Clinicopathological study of gastric cancer in a Malaysian tertiary public health care centre.

INTRODUCTION: Gastric cancer (GC) is one of the leading causes of all new cancer cases globally. Although it is no longer reported in the top 10th most common cancer in Malaysia, geographical distribution and ethnic influences still obviously exist. MATERIALS AND METHODS: This is a retrospective analysis of histopathological records in a public tertiary health care centre in Malaysia. The computerised laboratory information system from the histopathology department of the hospital was retrieved for the period of 2005-2018. Descriptive analysis was done using Microsoft Excel. RESULTS: There was a total of 233 histologically confirmed GC cases. The burden of GC was observed to be an increasing trend from 2016 onwards. Among them, 64% were male and 36% were female. The youngest age of diagnosis was 19, while the oldest one was 93. Malaysian Chinese were found to have the highest incidences (41.63%), followed by Malays (32.19%) and Malaysian Indians (23.61%). All cases were of adenocarcinoma cell types and were found to have poorly differentiated in majority at the time of diagnosis. CONCLUSION: Although this report only represents one tertiary health care centre in Malaysia, the Indian Enigma was still observed, as stated in other literatures. Over time, the incidence of GC in Malays has increased. Consideration of lifestyle modifications, health education and Helicobacter pylori eradication in various nations' National Health Insurance plans, are encouraged as prevention is always better than treatment or cure, including the cost load.

Study protocol for an open labelled randomised controlled trial of perioperative oral nutrition supplement in breast and colorectal cancer patients undergoing elective surgery.

BACKGROUND: While it is well established that perioperative use of oral nutrition supplement (ONS) improves nutrition status among severely malnourished surgical cancer patients, the evidence requires further substantiation for non-severely malnourished patients with cancer. This protocol paper presents the rationale and design of a randomised controlled trial to evaluate the effectiveness of preoperative as well as an extended 90-day postoperative use of ONS on nutritional and clinical outcomes among patients undergoing elective surgery for breast and colorectal cancer. METHODS: Patients with primary breast and colorectal cancer undergoing elective surgery are recruited from two tertiary hospitals. Eligible patients are assigned into one of the three intervention arms: (i) Group SS will receive ONS in addition to their normal diet up to 14 days preoperatively and postoperatively up to discharge; (ii) Group SS-E will receive ONS in addition to their normal diet up to 14 days preoperatively, postoperatively up to discharge and for an extended 90 days after discharge; and (iii) Group DS will receive ONS in addition to their normal diet postoperatively up to discharge from the hospital. The ONS is a standard formula fortified with lactium to aid in sleep for recovery. The primary endpoints include changes in weight, body mass index (BMI), serum albumin and prealbumin levels, while secondary endpoints are body composition (muscle and fat mass), muscle strength (handgrip strength), energy and protein intake, sleep quality, haemoglobin, inflammatory markers (transferrin, high sensitivity C-reactive protein, interleukin-6), stress marker (saliva cortisol), length of hospital stay and postoperative complication rate. DISCUSSION: This trial is expected to provide evidence on whether perioperative supplementation in breast and colorectal cancer patients presenting with high BMI and not severely malnourished but undergoing the stress of surgery would be beneficial in terms of nutritional and clinical outcomes. TRIAL REGISTRATION: ClinicalTrial.gov NCT04400552. Registered on 22 May 2020, retrospectively registered.

Emergency general surgery in a public hospital in Malaysia.

