The disorders of the thyroid gland are the most common endocrinological diseases. Treatment algorithms in this disease group, which occupy a significant part of our clinical practice, may differ from physician to physician. In this review, our objective was to summarize the approach of a general surgeon to these benign thyroid disorders.

Introduction. The use of topical negative pressure (TNP) in wound healing is widely accepted. This method has been also used as a modality to improve skin graft incorporation. The aim of this prospective study was to evaluate the effect of different settings of TNP when used as a bolster of split thickness skin grafting procedures.Material and Methods. From 2010 to 2016, 24 patients, who received split thickness skin grafts for covering various skin defects, were randomly divided in four groups (6 patients per group); in each group different pressure settings (0mm Hg, 50mm Hg, 100mm Hg and 150mm Hg) were applied. Skin graft incorporation was assessed clinically by two independed plastic surgeons and histologically at day 3 and 6 postoperatively. Statistical analysis of the results was carried out.Results. In 23 out of 24 cases, graft incorporation was estimated to be higher than 90%; in one case total rejection of the skin graft was recorded at day 3. Histological findings confirmed skin graft take and showed a higher degree of neovascularization in the 150mm Hg group, which was found statistically non-significant.Conclusion. Our study suggests that when topical negative pressure is used as a bolster for skin grafting, different pressure set-tings do not affect substantially the final outcome of the procedure.

Introduction: Immunohistochemical detection of p53 protein has recently come to light as one of the significant and independ-ent prognostic indicators in papillary thyroid carcinoma. Previous studies have conflicting results and to date, the association is still a matter of controversy. Our study is to examine the significance and prognostic values of p53 protein overexpression in pa-pillary thyroid carcinoma patients among Malaysia population, and provide extra evidence on significance of p53 protein in pa-pillary thyroid carcinoma prognostification. Methods: This is a single centre, retrospective cross-sectional study of association between p53 protein expression as a risk fac-tor in patient with papillary thyroid carcinoma with its clinicopathological features (tumour size, extrathyroid invasion, lymph node metastasis, and distant metastasis) as the outcomes. Expression of p53 was regarded as positive if more than 10% of cells were stained. Positive slides were further divided to weak (<40%), moderate (40%-70%), and strong (>70%). Results: Total 46 patients were recruited for the study. 34 (73.9%) cases showed positivity for p53 protein over-expression and 12 (26.1%) were negative. The average tumour size was 34mm for p53 positive cases and 33mm for p53 negative cases. Ex-trathyroidal extension was present in 15 (44.1%) of p53 positive cases and four (33.3%) of p53 negative cases. There were eight (23.5%) p53 positive cases and five (41.7%) p53 negative cases showed lymphovascular invasion. Lymph node metastasis was present in 21 (61.8%) p53 positive cases and eight (66.7%) p53 negative cases. All parameters (mean tumor size, extrathyroidal invasion, lymphovascular invasion, lymph node metastasis and distant metastasis) and the stain intensity revealed no significant correlation with p53 protein over-expression in statistical analysis. Conclusion: As a conclusion, our study showed that there was no correlation between p53 protein over

Background: Vitamin D deficiency as a risk factor for breast carcinoma has not been studied sufficiently in humans. The study of the literature is also not clear about its role as an anticancer agent. Hence there is a need for further studies to establish the role of vit-amin D in breast diseases.Aims: To study the correlation of levels of serum 25-Hydroxy vitamin D {25(OH) Vit D} in benign and malignant breast masses.Methods: After a thorough general and clinical examination, women aged less than 40 years were subjected to ultrasonography of bilateral breasts. Women aged more than 40 years were subjected to mammography of bilateral breasts. On the basis of ultrasonog-raphy/ mammography, patients with no breast lump were classified as group A. Women who were found to have breast lump were further subjected to Fine needle aspiration cytology (FNAC)/ Histopathological (HPE) examination. On the basis FNAC/HPE, women with benign lump were classified as group B and those with a malignant lump were classified as group C. Serum levels of 25-Hydroxy vitamin D was estimated in these women by chemiluminescence.Results: Patients with malignant breast disease (group C) had insufficient (>12-19 ng/ml) mean and median serum vitamin D levels, when compared with the patients in the other groups who had sufficient vitamin D levels (> 20 ng/ml). The result of age adjusted mean serum Vitamin D level was statistically significantly lower in patients with malignant breast disease (18.6 + 1.6, p = <0.001) when compared with controls (27.4 + 1.4, p = <0.001) and benign breast disease group (27.5 + 1.4, p = <0.001). There was no statis-tically significant difference between the control group and benign breast disease group (p = 0.955).Conclusion: The mean serum vitamin D level in breast carcinoma patients were significantly low when compared with the controls and benign breast disease patients

