GPBUZZ JUNE — AUGUST 2012
MICA (P) 242/03/2012
A PUBLICATION FOR PRIMARY CARE PHYSICIANS
G P BUZ Z | CO N T E N T S
IN THIS ISSUE 03
EDITOR’S NOTE
14
Advancing Hand, Wrist and Microsurgery
04
MILESTONES 100 Years of Surgery
16
Battling ‘Diabesity’ in Singapore
05
TRIBUTE TO THE TRAILBLAZERS
18
Winning the Fight Against Prostate Cancer: A Patient’s Journey
06
COVER STORY Pulse on Surgery
21
FITNESS Regain Fitness Post-surgery
10
FEATURES One-stop Solution to a Neck Lump
22
HEALTHY RECIPES
12
Cataract Surgery Techniques
23
EVENTS & IN THE NEWS
A/Prof Ivan Ng Hua Bak Dr Yeo Seng Beng Head, Otorhinolaryngology
Head, Neurosurgery, National Neuroscience Institute @ TTSH
Head, Ophthalmology
Prof Low Cheng Hock
Emeritus Consultant, General Surgery
A/Prof Chia Sing Joo Divisional Chairman, Surgery
Dr Chong Yew Lam Head, Urology
A/Prof Low Yin Peng
Emeritus Consultant, Orthopaedic Surgery
A/Prof Ong Peck Leong Senior Consultant, Neurosurgery, National Neuroscience Institute @ TTSH
2
Dr Wong Hon Tym
JUNE – AUGUST 2012
Dr Chiu Ming Terk Head, General Surgery
A/Prof Kwek Tong Kiat
Adj. Asst Prof Ganesan Naidu Rajamoney Head, Orthopaedic Surgery
Dr Yong Shee Heung, Victor
Head, Anaesthesiology, Intensive Care & Pain Medicine
Emeritus Consultant, Ophthalmology
Dr San Win Min
Emeritus Consultant, Anaesthesiology, Intensive Care & Pain Medicine
G P BU Z Z | E D I T O R ’S N O T E
A CENTURY OF
SURGICAL EXCELLENCE
W
e bring you a special commemorative edition of GP Buzz in celebration of 100 years of surgical excellence in Tan Tock Seng Hospital (TTSH). This is a shared achievement with our partners and patients who have witnessed the transformation of the hospital amidst changes and challenges. For the past 100 years, TTSH Surgical Division has always been focusing on innovation and excellence. As the Division marks its centennial year, it celebrates this tradition of exceptional patient care, surgical training and leading-edge technology. To commemorate the special occasion, the Clinical Heads of TTSH’s Surgical Team and eminent Emeritus Consultants were invited to grace the double-spread cover of GP Buzz. Let us walk you down the memory lane as we commemorate the hundred years of surgical excellence. For the cover story, Associate Professor Chia Sing Joo, TTSH’s Divisional Chairman of Surgery who has witnessed many transformations of the surgical team shares his passion for healthcare and surgical developments in the hospital. Our surgical specialists from Urology, Otolaryngology (Ear, Neck & Throat), General Surgery, Orthopaedic and Ophthalmology (Eye) pen their expertise in this exclusive surgical series, together with special physiotherapy exercises and recipes to aid post-surgical recovery. We invite our General Practitioners (GPs) to join us in the series of events, specially planned to celebrate 100 years of surgical excellence. As we advance to the next generation of healthcare, our vision of adding years of healthy life to the people of Singapore will never change. The TTSH Surgical Division is committed to continue its tradition of excellence through the next hundred years and beyond. Happy reading!
GP
THE GP BUZZ EDITORIAL TEAM The Editorial Team : Celine Ong, Jessie Tay and Lee Wei Kit Advisory Panel : Associate Professor Thomas Lew Associate Professor Chia Sing Joo Associate Professor Chin Jing Jih Dr Chong Yew Lam Dr Tan Kok Leong Joe Hau
We value your feedback on how we can enhance the content of GP Buzz. Please send in your comments and queries to gp@ttsh.com.sg. © All rights reserved. No part of this publication may be reproduced or transmitted in any form by any means without prior consent from Tan Tock Seng Hospital. Designed by Redbean De Pte Ltd.
G P BUZ Z | MILESTONES
1844 - 1910
HUMBLE BEGINNINGS
On 25 July, 1844, Mr Tan Tock Seng, a Chinese philanthropist from Malacca, donated $5,000 to lay the foundations of Tan Tock Seng Hospital (TTSH) at Pearl’s Hill. The hospital was then known as the Chinese Pauper’s Hospital, housing the poor and destitute from all races.
100
years of surgery
1912 - 1914
FIRST DOCUMENTED APPOINTMENT OF SURGEON AND SPECIALIST SURGEON IN TTSH Dr J Gray, Resident Medical Officer, TTSH, took up temporary duty of the new post of surgeon at the inaugural Department of Surgery. Dr C J Smith, FRCSE, the first surgeon in Singapore with a specialist qualification was appointed to TTSH in 1914.
1948 - 1960s TRANSITION TO A GENERAL HOSPITAL
1965 -1969 After the war, TTSH was designated as the centre for tuberculosis treatment, with the government building a $1.5 million operating theatre. The decline of tuberculosis in Singapore in the late 1960s gradually converted TTSH to a general hospital, paving the way for the growth of modern surgery.
Early 1970s
INCEPTION OF HEART SURGERY
Led by Dr NC Tan, TTSH set-up the Cardiothoracic department, its first medical speciality. Along with its inception, the anaesthesia service grew rapidly. In 1967, the first open-heart surgery in Singapore was carried out in TTSH. By 1969, over 100 open heart operations were done in TTSH, with a success rate of 95 percent.
BIRTHPLACE OF NEUROSURGICAL CLINICAL SERVICES
In 1972, the first Department of Neurosurgery in Singapore was opened in TTSH by Minister of Health, Chua Sian Chin. Dr CF Tham was appointed as the Head of Department and laid the foundations for the formation of the National Neuroscience Institute.
LATE 1970s 1980s
PROLIFERATION OF MEDICAL SPECIALITIES
Emergence of specialties of General Surgery (including Urology), Orthopaedic Surgery, Ophthalmology and Otorhinolaryngology at TTSH.
