PakarBedahAnda

Peutz-Jegher Syndrome

2011-08-27T15:24:00.005+08:00

Sometimes, when you see something. you just could not forget it . . .

Way back during the earlier years of my career, there was a little girl admitted to my ward with intestinal obstruction. She was found to have multiple polyps in the small and large intestines. She was operated and got well. While in the hospital (biasalah - university hospital - batches of medical students came to see her because she had distinctive pigmentations on her lips - malangnya her father who also had the same pigmentations listened to the medical students' discussion. Dia rasa bersalah kerana menurunkan baka penyakit itu kepada anaknya. Apa yang medical students tu cakap tak tahulah... hinggakan satu pagi dia dijumpai mati setelah terjun bangunan hospital lapan tingkat. Commit suicide !

So, when this man came to me with abdominal pain, I knew the diagnosis straight away... because of the distinctive lip pigmentations.

The dots or circum-oral pigmentations on the lip, or freckling of the mouth is a feature of a hereditary condition call Peutz-Jegher Syndrome.

I knew straight away that the abdominal pain was most probably due to intestinal polyps. X-ray showed feature of small intestinal obstruction. I took him to the operation room, and this was what I found !

Intestinal polyps causing intussusception (invagination of the intestine onto itself)

What is Peutz-Jegher Syndrome?

Peutz-Jeghers syndrome (PJS) is an inherited condition that puts people at an increased risk for developing hamartomatous polyps in the digestive tract, as well as breast, colorectal, and other types of cancer. A hamartoma is a growth of normal-appearing tissue that builds up into a non-cancerous tumor. However, the growth can transform into cancer over time. Cancer begins when normal cells begin to change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (non-cancerous) or malignant (cancerous, meaning it can spread to other parts of the body).

The lifetime risk of cancer in people with PJS is around 93%. People with PJS also tend to develop dark blue or dark brown freckling, especially around the mouth and on the lips, fingers, or toes. Freckles generally appear in childhood and may fade with age.

The proposed criteria for a diagnosis of PJS are:

Diagnosis of one or more hamartomatous polyps in the digestive tract, and at least two of the following:

1. Polyps in the small intestine
2. Characteristic freckling of the mouth, lips, fingers, or toes

3. At least one relative diagnosed with PJS

Apa maksudnya semua ini bagi pesakit tersebut? Ini bermaksud kemungkinan beliau untuk mendapat kanser (terutamanya kanser usus adalah tinggi) dan beliau mestilah menjalani satu skima pemeriksaan perubatan secara berkala untuk mengesan kanser sebelum ianya parah.

Bagi pesakit ini, beliau perlu menjalani pemeriksaan kolonoskopi dan ultrasound setiap 2 tahun.

Tak semua yang ganjil di kulit kita itu tanda lahir, ada antaranya tanda-tanda kanser.

Bertanyalah pada yang tahu. Setiap yang Allah jadikan itu ada sebabnya !

NEGERIKU DILANGGAR TODAK

2011-03-01T21:16:00.005+08:00

Take a break . . . . .this is not about cancer !

A 30 year old man was rushed to the hospital with a chest injury. He was swimming in the sea near Perhentian Island at about 9.30 pm one night. Suddenly he was hit on the chest by a sharp object; and he found a long 'ikan todak' stuck to his chest. He was rushed to a nearby district hospital where he was noted to have pneumothorax (paru-paru bocor) and a chest tube was inserted. He was then transferred to me for further management.

In this era of digital technology, the culprit was easily captured; of course, on camera.

This is it . . . . .

IKAN TODAK

Needlefish or Swordfish or Garfish

Tylosurus Crocodilus

To the contrary of the famous Malay epic; Temasik Dilanggar Todak (heronya budak botak bernama Hang Nadim), ikan todak is usually not dangerous

Wrote Susan Scott in http://www.aloha.com/~lifeguards/needle.html

As their name suggests, needlefish are long, narrow and silvery. The smaller common species reach about 15 inches long; the larger ones can grow to more than 3 feet. In all species, the fishes' needlelike beaks, filled with sharp teeth, merge with their bodies to form sleek, living spears.

Needlefish have two long jaws, good for catching fish. A needlefish strikes at passing prey with a sideways movement of the head, then swallows it whole.

Like their other close relatives, the flyingfish (malolo), needlefish can leap from the water at up to 38 miles an hour, skimming the surface before falling back to the water. This is where needlefish and people can clash.

At night, lights sometimes attract and excite these fish, causing them to jump at speed. Needlefish beaks have penetrated the wooden hulls of outrigger canoes.

Tragically, one also penetrated the eye of a 10-year-old Kauai boy while he was night fishing in a small boat with his father. The fish beak penetrated the boy's brain, killing him.

In other parts of the Pacific, needlefish have punctured people in the chest, abdomen, arms, legs, head and neck.

People at greatest risk of needlefish punctures are night reef fishermen carrying lights in low boats. For many village fishermen in the Pacific, needlefish are a greater occupational hazard than sharks.

Although it's rare, swimmers and divers have been seriously injured by needlefish in Japan, New Zealand and the Red Sea.

No such injuries have been reported in Hawaii, but it's a possibility. To prevent such an incident, night divers should leave lights off until well submerged. Fishermen in small boats should be aware of the potential danger of carrying lights at night.

Millions of people, including me, have snorkeled near, dived around and paddled into schools of needlefish countless times without any trouble at all.

These lovely, interesting fish aren't out to get you and injuries are indeed rare.

Still, it's good to know the facts. Now, when someone asks me if those skinny, silvery fish can hurt you, I won't say never. I'll say, almost never.

Jadi, sekiranya anda atau seseorang dilanggar todak, ia bukanlah satu serangan tapi satu kemalangan.

Sebaliknya

Jika sekiranya anda atau seseorang dilanggar kereta, ia bukanlah satu kemalangan tapi satu kecelakaan.

. . . . . fikir fikirkanlah !

LAGI-LAGI TUNGGU

2011-02-27T22:25:00.009+08:00

A 30 year old teacher presented with a progressive abdominal distension. It was painless, thus she waited until she could not hide it anymore in her loose outfit (jubah). She just smiled broadly when her colleagues tegur; anak keberapa tu? knowing very well that she was not pregnant.

She came to the gynecologist. This is one of the CT-scan pictures: large ovarian cyst with features of cancer.

This is the removed specimen; well encapsulated tumour but with features of cancer on CT - Oophrectomy (removal of the ovary) was done by the gynae. I came in the clear the omentum and the appendix; the organs that are usually affected by cancer seedlings.

And now she is waiting for her chemotherapy.

Kalaulah dia datang lebih awal . . . . .malangnya kalau, kalau, . . . . . . . . . . . .kalau !

Mungkin ini dah jadi budaya kita?

seperti yang terjadi padaku siang tadi;

bersesak-sesak bayar saman lalulintas tertunggak

di saat-saat akhir.

Kelate oh Kelate ku ......

2011-02-26T22:18:00.002+08:00

Dalam seminggu dua ni kita dikejutkankan dengan beberapa berita kematian. Mula dengan kematian seorang bekas pemain bolasepak, kemudian seorang VIP.

Yang berbezanya;

Seorang lelaki, seorang perempuan,

Seorang akibat kanser tekak (nasopharynx -NPC), seorang kanser payu-makdara

Persamaannya;

Dua-duanya bukan 'oghe kapung duduk dale rok'

Tapi 'anak Kelate hok ado namo'

Malangnya dalam kedua-dua kes ini, perubatan moden dianaktirikan, tok bomoh diutamakan

Bahkan dalam yang satu tu, sampai ke akhir hayatnya santau disalahkan

Inilah bahana yang melanda anak negeriku..

Kanser ni gapo ?

Ironinya di kampung saya (sebelah Hospital USM) ramai penduduknya dapat manafaat dari kanser. Apa tidaknya, oghe luar (orang dari luar Kelantan) sewa rumah/bilik ketika datang rawatan kemoterapi atau radioterapi di HUSM. Unit Onkologi HUSM adalah salah satu pusat rujukan rawatan kanser negara. Homestay tumbuh macam cendawan di sekeliling HUSM, disewa oleh keluarga pesakit kanser.

Kita ada macam-macam kemudahan, tapi kita tak caro nak guno.

Mungkin kita boleh reka slogan baru :

1 Kelantan, kanser diberitahu, Tok Bomoh didahulukan

GAYA HIDUP SIHAT

2011-02-26T22:13:00.003+08:00

Betul jugak ....... inilah ironinya kehidupan !

Penangan TOK BOMOH

2011-01-09T13:38:00.010+08:00

A 64 year old lady presented to the hospital with severe abdominal pain and high fever after balik berurut with a bomoh. She has been visiting this bomoh for a left sided abdominal mass since 6 months ago. According to her children, the mass was initially small in size but lately has grown much bigger. She had been adviced to seek treatment in hospital which she boldly refused.

When I saw her, she was in severe pain with signs of septicemia. There was a huge abscess (bisul yang nak pecah) in the abdomen with an underlying tumour.

CT-scan done showed a large sigmoid colon cancer with an overlying abscess cavity filled with pus and gas (or fecal matter)

abscess cavity

the colon cancer

Apa yang telah berlaku ?

Basically she has a neglected / untreated colonic cancer, now it has perforated through the abdominal wall (kena uli tok bomoh sampai pecah) . Soon, it would be coming out through the skin (itu pun if she survives the septicemia).

What needs to be done is to drain the abscess and feces through the skin and treat the infection. Once her condition improves, go and remove the cancer. But that was not in her mind. She wanted to go back to the bomoh. What could I do?. Furthermore she had the full support of her children. So be it.

This is it ........ CANCER and Kelantanese don't click !

I hope this is not the end of my struggle. I believe there are many more non-Kelantanese that would benefit from my writings.

KANSER BUAH PINGGANG

2010-10-25T14:57:00.006+08:00

A 40 year old man came with 'letih-letih' and not feeling well for the past one month. Ultrasound examination done by a general practitioner showed a tumour on the left kidney. CT-scan done revealed a large tumour arising from the upper pole of the left kidney.

This is one of his CT-scan films; it showed a large tumour involving the left kidney. This is most probably a Renal Cell Carcinoma (RCC) - kanser buah pinggang.

He was told of the diagnosis, treatment and the prognosis with and without treatment.

Prognosis tu maksudnya apa akan jadi dengannya selepas ini termasuk mati.

He was offered surgery; as the cancer is still resectable and most probably curable.
And the expected happened; the Kelantanese syndrome. He disappeared, I hope temporarily.

5 years ago, I operated on a 33 year old man with similar cancer; he survived. Now happily married and last week called me to inform me that he just got a baby girl.

This is the picture of his cancer.

The cancer was well-encapsulated, the capsule wasn't breached by the cancer. No chemotherapy was given.

And these are CT-scan picture of other patient with similar cancer on the right side (see how huge it is) and the picture of the removed specimen.

She waited for three months before agreeing to the surgery.

See, the cancer had breached the capsule, she was given chemotherapy. Two and a half years later, she came back with bone and brain secondaries (kanser merebak ke otak dan tulang) and died soon after.

Kadang-kadang, saya tak faham dengan orang kita. Bila doktor kata kanser, dia mungkin dengar risa; buang tak apa, tak buang pun tak apa.

In Kelantan, risa (pronounced reeso) is a benign tumour of the skin or subcutaneous structures; it could be a lipoma, sebaceous cyst, ganglion, etc.

SUDAH MUNTAH TAHI BARU NAK KOREK LUBANG..

2010-10-18T15:52:00.004+08:00

Pepatah Melayu :

Sudah terantuk baru tengadah
Hendak terberak baru nak gali lubang.

Inilah yang jadi kalau susah sangat nak faham

A 59 year old man, had fecal incontinence (tak boleh kontrol berak) two years ago. He went to a private hospital, told to have cancer of the rectum (usus besar dekat dubur) and adviced surgery. Refused, went to HUSM and told the same thing. Tak puas hati, went to Kota Bharu Hospital (HRPZII). Tak mahu faham juga.

He has cancer of the rectum, very close to the anus resulting in fecal incontinence (meaning the cancer has already involved the sphincter muscles). The surgery to the remove the cancer would also remove the sphincters. thus he would need a permanent colostomy.

Sebabkan tak mahukan colostomy, langsung tak mahu rawatan. Obviously, Tok Bomoh kata kolostomi tak perlu.