The purpose of our study was to determine the incidence and complications of gallstone spillage and bile leak during laparoscop-ic cholecystectomy as well as the factors predisposing to the intraoperative perforation of gallbladder. A total of 99 patients who underwent successful laparoscopic cholecystectomy between May 2015 and May 2016 were included in the study. It was a pro-spective observational study. Patients with intraoperative gallstone/bile spillage were followed up at 1 week, 1 month, 3 months and 6 months post operatively. Intraoperative gallbladder perforation occurred in 12.12% patients, of which half had spillage of gallstones and bile both and rest had spillage of bile only. Most common mechanism was during separation of gallbladder from the liver bed. No complication was noted up to 6 months post operatively. Although the complication rate due to gallstone/bile spillage is low, care must be taken to prevent it, and if it occurs, attempt must be made to retrieve all stones. Conversion to an open procedure is not routinely indicated

Objective: The aim of our open label randomized control study was to determine the incidence of total thyroidectomy transient hypocalcemia in Malaysia and the benefit of pre-operatively treatment oral vitamin D in total thyroidectomy. Method: Seventy four patient undergoing total thyroidectomy were randomized into two group. Study group: 37 patients treat-ed with oral vitamin D (calcitriol) 1.5ug/day for 2 days duration before operation followed by 1.0ug/day plus oral calcium lactate 1800mg/day for 7 days after operation. Control group: 37 patients did not received oral Vitamin D. Result: The incidence of post total thyroidectomy transient hypocalcemia in study group is about 16.7% compared with control group of 75%. Among the cases, 8.3% in study group and 47.2% in control group are symptomatic. The incidence of permanent hypoparathyroidism is 2.7%. No significant difference in the baseline of serum calcium and IPTH. There is significant difference between control and study group with regards to the trend of post-operative serum calcium changes. The post operative stay is significantly longer in control group, 4.59 days compared with study group, 3.92 days Conclusion: The administration of oral vitamin D had significantly reduced the incidence of transient hypocalcemia post total thyroidectomy.

Introduction: Inguinal hernia is one of the most common urgent problems encountered by surgeons. Material-Methods: Patients, who underwent surgery due to inguinal hernia diagnosis between February 1999 and February 2016, were investigated retrospectively. There were 1345 patients treated due to inguinal hernia diagnosis. Out of 250 patients who were operated under emergency conditions, 171 patients were operated within the first nine years and 79 patients were operated within the last eight years. 131 patients (106 male and 25 female) were treated with unilateral open preperitoneal mesh repair. Patients treated with unilateral preperitoneal mesh repair were assessed in two groups according to surgery conditions such as those with preperitoneal hernia repair under emergency conditions (group 1) and those with preperitoneal hernia repair under elective conditions (group 2). Results: There were total of 124 patients included in the study; in which 54 of them (37 male and 17 female, range of age: 43-92) (group 1) were operated under emergency conditions and 70 of them (61 male and 9 female, range of age: 21-88) (group 2) were operated under elective conditions. The mean age was 67 in group 1 and 58 in group 2. There was comorbidity in 28 patients of group 1 and 16 patients of group 2. 27.7% (n=15) of patients who underwent emergent surgery due to incarceration, while 38.5% (n=27) of patients who were operated under elective conditions had been operated due to hernia on the same side before. There were 10 femoral hernias in group 1 and 2 femoral hernia in group 2. Conclusion: There is no difference between postoperative complication and recurrence rates in inguinal hernia patients operated under elective conditions and inguinal hernia patients operated under emergency conditions with open preperitoneal mesh repair technique. Successful results were obtained even in the presence of surgical site contamination. It is noteworthy for open anterior preperitoneal repair that surgery can be finished with a single incision especially in cases accompanying strangulation. It is cheaper than laparoscopic repair, leads pain control and lack of neuropathic pain, has less testicular complications, and it is more advantageous than other open techniques (such as Lichtenstein).

