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Berita CSM

Title: Berita CSM October 2012
Date: 01-Oct-2012

Table of Contents

 

 

 

Message from the President

I would like to introduce the new council of the College of Surgeons, Academy of Medicine of Malaysia (CSAMM). Three council members have finished their term of office, Dr Chew Loon Guan, who was the Vice President, Dr Ashim Kumar Nandy and Dr Ramesh Gurunathan. I would like to thank them for their contribution to the college. We have three new council members, Prof Dr Chin Kin Fah, Assoc Prof Dr April Camilla Roslani, and Assoc Prof Dr Ismail Sagap. I remain as the President of the College, and Dr Peter Wong is the Vice President and Assoc Prof Dr Hanafiah Harunarashid is the Secretary. Dato' Dr Rohan Malek remains as the Treasurer. The other council members are Prof Dr David Choon, Prof Dato' Dr Lokman Saim, Prof Dr Rohaizak Muhammad, Assoc Prof Dr Andrew Tan and Prof Dr Liew Ngoh Chin.

The Annual Scientific Meeting and Annual General Meeting of the CSAMM was held from 24th-27th May 2012 in Kuantan, Pahang. Despite earlier fears that the Royal Australasian College of Surgeons (RACS) meeting held earlier in the month in Kuala Lumpur would overshadow our smaller meeting, this did not occur and the CSAMM meeting in Kuantan saw an attendance of nearly 500 delegates. The only difference was that we did not invite any international College presidents, who had attended the RACS meeting in Kuala Lumpur just two weeks before.

It has been quite an eventful year for the CSAMM. As well as continuing with the ATLS courses, which is now into the third year, and running well under the leadership of Assoc Prof Dr Lum Siew Keong, we have also started the Care of the Critically Ill Surgical Patient (CCrISP) course in May 2012, with two provider courses and an instructor course, with assistance from the Royal College of Surgeons of England (RCSEng) and the RACS. A memorandum of understanding (MOU) has been signed with the RCSEng, followed by a recent MOU between the Ministry of Health Malaysia and CSAMM (under the auspices of the Academy of Medicine) to provide this course for surgeons and surgical trainees in the MOH. The CCrISP course is led by Dr Ng Char Hong.

The CSAMM has also signed an MOU with the International Association of Endocrine Surgeons (IAES) and the Breast Surgery International (BSI) which are both integrated societies under the International Surgical Society to start a Breast and Endocrine Surgery Course in Malaysia, and the first course is scheduled for November this year, under the leadership of Prof Dr Rohaizak Muhammad. Following this, an MOU was signed with the MOH to provide this course to the MOH surgeons.

The College continues to be involved with surgical training and education, being members of the Conjoint Boards of different surgical disciplines. There have been discussions held with various international and regional surgical Colleges, such as the American College of Surgeons, the RCSEng, the Colleges of Medicine of South Africa, as well as the RCSEdinburgh on the "internationalisation" of surgical training, and a one-day international forum of surgical training is to be hosted by the Royal College of Surgeons of Thailand in Pattaya in August 2012.

For 2012-2013, the CSAMM will also try to coordinate the Surgical Skills Workshops that have been carried out, and Prof Dr Chin Kin Fah and Assoc Prof Dr Hanafiah Harunarashid, will organise the workshops together with Prof Dato' Dr P Kandasami and Dr Ramesh Gurunathan, who have been organising the hernia and bowel anastomosis workshops in Seremban Hospital.

The Basic Surgical Sciences Examination (BSSE) will continue under the leadership of Prof Dr David Choon, who has worked hard to make it a requirement for entry into the Masters programme and hopefully to replace the Part 1 Master of Orthopaedic Surgery examination. It is anticipated that the Master of Surgery programme will have a similar examination under the Conjoint Board which consists of the Ministry of Health, the four universities currently offering the Masters programme and the CSAMM. It is hoped that with a Part 1 type of examination as an entry criteria for surgical training, the quality of the trainees will improve and the failure rate will be less.

The CSAMM continues to have representation in various committees under the MOH and the Academy of Medicine, especially the new Fee Schedule (which is still pending), the Committee on the Aesthetic Practice Guidelines and the National Specialist Register.

Finally, I would like thank the Council for re-electing me as the President and I will continue the work that the past Presidents and Council of the CSAMM have started and maintain the linkages established with international and local organisations.

C H Yip
President, College of Surgeons
Academy of Medicine Malaysia
Email: chenghar.yip@gmail.com

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39th A M Ismail Oration 2012
A Long Journey of Hope - the Development of Paediatric Surgery in Malaysia
by Mahmud bin Mohd Nor

BACKGROUND

I am honoured and privileged to have been invited to give this year's 39th AM Ismail Oration. Tan Sri Dato' Abdul Majid Ismail, a renowned Orthopaedic surgeon is known to many. He founded the College of Surgeons of Malaysia and also became the Director General of the Ministry of Health in 1971. I am privileged to have started my career in medicine after my housemanship in 1971. He was the Director General of Health I reported to. In a way he shaped my future by seconding me to Universiti Kebangsaan Malaysia (UKM) as a trainee lecturer in surgery in 1972. He is known to many especially the older generation for his immense contributions to the development and modernisation of the Health care services of Malaysia. Not many are aware even in UKM of his contribution to the establishment of the Faculty of Medicine UKM and the support he gave to it in the early years of its development. It is especially important to mention his contribution to UKM as this year is the celebration of the 40th year of the establishment of UKM's Faculty of Medicine.

