Initial emergency laparotomy outcomes following a transdisciplinary perioperative care pathway in Singapore.

AIM: Emergency laparotomy (EL) is a common surgery associated with high morbidity and mortality. An enhanced care pathway incorporates evidence-based care bundles with the aim of providing standardized perioperative care. Prior to 2019, EL management in our institution was not standardized. This study aims to assess whether implementation of a transdisciplinary perioperative Emergency Laparotomy (ELAP) pathway improves clinical and efficiency outcomes of EL. METHODS: A prospective single-center audit was undertaken between 1 January and 31 December, 2019 following the implementation of the ELAP pathway. Comparisons were made with retrospective data from the preimplementation period between 1 January and 31 December, 2017. Demographics and clinical and efficiency outcomes were compared for patients (age > 16 years old) requiring EL for acute abdominal conditions. RESULTS: There were 152 and 162 patients from preimplementation and postimplementation periods, respectively. There was a nonsignificant reduction of 30-day mortality in the intervention group receiving perioperative pathway care compared with the preintervention group (3.1% versus 5.3%, respectively; P = 0.40). There was a decrease in postoperative complications in the intervention group, in particular for Clavien-Dindo IV complications (11.2% versus 3.1%, p < 0.01). Efficiency outcomes improved postimplementation with increased consultant surgeon and anesthetist presence in operating theater and postoperative geriatric assessment for elderly patients. There was an overall reduction in cost of hospital stay from S$32,128 to $27,947 (p = 0.24). CONCLUSION: Implementation of a transdisciplinary perioperative care pathway was associated with significant reduction in postoperative complications, improvement in 30-day mortality and efficiency outcomes at reduced hospital costs for patients following EL in our institution.

Role of Intercostal Artery Embolization in Management of Traumatic Hemothorax.

Intercostal artery bleeding from trauma can result in potentially fatal massive hemothorax. Traumatic hemothorax has traditionally been treated with tube thoracostomy, video-assisted thoracoscopic surgery, or thoracotomy. Transcatheter arterial embolization (TAE), a well-established treatment option for a variety of acute hemorrhage is not widely practiced for the management of traumatic hemothorax. We present 2 cases of delayed massive hemothorax following chest trauma which were successfully managed by transarterial embolization of intercostal arteries. The published studies are reviewed and a systematic approach to the selection of patients for TAE versus emergency thoracotomy is proposed.

Identifying barriers to early presentation in patients with locally advanced breast cancer (LABC) in Northern Singapore: Qualitative study.

INTRODUCTION: Breast cancer is the leading cause of death in Singaporean women, with advanced stage rendering a poorer prognosis. This study aims to explore the barriers to early presentation, information needs and sources in patients with locally advanced breast cancer (LABC). MATERIALS & METHODS: A convenience sample of patients who presented with locally advanced breast cancer to the Department of General Surgery in a teaching tertiary hospital were recruited for the study. We conducted semi-structured interviews face to face with the recruited patients. We recorded the interviews, transcribed them verbatim and analysed using thematic content analysis. RESULTS: Twenty-three participants were recruited of which 12 were Chinese and 11 were Malay women. Mean age was 60 years (± 13 SD). The most common knowledge barrier resulting in delay was the misconception that a breast lump must be painful to be malignant. Other knowledge barriers include the lack of knowledge and misinformation from the internet or other social media platforms. Some perceived barriers include fear of diagnosis, fear of treatment and fear of imposing financial burden on family members. A significant proportion of participants were also not aware of a national breast screening programme. CONCLUSIONS: Our study has found that barriers to early presentation of women with locally advanced breast cancer remain similar and have persisted over the years despite targeted efforts. There is a need for a rethink of existing strategies and to develop new innovative ways to reach out to this group of patients.

Impact of a dedicated emergency surgical service on appendicitis outcomes.

