[Show abstract][Hide abstract] ABSTRACT: Most cases of intussusception in adults present with chronic and nonspecifi c symptoms, and can sometimes be challenging to diagnose. We herein report on a patient w ith the rare symptom of colonic intussusceptions presenting with rectal prolapse and review the existing literature of similar case reports to discuss how to reach an accurate diagnosis. A 75-year-old woman with dementia presented with per rectal bleeding, rectal prolapse and lower abdominal pain. An operation was scheduled and a large sigmoid intussusception with a polyp as a leading point was found intraoperatively. She subsequently recovered well and was discharged. As large sigmoid intussusceptions may present as rectal prolapse, intussusception should be considered as a differential diagnosis for immobile patients, especially when the leading point is a lesion.
Preview · Article · May 2015 · Singapore medical journal
[Show abstract][Hide abstract] ABSTRACT: We aimed to report the outcomes of inguinal hernia repair performed at Tan Tock Seng Hospital and compare them with those performed at dedicated hernia centres.
We retrospectively analysed the medical records and telephone interviews of 520 patients who underwent inguinal hernia repair in 2010.
The majority of the patients were male (498 [95.8%] men vs. 22 [4.2%] women). The mean age was 59.9 ± 15.7 years. Most patients (n = 445, 85.6%) had unilateral hernias (25.8% direct, 64.3% indirect, 9.9% pantaloon). The overall recurrence rate was 3.8%, with a mean time to recurrence of 12.0 ± 8.6 months. Risk factors for recurrence included contaminated wounds (odds ratio [OR] 50.325; p = 0.004), female gender (OR 8.757; p = 0.003) and pantaloon hernias (OR 5.059; p = 0.013). Complication rates were as follows: chronic pain syndrome (1.2%), hypoaesthesia (5.2%), wound dehiscence (0.4%), infection (0.6%), haematoma/seroma (4.8%), urinary retention (1.3%) and intraoperative visceral injury (0.6%). Most procedures were open repairs (67.7%), and laparoscopic repair constituted 32.3% of all the inguinal hernia repairs. Open repairs resulted in longer operating times than laparoscopic repairs (86.6 mins vs. 71.6 mins; p < 0.001), longer hospital stays (2.7 days vs. 0.7 days; p = 0.020) and a higher incidence of post-repair hypoaesthesia (6.8% vs. 1.8%; p = 0.018). However, there were no significant differences in recurrence or other complications between open and laparoscopic repair.
A general hospital with strict protocols and teaching methodologies can achieve inguinal hernia repair outcomes comparable to those of dedicated hernia centres.
No preview · Article · Apr 2014 · Singapore medical journal
[Show abstract][Hide abstract] ABSTRACT: Introduction:
This study aimed to characterise interpersonal violence victims admitted to a major trauma centre.
Materials and methods:
A retrospective cohort study of interpersonal violence victims who were admitted to our centre from 1 January 2001 to 31 December 2010 was conducted. Data were obtained from our trauma registry.
Interpersonal violence victims constituted 444 (90.1% males and 9.9% females) out of a total of 8561 trauma admissions in the same time period. The average age was 36.6 years (range, 14 to 83 years). Majority were Chinese (53.4%) and Singaporeans (77.3%). The number of cases increased from 10 per year to 96 per year in the first 8 years, then decreased in the last 2 years (55 in year 2010). Time of injury was predominantly 0000 to 0559 hours (72.3%). Interpersonal violence mostly occurred in public spaces for both genders (88.7%). However, the number of females who were injured at home was significantly higher than males (P = 0.000). Blunt trauma (58.3%) was more common than penetrating trauma (41.7%). The average injury severity score (ISS) was 13.5 (range, 1 to 75); 34.9% of patients had major trauma (ISS >15). The average Glasgow coma scale (GCS) score was 13.5 (range, 3 to 15); 16.4% of patients had moderate-to-severe brain injury (GCS 3-8). Blunt trauma was significantly more likely to cause major trauma than penetrating trauma (P = 0.003). The sole case of firearm assault caused most morbi-mortality. Overall mortality was 4.5%. Major trauma (OR: 25.856; P = 0.002) and moderate-to-severe brain injury (OR: 7.495; P = 0.000) were independent risk factors of mortality.
There has been no prior published data on interpersonal violence locally. This study is thus useful as preliminary data for future population-based studies. It also provides data for authorities to formulate preventive and intervention strategies.
