Elective incisional hernia repair: lower risk of postoperative wound infection with laparoscopic versus open repair

INTRODUCTION@#The superiority of laparoscopic repair over open repair of incisional hernias (IHs) in the elective setting is still controversial. Our study aimed to compare the postoperative outcomes of laparoscopic and open elective IH repair in an Asian population.@*METHODS@#This retrospective study was conducted in an acute general hospital in Singapore between 2010 and 2015. Inclusion criteria were IH repair in an elective setting, IHs with diameter of 3-15 cm, and location at the ventral abdominal wall. We excluded patients who underwent emergency repair, had recurrent hernias or had loss of abdominal wall domain (i.e. hernia sac containing more than 30% of abdominal contents or any solid organs). Postoperative outcomes within a year such as recurrence, pain, infection, haematoma and seroma formation were compared between the two groups.@*RESULTS@#There were 174 eligible patients. The majority were elderly Chinese women who were overweight. Open repair was performed in 49.4% of patients, while 50.6% underwent laparoscopic repair. The mean operation time for open repair was 116 minutes (116 ± 60.6 minutes) and 139 minutes (136 ± 64.1 minutes) for laparoscopic repair (P = 0.079). Within a year after open repair, postoperative wound infection occurred in 15.1% of the patients in the open repair group compared to 1.1% in the laparoscopic group (P = 0.0007). Postoperative pain, recurrence and haematoma/seroma formation were comparable.@*CONCLUSION@#Elective laparoscopic IH repair has comparable outcomes with open repair and may offer the advantage of reduced postoperative wound infection rates.

Academy of Medicine, Singapore clinical guideline on endoscopic surveillance and management of gastric premalignant lesions

Gastric cancer (GC) has a good prognosis, if detected at an early stage. The intestinal subtype of GC follows a stepwise progression to carcinoma, which is treatable with early detection and intervention using high-quality endoscopy. Premalignant lesions and gastric epithelial polyps are commonly encountered in clinical practice. Surveillance of patients with premalignant gastric lesions may aid in early diagnosis of GC, and thus improve chances of survival. An expert professional workgroup was formed to summarise the current evidence and provide recommendations on the management of patients with gastric premalignant lesions in Singapore. Twenty-five recommendations were made to address screening and surveillance, strategies for detection and management of gastric premalignant lesions, management of gastric epithelial polyps, and pathological reporting of gastric premalignant lesions.

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.

Rapid Staining Using the Shorr Method for Intraoperative Peritoneal Washing Cytology in Advanced Gastric Cancer: a Pilot Study from a Single Institution

PURPOSE: Intraoperative peritoneal washing cytology (PWC) is used to determine treatment strategies for gastric cancer with suspected serosal invasion. However, a standard staining method for intraoperative PWC remains to be established. We evaluated the feasibility of a rapid and simple staining method using Shorr's stain for intraoperative PWC in advanced gastric cancer. MATERIALS AND METHODS: Between November 2012 and December 2014, 77 patients with clinical T3 or higher gastric cancer were enrolled. The sensitivity, specificity, and concordance between the Shorr staining method and conventional Papanicolaou (Pap) staining with carcinoembryonic antigen (CEA) immunohistochemistry (IHC) were analyzed. RESULTS: Intraoperative PWC was performed laparoscopically in 69 patients (89.6%). The average time of the procedure was 8.3 minutes, and the average amount of aspirated fluids was 83.3 mL. The average time for Shorr staining and pathologic review was 21.0 minutes. Of the 77 patients, 16 (20.7%) had positive cytology and 7 (9.1%) showed atypical findings; sensitivity and specificity were 73.6% and 98.2% for the Shorr method, and 78.9% and 98.2% for the Pap method with CEA IHC, respectively. Concordance of diagnosis between the 2 methods was observed in 90.9% of cases (weighted κ statistic=0.875) and most disagreements in diagnoses occurred in atypical findings (6/7). In overall survival, there was no significant difference in C-index between the 2 methods (0.459 in Shorr method vs. 0.458 in Pap with CEA IHC method, P=0.987). CONCLUSIONS: Shorr staining could be a rapid and reliable method for intraoperative PWC in advanced gastric cancer.

Factors that positively influence adherence to antiretroviral therapy by HIV and/or AIDS patients and their caregivers

Background: The importance of dedicated adherence to antiretroviral treatment (ART) in the management of Human Immunodeficiency Virus (HIV) is well documented. Multiple factors may affect adherence and this study explores patients' and their caregivers' perceptions of factors which may positively influence adherence to ART. Method: This study was a descriptive, qualitative study that used both free attitude interviews and focus-group discussions. Nineteen patients attending a busy ART-clinic at a district hospital in KwaZulu-Natal and eight caregivers were purposefully selected. Selection criteria included good adherence to ARTs as evidenced by excellent clinic attendance for more than one year with evidence of clinical, immunological and viral improvement. Interviews were tape recorded, transcribed and thematically analysed. Results: Ten female participants, nine male participants and eight caregivers took part in the study. Participants highlighted three main categories that positively affect their adherence to ART namely: patient, disease and health care provider-related factors. Sub-themes included issues related to acceptance, disclosure to significant others, symptomatic improvement on ARTs and the importance of supportive relationships. Participants greatly valued the health care provider relationship and felt that the main role of the health care provider was to educate and support. Conclusion: This study has shown that the factors which most influenced adherence were patient-related (acceptance, disclosure, determination, and family support), disease-related and treatment-related (symptomatic illness and improvement on ARTs), and healthcare worker-related (relationships, and adherence classes)

The effect of intramuscular loading dose of quinine on Myanmar patients (children and adults) with falciparum malaria

The effect of three doses of intramuscular quinine followed by oral quinine on ten adults and ten children with falciparum malaria (half of each group were highly parasitised) were studied. There were no complications associated with this method of therapy. the level of serum quinine in all the adults reached above the minimal inhibitory concentration (MIC) from the 2nd hour of the drug administration. So this method of administration should be recommended for severely ill patients before referral to hospitals. Anong the children, eight responded well to the therapy and the serum quinine level rose above MIC level from the second hour as in adults. There were two patients who failed to respone to the treatment. One had persistantly high level of quinine and was misdiagnosed as a case of cerebral malaria instead of quinine toxicity. He responded well when quinine was omitted and replaced with mefloquine. Another child had persistantly low level of quinine. He developed cerebral sings and symptoms and also responded well to mefloquine. Thus it is suggested that the level of serum quinine should be monitroed in children if possible, or toxicity ot quinine should be watched.