Two years sengsara pakai diapers. Now the cancer has totally oblitrated the rectum causing intestinal obstruction. Apa lagi, perut jadi kembung, tak boleh berak. Makanan masuk ikut mulut, tahi pun keluar ikut jalan yang sama.

Gambar X-ray usus besar kembung tiga kali ganda

Terpaksalah buat emergency operation. Sekarang bukannya nak buang kanser yang telah merebak (inoperable), tapi nak selamatkan nyawa, supaya boleh makan.

Grossly distended large intestine.

Akhirnya kena buat juga kolostomi juga. Now dah selamat; dah boleh makan dan berak melalui kolostomi.

Tapi kansernya tetap di situ.

AlhamdulilLah sekarang baru nak kemoterapi dan radioterapi. Tapi apakan daya !!!

Inilah cerita 'oghe kelate' ku.......

BARAH PAYU-JANTAN

2010-10-18T15:34:00.004+08:00

KOTA BARU: Three cases of breast cancer involving men were reported at Hospital Universiti Sains Malaysia (HUSM) in Kubang Kerian, here last year with one patient succumbing to the disease.
Coordinator of HUSM's breast cancer information centre, Dr Nik Munirah Nik Mahdi, said according to the last national cancer registry in 2006, six men in Kelantan had died of breast cancer."Breast cancer is seen more as a disease that affects women but it is not necessarily so. That is why it is important for people from both sexes to be well informed about it," she said after the launch of the information centre's blog and a workshop on women's health yesterday by the chairman of USM board of directors, Prof Emeritus Datuk Dr M. Zawawi Ismail. Read more: 6 Kelantan men die of breast cancer http://www.nst.com.my/nst/articles/20brest/Article#ixzz12kjXZy27

Jadi jangan sangka barah payudara (breast cancer) hanya terkena pada wanita, yang jantan juga boleh kena. Unfortunately breast cancer in men tends to be more aggressive. I have seen a man with breast cancer presented with brain secondaries. Maksudnya datang dengan tanda-tanda barah otak, setelah disiasat didapati puncanya adalah barah payudara (dalam kes ini payu-jantan).

Jadi abang-abang tu jangan asyik nak buat BSE (breast self examination) pada isterinya saje, sendiri juga mesti rasa .......

PRK DUN GALAS

2010-10-11T13:46:00.003+08:00

Lunch time: I was joined by a radiographer (juru-Xray) asking me 'kenapa dah lama tak update blog doktor?' Tiba-tiba saya teringat.... dah lama tak buka blog ni ! mungkin sibuk dengan 'kegilaan' baru di facebook. So I said; OK saya pergi update sekarang jugak.

Just before the lunch hour, I was in the A & E Department; attending to a patient presented with cough and breathlessness. She was a 35 year old teacher, has been coughing since 2 months ago, went to Kuala Krai hospital yesterday and claimed the doctor there refused to give her any medication. When I came closer to her bed, I smelled something familiar; 'bila lagi dah ada penyakit ini?' 'Baru 2 bulan batuk-batuk ni'. 'Bukan batuk, your breast cancer?' 'Mana doktor tahu saya ada kanser?' ' I can smell it !

Reluctantly she exposed her self; and there you were... large left breast cancer with involvement of the contralateral breast. Jarang jumpa ni, kanser payudara kiri dan kanan serentak. I examined the lungs, and I told her that most probably the cancer has infiltrated her lungs as well. Suprisingly she suggested; mungkin infection doktor, TB ke.. beri saya ubat antibiotik je!

Unbelievable.... inilah sikap orang kita (oghe kelate kito) the big C is nothing. So, to made her understand the serious situation she is in, I told her ; Kalaulah cikgu ni Tok Wakil, selepas PRK Galas ni, kita pergi mengundi kawasan DUN awak pulak ........

Saya harap dia faham, her days are numbered !!

JUMPA DOKTOR HANYA SETELAH HILANG 60 kg

2010-08-22T11:31:00.005+08:00

A 50 year old man came to see a physician with severe anemia and difficulty in swallowing. He had these symptoms for the last five months. Associated with that he also noted that his stools were dark (malenic - meaning there is blood in it). And he gradually loss his weight; from an astounding 130 kg to less than 70 kg during these 5 months. He could not take anything solid.

His friends including a doctor neighbor had adviced him to seek treatment. He went to his usual bomoh and tukang urut and once to a homeopathic practitioner. Last week, he could not swallow anything and only then he saw the physician.

On examinaton he was grossly wasted and dehydrated, and pucat lesi (Hb 5.4 gm%). After transfusing him with 4 units of blood, the physician referred him to me for scope (OGDS). He initially refused (couldn't imaging having a camera being pushed down his throat!), but after convincing him that there wouldn't be any pain, I managed to do the procedure. There was an obstructing tumour in his esophagus. Biopsy showed a well-differentiated adenocarcinoma and the CT-scan showed :

A huge cancer in the lower end of the esophagus extending into the stomach ( or vice-versa) with metastatic nodes. There is a trickle of contrast going into the stomach.

So, now with an massive cancer (adenocarcinoma) in the esophago-gastric junction, 'inoperable'; he is left with not many options.

This type of cancer does not respond to radiotherapy, poor results with chemotherapy and surgery has high morbidity and mortality. As a palliative measure, a stent could be placed so that he would be able to take something orally.

And of course his days are numbered.

To make the thing worst; after talking to him many times, he didn't seem to understanding ......
.

Kelantan, oh Kelantan ku

or rather

oghe kelate, oghe kelate....gapo nak jadi ni?

BUASIR LAGI . . . .

2010-08-10T23:00:00.004+08:00

A 55 year old man came to me for treatment of 'piles (buasir)'. He complained of passing out blood and mucus (lendir) during defecation, and lately the feeling of incomplete defecation (rasa berak tak puas). He had been seeing several doctors in his hometown for these symptoms, and all of them treated him with hemorrhoidal medications. None of them did a rectal examination.

When I examined him, there was an ulcerating tumour in the lower third of the rectum extending into the anal canal.

This is how it looks from the inside of the rectum (on colonoscopy). Anybody could have feel it if he sticks his finger into the rectum, but nobody did it. And the cancer was missed !

Anyway, after confirming the diagnosis with a tissue biopsy, I proceeded with surgery to remove the rectum (including the anus) and constructed him a permanent colostomy. This is the picture of the resected specimen.

The cancer can be seen very close to the anal skin.

This is the problem. A patient comes with very obvious symptoms, no proper assessment or examination done, yet, oh, you have buasir ! and a cancer is missed again until it's too late.

Susah sangatkah nak buat rectal examination ?

TERMENGANDUNG . . . . Apa nak buat ?

2010-08-10T10:51:00.005+08:00

Termengandung - literally 'accidentally gets pregnant' - but I am not talking about unplanned pregnancy.

This is about a woman who was adviced NOT to get pregnant but somehow found herseft pregnant. Cancer patients undergoing chemotherapy or hormonal therapy are not suppose to get pregnant.

This women came to me with right breast cancer, and had a breast conservative surgery done. What it means is - only the cancer and the surrounding breast tissues were excised, and she still has the breast. For that she was referred to an oncologist for chemotherapy. She went around in KL and Penang (with my referral letter) meeting several oncologists to find one who would agree with her not to have the chemotherapy. Unfortunately she found none! All the oncologists she met insisted that she should have the chemo. Finally she accepted it; and the chemotherapy was started 4 months ago. After 3 months (3 cycles of chemotherapy) she found herself pregnant. Tiga bulan baru tahu dah mengandung, susahlah kawe nak explain, hok ni kena tanya orang pompuanlah ! The oncologist referred her to an obstetrician for abortion. She called me yesterday for advice as both her physicians are non-muslims and she needs to know whether the abortion (in this circumstance) is permitted in Islam.

I am not an expert in Fiqh (Islamic jurisprudence) but I told her what I undertand and adviced her to seek the advice of Tok-tok Guru or Ustaz and 'alim-ulamak'.

As a doctor, I explained to her why she was adviced not to get pregnant when she went for chemotherapy.

Chemotherapy is a form of cancer treatment using drugs / medicines (chemotherapeutic agents). The drugs 'kill' the cancer cells. Kalau awak ada cacing, makan ubat cacing. Maka cacing mati dan awak jadi sihat. If you have TB germs in your lungs, you take TB medicines' kuman TB mati dan you jadi sihat!. Cancer is different... the cancer cells are parts of your bady, they are not germs or cacing. So a drug that kill cancer cells also kill normal cells. Then, how to kill cancer cells without killing the patient? Cancer cells are fast dividing cells, thus chemotherapeutic agents (ubat chemo) are designed to target cells that divide fast; yang cepat tumbuh. Malangnya dalam badan kita, bukan sel-sel kanser saja yang tumbuh dengan cepat; ada juga anggota badan yang tumbuh cepat; misalnya rambut, kuku, sel-sel darah dan sebagainya. Sebab itu bila kena kemo, rambut habis gugur, kuku jadi hitam, sel darah merah berkurangan (anaemia) dan sel darah putih rendah (mudah kena jangkitan dan kadang-kadang pesakit kanser perlu reverse isolation).

Just imaging if you were pregnant ! The budding foetus and the fast dividing cells within it are killed by the chemo drugs. Samada janin tu mati (anda keguguran) atau kalau dia hidup, dia cacat dengan teruk sekali. So, in the case of this particular patient, I told her that the pregnancy might aborts spontanenously or if it manages to mature, she might give birth to a severely deformed baby - tapi Allah lah yang menentukannya dan Dia Maha Mengetahui dan Maha Menyayangi !

Bagi doktor-doktor, dan adik-adik yang belajar perubatan; berilah penerangan yang jelas setiap kali anda menerangkan sesusatu kepada pesakit. Jangan anggap semua orang mudah faham sesuatu seperti anda. Ada di antara pesakit kita (sorry to say) 'slow' sungguh !.

I'll tell you my experience last week. Ada satu orang yang saya buat operation membuang sebahagian ususnya kerana kanser usus. Hari pertama selepas pembedahan, saya benarkan dia minum air kosong, hari kedua saya benarkan minum milo. Sebelah malamnya dia bertanya jururawat; "Misi, bolehkah saya campur gula dalam milo saya, tawar sangatlah! ... Bagi kita bila sebut milo, maksudnya tentulah ada air, milo, gula atau susu. Tapi tak semua orang begitu.

Jadi berilah penjelasan yang sejelas-jelasnya ...... sebelum terlambat atau pecah perut kerananya !

Air Tujuh Kolah

2010-03-13T14:37:00.007+08:00

Gallstones (Batukarang hempedu) is a common disease. It presents with upper abdominal pain and usually the symptoms mimic that of peptic ulcer disease (sakit gastrik). Treatment of uncomplicated gallstone is easy and straight forward; remove the gallbladder. The operation is called cholecystectomy. Previously, cholecystectomy is done through an incision in the abdomen just beneath the right costal margin. Now it is done laparoscopicaly (minimal invasive surgery - keyhole surgery). It can be done as a daycase surgery, and with minimal pain.

In Kelantan, most patients describe it as pembedahan laser (which is literally wrong). Despite the advanced technique and all its advantages, many Kelantanese still prefer to go somewhere else before coming to their surgeon.

Last week I did a laparoscopic cholecystectomy on a 42-year old teacher. Ultrasound examination done two weeks earlier showed multiple gallstones. However on the day of the operation, she insisted that I repeat the ultrasound before the surgery. Her reason : She had seen a bomoh who prescribed her with "air kolah tujuh buah masjid" - drank unboiled.

Saya percaya Allah berikan ilmu kepada sesiapa saja yang dikehendakiNya, dan ilmuNya begitu luas. Saya yakin ada di sana seseorang yang Allah berikan ilmu untuk merawat sesuatu penyakit dengan cara yang berlainan. Tetapi masaalahnya, bomoh-bomoh yang kita ketahui kebanyakannya tidak jujur dengan perbuatannya. Ada seorang insan di Jelawat Kelantan yang 'menyedut' batukarang hempedu dengan pelepah betik sebelum diludahkan dari mulutya. Ada pesakit yang bawa batu itu kepada saya. Yang saya lihat hanyalah batu kerikil sungai atau yang dikutip di tepi jalan. Yang bomoh tu tak tahu ialah batu karang hempedu diperbuat dari kolesterol (hard but smooth, multifaceted and shiny) atau pigmen hempedu (black, soft and dirty). Tentunya kalau di'scan' semula masih terdapat batu yang sama walau pun telah 'disedut' keluar oleh tokmoh.