INTRODUCTION: Patients undergoing emergency general surgery (EGS) are at risk for death and complications. Information on the burden of EGS is critical for developing strategies to improve the outcomes. METHODS: In this retrospective cohort study, medical records of all general surgical operations in a public hospital were reviewed for the period 1st January 2017 to 31st December 2017. Data on patient demographics, operative workload, case mix, time of surgery and outcomes were analysed. RESULTS: Of the 2960 general surgical operations that were performed in 2017, 1720 (58.1%) of the procedures were performed as emergencies. The mean age for the patients undergoing emergency general surgical procedures was 37.9 years (Standard Deviation, ±21.0), with male preponderance (57.5%). Appendicitis was the most frequent diagnosis for the emergency procedures (43%) followed by infections of the skin and soft tissues (31.6%). Disorders of the colon and rectum ranked as the third most common condition, accounting for 6.7% of the emergency procedures. Majority of emergency surgery (59.3%) took place after office hours and on weekends. Post-operative deaths and admissions to critical care facilities increased during EGS when compared to elective surgery, p<0.01. CONCLUSIONS: EGS constitutes a major part of the workload of general surgeons and it is associated significant risk for death and post-operative complications. The burden of EGS must be recognised and patient care systems must evolve to make surgery safe and efficient.

Comparison of features and outcomes of perforated peptic ulcer between Malaysians and foreigners.

BACKGROUND: Perforated peptic ulcers (PPU) present as serious surgical emergencies that carry high mortality and morbidity. Foreigners with PPU are also managed in our hospital setting. Their inclusion significantly alters the trend and pattern of PPU seen in Malaysia. AIM: To compare per-operative and post-operative features and outcomes of perforated peptic ulcers between Malaysians and foreigners. MATERIAL AND METHODS: This was an analytical crosssectional study. All patients who underwent repair of perforated peptic ulcer disease during a 6-year period were included. 50 consecutive patients' records with perforated peptic ulcer were analysed. Data were collected from operation theatre database and hospital medical records. Chi square and t test were performed using SPSS statistical software. RESULTS: Total of 50 patients, of which 30 were Malaysians and 20 were foreigners. The mean age of Malaysian patients was 58.3 ± 15.2 years whereas the mean age for foreign patients was 30.3 ± 6.7 years, with foreign patients being significantly younger than local patients. Foreigners had significantly smaller ulcers with only 5% of them having ulcers more than 1cm while 36.7% of Malaysian patients had ulcers more than 1cm. Post-operative complications are significantly higher in Malaysian patients (p<0.05) with 40% of Malaysian patients and 10% of foreign patients developing post-operative complications. CONCLUSION: Foreign patients are younger with significantly smaller perforated ulcers and better post-operative outcomes.

Delay in Diagnosis of Upper Gastrointestinal Cancer: whose fault is it?

BACKGROUND: Stomach and esophageal cancers are both deadly and difficult to diagnose early. Stomach cancer is the second most common cancer in Asia. Both these are one of the most common causes of cancer related death in the world. AIM: To determine the mean time delay from appearance of the symptoms to the endoscope procedure [OGDS] and rationalized the reason for this delay in diagnosis. METHOD: This is a cross sectional study of stomach and esophageal cancer data from Jan 2004- July 2008. All patients' records of histologically confirmed stomach or esophageal cancers during the study period were reviewed. RESULT: Total of 112 consecutive patients with stomach and esophageal cancer were analysed. 86 cases of stomach and 26 cases of esophageal cancer were reviewed. The average age for stomach and esophageal cancers are 60.8 years and 58.4 years respectively. The mean duration from the first appearance of cancer symptoms to endoscope procedure was 32.4 weeks for stomach cancer patient and 16.7 weeks for esophageal cancer patients. The reasons for the delays are due to 1) self-medication, 2) Empirical treatment for dyspepsia using antacid and H2 antagonist, 3) Delay in endoscope procedure for high risk patients. CONCLUSION: Reducing the delay in endoscope procedure may lead to early detection of cancer and thereby may improve the prognosis of these patients.

Laparoscopic staging in gastric cancer: An essential step in its management.

AIM: The role of laparoscopy in staging of gastric cancer is widely accepted; however, in Malaysia its usage has been limited. Patients can be classified as resectable or unresectable, which helps in avoiding an unwanted laparotomy and the morbidities associated with it. The aim of this study was to assess the value of laparoscopy in staging of gastric cancer in comparison with CT scan. MATERIALS AND METHODS: Patients with carcinoma of the stomach after a complete preoperative work-up underwent laparoscopy prior to surgical exploration. TNM staging was used to compare laparoscopy with CT, with the histopathological report used as the gold standard. RESULTS: Forty cases were included in this study. The sensitivity of laparoscopy for T3 tumours appears to be significant when compared to that of CT. Laparoscopy detected 90.3% of the cases as against the 58% detected with CT. There was not much difference in the N factor. With regard to M factor, the sensitivity was 100% for laparoscopy in comparison with CT. CONCLUSIONS: Laparoscopy has been shown to be sensitive in detecting metastasis in gastric cancer in comparison to CT, thus helping in avoiding unwanted laparotomy and thus providing a more systemic approach in managing gastric cancers.

