was transferred to Intensive Care sedated and ventilated and requiring inotropic support. Despite maximal therapy the patient deteriorated with multi-organ failure and succumbed two weeks later. There was however no further evidence of myonecrosis.

Histology showed that the caecum contained an adenocarcinoma causing the perforation, and the forearm showed gas gangrene (figure 1). Intra operative cultures from both sites confirmed the presence of Clostridium septicum. Post-mortem studies revealed no further malignancy or evidence of gangrene.

link wjes