Academy of Medicine, Singapore clinical guideline on the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting.

INTRODUCTION: In Singapore, non-anaesthesiologists generally administer sedation during gastrointestinal endoscopy. The drugs used for sedation in hospital endoscopy centres now include propofol in addition to benzodiazepines and opiates. The requirements for peri-procedural monitoring and discharge protocols have also evolved. There is a need to develop an evidence-based clinical guideline on the safe and effective use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting. METHODS: The Academy of Medicine, Singapore appointed an expert workgroup comprising 18 gastroenterologists, general surgeons and anaesthesiologists to develop guidelines on the use of sedation during gastrointestinal endoscopy. The workgroup formulated clinical questions related to different aspects of endoscopic sedation, conducted a relevant literature search, adopted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology and developed recommendations by consensus using a modified Delphi process. RESULTS: The workgroup made 16 recommendations encompassing 7 areas: (1) purpose of sedation, benefits and disadvantages of sedation during gastrointestinal endoscopy; (2) pre-procedural assessment, preparation and consent taking for sedation; (3) Efficacy and safety of drugs used in sedation; (4) the role of anaesthesiologist administered sedation during gastrointestinal endoscopy; (5) performance of sedation; (6) post-sedation care and discharge after sedation; and (7) training in sedation for gastrointestinal endoscopy for non-anaesthesiologists. CONCLUSION: These recommendations serve to guide clinical practice during sedation for gastrointestinal endoscopy by non-anaesthesiologists in the hospital setting.

Surgery for the palliation of intestinal perforation from secondary metastases in advanced malignancies.

AIM: This study aims to review patient and disease factors that predict survival after palliative surgery for intestinal perforation from metastases in advanced malignancies, with a goal to help decision-making in this clinical scenario. Secondary aims include validation of the UC Davis Cancer Centre nomogram to predict risk of 30-day morbidity and mortality for patients with disseminated malignancy undergoing surgical intervention. METHODS: The following factors were examined: age, preoperative albumin, total white blood cell count, creatinine, site of metastases, presence of ascites, presence of sepsis, steroid use, presence of dyspnea, presence of significant weight loss, preoperative chemotherapy, preoperative radiotherapy, type of operative procedure performed, Eastern Cooperative Oncology Group (ECOG) status, length of surgery, duration of inhospitalization and mortality. For univariate analysis, independent t-test and Fisher's exact test were used to analyze the association of continuous and categorical variables, respectively. For multivariate analysis, logistic regression using likelihood ratios was used. The nomogram was validated by assessing its extent of discrimination (c-index). RESULTS: Twenty palliative operations for intestinal perforation were performed during this period. On univariate analysis, presence of dyspnea, decreased preoperative levels of albumin and high ECOG status were significant predictors of increased mortality. On multivariate analysis, high ECOG status and decreased preoperative albumin were statistically significant. The concordance index in our data set was 0.64. CONCLUSION: Preoperative levels of albumin (>20 g/L) and low ECOG status (≤1) were independently associated with favorable postoperative outcomes. In patients with favorable prognostic factors such as absence of dyspnea, high preoperative levels of albumin and low ECOG status, surgical management should be considered. Conversely, in patients with unfavorable prognostic factors, medical management should be considered to avoid unnecessary surgery.

Evaluation of laparoscopic versus open colorectal surgery in elderly patients more than 70 years old: an evaluation of 727 patients.

BACKGROUND: With longer life expectancy, surgeons can expect to operate on older patients. Laparoscopic colorectal (LC) surgery has been demonstrated to be superior to open surgery. Controversy persists, however, regarding benefits of LC in the elderly due to increase in operative time. The aim of our study was to compare short-term outcomes of LC versus open colorectal (OC) surgery in elderly patients. MATERIALS AND METHODS: Patients ≥70 years old that underwent elective LC between 2005 and 2008 were compared with controls who underwent OC. Data was extracted from a prospectively collected database. RESULTS: Seven hundred and twenty-seven patients underwent colorectal resection in this study period (LC n = 225, OC n = 502). The laparoscopic arm was characterised by shorter incisions (LC 6.0 cm vs. OC 12.0 cm, p < 0.001) but longer operating times (LC 125 min vs. OC 85 min, p < 0.001). Median use of narcotics and length of stay were significantly shorter in the laparoscopic group (LC 2 days vs. OC 3 days, p < 0.001 and LC 6 days vs. OC 7 days, p < 0.001, respectively). There was no significant difference in median recovery of bowel function (LC 4 days vs. OC 4 days, p = 0.14) and post-operative morbidity (p = 0.725). Thirty-day mortality was significantly lower in the laparoscopic arm (LC 1.3% vs. OC 4.6%, p = 0.03) CONCLUSION: This is the largest series from a single institution comparing LC and OC in elderly patients. In our series, LC in elderly patients was safe and not associated with a higher morbidity. LC was also associated with less narcotic use and shorter length of stay.

