Sriwijaya Journal of Surgery

Isolated Gallbladder Ascariasis Causing Acalculous Hydrops: Management of a Rare Surgical Entity

Muhammad Arisma Dwirian Putra — 2026-01-06

Introduction: Ascariasis, caused by the nematode Ascaris lumbricoides, affects approximately one billion people globally. While hepatobiliary involvement is a recognized complication, isolated gallbladder ascariasis is exceptionally rare, accounting for less than 2.1% of biliary cases due to the anatomical resistance provided by the tortuous valves of Heister. This condition presents a significant diagnostic dilemma, often mimicking acute acalculous cholecystitis, and carries a high risk of complications if mismanaged.

Case presentation: We report the case of a 57-year-old female presenting with acute-on-chronic right upper quadrant pain. Physical examination revealed localized tenderness without jaundice. Laboratory investigations demonstrated leukocytosis (15,460/mm³), significant eosinophilia (8%; absolute count 1,236/mm³), and cholestasis with elevated Alkaline Phosphatase (133 U/L). Ultrasonography, the diagnostic gold standard, revealed a distended gallbladder consistent with hydrops and a mobile, tubular echogenic structure—the inner tube sign—extending into the cystic duct. The patient underwent an open cholecystectomy. Intraoperatively, a critical retrograde milking maneuver was performed to dislodge the worm from the cystic duct back into the gallbladder to prevent transection. The Common Bile Duct was palpated and confirmed to be free of stones or parasites. A viable Ascaris worm was extracted from the specimen.

Conclusion: Isolated gallbladder ascariasis must be considered in the differential diagnosis of acalculous biliary disease in endemic regions. Ultrasonography is superior to other modalities for diagnosis. Surgical intervention is mandatory when hydrops or cystic duct impaction occurs, with meticulous attention to cystic duct clearance to prevent biliary sequelae. The patient was discharged on postoperative day 3 without complications.

Giant Verruca Vulgaris of the Auricle Mimicking Verrucous Carcinoma: A Diagnostic and Surgical Case Study

Mega Ayu Saptaningrum — 2026-01-23

Introduction: Verruca vulgaris, universally recognized as the common wart, represents a benign epithelial proliferation induced by the human papillomavirus (HPV). While these lesions are ubiquitous in the general population, typically manifesting as small hyperkeratotic papules on the acral regions, the occurrence of giant variants exceeding 2 centimeters in diameter on the auricle is an exceptionally rare clinical entity. This unusual presentation creates a significant diagnostic dilemma for the head and neck surgeon, as giant auricular warts frequently mimic the clinical presentation of malignant neoplasms, specifically verrucous carcinoma and squamous cell carcinoma.

Case presentation: We document the case of a 36-year-old Indonesian male who presented with a massive, painless, exophytic mass on the posterior aspect of the right auricle. The lesion had persisted for ten years, exhibiting a slow, linear growth trajectory without spontaneous regression. Physical examination revealed a solitary, sessile, papillomatous lesion measuring 3.3 cm × 1.5 cm × 1.0 cm. Despite its alarming size, the mass remained mobile over the underlying perichondrium. Given the giant dimensions and the inability to rule out malignancy via visual inspection, the patient underwent total surgical excision with primary closure under general anesthesia. Histopathological analysis confirmed the diagnosis of verruca vulgaris, characterized by marked hyperkeratosis, papillomatosis, and pathognomonic koilocytosis, with an intact basement membrane ruling out invasive carcinoma.

Conclusion: Giant verruca vulgaris of the auricle is a rare pathology that requires a rigorous diagnostic approach. We conclude that auricular verrucous lesions exceeding 2 centimeters should be clinically managed as tumors of uncertain potential. Surgical excision remains the diagnostic and therapeutic gold standard, offering immediate aesthetic restoration and the essential histopathological confirmation required to differentiate benign giant warts from the deceptive pushing border of verrucous carcinoma.