1990s - 2003
PIONEERING SURGICAL BREAKTHROUGHS First in Singapore to: • Conduct laparoscopic choledys- tectomy in 1991. • Introduce CO2 laser surgery in Otorhinolaryngology in 1996. • Use accommodative intraocular lenses for cataract surgery in 2003.
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2012 - FUTURE AT THE FOREFRONT OF TECHNOLOGY
TTSH continues to be at the cutting-edge of surgery in Singapore with advanced laparoscopic and robotic surgical techniques. A commemorative book on TTSH’s 100 Years of Surgery will be launched in late July. For enquiries on the book, please email Ms Shakila Akbar at shakila_akbar@ttsh.com.sg.
T
100 YEARS OF SURGICAL EXCELLENCE
e t u b ri to theers
z a l b l i a r T
PROFESSOR LOW CHENG HOCK Emeritus Consultant, General Surgery 28 years of service in TTSH
ASSOCIATE PROFESSOR LOW YIN PENG Emeritus Consultant, Orthopaedic Surgery 24 years of service in TTSH
“ General Surgery has developed many sub-disciplines and there is a lot of focus on minimally invasive surgery. Subdisciplines are good and necessary for progress and improvement. However, we must never forget basic general training; build a strong foundation before learning more and more of less and less.
“ In my opinion, the surgical landscape has expanded over the years with paradoxically smaller surgical incisions, greater use of advanced imaging and newer techniques and equipment. And best of all, better results!
‘Surgery’ combines the ART and SCIENCE of medicine very well. Patient remains the top priority. We never stop learning. I am still learning from my colleagues and my patients who have shown me how to improve.”
I didn’t know in the beginning: to be a surgeon is a calling, a blessing, an honour and a life of awe and wonder.”
As Tan Tock Seng Hospital (TTSH) embarks on its journey of achieving another 100 years of surgical excellence, we pay tribute to our team of dedicated Emeritus Consultants (Surgical Division) for their unwavering care to our patients and their contributions. Despite their professional achievements and busy schedules, they have selflessly coached and imparted their skills to bring the next generation to new heights in the practice of medicine. Hear their views on how the surgical landscape has evolved over the years and uncover the key to their personal conviction as a Surgeon.
DR SAN WIN MIN Emeritus Consultant, Anaesthesiology, Intensive Care & Pain Medicine 28 years of service in TTSH
“ The Department of Anaesthesia evolved in tandem with the Surgical Department over the years. It has grown into a huge department with well over 20 specialist consultants complemented by a big pool of advanced trainees and resident medical officers. The Department offers a wide range of services to the Surgical Division which include pre-operative screening and preparation, clinical anaesthesia, postoperative care, acute and chronic pain management and Surgical Intensive Care. The hallmark of the Surgical Division is the close and warm working relationship between the surgeons and the anaesthetists. This ‘esprit de corps’ spirit is unique to Tan Tock Seng Hospital.”
DR YONG SHEE HEUNG, VICTOR Emeritus Consultant, Ophthalmology 22 years of service in TTSH
“ As far as eye surgery is concerned, it has changed from inpatient surgery to complete day surgery for elective procedures. I’ve experienced diversity as a surgeon practising in Tan Tock Seng Hospital. From doing surgery in the old huge operating theatres housed in the old Tan Tock Seng Hospital which were designed for general surgery or neurosurgery rather than eye surgery, we have progressed to performing the procedure at the state-of-the-art operating theatres in the new Hospital. As an Eye Surgeon, restoring or improving sight to someone brings immeasurable joy.”
JUNE – AUGUST 2012
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GP BUZ Z | COV E R S T O RY
Divisional Chairman for Surgery, Associate Professor Chia Sing Joo shares his insights on the surgical developments in Tan Tock Seng Hospital.
W
ith 26 years of surgical and clinical experience under his belt, A/Prof Chia’s choice of specialising in the field of Urology did not come as an option but by a sheer touch of fate. As a junior trainee in Tan Tock Seng Hospital (TTSH) then, the practice of Urology became his life career when all popular specialisations were taken up by his seniors. He has not looked back since.
providing the right treatment and care to patients. His philosophy to medicine is to give his best to patients and to think and speak from the patient’s perspective. Of course, without the full support and understanding from his family, A/Prof Chia would not be able to dispense his dual responsibilities as the Divisional Chairman for Surgery and Senior Consultant of Urology with ease.
Armed with an MBBS from the National University of Singapore in 1986, a FRCS in Postgraduate Studies in General Surgery from the Royal College of Surgeons of Edinburgh, UK in 1991 and an advanced trainee for Urology exit from the Academy of Medicine, Singapore in 1997, A/Prof Chia is one of the few surgeons trained in both the General Surgery and Urology disciplines.
In his third and final term as the Divisional Chairman for Surgery in TTSH, A/Prof Chia helms four key areas, namely the Operating Theatres (OTs), Endoscopy Centre, Clinics and Wards in TTSH. Apart from administrative and clinical responsibilities that come with this role, he is also an advocate of continuous learning and actively shares his surgical experiences with other fellow surgeons and young doctors in training.
These days, A/Prof Chia, aged 51, still devotes seven days of his week to work. What keeps him going is his passion for the job and his commitment to change people’s lives by
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We caught up with A/Prof Chia amidst his hectic schedule and spoke to him about the surgical practice and how it has evolved in TTSH.
100 YEARS OF SURGICAL EXCELLENCE
Many things have changed from the past. To create a safe environment to treat our patients, the hospital is equipped with better systems, patientfriendly facilities and advanced equipment.
GP BUZ Z | COV E R S T O RY
TTSH is also introducing more quality improvement projects such as evidence – care in both pre-operative and postoperative surgical procedures.