He and Dr Ungku Omar bin Ungku Ahmad the Director of the Institute for Medical Research (IMR) was instrumental in bringing to the attention of the Prime Minister Tun Abdul Razak the idea of another medical faculty. The Prime Minister was keen on the idea. This led Dr Ungku Omar to arrange for a meeting at the IMR. Among those present were Tun Razak himself, Tun Dato' Dr Ismail bin Abdul Rahman the Minister of Foreign Affairs himself a medical doctor, Tun Tan Sri Dato' Syed Nasir the Director of Dewan Bahasa dan Pustaka, Tan Sri Dato' Sheikh Hussein, Tun Tan Sri Dato' Abdullah bin Salleh, Tan Sri Dato' Dr Majid Ismail and a few others. This meeting affirmed the need for a second faculty of medicine in the country and at UKM to address the issue of under representation of Malays in the medical profession and to provide better opportunities for students coming from the Malay medium of instructions schools to do medicine. There were only about 4% Malay and Bumiputra doctors in the country around 1970 and in my class of eighty at the University of Malaya in 1965 there were only four Malays.

Tan Sri Dato' Dr Abdul Majid Ismail who was then the Director General of the Ministry of Health played a significant role in assisting the development of the faculty. A piece of land behind the Maternity Hospital adjacent to the TPCA Stadium was allocated to build five blocks of temporary wooden buildings which surprisingly has survived to this day. The building was completed in a record time of four months.

The Ministry of Health also removed bodies from the graves of unclaimed bodies of the hospital from an area close to Lake Titiwangsa and the Police Training school to a new site in Sungai Buloh. This piece of land was later used to construct the student's hostels and a few blocks of staff housing. To give a glimpse of the challenges faced by Tan Sri Abdul Majid Ismail in modernizing the health facilities after Merdeka a look at the early Hospitals of Kuala Lumpur (Pauper's Hospital) is relevant in this oration as this is the ground where Paediatric surgery took its roots. The first building was started in 1920. This was never completed during the slump. The ruins came to be known as the 'Huxley's Ruins' which is now the site of the Orthopedic clinic. A new hospital was built in 1930 with Malay, Chinese and Indian wards. British officers and family were at a better facility at Tanglin Hospital. A lot of credit must therefore be given Tan Sri AM Ismail who as Director of Planning in the Ministry of Health started the planning of a new hospital for Kuala Lumpur as we now see it.

His attempt to establish the College of Surgeons to be on the same footing as the British Royal Colleges however did not materialize as the government made the decision to place the responsibility for Postgraduate Medical Education to the Universities but with the involvement of the Profession and the Ministry of Health. This later led to the formation of the Conjoint Committee on Postgraduate Medical Education and its subcommittees around early 1980 consisting of the representatives of the Universities, Ministry of Health and Academy of Medicine. I was the first chairman of the main committee with Dr Yeoh Poh Hong and Dr Megat Burhanudin representing the Academy of Medicine and Ministry of Health respectively. The secretary was Dr Zainol Arif the under secretary of the Ministry of Education. This committee under the Ministry of Education was formed to advise the Minister on matters pertaining to Postgraduate Medical Education. The College of Surgeons of Malaysia is now playing an active role as a chapter under the umbrella of the Academy of Medicine in the subcommittees of all the surgical specialties including participation in the conjoint examinations.

INTRODUCTION

Paediatric Surgery Service in Malaysia

Paediatric surgery as a specialty of surgery has been well established in most parts of the developed world with every major city having hospitals for children where doctors in almost all the specialisations of Medicine contribute to the care of children up to the age of eighteen. In Malaysia only children age twelve years and below are categorised as children and may get admitted to a children's ward.

Unlike the developed countries there is not a single comprehensive specialised hospital for children. The care for children has all this while been mainly integrated with adults. Children often sharing the same facilities but where possible they were placed in different wards.

This was the scenario in the care of paediatric patients at the point of my graduation from the University of Malaya in 1970 as the second batch of graduates from the new medical faculty. In October 1972 I joined UKM as a trainee lecturer and was sent to the University Hospital to undertake academic training in General Surgery and later in Paediatric surgery at the Hospital for Sick Children Great Ormond Street London and at the Royal Children Hospital in Melbourne. The experience gave me an early insight into the development of Paediatric surgery in Malaysia.

This oration is about my own experience and observation of the growth and development of Paediatric surgery in Malaysia with special reference to its development at the General Hospital Kuala Lumpur (HKL) and the major role played by Universiti Kebangsaan Malaysia (UKM). It spans over 40 years and I will try in this short period of time to give a glimpse of its historic developments, the aspirations of many Paediatric surgeons and our hopes for the future of this specialty in our beloved nation.

Phases of Historic Development of Paediatric Surgery in Malaysia

From a historical perspective the development of Paediatric surgery in Malaysia can be divided into five phases:

  1. Prior to 1970
  2. 1970-1980
  3. 1980-1990
  4. Post 1990: Institute of Paediatrics
  5. Post 2000

Paediatric Surgery Prior to 1970 'Phase of Relative Ignorance'

In this phase throughout the country surgery of children was the responsibility of general surgeons who operated on almost everything in adults and children. Undoubtedly the outcome especially the newborns could be described as disastrous. The infrastructure was poor and the human resources were inadequate to support surgery of children especially newborns. The earliest surgery done on babies by a properly trained paediatric surgeon was at the University Hospital by Prof Dato' K Somasundram. He had his training at the Hospital for Sick Children Great Ormond Street London. Dr Karpal Singh was the Surgical Registrar in General Hospital Kuala Lumpur from 1964 to 1966 and then became the Senior Registrar from 1967 to 1968. During this time he took care of most of the Paediatric and neonatal surgical problems though he did not have full training in Paediatric surgery at that time. There was no special ward for children requiring surgery and they were placed in the Paediatric medical ward. The wards were situated on the ground of the old Malay ward I & II. (Present site of Institute of Pediatric).