AIM: The Emergency Surgery and Trauma (ESAT) team is a dedicated consultant-led service to streamline the emergency surgical workload in Singapore. As acute appendicitis is one of the most common acute surgical conditions, we aim to compare outcomes of patients with appendicitis in the ESAT model as compared to the traditional on-call model. METHODS: A retrospective review of patients admitted to Khoo Teck Puat Hospital, Singapore, with acute appendicitis between two periods: May-October 2014 (6 months pre-ESAT) versus January-June 2017 (post-ESAT). Patient demographics, operative details, efficiency, clinical outcomes, and hospital bill savings were evaluated. RESULTS: There were 192 patients in the pre-ESAT period and 179 patients in the post-ESAT period. Patient demographics and comorbidities were comparable (P > 0.05). Time from emergency department referral to surgical review was significantly reduced in the ESAT period: 77.8 ± 46.9 min versus 127 ± 102 in the pre-ESAT period (P = 0.002). Time from case booking to operating theatre was significantly shorter in the ESAT period: 72.4 ± 55.2 min compared to 157.3 ± 209.1 (P < 0.01). More cases were carried out in the daytime during the ESAT period, 50.2% versus 39.1% (P = 0.029). The majority underwent laparoscopic appendectomy 156/179 (87.2%) in the ESAT period, with fewer open appendectomies 3/179 (1.7%) as compared to the pre-ESAT period (P = 0.062). There were higher intraoperative consultant supervision rates during the ESAT period, 38/166 (22.9%) as compared to 12/166 (6.7%) in the pre-ESAT period (P = 0.001). There were fewer complications (Clavien-Dindo grade II and above) in the ESAT period, 1 (0.6%) as compared to 6 (3.4%) pre-ESAT (P = 0.07). CONCLUSION: The ESAT service is associated with better efficiency outcomes for patients with acute appendicitis.

Hospital Seeing More Personal Mobility Device Accidents and Serious Injuries Despite Active Mobility Act.

INTRODUCTION: E-scooters or personal mobility devices (PMDs) have recently been growing in popularity in Singapore. These devices can be especially helpful for those who have reduced mobility or who need to move between several relatively near locations multiples times per day or who simply appreciate the added convenience of having another transportation option. The increasing popularity of PMD has met with growing public concern over safety. Singapore government passed the Active Mobility Act (AMA) in January 2017 to regulate the usage of PMD. In Khoo Teck Puat Hospital, PMD-related accident has increased year on year by 20%-30%. Our study is to compare the incidence and severity of PMD-related accidents before and after the implementation of the AMA. MATERIALS AND METHODS: A retrospective study of patients presented to the emergency department (ED) of Khoo Teck Puat Hospital for PMD-related accidents between November 2014 and October 2017. In year 1 of the study, we included patients presenting between November 2014 and October 2015. In years 2 and 3, we included patients presenting between November 2015 and October 2016 and November 2016 and October 2017, respectively. Data collected included demographic information, type of device used and impact, outcome, and injury severity score (ISS). RESULTS: A total of 697 PMD-related accidents were seen in our center. We observed an increasing trend of accidents with significant injuries. There were 157 accidents reported in year 1, 233 in year 2, and 307 in year 3. The mean age of patients increased from 28 ± 15 years (range, 5-89 years) in year 1 to 33 ± 15 years (range, 4-83 years). Most patients were males (61.8% in year 1, 76.8% in year 2, and 73.3% in year 3) and Chinese (55.4% in year 1, 62.7% in year 2, and 65.5% in year 3), followed by Malays, Indians, and others. Devices commonly associated with injury were E-scooters, skateboards, and E-bicycles. E-scooters accidents had increased drastically from 12.1% in year 1 to 58.3% in year 3, but E-bicycles and other PMD accidents had decreased in year 3. Most patients were injured from falling off their devices (83.4% in year 1, 83.7% in year 2, and 79.5% in year 3), followed by collisions. Most patients arrived to the ED with own transports and were triaged to the patient acuity category 3 or 4. Most injuries were mild, with ISS <9 (97.5% in year 1 and 94.9% and 94.1% in year 2 and 3, respectively). The most common PMD-related injuries involved external injuries, followed by upper and lower extremities injuries. For more severe injuries (ISS ≥9), the number had increased from 4 in year 1 to 18 in year 3. Most patients were discharged. The number of patients required admissions increased from 12 to 44 in year 3, with two high-dependency or intensive care unit admissions. The mean hospital stay reduced from 5.0 ± 6.0 days to 3.6 ± 4.1 days, with the survival rate remained at 100%. There was only one fatality was reported in year 2. CONCLUSION: There is an increase in injuries and severity of PMD accidents despite AMA being implemented in January 2017. More need to be done to ensure the safety of PMD-related use in Singapore footpaths and roads.