Systemic Neuroinflammatory Signatures in Lumbar Spinal Stenosis: An Exploratory Correlation of Serum IL-1β and hs-CRP with Schizas Morphological Grading

Arazy Gifta Prima — 2026-02-23

Introduction: The clinical-radiological paradox in lumbar spinal stenosis (LSS) suggests that anatomical compression alone fails to explain symptom severity. Emerging evidence points to a bio-active stenotic environment driven by chronic neuroinflammation. This study aimed to investigate whether the morphological severity of stenosis, graded by the Schizas classification, correlates with systemic inflammatory biomarkers (Interleukin-1β and high-sensitivity C-reactive protein) after strictly controlling for pharmacological confounders.

Methods: A prospective, cross-sectional exploratory pilot study was conducted on 30 patients with degenerative LSS. To isolate stenosis-induced inflammation, strictly non-obese patients (BMI <30 kg/m²) underwent a verified 7-day NSAID/steroid washout period. Stenosis severity was graded on MRI using the Schizas classification. Due to small sample size in extreme stenosis, Grades C and D were merged into a severe stenosis cohort. Serum IL-1β and hs-CRP were quantified via ELISA. Statistical analysis utilized Kruskal-Wallis tests and bootstrapped multivariate linear regression (1,000 resamples) to control for Age, BMI, and multicollinearity (VIF).

Results: The cohort was stratified into Grade A (n=10), Grade B (n=11), and Severe Grade C/D (n=9). Systemic inflammatory markers demonstrated a significant stepwise elevation corresponding to morphological severity. Median IL-1β levels rose from 5.60 (IQR 4.9–6.4) pg/mL in Grade A to 11.20 (IQR 9.1–13.8) pg/mL in the Severe group (p<0.001). Similarly, hs-CRP increased from 2.15 mg/L to 4.90 mg/L (p=0.003). Bootstrapped regression confirmed that Schizas severity remained a significant independent predictor of IL-1β (β=0.46, p=0.012) and CRP (β=0.49, p=0.009) with acceptable variance inflation factors (VIF < 2.5), validating the model despite age-related correlations.

Conclusion: Morphological severity of the dural sac significantly correlates with systemic inflammatory burden. Severe mechanical compression appears to induce a spillover effect, creating a detectable peripheral inflammatory signature. These biomarkers may serve as objective adjuncts to MRI in conflicting clinical scenarios.

Mortality Predictors in Spontaneous Intracerebral Hemorrhage: External Validation of the ICH Score in the Indonesian Surgical Population

Grady Christian — 2026-02-27

Introduction: Spontaneous intracerebral hemorrhage (ICH) is a major contributor to stroke-related mortality and long-term disability, particularly in Indonesia, which faces the highest age-standardized stroke mortality rate in Southeast Asia. This study evaluates the predictive accuracy of the ICH Score for 30-day mortality among patients undergoing surgical intervention at a primary referral center in South Sumatra.

Methods: This analytical observational study utilized a retrospective cohort design, analyzing 81 patients with spontaneous ICH who underwent surgical evacuation at Dr. Mohammad Hoesin Central General Hospital Palembang between July 2024 and June 2025. Demographic, clinical, and radiological parameters were evaluated. Accuracy was determined using Receiver Operating Characteristic (ROC) curve analysis to establish the Area Under the Curve (AUC), sensitivity, and specificity.

Results: The cohort was predominantly male (56.8 percent) and aged under 80 years (86.4 percent). Significant predictors of 30-day mortality included age 80 years or older (p < 0.001, OR 26.84), lower Glasgow Coma Scale (GCS) scores (p = 0.012), and the presence of intraventricular hemorrhage (IVH) (p < 0.001, OR 15.24). ROC analysis demonstrated an AUC of 0.958 (95 percent CI 0.910–1.000). An optimal ICH Score cut-off of 3 or higher yielded a sensitivity of 86.2 percent and a specificity of 100 percent.

Conclusion: The ICH Score serves as an exceptionally accurate prognostic tool in the Indonesian surgical population. An admission score of 3 or higher is a definitive predictor of mortality, facilitating risk stratification and informed clinical decision-making.