GP
TTSH’S VISION IS “ADDING YEARS OF HEALTHY LIFE”. WHAT ARE THE SIGNIFICANT BREAKTHROUGHS IN SURGICAL TREATMENT THAT YOU THINK BENEFITED AND IMPROVED THE HEALTH OF OUR PATIENTS? Many things have changed from the past. To create a safe environment to treat our patients, the hospital is equipped with better systems, patient-friendly facilities and advanced equipment. There are larger induction rooms and operating theatres. One of our operating theatres is also fitted with cutting-edge endoscopy equipment. Surgery in TTSH has also evolved from simple open surgeries to more minimally invasive and robotic surgeries. Patients may now be discharged early and they recover faster with fewer complications through these advanced procedures. This also means that there are lesser inpatient cases and the patient saves money as a result. What is unknown to the patients is the team-care element behind their treatment plans. Our team of doctors and surgeons discuss and share experiences on patient treatment plans during the TTSH’s weekly Mobility and Mortality Rounds as well as Pre-operation Rounds. These ensure that patients get the best form of holistic team-based treatment from the hospital. Now, we are encouraging our surgeons to reach out more to the community of General Practitioners (GPs) to give talks on not only on their skills but to educate and encourage prevention of health issues. We hope to create an integrative partnership where we can share effective treatment protocols for early diagnosis and detection by the GPs. With evidence-based integrative care, future patients will benefit by uncovering symptoms early and seeking timely treatment.
GP
WHAT ARE THE CHALLENGES FOR OUR SURGEONS TODAY? Surgeons now have a steeper learning curve. They are straddled between open surgeries and minimally invasive surgeries; hence they need to master both procedures which are vastly different. With minimally invasive surgeries, the skill sets and patients’ risks are different. Unlike open surgeries, surgeons performing minimally invasive surgeries are confined to a 2D and 3D video screen and are unassisted when they perform the procedures. In TTSH, we have a strong group of experienced and committed senior surgeons. The hospital is also training and educating the junior doctors which is important in ensuring that processes are run properly and safely, in line with international standards and protocols.
GP
MOVING FORWARD, WITH THE EMPHASIS ON TEAM-CARE AND EVIDENCE-CARE (BEST PRACTICES CARE), HOW DOES TTSH NURTURE ITS NEXT GENERATION OF SURGEONS? I always believe that training and education are part and parcel of ensuring that patients are given the appropriate care at all times. I’ve mentioned earlier that we have some platforms to facilitate sharing and learning between the senior and junior surgeons, such as the weekly Mobility and Mortality Rounds and Pre-operation Rounds. Not forgetting the Ward Rounds
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JUNE – AUGUST 2012
100 YEARS OF SURGICAL EXCELLENCE
I always believe that training and education are part and parcel of ensuring that patients are given appropriate care at all times.
and other informal channels too. In these sessions, the surgeons share their experiences in treating patients and discuss areas for improvement. Ultimately, we work as a team to care for the patient and to ensure that the patient receives the best treatment without complications. In addition, we train our junior doctors on the importance of proper communication
and
being
more
empathetic
towards
their
patients.
They need to realise that medicine is more than just treating the patient’s condition, it is also about building a meaningful relationship with both the patient and their family members. We need to pers0nalise our care according to the needs of our patients. These platforms together with training for junior doctors as well as the future Surgical Science and Training Centre will add on to introducing new blood to the healthcare system. GP
ARE THERE ANY EXCITING SURGICAL DEVELOPMENTS IN THE PIPELINE? We will see more cutting-edge surgery like robotic surgeries and endoscopic procedures in TTSH. More and more disciplines will also be inducted to these advanced techniques to benefit our patients. TTSH is also introducing more quality improvement projects such as best practices care in both pre-operative and post-operative surgical procedures. Our patient benefits with better education and has more information about procedures, risks and complications. We understand that patients are part of the team and what they do will affect their treatment and recovery process. We may have done the best surgery but it will be deemed a failure if the patient does not know how to look after himself or herself well. Medicine is a continuous improvement process and hence the hospital also advocates collaboration and research to introduce new ways of doing things. TTSH is working with the National Technological University (NTU) to improve some of the equipment that we use in the OTs. Currently, most of the surgical tools and equipment are produced based on the experiences of western nations. The hospital believes that local experiences will give us different exposures and NTU is enhancing these equipment based on best practices from the local context.
GP
WHERE DO YOU SEE SURGERY IN SINGAPORE IN THE NEXT FIVE TO TEN YEARS? In the next five to ten years, I foresee lesser use of open surgery as a treatment intervention. With greater outreach to the community, better public education and closer partnerships with our GPs, health issues can be detected and diagnosed early. This will also increase the likelihood of patients being cured by non-surgical treatments such as taking medication or by other minimally invasive procedures. Patients will then experience lesser downtime and this paves the way for better outcomes and faster recovery too. In a nutshell, proper patient education as well as best practices care and team-care are key factors which will benefit our patients and the practice of medicine. I look forward to more exciting developments in the future of medicine. GP JUNE – AUGUST 2012
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GP BUZ Z | F E AT URE
ONE-STOP SOLUTION
Patients with neck lumps can look forward to a rapid and accurate diagnosis at Tan Tock Seng Hospital, the first one-stop neck lump clinic in Singapore. This concept drastically reduces the time-to-treatment, which is crucial in the detection and treatment of all cancer cases.
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JUNE – AUGUST 2012
100 YEARS OF SURGICAL EXCELLENCE
TO A NECK LUMP
N
eck lumps are common. A neck
confirmed before the patient leaves the clinic. This ensures
lump may be benign such as a reactive
a rapid and accurate diagnostic journey for our patients.
lymph
node
following
a
simple
upper respiratory tract infection, or
In most cases, a tentative diagnosis is made and
a malignant node from metastatic
communicated to the patient before he or she leaves the
nasopharyngeal carcinoma.
clinic. Patients are usually seen in the next five to seven days once their biopsy results are available.
