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Role of QuantiFERON TB Gold Test for Diagnosis of Tuberculosis Infection in Prosthetic Knee Joint: A Case Report

Journal of Surgical Academia.2018;8(1):28-31.

Mycobacterium tuberculosis (MTB) is a rare cause of prosthetic joint infection. The diagnosis is challenging especially in cases of latent tuberculosis. QuantiFERON-TB Gold (QFT®) is an interferon-gamma relative assay (IGRA) which is highly specific and sensitive for detection of MTB infection. We report a case of 76-year-old lady diagnosed with tuberculous prosthetic joint infection following total knee replacement. Histological examination of abnormal synovial tissue taken intraoperatively reveals chronic granulomatous lesion and raised suspicion of tuberculous infection in otherwise asymptomatic patient. The tuberculin skin test, MTB acid-fast stain and tuberculosis polymerase chain reaction were negative. The diagnosis dilemma was solved with positive result of QuantiFERON TB Gold Test. The patient was treated with anti-tuberculous drug without any surgical intervention. At five months follow-up, patient was clinically well with no symptoms and signs of infection
Interferon-gamma ; latent tuberculosis ; mycobacterium tuberculosis ; total knee replacement ; tuberculosis

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Endometrial Stromal Sarcoma with Cd56 Expression: A Case Report

Azizan N

Journal of Surgical Academia.2018;8(1):36-38.

Endometrial stromal sarcoma (ESS) is a rare malignant tumour of the endometrium, accounts for less than 1% of all uterine malignancies. Routinely, it is diagnosed morphologically, supported by immunomarkers of CD10 and vimentin. CD56 is used widely in neuroendocrine tumour. In our current practice, CD56 is not used to support the diagnosis of ESS. We present a case of a postmenopausal lady with advanced ESS who had expression of CD56 upon immunohistochemical study
CD56 ; endometrial stromal sarcoma ; immunohistochemistry ; uterine leiomyoma ; vaginal neoplasm

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Scarless Thyroid Surgery

Rohaizak M

Journal of Surgical Academia.2018;8(2):1-2.

Traditionally, treatment for thyroid diseases is associated with very high mortality and morbidity. Various techniques been performed in the past including finger dissection and the use of finger nails to remove the thyroid tissues. The earliest reported thyroidectomy was probably by Abu al-Qasim al-Zahrawi or Albucasis. It was mentioned that, he performed an enucleation of a thyroid nodule in the 11th century in Spain. This was followed by Salerno in the twelfth centuries, using different technique, including setons, hot irons and caustic powders. The first documented partial thyroidectomy was performed by Pierre Joseph Desault in 1791. But at that time, thyroidectomy was considered as a barbaric surgery with high mortality. The poor result and high mortality had lead to the imprisonment of surgeons and total ban of the operation by the French Academy of Medicine in 1850. The advancement of thyroid surgery was most obvious in the second half of the nineteenth century when Theodor Billroth managed to reduce the mortality dramatically, thanks to the establishment of antisepsis, arterial ligation and precise capsular dissection which was introduced at the same time. There was further improvement on the mortality of the thyroid surgeries to almost zero, but the basic principles remain the same: identification of the recurrent laryngeal nerves and preservation of the parathyroid glands. What becoming a more important issue is the surgery now been performed for smaller thyroid for cosmetic reason, with the need to avoid visible scar in the neck

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Osteometric Assessment of Coracoid Process of Scapula-Clinical Implications

Kumar V

Journal of Surgical Academia.2018;8(2):3-10.

The coracoid process is a bony projection arising from the antero-lateral aspect of the scapula. The variation in the height and length of the coracoid process are responsible for altered size and shape of the space between the coracoacromial arch and the rotator cuff. The study was conducted on sixty-four dry adult human scapulae of unknown age and sex with a view to elucidate the morphological and osteometric details. The length of coracoid process on right side was 41.01±3.55 mm and it was found to be 40.88±3.83 mm on left sided. The breadth of coracoid process was observed as 13.93±1.13 mm and 13.25±1.26 mm on right and left side respectively and the difference between the two sides was statistically significant (p=0.026). Thickness of the coracoid process was 8.59±1.32 mm and 8.01±1.16 mm in right and left sided scapulae. The acromiocoracoid distance was found to be 38.48±4.03 mm on right side and 35.51±3.83 mm on left sided scapulae and the difference between to the two sides showed high statistically significance (p=0.004). Mean coracoglenoid distance was noted 26.23±3.05 mm and 24.94±2.75 mm on right and left sided scapulae respectively. Values of the thickness of coracoid process recorded in the present study are at appreciable variance with the result of previous study. The coracoid process constitutes an important component of the scapular glenoid construct and is involved in many surgical interventions on the glenohumeral joint. Comprehension of standard morphometric details of the coracoid process is vital in traumatic cases, surgical interventions and replacement surgeries in the shoulder region.
Coracoid ; process ; scapula ; osteometric ; clinical