Pastinya bomoh itu tahu yang dia menipu, dia lakukan juga untuk cari makan. Malangnya orang kita mudah sangat percaya. Hujah mereka IKHTIAR. Memanglah Allah suruh kita ihktiar, tapi Dia juga beri kita otak. Dan Dia suruh kita gunakannya untuk berikhtiar.

Tok moh, tok moh ...........................

KITA MINUM DULU ....

2010-03-01T16:44:00.008+08:00

Masihkah kita ingat pelakon ini?

Allahyarham Shukery Hashim, 55 tahun, menghembuskan nafas terakhir jam 1.45 petang 10/06/2009.

(ataupun ada yang menyangka bahawa beliau masih hidup, kerana melihat drama lakonan beliau yang masih baru di kaca TV hampir setiap minggu?)

Beliau meninggal dunia 3 bulan setelah disahkan mengidap kanser pankreas.

Kanser pankreas biasanya dikesan lewat, dan pengidapnya mengalami sakit perut yang teruk (body & tail of pancreas) atau jaundis (head of pancreas). Prognosis biasanya teruk, maksudnya jangka hayat pesakit adalah pendek. My longest surviving patient after surgery (Whipple's operation) lasted only two years. Yang lainnya hidup 6 bulan ke setahun. Tanpa pembedahan, none lasted more than 6 months.

Picture: Advanced cancer pancreas with intra-peritoneal disseminations (carcinomatosis peritoneii)

Pesakit dalam gambar ini datang dengan ketumbuhan dalam perut, busung (ascites) dan disahkan mengidap kanser pankreas. Hanya biopsi yang dapat dilakukan. Beliau kembali ke rahmatulLah 4 bulan kemudian

Kajian terbaru tentang kanser ini amat mengejutkan saya:

Soft Drink Consumption Linked to Pancreatic Cancer. February 2010: Cancer Epidemiology, Biomarkers & Prevention. Kajian selama 14 tahun ini dijalankan di Singapore dikalangan penduduknya yang berbangsa China (Singapore Chinese Health Study (n = 60,524). Mereka mendapati those consuming 2 or more soft drinks per week experienced a statistically significant increased risk for pancreatic cancer (hazard ratio [HR], 1.87; 95% confidence interval [CI], 1.10 - 3.15). The results of the new study found that individuals who consumed 2 or more soft drinks per week had an 87% increased risk for pancreatic cancer, compared with those who did not. Satu serving soft drink adalah satu tin kecil yang biasa kita beli dengan harga RM1.50

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Maksudnya kebiasaan kita dan anak-anak kita yang minum minuman bergas hampir setiap hari akan mendedahkan kita kepada kanser pankreas. Ingatlah, dalam minuman itu yang ada hanya air, yang lainnya adalah kimia; pemanis, perasa, perisa, pewarna, pengawet dan penstabil (biasanya ditambah perkataan yang dibenarkan. Pernahkah kita bertanya: siapa yang benarkan?)

Oleh itu berhati-hatilah.

"Mamak, air kosong satu" - adalah satu pilihan bijak, and no longer an indication of poor financial planning !

Tepuk dada, tanya selera !!

Nak Fikir Dulu Doktor, Nanti Saya Telefon Kalau jadi....

2010-02-09T15:39:00.005+08:00

09/02/2009

A 37 year-old teacher, single - referred by a General Practitioner for a left breast lump. On examination, there was a 2X2 cm lump in the left breast. Ultrasound examination showed features suggestive of a probable cancer. Adviced biopsy.

Nak fikir dulu doktor, nanti saya telefon kalau jadi.......

26/06/2009

Came with a much larger lump, this time with her newly-wed husband, kami baru kahwin 40 hari. On examination, the lump was 8X8 cm with areolar skin involved. Due to the rapid progression of the lesion, I told her that it was most probably a cancer. She needed proper treatment: surgery KIV chemo and radiotherapy.

OKlah doktor, buang butir saja, kalau pun kanser, kami tak mahu buang semua (mastectomy) . kami kan baru kahwin....

Excision done and the histology report came back as expected - CANCER - infiltrating ductal carcinoma. Gikgu... you need a proper cancer treatment!

Nak fikir dulu doktor, nanti saya telefon kalau jadi.......

September - December 2009: contacted patient several times. Please, you need proper treatment. Each time, the answer was :

Nak fikir dulu doktor, nanti saya telefon kalau jadi......

(09/02/2010)
Today she came without an earlier appointment, AlhamdulilLah terbuka hatinya untuk mendapat rawatan!

Saya datang ni nak minta surat pengesahan doktor yang saya ada kanser untuk saya diberi pengecualian dari menghadiri kursus!

Can I see you first? Now the cancer has come back; 6X6 cm with skin and axillary nodal involvement.

Memang saya nakkan rawatan, tapi ginilah doktor:

Nak fikir dulu doktor, nanti saya telefon kalau jadi........

Inilah my well-educated patient; Nak fikir dulu, nanti saya telefon kalau jadi.........

She came with a curable 2X2 cm lesion, and the concerned surgeon is just a phone-call away, yet she chose to end her life in a miserable way.

Probably, in the future if someone says ;

Nak fikir dulu doktor, nanti saya telefon kalau jadi,

I would say;

Ikut mu lah.....

Breast Cancer in NST

2010-02-06T12:22:00.002+08:00

http://www.nst.com.my/Current_News/NST/articles/19afn/Article/index_html

Breast Cancer: Many come when it is too late

At least 40 per cent of Malay women who came to the department were diagnosed with either third or fourth stage of breast cancer.The percentage among Chinese and Indians was lower.

In my practice, probably more than 70 percent of Kelantanese women with breast cancer presented with stage 3 or 4 disease (Locally advanced or metastatic)

Moga-moga tahun 2010 ini memberi perubahan yang positif bagi wanita Kelantan !

I lost a patient with umbilical hernia

2010-01-25T15:12:00.009+08:00

Umbilical hernia is hardly a fatal disease. In most cases, umbilical hernia is a congenital condition. To Kelantanese, it is known as pusat bujil or uluran; and is usually seen in neonates and premature babies. Strap a 50 cent coin there or apply a 'barut perut' - settle the problem in most infants. Those who still have the hernia after the age of one year, would most probably need surgery to repair it.

This is how an umbilcal hernia looks like:

In children, the content is usually a loop of small intestine. If the umbilical hernia occurs in adult, more often than not it contains omental fat (lemak dari dalam perut).

Complications come in the form of obstruction; a loop of intestine herniates or protrudes out (into the hernial sac) and could not go back inside (into the abdominal cavity). Thus the hernia could not be reduced or pushed in. Sakitlah jadinya ! Reducible hernia is usually painless. On top of that, when the intestine gets blocked; perut jadi buncit, tak boleh makan dan muntah-muntah. It may get worse, if the blood supply to the obtructed intestinal loop is cut off by the pressure of the swollen bowel to the hernial ring. This is now called strangulated hernia. If not relieved immediately, the intestinal loop would become gangrenous (mapuh le tu!).

This is a picture of a gangrenous bowel loop in a stranguled hernia:

For many Malaysians (biasalah, selagi tak sakit, selagi itu tak buat apa-apa) they come for treatment when the hernia got obstructed. Since the last Hariraya I operated on two patients with strangulated inguinal hernia and one with strangulated umbilical hernia. The first two were operated immediately; loops of vascular-compomised intestine resected, hernioplasty done and the patients went home after few days.

The third patient came seriously ill, she came with septicemia (very ill with overwhelming infection and multiple organ failure). She was resuscitated, blood pressure stabilised and taken to the operation theatre. Her condition was made worse by her uncontrolled diabetes.

This is how her tummy looked like. This picture was taken after I had painted the abdomen with iodine solution to sterilise it for the surgery (before draping).

Once I opened the abdomen, I noted the bowel was gangrenous and feaces (tahi) all over the abdominal cavity and in the hernial sac. I had a difficult job; resecting the dead and necrotic large bowel, cleaning all the spilled-over tahi and at the same time try not to breath in too much air through my surgical mask.

Post-operatively she was pushed to the ICU and ventilated. Despite of a very aggresive management she did not recover from her septicemia and finally succumbed to her illness.

This time I did not need to put a 'sympathetic face' and say to the family ; sorry, we lost your dearest one ! Insteads, they came to me apologitically "apa nak buat, kami dah puas pujuk, suruh dia buat operation lama dulu, tapi dia yang degil"

Inilah orang kita, selagi tak nampak bayangan malaikat maut, tak mahu berubat.

Nak tidur baru nak cari bantal, nak berak baru nak korek lubang !!

Start blogging again ....... The usual Kelantanese stuff !

2010-01-11T12:56:00.011+08:00

A 43 year old 'well-educated' gentleman presented to me last July with symptomatic anemia i.e. he complained of tiredness and breathlessness. On examination, he was pale (Hb 4.0 gm/dL), his blood pressure was normal but his heart rate was a bit faster than it should be. His lungs, heart and the abdomen were essentially normal.

On enquiry as what could be the source of his chronic blood loss, he admitted to have some bleeding piles for many years. On examination, this is what it looked like: a bleeding and prolapsed piles.

"Picture DELETED"

Piles or hemorrhoids (for treatment purposes) are classified as first, second, third or forth degree, in term of severity. First degree piles are those situated in the anal canal and they stay there. Second degree piles come out when you strain but goes back inside spontaneously when you stand up. A third degree piles needs to be pushed inside, and a forth degree could not be reduced at all.

What he need was blood transfusion to correct the anemia and a hemorrhoidectomy surgery to treat the third degree piles. He accepted the blood but refused the surgery. Fair. Many people are scared of surgical proceedures. So he was transfused with several pints of blood, given medications to treat the piles and was discharged from the hospital.

Last night, he came back(after 5 months). Again with breathlessness and severe anemia. His Hb was 4.3 gm/dL. The piles were still the same; bleeding and prolapsed. And he still refused definitive treatment. The reason is : "ada orang kata kita boleh mati ketika buat operation". I gave him a lecture on risk-management: what ever we do, there are risks involved. The important thing is how we face and manage the risks. Tak faham juga. So I told him; nanti keluar hospital jangan guna lift, kalau lift terjatuh boleh mati. Balik rumah jangan naik kereta atau motor, nanti accident, boleh mati. Jangan jalan tepi jalanraya (pedestrian), kena langgar kereta terus mati.

"Doktor, you bagi I darah cukuplah, I tak mau dengar itu semua" So he got it. But before I transfuse him with the blood, I asked him to sign the 'Blood Transfusion Consent Form'. For your information, the MOH has implemented this policy after facing few cases of medical litigation following complications of blood transfusion, mainly transfusion of HIV-infected blood.

"Masuk darah pun kena sain ke?" I told him: The chance of you dying from the blood transfusion is higher than that of dying from a hemorrhoidectomy surgery.

Itulah orang kita......to be exact....oghe kelate kito !

1 Malaysia

2009-10-18T15:28:00.005+08:00

In Malaysia, 1Malaysia (ONEMALAYSIA) is now the most spoken word on TV. Most corporate advertisements are circling around this theme.

This morning, while doing my round in the ward, my phone rang. A patient who has recently been discharged from the hospital called to enquire about his wound (he had an abdominal surgery few days ago; bowel perforation from a motorvehicle accident). He is an ethnic Chinese asking about 'begho' around his wound, in Bahasa Melayu of Kelantanese dialect. Not understanding what 'begho' means, I asked the patient in front of me, who is an ethnic Siamese. (maksudnya; orang Cina cakap Melayu kepada orang Melayu, Melayu tak faham, tanya orang Siam, orang Siam explain istilah Melayu kepada orang Melayu.....baru kawe faham). 'Begho' tu lebam-lebam le doktor!.

Point-nya : In Kelantan, 1Malaysia is not a 'propaganda', it is 'darahdaging' !!!

Anyway, I am not a pure Kelantanese, only S.K.M.K - Sudah Kahwin Mek Kelate !

(Sorry for 'out of the topic' writing - just to start blogging again after the long raya holiday).

Seronoknya Beraya Di Kampung

2009-09-14T14:32:00.006+08:00

Musim raya datang lagi. Alangkah seronoknya anak-anak. Ibu bapa pun tak kesah apa yang anak-anak buat, maklumlah minggu terakhir ramadhan.