To the patient, the discovery of a mass in the neck may instil tremendous anxiety. These patients often present to the General Practitioners (GPs) with nothing more than a neck lump and the GPs do not have the equipment to diagnose. Even the most thorough history-taking may reveal no obvious diagnosis. Empirical treatment with antibiotics is often employed and the patient may then seek multiple opinions from several GPs. A referral may then be made to the hospital or specialist which in turn has to triage these referrals with little useful information. Often when a patient is seen with a neck lump in a specialist outpatient clinic, an immediate answer to the problem is not forthcoming. Further empirical treatment may be offered before ultrasound scans, fine needle aspiration cytology and nasal endoscopy are performed. These delays heighten anxiety and may also add unnecessary costs to the patient. In
Tan
Tock
Seng
Hospital,
the
Department
Early detection of cancer clearly improves outcome and the neck lump clinic expedites the time-to-treatment.
of
Otolaryngology (Ear, Nose & Throat) runs a directaccess, consultant-led, one-stop neck lump clinic twice a week. This is the first one-stop neck lump clinic in Singapore. In the neck-lump clinic, a Consultant Neck Surgeon conducts a thorough clinical evaluation including nasal endoscopy. Laryngeal videostroboscopy is used in examining the larynx in greater detail, and also transnasal oesophagoscopy which
Once a diagnosis is made, the subsequent management of most benign and malignant conditions are treated within the Otolaryngology department or related departments. This seamless integrated consultation, diagnostic and treatment platform ensures that potential and current head and neck cancer patients are given holistic and timely care for their condition. GP
can be performed in the clinic with minimal preparation. In the clinic, our fibreoptic scopes also have narrowband imaging (NBI) to aid diagnosing mucosal lesions. An ultrasound machine with elastography helps us better evaluate neck lumps and guides fine needle biopsies. All fine-needle aspiration cytology is assisted by a technician. Smears are stained immediately and an adequate cell yield is
Adj Asst Prof Jeeve Kanagalingam Adj Asst Prof Jeeve Kanagalingam is a Consultant, Otorhinolaryngology and Head & Neck surgeon at Tan Tock Seng Hospital and Lead for Otorhinolaryngology at the Lee Kong Chian School of Medicine. In 2011, he received an HMDP fellowship to pursue care for the professional voice at the University of Pittsburgh Medical Center. His main area of subspecialty interest is in head and neck surgical oncology, thyroid surgery and laryngology.
JUNE – AUGUST 2012
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G P BUZ Z | F E AT URE
CATARACT SURGERY TECHNIQUES
[
[
Cataract extraction is the most common surgery performed in developed countries. Technological advances have allowed for improved surgical techniques through smaller incisions, improvements in designs, materials, and lens implantation techniques, providing better visual outcomes that were previously not possible. In this article, we will share with you the different cataract surgical techniques.
100 YEARS OF SURGICAL EXCELLENCE
C
ataract surgery was first described in India in the 6th century B.C., when a curved needle was used to push the cataractous lens into the posterior segment of the eye. Although this technique, “couching”, was rather primitive, dangerous and often resulted in blindness, it remained in use for many centuries. Fortunately, cataract surgery has evolved into a very safe surgery and is performed as a day procedure under local anaesthesia. Figure 1 shows how nucleosclerotic cataracts look like.
2.
EXTRACAPSULAR CATARACT EXTRACTION (ECCE)
This technique is used for denser cataracts which may be too hard to emulsify using phacoemulsification. A larger incision (10 to 12mm) is made at the corneoscleral limbus through which the entire nucleus is manually expressed out of its capsular bag and out of the eye. As the wound is large, closure with sutures is required but as the sutures may induce astigmatism, some of them may need to be removed after a month. Although visual rehabilitation is usually slower due to the larger wound and astigmatism, visual outcomes are comparable to phacoemulsification.
3.
INTRACAPSULAR CATARACT EXTRACTION (ICCE)
This was the main technique used before the advent of ECCE and is now mainly reserved for subluxed cataracts as the lens is removed along with its capsular bag. ICCE requires an even larger incision and sometimes a cryoextractor is used to hold the lens and pull it out through the wound. Figure 1. Nucleosclerotic cataracts impart a cloudy, brownish tinge to the lens
TECHNIQUES FOR CATARACT SURGERY 1. PHACOEMULSIFICATION
First introduced in 1967, phacoemulsification is now the default technique in the developed world, and uses ultrasonic vibrations to dissolve the lens. A small incision (2 to 3mm) is made on the cornea and after creating an opening in the anterior lens capsule, the cataractous lens is fragmented and aspirated by the ultrasound probe. This quick procedure often takes less than 30 minutes, and the wound is usually self-sealing and does not require sutures. The use of lasers to facilitate phacoemulsification is currently being studied. Please refer to Figure 2.
Cataract surgery has evolved into a very safe surgery and is performed as a day procedure under local anaesthesia.
4.
MANUAL SMALL INCISION CATARACT SURGERY (SICS)
This method has become increasingly popular as an alternative to ECCE, especially in countries where phacoemulsification is not the default. It involves the creation of a small tunnel incision in the sclera (about 5 to 7mm) which extends through the cornea and into the anterior chamber. The nucleus is prolapsed out of its capsular bag and subsequently delivered out of the eye through the scleral tunnel using special instruments. The scleral wound is self-sealing and does not cause any significant astigmatism. GP Dr Chin Chee Fang
Figure 2. Phacoemulsification
Dr Chin Chee Fang is an Associate Consultant at The Eye Clinic in the Tan Tock Seng Hospital. Dr Chin’s clinical interest is in General Ophthalmology. She received her Bachelor of Medicine and Bachelor of Surgery from the University of Edinburgh, United Kingdom (UK) and obtained a Master of Medicine (Opthalmology) from the National University of Singapore. She is a member of the Royal College of Surgeons of Edinburgh, UK.
JUNE – AUGUST 2012
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G P BUZ Z | F E AT URE
Advancing Hand, Wrist and Microsurgery
The management of hand and microsurgery patients in Tan Tock Seng Hospital (TTSH) goes back to 1997. In 2009, the Hand and Microsurgery Section (HMS) became the third accredited hand surgery training centre in Singapore. HMS also performed the first total wrist arthoplasty in Singapore.
BACKGROUND
H
and Surgery is a specialised branch of musculoskeletal surgery with a unique set of expertise required, including skills from orthopaedic surgery and plastic surgery. As a recognised specialty by the Specialist Accreditation Board (SAB) 15 years ago, hand surgery has grown significantly in the Tan Tock Seng Hospital (TTSH) since the 1990s. Since February 2009, a full-fledged hand surgery unit, the ‘Hand and Microsurgery Section’ (HMS) was formed to take care of all the soft tissue coverage needs of the department, including those with open fractures of the lower limb. In May 2009, HMS became the third unit to be approved by the Joint Commission for Specialist Training (JCST) as an accredited national training centre for hand surgery.