Injury patterns associated with personal mobility devices and electric bicycles: an analysis from an acute general hospital in Singapore.

INTRODUCTION: The increasing popularity of personal mobility devices (PMDs) and electric bicycles (e-bikes) in Singapore has met with growing public concern over safety. Following the passing of the Active Mobility Bill, there remains a gap in the local literature in terms of injury patterns arising from the use of these devices. METHODS: A retrospective study was conducted on the Singapore National Trauma Registry (SNTR) from the emergency department of an acute hospital from 1 January 2016 to 31 December 2016. All patients with injuries related to the use of PMDs and e-bikes were included. Data captured included demographic information, device used and injury severity score (ISS). RESULTS: The 259 patients identified had a mean age of 32.1 years and a male predominance. Most (83.4%) were injured from falling off their devices. Devices commonly associated with injury were scooters, skateboards and motorised bicycles. Most injuries were mild (94.6%, ISS < 9) and were mainly external wounds (89.2%) and upper and lower limb injuries (35.5%). There was no difference in ISS in terms of the device used (motorised vs. non-motorised). More severe injuries (ISS ≥ 9) were caused by e-bikes (42.9%) and electric scooters (28.6%). Factors associated with these injuries were older age, use of e-bikes, and injuries to the head, face and thorax. Most patients (86.1%) were discharged and one died. CONCLUSION: While most injuries associated with PMDs and e-bikes are minor, serious injuries could result from their use. The SNTR should be updated to include PMDs and e-bikes as a category.

Evolution of a Dedicated Emergency Surgery and Trauma (ESAT) unit over 3 years: sustained improved outcomes.

INTRODUCTION: The traditional 24-h call model faces pressure from competing needs between emergency and elective services. Recognizing this, a dedicated ESAT service was developed in Khoo Teck Puat Hospital in Singapore, with improved clinical outcomes. It was initially led by a single consultant (SC) in 2014, and subsequently evolved to a weekly consultant rotation (WC) roster in 2017 to achieve sustainability. METHODS: Each consultant led the ESAT WC service for a week and maintained ownership of their patients thereafter. All emergency surgical admissions between two distinct 6-month periods were reviewed, from May to October 2014 (pre-ESAT) and January to June 2017 (ESAT WC). Patient demographics, diagnoses, and operations were compared. Efficiency and clinical outcomes were evaluated. RESULTS: There were 1248 and 1284 patients in the pre-ESAT and ESAT WC group, respectively. Majority were males and in their 50s. Acute appendicitis, gallstone conditions, and soft-tissue infections made up half of the admissions. Trauma workload was comparable (7.8% pre-ESAT vs 9.5% ESAT WC). Cholecystectomies doubled during the ESAT period, 14.2% vs 7.2%, (p = 0.01). More consultants were involved in major cases (95.9% vs 86%), (p = 0.01) and more operations were performed during the day (52.1% vs 47.9%), (p = 0.01). Average time to OT was shorter and there were less major surgical complications (p = 0.02). Mortality (p = 0.08) and length of stay were reduced (4 vs 4.5 days), (p = 0.01). CONCLUSION: The ESAT WC service has sustained improved outcomes in our institution.

Outcomes of emergency thoracotomy for trauma in a general hospital in Singapore.