No preview · Article · Mar 2014 · Annals of the Academy of Medicine, Singapore
[Show abstract][Hide abstract] ABSTRACT: Background:The controversy surrounding the impact of Body Mass Index (BMI) on the outcome of trauma patients has been widely studied in the West. However, no such studies have looked at an Asian trauma population. The aim of our study was to investigate the impact of BMI on mortality, morbidity, severity and pattern of injury in trauma patients of multicultural Singapore. Methods: In this prospective study, we recruited all trauma patients admitted to Tan Tock Seng Hospital over a 13 month period. Both the international World Health Organization (WHO) and Asian modified classifications of BMI were used for the purpose of our study. Patient demographics, co-morbidities, mechanism of injury, injury severity score (ISS), body regions injured, morbidity and mortality were collected using inpatient medical records. Results: 964 patients with a mean age of 50.5 years were recruited. Majority of injuries sustained were due to falls. There was no association between Asian BMI and ISS. Head, neck and cervical injuries occurred less commonly in the overweight and obese group, but BMI does not confer protection from truncal injury. BMI was not a significant risk factor for morbidity or mortality. Conclusion: Being overweight does not appear to increase severity of injury in Asian trauma patients. BMI as an independent risk factor does not contribute to trauma mortality or morbidity. We conclude that BMI is not a significant contributing factor to adverse trauma outcomes in Asians. (Hong Kong j.emerg.med. 2012;19:312-318)
No preview · Article · Sep 2012 · Hong Kong Journal of Emergency Medicine
[Show abstract][Hide abstract] ABSTRACT: Purpose
Traumatic rib fractures account for 7–40 % of trauma admissions and most of them heal spontaneously and do not contribute to disability. The prevalence of chronic pain and its impact on quality of life following a traumatic rib fracture has not been studied adequately.
A retrospective review of electronic medical records of all the traumatic rib fracture admissions from January 2007 to December 2008 was conducted. This was followed up with a brief telephonic survey of the following questions: (1) Do you have pain following the trauma? (2) If YES, how severe is your pain from a score of zero to ten? (3) Does the pain affect your life style? (4) Does the pain affect your work? (5) Do you need to take regular pain medications?
One hundred and two patients responded to the survey and 23 patients (22.5 %) complained of chronic persistent pain. In patients with pain, six patients (26 %) had chronic pain that required regular use of analgesics, eight patients (35 %) complained of impairment of work life, and three patients (13 %) complained of impairment of personal quality of life. Chronic pain was not related to age, number of ribs fractured, flail chest, hemothorax and/or pneumothorax, chest tube insertion, or Injury Severity Score (ISS).
This study confirms the high incidence of chronic pain after a traumatic rib fracture. While the majority of the patients can manage this pain without interference of their quality of life, a few do suffer from life style/work interference and may have to resort to regular analgesic usage.
No preview · Article · Aug 2012 · European Journal of Trauma and Emergency Surgery
[Show abstract][Hide abstract] ABSTRACT: Introduction
Les lésions de l'aorte thoracique secondaires à des traumatismes fermés constituent une pathologie menaçant le pronostic vital, avec une mortalité et une morbidité significative lorsqu'elles sont traitées par chirurgie ouverte. Les modalités endovasculaires émergent comme alternatives thérapeutiques attractives et moins invasives. Nous rapportons notre expérience du traitement endovasculaire par endoprothèse couverte des traumatismes fermés de l'aorte thoracique.
De Janvier 2003 à Aout 2009, six patients avaient un traitement endovasculaire pour traumatisme fermé de l'aorte thoracique. Les données des dossiers médicaux de ces patients étaient analysées.
Tous les patients avaient des traumatismes par décélération conduisant à la formation d'un pseudoanévrysme thoracique au niveau de l'isthme aortique, juste en aval de l'artère sous-clavière gauche. Quatre patients étaient des motocyclistes blessés dans le cadre d'accidents de la route et deux patients étaient pris en charge suite à une chute importante. L'Injury Severity Score moyen était de 33,8 (range, 21-43). Toutes les procédures étaient réalisées au cours des 48 heures suivant l'admission et le succès technique était de 100%. Cinq patients (83,3%) avaient une couverture délibérée de l'artère sous-clavière gauche par l'endoprothèse pour permettre un ancrage proximal adéquat. Aucun de ces patients n'avait d'ischémie du membre supérieur ou d'accident vasculaire cérébral après la procédure. L'artère sous-clavière gauche était conservée chez un patient dont l'angiographie vertébrale peropératoire montrait une artère vertébrale droite hypoplasique. Aucune autre complication procédurale, paraplégie ou décès, n'était notée. Le suivi moyen était de 18,8 mois (range, 1,5-42 mois).
