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Long-Term Oncological Safety of Minimally Invasive Hepatectomy in Patients with Hepatocellular Carcinoma: A Case-Control Study.

Stephen Ky CHANG ; Chee Wei TAY ; Liang SHEN ; Shridhar Ganpathi IYER ; Alfred Wc KOW ; Krishnakumar MADHAVAN

Annals of the Academy of Medicine, Singapore.2016;45(3):91-97.

INTRODUCTIONMinimally invasive hepatectomy (MIH) for patients with hepatocellular carcinoma (HCC) is technically challenging, especially with large posteriorly located tumours or background of liver cirrhosis. This is a case-control study comparing the long-term oncological safety of HCC patients who underwent MIH and open hepatectomy (OH). Most of these patients have liver cirrhosis compared to other studies.

MATERIALS AND METHODSSixty patients were divided into 2 groups, 30 underwent MIH and 30 underwent OH for HCC resection. The patients in both groups were matched for extent of tumour resection, age and cirrhosis status. Patient characteristics, risk factors of HCC and all oncological data were studied.

RESULTSNegative resection margins were achieved in 97% of patients in both groups. The mean blood loss during surgery was significantly lower in the MIH group compared to the OH group (361 mL vs 740 mL; 95% CI, 222.2, 734.9; P = 0.04). Hospitalisation is significantly shorter in MIH group (7 days vs 11 days; 95% CI, 6.9, 12.2,; P = 0.04). Eight patients (27%) in the MIH group and 13 patients (43%) in the OH group developed HCC recurrence (P = 0.17). One, 3 and 5 years disease-free survival between MIH and OH groups are 76% vs 55%, 58% vs 47%, and 58% vs 39% respectively (P = 0.18). One, 3 and 5 years overall survival between MIH and OH groups are 93% vs 78%, 89% vs 70%, and 59% vs 65% respectively (P = 0.41).

CONCLUSIONMIH is a safe and feasible curative treatment option for HCC with similar oncological outcomes compared to OH. MIH can be safely performed to remove tumours larger than 5 cm, in cirrhotic liver, as well as centrally and posterior located tumours. In addition, MIH patients have significant shorter hospitalisation and intraoperative blood loss.

Blood Loss, Surgical ; Carcinoma, Hepatocellular ; complications ; pathology ; surgery ; Case-Control Studies ; Disease-Free Survival ; Hepatectomy ; methods ; Humans ; Laparoscopy ; Length of Stay ; Liver Cirrhosis ; complications ; Liver Neoplasms ; complications ; pathology ; surgery ; Margins of Excision ; Minimally Invasive Surgical Procedures ; methods ; Neoplasm Recurrence, Local ; epidemiology ; Tumor Burden

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2015 Young Surgeon's Award Winner: Long-term Prognosis in Patients with Diabetes Mellitus after Coronary Artery Bypass Grafting: A Propensity-Matched Study.

Philip Yk PANG ; Yeong Phang LIM ; Kim Kiat ONG ; Yeow Leng CHUA ; Yoong Kong SIN

Annals of the Academy of Medicine, Singapore.2016;45(3):83-90.

INTRODUCTIONWe aimed to determine the impact of diabetes mellitus (DM) on long-term survival after coronary artery bypass grafting (CABG) in patients with multivessel coronary artery disease.

MATERIALS AND METHODSA retrospective review was conducted for 5720 consecutive patients who underwent isolated first CABG between 1982 and 1999. Outcomes were reviewed to include in-hospital mortality and long-term survival. Mean follow-up was 13.0 ± 5.8 years. To obtain comparable subgroups, 561 diabetic patients were matched with 561 non-diabetic controls based on estimated propensity scores.

RESULTSMean age was 59.3 ± 9.1 years with 4373 (76.5%) males. Amongst 5720 patients, 1977 (34.6%) had DM. Hypertension and dyslipidaemia were the most common cardiovascular comorbidities, present in 2920 (51.0%) and 2664 patients (46.6%) respectively. Emergency surgery was performed in 563 patients (9.8%). In-patient mortality occurred in 115 patients (2.0%), 48 (2.4%) in the DM group and 67 (1.8%) in the non-DM group, (P = 0.102). In the unmatched cohort, overall 20-year survival rates were 30.9 ± 1.6% in diabetics and 49.2 ± 1.0% in non-diabetics (P <0.001). Freedom from cardiac mortality at 20 years was 56.0 ± 2.0% in diabetics and 68.4 ± 1.0% in non-diabetics (P <0.001). In the propensity-matched group, overall 20-year survival rates were 35.4 ± 2.5% in diabetics and 48.9 ± 2.9% in non-diabetics (P <0.001). Freedom from cardiac mortality at 20 years was 57.8 ± 3.0% in diabetics and 70.2 ± 2.9% in non-diabetics (P = 0.001). Multivariable Cox regression analysis identified age (hazard ratio (HR): 1.03/year), female gender (HR: 1.43), DM (HR: 1.51), previous myocardial infarction (HR: 1.54) and left ventricular ejection fraction (LVEF) <35% (HR: 2.60) as independent factors influencing long-term cardiac mortality.