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Dexamethasone and Postoperative Capillary Glucose Levels in Type 2 Diabetes Mellitus

Elliza R

Journal of Surgical Academia.2018;8(2):11-16.

Perioperative intravenous (IV) dexamethasone is administered prophylactically for post operative nausea and vomiting. However, its glucocorticoid property which raises blood glucose is of concern, especially among diabetic patients. The surgical stress response also contributes to increased perioperative blood glucose. Prior studies showed higher glucose levels with dexamethasone 8 mg compared to 4 mg, hence we studied the effect of the lower dose amongst diabetic patients. This prospective, single blinded, randomised study recruited forty-six type 2 diabetes mellitus patients planned for surgery under general anaesthesia. They received IV dexamethasone 4 mg or saline (placebo) after induction of anaesthesia. Capillary blood glucose levels were recorded preoperatively, and subsequently at recovery (T0), and at 6, 12, 18 and 24 (T6, T12, T18, T24) hours post-operatively. Median glucose levels were higher at 9.0 [10.5-7.7] mmol/l in the dexamethasone group, versus 7.4 [9.2-5.9] mmol/l in the placebo group at T0, p = 0.022. Similarly at T6, the dexamethasone group recorded higher glucose levels of 11.2 [15.0-9.3] mmol/l, versus 7.7 [9.0-6.2] mmol/l in the placebo group, p = 0.001. This corresponded to a significant difference between the groups, in the change of glucose levels from baseline values, p = 0.042. Subsequent readings at T12, T18, and T24 were comparable between the groups. In conclusion, IV dexamethasone 4 mg in type 2 diabetic patients, resulted in higher glucose levels immediately postoperative and 6 hours later. The change in blood glucose from baseline levels was significant between the groups at 6 hours postoperatively. Glucose levels however remained within acceptable range of approved guidelines in both groups at all recorded intervals
capillary ; dexamethasone ; glucose ; postoperative ; type 2 diabetes mellitus

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A Comparison of Patient-Controlled Analgesia with Oxycodone and Morphine After Total Abdominal Hysterectomy Surgery

Chen JL

Journal of Surgical Academia.2018;8(2):17-22.

We compared the analgesic profile between patient-controlled analgesia (PCA) using oxycodone and morphine in post total abdominal hysterectomy patients. Eighty-four ASA I or II patients, aged 18 to 65 years who underwent total abdominal hysterectomy were recruited into this prospective, double blind, randomised controlled study. They were randomised to receive either PCA oxycodone 0.7 mg per bolus or PCA morphine 1 mg per bolus for postoperative pain relief. At the end of surgery, all patients received IV morphine 0.1 mg/kg and skin incision was infiltrated with 20 mls of bupivacaine 0.25%. Post-operative pain scores, opioids consumptions, sedation scores and side effects were assessed upon arrival and at 30 minutes after arrival to recovery area, as well as at 6 hours and 24 hours after the operation in the ward. Patients’ overall satisfaction was also assessed 24 hours postoperatively.No significant differences were observed in terms of postoperative pain scores, opioids consumption, sedation scores, side effects as well as patient’s overall satisfaction between the PCA oxycodone and PCA morphine group. Oxycodone was comparable to morphine as PCA in terms of total opioid consumption, pain scores and satisfaction level for patients undergoing total abdominal hysterectomy and therefore may be an alternative to morphine in postoperative pain management as PCA
morphine ; oxycodone ; pain scores ; patient controlled analgesia ; total abdominal hysterectomy

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Intrastromal Corneal Foreign Body – Case Series and Discussion on the Physics of Injury

Andrea BK

Journal of Surgical Academia.2018;8(2):23-26.