Endoscopic drainage of empyema of the gallbladder through a concurrent cholecystoduodenal fistula.

The duodenum is the most common site of cholecystoenteric fistulation resulting from cholecystitis or empyema of the gallbladder. This rare condition is usually only diagnosed intraoperatively and managed incidentally. This paper presents the endoscopic diagnosis of a case of cholecystoduodenal fistula arising from the late presentation of empyema of the gallbladder and its subsequent drainage through the fistula. As far as we can determine, this is the only reported case of opportunistic drainage of an empyema of the gallbladder through a concurrent cholecystoduodenal fistula.

Clinical and endoscopic features of peptic ulcer bleeding in Malaysia.

The characteristics of patients and the endoscopic features of 196 patients with bleeding peptic ulcer in a multi-ethnic population were investigated. There was a male preponderance (M: F= 6.3: 1) and their mean age was 63.5 years. The prevalence of peptic ulcer bleeding in the Malays and Indians was similar to the ethnic distribution of population. However, the Chinese were over represented. Nearly 40% of patients studied had at least one co-existing medical illness. Hypertension and ischaemic heart disease were the most common diseases. History of non-steroidal anti-inflammatory drug usage was identified in 48% of the patients and it was the commonest risk factor associated with bleeding ulcers. More than 80% of bleeding ulcers were located in the duodenum and the pylorus. Endoscopic features of active bleeding or recent bleed were identified in more than 60% of the patients. The study notes that bleeding peptic ulcer is a serious and a potentially life threatening condition. It is a disease of the elderly and, with the steadily increasing elderly population in the country, the admissions rates of peptic ulcer bleeding is expected to rise. There is a need to plan for appropriate technical support, critical care facilities and expertise to avoid unacceptable outcomes.

Gastric cancer in Malaysia: the need for early diagnosis.

Gastric cancer is an important cause of death among patients with malignancies in Malaysia. Survival of patients with gastric cancer is dependent on the stage at which diagnosis is made. We report our experience in dealing with gastric cancer in a major Ministry of Health Hospitals in Malaysia. A retrospective review of two hundred and fifty consecutive histologically proven gastric adenocarcinoma at Hospital Ipoh for the period January 1988 to 1998 was performed. The study confirms that gastric cancer is a disease of the elderly and has a male preponderance. It is also identifies the Chinese and Indians to be at increased risk of gastric cancer when compared to the Malays. The most striking finding in this study was the very late stage of disease at time of presentation. Eighty-two percent of the patients presented with stage IV disease and curative surgery was offered only to a 16% of them. In a substantial number of patients not even a palliative procedure was offered. Early detection is the key to improving survival in gastric cancer patients. There is an urgent need for clinicians to change their approach to the management of the disease. Patients with dyspeptic symptoms should be investigated early rather then wait for classical symptoms of gastric cancer.

Perioperative death in Malaysia: the transition phase from a developing nation to a developed one.

This paper examines the surgical pathology associated with perioperative deaths in a country that is undergoing the transition from a developing to a developed nation status. The data from an ongoing nation-wide perioperative mortality study was prospectively collected for the period July 1996 to December 1997 and analyzed. The surgical pathology related to perioperative deaths in Malaysia is different from other developing and developed countries. While death from trauma and the late presentation of surgical conditions are similar to developing countries, infective gastrointestinal conditions were rarely encountered. Diseases associated with advanced age such as colorectal cancer, peptic ulcer, urological diseases and vascular conditions are beginning to emerge. As the country races towards a developed nation status, increasing life expectancy and changing life-styles are expected to influence the disease pattern. The planning of surgical facilities and manpower development must recognize the changes taking place.