Results of 7302 stapled haemorrhoidectomy operations in a single centre: a seven-year review and follow-up questionnaire survey.

BACKGROUND: This study aims to evaluate the results of all 7302 stapled haemorrhoidectomy operations performed in a single centre. METHOD: A retrospective review of all 7302 patients who underwent stapled haemorrhoidectomy at our department over seven years was conducted. The hospital database was reviewed for subsequent readmissions and re-operations. A questionnaire survey was also sent out to all the patients. RESULTS: A total of 302 patients (4.1%) were admitted with post-operative bleeding and 281 stopped with conservative measures. Twenty one required surgical haemostasis. A total of 301 patients (4.1%) were admitted for an inability to void and 191 (2.6%) had true acute retention of urine, requiring catheterization. There were 124 patients (1.7%) admitted for pain, but all resolved with oral analgesia subsequently. Anal stricture requiring surgery occurred in only 86 patients (1.2%). Serious complications such as staple line dehiscence or anorectal sepsis occurred in seven patients. There were a total of 14 recurrences requiring readmission over this seven-year period, of which 12 were treated successfully with a second haemorrhoidectomy. A total of 1834 patients returned their questionnaire surveys and 95% of the patients reported complete resolution or improvement of their symptoms. Only 27 patients reported subsequent severe bleeding requiring medical attention. CONCLUSION: Stapled haemorrhoidectomy is safe, and most patients are satisfied with the long-term outcome.

Laparoscopic resection for colorectal polyps: a single institution experience.

BACKGROUND: Endoscopic polypectomy, although routinely used for the treatment of colorectal polyps, may be limited by polyp size, location and histology. Laparoscopic resection for malignant polyps and polyps not amenable to endoscopic removal has the advantage of adequate disease clearance as well as the short-term benefits of laparoscopic surgery. This study evaluates the outcomes of such an approach. METHODS: Patients who had laparoscopic resection for colorectal polyps between January 2005 and July 2008 were identified from a prospective database. Polyps that were malignant, large, difficult to snare or incompletely excised, were included. Demographics, perioperative details and histopathology were analysed. RESULTS: Seventy-eight patients (44 male) with a median age of 62.5 years (range 24-86) were studied. The majority (79%) were laparoscopic anterior resections for sigmoid or rectal polyps. Median operating time was 125 min (range, 65-225). Eight cases (10.3%) were converted to open mainly due to adhesions. There was no post-operative mortality. Perioperative complications occurred in seven patients (8.9%). Median hospital stay was 6 days (range 4-78). Median polyp size was 20 mm (range, 5-75). There were 44 benign polyps (55.7%); majority were tubulovillous adenomas (n= 22), and tubular adenomas (n= 10). Thirty-five patients (44.3%) had invasive cancer, with T1 (n= 27) and T2 (n= 2) tumours. Three of these patients (8.6%) had lymph node metastases. Median number of lymph nodes sampled was six (range 0-23). CONCLUSION: Laparoscopic resection is safe and effective for colorectal polyps not amenable to colonoscopic removal, and is especially important for adequate clearance in the case of malignant polyps.

Evaluation of current devices in single-incision laparoscopic colorectal surgery: a preliminary experience in 32 consecutive cases.

BACKGROUND: Single-incision laparoscopic colorectal surgery (SILS) suggests a promising alternative to conventional laparoscopic surgery. In this report we describe our initial experience with SILS for both right hemicolectomies and anterior resections. METHODS: Between June 2009 and May 2010, SILS was performed for 32 consecutive cases with benign and malignant pathology. Demographic data, intraoperative parameters, postoperative data, and pathologic data were assessed. RESULTS: Twenty-one SILS right hemicolectomies, ten ARs, and one abdominal perineal resection (APR) were performed. For SILS right hemicolectomies, one case required full "conversion" to a laparoscopic procedure. The median operating time was 85 min (range 45-150 min) and the median wound length was 5.0 cm (range 3.0-10.0 cm). Median number of lymph nodes extracted in malignant cases was 17(range 10-30) and the overall median length of stay was 6 days (range 5-11). For left-sided lesions, ten cases of ARs (7 high ARs, 2 low ARs, 1 ultralow AR) and one APR were performed. Three cases were completed successfully via the SILS procedure, four cases required one additional port, and four cases required full "conversion" to a laparoscopic procedure. The median operating time was 120 min (range 65-235 min) and the median wound length was 5.0 cm (range 3.0-7.0 cm). Overall median length of stay was also 6 days (range 5-21). There was one case of anastomotic leak and one case of postoperative bleeding. CONCLUSION: In our experience, SILS for right hemicolectomies is safe and effective with reproducible oncologic results. SILS AR, however, requires greater modifications in current devices and techniques. SILS AR can be performed for both malignant and benign diseases but additional ports may be necessary for the safe completion of the procedure.