Background An emergency thoracotomy can be performed either immediately at the site of trauma or in the emergency department or operating room for resuscitation of patients in extremis or life-saving treatment for patients with thoracic injury. It remains a procedure associated with high mortality rates, and there is a paucity of data from Asia. This study analyzed our six-year experience of emergency trauma thoracotomy in an acute general hospital in Singapore. Methods This retrospective analysis was based on experience in a single institution with all emergency trauma thoracotomies performed by general surgeons. All patients who underwent an emergency trauma thoracotomy in Khoo Teck Puat Hospital between January 2011 and December 2016 were studied. Data collected included patient demographics, mechanism of injury, Injury Severity Scores, surgical approach, and postoperative outcomes. Results Twenty-three patients underwent an emergency thoracotomy, 8 in the emergency department and 15 in the operating room. The mechanism of injury was blunt in 20 (87%) patients and penetrating in 3 (13%), with road traffic accidents the most common cause (70%). Six (40%) patients who underwent an emergency thoracotomy in the operating room survived beyond 24 h, and 4 (27%) survivors were eventually discharged from the hospital with no neurological deficit. No patient who underwent a thoracotomy in the emergency department survived beyond 24 h. Conclusions Emergency thoracotomy is associated with high mortality rates, especially when required in the emergency department or for blunt trauma. Nevertheless, it is a potentially life-saving procedure that offers a chance of survival in selected patients.

Emergency general surgery and trauma: Outcomes from the first consultant-led service in Singapore.

INTRODUCTION: There is a significant burden on public health systems from emergency surgical and trauma (ESAT) patients. In Western countries, the response has been to separate acute and elective surgery with the creation of a new sub-specialty: acute care surgery. Dedicated acute units have shown improvements in efficiency and clinical outcomes for patients. The aim of this study was to assess the results of the first such unit in Singapore. MATERIALS AND METHODS: A retrospective analysis was performed of a 12-month period of acute admissions between May 2014 and April 2015, with comparison of 6-months before and after the creation of the ESAT service. The ESAT service was a consultant led dedicated team managing all daily acute and trauma patients. Demographic, efficiency and clinical outcome key performance indicators were compared. RESULTS: There were 2527 acute admissions split between the two time periods. The ESAT service (N=1279) managed soft tissue infections (257, 20%), appendicitis (199, 16%) and biliary disease (175, 14%) most commonly. The most common of the 573 procedures performed were incision and drainage (242, 42%), appendicectomy (188, 33%) and laparotomy (84, 16%). Clinical outcome during the ESAT service included reduction in overall mean length of stay (4.5d to 3.5d, P<0.01) and mortality (24/1248 (1.9%) to 11/1279 (0.9%), P=0.03). Efficiency gains in theatre booking time, ED surgical review and overall costs were also noted. CONCLUSION: The creation of an ESAT service has led to improved efficiency of care with no worsening of clinical outcomes for acute general surgical and trauma patients.

Changing models of care for emergency surgical and trauma patients in Singapore.

The last 15 years have seen changing patterns of injury in emergency surgery and trauma patients. The ability to diagnose, treat and manage these patients nonoperatively has led to a decline in interest in trauma surgery as a career. In addition, healthcare systems face multiple challenges, including limited resources, an ageing population and increasing subspecialisation of medical care, while maintaining government-directed standards and managing public expectations. In the West, these challenges have led to the emergence of a new subspecialty, 'acute care surgery', with some models of care providing dedicated acute surgical units or separating acute and elective streams with the existing manpower resources. The outcomes for emergency surgery patients and efficiency gains are promising. In Singapore, Khoo Teck Puat Hospital has implemented its first dedicated acute surgical unit. This article outlines the evolution of acute care surgery and its relevance to Asia.

Outcomes of parathyroidectomy in renal hyperparathyroidism in patients with No access to renal transplantation in Singapore.

