Introduction: Hepatocellular carcinoma (HCC) is the commonest primary tumor in the liver. It has been shown to have a strong association with hepatitis B and C. HCC not only commonly metastases to the other part of the liver but also commonly metastases to the lung. Involvements of upper gastrointestinal organs are rare. We report a case of hepatocellular carcinoma with duodenal metastases. Method: A 58 years old Chinese man with a background history of hepatitis B presented with right hypochondrium pain. No jaundice or any constitutional symptoms noted. Physical exams revealed irregular right hypochondrium mass. No ascites palpable. Most blood investigation was unremarkable except for a raised Alpha fetoprotein of 2920. Imaging studies confirmed a diagnosis of a segment 4B HCC with enlarged portal nodes and left portal vein thrombosis. Despite his Child�s score A, he was deemed inoperable and subjected to chemoembolization. During a subsequent follow up, he developed symptomatic anaemia with hemoglobin level of 6.2 g/dl. He developed multiple episodes of anaemia and Upper GI endoscopy shows a bleeding tumor at first part of duodenum extending to the second. Biopsy revealed as metastatic HCC. Results: Conclusions: Hepatocellular carcinoma is known to spread via haematogenous, lymphatics or trancoelomic. The usual sites of metastases are lung, regional lymph nodes and bones. Metastases via direct spread are uncommon hence the rarity of metastases to other upper gastrointestinal organs especially small bowel. This presentation imposed a treatment dilemma due to the limited approach to both primary and the metastases lesion.

Objective: Pancreaticoduodenectomy is a technically challenging surgery requiring longer period of recovery post operatively. This study aims to examine the implementation of an enhanced recovery after surgery (ERAS) protocol following pancreaticoduodenectomy. Methods: All patient undergone pancreaticoduodenectomy were managed following ERAS protocol. Outcomes measured include postoperative morbidity, mortality, length of stay and readmission rate within 30 days. Protocol targets were: removal of NG tube (PoD1), resumptions of oral fluids (PoD2), mobilization, removal of IV fluids, removal of H-J drain and urinary catheter and discharges from high dependency unit (PoD3), tolerating soft diet (PoD4), removal of P-J drain (PoD5), tolerating normal diet and full mobilization (PoD6) and hospital discharge (PoD7). Results: Data were collected for 15 patients. Rates of mortality, morbidity and readmission were 7%, 53% and 20% respectively. The median length of stay was 10 days. The proportions of patients achieving key targets were; 40% for NGT removal; 67% for resumption of oral fluids; 60% for urinary catheter removal; 53% for HDU discharge; 53% for tolerating diet; 67% for meeting mobility targets and 33% and 67% for H-J and P-J drain removal respectively. PoD 7, eight patients by PoD 11, discharged four patients and 2 complicated patients were discharged within day 17. Conclusion: ERAS protocol implementation in pancreaticoduodenectomy (PD) is feasible and safe. Achieving key target protocol was challenging. A further modification of the ERAS protocol may be needed to ensure more compliance.

Fat embolism syndrome is manifested by the fat globule systemic presence involved in a motor vehicle in the pulmonary and circulation. A 34-year-old man was accident with a fracture of the left femur and avulsion fracture of the left posterior cruciate ligaments. He developed signs and symptoms that suggested an early diagnosis of fat embolism syndrome. Intravenous methylprednisolone administration was administered as part of the treatment. The role of methylprednisolone in a patient with fat embolism syndrome is controversial due to unproven effectiveness. In this case, fat embolism syndrome after a femur fracture was treated successfully with methylprednisolone. Keywords: fat embolism syndrome, methylprednisolone, femur fracture.