Redefining conversion in laparoscopic colectomy and its influence on outcomes: analysis of 418 cases from a single institution.

BACKGROUND: The reported rates of conversion in laparoscopic colectomy are varied. The incidence of conversion is not, however, well defined. The aim of the present study is to redefine conversion and to analyze differences in outcome. METHODS: Treatment parameters of a total of 418 consecutive patients who underwent laparoscopic colonic resection from 2005 to 2007 were analyzed. Treatment was classified as laparoscopic colonic resection, laparoscopy-assisted colonic resection (lap-assisted), and laparoscopic conversion. RESULTS: There were significant differences in median operating time between laparoscopic colonic resection, lap-assisted, and laparoscopic conversion (125 min, 160 min, and 140 min; p = 0.0001); median hospital length of stay was significantly different (laparoscopic, 5.0 days, versus lap-assisted, 6.0 days, versus laparoscopic conversion, 6.5 days; p = 0.0001); and median incision length was also noted to vary significantly (laparoscopic, 5.0 cm, lap-assisted, 8.0 cm, and conversion, 12.0 cm; p = 0.00001). Multivariate analysis reveals that older age (Odds Ratio [OR] = 1.07, 95% Confidence Interval [CI] = 1.02-1.12), higher Body Mass Index ([BMI], OR = 1.15, 95% CI = 1.03-1.29), and pT stage were significant factors affecting conversion. Disease-free survival for cancers was not influenced by conversion (p = 0.653). The overall complication rate was 16.7% and was significantly increased in lap-assisted cases and in conversion cases (26% versus 13%; p = 0.003). CONCLUSIONS: A consistent definition for conversion in laparoscopic colonic resection is required. Our proposed definitions may provide a solution. The definition of lap-assisted as a separate entity serves as a bridge between laparoscopy and full conversion. Risk factors of age, BMI, and advanced tumor stage are conversion predictors and are associated with increased hospital stay and postoperative morbidity.

Arterio-pancreatic syndrome.

Acute pancreatitis is a single-organ disorder that has multi-organ sequelae. As a result, it can have varied presentations. Acute pancreatitis presenting as acute limb ischemia is rare. We present a patient with acute pancreatitis presenting with bilateral lower limb ischemia. The episode of acute pancreatitis resolved but the acute lower limb ischemia precipitated as the pancreatitis progressed, and necessitated bilateral above-knee amputations. We review the literature and discuss the pathogenesis of such a phenomenon.

Single site laparoscopic right hemicolectomy: an oncological feasible option.

INTRODUCTION: We present the first 7 cases of single site right hemicolectomy in Asia using the new Single Site Laparoscopy (SSL) access system from Ethicon Endo-surgery. METHODS: Right hemicolectomy was performed using the new Single Site Laparoscopy (SSL) access system. Patient demographics, operative time, histology and post operative recovery and complications were collected and analysed. RESULTS: The median operative time was 90 mins (range 60 - 150 mins) and a median wound size of 2.5 cm (range 2 to 4.5 cm). The median number of lymph nodes harvested was 24 (range 20 to 34 lymph nodes). The median length of proximal margin was 70 mm (range 30 to 145 mm) and that of distal margin was 50 mm (35 to 120 mm). All patients had a median hospital stay of 7 days (range 5 to 11) and there were no significant perioperative complications except for 1 patient who had a minor myocardial event. CONCLUSION: Right hemicolectomy using SSL access system is feasible and safe for oncologic surgery.

Critical analysis of mucin and signet ring cell as prognostic factors in an Asian population of 2,764 sporadic colorectal cancers.

INTRODUCTION: Conflicting data on the clinicopathological characteristics as well as prognosis and survival of signet ring cell (SRC) and mucinous adenocarcinomas (MA) of the colorectum persist. METHODS: Consecutive patients (2,764) with sporadic colorectal cancer from 1999 to 2005 were evaluated. The clinicopathological characteristics of these patients were reviewed. Univariate analysis was performed, and survival curves were constructed using the Kaplan-Meier method. Multivariate analysis assessed independent prognostic factors. RESULTS: The incidence of MA and SRC is 6% and 1.1%, respectively. MA and SRC tend to occur in patients aged

Laparoscopic versus open right hemicolectomy: a comparison of short-term outcomes.