Traumatic injury to the eye can occur due to various causes, most of which are avoidable. Here we report three cases of intrastromal corneal foreign bodies (FB) which required surgical removal. Most corneal FBs are removed easily at the slit lamp, however, these cases required surgical intervention due to the mechanism of which the FB penetrated into the stroma. Although the mechanism of injury was similar, with all three cases occurring at high velocity, we observed that the entry and level of penetration differed in each case. In the first case, the corneal FB penetrated the cornea and was embedded in the anterior stroma, whereas in the second case, the FB was embedded in the posterior stroma, but with an intact endothelium. In the third case, the FB caused a full thickness, self-sealed laceration wound but remained embedded in the stroma. Through further evaluation, we noted that several factors contribute towards the severity of the injury, namely, anatomy of the cornea, area affected, shape, size, mass and velocity of the object. We speak in depth about the mechanism of injury and physics associated with these injuries and why the penetration differed in each case.
corneal stroma ; foreign bodies ; injury ; mechanics ; physics

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Microperforate Hymen Presenting as Tubo-Ovarian Abscess in Adulthood

Tan GI

Journal of Surgical Academia.2018;8(2):27-30.

Microperforate hymen is a rare vaginal anomaly that is usually reported in childhood due to recurrent urogenital infections. Unlike imperforate hymen where the presenting complaints are classical due to complete vaginal obstruction, the less profound and varied presentation of microperforate hymen may go unnoticed. We report a case of a 39-year-old, with a background history of amenorrhea, who presented with acute abdomen suggestive of tubo-ovarian abscess, and was finally diagnosed to have microperforate hymen. She underwent hymenectomy to correct the anomaly. To our knowledge, this is the oldest age of presentation of a congenital form of microperforate hymen. A high index of suspicion and early detection of microperforate hymen and properly timed intervention is essential to prevent acute symptoms and long term detrimental sequalae to women’s reproductive and psychosexual health
congenital anomalies ; imperforate hymen ; microperforate hymen ; surgical correction ; tubo-ovarian abscess

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Anomalous Insertion of Extensor Hallucis Longus and Its Clinical Importance

Shikha S

Journal of Surgical Academia.2018;8(2):31-34.

Frequent variations are reported in muscles and ligaments of lower limb suggesting that these muscles are yet to achieve the evolutionary fate. Extensor Hallucis longus (EHL) is one such muscle exhibiting anomalies which prove to be of importance while explaining functional anatomy and clinical correlations of the foot. The current study reports unilateral presence of variant EHL tendon encountered during cadaveric dissection of dorsum of foot for undergraduate teaching. The tendon bifurcated into two slips (medial and lateral) at the base of first metatarsal. The main tendinous slip (lateral) was found to be inserted as usual on the dorsal aspect of the terminal phalanx of great toe. The thin medial slip was attached to the medial half of dorsal aspect of base of proximal phalanx of the great toe medial to the insertion of extensor hallucis brevis. An attempt is made to discuss the clinical implications of the variation in the light of available anatomical literature. The results of current study are of clinical relevance to orthopedicians and reconstructive surgeons.
Accessory tendon ; Hallux valgus ; Extensor hallucis longus ; Reconstructive surgery ; Tendon repair

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Keeping an Eye Out for Klebsiella Endopthalmitis: Klebsiella Pneumoniae Invasive Liver Abscess Syndrome

Jia Ying S

Journal of Surgical Academia.2018;8(2):35-38.

Hypervirulent Klebsiella pneumoniae strain is a major cause of liver abscess and this bacteria has metastatic properties. This distinct liver abscess syndrome has been increasingly reported in Asia over the past two decades, but is emerging as a global disease. We described an 81-year-old lady, who presented to the emergency department with 1-week prior duration of fever and right eye swelling. She had been admitted for recurrent liver abscess prior to this. Hence, she was initially treated as sepsis secondary to recurrent liver abscess. Meanwhile, she was managed concurrently by ophthalmology team for endophtalmitis. Despite the initiation of treatment with antibiotics, she did not show any improvement and required right eye evisceration to treat the sepsis. Invasive liver abscess syndrome with metastatic endophthalmitis should be screened in patient with Klebsiella liver abscess. They should be monitored for ocular symptoms as early recognition can prohibit delays in treatment, which has debilitating consequences.
Klebsiella pneumoniae ; pyogenic liver abscess ; endophthalmitis ; invasive liver abscess syndrome ; opthalmology

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