Mercun; budaya entah dari mana sudah jadi darah daging. Bila malam menjelma, meletup bagai nak rak. Nak solat terawih pun jadi tak kusyuk. Mak bapa pulak tu yang beli. Mercun yang kecil-kecil, mak belikan di pasar ramadhan. Yang besar-besar, bapak belikan dari 'polis' (bad cops atau agen penyeludup) yang jual 'mercun rampasan'. Anak pun apa lagi. Dalam seronok-seronak tu, adalah jari-jari yang putus dan ada mata yang buta. Yang susah doktor jugak yang kena jahit.

Biasalah tu. Terutama di Kelantan dan Terengganu. Kalau tak ada jari yang putus akibat main mercun, tak raya lah kita. Modus operandinya sama. Beli mercun, buka pembalutnya, ambil belerang dan sumbat dalam besi paip. Kalau meletup baru uummmp. Tahun ini Terengganu dah pecah rekod. Kalau berterusan macam ni, lama-lama boleh panggil Terengganu Darul Kudung.

Apa nak jadi ayahwang?

Ini pulak lain. Anak orang bandar (KL le tu!) bila balik kampung, jumpa basikal buruk, terus naik. Tak sempat nak periksa, pelana (seat) ada ke tidak.

Akibatnya burung kena sembelih. Kan dah susah. Nasib baik kulit saja yang terlapah. Kalau putus habis, masuk Harian Metro (akhbar sensasi). Kalau silap hari, tok nikah mu sapai ke tuo.

Mak ayah tu, tengoklah anak-anak. Doktor pun nak raya juga!

Maaf. Cuma nak lepaskan geram dengan orang kita yang tak serik-serik.

SELAMAT HARI RAYA MAAF ZAHIR BATIN.

DEMI HARIRAYA.... (If Not for the Hariraya..)

2009-08-30T11:47:00.011+08:00

Hariraya (Eidulfitri) is a very important and significant day in our life; for that matter, the lives of all Muslims throughout the world. Just like Christmas to the Christians. We prepare for the big day that comes at the end of Ramadhan (the fasting month). For Malaysians, we decorate our homes, buy new clothes for our childrens, bake some cookies and prepare for the balik-kampung. In the morning of Hariraya, we take bath (mandi sunat raya), put on our best clothes, springkle perfumes and walk to the nearest mosque for solat raya.

But what if you have an ulcerating, foul-smelling breast cancer like this.

Your close friends wouldn't come near you, your childrens try to avoid you. Your last Hariraya becomes your worst Hariraya.

This is exactly what this lady was expecting. So she came to me 5 days ago. She knew what she was having; CANCER. She hopped from one bomoh to another during the two years she had the lesion. When I saw her, she was anemic (pale) with Hb 5.0 gm%. The left breast busuk dan meloyakan, and bleeding noted from the edges. The underlying pectoralis muscle was involved. The axillary nodes were massive and fixed.

Her request (or probably instruction) to me was simple : I want to celebrate the Hariraya, I don't want my friends and relatives to avoid me. . . . (with a please! at the end).

So I offered her Toilet Mastectomy. Meaning removing the ulcerating cancer with palliative surgical intention. Surgeries for cancer can be either curative or palliative. In this case, it means to make her remaining days better without the foul-smelling and bleeding cancer. She agreed, so I transfused her with some blood and proceeded with the toilet mastectomy. (Toilet ini bukan jamban tapi maksud serupa; to ease and clean). Lucky that I managed to close the wound gap. Today she is going home, and beeming with smile on her face. Before I let her go, I explained to her the treatment that she should undergo after this Hariraya. That's include a chemotherapy, radiotherapy and even hormonal therapy. I even warned her that the cancer would come back in no time should she defaults treatment.

With the smile on her face, I reallyI hope she understands what I mean and takes my advice seriously. With proper treatment this Hariraya Eidulfitri 1430 H shouldn't be her last. WalLahu 'aklam. As for me, this is one occasion that I am bersyukur that God has made me a surgeon; giving hope to the 'hopeless' and cheer them for the Hariraya.

SELAMAT HARI RAYA, MAAF ZAHIR BATIN untuk semua pembaca !

Immediate Breast Reconstruction - Is this the Solution ?

2009-08-15T22:39:00.013+08:00

Running away from proper medical treatment for breast cancer especially surgery resulting in late presentation. This in turn manifested in poor prognosis and untimely death. But for most Malaysians women, that is not the problem. Biar mati berkopek asal jangan .....whatever!. The irony is that, if they have a small benign goitre (thyroid swelling) in the neck or a ganglion in the wrist joint, they rush to us for removal. Maklumlah tak comel dipandang mata.

Tak boleh juga nak salahkan orang perempuan, yang jantan juga utamakan yang tu .... macam si tua ini.

So, if surgeons can offer our breast-cancer-striken women a 'replacement' after mastectomy, probably more will come for proper treatment, instead of going to the bomoh.

I personally believe that mastectomy is a body mutilating procedure. But what option do we have? We have to get rid of the cancers and save the women.

If I ask you to choose between A (post mastectomy and cured of cancer) and B (maggot-infested cancer and imminent death), many of you will choose A.

No, not for many Malaysian women that I have seen. That is why I have a collection of them - gambar le ! They rather die a 'whole woman' rather than live an 'incomplete women'.

Thus if surgeons can reconstruct that 'thing' to make them 'complete' again, then we can probably save more women. Those who came to me are always given options for reconstruction either immediate or late. Immediate reconstruction is done together with the mastectomy. Meaning, if they go to the operation theatre with the cancerous breast, they wake up from the surgery with a new breast free of cancer. Whereas late reconstruction is done later after they are cured of the cancer, usually after completion of chemotherapy or even later, when dia terasa nak comel semula.

Late reconstruction (the woman A)

Immediate reconstruction :

The nipple can be reconstructed later upon request.

Saya tidak berniat untuk menyinggung perasaan sesiapa yang mendapati gambar-gambar ini offensive atau memalukan. Niat saya untuk mendidik. Saya pohon maaf sekiranya anda berasa demikian.

CANCER SURVIVOR - A DIFFERENT PERSPECTIVE

2009-08-10T21:17:00.008+08:00

Last week, a 56 year old lady presented with lethargy and poor appetite. Her hemoglobin was 8.6 gm/dL and her Liver Function Test showed low albumin/protein. CT-scan of the abdomen revealed multiple liver metastases (cancers spread to the liver). She was a very 'strong' lady; despites her incurable cancer, she smiled and told me her story which I personally knew part of it.

In July. 2007, she came to my clinic with a 1-cm lump in her left breast. Ultrasound and a mammogram done showed the lesion was most likely a cancer. I explained to her what a cancer means and adviced her to have a biopsy and the subsequent treatments including surgery. Unfortunately she disappeared after that. Apparently the lump rapidly increased in size till it started to ulcerate in Feb. 2008. On the coersion of her children, she agreed for a mastectomy which was done in a hospital in KL. Again she refused adjuvant treatments. Now, she comes with the cancer spreading to her liver and is killing her slowly..... yet she is smiling happily.

Her story: In early 2007, she and her husband were planning to establish a 'tahfiz school'. Unfortunately he passed away leaving her with hundreds of thousand in 'infaq' or donated money. When she was told to have the breast cancer, she 'knew' that she would soon follow her husband. So she decided 'not to waste' whatever short time she had, for the cancer treatment. She started to work on the 'tahfiz' until it was completed and started to enrolled local girls. Now, the tahfiz school is running well. And she is now ready to join her husband ! Beliau bersyukur kerana Allah telah memanjangkan hayat beliau sehinggalah siapnya sekolah tahfiz beliau. Moga-moga Allah mengangkat beliau sebaris para syuhadaNya - Amin.

In Malaysia, there are now many organisations either established by the government or the NGOs to help cancer patients and cancer survivors. Cancer survivor is a term used for a person who had cancer and survives the disease for five years or more. Unfortunately, I believe not many Malaysians know about these organisations. Hence, once a person is diagnosed of having a cancer, he or she feels hopeless. They turn to all sorts of people, conmen and some even end their life prematurely. When I was a Medical Officer in Penang (1986-7), Penang bridge was a favourite place for some of the desperate patients to find a shortcut to 'heaven' (saya rasa neraka).

In Kota Bharu, there is a volunteer organisation called KAWAN which give supports and advices (and probably where you can buy a breast prosthesis - after mastectomy). I was invited to participate in one of their workshop once - where a man said to his wife (a nurse who had a mastectomy for left breast cancer) ' I love you with or without your breast!'

As a muslim, I believe that God determines everything, and He says He does so with reasons. It is up to us to find the reasons. If we wants to be cured of a cancer, we find the reasons. And as a scientist, I believe a proper medical treatment is the reason. Off course, in the end He determines whether we are cured or not. It is His prerogative.

When a patient comes to me with breast cancer, I always tell them about 'living examples'. And this is my favourite living example. Australian singer, Kylie Minogue.

Diagnosed to have a 1 cm breast cancer many years ago. Underwent a local excision, followed by a course of radiotherapy and a regime on chemotherapy. Now cured and kicking well; back to her singing stages.

On the other hand; we have our 'equivalence', an actress who hid her breast cancer till it fungated and smelly. Now begging for mercy; asking donations for her chemotherapy.

God is Great; He gives to whoever strives for His Mercy. He helps those who help themselves !

As for the lady in my story; deep down in my heart, I believe if she had decided to receive a proper treatment when she came with a centimetre lesion, she might not only able seeing her tahfiz kicked off, but be with it till many years to come. Wallahu 'aklam

Tropical Fruit Season

2009-07-23T10:30:00.011+08:00

Fruit season is a very much awaited time of the year in the rural areas of Malaysia. Plenty of delicious fruits are available freely (for those who have the trees) or cheaply (if you need to buy it from the mushrooming roadside fruit stalls) .

For some rural folks and the orang asli (the aboriginies) - those who kais pagi makan pagi, they don't need to go to work, they just stay home and eat. They just need to pluck the fruits and eat. So they eat and eat and eat.

Sometime you see complications... especially if they swallowed the seeds. Tropical fruits are not like apples; thick 'flesh' and small seeds. Furthermore, some fruits you have to swallow the seeds, otherwise no 'uumph'. Mangosteen and rambai are examples of this type of fruits.

Last night a senile elderly lady, was brought in to the hospital with constipation and severe anal pain. Abdominal X-ray showed dilated colon packed with hundreds of 'seeds. I spread-opened her buttock, and I could see those seeds impacting the anal canal. I had to manually evacuated the seeds. Memanglah sakit tapi lepas tu lega. They are manggosteen seeds, and that suprised me. A mangosteen usually has six fleshs; only one or the most two have seeds. That means she really ate plenty of those fruits probably more then a hundred in several days.

When I was a medical officer in Mentakab, an orang asli girl presented with abdominal colic caused by similar problems.... and I had to dig out hundreds of 'setol' seeds. She literally picked up the fruits from the floor of the jungle and ate them. I had to sedate her with Ketamine and removed the seeds with my finger till clear.

A fellow physician once told me; The most honorable thing a surgeon does is to digitally relieve a patient with an impacted rectum !

Hard objects impacted in the colon cause ulcers in the colonic mucosa by pressure necrosis. These ulcers are called stercoral ulcers. Not uncommon, the ulcers perforate through and caused peritonitis. Few years ago when I was in the university, an old lady presented with peritonitis. I took her to OT and opened her abdomen. To my astonishment; I found hundreds of rambai seed in the peritoneal cavity. What happened was she ate the rambai and swallowed the seeds; her colon was packed with the seeds resulting in the colonic perforation. I had to pick up all the seeds, washed the peritoneal cavity and exteriorised the colonic perforation as a loop colostomy. Later when she was well, I closed the colostomy.

This picture showed ripe rambai fruits. Each fruit contains three glistening, usually sweet and sour flesh with a seed in the middle. You don't need to chew them, just put in your mouth and swallow them.

The lesson is: If you really like these fruits, eat them by all means. But please don't swallow the seeds. Otherwise someone has to stick his finger into your arse.

Tired and Betrayed

2009-07-11T12:24:00.011+08:00

Last Thursday was a busy day for me, I had several surgeries and some endoscopies. As I was about to settle down just before midnight (malam Jumaat beb), a lady was brought in with difficulty in breathing. She was pale as a sheet, her hemoglobin was 3.2 gm/dL(normal > 11). As I was asking where and what could be the source of her chronic blood loss, I smelled something bad from her body; smell of necrotic tissues.

After much persuation and explanation including by her sister (whom I thought I've seen before)she reluctantly showed me this;

The usual thing . . . . . . . . . . . . . . . . . . !

Advanced ulcerating cancer of the right breast with chronic bleeding from the ulcers.

