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Table of Contents
Foreword 3
Messages 6
50th Postgraduate Course Scientifc Activities
Opening Ceremonies Program 10
14th Chancellor Alfredo T. Ramirez Memorial Lecture 12
Scientifc Programme 18
Scientifc Session Abstracts 23
Participants Profle 43
Event Pictures 44
Scientifc Activities
Opening Ceremonies & ATR Memorial Lecture
Scientifc Sessions
Meet the Professor Dinners
Fellowship Night
Participants, Consultants, Residents & Alumni
Department of Surgery Offcers 160
Consultant Staff 161
Resident Staff 162
The frst UP-PGH Department of Surgery Postgraduate course
dates back in 1969 when Dr. Alfredo T. Ramirez, then the executive
offcer of the depar tment initiated short intensive postgraduate
courses in surgery. Since then it became a regular educational
postgraduate activity of the department. In the last ffteen years,
the UP-PGH postgraduate course was titled Mastery in Surgery to
highlight exceptional surgical issues as topic content with resource
speakers who are experts in their own felds as key component
of this event.Yearly, the scientifc program varies in its content
and strategy depending upon its theme.When the Foundation for
the Advancement of Surgical Education, Inc. (FASE) was formed
in 2003, through the initiative of Dr. Jose C. Gonzales, then the
Chair of the Department of Surgery, UP-PGH and Dr. Eduardo R.
Gatchalian, the frst FASE President, it regularly helped sponsor this
activity to realize the departments commitment in helping surgical
practitioners nationwide in advancing their knowledge and expertise
in the comprehensive management of the different surgical disorders.
Mastery in Surgery 2014 theme isInnovations and Advances
in Surgery. Proceeds of this event will be donated to the Foundation
for the Advancement of Surgical Education (FASE), which will
then help fund the indigent surgical patients of the Department
of Surgery, UP-PGH; training of surgical residents to help them
achieve the highest quality of surgical training responsive to the
needs of the Filipino people; and assistance in the professional
development programs for the consultant staff of the department.
Message from the
I extend my warm greetings and congratulations to the
members of the Foundation for the Advancement of Surgical
Education (FASE), Inc, and the College of Medicine-Philippine
General Hospital Department of Surgery, UP Manila, on the
conduct of the 50th Postgraduate Course, Mastery in Surgery
2014, with the theme Innovations and Advances in Surgery.
Surgery is one of the broadest and most chal-
lenging health disciplines in patient care. With the ev-
er-expanding range of diseases that are treated surgi-
cally and the development of new therapies, surgeons
are expected to learn more in a limited period of time.
Today, surgical education is characterized by rapid
and vibrant changes in knowledge, understanding of surgi-
cal diseases, and new procedures and technologies. In ad-
dition, demand for greater accountability and patient safety,
including institutions where training occurs and heightened
requirements for oversight in training programs, is increas-
ing. Novel educational and training paradigms are necessary
to meet the challenges of the 21st century and ensure the
production of professional, competent, and skillful surgeons.
Through the years, this course has proven to be a
good venue for the discussion and tackling of different themes
related to surgery by doctors from different institutions and
settings nationwide. It gathers the biggest number of sur-
geons from different specialties and in such an environment,
enrichment of learning that is essential to practice is assured.
On this note, I welcome the participating sur-
geons from the provinces in the Philippines and I com-
mend you for never missing the opportunity to share and
learn new insights and experiences through this course.
Professor and Chancellor
University of the Philippines Manila
Message from the Dean
I would like to congratulate once again, the UP-
PGH Department of Surgery and the Foundation for the
Advancement of Surgical Education (FASE), Inc. on your
annual postgraduate course, Mastery in Surgery 2014: In-
novations and Advances in Surgery. This yearly activity is
being awaited by other surgery practitioners from other in-
stitutions and from different parts of the country, because of
its high-quality, up-to-date and interesting topics that your
organizing committee always ensures in developing your
annual program. In addition, the active participation of your
Departments top caliber faculty, makes this postgradu-
ate course a much anticipated event in the feld of surgery.
The College of Medicine will always be your proud part-
ner in this endeavor. Again, congratulations and more power!