1970-1980 'Phase of Awareness'

This phase of development coincided with the redevelopment of the entire Hospital Kuala Lumpur complex. Hospital Kuala Lumpur was intended to be the teaching hospital of UKM with a Management Board. Various institutes were established. The idea was that UKM will provide the academic umbrella and all specialists in the hospital would participate in service, teaching and research proportionately according to a formula depending on whether they were from the Ministry or UKM. This idea did not come to full realization due to legal impediments. It eventually became a hospital where teaching was done mainly by UKM teaching staffs. This prompted UKM in later years to develop its own hospital for its future growth and development. There was a separate Maternity Hospital with its own special care nursery but without a Gynaecology ward. The main hospital complex consisted of various departments. The Paediatric department had its own Neonatal care ward. Mr Karpal Singh was sent to Melbourne for training in Paediatric surgery in 1970 and returned with an FRACS in Paediatric surgery in 1972. He recommenced proper paediatric surgical practice in February 1972 in Unit 1 under Dato' K A Menon.

I came into the picture of Paediatric surgery in Malaysia at Hospital Kuala Lumpur in August 1976 after my Fellowship and a stint at Hospital for Sick Children Great Ormond Street (GOSH) and University Hospital. I was asked to start the department of surgery of UKM. In January 1976 the academic department of surgery UKM was established and soon followed by the establishment of the UKM surgical unit at HKL which took over Surgical Unit III from Mr Husin Salleh who resigned leaving two medical officers Dr Ahmad Zulkifli Laidin and Dr Yusha Abdul Wahab. Later in the year when Mr Karpal Singh resigned, the Paediatric surgical unit under Unit I was transferred to the UKM surgical unit together with Dr Leela Perumal as the medical officer. The UKM unit was on call every third day for general surgery and every day for Paediatric surgery with a single surgeon and three medical officers. Later Dr Freda Meah, Dr Bahari Habib Mohd and Dr Ismail Abdullah joined the unit in general surgery. This unit was later assisted by a Canadian trained Malaysian surgeon Dr Bakri Musa who also had some training in Paediatric surgery for close to a year before he was transferred to Johor Bahru.

There was now a greater degree of awareness on the need for more and better trained surgeons to deal with children especially babies. It was during this period that there was serious planning for new Paediatric facilities which was initially supposed to be a children hospital.

It was my dream, vision and hope when I took over the unit that one day we will be able to provide the kind of care for children similar to the ones that were provide by the developed countries like the one I saw at the children hospital in London.

  1. Children will be treated differently from adults
  2. Healthcare facilities addressing the special of children
  3. Children requiring hospitalization will be treated in a hospital that is designed especially for children.
  4. Children will be cared for by healthcare personnel specially trained to treat and care for children
  5. The hospital would be well known as a teaching and research hospital.

Up to 1976 most of the surgery done on neonates was for anorectal malformations. Other surgery like Intestinal Atresias and Hirschsprung's disease were also done but the outcome of surgery was not well documented (Figure 1)

Lesions No
Bowel atresias and malrotation 50
Oesophageal Atresias 40
Hirschsprung's Disease 47
Anorectal Malformations 158
Others 73

Figure 1: Congenital GUT anomalies at Hospital Kuala Lumpur (HKL) 1970 to mid 1981

After 1976 there were significant improvements in the surgery of children at HKL despite the numerous challenges of this new surgical service. The infrastructure support for newborns was poor. Initially the other surgical units also insisted on carrying out surgery in children, as was the practice throughout the country. It was not surprising that the outcome of surgery then as measured by the neonatal surgical mortality rate was horrendous compared to the present day situation.

In the initial period of my undertaking the service the outcome of surgery especially in the newborn was dismal. We were handicapped not only by the lack of appropriate surgical instruments like small size scissors and forceps to do surgery in children but also by a lack of trained nursing staff in the operating theatre. The operating theatres were cold and there were no equipments like warming blankets to keep the child warm throughout surgery. The diathermy apparatus were big and not of the right size for children especially babies. We had to improvise ways to keep the baby warm during surgery. Despite these efforts many babies after long surgery became cold and hypothermic which led to metabolic complications like acidosis. Sclerema neonatorum a complication of hypothermia was quite common. It was not surprising that many babies died after surgery except for the simple conditions that did not require prolong surgery. The ward nursing staffs were also not well trained to handle children especially the low birth weight and premature babies. There was not a single case of oesophageal atresia that survived surgery for the first three years (Figure 2). Many of them died soon after surgery. A few survived for about two weeks. Better result was obtained for other abdominal operations and in Diaphragmatic hernias especially those that did not require preoperative ventilation or presenting late.

Period No Death %
1970-1975 18    
1976-1977 9 9  
TOTAL 27 26 96.3
1978-1979 6 4  
1980-mid 1981 7 1  
TOTAL 13 5 38.5 (p<0.01)

Figure 2: Mortality of Oesophageal Atresias at HKL 1970-1981

With the concentration of most Paediatric care in one unit the overall survival of neonates after surgery gradually improved. Initially the other units also carried out surgery of the newborn but with better outcome demonstrated by Unit 3 (UKM) and as words spread around about our successes more patients were referred directly to the unit and later the other units gave up entirely their work on children.

As a result, the period between 1976 and 1981 saw some encouraging improvement in the postoperative survival of neonates compared to the years before that. In 1970 the postoperative mortality for neonates undergoing thoracic or abdominal operations was 75%. In 1975 it was 51.8% but in 1976 it began to drop rapidly from 47.6% to 10.3% in mid 1981 (Figure 3). The mortality rate for all operations in the neonates has since remained below 15%. This was a measure of success in the effort to improve the care of children especially neonates.

Figure 3: Emergency Thoraco-abdominal operations in neonates at HKL and UKM 1970-mid 1981

Oesophageal atresia was dubbed as the 'epitome of modern surgery' by NA Myers whom I worked under at the Royal Children Hospital Melbourne. Success in the surgery for this condition is cited not only as a measure of the skill of the surgeon, but also a reflection of the quality and sophistication of a Paediatric surgical unit and its supporting facilities. Prior to 1976 there was only a single survivor for this condition. After 1976 the first survivor was reported only in 1979 followed by a few more successes. During the period of 1976 to 1981 the total mortality for this condition was 38% and the deaths were mainly in the high-risk groups with severe associated anomalies or with very low birth weight (Figure 4).

