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.

Recent Advances in Intra-peritoneal Chemotherapy for Gastric Cancer

Peritoneal metastasis (PM) frequently occurs in patients with gastric cancer (GC) and confers a dismal prognosis despite advances in systemic chemotherapy. While systemic chemotherapy has poor peritoneal penetration, intraperitoneal (IP) chemotherapy remains sequestered, resulting in high peritoneal drug concentrations with less systemic side-effects. The first application of IP treatment was hyperthermic intraperitoneal chemotherapy (HIPEC) with cytoreductive surgery (CRS) for gastric cancer peritoneal metastasis (GCPM); but was associated with an increased morbidity and mortality rate without significantly improving overall survival (OS). While CRS confers limited benefit, the potential role of prophylactic HIPEC and laparoscopic neoadjuvant HIPEC are currently being evaluated. Combination systemic and IP chemotherapy (SIPC) gained popularity in the 1990s, since it provided the benefits of IP treatment while reducing surgical morbidity, demonstrating promising early results in multiple Phase II trials. Unfortunately, these findings were not confirmed in the recent PHOENIX-GC randomized controlled trial; therefore, the appropriate treatment for GCPM remains controversial. Small observational studies from Japan and Singapore have reported successful downstaging of PM in GC patients receiving SIPC who subsequently underwent conversion gastrectomy with a median OS of 21.6–34.6 months. Recently, the most significant development in IP-directed therapy is pressurized IP aerosol chemotherapy (PIPAC). Given that aerosol chemotherapy achieves a wider distribution and deeper penetration, the outcomes of multiple ongoing trials assessing its efficacy are eagerly awaited. Indeed, IP-directed therapy has evolved rapidly in the last 3 decades, with an encouraging trend toward improved outcomes in GCPM, and may offer some hope for an otherwise fatal disease.

Surgical management of obesity - National University Hospital experience

<p><b>INTRODUCTION</b>The Singapore National Survey of 2004 reported the prevalence of obesity to have increased to 6.9%, thus reflecting the profound changes in our society's lifestyle and eating habits. Bariatric surgery has steadily been increasing to counter the ill effects of obesity.</p><p><b>MATERIALS AND METHODS</b>We audited our prospective series of 31 patients who had laparoscopic adjustable gastric banding (LABG) for morbid obesity performed by our multidisciplinary team at the National University Hospital, Singapore, between August 2004 and December 2006.</p><p><b>RESULTS</b>The median age at presentation was 40 years old including 6 males and 25 females. Their median BMI was 42.35 kg/m(2). At a median follow-up of 26 months, the median percentage of excess weight loss (%EWL) was 41.95%. The positive impact of gastric banding on comorbidities are evident whereby 15 (94%) of the diabetics had improved glycaemic control with HbA(1)C of 7.7% preoperatively improving to 5.9% postoperatively, and also 8 (58%) now take smaller doses of oral hypoglycaemic agents. Hypertension improved in 4 patients and 2 (11%) were cured. All our patients with dyslipidaemia had their statin doses reduced with marked lowering of serum lipid levels. We had 2 patients (6.45%) with band erosion and another 2 with reflux oesophagitis. Our article also summarises the available surgical procedures while discussing the pros and cons of each.</p><p><b>CONCLUSION</b>Our results showed that a multidisciplinary programme can achieve significant weight loss for obese patients in Singapore. To achieve long-term weight loss, a commitment of both the medical team and the patient is necessary. Laparoscopy has revolutionised the practice of bariatric surgery worldwide. LAGB is an effective and safe procedure.</p>