BACKGROUND: The laparoscopic approach is increasingly becoming the gold standard for colorectal resections. While laparoscopic surgery of the left colon and rectum has been evaluated in many studies, laparoscopic resection of the right colon has not been as widely examined. The aim of this study was to examine the short-term outcomes after laparoscopic right hemicolectomies and to determine if they were superior when compared with those after open resection. PATIENTS AND METHODS: Consecutive cases of laparoscopic right hemicolectomies performed between May 2005 and December 2007, in the Department of Colorectal Surgery, Singapore General Hospital, were compared with a matched series of patients who underwent open surgery. RESULTS: From a total of 37 laparoscopic cases, 36 patients successfully underwent laparoscopic right hemicolectomies. There was one conversion, giving a conversion rate of 2.7%. These 37 patients were compared with 40 patients who underwent open right hemicolectomies. The laparoscopic arm was characterised by shorter length of incisions (5.7 vs. 11.2 cm, p < 0.001) but longer operating times (110.8 vs. 71.6 min, p < 0.001). Mean number of lymph nodes harvested and length of proximal and distal margins were similar in both groups. There were also no significant differences between the groups in terms of narcotic use, recovery of bowel function, length of stay, post-operative morbidity and 30-day mortality. CONCLUSION: Laparoscopic right hemicolectomies are as feasible and safe as the open technique. They confer improved cosmesis with smaller incisions but at the expense of longer operating time.

Improved survival in an Asian cohort of young colorectal cancer patients: an analysis of 523 patients from a single institution.

BACKGROUND: Colorectal cancer (CRC) in the young is rare. Outcomes remain varied compared to older populations. The study reviews characteristics and overall survival (OS) of CRC in patients < or =50 years old. MATERIALS AND METHODS: Five hundred and twenty-three (14%) of 3,796 sporadic CRCs were identified. Patients were compared for demographics, tumour characteristics, treatment, and 5-year overall specific survival. Independent prognostic factors were evaluated. RESULTS: The majority were males (54%) with a median age of 45 years (range 19-50 years). Sixty-three percent of the patients presented with advanced stage disease (stage III and IV), and tumours were predominantly left-sided (83%). A higher frequency of mucinous or signet ring cell histological subtypes (16% vs 9%, p = 0.028) as well as poorly differentiated tumours (30% vs 12%, p = 0.0001) were present in younger patients < or =40 years. With a median follow-up of 41 months, the 5-year OS is 58% (95% confidence interval 53-64%). Younger patients < or =40 years had significantly superior 5-year OS of 62% vs 58% in the age group 41-50 years old (p = 0.004). Multivariate analysis identified five independent prognostic features: age group of 41-50 years, poorly differentiated tumour grade, presence of perineural infiltration, high tumour stage, and carcinoembryonic antigen values > or =5 ng/ml. CONCLUSION: This study has revealed significantly improved 5-year survival in young CRC compared to those reported in the literature.

Laparoscopic resection for rectal cancers: lessons learned from 579 cases.

OBJECTIVE: The aim of this study is to evaluate the short-term outcomes and long-term survival of laparoscopic rectal cancer resection at a single institution with 579 cases over a 15-year period. SUMMARY BACKGROUND DATA: The use of laparoscopic resection for colon cancer has been shown to be safe with comparable oncological outcomes. However, the role of laparoscopic resection for rectal cancer is still controversial with few studies looking into long-term outcomes. METHODS: From May 1992 to April 2007, 579 patients underwent laparoscopic resection for rectosigmoid and rectal cancer. The clinical data of these patients were retrospectively reviewed from a prospectively collected database. Data evaluated includes short- and long-term results, with survival outcomes calculated using the Kaplan-Meier method. RESULTS: Over this 15-year period, 316 patients had laparoscopic anterior resection for rectosigmoid and upper rectal cancer, 152 patients had laparoscopic sphincter-saving total mesorectal excision, 92 patients had laparoscopic abdominoperineal resection, 17 patients had laparoscopic Hartmann procedure for rectal cancer, and 2 patients had proctocolectomy. The median age of these patients was 68 years (range, 35-95). The overall early and late operative morbidity was 18.8% and 9.7%, respectively. Conversion to open surgery was required in 5.4%of patients. Anastomotic leak rate was 3.5%. The median follow-up time was 56 months (range, 8-288). Port-site recurrence occurred in 2 patients. Locoregional recurrence occurred in 7.4% of patients after curative resection. The overall 5- and 10-year survivals for rectal cancer were 70% and 45.5%, respectively. The cancer-specific 5- and 10- year survival was 76% and 56%, respectively. CONCLUSIONS: The results of this study with large number of patients over a long follow-up period suggested that laparoscopic resection for rectal cancer is safe with good long-term oncological outcomes.