Acute pancreatitis in a multi-ethnic population.

There is very little information in literature describing ethnic variations in etiologic and clinical outcome of acute pancreatitis in the Asian population. This study describes the demographic, etiologic and clinical course of acute pancreatitis among the three main races in Malaysia namely, the Malays, Chinese and Indians. One hundred and thirty-three consecutive patients were admitted for acute pancreatitis for the period January 1994 to July 1999 and they consisted of 77 males and 56 females with a mean age of 43.5 years (SD+/- 14.7). The racial breakdown of acute pancreatitis was: Malays 38 (28.6%), Chinese 19 (14.3%), Indians 75 (56.4%) and 1 (0.8%) patient was an orang asli. The incidence of alcohol association with acute pancreatitis was significantly increased in the males, while gallstone pancreatitis was principally a disease of the female. Alcohol was identified as the predominant factor associated with acute pancreatitis among the Indians (73.3%) and in contrast, gallstone was the commonest associated etiologic factor for the Malays and Chinese. No etiologic factor could be identified in a substantial proportion of the Malay patients (60.5%) when compared to the Chinese (36.8%) and Indians (35%). Severe disease developed in 25% of the cases reviewed but there was no difference in of the rate of severe pancreatitis in terms of ethnic groupings or etiologic factors. The overall mortality rate was 7.5% and the commonest cause of death was multi-organ failure. The study recognises that there are differences in the characteristics of acute pancreatitis among the three major races in the country and this divergence is primarily due to sociocultural habits.

Bleeding peptic ulcer: experience with endoscopic therapy.

Bleeding is a serious complication of peptic ulcer and mortality rate has remained at approximately 10% or more. Traditionally surgeons selected patients who were at significant risk of continued or re-bleeding and advocated early surgery. However, patients with bleeding peptic ulcers are generally elderly with coexisting medical illness and surgery results in significant morbidity and mortality. In the last decade, endoscopic haemostatic therapy has been effective in arresting the bleeding with surgical option considered only after endoscopic treatment has failed. We report the outcome of 196 patients who were endoscopically diagnosed to have bleeding from peptic ulcers. One hundred and thirty patients were to have active bleeding or recent bleed from the ulcer. Endoscopic adrenaline injection therapy was used in 53 patients who had active bleeding ulcers and another 77 patients with endoscopic evidence of recent bleed. The injection therapy was successfully in 127 (97.7%) patients. The treatment failed in three patients and they underwent urgent surgery. Re-bleeding occurred in 26 (20.5%) patients and endoscopic adrenaline therapy was repeated in these cases. Haemostatic was achieved in 19 patients, however 7 patients continued to bleed and required surgery. There were 3 deaths, principally from advanced age and coexisting medical illness. Endoscopic therapy for bleeding peptic ulcers is simply to apply, safe and effective. In cases of re-bleeding after initial endoscopic hemostasis, re-treatment is a preferable alternative to surgery. The role of surgery is limited to bleeding that is refractory or inaccessible to endoscopic control.

Optimal treatment for duodenal ulcer disease: a cost-decision analysis in Malaysian patients.