If you observe the surrounding skin, there were multiple nodules. There are cancerous metastases called stellite nodules. The other breast were also involved, with peau d'orange (skin lymphatic infiltration)

She forewarned me not to do anything to the tumour as she was at present on treatment; homeophatic medicine and after this is going to another bomoh in Melaka. All she wanted was the treatment for the breathlessness.

The breathlessness was caused by severe anemia. So I transfused her with 4 unit of concentrated blood (packed cells). When she felt better, she insisted on going home. I asked her who was doing the dressing all the while, the answer; my sister. I turned to her sister; have we met before? Yes, I was a head-nurse in xxxxx department when you were in the university.

Oh Tuhan, apa dah jadi ni? (O God, help me!)

I put much efforts to make Malaysian ladies seeking proper treatment for their cancers, to avoid unnecessary deaths and morbidity. I gave lectures to nurses and women groups. Promoting breast-self-examination and mammogram screening. But now I have a senior nurse who I knew personally, yet is 'encouraging' her own sister to go to the bomoh. No wonder, there are bomoh bragging that doctors and nurses are among their patients. Once I had a patient (hernia surgery) who is a bomoh patah(he treats fractures) himself, he boasted that many doctors went to him for their fractures.

Common chaps, if you don't believe in what you practice (modern medicine), then stop practising. Don' t misled others. Go out and do something else !

As for the lady, she chooses to end her life in a miserable way with other people avoiding her due to the foul-smelling cancer on her body.

As for me, I am tired and feel betrayed by my own colleagues . . . .

PILES, So What .......?

2009-06-22T10:10:00.006+08:00

Buasir je, tak payah susah-susah lah.....

Not everything that comes out of the anus is faeces

Not everything that protrudes out of it is hemorrhoids

An old man came to the hospital with severe anal pain and faecal incontinence (tak boleh kontrol berak le tu). He was dehydrated and emaciated and this thing (picture) was seen in the anus.

It was a fungating anal cancer which was later confirmed by a biopsy. So I told him the diagnosis. Buasir je... saya telah jumpa doktor panel banyak tahun, dia kata buasir, tak bahaya pun!

So this is the problem; "patients come with rectal bleeding and prolapsing anal mass - hemorrhoids until proven otherwise" No examination done, given some medications and sent home. Subsequent visits - same medications. No reassessment or referral to the appropriate specialists.

This is what happened to this unfortunate old man. Deadly cancer treated as a common disease; piles. The biopsy was reported as malignant melanoma; a rare but deadly cancer. On top of that, his chest X-ray revealed multiple metastases (cancer spread) . . . . . . . . . . . . . . . . . and the old man's days now are numbered .... KKM-DKP.

Ironically, this is not just 'a case I saw', I have seen many cases including referrals treated for months as hemorrhoids / piles / buasir / ti cheng / zhi chang or what ever you like to call it - but actually are anal or rectal cancers. Once I attended an surgical workshop on PPH (new technique of treating hemorrhoids); the patient was already put to sleep and when the legs were lifted, poop.. out came an anal cancer. That case was pre-selected by a surgeon for the demonstration! . See, hemorrhoids are probably not just a simple disease to diagnose.

If you are primary care doctors, think of a differential diagnosis beside your provisionals.

And if you are a patient, always ask for an explanation especially when things are not as expected.

and TABIB BUASIR is not part of the solution.

Any way, KKM-DKP stands for kubur kata mari, dunia kata pergi ..............

CARCINOGEN

2009-06-06T16:46:00.007+08:00

Today, my PA put five Cancer Notification forms on my table. The MOH requires medical practitioners to notify The National Cancer Registry all new cases of cancer they diagnosed. 5 new cases a week is common in a big goverment hospital surgical depatment. But for a single surgeon like me in a 100-bed private hospital, this is a record. In the last one week I encountered 2 breast cancers, one skin cancer (BCC), one stomach cancer and an occult cancer with liver metastases.

This is unfortunately not a suprise. The incidence of cancer generally is on the rise. Although different cancers have different causes, the upward trend is usually associated with the rampant use of chemicals that induce normal cells to change to cancer cells. These chemicals are called carcinogens.

Carcinogens are found in industries, drugs/medicines, clothings and most disturbing our foodstuff. Almost all factory-made food items contained some sorts of carcinogen. Some in traces, others full of them.

One day, my young son bought a coloured, flavoured drink in a plastic container in the shape of 'ultraman'. There was a small note: Ingredients: Air, Pemanis, Pewarna, Perisa dan Penstabil yang dibenarkan. Basically it contains water, and four chemicals to change it colour and taste. In another words, it contains water and most probably four carcinogens to shorten our lives. In Kelantan, if you look for the traditional nasi kerabu hitam which is stained purple by daun mengkudu, you would never find it. Insteads you will get a nasi kerabu stained blue by a dye usually used to colour tikar mengkuang and this is highly carcinogenic. Your mee goreng or mee latna are usually added a big spoonful of Thailand's ajinomoto (which is also used as additive to farmer's racun lalang to make sure the lalang dies sampai ke akar).

See my point: Nak makan sedap, you may risk shortening your life.

That is my bad news for the week. BUT the good thing is : Hari ini every junction from Kota Bharu to Kubang Kerian along Jalan Bayam is beautified with bunga manggar. Maklumlah, cuti umum Agong' Birthday bertindih dengan cuti sekolah. Ramai ambil kesempatan buat kenduri kahwin. Baguslah tu, kurang peluang syaitan nak suruh orang buat maksiat. Yang sebelumnya haram dah jadi halal, dapat pahala pulak tu!. Dalam pada tu, malam tadi ada yang datang ke hospital melahirkan anak dengan jari yang masih penuh berinai. Bila kahwin dik?. dua hari lepas doktor....

AstaghfirLah hal azim...apa nak jadi dengan orang mim lamalif ya waw................................

Young Malay Ladies

2009-06-01T16:27:00.009+08:00

Forget about this picture, I am not writing about it. I am using it only to beautify my posting.

(Anyway it is a picture of a myomectomy operation - removing a uterine fibroid - done by a gynecologist friend of mine; Dr. Ang Koh Seng)

Last week I attended our Annual Scientific Meeting & AGM, College of Surgeon, Academy of Medicine of Malaysia in Langkawi.

College of Surgeon bukannya sebuah kolej tetapi lebih kepada kesatuan profesional (seperti Bar Council) yang dianggotai oleh pakar-pakar bedah seluruh Malaysia.

A lot of important things presented and discussed; new technologies demonstrated and things that had happened reviewed and learned.

One thing that is relevent to this blog is a presentation from University Malaya Medical Centre (UMMC) on breast cancer survival. They presented a paper: The Impact of Defaulting Breast Cancer Treatment; Halving The Survival Time For 1466 Breast Cancer Patients.

They studied the outcome of all their breast cancer patients from 1993 to 2002. Out of those, about 100 defaulted treatment. What they found was;

1. These defaulters succumbed to their cancers much earlier; their 5-year survival rate was only 47 %. Maknanya selepas 5 tahun hanya tinggal 47%, yang lainnya telah berpindah ke alam barzakh

2. Majority of the defaulters were Malays

3. Many of these poeples were younger than 40 years old.

Their findings and the messages are easy to understand. Pertama: You ada kanser payudara, tak rawat you mati (of-course semua orang mati, tapi you mati menderita kanser). Kedua: Orang Melayu, kita ada bomoh yang memang kita tak percaya pun, tapi bila kita kena kanser bomoh inilah yang kita cari. Ketiga: Yang ini yang saya tak faham; kenapa yang muda banyak yang jadi defaulter.

I have seen young, well educated, some are extremely rich and of course yang berpangkat ladies when told about about the cancer, they say thank you, I am off to my bomoh. In my personal experience, teachers are the worst. If you have a Malay teacher with breast cancer; I can bet; she presents early (kena paksa oleh kawan-kawan), when I told her it is cancer, she disappears, and a months or two before she dies, she comes back to you crying as if you are the Archangel Izrael. I tak cakaplah off you go, but at that stage nothing much could I do.

I hope my message is loud and clear .................................

Hanya Jauhari Yang Kenal Maknikam

2009-05-11T11:30:00.019+08:00

Yesterday, a lady with advanced breast cancer came to me requesting breast cancer surgery. All the while she didn't bother to see a doctor because there was no pain, but lately the cancer became painful (usually indicating the cancer is penetrating through the skin, soon it is going to ulcerate). She and her family knew very well that it was cancer, and the chance to have a proper curative treatment was wide open to her right from the begining. One of her anakbuah is a doctor working in a hospital designated for breast cancer treatment; the Putrajaya Hospital. Instead she opted for the mercy of a bomoh .

Bomoh bukan sebarang bomoh
Bomoh bergelar dari Keraton

Barah dirawat dengan surgeri
Sakit tidak berdarah pun tidak
Bahkan dirakam kamera VCD
RM 7000 dibayar pengeras diberi

The bomoh 'operated' on her. He 'performed surgery' to treat her cancer !

When I saw her, the cancer was huge, axillary nodes are massive and fixed, there chest wall was involved. Basically it was non-operable. There was no evidence of any surgery or intervention what so ever. The bomoh had done nothing but had taken her for a ride. What she needs now are chemotherapy and radiotherapy. Surgery can be considered later if the cancer managed to be down-sized by the chemo.

Back to the bomoh thing, out of inquisitiveness I searched the web for the center. They have a nice homepage, even daringly posted few of their 'surgeries' for us to see.

One thing I believe; you should know your limits. Once your cross the line, you are exposed. There was a bogus doc way back in 1985 in HKL. A failed year 3 medical student impersonating a doctor (teringin sangat lah tu!). He managed to work 'undetected' for more than a month in a medical ward. But on the day he went to OT to assist a surgery (he crossed the line), his identity was exposed.

.
I tell you a story. A friend of mine sent his Mercedes to a mechanic. The next day the mechanic told him that he had changed the alternator and showed him the one that he had 'removed'. This friend took the rosak alternator home. Another mechanic saw the thing and said; ini bukan mercedes punya, ini Wira punya dah !

You need a mechanic to know what a mechanic does .......... !

I saw a video of a 'bare-hand' surgery from Philipines, the 'bomoh' put his hand on the victim's tummy and pulled out a 30 cm of intestine (claimed colon cancer). That thing was so small for a human intestine. That must be usus ayam (chicken intestine). I know exactly how colon or intestine look like. Any medical student or doctor knows it. To some non-medical peoples; wow, hebatnya, boleh bawak keluar usus dengan tangan kosong..... memanglah kalau usus ayam !

You need a surgeon to know what a surgeon does ........... !

I am going to blow up the cover of this bloody con man with big tittles hiding behind verses of quran and Islamic medicine.

So back to this bomoh Keraton; he put his hand into a patient chest, pulled out a very small heart, too small for a human heart. My bet is that was jantung kambing! Maklumlah susah nak cari jantung yang sama saiznya dengan jantung manusia. Jantung lembu terlalu besar.But sir, if you want a jantung that of the size of a human heart, ambillah jantung BABI. Jangan kena influenza H1N1 sudahlah.

That's not all. What about the technical aspects of the surgery, physiology, infection, blood and etc. My adviced to this bomoh, if you want to help, do what a bomoh does. If you decide to operate, then you have crossed the line. Your wickedness would be uncovered. Kalau nak tipu pun biarlah orang tak tahu. Dahlah menipu orang yang susah, yang sakit dan yang amat mengharapkan, guna pula nama Islam. Memalukan ugama dan bangsa.

Malangnya bilakah orang kita nak sedar....

Yang nak kaya, ambil jalan mudah; skim cepat kaya,

Yang nak nama, bayar ejen untuk dapat Dato'

Yang nak jawatan, bayar rasuah

Yang nak rebut DUN pun , panggil bomoh, puh sana, puh sini

Alahai .

RENTOKIL

2009-05-05T12:32:00.023+08:00

Rent To Kill

Yesterday was a historical day for me. I was hired to remove pests; unfortunately a 'friendly' ones. At 3.00 am in the morning, a lady came screaming to the A & E unit; '......takutnya, tolonglah takutnya........' jumping up and down. Some creatures creaping out of her breast !

This is what the breast looks like

And these are the scarry chaps.....

Friendly larvae trying to clean the necrotic cancer tissues away.

Berbuih mulut trying to explain to her and her family about proper cancer treatments. Although already a locally advanced disease, her quality of life might improved with palliative 'toilet' mastectomy, radiotherapy or even chemotherapy. But she insisted on getting rid of the good little fellas and went home to continue with her own treatment using some expensive 'DNA milk' or what ever.