Notre expérience préliminaire du traitement des traumatismes fermés de l'aorte thoracique par endoprothèse suggère que cette technique émergente est sûre dans le traitement de cette pathologie chez notre population Asiatique. L'artère sous-clavière gauche peut être sacrifiée si une zone d'ancrage proximale satisfaisante est nécessaire pour l'endoprothèse, ou lorsque l'angiographie vertébrale ne montre pas d'artère vertébrale gauche dominante.
No preview · Article · Jul 2011 · Annales de Chirurgie Vasculaire
[Show abstract][Hide abstract] ABSTRACT: Thoracic aortic injury from blunt trauma is a life-threatening condition with significant mortality and morbidity with open surgical repair. Endovascular means of treatment is emerging as an attractive and less invasive option. We report our experience with endovascular stent-graft repair for blunt traumatic thoracic aorta injury.
Between January 2003 and August 2009, six patients underwent endovascular repair of blunt traumatic thoracic aorta injury. Data from the medical records of these patients were analyzed.
All patients had deceleration injury resulting in thoracic aorta pseudoaneurysm at the aortic isthmus just distal to the left subclavian artery. Four patients were motorcyclists who had been involved in road-traffic accidents and two had fallen from a height. The mean Injury Severity Score was 33.8 (range, 21-43). All procedures were performed within 48 hours of admission and technical success was 100%. Five patients (83.3%) had the left subclavian artery intentionally covered by the stent-graft to achieve adequate proximal landing zone. None of them had any left upper limb ischemic complications or cerebrovascular events after the procedure. One patient had preservation of the left subclavian artery because intraoperative vertebral angiogram showed a hypoplastic right vertebral artery. No other procedural complications, paraplegia, or deaths were reported. Mean follow-up was 18.8 months (range, 1.5-42 months).
Our early experience of endovascular stent-grafting for blunt traumatic thoracic aorta injury suggests that this emerging technique is safe for treatment of such pathology in our inherently Asian population. Left subclavian artery may be sacrificed if adequate proximal landing zone is required for the stent-graft; and when vertebral angiogram was performed which did not show a dominant left vertebral artery.
No preview · Article · Mar 2011 · Annals of Vascular Surgery
[Show abstract][Hide abstract] ABSTRACT: Purpose Traumatic perforation of the gastrointestinal tract (GIT) poses numerous challenges for surgeons worldwide. We aimed to review
our institution’s experience and highlight the pertinent issues in managing this problem.
Methods A retrospective review was performed for all patients with perforation of the GIT following traumatic blunt injuries.
Results Twenty-one patients, with a median age of 40 years, formed the study group, all of whom underwent surgery. Four patients were
sent straight to the operating theater from the emergency department due to hemodynamic instability, while another two patients
had pneumoperitoneum on their X-rays. Computed tomography (CT) scan was performed in 15 patients, with the findings of pneumoperitoneum
(n = 7, 46.7%) and free fluid without solid organ injury (n = 9, 60.0%) being the most common result. The jejunum (n = 11, 52.4%) and ileum (n = 5, 23.8%) were the most common sites of perforation. Direct repair was performed in 9 (42.9%) patients, while resection
of the perforated segment(s) was performed in the remaining 12 (57.1%) patients. Other associated intra-abdominal injuries
included mesenteric (n = 6, 28.6%) and splenic lacerations (n = 4, 19.0%). Surgery was performed within 8 h of the accident in only 11 patients (52.4%). Some of the complications included
wound infection (n = 7, 33.3%) and intra-abdominal abscesses (n = 3, 14.3%). Two patients underwent relook laparotomy after an initial damage control laparotomy.
Conclusion Prompt and early surgery for traumatic gastrointestinal perforation is advised. Any abnormal CT scans warrants either surgery
or close monitoring. Direct repair of the perforation is preferred, if possible.
No preview · Article · Feb 2011 · European Journal of Trauma and Emergency Surgery
[Show abstract][Hide abstract] ABSTRACT: Angio-embolisation in trauma is a relatively new technique that is gaining popularity and recognition in identifying and arresting bleeding in trauma patients. We studied the possibility whether angio-embolisation using the Digital Subtraction Angiography (DSA), in the operating theatre (OT) could achieve successful haemostasis in trauma patients. We further studied the feasibility of using this technique as part of trauma resuscitation/damage control.