The aim of the present study was to determine the cost-efficiency of different duodenal ulcer disease treatment practices in Malaysia. Six Malaysian gastroenterologists met to discuss the direct costs related to Helicobacter pylori (HP) eradication treatment. Five treatment strategies were compared: (i) histamine H2 receptor antagonists (H2RA), acid suppression therapy for 6 weeks followed by maintenance therapy as needed; (ii) bismuth triple + proton pump inhibitor (PPI), bismuth (120 mg, q.i.d.), metronidazole (400 mg; t.i.d.), tetracycline (500 mg, q.i.d.) for 7 days and PPI, b.i.d., for 7 days; (iii) OAC, omeprazole (20 mg, b.i.d.), amoxycillin (1000 mg, b.i.d.) and clarithromycin (500 mg, b.i.d.) for 7 days; (iv) OMC, omeprazole (20mg, b.i.d.), metronidazole (400mg, b.i.d.) and clarithromycin (500 mg, b.i.d.) for 7 days; and (v) OAM, omeprazole (20 mg, b.i.d.), amoxycillin (1000 mg, b.i.d.) and metronidazole (400 mg, b.i.d.) for 7 days. A decision tree model was created to determine which therapy would be the most cost-effective. The model considered eradication rates, resistance to anti-microbial agents, compliance and cost implications of treatment regimens, physician visits and ulcer recurrences during a 1 year time period assumption. The H2RA maintenance therapy was the most expensive treatment at Malaysian Ringgit (MR) 2335, followed by bismuth triple therapy (MR 1839), OMC (MR 1786), OAM (MR 1775) and OAC, being the most cost-effective therapy, at MR 1679. In conclusion, HP eradication therapy is superior to H2RA maintenance therapy in the treatment of duodenal ulcer disease. Of the HP eradication regimens, OAC is the most cost-effective.

Management of Helicobacter pylori infection--a Working Party Report of the Malaysian Society of Gastroenterology and Hepatology.

The Working Party Report on the Management of Helicobacter pylori serves as a clinical practice guideline for Malaysian doctors. H. pylori is not uncommon in the Malaysian population. Marked racial differences and the consistently low prevalence rates amongst Malays are noted. The working party recommends that if endoscopy is to be performed, a rapid urease test should be used for diagnosis. Where suspicion of the infection is strong and the urease test is negative, histology should be performed on gastric biopsies. Culture should be used to monitor resistance patterns to antibiotics and regional laboratories should assume this responsibility. The urea breath tests are highly accurate tests for diagnosis of H. pylori but is as yet not widely available in Malaysia. The working party strongly recommends that all peptic ulcer patients infected with H. pylori whether active, in remission and complicated ulcers should be treated for the infection. Patients with low-grade gastric mucosal lymphoid tissue lymphoma should also be treated for H. pylori infection. It is considered advisable that patients on long term nonsteroidal antinflammatory drug (NSAID) treatment with a history of peptic ulcers or dyspepsia and patients following resection of early gastric cancer or those with a family history of gastric cancer should also be tested and treated for H. pylori. The working party recommends, as first line treatment a 7-day combination therapy of a proton pump inhibitor, clarithromycin and metronidazole or amoxicillin. High metronidazole resistance rates locally may adversely affect regimens containing the antibiotic. It should also be noted that regimens that yield lower eradication rates may result in higher long term expenditure.

A 2-year audit of perioperative mortality in Malaysian hospitals.

An audit of all perioperative deaths within seven days of surgery in 14 major public hospitals is presented. This study is part of a quality assurance programme examining the surgical and anaesthetic practices in these hospitals. During the study period from July 1992 till June 1994, 211,354 surgeries were performed and 715 deaths were reported out of which 699 were available for analysis. The data was obtained by confidential enquiry using predetermined questionnaires filled by participating surgeons and anaesthetists and analysed by a group of peers. The overall crude mortality rate was 0.34% and the majority of the deaths occurred in severely ill patients in whom the clinical management was satisfactory. Polytrauma including head, intra-abdominal and skeletal trauma accounted for 253 of the deaths (36.19%). The other causes were bowel obstruction with sepsis, burns, ischaemic limbs, congenital malformations in neonates and pregnancy-related hemorrhage. 62.52% of the deaths occurred within two days of surgery and 85.87% were related to emergency procedures. The review identified some shortfalls in perioperative care and these were lack of adequate critical care facilities, lack of supervision, unnecessary surgery in the moribund and inadequate preoperative optimisation. The results of the study have been forwarded to all participating hospitals for implementation of remedial measures.

Fournier's gangrene: its aetiology and management.

The clinical features and management of 12 patients with Fournier's gangrene are described. The patients differed from the usual description of Fournier's gangrene in that they were older, the disease had a less abrupt onset and a definite predisposing factor was identified in 10 of the 12 patients. The importance of early diagnosis and excision of necrotic tissue is emphasized.