Inverse Association between Occupational Ultraviolet Radiation and Renal Cell Carcinoma Incidence: A Systematic Review and Meta-Analysis

Rezza Dwi Haryanto — 2026-03-31

Introduction: Renal cell carcinoma (RCC) incidence is rising globally. While lifestyle risk factors like obesity and smoking are established, environmental modifiers remain contested. Ultraviolet (UV) radiation induces endogenous vitamin D synthesis, which exhibits potent antineoplastic properties in renal tissues. This systematic review and meta-analysis investigated the association between occupational UV radiation exposure and RCC incidence, addressing confounding variables and geographic variations.

Methods: Following PRISMA guidelines, a comprehensive search of PubMed, EMBASE, Cochrane Library, and Web of Science was conducted for observational studies published up to August 2024. Data extraction focused on occupational UV exposure and RCC incidence. Methodological quality was assessed using the Newcastle-Ottawa Scale. Meta-analysis utilized RevMan software to calculate pooled odds ratios (OR) and Standardized Mean Differences (SMD) with 95% confidence intervals (CI). Publication bias was evaluated via funnel plots and Egger’s test.

Results: Ten high-quality studies encompassing 364,959 participants were included. The pooled meta-analysis demonstrated a statistically significant inverse association between occupational UV radiation and RCC incidence (OR 0.89; 95% CI 0.87–0.91; p < 0.00001) using a fixed-effects model. SMD analysis of cumulative exposure supported these findings. Subgroup analyses by gender indicated protective trends for both males (OR 0.80) and females (OR 0.75). Funnel plot symmetry indicated no significant publication bias.

Conclusion: Long-term occupational UV radiation exposure is significantly associated with a reduced risk of RCC. This protective effect is likely mediated by sustained vitamin D synthesis modulating the renal tumor microenvironment. Future research must utilize personal dosimeters and account for latitudinal gradients to refine occupational health guidelines.

Prognostic Factors for Pain Reduction After Balloon Kyphoplasty in Osteoporotic Vertebral Compression Fractures: A Case Series

Rachmad Susilo — 2026-04-14

Introduction: Osteoporotic vertebral compression fractures (OVCFs) are a leading cause of morbidity and disability worldwide. While balloon kyphoplasty provides significant pain relief, prognostic factors for optimal pain reduction outcomes remain debated, particularly in Southeast Asian populations with distinct epidemiological characteristics.

Methods: A retrospective case series analysis of 30 patients with OVCFs who underwent balloon kyphoplasty at Dr. Mohammad Hoesin General Hospital, Palembang, Indonesia, between January 2024 and December 2025. Pain was assessed using the Numerical Pain Rating Scale (NPRS) before surgery and at discharge. Seven potential prognostic variables were examined: age, gender, bone mineral density (BMD), kyphotic angle, duration of complaints, number of vertebral levels treated, and preoperative pain severity. Bivariate analysis using Pearson and Spearman correlation coefficients was performed, followed by multivariate linear regression analysis with entry criteria of p < 0.25.

Results: Mean age was 67.2 ± 7.39 years (range 54-82 years), with 80% female patients (n = 24). Pain scores decreased significantly from a preoperative mean of 7.43 ± 0.77 to a postoperative mean of 2.8 ± 0.81 (p < 0.001), representing a 62.3% reduction. Bivariate analysis revealed significant associations for six variables. Multivariate regression analysis identified two independent prognostic factors: duration of complaints (β = -1.881, p < 0.001) and age (β = -0.428, p = 0.039), with an adjusted R² of 0.702. Patients with shorter symptom duration and younger age experienced greater pain reduction. Asymptomatic cement leakage occurred in two patients (6.7%), with no serious complications observed.

Conclusion: Balloon kyphoplasty effectively reduces pain in osteoporotic vertebral compression fractures. Duration of complaints and patient age are independent prognostic factors for pain reduction outcomes. These findings may guide patient selection and expectation management in clinical practice.

Baumann's Angle and Shaft-Condylar Angle as Predictors of Functional Outcome After Surgery for Neglected Supracondylar Humerus Fractures in Children

Bunyamin — 2026-04-14

Introduction: Neglected supracondylar humerus fractures in children remain a significant source of functional impairment, particularly in developing countries. Radiographic parameters such as Baumann's angle and shaft-condylar angle have been proposed as indicators of fracture alignment, yet their association with functional outcomes after surgical intervention has not been systematically evaluated in neglected cases within Southeast Asian populations.