Phenotypic characteristics of hereditary non-polyposis colorectal cancer by the Amsterdam criteria: an Asian perspective.

BACKGROUND: Hereditary non-polyposis colorectal cancer (HNPCC) is an autosomal disease with a 68-82% lifetime risk of colorectal cancer (CRC). This study examined the phenotypic characteristics of CRC in Amsterdam criteria-positive Asian patients from the Singapore Polyposis Registry. METHODS: Hereditary non-polyposis CRC patients, defined by the Amsterdam I and II criteria, prospectively monitored in the Singapore Polyposis Registry over a 16-year period were reviewed. Clinical data were obtained from a computerized database and parameters, such as age of diagnosis, type and location of CRC, other associated cancers in the pedigree, cancer recurrence and survival were analysed. RESULTS: Fifty-two patients (31 men and 21 women) from 42 unrelated families, with a median age of 44.5 years (range 27-73 years), fulfilled either Amsterdam I or II criteria and were included in our analysis. The racial distribution was 91% (n = 47) Chinese and 9% (n = 5) Malays, with a median follow up of 44.9 months (range 2-183 months). Significantly, 69% of tumours in this Amsterdam-defined cohort were left sided, with most being sigmoid cancers. Sixty per cent of all the tumours presented at a late stage (Dukes' C or D). Left-sided tumours presented with more advanced Dukes' stage (P = 0.096) and a higher rate of metastatic disease (P = 0.08) compared with right-sided lesions. There were, however, no significant differences in either disease-free or overall survival between right-sided and left-sided tumours. CONCLUSION: This study emphasized the significant left-sided predominance of CRC in Amsterdam I and II-defined patients from our predominantly Chinese population, in contrast to those classically described in Lynch syndrome. Amsterdam criteria thus may not be suitable for diagnosing HNPCC in Asian populations and a greater emphasis should be made towards routine molecular diagnosis of mismatch repair gene defects in suspected HNPCC patients of Asian decent.

Modified stapled haemorrhoidectomy: a suggested improved technique.

BACKGROUND: Longo's technique of stapled haemorrhoidopexy has revolutionized management of symptomatic haemorrhoids. However, several problems have been identified in the original Longo's technique. In particular, recurrence of haemorrhoidal tissue has been found to be significantly higher. METHODS: An improved technique with key differences to address these shortcomings is described. The modified stapled haemorrhoidectomy procedure described is carried out without the circular anal dilator and includes the placement of a low purse string of 2-3 cm. CONCLUSION: This technique is proposed as an improvement to the current stapled haemorrhoidopexy.

Charity colonoscopy event to commemorate the 185th anniversary of Singapore General Hospital.

INTRODUCTION: Colorectal cancer is now the cancer with the highest incidence in Singapore. However, the overall mortality rate is still about 50% because the majority of the patients present at a late stage of disease. A charity event of screening colonoscopy was offered to the public in conjunction with the 185th anniversary of Singapore General Hospital. The aim of this event was to raise awareness about early detection of colorectal cancer and the safety of colonoscopy. MATERIALS AND METHODS: We conducted a one-off free screening event for colorectal cancer using colonoscopy. Four hundred and ninety individuals responded to a multimedia advertisement for the event. Of these, 220 individuals were selected for the screening based on National Guidelines for colorectal cancer screening and financial status. RESULTS: One hundred and fifty-two individuals turned up for the colonoscopy. The median age was 55 years (range, 22 to 82), with 84 males. Significant pathology was found in 33% of the individuals (n = 51). Colorectal polyps were detected in 34 individuals (22%). A total of 45 polyps were removed, with 20 hyperplastic polyps and 25 adenomas. Eight out of 25 adenomas were located proximal to the splenic flexure. Rectal cancer was diagnosed in 1 individual (0.6%). One individual had a large dysplastic rectosigmoid ulcer and refused further intervention. There were no significant complications from any of the colonoscopies. CONCLUSIONS: Colonoscopy is an invaluable screening modality as it has a high pick-up rate for colorectal polyp and cancer in an asymptomatic population. It is also proven to be safe in our study. It has the added advantage over flexible sigmoidoscopy of detecting a significant number of proximal lesions. Also, therapeutic polypectomy can be performed in the same setting.