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 .....

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 ??)

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 !

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.

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.

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 . . . . !

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 !

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?

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Mat Saleh pun sama laa ....

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From the web !

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 !

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 !

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.

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

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!"

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

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 !

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 !