Methods: This cross-sectional observational analytic study examined medical records of 28 children treated surgically for neglected supracondylar humerus fractures at Dr. Mohammad Hoesin General Hospital, Palembang, Indonesia. Radiographic measurements of Baumann's angle and shaft-condylar angle were obtained preoperatively and at three months postoperatively. Functional outcomes were assessed using the Flynn criteria. Receiver operating characteristic curve analysis with the Youden index determined optimal cut-off values.

Results: Mean age was 9.04 ± 3.0 years, with male predominance (75%) and left-sided involvement (71.4%). Mean surgical delay was 188.4 ± 166.3 days. Postoperatively, 100% achieved satisfactory cosmetic outcomes, while functional satisfaction occurred in 64.3% of patients. Normal Baumann's angle was associated with satisfactory functional outcomes (odds ratio 18.667, 95% confidence interval 2.533–137.587, p=0.003). The shaft-condylar angle with population-specific cut-off of 41.80° demonstrated a significant association (odds ratio 11.333, 95% confidence interval 1.048–122.549, p=0.041). Absolute risk difference for Baumann's angle was 62.0%, and for the shaft-condylar angle, the cut-off was 53.9%.

Conclusion: Normal Baumann's angle was strongly associated with satisfactory functional outcomes following surgical management of neglected supracondylar humerus fractures. A population-specific shaft-condylar angle cut-off of 41.80° showed a significant association with functional outcomes. Both parameters warrant consideration during operative planning, with multivariate confirmation recommended in larger prospective studies.

Neglected Transverse Patella Fracture in a Geriatric Patient Following Traditional Bone-Setting: Successful Surgical Salvage with Combined Tension Band Wire and Circumferential Cerclage Construct

Restu Adi Wardana — 2026-04-22

Introduction: Patellar fractures constitute about 1% of all skeletal injuries and disproportionately affect elderly women because of osteoporosis and low-energy falls. Displaced transverse fractures disrupt the knee extensor mechanism and, if unaddressed, predispose to non-union and permanent disability. In many low- and middle-income settings, initial referral to traditional bone-setters remains common and frequently delays definitive care.

Case presentation: A 66-year-old woman presented one month after a simple fall with a displaced transverse fracture of the left patella and Kellgren–Lawrence grade II osteoarthritis of the same knee. Prior care was limited to traditional bone-setting without improvement. On admission, she had a palpable patellar gap and an inability to actively extend the knee. Radiographs confirmed displacement of 10 mm. Single-stage open reduction and internal fixation with a modified tension band wire construct reinforced by circumferential cerclage was performed. Active-assisted flexion began on postoperative day 14; by four weeks, she had 30° of pain-free flexion, full active extension, and primary wound healing, and was discharged for structured outpatient physiotherapy.

Conclusion: A combined tension band wire plus circumferential cerclage construct provided reliable fixation and an encouraging early functional result despite a one-month delay and prior bone-setter manipulation. Prompt referral and structured rehabilitation remain pivotal for minimising non-union, hardware failure, and long-term disability in geriatric patellar fractures.

Diagnostic Accuracy of the Modified ABSI Versus the Revised Baux Score for In-Hospital Mortality Prediction in Adult Burn Patients at a Tertiary Indonesian Burn Centre

Ilham Taufan Ikramiawan — 2026-05-06

Introduction: Rapid bedside risk stratification of burn-injured patients informs intensive-care admission, fluid-resuscitation intensity, and timing of early surgical excision and grafting. The Modified Abbreviated Burn Severity Index (mABSI) and the Revised Baux (R-Baux) score are widely cited but have not previously been compared head-to-head in a Sumatran tertiary burn unit.

Methods: STARD-aligned retrospective diagnostic-accuracy study of consecutive thermal-burn patients admitted to the Burn Unit, Dr. Mohammad Hoesin General Hospital Palembang (January–December 2025). Patients with concurrent major trauma or incomplete records were excluded. Both scores were calculated from medical records by an investigator blinded to the outcome. In-hospital mortality was the reference standard. Receiver-operating-characteristic, Wilson-CI sensitivity/specificity, DeLong AUC comparison, McNemar paired test, and Cohen's κ analyses were performed in SPSS v25 (α = 0.05).