Trauma is a major health problem in Malaysia. An understanding of the trauma epidemiology is important in developing a reliable trauma service. The aim of this study is to understand the pattern of trauma in our institution and to highlight the need for a dedicated trauma service. In this database, 142 cases were included. Majority were males (127, 89.4%). Most common injury types are motor vehicle accidents (87.3%) followed by falls (7.7%), and stabs (3.5%). Most Injury Severity Score (ISS) falls under moderate score with 38.7%. Mean Abbreviated Injury Score (AIS) was 3 with most involving the chest and 90% of the patients have injuries involving at least 2 regions. Average hospital length of stay (LOS) was 11.4 days ±11.5 SD; with most patients (71.8%) were discharged without permanent disability. The mortality rate was 9.2% with all having ISS>16. ISS found to be strongly related to longer hospital stay and worse outcome (0.59, p < 0.0001, 0.4, p < 0.0001). This data is equivalent to the compared registries from 4 different trauma centres. However, steps need to be taken to improve this database. In conclusion, this university hospital receives a reasonable load of trauma cases yearly which is equivalent with other trauma centres. The increasing trauma cases will benefit from an implementation of a dedicated trauma service. This trauma database needs more depth in its elements and better data handling to ensure a quality and complete registry.

Hypophosphataemia occurs in an abnormally low serum phosphate level. Three main mechanisms are postulated: decreased intestinal absorption, increased renal excretion, and extracellular shifts to intracellular compartments. It is potentially a fatal disease if not intervene. The management is merely treating the underlying disorder, giving phosphate supplement and requiring close biochemical monitoring. The incidence of symptomatic isolated hypophosphataemia is extremely rare. In this case report, a 33-year-old man presented with three days history of dysphagia, inability to complete sentences and generalized muscle weakness. He developed blurred vision especially upon exposure to bright light. He had a history of single parathyroidectomy for parathyroid adenoma 2 years ago. Physical examinations were unremarkable. Laboratory investigations were normal except for phosphate level of 0.30 mmol/L. Intravenous KH2PO4 with a dosage of 10 mmol was administered in slow bolus in 3 hours. His symptoms resolved slowly after correction. Although isolated hypophosphataemia is rare but need to recognize the symptoms and signs of hypophosphataemia and treat accordingly.

Advanced hepatocellular carcinoma carries a bad prognosis with a survival of only few months. Barcelona Clinic Liver Cancer (BCLC) Guidelines recommended sorafenib monotherapy as the treatment modality for advanced BCLC Stage C disease, citing a two-month increase in survival rates. Here, we highlight a case with advanced HCC (BCLC Stage C) treated with combination therapy of liver resection and Sorafenib therapy. The patient's current survival rate was beyond 10 months. We also discuss the current evidence on liver resection with Sorafenib therapy in hepatocellular carcinoma. The description of the case may benefit in future diagnosis and treatment.

Fracture is common after trauma. Proximal humeral fracture can occur in the elderly after fall and in youngsters after motor vehicle accidents (MVA) and sport injuries. A 37-year-old man was admitted with a fracture of his left proximal humerus following an MVA. He sustained a 3-part fracture and treated surgically using a PHILOS plate. There are few options in managing proximal humerus fracture ranging from conservative to surgical intervention based on its severity. We reminiscent the usage of PHILOS plate as a mode of treatment of such fracture.

Aim: This paper describes the surgical procedure for spleen auto transplantation in rats. Splenectomy is an important surgery protocol in research studies involving immunology and hematopoietic diseases. Spleen auto transplantation is an alternative method undertaken to preserve the splenic function as the absence of spleen (asplenia) is associated with lifelong risk for sepsis, especially by encapsulated bacteria. Method: Four six weeks old male Sprague-Dawley rats, with range of weight from 248-281 grams, underwent spleen autotransplantation via midline laparotomy incision. In this procedure the spleen was completely removed (total splenectomy); it involved removing the spleen and re-transplanted in greater omentum. A piece of the spleen weighing approximately 0.34 grams was transplanted inside the greater omentum and held in place with an absorbable suture knot. The muscle layer and skin incision were then closed using absorbable suture. The surgery was conducted under deep sedation and the rat was monitored post-operatively until it fully recovered. Outcome: The post-operative recovery of the rat was uneventful. Six-weeks after the surgery, the rat underwent a re-look laparotomy and the auto-transplanted spleen was examined. There was a three-fold increase in the size and weight of the spleen. Conclusion: This spleen auto transplantation model, which utilized an omental pouch, was not only successful in preserving the spleen, but also allowed for spleen regeneration. This model provides future platform for further research in auto-transplanted spleen.