MILESTONES Dedicated to the teaching and training of hand and microsurgery in Singapore and beyond, HMS has achieved some key milestones. Since February 2009, three regional workshops on Arthroscopy of the Wrist were organised, with the last session comprising arthroscopy of the small joints of the hand. Fracture Fixation workshops and two Hand and Wrist Arthroplasty workshops were organised, with participants from the Asia Pacific region.
14 J UJNU EN E–
A – UAG UU GSUTS T2 021021 2
HMS surgeons are also committed to research, and regularly present and publish research papers. A register for distal radius fractures for the purpose of prospectively collecting data on our management and outcome has also been established. Procedures like arthroscopy of the wrist and of the small joints of the hand were also introduced recently. Complex cases were also done with arthroscopy, such as arthroscopic bone grafting of scaphoid fracture non-union. Besides fractures, wrist ligament injuries, degenerative conditions of the hand and wrist (such as osteoarthritis), inflammatory conditions (such as rheumatoid arthritis resulting in deformities or tendon ruptures), nerve entrapment and injuries (including brachial plexus surgery) and amputation injuries were also treated. Open fractures of the lower limb with exposed bone or vital structures are covered with pedicled or free soft tissue flaps.
Dr Winston Chew (with glasses) carrying out Singapore’s first wrist replacement surgery in November last year.
VISION HMS has expanded and progressed significantly. This brings TTSH HMS closer to its aim of continually providing high-quality, dedicated specialist care for all patients with upper limb lesions and injuries that affect the function of the hand, and to become a renowned centre for the hand and microsurgery in the areas of clinical service, teaching and training, and clinical research. GP
Dr Winston Chew Dr Winston Chew is the Head and Senior Consultant of the Hand and Microsurgery Service at Tan Tock Seng Hospital. Dr Chew underwent training in hand and microsurgery in NUH under Professor Robert Pho, and obtained the HMDP scholarship to train in the renowned Christine M Kleinert Institute for Hand and Microsurgery in Louisville, Kentucky, USA. He exited in both orthopaedics and hand surgery. He has a special interest in hand and distal radius fractures, wrist arthroscopy, and hand and wrist arthroplasty.
TTSH HMS aims to continually provide high-quality, dedicated specialist care for all patients with upper limb lesions and injuries that affect the function of the hand.
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GP BUZ Z | F E AT URE
Battling
‘DIABESITY’
IN SINGAPORE
There are several treatments for ‘Diabesity’ or Type 2 Diabetes Mellitus (T2DM). A multi-disciplinary Bariatric Programme at Tan Tock Seng Hospital ensures proper patient selection, preparation and education, safe and effective surgery and long-term follow-up by a team of doctors to optimise success. ABOUT TYPE 2 DIABETES MELLITUS (T2DM)
‘D
iabesity’ is a new term that describes the epidemic of obesity related to Type 2 Diabetes Mellitus (T2DM) that is sweeping Asia including Singapore. Obesity has been redefined for the Asian population and the current recommendations are that Asians with Body Mass Index (BMI) of higher than 23 will be considered ‘Overweight’ and those with BMI higher than 27 will be considered ‘Obese’. Overweight individuals are at moderate risk and obese individuals are at high risk to develop cardiovascular disease and T2DM. Researchers have also identified a steep rise in mortality for women with waist circumference of greater than
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JUNE – AUGUST 2012
80cm and men, a waist circumference greater than 90cm. So far, public health efforts, diet and exercise programmes and anti-obesity medications have had very limited success in dealing with diabesity and the metabolic syndrome. It has been projected that the human and financial costs of diabesity may be crippling many of the emerging Asian economies.
EVALUATING TREATMENTS In 1995, Dr Walter J. Pories reported the results of their study on 604 patients who had undergone Rouxen-Y Gastric Bypass Surgery (RYGB) and were observed for the past 14 years. Over 83% of patients with T2DM experienced long-term resolution of their T2DM with normalised Hb A1C, normal FSB and Insulin levels. They also noted resolution of hypertension, sleep
apnoea, hypercholesterolemia and hyperlipidemia in the majority of patients. Other studies done in USA, Asia and Europe, evaluating patients with BMI lower than 35kg/m2 who underwent a RYGB also reported that over 84% of diabetic patients experienced complete resolution of T2DM after undergoing Gastric Bypass surgery, often before significant weight reduction. The studies concluded that the rapid time course and disproportional degree of T2DM improvement after Gastric Bypass compared with equivalent weight loss from other interventions showed that the effects of Gastric Bypass surgery are independent of weight loss and should also benefit patients with lower BMIs and T2DM. The effects of Gastric Bypass surgery appear quickly (within days of surgery) and also appear to be sustained over time.
100 YEARS OF SURGICAL EXCELLENCE TYPES OF METABOLIC SURGERY
1
LAPAROSCOPIC RYGB
Currently, the Laparoscopic RYGB is the most common metabolic surgery performed worldwide with over 100,000 procedures performed yearly in USA alone at a mortality rate of under 0.3%. The mechanism through which DM resolution is achieved may be related to the release of Insulin modulators like GLP-1 and Peptide-YY that decrease peripheral tissue resistance to Insulin and stimulate the beta cells. Insulin modulator release is triggered by gastric restriction, gastric bypass, delivery of unaltered nutrients directly to the Jejunum, alteration in bile flow and re-absorption and changes in vagal activity according to the Foregut Theory.
2 LAPAROSCOPIC VERTICAL SLEEVE
The Laparoscopic Vertical Sleeve Gastrectomy (LVSG) is becoming an increasingly popular metabolic operation with T2DM resolution rates of 50% to 80% and resolution of the metabolic syndrome in up to 80% of obese patients. Although the effects of LVSG mostly depend upon calorie restriction and weight loss, a recent study from Taiwan was able to demonstrate over 50% resolution of severe T2DM in patients with BMI lower than 30kg/m2. This study suggests another mechanism for DM resolution that may involve reduced levels of ghrelin after sleeve gastrectomy. The ‘sleeve’ has a volume of 80-120cc and has restrictive and appetite suppression effects that appear to be durable of up to five years after surgery according to the studies. Post-operative morbidity and mortality are low with few longterm adverse metabolic consequences making the sleeve an attractive metabolic surgery.