Professor and Dean
UP College of Medicine
Message from the Dean
Once again, on behalf of the UP College of Medicine I would
like to congratulate the Foundation for the Advancement of Surgical
Education (FASE) and the UP-PGH Department of Surgery on
your 49th Postgraduate Course, Mastery in Surgery 2013 with this
years theme Back to Basics: Preventing Complications, Improving
I am glad that your Foundation and Department continue to strive to be relevant
to the changing times. With our theme last year being From Simple to the Spectacular,
you attempted to present the latest and pioneering developments in your eld. This
years theme, however, Back to Basics has the clear intention of emphasizing what
has always been signicant in yours as well as in other specialties, that of preventing
complications and improving outcomes. This is particularly important in the light of
the very limited resources allotted to healthcare but with the expectation of a more
cost-effective treatment option. Improved outcomes, therefore, becomes a goal for all
management modalities to strive for.
Again, congratulations to FASE and more power in your future activities.
Professor & Dean
UP College of Medicine
Message from the
To my most beloved department in the Philippine
General Hospital, my sincere congratulations on its 50th
postgraduate course. The theme Innovations and Advances
in Surgery embodies the challenges the department will face
in the 21st century, shaping our commitment to being the
premiere surgical training institution in the country. As I look
back on the history of the Department of Surgery and refect
on its years of struggle and evolution, I cannot help but feel
a profound sense of pride at the distinction we have earned
as the maven and trendsetter for all surgical specialties.
This annual postgraduate course is a testament to
our enduring commitment to continuing surgical education,
training and research. We have set the pace and trend for
other institutions and remain to be the benchmark of excel-
lence. The department is blessed with a multitude of tal-
ent, skill and intellect. The departments capability to har-
ness this diversity and direct it all towards common shared
goals is its strength and the foundation on which it stands.
I am one with you in your aspirations and struggles,
as well as in your failures--however few they may be -- and
triumphs. The PGH remains steadfast in its support of your
goals and ambitions. Together we can accomplish much.
Philippine General Hospital
Message from the
Greetings to all participants of the 50th Post-
graduate Course of the Department of Surgery in co-
operation with the Foundation for the Advancement
of Surgical Education (FASE), Inc. The postgraduate
course, being the 50th, we felt it very appropriate to pre-
sent to you Innovations and Advances in Surgery.
We have lined up an array of topics from:
our roles and liabilities as Trainers in Surgery, up-
date on the management of different surgical condi-
tions and advances in minimally invasive surgery.
We have also lined up didactics on the different
specialties. As in the past, we will have our Meet the Pro-
fessor dinners and we continue to offer our short courses.
I hope you fnd our 50th Postgraduate Course: Mas-
tery in Surgery 2014 as interesting as our previous courses.
Foundation for the Advancement of
Surgical Educaiton Inc.

Message from the Chair
The Department of Surgery, UP-PGH is pre-
senting its 50th Postgraduate Course: Mastery in Sur-
gery 2014, Innovations and Advances in Surgery.
For 49 postgraduate courses, the UP-PGH Surgery
Department has been a partner with you, our partici-
pants, in your continuing professional development to-
wards lifelong learning in the art and science of Surgery.
For this 50th postgraduate course, the postgradu-
ate course committee has come up with another excel-
lent course on whats new and innovative especially with
the tremendous developments in minimal access surgery.
Aside from the lectures, we are again offering
Meet the Professor dinners where you will have sessions
with selected consultants where you can share your prob-
lematic cases with them and discuss treatment options.
We are also offering 4 workshops where you will learn
skills and management options of particular surgical conditions.
We know that all of us will learn a lot from this
50th offering of our postgraduate course and we hope to
see all of you again for the next 50 postgraduate courses.
Professor and Chair
Department of Surgery - UPCM
UP-Philippine General Hospital

Message from the
Post-Graduate Chair
In behalf of the Foundation for the Advancement
of Surgical Education, Inc. and the UP-PGH Department
of Surgery through the Post-Graduate Courses Commit-
tee, may I welcome you to our 50th Postgraduate Course,
Mastery in Surgery 2014 with the theme Innovations and
Advances in Surgery on September 3-5, 2014 at the Dia-
mond Hotel Manila. We are privileged to present to you a
scientifc program that involves the eleven divisions of the
Department of Surgery, UP-PGH. Expect extensive discus-
sions on theme-aligned issues in General Surgery as well
as Subspecialty Surgery. This will also include special ses-
sions by the Residency Training Committee (Session 1)
and the Research Committee (Session 13) of the Depart-
ment. You are also encouraged to participate in the four
simultaneous Meet the Professor Dinners for the chance
to have a close and informal small group discussion with
four General Surgery Professors. Four simultaneous short
courses on the third day will again be offered to participants
who are interested to have an additional course on any
of the topics designed to help them advance their knowl-
edge and skills needed in their day-to-day patient care. We
also enjoin you to attend the Fellowship Night for a night
of fun, food, drinks and games to commemorate the mem-
ories of the ffty postgraduate courses of the department.