A retrospective study of trauma patients, with Injury Severity Score (ISS ≥ 9), admitted to Tan Tock Seng Hospital (TTSH) from January 2004 to December 2008 was done. Patients who had received angio-embolisation in the OT or angiography suite were evaluated in terms of age, gender, ISS, the site and type of angioembolisation used. The primary end point was to assess the success rate of angioembolisation using the C-Arm DSA in the OT, and whether there were any complications necessitating a repeat procedure or surgical intervention. The secondary end points of the study were aimed at studying the cost effectiveness of this technique, logistical feasibility and evaluating this technique as part of the initial trauma resuscitative efforts.
A total of 43 trauma patients received angioembolisation. 32 patients had the angio-embolisation done using the C-Arm DSA in the OT (n = 32). None of the patients who received angioembolisation in the operating theatre (n = 32) had any re-bleeding. 15 out of 32 survived. There were no complications related to the angio-embolisation procedure. The majority of angio-embolisations done were for pelvic fractures.
The success of angio-embolisation in the OT using the C-Arm DSA for a trauma patient and its complication rates are similar to that done in a dedicated angio-graphic suite. We conclude that angio-embolisation in the operating theatre using the C-Arm DSA is feasible, cost effective and can be a modality in the initial trauma resuscitation/damage control in any lead lined operating theatre. We believe that we are the first to describe this method of angio-embolisation using the C-Arm DSA in a conventional lead lined trauma operating theatre and its use as a feasible option in a trauma resuscitation/damage control algorithm.
[Show abstract][Hide abstract] ABSTRACT: Extra-hepatic bile duct injury from blunt abdominal trauma is uncommon. Complete traumatic transection of the common bile duct (CBD) with subsequent complication of a choledochoduodenal fistula is extremely rare and only a handful of reports are found in the medical literature. We describe a 20-year-old male patient who presented with a complete transection of the CBD following blunt abdominal trauma and his subsequent planned staged management.
[Show abstract][Hide abstract] ABSTRACT: Major workplace related accidents pose a significant healthcare resource challenge in Singapore.
Our study looks at the epidemiology of patients who were admitted for workplace related accidents, in a single institution, with an Injury Severity Score of >9.
There were 196 cases of major workplace related accidents admitted between January 2006 and December 2007. The median age of patients admitted was 37 years with a large percentage being males (95.4%) and non-residents (57.1%). The most common ethnic group was Chinese (53.1%) followed by Indians (23.5%). The most common mechanism of injury was fall from height (66.3%) followed by injuries as a result of falling objects at work (21.9%). The percentage of patients who required surgical intervention was 69.9%. Patients admitted for major workplace related accidents had a median length of stay of 5 days in the hospital, a median length of 24 days of medical leave (ML), certifying them unfit for duty and the average cost of stay for each patient was S$11,000.
We have a better understanding of the epidemiology and socio-economic impact of workplace related accidents through this study. Workplace related accidents result in significant number of man-days lost from work and monetary cost to employers, medical insurance and the hospital. With an improved understanding, we propose methods to prevent and reduce such accidents in future. A direct consequence of which will be the possible reduction of hospitalisation costs and better allocation of healthcare resources in the future.
Preview · Article · Dec 2010 · Annals of the Academy of Medicine, Singapore
[Show abstract][Hide abstract] ABSTRACT: Forty-two patients with traumatic blunt splenic injuries were admitted over a six year period. Vehicular-related collisions and fall from height accounted for the injuries in 38 (90.5%) of them. Eleven (26.2%) underwent immediate surgery (7 splenectomy and 4 splenorrhaphy), while the remaining 31 patients were treated nonoperatively of which 3 underwent angio-embolisation. Twenty seven patients had either grade III or IV splenic injuries. Operative management was more likely in patients with lower haemoglobin or with more severe splenic injury. Nonoperative management can be adopted in patients with blunt isolated splenic injuries but operative management is still indispensable in certain instances.
Full-text · Article · Dec 2010 · The Medical journal of Malaysia
[Show abstract][Hide abstract] ABSTRACT: Diagnosis of diaphragmatic rupture is difficult, and delays could result in a catastrophic outcome. We reviewed our institution's management of patients with diaphragmatic rupture after blunt trauma.
All patients in this study were treated at Tan Tock Seng Hospital, Singapore, from March 2002 to October 2008. Patients with penetrating injuries were excluded. The parameters included age, mechanism of injury, haemodynamic status at admission, Glasgow coma scale (GCS) score, injury severity score (ISS), imaging studies, location of diaphragmatic injuries, associated injuries and outcome.