By the way, live maggots are flushed out of the dead tissues using turpentine (minyak gas). Get some turpentine from a hardware shop (not pharmacy), and pour it onto the tissues. The maggots would crawl out of the necrotic tissues. If you use some other chemicals, they might get killed and left rotting in the tissues.

Anyway... just before she left for home, I told her....."You don't need a surgeon to do this, next time just call RENTOKIL .

..............................................................RENTOKIL provides pest-control service in Malaysia

BOMOH - In All Strata Of The Society

2009-04-22T21:26:00.006+08:00

Look at these 2 CT-scan films

The first was taken on 17/02/2009, and the second was taken on 20/04/2009 They are 2 months apart. Name deleted.

This CT-scan film belongs to is a 50 year old lady (not a commoner) who presented two month ago with lower abdominal pain. She was diagnosed to have ovarian cancer and was adviced (by the gynaecologist) for surgery and chemotherapy.

She went off AOR (at own risk), refused the treatment and opted for the bomoh 'therapy'.

Bomohs are usually more friendly than doctors, but their 'treatments' are cheaper. Wrong ! some charge much more than what I charge for a laparoscopic cholecystectomy for a single consultation.

Back to this lady, she came back to me 2 months later with intestinal obstruction. The intestine was blocked completely by the cancer. She could not eat or drink, vomitted her stomach out. She now agreed for anything, belahlah, colostomy pun tak apa !

But everything was too late. The tumour was not resectable; anyway I did I could do to help her. And she now is counting her days.

Kadang-kadang terfikir juga, apa salahku? Mungkinkah aku tak tahu nak explain apa dia kanser. Mungkinkah aku kena cakap ...Makcik, kalau tak rawat ini, makcik mati dua bulan lagi.

In Kelantan, this bomoh things are killing more people than what the Mat Rempits do on the road. Nak salahkan siapa ?

Ada orang kata ............ ini budaya kita.

Ada juga yang kata ..... ini mentaliti dunia ketiga

Janganlah kata.............. Melayu mudah lupa

I saw TV9's Tanyalah Ustaz 3 days ago. Ustaz Amran Kasimin answering questions, very interesting.

Radiologist blues

2009-04-07T11:20:00.008+08:00

COMMON SENSE !!!!
COMMON SENSE !!!!
COMMON SENSE !!!!

When I was a lecturer in the university, I got very irritated when my students demonstrated 'lack of common sense'.

Medical students are unique creatures; there are usually intelligent, capable of memmorising many things, giving 1001 rare differential diagnoses, but (now I begin to realise that) they are actually lack of common sense.

I used to think of that long time ago, but I kept pushing that idea to a deep corner of my head. Maklumlah, they are top scorers in their schools and colleges. But more often than not, when you asked them simple straight forward things, they could not give you the answer. They think that you simple questions are tricky, and give you around-the-corner answers. If I do post-grad teaching, it is usually highly 'technical' (or rather surgical), but if I take year IV medical students, it becomes philosophical. This is because I want to inculcate 'common sense' into their brains.

With teaching and training, they 'come back to their sense'. Many of them become good doctors after graduating, but some of them maintain this bad attitute in their professional life.

This is demostrated in this particular case.

This CT-scan film belongs to a 52 year old lady who came to me two days ago. She complained of a severe upper abdominal pain and a progressively enlarging mass in the area. Associated with that she had occasional fever, poor appetite and a weight loss of 16 kg in the past 6 weeks. The pain was so severe that it was only temporarily relieved by pethidine.

She was seen in three hospitals in the last 6 weeks, the last was on 26/03/09 on which a CT-scan was done. She was asked come back for the CT scan report on 26/05/2009 (The radiologist wrote TCA - 2 months, the nurse gave appointment on 26/05/09).

The scan above (taken in my hospital) shows a huge multicentric liver cancer, which is about to rupture (the severe pain is due to liver capsular stretching). I bet on 26/05/2009, she is already 6 feet underground. In the hospital her pain was only controlled with i/v Fentanyl PCA (patient control analgesia), Oxycontin and amytriptyline. Yet the 'good-thinking chap' requested 2 months to report a CT-scan of a terminally ill, dying mother of 5 children presented with an impending rupture of liver cancer.

Inilah yang dikatakan "ada akai tapi tak pakai" atau NO COMMON SENSE !

Outright Bluffer

2009-03-08T16:10:00.002+08:00

Yesterday I was visited by a 49 year old lady who later turned out to be my ex-MU college mate (78-79) asking my opinion regarding her newly diagnosed breast cancer. She is a very educated lady; knows her disease pretty well, but 'caught in between her scientific knowledge and traditional belief'. She is scheduled for a mastectomy and axillary clearance (surgery for the breast cancer) sometimes next week in KL. She came back to Kelantan before her surgery to visit her parents.

Offering to help, her mother invited a bomoh to 'treat her' and later 'certified cured' by the man. Not to offend her mother she came to me to be re-investigated to see whether the cancer is still there or not. Of course, it is there !

You see, even a very educated person can be swayed by this so-called faith healer, what more ordinary kampung folks. What I don't understand is the bomoh themselves.... They don't even know what cancer is all about, yet claim 'can treat and certified cured' a cancer patient. To me, these are not faith-healers or traditional medicine men, they are outright bluffers !

Ada bomoh-bomoh yang jujur dan mampu merawat penyakit-penyakit tertentu (yang boleh dibomohkan), tapi bagi penyakit yang bukan bidang mereka, tak payahlah menyusahkan orang. Ini ada sampai ada yang tertipu dan akhirnya mati dengan keadaan yang menyedihkan.

P/s The picture above has nothing to do with the lady in this article. It is a picture of the breast cancer of a lady (deceased) who came to me last year with lung metastases after months of intensive treatment by various bomoh.

Dancing With Dr Death

2009-02-15T22:05:00.005+08:00

New Straits Times: Tuesday, Feb 10, 2009

Bungling US doctor charged in Australia.

When I read this news in NST and later read the event from major Australian online newpapers - I found some similarities with what happened here about 20 years back.

In the late 80th and early 90th, there used to be many expatriate (foreign) doctors in Malaysian hospitals employed by the goverment to overcome shortage of specialists in this country. Many of these people came here from countries which were generally 'poorer' than Malaysia. You can't expect doctors from UK or Australia to come here since their income in their home country is much higher than here. Since the salary we paid them was relatively low, we couldn't expect to get first class specialists. Bak kata pepatah: You give peanuts, you get monkeys ! Jadi ramailah yang datang ke sini buat-buat pandai, ada yang datang dengan 'blown-up CVs'. Ada seorang tu, dalam CV pernah buat lebih 1000 endoscopy, tapi bila pegang OGDScope, nampak sangat tak tahu!. Every thyroid operation, blood loss would be more than a litre. I still remember very well; few medical officers 'diverting' cases to other surgeons whom they believed were more competent. I have assisted a surgeon doing esophagectomy - after the surgery I thanked him for allowing me assisting him although I was not in his team; I said "thanks sir, this is my first esophagectomy", he said "thanks to you, this is also my first, I choose you because I saw you opened a chest before". Laa, patutlah dia sungguh-sungguh suruh aku belah dada kawan tu!

I believe those era has long gone; we are now having many capable doctors. Some of our hospitals are the best in the region; for example the IJN. But recently the cycle might have come back. With prosperity, more private hospitals were opened. More specialists moved from the public to the private sector, leaving the public hospitals short of senior doctors. Again the vacancies are filled with foreigners.

Janganlah pisang berbuah dua kali...... The goverment mungkin perlu ingat .... you give peanuts, you get monkeys. Sorry !

Hirschsprung Disease

2009-02-02T16:13:00.005+08:00

Hirschsprung disease is a disease seen in neonates where congenital absence of special nerve cells in the rectum called ganglion cells resulting in the failure of the that segment of large intestine fails to function. Newborns fail to pass meconeum, and they are diagnosed and operated by paediatric surgeon as soon as possible to save them. A very small percentage of children born with this disease might survive with chronic constipation. This is usually when the affected intestine is very short; short segment Hirschsprung disease. Rarely they live beyond that and into adulthood untreated. This is what I am highlighting today.

In the last 20 years of my practise, I have seen many such patients, 16 to be exact. These people was never brought to seek treatment by their parents when they were small kids. Some was forced by their teachers and friends to seek help because they were smelly with overflow incontinence - cursed busuk, tak tau basuh punggung ke?

This is an intra-operative picture of a segment of a large intestine (rectum) in a 33 year old policeman with Hirschsprung disease. (I once joked to a colleague; I removed a cat that accidentally went into the man's rectum while he pleasured himself with the animal ! )

He had a laparotomy and colostomy done in a nearby hospital when his colon perforated. He was then referred to me for the definitive surgery called Duhamel operation, and later closure of the colostomy.

The point is - our peoples wait till the last minute to seek treatment. If they had done so earlier; they would have led a normal life. But they rather wait and suffer the consequences; in this disease - chronic constipation, abdominal distention, overflow incontinence (ke mana pergi busuk bau taik) and if unlucky enterocolitis and death.

Ini sebut je operation, tak payah lah. Tunggu besar lah; bila besar yang senang dah jadi susah. Apa nak jadi !!!

Sorry, I need to talk to BOMOH first

2009-01-24T15:45:00.002+08:00

This CT scan image belongs to a middle-age man who came to the hospital for prolonged fever and multiple lymphnode enlargement. He was found to have generalised lymphadenopathy involving those in the neck, abdomen, inguinals and in the chest. CT-scan diagnosis was Non-Hodgkins Lymphoma stage IV, and the managing physician advised him to have a biopsy of one of the nodes. This was when I came to the picture.

I explained to him that the biopsy will involve making a small incision in the neck or in the inguinal, and taking out a lymphnode for the pathologist to study. All he said was ..."Sorry, I need to talk to my BOMOH first". With that, he discharged himself from the hospital despite many attempts to make him understand what a lymphoma or a cancer means.

I am speechless ! Whoi !

2009-01-24T13:08:00.004+08:00

APA NAK JADI DENGAN DOKTOR-DOKTOR KITA ?

Last week I joined my gynaecologist operating on this patient; inserting bilateral ureteric stents and assisted him in his surgery. The patient was an elderly lady with advanced ovarian cancer. She had earlier seek treatment for a progressively enlarging abdominal mass and lower abdominal pain in a nearby public hospital. She went to the gynae clinic there; saw one MO (medical Officer - ? trainee gynecologist) who did an ultrasound scanning. Detecting the mass, he requested for a CT-scan examination. During the next visit, CT was done and she was seen by another MO and was asked to come at a later date to see the gynecologist in-charge. On the given date, she came but this time she was seen by another MO and no decision was made. She was then given another date. The time interval from the first to the last visit was four and half months. Upset with the long wait, her childrens later decided to bring her to our hospital; saw our gynaecologist on one day, admitted her and got the CT-scan and IVU done on the next day, TAHBSO surgery on the day after. Now, she is awaiting her chemotherapy.

Look, I am neither comparing (the efficiency or what) nor advertising; but to highlight the attitude of some of our doctors in dealing with cancer patients. When you suspected a cancer, you should put high priority in the case, deal with it 'urgently' . You are not dealing with a reducible inguinal hernia or a lipoma where you can take your sweet time and schedule the surgery electively at the end of your long elective surgery list.

No wonder we are seeing advanced diseases with poor prognosis !

Kalaulah orang lain buat benda macam ini pada kita atau orang kesayangan kita, tentu kita marah. Jadi rawatlah pesakit kita sebagaimana kita mahu dilayani atau dirawati.

2008-12-30T22:12:00.005+08:00

TB Peritoneum

A man (one of the many foreign workers in Malaysia) was referred to me with ascites (fluid in the peritoneal cavity) and weight loss. The working diagnosis was tuberculosis. Mantoux test was negative, PCR and ESR were not suggestive. Chest X-ray was clear. The peritoneal fluid was tapped but the cytology was negative. I did a laparoscopy recently; and this is what I saw. Thousands of small 'soft' nodules (which I prefer to call tubercles) studded the surface of the peritoneum, intestines and other intraperitoneal organs. These were biopsied and the diagnosis of tuberculosis confirmed. He was sent back to the referring physician to recieve anti-tuberculosis treatment.