Risk
Classification Of
Atresia
1974-1977 1978-May 1982
No
operated
No
died
% No
operated
No
died
%
A 1 1 100 5 0 0
B 13 12 92.3 13 3 23.1
C 2 2 100 5 4 80

Figure 4: Death with Oesophageal Atresias at Hospital Kuala Lumpur 1974-1982

The tremendous improvement in the survival of neonates with oesophageal atresia can be attributed to the establishment of a special neonatal unit and special care nursery at the General Hospital (HKL) main complex in 1980. The Intensive Care Unit was also improved with the purchase of open incubators and monitoring equipments. With better-trained nurses and neonatal specialists from the Ministry of Health working together with the neonatologist from UKM there was an overall improvement of the care of the sick newborns. The achievements were also contributed in no small measure by a group of dedicated anaesthetists from both HKL and UKM and improved facilities in the intensive care unit. The dramatic fall in the postoperative mortality of neonates was a landmark achievement of Hospital Kuala Lumpur. There can be no doubt that the involvement of UKM specialists in the care of patients at the hospital led to an overall improvement in patient care of the whole hospital.

Paediatric Surgery 1980-1990

The post 1980 period saw a greater degree of recognition for Paediatric surgery as a very special branch of surgery with many interests shown by trainee doctors and nurses. Paediatric surgery was undertaken entirely by the UKM surgical department. There was greater support from the administration of the hospital in providing more personnel and financial resources for the purchase and upgrading of equipments especially in the operating theatre and Intensive Care Unit. It was during this period that many trainees offered themselves to be trained.

There was news that a children hospital was in the pipeline but there was slow progress and work only started in the early 80's at the old site of the Paediatric wards. There was considerable delay in the progress of the hospital. Construction work of the new Institute started around 1984 but soon stopped after the stage of piling. I can still remember seeing steel structures left visibly protruding above ground for quite some time after cessation of work. A photograph taken on 20th May 1985 showed that shrubs and trees have overtaken the structures. This raised concern in many quarters and was even raised in Parliament by Dato' Zainal Abidin an MP from Kedah. It was discovered that the ground was soft and of lime stone and the foundation would not take all the floors that had been originally planned. There was a long period of waiting and coupled with the recession of 1987 the construction only recommenced in 1989. A few floors had to be scrapped from the original design. It now consists of three levels with remnants of a staircase that can still be seen going up from level three to a non-existent floor. I was appointed Dean of the Faculty of Medicine UKM in February 1984 and was able to obtain from the University additional financial resources for the unit.

1990-2000: Institute of Paediatrics: Phase of Consolidation and Expansion

The Paediatric service of HKL finally moved to the new Institute of Paediatrics in May 1991. There were considerable discussions at various levels on what name to give to this new facility. Finally it was decided to name it the Institute of Paediatrics or Institut Pediatrik to be consistent with the name given to the other Institutes in HKL.

It was decided that the new facility was only for general paediatrics and general surgery. Following protests from Dr Sivanantham the head of department of Orthopaedics, the scope of service was expanded to include orthopaedic surgery but orthopaedics would have to share the wards with general surgery. Thus from the very start the facility was not adequate for the needs of all children and it was never designed to be a comprehensive children hospital.

Beside the considerable delay in the construction of the Institute, its floor space was reduced and when it was finally ready it was already outdated in its design. Despite this, it was a significant development in the care of children in general as for the first time most of the children in HKL were put under one roof. Unfortunately there were not enough beds to include patients in all the surgical specialties. In the early part only general surgery and orthopaedic patients were admitted to the Institute. The Institute could not initially be provided with all the facilities like a Burn unit, physiotherapy and supporting diagnostic services. Over the years some renovations were done to include some of these services. Some diagnostic services like MRI and CAT scan are still shared with the adult patients in the main block and patients have to be transported there with some risks.

The decade between 1990 and 2000 can be considered as a great decade for Paediatric surgery. There were many outstanding surgeons from UKM and HKL and surgeons in training in the unit. More complex surgeries were performed with success due to better peri-operative care of patients especially neonates. The neonatal surgical mortality from 1990-93 remained at an acceptable level of 9.3% to 11.9% (Figure 5).

When HUKM was opened in 1997 all UKM members of the team had to move to Cheras to their own teaching hospital.

Year Admission Death Percentage (%)
1990 336 31 9.33
1991 318 22 6.92
1992 278 31 11.10
1993 309 37 11.9

Figure 5: Neonatal Surgical Mortality at Hospital Kuala Lumpur 1990-1993

The Paediatric surgery department then came entirely under the Ministry of Health. Many improvements were achieved by using funds obtained from donations by the public and corporate organizations. Without the generous contributions of the public it would not have been possible to improve the facilities and reach the level of child friendly care that has been achieved by the Institute of Paediatric. This effort to develop and promote a more child friendly healthcare for children culminated in the formation of the Child friendly Healthcare Association of Malaysia to develop standards and criteria and promote child friendly practices. I was the inaugural President.

Paediatric Surgery Post 2000 at Institute of Paediatrics

There were further significant improvements in the outcome of surgery. The neonatal surgical mortality from 2003 to 2007 showed a mortality rate of between 10 to 12 percent, a slightly higher figure compared to previously (Figure 6). This is a reflection of more complex and high risk cases undertaken. The mortalities were mostly from necrotising Enterocolitis and abdominal wall defects (Figure 7). The mortality for oesophageal atresias between 17-24 percent has shown better outcome for high risk group (Figure 8). More complex surgical operations like separation of conjoined twins were carried out with success and there were better salvage and outcome of low birth weight babies.