Abdominal actinomycosis is an uncommon infection which can mimic inflammatory and malignant disease. We report a 65-years old lady who was previously treated for perforated appendicitis, presents with cecal tumour. We also discuss bacteriology, pathophysi-ology, epidemiology, investigation modalities and management of abdominal actinomycosis from the literature. Abdominal actino-mycosis requires a high index of suspicion in diagnosis. Isolating the organism from the specimen is diagnostic. Definitive treatment is antibiotics however surgery has its role in diagnosis and treatment of complications

Pulmonary tuberculosis is still prevalent in Malaysia and presents a diagnostic challenge to our primary health care practitioners. Many cases are diagnosed late and present in advanced disease or with complications. We report a case of miliary tuberculosis with bilateral pneumothoraces and discuss our surgical approach to management.

Neurological deficits after spinal or epidural anesthesia are extremely rare, with estimated incidence of hematoma formation 1/150.000 in epidural injection and 1/220.000 in spinal effusion. However, when the patient receives prophylactic dose of low molecular weight heparin (LMWH) this percentage reaches to 1/1000-1/10.000. The risk is multiplied if the patient receives high dose of LMWH for comorbidities such as the common atrial fibrillation. We present the case of an 81-year-old patient who developed extensive epidural hematoma following hip hemiarthroplasty due to femoral neck fracture following spinal anesthesia. The patient was treated with pentoxifylline due to peripheral arterial disease while receiving high doses of enoxaparin due to atrial fibrillation. She developed gradual paraplegia thirty-six to forty-eight hours postoperatively, but she denied spine decompression via hematoma evacuation. Until today there is no recommendation for interruption of administration of anticoagulant agents such as pentoxifylline and aspirin, in elderly patients who already receive LMWH and there are going to have a surgery under spinal anesthesia. Based on the cases reported in the literature, we strongly believe that in these patients, the above-mentioned anticoagulant agents should be discontinued (except from specific situations) and special attention is needed for LMWH management. Surgeons of all subspecialties should be informed about perioperative management of anticoagulant therapy in these complex cases and must be ready for early diagnosis of this disastrous neurological complication. High index of cooperation between anesthesiologists, cardiologists and surgeons is mandatory to avoid such complications.

Non-functioning pancreatic neuroendocrine tumours (NF-PNETs) are more difficult to detect than functioning ones as they do not have a characteristic clinical syndrome, due to which patients generally present late with large primary tumours and advanced dis-ease. We present a case of a NF-PNET, in a 75-year-old man which was detected early and excised intoto, thus achieving cure.

Fulminant amoebic colitis (FAC) is a very rare manifestation with high mortality rate if associated with peritonitis. Diagnosis is confusing as it has similar overlapping clinical features with other colonic diseases like infectious colitis, enteric fever, inflamma-tory bowel disease, gastrointestinal tuberculosis.We present a case of FAC with an initial diagnostic dilemma, presented with peritonitis and multiple colonic perforations with gross contaminations, Hartmann’s procedure done which later complicated with peritonitis, sepsis and multi-organ failure. Re-laparotomy noted extensive gangrenous ileum all the way to the rest of large bowel proximal to the exteriorised stoma. High index of suspicion is needed for early diagnosis and management.