The prevalence of tuberculosis mainly PTB was high in Malaysia previously. With good public health programme and vaccination, it was brought under control. Unfortunately, lately it has resurged. One of the reasons given was HIV; low immunity. But I believe the influx of immigrant workers from countries which don't have efficient anti-TB programme is the main reason.

The authority should look seriously into this. Now, we have new diseases that we never heard about before: Chikungunya, Yellow Fever, Kala Azar and what not !!!!

Globalisation doesn't come without a price .....

2008-12-30T21:47:00.004+08:00

Sebaceous Cyst

A sebaceous cyst is a closed sac below the surface of the skin that has a lining that resembles the uppermost part of a hair follicle and fills with a fatty white, semi-solid material called sebum. Sebum is produced by sebaceous glands of the epidermis. Usually patients present with a lump (most often painless) on the body or limb. Not unusual, the cyst gets infected and patients present with and abscess, and this is painful.

This is one of the few huge sebaceous cysts that I have removed. The patient was a man who had kept the lump for more than 10 years, and he came only when he couldn't sit properly.

He was lucky; this is a benign disease, not a cancer. If this were cancerous, then he would be in deep trouble !

SUSAH SANGATKAH NAK DATANG AWAL ???(Is it difficult to come for treatment early ??)

2008-11-18T21:33:00.006+08:00

3 in 1

Three cancers in one patient

Last year, a woman came to me with progressive jaundice (deepening yellowish discoloration of the skin). Initial investigations showed that it was an obstructive jaundice; meaning, the bile flow was obstructed resulting in bile seeping into the skin and sclera. In this lady, the obstruction was caused by a cancer in the head of pancreas, as shown in the CT-scan picture below.

However, she was also noted to have a fungating
tumour in her left breast. (picture below)

Biopsy (core-needle biopsy) showed that it was an infiltrating ductal carcinoma; meaning this was a confirmed breast cancer.

The CT-scan film showing the primary cancer of the left breast

Further examination also revealed a tumour in her right thyroid lobe.

Biopsy (Fine needle aspiration cytology - FNAC) showed that it was a follicular lesion.

A follicular thyroid swelling can be either benign or cancerous, but looking at the tumour clinically and on CT-scan, I was almost certain that it was a follicular cancer.

She underwent a surgery for the breast cancer (left mastectomy with axillary clearance ), a palliative by-pass of the pancreatic head cancer (gastro-jejunostomy, hepatico-jejunostomy - biopsy confirmed adenocarcinoma of the pancreas)

So, what am I trying to say ?

I am saying that this lady had three (3) primary cancers. This is extremely rare (I am waiting for my report to be published in a peer journal). But this is not my point to you. What I want to highlight here is how 'fantastic' our patient can be. Should she presented much earlier, she could have been saved. She succumbed to her diseases not long after the surgery.

By the way, it was reported in most news today, that the country is in need of more oncologists (cancer specialists) - "We need more than 200 oncologists but the country has only 39" - say the Health Minister. But with this attitude of not seeking treatment until it is too late, I dont see the urgency. The ministry of health has to come out with a policy / campaign / or what so ever to get cancer patients to the hospital, and to do so early !

2008-06-15T21:29:00.002+08:00

CANCER TREATMENT; ADJUVANT THERAPY

Most solid cancers are treated surgically. Cancers such as breast and colon cancers require surgery as the mainstay of their treatment. However, for advanced diseases, other modes of treatment are required to eradicate 'left-over' cancer tissues or cancer cells that have spread to distant organs (metastasis). These treatments are called adjuvant therapies; examples are chemotherapy, radiotherapy, hormonal and etc. So if a patient presents with advanced disease, beside surgery, he or she would requires other form of adjuvant therapies to treat the cancer.

For example, patients with cancer of the rectum (the lower end of the colon) would need surgery to remove the segment that contains the cancer (see pictures below). The removed specimen would then subjected to a thorough examination by a pathologist to determine the aggresiveness (grading) and how advance (staging) the cancer is. The managing surgeon or the oncologist would then decides on whether the patient requires some form of adjuvant therapies or not.

Low rectal cancer removed in a surgery called abdomino-perineal excision

The specimen opened to show the cancer within it

What I want to highlight today is that many patients do not understant the importance of adjuvant therapy after having had their surgery. Today a patient whom I operated two weeks ago for 'stage 3' rectal cancer (Duke C - staging) refused chemotherapy. She is a nurse and she said "I have seen enough patients who suffers the side effects of chemotherapy.." What could I do? When I was a medical student, there was a patient with a lymphoma (cancer of the lymphatic system); the only curable cancer at that time (1984), when told that he requires chemotherapy, said 'cukuplah ..! Now almost 25 years down the line, the attitude is still the same. The problem is; when they are very sick and the cancers are very advance involving all over their body, they come back asking for all sort of things. Last month, a man requested me to insert a chemo-port (a special catheter for administeration of chemo-drugs). He had advanced renal cancer, had refused treatment earlier, and now in acute renal failure. In that condition nobody is going to give him the chemo ! He died a week later.

Bak kata pepatah....Bila sudah terantuk, baru terngadah.

2008-06-03T20:56:00.004+08:00

KAMU BOLEH TUNGGU, TUNGGU DIA MATI.

Semalam, dalam HARIAN METRO terdapat satu berita yang memapar kekecewaan sebuah keluarga yang kehilangan seorang anggota keluarga mereka. Yang mereka kesalkan adalah sikap doktor yang merawat anak mereka, bersikap sombong dan biadap, sehingga sanggup mengeluarkan kata-kata 'Kamu boleh tunggu, tunggu dia mati" Mulanya saya rasakan ini biasalah bagi seorang yang baru ditimpa musibah (grief reaction). Apatah lagi dalam kesibukannya doktor itu gagal memberi penerangan yang memuaskan. Di petang hari yang sama seorang lelaki datang ke pejabat saya, bertanyakan sanggupkan saya merawat anaknya yang mengalami perdarahan di otak selepas satu kemalangan jalan raya. Anaknya masa itu sedang dirawat di unit Neurosurgeri hospital yang sama; beliau takut anaknya itu 'diapa-apakan' oleh seorang doktor di situ yang dikatanya sangat sombong dan tidak bertimbang-rasa. Saya jelaskan kepadanya bahawa pembedahan otak bukanlah kepakaran saya, dan saya nasihatkan beliau untuk selesaikan perkara itu dengan pehak bertanggungjawab di hospital tersebut.

Wow, mungkinkah ini satu sebabnya pesakit datang lewat mendapatkan rawatan seperti yang saya 'highlight'kan sebelum ini. Sikap doktor-doktor yang dikatakan sombong dan kurang bertimbangrasa. Sedangkan rata-rata tok bomoh dan singseh bermulut manis memukau. Bomoh patah mengurut tulang penuh sopan dan mesra sedangkan doktor otopedik menarik tulang sambil menyumpah seranah (pesakit mungkin sedar walau pun diberi sedation).

Petang tadi seorang pesakit datang kepada saya memohon penjelasan tentang penyakitnya. Beliau ada satu ketumbuhan kecil dipayudaranya, telah dibiopsi di hospital (yang sama di atas) dan tak faham penjelasan doktor yang merawat beliau. Lapurannya (biopsy report) tiada dibawanya. Saya terangkan kepada beliau, yang saya tidak dapat membantu, lainlah kalau ada lapuran itu ataupun beliau dapat sebutkan nama doktor berkenaan. Bolehlah saya 'hello'kan kepadanya dan tanyakan perkara tersebut. Inilah masaalahnya, sukar sangatkah untuk memberi penjelasan. Kalau pesakit tak faham istilah perubatan, buatlah analogi dengan barang, tumbuhan sekeliling agar mereka mudah faham. Kalau bahasa yang menghalang carilah seorang penterjemah. Hendak seribu daya, tak mahu seribu dalih!

Fikir-fikirkanlah .....................

Senyumlah wahai doktor-doktor ! It makes a lot of difference.

2008-05-31T20:16:00.000+08:00

Malam Pertama - Rupanya Sudah Ditebuk Tupai !

When I was working in the university few years ago, I was once invited by a gynecologist colleague to assist him in a surgery to removed a huge fibroid (a non-cancerous uterine tumor). The patient was a 30 something year old lady who seek treatment only to proof that she was a 'virgin'. The story went on like this. This particular girl had a progressively enlarging tummy for several years. She used to avoid marriage proposals due to that, until the day she could not give anymore excuses to her parents. It was an arranged marriage - much a common practice in Kelantan. Came 'malam pertama' - the first night after concilliation of the marriage vow - in her husband's advance he noticed the big tummy, almost the size of a full-term pregnancy. Wow... he became furious...... accusing the poor girl and his in-laws of cheating him. "Apa ni, sudah ditebuk tupai !" Only to proof her innocence, did the girl came to the gynecologist. And we took out a 6.5 kg fibroid.

These pictures were given to me by another gynecologiost working in my present hospital. The presentation was more or less the same except this time it was a huge ovarian cyst, not a fibroid.

At the begining of surgery, I thought she was going to do a ceaserian section

A long midline incision; the usual ceaserian section is through a pfnenstiel or bikini incision

There was it; a huge cyst, the fluid was being sucked out !

So you see my point, our peoples wait till the last minute. If you are a girl, and something starts growing in your tummy, you should become worry, very worry. Unless you know for sure that it is your much-awaited baby.

I really hope that the authorities do something about this. I wish my ex-classmate (MU 80/85) who is the Deputy Minister of Health gives some emphasis on this. Forget about certain 'license to . . . . !

2008-05-29T21:58:00.000+08:00

CUTI SEKOLAH - MUSIM BERSUNAT

(School Holiday - Circumcision time)

Di Malaysia, bila bermula cuti sekolah, tibalah musim bersunat. Kalau dulu inilah masanya tok-tok mudim buat bisness, tapi sekarang tak lagi. Ramai ibubapa membawa anak-anak mereka ke hospital atau ke klinik bertauliah untuk menyunatkan anak lelaki mereka. Namun masih ada yang selesa dengan yang tak bertauliah. Dalam banyak kes, yang haram tu lah yang seronoknya. Sesetengah tok-tok mudim itu pula adalah kakitangan paramedik yang cari duit tambahan. Musim cuti ni ambil cuti tahunan. Jadi kenalah buat cepat-cepat, maklumlah ramai yang beratur diluar menunggu untuk disunatkan. Setiap musim bersunat ini, ada saja kes yang dirujuk ke pakarbedah untuk tolong repairkan yang dah terlebih potong. Biasanya kes macam ini tidak dihantar ke hospital kerajaan, sebab besoknya akan terpampanglah cerita di Harian Metro yang tunggu saja berita-berita sensional.

Ini adalah satu darinya, habis seluruh kulit burung budak tu dilapahnya. Nak repair bukannya senang, terpaksa ambil kulit dari bahagian lain ditampalkan ke situ.

Akhir tahun lepas, seorang kena potong 'kepala'nya, terkulai. Ini baru yang datang kepada saya, tapi masih ramai lagi pakarbedah yang dapat kes semacam ini. Moga-moga cerita ini menyedarkan ibubapa. Janganlah kerana seringgit dua, naya anak tu. Tapi orang kita memang macam ini, duit beli rokok habis beratus ringgit sebulan, tapi untuk kesihatan atau pelajaran berkira macam nak mati.

Kepada ayah ibu tu, bawalah anak anda ke tok mudim atau doktor yang bertauliah. Bagi kebanyakan kanak-kanak yang berumur 9 tahun ke atas, bersunat dengan bius setempat adalah selamat. Bagi yang kurang dari 9 tahun, pilihlah bersunat dengan bius penuh (general anaesthesia). Sekarang telah jadi trend, bawak anak-anak berumur 5 - 6 tahun untuk bersunat, puas lah pujuk; dan setelah kena sejarum, selak budak tu. Kesian budak tu - sampai ke tua takutkan doktor. Selari dengan garis panduan Kementerian Kesihatan; bagi yang berumur kurang dari 9 tahun, bersunat disyorkan dengan bius penuh. Kalau tidak, tunggulah sehingga anak itu cukup umurnya.

Dan kepada anak-anak tu, selamat bersunat !

2008-05-26T21:20:00.000+08:00

HEMORRHOIDECTOMY; Surgery for Hemorrhoids

Today I received an e-mail from someone who enquired about prolapsed hemorrhoids, and what to do to it. Hemorrhoids or piles is an interesting disease. It is an 'old' disease that surgeons thought the treatment is already established long time ago. However with the 'new' understanding on the pathogenesis (how it comes about) of the hemorrhoids, came new treatment modality. We believe that hemorrhoidal tissue is a part of a normal structure (endocushions) in the anal canal that helps in maintaining continence of the anal sphincter. You just imaging without this, if you fart or jump, you might get fecal soiling of your underpant. I prefer to use the word 'hemorrhoidal disease' to 'hemorrhoids' per se.