Year Admission Death Percentage (%)
2003 213 22 10.18
2004 204 28 13.72
2005 232 24 10.34
2006 250 30 12.00
2007 249 30 12.05

Figure 6: Neonatal Surgical Mortality at Institute of Paediatrics 2003-2007

Cases No Death (%)
Gastroschisis 64 7 10.93
Exomphalos 44 15 34.09
Intestinal atresia 48 1 2.08
Duodenal atresia 48 6 12.50
Duodenal stenosis 28 1 3.57
Diaphragmatic Hernia 44 6 13.63
NEC 39 6 41.02

Figure 7: Neonatal Mortality according to diagnosis at Institute of Paediatrics 2003-2007

Year No Death (%)
2003 23 4 17.40
2004 21 5 23.80
2005 14 0 0
2006 28 6 21.43
2007 18 4 22.22
2008 (up to March) 1
transferred from KK
10+1 1 ?

Figure 8: Oesophageal Atresia Mortality at Institute of Paediatrics 2003-2007

SURGERY OF CONJOINED TWINS

I would like to make a special mention about the surgery of Conjoined twins in the department. Separation of Conjoined twins is a very special operation requiring meticulous organization, preparation, and coordinated team effort involving several categories of health professionals. For the record, the first Siamese twins were successfully separated at the University Hospital by a team led by Prof Somasundram on 5th March 1981 followed by another pair on 19th April 1982. Both were Ischiopagus tetrapus females and both survived.

On 17th July 1988 Hospital Kuala Lumpur created history of some sort by successfully separating its first pair of Siamese twins joined at the upper abdomen and lower chest (Xipho Omphalopagus). The success was a great morale booster to the paediatric and surgical fraternity of HKL and was widely publicised in the news media. To date I have been involved in the separation of ten pairs of Siamese twins losing two full pairs and one each of two pairs i.e. 12 survivors (Figure 9). Hospital Kuala Lumpur has performed ten separations of conjoined twins over a period of fourteen years with good results. Of the babies who survived surgery and discharged home all are alive and well. We have twelve babies surviving out of a possible total of eighteen. This is a record that we can be proud of.

Type Date Outcome
Xiphoomphalpagus (F) 17.07.1988 Both survived
Ischiopagus tetrapus (M) 05.03.1989 Both survived
Xiphoomphalopagus (F) 29.05.1989 Both survived
Thoraco omphalopagus dipus (F) 11.11.1989 Both died
Omphalo ischiopagus tetrapus 19.10.1995 Both died
Xiphoomphalopagus (F) 11.02.1995 One survived
Xiphoomphalopagus (F) 24.06.1995 Both survived
Ischiopagus parasitic twin (F) 18.09.2002 One survived
Xiphoomphalopagus (F) 27.11.2002 Both survived
Ischiopagus tetrapus (F) 02.02.2008 Both survived

Figure 9: Types and Outcome of Conjoint Twin separated at HKL 1988-2008

LIVER TRANSPLANTATION

Initially liver transplantation in children was planned to be done at the Institute of Paediatrics. Many attempts at getting support for it from the Ministry of Health failed because of financial constraints. This is understandable, as a liver transplantation service requires heavy financial investments not only in setting it up but also in maintaining the programme. We decided to try for an alternative source of funding from the private sector through donations. We were successful in securing an initial sum of RM 5 million to start the programme with a promise of another RM 4 million a year to support the programme from Maybank. The Ministry of Health later decided that liver transplantations must be done at the new Selayang Hospital. RM 5 million of the money pledged to us was transferred to Selayang Hospital.

The first liver transplantation in a child at a Ministry of Health hospital was carried out successfully in April 2002 at Selayang Hospital. The hospital invited Prof Russell Strong from Brisbane and Dr S T Fan from Hong Kong for the surgery. Dr S T Fan and some local members of the transplant team did the harvesting of the donor organ while Prof Russell Strong and surgeons from Selayang Hospital and Dr Zakaria from the Institute assisted in the operation to transplant the organ. Anaesthetists and nurses from the Institute were also at hand to assist in the operation. Since then two more live living related donor transplants were carried out, the second operation was carried out by Dr Prabakharan from Singapore with the assistance of our local surgeons. The third transplant was carried out entirely by our local surgeons including Dr Zakaria Zahari and other staffs from the Institute of Pediatric.

Paediatric Surgery outside Hospital Kuala Lumpur

Paediatric surgery initiated by Prof Somasundram in the late 60's continued at the University Hospital and is now an active postgraduate training centre training centre. At the University Hospital in Kubang Kerian a general surgeon took an interest in Paediatric surgery and started operating on children in 1990. The service is continuing and there is also now paediatric surgical service at Kota Bahru hospital. Starting from the early 1990's Paediatric surgical services were also extended to Kota Kinabalu, Kuantan, Penang and Ipoh with expatriate surgeons from India. Unfortunately the service in Kuantan had to be discontinued after the resignation of the surgeon from service. The service in Johor Baru was started on 1st October 1994 and has continued since. In October 1996 Kuching Sarawak started the service at the Sarawak General Hospital and is continuing. The service in Alor Star started in December 1997 and to date the service is maintained. In February 2000 Melaka started the service there but is discontinued due to absence of a surgeon. Thus at the beginning of 2004 Paediatric surgery outside Kuala Lumpur in the Ministry of Health hospitals are available in Alor Star, Melaka, Johor Baru, Kuching and Kota Kinabalu. Unfortunately all these hospitals are a single consultant surgeon service, which makes them vulnerable to cessation of service without a backup senior surgeon.

Performance at the National Level

There is no accurate data to gauge our performance at the national level. Some indication of outcome can be gauged from the National Peri operative Mortality study from January 2000-December 2001. There were 152 deaths of patients below 12 years of age which accounts for 17.5% of all reported deaths. Majority of deaths were in neonates. The vast majority of deaths were due to failure to recognize, delay in diagnosis and operation, inadequate resuscitation and preparation for surgery.