Chest trauma is one of the leading causes of death and accounts for 25-50% of all trauma related injuries. A 63 year old industrial worker presented following a penetrating injury to the left anterior chest wall caused by a dislodged metal grinder blade. Following aggressive resuscitation, he was subjected to emergency surgery as he was hemodynamically unstable for further imaging. Decision on the choice of access was made based on the chest radiograph findings. Intraoperatively, he was noted to have a large hematoma overlying a 7cm long full thickness laceration of the left ventricle adjacent to the left anterior descending artery and open fracture of the left 3rd to 6th ribs at the costochondral junctions sparing the left lung of any injury. An emergent median sternotomy, left ventric-ular repair as well as wound debridement and suturing of the external chest wound was performed and the patient was discharged home well 6 days later. A follow up echocardiogram on day 14 showed good contractility of the heart with no regional wall motion abnormalities. Managing penetrating chest injuries involve making the right choice of access and prompt surgery with emphasis on the technique of myocardial repair without compromising cardiac perfusion.

Midgut malrotation is a congenital anomaly of intestinal rotation which generally regarded as pediatric pathology with the ma-jority of patients presenting in childhood. The diagnosis is rare in adult population which sometimes leads to delay in diagnosis and treatment. Due to the non specific presentation, it should kept in mind as differential diagnosis of acute abdomen. We pre-sent a case of 23 year old woman who presented with acute abdomen with preoperative computed tomography scan and oper-ative findings confirming midgut volvulus with midgut malrotation. The patient underwent an emergency laparatomy with an uneventful postoperative recovery. Conclusion, high index of suspicion is crucial in order to ensure prompt surgical intervention and thereby preventing an attendant bowel ischaemia with its associated high fatality

Small bowel intussusception caused by inflammatory fibroid polyp (Vanek’s tumor) is relatively uncommon. The tumor arises from submucosal layer of gastrointestinal tract. It can occur anywhere along the GI tract and the presenting symptoms depend on the location and size of the tumor. The symptoms can be acute or chronic abdominal pain, obstructive symptoms, bleeding and in our case intussusception. Computer tomography scan has been shown to be an effective modality in diagnosing intussusception. In case of IFP presenting as intussusception, resection of the involved bowel segment has been the mainstay of treatment especially in emergency setting since there is no way of knowing the true histopathological nature of the tumor unless frozen section is easily available after office hours.

Duplication cyst is a rare congenital anomaly. Its incidence in gastrointestinal tract (GI) is only accounts for about 1% of all GI congen-ital anomaly. It is commonly diagnosed in children up to 2 years old and its incidence in adults is very rare. Jejunum is the common-est site for small bowel duplication cyst followed by ileal and duodenal. Its clinical presentation is varied and includes GI bleed, small bowel perforations or intestinal obstruction. The management is therefore according to its presentation. We present a case of an elderly who presented with intestinal obstruction. Intra-operative findings of jejunal duplication cyst with perforation. Although rare, it still can present in elderly as it is commonly asymptomatic

Gastrocolic fistula is an uncommon presentation of colonic malignancy. The symptoms are mostly nonspecific, but the classical triad include faeculent vomiting, weight loss and diarrhea. The authors hereby present a case with characteristic symptoms. Fur-ther investigations revealed a malignant Gastrocolic fistula following carcinoma transverse colon. Radical en-bloc resection of tumor was done which was followed by adjuvant chemotherapy.

Testicular or paratesticular adenomatoid tumors are of the more common benign swellings of the male genital tract. Although benign, they prove a challenge to diagnose clinically, and thereafter treat appropriately. Often, an adenomatoid tumor can be mistaken for a testicular malignancy, causing a patient to undergo an orchidectomy. As testis sparing surgery can be performed in these patients, it is essential to establish the benignity of the tumor preoperatively, which is a difficult task. We present such a case with literature review, where in an intratesticular parenchymal adenomatoid tumor is a rare occurrence