BACKGROUND: Total parathyroidectomy with autotransplantation (TPTX + AT) and subtotal parathyroidectomy (SPTX) are considered standard surgical treatments for refractory renal hyperparathyroidism. However, there is little data available comparing their outcomes in an area with poor access to renal transplant and calcimimetics. METHODS: Patients with renal hyperparathyroidism who underwent TPTX + AT and SPTX in a tertiary institution from 2006 to 2013 were studied. Patient characteristics, pre- and post-operative biochemical marker levels, and outcomes including recurrence rates, post-operative morbidity and mortality were analysed. RESULTS: 87 patients underwent parathyroidectomy for renal hyperthyroidism. Transplant patients were excluded in this study. 81 patients were on long-term dialysis, with a median time of 7 years from initiation of haemodialysis to parathyroidectomy. 57 patients (70.4%) underwent TPTX + AT while 24 (29.6%) underwent SPTX. Post-operatively, there was significant decrease in parathyroid hormone (PTH), calcium and phosphate levels in both groups. PTH and phosphate levels were significantly lowered with TPTX compared to SPTX (p = 0.004, 0.003). Symptomatic hypocalcaemia was seen in both groups. In a median follow-up of 4 years, 11 patients developed biochemical recurrence, with a median time of 29 months to recurrence. Median PTH at recurrence was 67.1 pmol/L. Rate of recurrence was higher in patients who underwent SPTX (20.8% vs 10.5%), with a shorter median time to recurrence (median 62.1 vs 81.3 months). 2 patients required resection of the autograft. Cohort mortality was 11 patients (13.4%), with 3 deaths secondary to cardiovascular events. CONCLUSION: Total parathyroidectomy with autoimplantation is superior to subtotal parathyroidectomy in the short to intermediate term.

Single-port access adrenalectomy: our initial experience.

BACKGROUND: After being introduced in 1992, laparoscopic adrenalectomy has been accepted as the gold standard today for benign diseases. The need is now being realized for newer innovations to further reduce the trauma of surgical access. We report our experience and outcome of the first case series of single-port access adrenalectomy by using SILS™ port. METHODS: Between June 2009 and November 2010, 6 patients with adrenal tumors underwent single-port access adrenalectomy via SILS port. The device was placed through a single 3 cm incision. The patients' demographics, adrenal mass characteristics, operative time, conversion rate, intraoperative and postoperative complications, and postoperative pain score were measured. Five patients underwent adrenalectomy by using the retroperitoneal approach and 1 by using the laparoscopic transperitoneal approach. RESULTS: Three men and 3 women with mean age 51 years (range, 37-67) underwent single-incision adrenalectomy. The mean tumor size was 3.3 cm (range, 1.5-6). Three of these cases were Conn's syndrome, and the remaining 3 were incidentaloma. No significant complications or conversions to the conventional procedure were recorded. The mean operative time was 121 minutes (range, 70-165). The mean hospital stay was 2.7 days (range, 2-4). No local recurrences or hormonal relapse have been recorded to the present with a median follow-up of 12 months (range, 3-20). CONCLUSIONS: In our short experience, single-port access adrenalectomy seems to be safe and feasible in improving the advantages of laparoscopic approach, especially in terms of cosmesis, but further randomized controlled trials are needed to evaluate the benefits of this novel approach.

Laparoscopic transabdominal preperitoneal (TAPP) hernia repair via a single port.

INTRODUCTION: To report our initial experience and outcome of 7 cases of single port laparoscopic transabdominal preperitoneal (TAPP) hernia repair. METHODS: Between May 2009 and June 2010, 7 patients underwent single port TAPP hernia repair for inguinal hernia. The device was placed through a single 2 cm infraumbilical incision. Patients' demographics, hernia characteristics, operative time, conversion rate, intraoperative and postoperative complications, and recurrence were measured. Five patients had unilateral and 2 had bilateral hernias. RESULTS: The mean operative time was 67 minutes (range: 36 to 111 min). None of the patients required any conversion to conventional TAPP. No intraoperative and postoperative complications were recorded and no recurrences have been recorded to the present with a median follow-up of 6 months (range: 2 to 8 mo). CONCLUSIONS: Single port TAPP hernia repair is safe and feasible. Further study is needed to evaluate the benefits of this novel approach compared with the conventional laparoscopic approach.