Future Needs of Paediatric Surgery

The country needs at least one new Children hospital in Kuala Lumpur and several more regional child-friendly hospitals for the children of Malaysia if we want to be called a developed nation. Australia as an example with a similar population has at least a children hospital in each state. Sydney has two and Melbourne has the most recent and modern children hospital. It is proposed that the regional children hospitals should be in Kota Kinabalu Sabah Kuching Sarawak, Alor Star, Johor Baru and Kota Bahru in Kelantan.

We also need specialists in other areas like Fetomaternal Medicine, better transportation of neonates, more trained personnel, a system of patient retrieval and long term follow up system, registry of surgical neonates and more postgraduate and research activities.

Several attempts were made to lobby for the first proper children hospital but to no avail. The Minister of Health finally agreed to a Women's and Children's Hospital but to be built on the existing hospital ground. Unfortunately like the Institute of Paediatrics the project after a promising start at the Hospital Kuala Lumpur ground was unexplainably stopped and the construction delayed till today. It is uncertain when it will start again.

The Training of Paediatric Surgeons

There is an urgent need to increase the output of surgeons through our local postgraduate training programme as we are extremely short by 98 in 2008 in accordance with our population requirement (Figure 10). Paediatric surgery in Malaysia was a subspecialty of General Surgery. Most general surgeons conducted surgery in children including neonates without any special training. Paediatric surgery was only recognised as a separate specialty in the Ministry of Health on my return from UKM to the Ministry in 1990. I was the first to be gazetted as a paediatric surgeon on the recommendation of Tan Sri Abu Bakar Suleiman. Some surgeons went to Australia for higher training in Paediatric surgery and obtained the Fellowship in Paediatric surgery. General surgeons with recognized qualifications could also be gazetted as a Paediatric surgeon after two years of service as a general surgeon and another three years of supervised training in the Fellowship programme of the Ministry of Health. This was formalized in 2002. This is a long route and not a favourite choice of most surgeons. In 2010 UM took in the first Malaysian candidate of its four years Masters in Paediatric surgery. This seemed to be a better option to most aspiring Paediatric surgeons. The University Kebangsaan Malaysia will also start its Masters in Paediatric surgery programme in collaboration with University Malaya and the Ministry of Health. Its curriculum is a combination of the European Board of Paediatric Surgery and the Royal Australasian College of Surgeons. It is also now an examination centre for the Fellowship of European Board of Paediatric surgery.

  2004 2005 2006 2007 2008
Stock 25 26 28 29 30
Need 118 121 123 126 128
Deficit -93 -95 -96 -97 -98
Source: Ministry of Health Malaysia. Population 2004=25, 580,899. Population
2007=27, 728, 699

Figure 10: Projection of Paediatric Surgeons 2004-2008; using Full Canadian Norms i.e. 1:216, 000

Recent Developments at UKM Medical Centre

UKM will be developing a new children hospital. Hopefully this will be completed within the next four years. A new training facility called the Advanced Surgical Skills Centre which includes a facility for training in Laparoscopic surgery is almost ready. The UKM medical centre now has a well established laparoscopic service in children capable of performing surgeries in children and newborn as early as 2 weeks. Many surgical procedures are now done laparoscopically. Recently it performed an unprecedented near total pancreatectomy in a two week old baby successfully.

I have been reliably informed that we have a justifiable hope that we will get two children hospitals in Kuala Lumpur within the next five years. One will be at UKM and the other at HKL. May Allah realise the dreams and hopes of our long journey.

Summary

  1. Paediatric Surgery in Malaysia has grown from a sub specialty of General Surgery to a separate specialty in line with similar developments of this specialty worldwide.
  2. The outcome of treatment as a result has shown vast improvements and there is now greater awareness in Malaysia that a child should be treated by health personnel who are specially trained to care for them.
  3. There is a recognised need that for better care, child friendly children hospitals have to be developed to serve identified regions of the country.
  4. If Malaysia is to join the rank of develop nations it is imperative that a more serious effort should be taken and for a start to expedite the development of two Children Hospitals in Kuala Lumpur.
  5. There is hope that the two new children hospitals will be ready within the next five years in Kuala Lumpur. We are hopeful that our long journey will end in joy and celebration as we proudly enter the status of a developed nation in 2020 with excellent care of our sick children.

"In Greek Mythology Pandora opened the box to the world and released all evils except hope. Hope was considered dangerous as its bedfellow can be delusion. Hope is also seen as the evil that prolongs human torment. Eventually Pandora released hope because without hope humanity was filled with despair".

With the recent developments in our effort to establish children hospitals in the country we are now more hopeful in the coming years of a better future in the health care of our children.

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Signing of the Memorandum of Understanding between Ministry of Health Malaysia and Academy of Medicine of Malaysia

The Ministry of Health (MOH) recognises that surgeons in the Ministry of Health are required to update their knowledge and to acquire new skills to be able to provide the best care for their patients. In recent years, the MOH has worked with the College of Surgeons, Academy of Medicine (CSAMM) to develop courses that will meet this objective. One of these courses is the ATLS (Acute Trauma Life Support) Course, which was started three years ago.

Recognising the burden of care of the critically ill surgical patients in the Ministry of Health hospitals, the Ministry is committed to take measures to improve the care of the critically ill patients. The CSAMM has introduced the CCrISP (Care of the Critically Ill Surgical Patient), which is a structured course developed by the Royal College of Surgeons of England (RCSEng), into Malaysia for the first time in April 2012. In this initial phase, two provider courses were held and one instructor course was carried out with two instructors from the RCSE, and eight instructors from Australia. Currently there are ten Malaysian instructors trained, and they will be able to run the CCrISP provider course in the future. A Memorandum of Understanding (MOU) has been signed between CSAMM and RCSEng to provide this course in Malaysia.