3
LAPAROSCOPIC ADJUSTABLE GASTRIC BAND
The Laparoscopic Adjustable Gastric Band (LAGB) used to be a popular choice for weight loss in Singapore few years ago but is being performed fewer these days. Long-term studies have yielded disappointing results with failure rates of up to 40% and re-operation rates up to 30%. The attraction of the LAGB is ease of
It has been projected that the human and financial costs of Diabesity may be crippling too many of the emerging Asian economies. placement and very low operative mortality. For successful weight loss and resolution of co-morbidities patients require close follow up and frequent band adjustment, lack of which may contribute to the high failure rate. Resolution of co-morbidities especially T2DM is predicated on significant weight loss. Patients who failed with the band have been salvaged successfully with the bypass and sleeve operations.
4
OTHER SURGICAL OPTIONS
Several other metabolic surgeries have been performed and abandoned over the years, including the Ileal Bypass which was associated with severe malabsorption and hepatic failure and the Vertical Banded Gastroplasty that was replaced by the LAGB. Some surgeons perform a ‘mini gastric bypass’. This technique is often associated with bile reflux into the stomach pouch and has therefore not gained wide acceptance.
Temporary measures to lose weight include the ‘gastric balloon’, which is an endoscopically-placed silastic balloon that induces a feeling of satiety. A new innovation that shows promise in the short-term treatment of T2DM is “the endoluminal sleeve”, a silastic sheath that extends from the pylorus to the jejunum separating nutrients from the intestinal wall.
CONCLUSION
Currently, Metabolic Surgery is the only effective and durable solution to the epidemic of diabesity. Early surgery and resolution of comorbidities like diabetes, hypertension, hyperlipidemia, and sleep apnoea will result in better health and quality of life in Singapore and greatly decrease the economic burden and health care complexities. These chronic conditions pose a burden to the health care system. A multidisciplinary Bariatric Programme at TTSH ensures proper patient selection, preparation and education, safe and effective surgery and longterm follow-up by a team of doctors to optimise success. GP Dr Jaideepraj Rao Dr Jaideepraj Rao is the Head and Consultant of the Upper Gastrointestinal & Minimal Access Surgery Unit, and the Director of the Bariatric Surgery Programme in the Department of Surgery at Tan Tock Seng Hospital. Dr. Rao did his fellowship in advance laparoscopic and Robotic Surgery in Korea. He is also one of the founding members of the Obesity and Metabolic Surgery Society of Singapore. REFERENCES: 1. Serena Low. Rationale for redefining obesity in Asians. Ann Acad Med Singapore 2009; 38:66-74. 2. H. Ashrafian. Diabetes resolution and hyperinsulinemia after metabolic Roux-en-Y gastric bypass. Obesity Reviews 2010. 3. Francisco Rubino. The mechanism of diabetes control after gastrointestinal bypass surgery reveals a role of the proximal small intestine in the pathophysiology of type 2 diabetes. Ann Surg 2006; 244: 741-749. 4. Walter J. Pories, M.D. Who would have thought it.etc. Ann Surg 1995; 222:339-352. 5. A.L Depaula. Laparoscopic treatment of type 2 diabetes treatment for patients with a body mass index less than 35. Surg Endosc 2008; 22:706-716. 6. Joshua P. Thaler. Hormonal and metabolic mechanisms of diabetes remission after gastrointestinal surgery. Endocrinology 2009; 150:2518-2525. 7. Langer FB. Sleeve gastrectomy and gastric banding: Effect on plasma ghrelin levels. Obes Surg 2005; 15(10):1501-2. 8. Daniel M. Herron. Role of surgery in management of type II diabetes. Mt Sinai Jour of Med 2009; 76:281-293. 9. Lee WJ. Laparoscopic sleeve gastrectomy for diabetes treatment in nonmorbidly obese patients:Efficacy and change of insulin secretion. Surgery 2010 May; 147(5):664-9.
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GP BUZ Z | F E AT URE
Winning the Fight Against ostate Cancer:
A Patient’s Journey
The treatment for prostate cancer has evolved. It is not only about treatment but also about caring for the well-being of the patient even after the treatment. With a step-by-step care path, patients with prostate cancer can now enjoy better treatment and support for recovery. In this issue, we also bring you a real-life account of a prostate cancer patient’s journey to recovery.
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100 YEARS OF SURGICAL EXCELLENCE
H
aving prostate cancer can put a strain in a patient’s outlook towards life, both physically and emotionally. A patient will be concerned about his change in lifestyle, the treatment and its potential outcomes. With new advances in medical technology evolving towards minimally invasive methods of treatment, most prostate cancer patients who get appropriate treatment early go on to live active and productive lives. Today, the focus of care has extended beyond just good cancer control, but also managing quality of life issues that come along with the disease and treatment. It is with this aim that Tan Tock Seng Hospital (TTSH) has developed its multi-disciplinary approach of care which provides patients with holistic support to cope with the challenges of being diagnosed with cancer, seeking treatment and to achieve even better outcome in recovery.
Today, the focus of care has extended beyond just good cancer control, but also managing quality of life issues that come along with the disease and treatment. Robotic prostatectomy offers numerous benefits over traditional open surgery, including effective cancer control, shorter hospital stay, significantly lesser pain, lesser blood loss and fewer blood transfusions. PROSTATE CANCER Prostate cancer is a disease in which malignant (cancer) cells form in the tissues of the prostate – the gland that contributes fluid to semen. Although experts do not know exactly what causes prostate cancer, certain risk factors such as being over the age of 65, and family history of prostate cancer can put an individual at a greater risk of developing this disease.
TREATMENT OPTIONS When prostate cancer is assessed to be localised within the prostate gland, there are essentially three treatment options available to a patient, that is surgical removal of the cancerous prostate (radical prostatectomy), radiation therapy and active surveillance.
