Clinical guidance on endoscopic management of colonic polyps in Singapore

Colonoscopy with endoscopic resection of detected colonic adenomas interrupts the adenoma-carcinoma sequence and reduces the incidence of colorectal cancer and cancer-related mortality. In the past decade, there have been significant developments in instruments and techniques for endoscopic polypectomy. Guidelines have been formulated by various professional bodies in Europe, Japan and the United States, but some of the recommendations differ between the various bodies. An expert professional workgroup under the auspices of the Academy of Medicine, Singapore, was set up to provide guidance on the endoscopic management of colonic polyps in Singapore. A total of 23 recommendations addressed the following issues: accurate description and diagnostic evaluation of detected polyps; techniques to reduce the risk of post-polypectomy bleeding and delayed perforation; the role of specific endoscopic resection techniques; the histopathological criteria for defining endoscopic cure; and the role of surveillance colonoscopy following curative resection.

Endoscopic submucosal dissection of colonic lesions: first 50 cases at a local institution

INTRODUCTION@#Endoscopic submucosal dissection (ESD) in the colon and rectum has been developed with good reported outcomes. The main advantage of ESD is the ability to perform en bloc resection, which has implications for complete excision and pathological analysis. Locally, the use of ESD in colonic lesions has seen recent traction. Our study aimed to review the outcomes of the first 50 cases of endoscopic excision of advanced colonic lesions using ESD at our institution.@*METHODS@#This was a retrospective study of all patients who underwent ESD at our institution from September 2010 to October 2016. Data collected included patient demographics, resection technique, conversion rate and morbidity.@*RESULTS@#51 patients underwent ESD during the study period. All patients were of American Society of Anesthesiologists (ASA) class 1-3. Their median age was 60.0 years and the majority (n = 36) were male. The mean procedure time was 80.9 minutes. 36 (76.6%) of cases underwent en bloc resection. 4 (7.8%) cases required conversion to surgery, mainly due to difficulty in raising the colonic lesions. 3 (5.9%) patients had malignancy as the final histology. 2 (4.3%) patients had recurrence during surveillance scope. No cases of early mortality were reported.@*CONCLUSION@#Our results suggest that ESD for advanced colonic lesions can be safely performed. Expertise needs to be developed to achieve satisfactory en bloc resection rates.

Extent of field change in colorectal cancers with BRAF mutation

<p><b>INTRODUCTION</b>Sporadic colorectal cancers with BRAF mutations constitute two distinct subgroups of colorectal cancers. Recent studies have linked the presence of the BRAF mutation to a familial inheritance pattern. This was a proof-of-concept study that aimed to examine: (a) the extent of field change in sporadic colorectal cancers with BRAF mutation; and (b) the extent of resection margins required and the pattern of DNA mismatch repair protein loss in these tumours.</p><p><b>METHODS</b>Eight microsatellite instability-high tumours with positive BRAF mutation from an existing histopathological database were selected for BRAF mutation and mismatch repair protein analysis.</p><p><b>RESULTS</b>All the resection margins were negative for BRAF mutation. Three tumours had loss of MLH1 and PMS2 expressions, and five tumours had no protein loss. Six peritumoral tissues were negative and one was positive for BRAF mutation.</p><p><b>CONCLUSION</b>The results suggest that any early field change effect is restricted to the immediate vicinity of the tumour and is not a pan-colonic phenomenon. Current guidelines on resection margins are adequate for BRAF mutation-positive colorectal cancers. Any suggestion of a hereditary link to these tumours is likely not related to germline BRAF gene mutations. The pattern of protein loss reinforces previous findings for the two subgroups of BRAF mutation-positive colorectal cancers.</p>

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.

Cutaneous and subcutaneous metastases of adenocarcinoma of the colon and rectum

<p><b>INTRODUCTION</b>The interesting topic of cutaneous and subcutaneous metastasis from rectal carcinoma is discussed using 3 cases.</p><p><b>CLINICAL PICTURE</b>The first case was a 70-year-old man with T3N2M0 rectal mucinous adenocarcinoma, who developed an inflammatory subcutaneous metastasis at the left scapula 2 years after anterior resection. The second case was a 51-year-old man with T4N2M0 splenic flexure mucinous adenocarcinoma, who developed metastatic disease including a subcutaneous secondary to the back. The third case was a 53-year-old woman who developed vulval recurrence 10 months after abdomino-perineal resection for a low T3N1M0 rectal adenocarcinoma.</p><p><b>TREATMENT</b>All underwent wide resection.</p><p><b>CONCLUSION</b>This entity is rare and usually signifies disseminated disease if found remote from the resection site and warrants a thorough metastatic work up. A high index of suspicion is recommended when encountered with unresolving skin lesions in cancer patients.</p>