Breast cancer is the commonest cancer in Malaysian women, and thyroid disease is also very common In Malaysia. Breast and Endocrine Surgery (BES) is one of the subspecialties under General Surgery and the Ministry of Health has a 3-year fellowship programme for surgeons interested in taking up this specialty. Breast Surgery International (BSI) and International Association of Endocrine Surgeons (IAES) are integrated societies under the International Surgical Society which has its headquarters in Geneva. These two societies also have a goal to work for international teaching in surgery in developed and developing countries. BSI and IAES have expressed an interest in running a BES Workshop in Malaysia, and CSAMM has signed an MOU with these two societies to work together with a local organising committee to develop a curriculum for a BES course that will benefit surgeons interested in BES in Malaysia. Under this MOU, two surgeons from each of these international societies will work together with Malaysian surgeons to teach and train surgeons in BES in Malaysia.

A memorandum of understanding was signed between the MOH and the CSAMM on 25th May 2012 in the Ministry of Health, Putrajaya, to provide these two courses for surgeons in the MOH. The signing of the MOU was officiated by the Minister of Health, Datuk Seri Liow Tiong Lai. The Secretary-General of Ministry of Health, Datuk Kamarul Zaman Md Isa, represented the government while Academy of Medicine was represented by the Deputy Master Datuk Dr N Arumugam. Dr Rob Parkyn represented the International Surgical Society. Datuk Dr Noor Hisham Abdullah, Deputy Director-General of the MOH, and Dr Chew Loon Guan, Vice President of the CSAMM, were in attendance at the ceremony.

Under this MOU, the CSAMM will assume the responsibilities associated with the course. With these two programmes, it is hoped that surgeons in the MOH will now be able to provide better care for the acutely ill patient, and also improve their skills in the management of breast and endocrine diseases.

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Immediate Past President of the College of Surgeons awarded FRACS (Hon)

Assoc Prof Dr Lum Siew Kheong, Head of the Department of Surgery, International Medical University was awarded the Honorary Fellowship of the Royal Australasian College of Surgeons at the Opening Ceremony of the Annual Scientific Meeting of the Royal Australasian College of Surgeons (RACS) on 6th May 2012. This is the most prestigious award of the Royal Australasian College of Surgeons and has been awarded to only a handful of Asian surgeons since the award was inaugurated in 1928.

Assoc Prof Lum Siew Kheong was President of the College of Surgeons, Academy of Medicine of Malaysia, from 2007-2010. During his tenure as President, he introduced the Advanced Trauma Life Support (ATLS) programme of the American College of Surgeons to Malaysia. He also commenced the Johns Hopkins Travelling Fellowship to the Annual Scientific Meeting of the College of Surgeons of Malaysia and forged strong links with the surgical colleges in the ASEAN region, the RACS and the American College of Surgeons. His other major contributions include managing the teething problems associated with the introduction of the National Specialist Register, the construction of the new Academy of Medicine Building and the involvement of the College of Surgeons in postgraduate examinations when the National Conjoint Board in General Surgery was started in 2007.

He has continued his contribution to the College of Surgeons and the country in the training of surgeons, emergency physicians and doctors as the ATLS Course Director for Malaysia. He is also a Trustee for the Academies of Medicine Building representing the College of Surgeons.

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Council & Committees

Executive Committee
President Dato' Dr Yip Cheng Har
Senior Vice President Dr Peter Wong Toh Lee
Hon Secretary Assoc Prof Dr Hanafiah Harunarashid
Hon Treasurer Dato' Dr Rohan Malek
Council Members Assoc Prof Dr April Roslani
Prof Dr Chin Kin Fah
Prof Dr David Choon Siew Kit
Assoc Prof Dr Ismail Sagap
Prof Dr Liew Ngoh Chin
Prof Dato' Dr Lokman Saim
Prof Dr Rohaizak Muhammad
Assoc Prof Dr Andrew Tan Khian Khoon
   
Continuing Professional Development
Director Assoc Prof Dr Andrew Tan Khian Khoon
Members Representatives from surgical societies
   
Education Fund Committee
Chairperson Dato' Dr Rohan Malek
Committee Members Assoc Prof Dr Andrew Tan Khian Khoon
Prof Dr Chin Kin Fah
   
Surgical Skills Courses
Chairperson Prof Dato' Dr P Kandasami
Committee Members Prof Dr Chin Kin Fah
Assoc Prof Dr Hanafiah Harunarashid
   
Basic Surgical Sciences (Orthopaedic Surgery)
Convenor

Prof Dr David Choon Siew Kit
Board of Examination
Dato' Dr Yip Cheng Har, President, CSAMM
Prof Dato' Dr Tunku Sara Ahmad, Chairperson, Conjoint Board
of Orthopaedic Surgery
Members of the Conjoint Board of Orthopaedic Surgery
Elected Basic Sciences/Orthopaedic Examiners
   
Organising Committee
Chairman Assoc Prof Dr Kwan Mun Keong
Secretary Prof Dr Azhar Mahmood Merican
Treasurer Assoc Prof Dr Azlina Amir Abbas
Coordinator Assoc Prof Dr Jamari Sapuan
Examination Committee Prof Dr Sharaf Ibrahim
Members Prof Dr Mohammad Hassan Shukor
Assoc Prof Dr Sabarul Afian Mokhtar
Assoc Prof Dr Shalimar Abdullah
Dr Abdul Halim Rashid
   
ATLS Task Force
Course Director and Instructor
Dr Lum Siew Kheong
Deputy Director
Dr Andre Das
   