It is reassuring to know that prostate cancer is a very treatable condition. Here in TTSH, Urologists will advise on the options available and develop an individualised treatment plan for the patient as well as explain what to expect before, during and after treatment. The appropriate treatment choice depends on many things, such as age, the stage and grade of the cancer, surgical fitness and any other health problems the patient may have.
SURGICAL INTERVENTION In the case of a surgical removal, the surgery can be performed via an open, laparoscopic or robotic approach. Increasingly, patients are seeking robotic prostatectomy just like in the United States of America. Robotic prostatectomy is performed with a surgical system, which is designed to provide surgeons with enhanced capabilities, including latest high-definition 3D vision and a magnified view. The system translates the surgeon’s hand movements into smaller, more precise movements of tiny instruments inside a patient’s body. Though it is often called a “robot”, the system cannot act on its own. Instead, the surgery is performed entirely by a trained surgeon. The technology allows the surgeon to perform complex procedures through just a few tiny openings. As a result, a patient may be able to get back to his normal activities faster – without the long recovery process that usually follows after an open surgery. For qualified candidates, robotic prostatectomy offers numerous benefits over traditional open surgery, including effective cancer control, shorter hospital stay, significantly lesser pain, lesser blood loss and fewer blood transfusions. This surgery approach has been used successfully worldwide in hundreds of thousands of procedures to date.
A MULTI-DISCIPLINARY APPROACH Coming to terms with the cancer diagnosis can be a depressing and anxious experience for the patient. Through TTSH’s team-based approach with a step-by-step multidisciplinary care path, we hope to help prostate cancer patients address their concerns and put them at ease. For example, after the Urologist has discussed treatment options and counselled a patient who wants prostate cancer surgery, a nurse clinician will have a counselling session with the patient to help reinforce his understanding about the surgery and also introduce the importance of Pelvic Floor Exercise as part of post-surgery rehabilitation. A patient information booklet which covers pre-, during and post-operative care is also given to all prostate cancer patients with clear instructions during the counselling session. Implementation of the inpatient care path further reinforces the treatment process so that the prostate cancer patient receives evidence-based clinical care in a timely manner. The result is better treatment outcomes which improve the patients’ journey and experience. Men may not be comfortable talking about their condition and emotions. To give them an outlet to share and get support JUNE – AUGUST 2012
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from people going through prostate cancer treatment, TTSH initiated a prostate cancer support group in 2011. We believe that the best way of coping with any issues and challenges is to keep the lines of communication open.
anxiety, improve the patients’ ability to access appropriate information, and ensure that patients receive the best appropriate treatment at the right time. GP
Dr Chong Yew Lam
CONCLUSION To get the best outcome out of healthcare services, it is increasingly recognised that a team-care approach provides the synergy to do so. TTSH’s experience with prostate cancer treatment and surgery has shown us that a multi-disciplinary approach can help ease patients’
Dr Chong Yew Lam is the Head and Consultant of the Department of Urology, and Assistant Chairman Medical Board (Clinical Development) at Tan Tock Seng Hospital. Dr Chong completed his fellowship training in Endourology and Minimally Invasive Urologic Oncology at the Thomas Jefferson University Hospital in Philadelphia, USA. His specialty interests are in the application of minimally invasive surgical techniques in the management of urinary stone disease and urologic cancers.
Dr Chong and his surgical team with the da Vinci robot.
Photo Courtesy of The Straits Times © Singapore Press Holdings Limited.
“FASTER RECOVERY” THROUGH ROBOTIC PROSTATECTOMY A PATIENT’S JOURNEY The first time I had an elevated Prostate-Specific Antigen (PSA) reading of 6.17 during a routine blood test in December 2008, no red flags were raised and I thought nothing of it and carried on life as usual. However, when my PSA tested at 9.5 in May 2011 at the Hougang Polyclinic, I was referred to Tan Tock Seng Hospital (TTSH) for further tests. In June 2011, my PSA tested at 12.89 and I was recommended to do a biopsy. My biopsy in TTSH in August 2011 confirmed that I had stage 2 prostate cancer. After much discussion with both surgeons and oncologists in the Urology team at TTSH about treatment options, I asked Dr Chong Yew Lam, whom I had read about in The Straits Times, if he would perform robotic prostatectomy on me. Though the
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costs were higher compared to conventional open surgery, I was convinced recovery would be faster as I travel regularly for business. I was operated in December 2011 and stayed 2 nights for post-operative recovery and observation. Other than the inconvenience of the catheter, and though my pathology report said I had stage 4 cancer, all went well. The professionalism and patience of the counselors, nurses and attending doctors at Pre-Admission Counselling and Evaluation (PACE) Clinic, Dr Chong, his surgical team, doctors, assistants and nurses at the Urology Department, the nurses and attendants at the ward made the processes, surgery and stay at TTSH a pleasant experience. Mr Quah, 54, has had 2 PSA tests done since his surgery and there is currently no evidence of any prostate cancer.
G P BU Z Z | F I T N ESS
REGAIN FITNESS POST-SURGERY De-conditioning is a complex process of physiological change following a period of inactivity or sedentary lifestyle. It is common in patients who have undergone abdominal surgery. Learn exercises and techniques to combat de-conditioning for a smooth post-surgery recovery.
Factors contributing to post-operative cardiovascular de-conditioning include: • Bed rest associated with hospitalisation and stress response. • Tissue injury and metabolic changes due to the surgical procedure. • Abdominal muscles become weak and lose its tone during the procedure. These complications can affect ability to perform activities of daily living, resulting in frailty and decreased quality of life. To counter de-conditioning, gradual increase of cardiovascular and abdominal exercises is essential post-discharge from the hospital.
PROGRESSION OF ACTIVITY FOR POST-ABDOMINAL SURGERY
ar
H
• Cycling
er
• More strenuous household chores like vacuuming the floor or washing the car
• Lie on your back with your hips and knees comfortably bent.
• Lie on your back with your hips and knees comfortably bent.
• Tuck chin towards chest and slowly bring your shoulders 2 to 3 inches off the floor towards your knees.
• Tuck chin towards chest and slowly bring your shoulders halfway off the floor towards your knees.
• Slowly lower yourself down to the starting position.