CONCLUSIONDespite low operative mortality, long-term survival and freedom from cardiac death are significantly lower in patients with DM compared to non-diabetics. Aggressive treatment of DM, cardiovascular comorbidities and smoking cessation are essential to improve long-term survival in diabetic patients.

Age Factors ; Aged ; Awards and Prizes ; Case-Control Studies ; Comorbidity ; Coronary Artery Bypass ; Coronary Artery Disease ; epidemiology ; surgery ; Diabetes Mellitus ; epidemiology ; Dyslipidemias ; epidemiology ; Female ; Follow-Up Studies ; Hospital Mortality ; Humans ; Hypertension ; epidemiology ; Male ; Middle Aged ; Multivariate Analysis ; Myocardial Infarction ; epidemiology ; Prognosis ; Propensity Score ; Proportional Hazards Models ; Retrospective Studies ; Sex Factors ; Singapore ; epidemiology ; Stroke Volume

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The Art of Public Health in the Context of a Paradigm Shift.

Raymond Bt LIM ; Hin Peng LEE

Annals of the Academy of Medicine, Singapore.2016;45(3):80-82.

Communicable Diseases, Emerging ; Communication ; Dengue ; prevention & control ; Dengue Vaccines ; therapeutic use ; HIV Infections ; prevention & control ; Health Education ; Health Policy ; Humans ; Mosquito Control ; Obesity ; prevention & control ; therapy ; Public Health ; Public Health Practice ; Risk ; Risk Reduction Behavior ; Sexually Transmitted Diseases ; prevention & control ; Singapore ; Tobacco Use ; prevention & control ; therapy

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Progress in Singapore Family Medicine: Reflections over the Decades from 1931.

Chin Hin CHEW

Annals of the Academy of Medicine, Singapore.2016;45(2):73-79.

Education, Medical ; history ; Family Practice ; history ; History, 20th Century ; History, 21st Century ; Humans ; Medicine in the Arts ; Singapore ; Tuberculosis ; history

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Detection of Residual Lentigo Maligna Using the In Vivo Reflectance Confocal Microscopy.

Sai Yee CHUAH ; Kong Chong TAN ; Anjula THOMAS ; Hock Leong EE ; Steven Tt GUAN

Annals of the Academy of Medicine, Singapore.2016;45(2):71-72.

Dermoscopy ; Facial Neoplasms ; pathology ; Humans ; Hutchinson's Melanotic Freckle ; pathology ; Intravital Microscopy ; Male ; Microscopy, Confocal ; Middle Aged ; Skin Neoplasms ; pathology

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Generalised Anhidrosis Secondary to Intracranial Haemorrhage.

Brian Ky CHIA ; Wei Sheng CHONG ; Hong Liang TEY

Annals of the Academy of Medicine, Singapore.2016;45(2):69-70.

Adult ; Basal Ganglia Hemorrhage ; complications ; diagnostic imaging ; Humans ; Hypohidrosis ; diagnostic imaging ; etiology ; Intracranial Arteriovenous Malformations ; complications ; diagnostic imaging ; Intracranial Hemorrhages ; complications ; diagnostic imaging ; Magnetic Resonance Imaging ; Male ; Rupture ; Thalamus ; diagnostic imaging ; Third Ventricle ; diagnostic imaging ; Tomography, Optical Coherence

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Way Seah LEE ; Sik Yong ONG

Annals of the Academy of Medicine, Singapore.2016;45(2):61-68.

INTRODUCTIONThis study aimed to quantify and investigate factors affecting the health-related quality of life (HRQoL) in children with biliary atresia (BA) living with their native livers.

MATERIALS AND METHODSA cross-sectional study on the HRQoL using the PedsQL4.0 generic core scales in children with BA aged between 2 to 18 years followed up at the University Malaya Medical Centre (UMMC) in Malaysia was conducted. Two groups, consisting of healthy children and children with chronic liver disease (CLD) caused by other aetiologies, were recruited as controls.

RESULTSChildren with BA living with their native livers (n = 36; median (range) age: 7.4 (2 to 18) years; overall HRQoL score: 85.6) have a comparable HRQoL score with healthy children (n = 81; median age: 7.0 years; overall HQRoL score: 87.4; P = 0.504) as well as children with CLD (n = 44; median age: 4.3 years; overall score: 87.1; P = 0.563). The HRQoL of children with BA was not adversely affected by having 1 or more hospitalisations in the preceding 12 months, the presence of portal hypertension, older age at corrective surgery (>60 days), a lower level of serum albumin (≤34 g/L) or a higher blood international normalised ratio (INR) (≥1.2). Children who had liver transplantation for BA did not have a significantly better HRQoL as compared to those who had survived with their native livers (85.4 vs 85.7, P = 0.960).

CONCLUSIONHRQoL in children with BA living with their native livers is comparable to healthy children.