Some Malaysians go to Singseh or Tabib Buasir for their hemorrhoids. I am not against 'alternative medicines'. Unfortunately not all prolapsed anal lesions are hemorrhoids. I have seen many anal or rectal cancers 'treated' as hemorrhoids. Furthermore they are something called secondary hemorrhoids; these are hemorrhoids that formed as a result of (secondary to) other rectal disease, usually cancers. My advice is that if you notice some mucus on your feces or the blood from your 'hemorrhoids' mixed (not stain on the surface) of your feces; you should go to a surgeon instead of a singseh. You might be having life-threatening cancer.

This is a hemorrhoids, the more reddish inner part is the internal component,

while the darker outer part is the external component.

Prolapsed hemorrhoids is best treated surgically. The old surgical techniques are usually painful. Now, there is a new technique recently introduced by Prof. Antonio Longo from Italy called the Stapling Hemorrhoidectomy or the PPH (Procedure for Prolapse and Hemorrhoids). I personally believe that this method has revolutionised surgical treatment of hemorrhoids. The main advantage is painlessness of this surgery. This is how some of the staplers look like.

Basically it cuts out a segment of rectal mucosa and staples the two ends together with small titanium staples. As a result, the prolapsed tissues are pulled back into the anus and rectum back to their original position. Since the cutting and stapling are done well inside the rectum, you won't feel the pain. Some patients might complain of some degree of pain, this is from the stretching of the anal canal , and this is usually minimum. The only 'setback' of this instrument is its cost. You may need to pay about RM 1700 for this single-use gadget.

These pictures show the hemorrhoids after and before stapling (PPH)

Before procedure
Immediately after completion of surgery

A nurse told me this morning that one of her relatives has a 'huge' prolapsed piles that made him unable to wear a trouser for many months. The same old story, repeatedly....LATE PRESENTATION !

Apa nak jadi ni?

********************************

Mat Saleh pun sama laa ....

From the web !

2008-05-25T23:58:00.000+08:00

WHY WAITING ?

Late presentation of cases occurs in all types of cancer. I believe the common cause for this is absence of pain. Unfortunately for many cancers, pain is not an important feature; unlike inflammatory disease such as infection. Look at these pictures; the elderly lady had a fungating cancer in the groin. An infective ulcer would usually be very painful, but this is a lymphoma; a potentially curable cancer of the lymphatic system. The lymphoma is usually treated with chemotherapy. Surgery is usually limited to biopsy in order to get to the diagnosis. The lady had to be operated, leaving a huge defect that required a vascularised myocutaneous flap from her thigh to cover the defect. She was then referred to the oncologist for chemotherapy, ...... and she defaulted !

The fungating tumour

Covering the defect with a flap

End of surgery

There are cases of neglected inflammatory or infective ulcers. As the general rule, this is usually painful, but some patients do come with advanced lesion; more appropriately neglected lesions. These are usually elderly peoples, diabetics or in the next pictures a schizophrenic.

You can see maggots squirming in it

During surgery; the infection was noted extending into the pelvis, perineum and even the bones. And at the end of the operation I did not charge for the procedure I did, but for the smell that I had to bear !

After all these, I am still wondering why patients need to wait till it is very late !

2008-05-23T22:58:00.001+08:00

TAKING A BREAK .......

Other than doing surgery, I love 4X4 driving. Venturing deep into tropical forest of Malaysia, experiencing the beauty of its flora and fauna. During my latest expedition, I was caught in a flash flood 20 minutes after a heavy tropical downpour.

At 5.30 pm; not able to cross a river, the log-bridge couldn't be seen

7.30 pm; it was getting dark, alone, 28-km from the nearest civilization

Finally out by 8.40 pm, intact to continue the challenge of a life of a surgeon !

2008-05-23T21:37:00.000+08:00

Surgery time

(Simple mastectomy with axillary clearance and immediate breast reconstruction using free transfer TRAM flap)

This is a picture taken during one of my cancer surgeries. We were removing a cancerous breast (mastectomy and axillary clearance) and immediately reconstructing a 'new breast' using the abdominal wall muscle (free TRAM-flap). You can see me (using a magnifying operating glass) doing the mastectomy, and the plastic surgeon harvesting the TRAM flap simultaneously. My part usually takes 2 hours but the plastic surgeon takes another 6 to 8 hours. Patients having mastectomy with immediate breast reconstruction were usually much happier as their 'body contour' is maintained. They didn't feel 'mutilated' after the surgery. I am hoping that with the availability of this type of surgery, Malaysian patients should not be delaying their treatment for fear of loosing their 'womenhood'. And of course we practise breast conservative surgery for early diseases.

2008-05-23T21:08:00.000+08:00

Goitre (thyroid enlargement)

Multinodular goitre is another disease which I used to see late presenters. Now the incidence of huge goitre is much less; I presume that it is not easy to hide. This is one of those cases. She was a patient of one of my colleagues.

During my days working in the university, I had a patient with a thyroid cancer (papillary type)weighting 1.3 kg. Way back in the late 80'th when I was a junior doctor in Mentakab, I used to see young women from Jerantut (Kg. Bantal) with large multinodular goitre. Those were the so-called endemic goitres; due to deficiency of iodine in their drinking water.

In Kelantan, we have a specific term for this large multinodular goitre; GONDOL

2008-05-19T22:02:00.000+08:00

Late presentation of surgical conditions is not only in cancer cases, but in other non-cancerous conditions as well. Most common is hernia. Our people tend to keep their hernias 'secret' till the time they couldn't hide it anymore. Either it is too big or it gets obstructed or strangulated.

There are the 'common' presentations;

A 42 year old man

A 63 year old man

I could not imaging how these people get on with their life, having to carry huge things in between their thighs. How did they hide this from other peoples? Once I saw a man in a 'kenduri' who had to adjust something in his sarong in order to sit down and eat; and the way he did that, it must be a huge thing.

The usual hernia that you see bulging in the groin (called bubonocele-type) or that of inguino-scrotal type is usually repaired in a relatively simple and fast operation; herniotomy (in children and adolescents), herniorrhaphy (the weak area is sutured to strengthen it) or hernioplasty (meshes used to strengthen the posterior wall). This operation usually never take more than one hour to do and in my hospital it costs between RM4000 - RM5000. Huge hernias are of course more difficult to repair and more costly.

This is a hernia that I repaired two years ago. It tooks the man 40 years to come, seven days in the hospital including two days in ICU, and RM35,000 in hospital bill.

A 57 year old man

Almost the whole bowel, from the jejunum to the sigmoid colon were in the hernia. X-rays taken before operation showed bowel shadows lie near the knee joints.

Is there a way to make patients come early?

Probably the goverment (Ministry of Health) should start putting billboards on the highways with a picture like the above with a caption " JANGAN TUNGGU SAMPAI MACAM INI" or "MACAM MANA NAK BUAT KERJA KALAU INI MACAM!"

2008-05-10T22:26:00.001+08:00

Why breast cancer patients in Kelantan present late ?

I have been asking this question to my patients and to myself regularly in an attempt to understand their attitude towards this deadly disease. Some of them found the question insulting, others didn't mind sharing.

1. In Bahasa Melayu, cancer is 'barah', breast cancer is 'barah payudara' . In Kelantanese dialect, there is something called 'barah susu'. This is not breast cancer, but it is used to describe lactating breast abscess. If you ask a patient whether she has a family history of barah, she might say yes, you ask what happen to the patient, you will get: 'OK sembuh dah, tak payah buat operation pun!" and this is misleading. When I was working in Penang, a friend of mine told a Chinese patient that he had a barah, the man jumped off the then newly-built Penang bridge. He knew exactly that he had a grave disease that he took his own life prematurely. Now I never use the word barah when communicating with my patients, I use 'kanser'. Tak faham juga, I said; penyakit yang membunuh our ex-No.1 lady. Ohh... baru faham. Bagus juga if some well-known peoples get certain diseases, boleh buat contoh. Anyway, I used Kylie Minogue's name to explain breast conservative surgery.

2. Even if the lady understands that she has a breast cancer, and she knows that she needs to remove the breast in order to save her life, she may not in a position to decide on that. You might laugh on this, but I have seen cases after cases where the ladies said no because the bloody husbands said no to mastectomy. In 1998, a man told his wife(my patient); if you consent to the surgery I am going to divorce you! Somehow she agreed to the mastectomy which I did. When a nurse asked me where to put the specimen, I told her to send it to the man so that he could do whatever...(He divorced the poor lady a as soon as she went home after the operation) Of course not all husbands are the same; there was man who told his wife; I love you with or without your breasts!

3. BOMOH - This is an irritating element in the society. They offer to treat all sorts of diseases, usually without surgery. Of course the poor patients fall to their trick, and in the end the patients come to seek your help with a locally-advanced or metastatic disease.

This experience has thought me to offer breast reconstruction to patients undergoing mastectomy surgery; either immediate or late reconstruction. And whenever possible, I will always offer them breast conservative surgery.

Terminology:

Mastectomy - surgery where the whole breast is removed

Metastasis - cancer that has spread to distant organs

2008-05-07T22:32:00.003+08:00

Let's get real. I will show you some statistics

Are Malaysian Chinese and Indians more prone to get breast cancers compared to Malay women? I don't think so. The apparent lower incidence among Malay women is because we lost these people to the bomoh; they didn't come to the hospital.

They prefer to go anywhere else, but not to the doctors. For example , this 25 year old well-educated girl seek treatment from a 'bomoh who operates" for her breast lump.

"Picture DELETED"

After undergoing 'surgery' and acquiring disfiguring scars, the lump was still there. She came to me for a' second opinion'. Luckily it was a breast mouse; a fibroadenoma, a non-cancerous or benign condition.

Whooi, what's this?

During my 20 years of surgical practice, I have seen 5 such cases. The first one was 15 years ago in Mentakab, the woman walked into my clinic with a towel over her shoulder and her arm was supporting something underneath the towel. It was a FIFA-standard-football size lesion. This lady in the picture came last year. The last patient came last week, all the way from Penang. This lesion is called Phylloides tumour (giant fibroadenoma - but ours are really giants!) The point is, why our ladies presented with this huge lesion? Why so late? Why don't you come early and get treated with a small lumpectomy. This tumour changes to cancer after sometime. When it does, it becomes a sarcoma; a cancer with even worth prognosis compare to that of the usual breast cancers.

When I decided to start this blog, all I have is this in mind... To get rid of this third world mentality out of our mind. We have first class medical facilities ! I am not talking about KL or Penang, but in most major towns and cities in Malaysia. Probably before we start talking about medical tourism, we should get our people to recognised our hospitals as a place to come for medical treatment !

2008-05-07T22:14:00.000+08:00

I am going to start with breast cancers.

In the last 5 years of my private practice, many women came to me to seek treatment for their disease (breast cancers). Unfortunately many of them came with advanced diseases. They were not old ‘makcik’ from far-away ‘kampongs’, but they were women with good education, wealthy background or wives of ‘somebody’. The usual story is that they were diagnosed to have breast cancers one or two years’ earlier, advised treatment but defaulted. They then seek ‘treatment’ from bomoh or singseh, spend thousands of ringgits, went overseas as far as Turkey or Egypt, not to see surgeons or oncologists, but the bomoh-equivalents of course. When the cancers ulcerated, infested with maggots and they themselves couldn’t bear the smell, they came to me; ‘Doktor, tolonglah, buatlah apa saja, saya terimalah !’ At that stage, the most I could offer is palliative treatments. In two circumstances, the only thing I did was to chase-away the maggots with turpentine, before they succumbed to their disease; ‘peacefully’- maggot-free !

This was one of the cases.
When I was working in the university, after seeing many of these ladies dying in this miserable way, I hope not to see this again. Now, after so much publicity on the cancer and the government efforts in preventing advanced diseases, campaign on free mammogram; things are not changing. What has happened to Malaysian women?
Is this is part of the famous ‘tunggu saat-saat akhir’ attitude of Malaysians? Wait till the last minute to renew your licence – fair, but this cancer, you lost your life.

I will try to discuss the causes of this in my next posting. Before I stop, see this….
This is mat saleh,….. minah saleh to be exact, from a textbook.
Bukan Pak Pandir sorang yang mati anak !