Results: Of 45 included patients (mean age 40.8 years; 77.8% male; 64.4% fire burns), 20 (44.4%) died. Optimal cutoffs were mABSI ≥ 5 (AUC 0.811, 95% CI 0.688–0.934; sensitivity 72.0%, specificity 75.0%, Youden 0.47) and R-Baux > 60 (AUC 0.808, 95% CI 0.678–0.938; sensitivity 52.0%, specificity 82.0%, Youden 0.34). Inter-test agreement was substantial (κ = 0.69, 95% CI 0.48–0.90; p < 0.001), with overall accuracy of 84.4% when R-Baux was treated as the comparator.

Conclusion: Both scores discriminated burn mortality well; the Modified ABSI offered higher sensitivity and Youden index, supporting its evaluation as a primary triage tool in similar Indonesian tertiary burn units, while the Revised Baux retained complementary specificity for confirmatory risk classification.

Synchronous Low-Grade Appendiceal Mucinous Neoplasm, Perforated Ascending Colon Diverticulitis, and Mature Ovarian Cystic Teratoma in a 52-Year-Old Female: Diagnostic Challenges and Surgical Decision-Making

I Made Aridana Sandika — 2026-05-27

Introduction. Low-grade appendiceal mucinous neoplasm (LAMN) is a rare mucin-producing epithelial tumor identified in roughly 0.13–1% of appendectomies, with a recognized risk of pseudomyxoma peritonei (PMP) on rupture. Synchronous coexistence with perforated ascending colon diverticulitis and an ipsilateral ovarian mature cystic teratoma is exceptional and creates a triple-layered diagnostic and operative challenge.

Case Presentation. A 52-year-old Indonesian female presented with one month of right lower quadrant (RLQ) pain that worsened over forty-eight hours, accompanied by nausea and vomiting. Examination revealed McBurney tenderness, local muscular defense, and a palpable RLQ mass. Leukocytosis with neutrophilic predominance (white blood cells 19.18×10³/µL; neutrophils 91%) was noted. Ultrasonography demonstrated a lobulated, hyperechoic pelvic mass measuring 10.46 cm. Contrast-enhanced computed tomography showed a solid–cystic pelvic lesion with fat and calcification consistent with mature cystic teratoma alongside a periappendicular infiltrate. Exploratory laparotomy disclosed ~50 mL of purulent fluid, an abnormally enlarged appendix, multifocal ascending colon diverticulitis with perforation, dense adhesions, and a right ovarian mass. Right hemicolectomy with transverse colon stump and end ileostomy together with total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO) were performed. Histopathology confirmed LAMN with periappendicular infiltrate and a mature cystic teratoma of the right ovary.

Conclusion. Coexistence of LAMN, perforated colonic diverticulitis, and mature ovarian teratoma can mimic adnexal or inflammatory disease and obscure recognition of the appendiceal neoplasm. Vigilant intra-operative inspection of the appendix and adjacent colon, oncologically appropriate resection, and definitive histopathology are essential to prevent PMP.

Marshall CT Classification as an Early Radiological Predictor of In-Hospital Mortality in Adult Surgical Traumatic Brain Injury: A Tertiary Indonesian Cohort Study

Vandy Ikra — 2026-06-01

Introduction: Computed tomography (CT) classification anchors surgical triage in traumatic brain injury (TBI), but contemporary Indonesian data on the prognostic performance of the Marshall CT score in surgically managed patients are scarce.

Methods: An observational retrospective cohort study was conducted at Dr. Mohammad Hoesin Central General Hospital, Palembang. Consecutive adult surgical TBI patients operated on between January 2023 and December 2025 were enrolled. Marshall CT categories were assigned from non-contrast head CT scans by two independent raters (κ = 0.87). The primary outcome was in-hospital mortality. We quantified the association between Marshall score and in-hospital mortality using Spearman rank correlation, point-biserial correlation, penalised L2 logistic regression, and ROC analysis.

