Effective disinfecting of protective devices used in the course of treating SARS-CoV2-positive patients.

BACKGROUND: Powered Air-Purifying Respirator (PAPR) was widely used in Sengkang General Hospital (SKH) during the SARS-CoV-2 outbreak. Ensuring a sustained supply of clean and reusable PAPR masks for frontline medical team is an immediate challenge. The Central Sterile Supplies Unit (CSSU) adopts existing disinfection methods and technology for the reprocessing of reusable personal protective equipment (PPE) such as PAPR masks and goggles. OBJECTIVE: To determine an effective disinfecting method for protective devices used in the course of treating SARS-CoV2-positive patients. METHOD: A comparison on surface disinfection and modified thermal disinfection outcome was conducted on 30 PAPR masks through detecting the presence of adenosine triphosphate (ATP) by swab following both disinfecting methods. RESULTS: The modified thermal cycles emerged as the recommended disinfection method. DISCUSSION: The outcome of this study has enhanced understanding on the risk imposed on frontline healthcare personnel who perform surface disinfecting on masks for reuse during the work shift. Leveraging on the current expertise from existing instrument logistics, CSSU takes charge of the processing and stock management of SKH's PAPR masks. An additional workflow is needed to establish reprocessing methods for other reusable PPEs such as face shields or overalls.

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.

Disseminated peritoneal leiomyomatosis: a devastating sequelae of unconfined laparoscopic morcellation

There has been growing concern surrounding the use of unconfined power morcellation in laparoscopic surgeries for uterine leiomyoma due to its associated risks and long-term clinical sequelae, including parasitic leiomyomas and disseminated peritoneal leiomyomatosis (DPL). We present a case of DPL resulting from previous laparoscopic morcellation and a review of the existing literature. DPL is a potentially devastating consequence of unconfined laparoscopic morcellation in the surgical management of uterine fibroids. A multidisciplinary approach is recommended in the management of DPL, especially in cases of multivisceral involvement. Clinical caution ought to be exercised when using power morcellators; when unavoidable, confined laparoscopic morcellation offers a promising mitigation and should be adopted if practicable.

A case report of large gastric diverticulum with literature review.

INTRODUCTION: A gastric diverticulum is a rare form of diverticular disease due to outpouching of the gastric wall. It is equally presented within both sexes and commonly occurs in fifth and sixth decades of life. Patients mostly asymptomatic but may present with mild gastric symptoms. Surgical treatment is largely dependent on the patient's symptoms, and a laparoscopic approach is usually recommended for surgery. CASE PRESENTATION: A 77-year-old gentleman presented to the outpatient clinic with a one-month history of passing black stools. He was arranged for an oesophagogastroduodenoscopy (OGD) which revealed a gastric body polyp and a diverticulum in the fundus of the stomach. DISCUSSION: Gastric diverticulum is defined as an outpouching of the gastric wall. They are uncommon, with an incidence between 0.01-0.11%. Predisposing factors include: areas of weakness caused by splitting of the longitudinal muscle fibres, an absence of peritoneal membrane and perforating arterioles. The management of patients with gastric diverticulum depend largely on their symptoms. There is no specific treatment required for an asymptomatic diverticulum. CONCLUSION: Gastric diverticula are rare conditions which are largely asymptomatic but may present with varying signs and symptoms and may require surgical intervention.

Genomics of Hereditary Colorectal Cancer: Lessons Learnt from 25 Years of the Singapore Polyposis Registry

<p><b>INTRODUCTION</b>The Singapore Polyposis Registry (SPR) was established in 1989 in Singapore General Hospital (SGH). The aims were to provide a central registry service to facilitate identification, surveillance and management of families and individuals at high risk of colorectal cancer.</p><p><b>MATERIALS AND METHODS</b>This is a review of published literature in the department.</p><p><b>RESULTS</b>The registry currently has 253 families with several genetic conditions-93 familial adenomatous polyposis (FAP) families, 138 Amsterdam-criteria positive presumed Lynch syndrome (LS) families, 12 families with Peutz Jeghers syndrome, 2 families with Cowden's syndrome, and 8 families with hereditary mixed polyposis syndrome (HMPS). There are also 169 families with a strong family history of colorectal cancer but no abnormal genes yet identified. In FAP, a diagnostic tool developed has allowed a 94% local APC germline detection rate in FAP families. Knowledge obtained studying the phenotype of FAP patients has allowed better choice of surgery between ileal pouch anal anastomosis (IPAA) against an ileal-rectal anastomosis (IRA). In LS, our review has noted a highly heterogenous mutational spectrum and novel variants made up 46.7% (28/60) of all variants identified in this cohort. This may suggest that our Southeast Asian ethnic groups have distinct mutational variants from Western populations. Pathogenic mutations were only confined to MLH1 and MSH2, and identified in 28.8% of families.</p><p><b>CONCLUSION</b>The impact of predictive gene testing for hereditary cancer risk in clinical practice has allowed evolution of care. Risk-reducing surgery and aggressive surveillance allows reduction in morbidity and mortality of patients. The SPR will continue to grow and improve outcomes in hereditary colorectal cancer patients and families.</p>

Nonsurgical faecal diversion in the management of severe perianal sepsis: a retrospective evaluation of the flexible faecal management system

<p><b>INTRODUCTION</b>Severe perianal sepsis is often difficult to manage after surgical debridement due to faecal contamination. Diversion of the faecal stream has been attempted with faecal pouches and rectal tubes, and in some cases, a diverting stoma is created. However, reversal of the stoma may be delayed due to prolonged sepsis and this is not without risks. Herein, we review the use of a flexible faecal management system in patients with severe perianal sepsis.</p><p><b>METHODS</b>We retrospectively evaluated 15 patients who made use of the ConvaTec Flexi-Seal® Fecal Management System (FMS) between 1 January 2007 and 31 December 2010. The demographics and comorbidities of the patients, as well as the treatment received, were recorded and reviewed.</p><p><b>RESULTS</b>None of the patients required the creation of a stoma to divert the faecal stream. Nursing requirements and wound care were found to be improved with the use of the Flexi-Seal® FMS (fewer changes were needed). No severe complications were observed in our series. Two deaths were encountered, but the cause of death was not directly due to the initial perianal sepsis. Overall, the wound healing rate was 80.0%, with one graft failure (11.1%).</p><p><b>CONCLUSION</b>The use of the Flexi-Seal® FMS in patients with perianal sepsis following extensive debridement is feasible and can be considered before stoma creation.</p>