Annual Scientific Meeting 2013
31st May to 2nd June 2013, Kuala Lumpur
Chairperson Assoc Prof Dr April Roslani
Business Manager Assoc Prof Dr Law Chee Wei
Publicity Dr Sandip Kumar
Scientific Committee Assoc Prof Dr April Roslani
(Co-Chairperson)
Prof Dr Nur Aishah (Co-Chairperson)
Scientific Committee Members Prof Dr Azad Hassan
Prof Dr Chin Kin Fah
Prof Dato' Dr P Kandasami
Assoc Prof Dr Hanafiah Harunarashid
Dr R Krishnan
Assoc Prof Dr Law Chee Wei
Dr Nur Hashim Haron
Dr Sandip Kumar
Pre-Congress Prof Dr Chin Kin Fah
Workshop Assoc Prof Dr Hanafiah Harunarashid
Prof Dato' Dr P Kandasami
   
Constitution Review Committee
CSAMM Council  
   
News Bulletin
Editor /Chairperson Assoc Prof Dr Andrew Tan Khian Khoon
Committee Members Dato' Dr Yip Cheng Har
   
College Website
Chairperson Prof Dr David Choon Siew Kit
   
College's Representatives
Board of Management, Academies Building
Dato' Dr Yip Cheng Har
Dato' Dr Rohan Malek (Alternate to Dato' Dr Yip Cheng Har)
   
Regional Representatives
Johor Dr Andrew Gunn Kean Beng
Kedah/Perlis Dr Manisekar Subramaniam
Penang Assoc Prof Dr N Premnath
Kelantan Dr Nik Shukri
Terengganu Dato' Dr Jamil Abdullah
Melaka Dr Leong Choon Keong
Negeri Sembilan Prof Dato' Dr P Kandasami
Pahang Dato' Dr Jeffri Din
Perak Dr Yan Yang Wai
Sabah Dr Chuah Jit Aun
Sarawak Dr Clarence Lei
   
Representatives on Conjoint Boards,
Ministry of Higher Education
ENT Surgery
1) Dr Yap Yoke Yeow
2) Dr Primuharsa Petra Sabit Husin
General Surgery
1) Dr Lum Siew Kheong
2) Assoc Prof Dr Yushak Abdul Wahab
Orthopaedic Surgery
1) Dato' Dr K S Sivananthan
2) Dato' Dr Abdul Hamid Abdul Kadir
Ophthalmology
1) Dr Pall Singh
2) Assoc Prof Dr Andrew Tan Khian Khoon

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Annual Scientific Meeting & Annual General Meeting 2012
Report by Dr Rohaizak Muhammad, Organising Chairman

The Annual Scientific meeting and Annual General Meeting 2012 of the College of Surgeons, Academy of Medicine of Malaysia was successfully held on 25th till 27th May 2011 in Kuantan, Pahang Darul Makmur. This meeting was very special as this was the first time it was held in Kuantan.

The theme for this year was "Rejuvenating General Surgery" which put forward the relevant topics for the main specialty i.e. GeneralSurgery. With the increasing trend for sub-specialization, General Surgery has lost most of its former glory and scope. Nonetheless, it continues to be a somewhat competitive, rewarding and demanding specialty on its own right.

During this meeting, we were fortunate to have two travelling fellows, David Efron (John Hopkin's Travelling Fellow) and Craig Jurisevic (RACS Travelling Fellow). There were also invited speakers from countries including United Kingdom, India, Bangladesh, Vietnam and Singapore. Our local speakers for this year were the most distinguished and prominent surgeons of various specialties in their own respective countries who presented the latest advances in their respective fields.

Two scientific writing workshops were successfully conducted by editors from the British Journal of Surgery, led by its chief editor, Prof Derek Alderson. The first workshop which was held in UKM Medical Centre was over-subscribed and, similarly, the second workshop which was held at the UIAM was well attended. This showed the increasing interest among the surgeons to write and publish their work.

The live workshop on general surgery (Hernia and Anorectal Disease) was also successfully conducted at the Hospital Tengku Ampuan Afzan, Kuantan, Pahang and managed to gather more than 50 participants.

The conference was officially opened by the Master of Academy od Medicine, Dr Chang Keng Wee. This was followed by the 39th A M Ismail's Oration which was delivered by Dato' Dr Mahmud Mohd Nor, who touched on the establishment and progress of Paediatric Surgery in Malaysia and also the need to have a paediatric hospital for the country.

The conference was successfully attended by more than 460 participants and there were more than 226 papers presented during the three-day meeting. There were seven plenary sessions, ten symposia and one "How I do it session" covering and discussing on the most common topics and problems in General Surgery. The tradition of Ethicon Prize competition continued and the winner this year went to Dr Lilly Sofida Rahim from the University Malaya Medical Centre.

During the Congress Dinner, it was also announced the S M A Alhady Gold Prize for the best doctor in Masters of Surgery went to Dr Siti Fareeda bt Ahmad Nor from Universiti Kebangsaan Malaysia.

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The British Journal of Surgery Writing Workshop
Report by Assoc Prof Dr Hanafiah Harunarashid


This year for the first time in history, the prestigious British Journal of Surgery team headed by the Editor in chief, Professor Derek Alderson, conducted the inaugural pre-congress workshop on medical publishing entitled "How to write a paper" in conjunction with the CSAMM Annual Scientific Meeting 2012. The workshop was successfully held at the UKM Medical Centre on the 23rd May 2012, attended by 42 participants from all disciplines inclusive of senior professors and trainees alike. On 24th May 2012, a similar workshop was held at the UIAM Kuantan Medical campus attended by 30 participants, this time mainly consist of surgical trainees. This workshop uses the exact programme that was designed for the regular BJS workshops held in Europe. At the workshop, apart from serial lectures, participants worked in small groups with a personal tutor each during the hands-on tutorial sessions. The powerful editorial team includes Prof Dr John Murie, Prof Dr Desmond Winter, Prof Dr Bas Wijnhoven and Prof Dr Kjetil Soreide. The feedback we received was good and it is hoped that more young writers from Malaysia will be able to produce high quality articles that is publishable in a world reputable journal such as BJS in the future.

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