Results: Thirty-six patients met the inclusion criteria (75.0% male; median age 25 years). In-hospital mortality was 19.4% (7/36; 95% CI 9.8–35.0%). Spearman correlation between Marshall score and mortality was ρ = 0.532 (95% CI 0.245–0.731, p = 0.001). Marshall category was an independent predictor in penalised logistic regression (adjusted OR 3.12, 95% CI 1.63–4.41; p = 0.013). ROC AUC was 0.852 (95% CI 0.724–0.960), numerically superior to admission GCS AUC of 0.778 (DeLong p = 0.298).

Conclusion: Marshall CT classification is an independent, point-of-CT predictor of in-hospital mortality after surgery for TBI in an Indonesian tertiary cohort. Integration into structured operative triage may enhance early risk stratification.

Open Reduction and Internal Fixation of a Displaced Both-Bone Forearm Fracture in a Child Using Oversized Tubular Implants in a Resource-Limited Regional Hospital: A Case Report

I Gusti Putu Agung Pratama Putra — 2026-06-03

Introduction. Both-bone diaphyseal fractures of the forearm are among the most common injuries of childhood, and the majority are successfully managed by closed reduction and cast immobilisation. Operative fixation is reserved for irreducible, unstable, open, or markedly displaced fractures, and is favoured in older children whose capacity to remodel diaphyseal deformity is limited. In peripheral and regional hospitals the surgeon may face an additional, under-reported obstacle: an incomplete implant inventory that offers neither the ideal plate dimensions nor the full range of screw calibers.

Case presentation. We report a 12-year-old boy who sustained a closed, displaced fracture of the middle third of the left radius and ulna after a fall on the outstretched hand at school. Examination demonstrated forearm deformity, swelling, tenderness and crepitus, with an intact distal neurovascular status. Radiographs confirmed displaced both-bone diaphyseal fractures with angulation. Because the only implants available in the regional setting were relatively oversized tubular plates and a limited selection of screws, the operating surgeon adapted the technique while preserving the principles of anatomical reduction and stable fixation, performing open reduction and internal fixation of both bones. The postoperative course was uneventful; serial radiographs showed progressive consolidation, and the implants were electively removed at twelve months, revealing united bone without refracture.

Conclusion. Open reduction and internal fixation can achieve anatomical union of a paediatric both-bone forearm fracture even when only suboptimal implants are available, provided reduction quality and construct stability are respected. Adaptive surgical judgement is central to safe orthopaedic practice in resource-limited regional settings.

CORA-Based Single-Stage Double-Level Corrective Osteotomy for Pediatric Distal Tibiofibular Malunion with Multiplanar Valgus Ankle Deformity: A Case Report

Totok Siswanto — 2026-06-05

Introduction. Distal tibiofibular malunion in the skeletally immature patient can generate a progressive multiplanar valgus ankle deformity that alters joint mechanics and threatens long-term function. Correction is especially demanding after neglected, non-medical treatment, which remains common in low- and middle-income settings.

Case Presentation. A 13-year-old boy presented with a one-year history of progressive valgus deformity of the right ankle following a road-traffic injury initially managed by a traditional bone setter without radiographs. Imaging confirmed distal tibiofibular malunion with center of rotation of angulation (CORA) values of 16.9° in the coronal plane and 18.1° in the sagittal plane; the tibial anterior surface (TAS) angle was 76.4° and the tibial lateral surface (TLS) angle was 76.0°. A single-stage, CORA-based double-level closing-wedge osteotomy of the distal fibula and distal tibia was performed, stabilized with a one-third tubular plate and a distal tibial T-locking plate. The TAS improved to 93.0° and the TLS to 84.0°. At one-year follow-up the patient showed bony union, improved ankle motion, restored mechanical alignment, and painless ambulation without complications.

Conclusion. CORA-guided single-stage double-level osteotomy with stable internal fixation can restore alignment, ankle congruity, and function in pediatric distal tibiofibular malunion with multiplanar valgus deformity. Early orthopedic evaluation and timely correction are essential to prevent long-term disability.