14 patients with a median age of 38 years formed the study group. Vehicular-related incidents accounted for 71.4 percent of the injuries. The median GCS score on admission was 14 (range 3-15), while the median systolic blood pressure and heart rate were 94 (range 50-164) mmHg and 110 (range 76-140) beats per minute, respectively. The median ISS was 41 (range 14-66). All had chest radiographs performed in the emergency department, six (42.9 percent) had computed tomography performed before surgery, while the remaining eight (57.1 percent) were sent straight to the operating theatre from the emergency department. There were five (35.7 percent) right-sided and nine (64.3 percent) left-sided diaphragmatic ruptures. The mortality rate was 35.7 percent. Some of the associated injuries included eight (57.1 percent) splenic lacerations, five (35.7 percent) haemothorax and lung injuries, four (28.6 percent) bone fractures and three (21.4 percent) liver lacerations. 12 (85.7 percent) patients underwent repair of the diaphragmatic rupture using interrupted polypropylene suture, while the remaining two (14.3 percent) were too haemodynamically unstable to undergo definitive treatment. Advanced age, haemodynamic instability and raised ISS were associated with mortality.
An accurate diagnosis of diaphragmatic rupture in trauma patients is difficult, and a thorough examination of both the hemidiaphragms is mandatory during emergency laparotomy for these patients. Those with more severe injuries and decreased physiological reserves usually fare worse.
Full-text · Article · Dec 2009 · Singapore medical journal
[Show abstract][Hide abstract] ABSTRACT: Pancreatic injuries after blunt abdominal trauma could result in significant morbidity, and even mortality if missed.
Our aim was to review our institution's experience with blunt pancreatic trauma.
Our study included all cases of blunt traumatic pancreatic injuries.
Sixteen patients (median age 41 years; range: 18-60 years) were treated for blunt pancreatic trauma from December 2002 to June 2008.
Pancreatic injuries were graded according to the definition of the American Association for the Surgery of Trauma (AAST).
CT scans were performed on 10 (62.5%) patients, with the remaining 6 (37.5%) sent to the operating theatre immediately due to their injuries. Of the 12 (75.0%) patients who underwent exploratory laparotomy, 2 (12.5%) had a distal pancreatectomy (AAST grade III), 1 (6.3%) underwent a Whipple procedure (AAST grade IV) while another 2 (12.5%) were too hemodynamically unstable for any definitive surgery (AAST grade IV and V); the remaining 7 (43.8%) pancreatic injuries were managed conservatively. Four (25.0%) patients had their injuries managed non-operatively. Some of the associated complications included intra-abdominal collection (n=2, 12.5%) and chest infection (n=2, 12.5%).
Blunt pancreatic trauma continues to pose significant diagnostic and therapeutic challenges. In view of the numerous associated injuries, priority must be given to stabilizing the patient before any definitive management of the pancreatic injuries is carried out. Mortality in these patients is usually a result of the magnitude of their associated injuries.
Full-text · Article · Nov 2009 · JOP: Journal of the pancreas
[Show abstract][Hide abstract] ABSTRACT: In Singapore, road traffic accidents (RTAs) are the second most common cause of deaths in trauma. Motorcycle casualties account for 54% of all fatalities. Studies have shown that the mean age of motorcycle casualties is significantly younger than that of other RTA victims.
We reviewed the mortality of all motorcycle casualties>or=16 years admitted to an acute hospital as emergencies from January 2004 to December 2006. To determine the impact of age on mortality, we divided our patients into two groups, one<or=21 years (younger group) and another>21 years (older group). A subset analysis based on riding position (driver versus passenger) was performed to determine the inpatient mortality rate in these two groups.
There were 96 (14%) patients in the younger group and 586 (86%) patients in the older group. The mortality rate for younger motorcycle casualties was significantly higher (14.6% versus 8%; p=0.04). Also, there were significantly more passengers in the younger group (25% versus 8.4%; p=0.0001). The mortality rate among young passengers was significantly higher than that among young drivers (29.2% versus 9.7%; p=0.019). Likewise, the mortality rate of the young passengers was also significantly higher than that among older passengers (29.2% versus 10.2%; p=0.04).
Young motorcycle casualties have a significantly higher mortality rate than older motorcycle casualties. Young passengers have the highest mortality rate and contribute significantly to the death rate among young motorcycle casualties.
No preview · Article · Apr 2009 · World Journal of Surgery