• Slowly lower yourself down to the starting position.
d
• Simple household chores like sweeping floor or ironing clothes
e
at
• Stairs climbing
od
• Brisk walking
M
ht
• Walking (in the house or along the corridor)
Lig
Cardiovascular Exercises
Abdominal Exercises
• Lie in a comfortable position, pull your belly button inward by contracting your abdominal muscles for 5 seconds, and then relax.
interval exercises; do frequent short sessions of 1 Practise walking instead of a continuous session. strenuous exercise such as lifting, carrying, 2 Avoid pulling or moving of heavy objects (not more than the
5 SIMPLE TECHNIQUES
weight you can carry with one hand).
progression of activity by increasing duration 3 Gradual of exercise or decreasing duration of break. symptoms (pain or breathlessness level) to determine 4 Use threshold of activity. contact sports (for example, soccer, basketball 5 Avoid and tennis) until the doctor advises you to do so.
Ms Sarah Goh Ms Sarah Goh is a Senior Physiotherapist in the Physiotherapy Department of the Tan Tock Seng Hospital and is certified by the American College of Sports Medicine. Ms Goh works closely with weight-management and heart disease patients. Her interest is in exercise rehabilitation.
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GP BUZ Z | H E A LT H Y R E C I P E S
Herbal Stock Steamed Cod Fish in ma Mushrooms er d o n a G d n a i k o n E with
INGREDIENTS 100 grams Cod 10 grams Red Dates (
)
HERBS
5 grams Bai He ( ) 10 grams Huai Shan ( 10 grams Dang Shen ( 10 grams Yu Zhu ( ) 5 grams Wolfberries (
) ) )
MUSHROOMS
15 grams Enoki Mushrooms 15 grams Ganoderma Mushrooms PREPARATION 1 Place herbs in a pot with 300 grams of water and boil for 35 minutes 2 Steam cod fish over high heat for 6 minutes 3 Add the mushrooms to cod, and steam for 2 more minutes 4 Pour herbal stock over cod and serve hot on a plate NUTRITIONAL INFORMATION Each serving provides 316 calories, 30 grams protein, 2 grams fat, 52 grams cholesterol and 87 grams sodium.
INGREDIENTS 30 grams Avocado 100 grams Papaya (Half-ripe or Unripe) 60 grams Chicken Breast DRESSING
50 10 50 80 30
ml Light Soy Sauce ml Sesame Oil grams Sugar ml White Vinegar grams White and Black Sesame
PREPARATION
1 Halve, pit and peel avocado 2 Shred papaya into thin strips 3 Boil chicken breast and slice into strips 4 Mix dressing with chicken 5 Serve with avocado and papaya NUTRITIONAL INFORMATION Each serving provides 214 calories, 10 grams protein, 8 grams fat, 24 grams cholesterol and 420 mg sodium. Recipes were designed in collaboration with Hospitality & General Services, Complementary Integrative Medicine Clinic and Dietetics Department, Tan Tock Seng Hospital (TTSH). Photos courtesy of Mr Henry Lim, Photographer, TTSH.
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Avocado Papaya Sa Chicken in Sesam lad with e Dressing
Event EVENT
GP BU Z Z | E V E NT S & I N T H E NEWS
SCHEDULE: JULY TO AUGUST 2012 DATE
TIME
VENUE
HOW TO ATTEND
GP CME EVENTS Centenary Surgical Conference (GP Forum)
21 July
12.30pm – 3.30pm
Tan Tock Seng Hospital
DID: 6357 7668 EMAIL: TTSH_Centenary_Surgery@ttsh.com.sg
Management of Neck Lumps in Primary Care Setting
3 August
1.15pm – 2.00pm
Jurong Polyclinic
DID: 6357 7601 EMAIL: Cindy_SY_Lim@ttsh.com.sg
Updates in ENT for the Family Practitioner
18 August
1.00pm – 4.30pm
Tan Tock Seng Hospital Conference Room 1 & 2
DID: 6357 7664 EMAIL: ruhaizah_aman@ttsh.com.sg
ACTIVITIES FOR 100 YEARS OF SURGICAL EXCELLENCE LECTURES: Korea-ASEAN Joint Laparoscopy Workshop
Surgical Excellence Photo Exhibition
7 July
29 July – 6 August
LECTURES:
9.00am – 1.00pm
Oasia Hotel Conference Room, Basement Level
PRACTICALS:
PRACTICALS:
1.00pm – 5.00pm
Surgical Science & Research Lab, Level B1, NNI Block
9.00am – 9.00pm
Tan Tock Seng Hospital Atrium
DID: 6357 7601 EMAIL: Cindy_SY_Lim@ttsh.com.sg
Registration is on first-come-first-serve basis.
Open to public
For an updated listing of CME and event schedule, please visit www.ttsh.com.sg/medical-professionals. Event details are correct at the time of publishing.
The Healthcare Humanity Awards 2012
Ten of our healthcare professionals received medals of honour by President Tony Tan Keng Yam in the annual Healthcare Humanity Awards (HHA) 2012 ceremony held at the Biopolis on 15 May. HHA is a continuation of the Courage Awards, which were given out in 2003 to honour healthcare workers who battled the deadly SARS epidemic with exceptional selflessness and dedication.
Top from left: Dr Tan Thai Lian, Head & Senior Consultant, Geriatric Medicine; Dr Poi Choo Hwee, Associate Consultant, General Medicine; Mr Chionh Chai Kuei, Senior Therapy Assistant, Physiotherapy; Ms Yang Juan, Staff Nurse, Ward 10C; Ms Joey Yeo Jiayang, Senior Staff Nurse, Continuing & Community Care; Ms Nadiah Erniyanti Binte Maliki, Senior Staff Nurse, Ward 7A; Ms Ang Ching Ching, Advanced Practice Nurse, Palliative Care; Ms Koo Sie Liu, Staff Nurse, Operating Theatre; Ms Wang Na, Staff Nurse, Ward 8A; and Ms Maggie Lim, Senior Staff Nurse, Operating Theatre.
TTSH award winners with members of the Management team.
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GPBUZZ JUNE — AUGUST 2012
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JUNE – AUGUST 2012
MICA (P) 242/03/2012
A PUBLICATION FOR PRIMARY CARE PHYSICIANS