Adolescent ; Age Factors ; Biliary Atresia ; complications ; physiopathology ; psychology ; surgery ; Case-Control Studies ; Child ; Child, Preschool ; Chronic Disease ; Cross-Sectional Studies ; Female ; Health Status ; Humans ; Hypertension, Portal ; etiology ; physiopathology ; psychology ; Liver Diseases ; physiopathology ; psychology ; Liver Transplantation ; Malaysia ; Male ; Quality of Life ; Serum Albumin

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Survival Prognostication in Patients with Skeletal Metastases from Nasopharyngeal Carcinoma: An Evaluation of the Scandinavian Sarcoma Group, Katagiri and Bauer Scoring Systems.

Jonathan Jh TAN ; Aye Sandar ZAW ; Rishi MALHOTRA ; Khin Lay WAI ; Joel Yh TAN ; Naresh KUMAR

Annals of the Academy of Medicine, Singapore.2016;45(2):51-60.

INTRODUCTIONNasopharnygeal carcinoma (NPC) is characterised by early metastases with the skeleton being the most common site of metastases. The ability to prognosticate survival is crucial in the decision whether or not to offer surgery to these patients and the choice of surgery offered. We aimed to evaluate the scoring systems namely: Bauer, Katagiri and Scandinavian Sarcoma Group (SSG) in NPC patients with skeletal metastases.

MATERIALS AND METHODSA total of 92 patients with skeletal metastases from NPC were studied. We retrospectively analysed the actual survival of these patients and compared with predicted survival according to the 3 scoring systems. The predicted survival according to each system was calculated and labelled as A scores. These were then re-scored by assigning NPC as a better prognostic tumour and labelled as B scores. The predicted survival of scores A and B were compared to actual survival. Univariate and multivariate Cox regression analyses were performed. The predictive values of each scoring were calculated.

RESULTSThe median overall survival for the whole cohort was 13 months (range: 1 to 120 months). In multivariate analysis, general condition and visceral metastases showed significant effect on survival. There were statistically significant differences (P <0.001) between the subgroups of the SSG B as well as Katagiri B scoring systems where NPC was classified as a better prognostic tumour. SSG B provided the highest predictive value (0.67) as compared to the other 2 scoring systems.

CONCLUSIONThe SSG and Katagiri score could be used to prognosticate NPC with a statistically significant association with actual survival.

Bone Neoplasms ; mortality ; secondary ; Carcinoma ; mortality ; secondary ; Humans ; Multivariate Analysis ; Nasopharyngeal Neoplasms ; mortality ; pathology ; Prognosis ; Proportional Hazards Models ; Retrospective Studies ; Survival Rate

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Efficacy, Immunogenicity and Safety of a Human Rotavirus Vaccine RIX4414 in Singaporean Infants.

Kong Boo PHUA ; Fong Seng LIM ; Seng Hock QUAK ; Bee Wah LEE ; Yee Leong TEOH ; Pemmaraju V SURYAKIRAN ; Htay Htay HAN ; Hans L BOCK

Annals of the Academy of Medicine, Singapore.2016;45(2):44-50.

INTRODUCTIONThis was the first study conducted to evaluate the efficacy of 2 oral doses of the human rotavirus vaccine, RIX4414 in Singaporean infants during the first 3 years of life.

MATERIALS AND METHODSHealthy infants, 11 to 17 weeks of age were enrolled in this randomised (1:1), double-blinded, placebo-controlled study to receive 2 oral doses of RIX4414 vaccine/placebo following a 0-, 1-month schedule. Vaccine efficacy against severe rotavirus (RV) gastroenteritis (Vesikari score ≥11) caused by wild-type RV strains from a period starting from 2 weeks post-Dose 2 until 2 and 3 years of age was calculated with 95% confidence interval (CI). Immunogenicity and safety of the vaccine were also assessed.

RESULTSOf 6542 infants enrolled, 6466 were included in the efficacy analysis and a subset of 100 infants was included in the immunogenicity analysis. Fewer severe RV gastroenteritis episodes were reported in the RIX4414 group when compared to placebo at both 2 and 3 year follow-up periods. Vaccine efficacy against severe RV gastroenteritis at the respective time points were 93.8% (95% CI, 59.9 to 99.9) and 95.2% (95% CI, 70.5 to 99.9). One to 2 months post-Dose 2 of RIX4414, 97.5% (95% CI, 86.8 to 99.9) of infants seroconverted for anti-RV IgA antibodies. The number of serious adverse events recorded from Dose 1 until 3 years of age was similar in both groups.

CONCLUSIONTwo oral doses of RIX4414 vaccine was immunogenic and provided high level of protection against severe RV gastroenteritis in Singaporean children, during the first 3 years of life when the disease burden is highest.

Antibodies, Viral ; immunology ; Double-Blind Method ; Female ; Gastroenteritis ; prevention & control ; virology ; Humans ; Immunogenicity, Vaccine ; Immunoglobulin A ; immunology ; Infant ; Male ; Rotavirus ; immunology ; Rotavirus Infections ; prevention & control ; Rotavirus Vaccines ; immunology ; therapeutic use ; Singapore ; Treatment Outcome ; Vaccines, Attenuated ; immunology ; therapeutic use

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Active Ageing to Gerotranscendence.

Gabriel Hz WONG ; Philip Lk YAP

Annals of the Academy of Medicine, Singapore.2016;45(2):41-43.

Aging ; Humans ; Singapore ; Spirituality

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