Again, we hope that this years theme will be of great
help in your quest for mastery in the feld of surgery that is essen-
tial in the improvement of the overall management outcome.
May I thank all the members of the Postgraduate Courses
Committee for their sincere dedication and help in coming
up with this endeavor and most especially to our Depart-
ment Chair, Dr. Wilma A. Baltazar, Dr. Jose Macario V. Fay-
lona, Dr. Mark Richard C. Kho and the rest of the consultant
staff for facilitating the attainment of major logistical support.
Chairman Postgraduate Courses Committee
Department of Surgery
Philippine General Hospital
Clinical Associate Professor
UP College of Medicine

The Scientifc
Scientifc Session
Clinical Associate Professor
Division of Pediatric Surgery
Department of Surgery, UP-PGH
Early diagnosis of a childs lesion is critical be-
cause it will lead to proper management. These le-
sions were collectively known as hemangiomas, birth-
marks, portwine stains, etc. In the 1980s and 1990s,
these lesions were classifed into two general sub-
types: hemangiomas and vascular malformations.
The main difference between the two sub-
types was the natural history of the condition. He-
mangiomas have a natural regression history while
vascular malformations are permanent structures.
Hemangiomas are further subdivided into infantile
hemangiomas, congenital hemangiomas and deeper he-
mangiomas. Newer classifcations have been added since
the 1990s. Because of the natural regression history, it is
important for parents to understand that time will decrease
the size of the lesions. Presently, drugs like steroids and
propanolol are used to hasten the hemangiomas regression.
Vascular malformations are slow-fow mal-
formations or fast-fow lesions. Slow-fow lesions in-
clude capillary, lymphatic and venous malforma-
tions. However, these types of malformations can
be a combination of lymphatic and venous tissues.
Fast-fow vascular malformations in children in-
clude aneurysms, arteriovenous fstulas and arteriorvenous
malformations. Obviously, these fast-fow lesions have an
element of arterial supply. These lesions are more for the
realm of vascular surgeons and interventional radiologists.
The most helpful diagnostic stud-
ies for hemangiomas and lymphangiomas in-
clude ultrasound in its different guises and MRI.
Like a lot of diffcult congenital conditions in the
pediatric age group, the multidisciplinary approach to treat-
ment must not be ignored. Together with other specialists,
pediatric surgeons are usually involved in the diagnosis and
treatment of slow-fow vascular malformations. Depend-
ing on what type of lesion is present in the child, surgery
and/or sclerosants, embolization and lasers can be used.
Clinical Associate Professor
Division of Colorectal Surgery
Department of Surgery UP-PGH
The management of cancer in the colon and ano-
rectum has evolved with the advent of improved technology
resulting in better diagnostic imaging and use of advances in
equipment and knowledge to treat cancer. These include but
are not limited to: the multidisciplinary team (MDT) confer-
ence, neoadjuvant treatment, utilization of endoscopic treat-
ment, aggressive treatment of curative Stage IV disease and
enhanced recovery after surgery (ERAS).
The progress of the Multidisciplinary Team confer-
ence arose from the need to have all members of the medi-
cal team involved in the management of the patient to sit
down together to discuss and develop a treatment plan tai-
lored to a particular patient in accordance to his/her clinical
condition and stage of disease.

The use of Neoadjuvant Treatment, particularly the
combination of radiotherapy and chemotherapy for middle
and lower rectal cancer has resulted in improved survival
and lower recurrence rates. This is secondary to the up-
graded quality of diagnostic imaging modalities such as the
magnetic resonance imaging, computed tomography, endo-
rectal ultrasound and colonoscopy to better stage the dis-
The use of Endoscopy and Minimally Invasive Tech-
niques have revolutionized surgical procedures in the colon
and rectum. The advantage of using small incisions with the
capability of performing oncologic resections has resulted in
better patient tolerance for surgical procedures.
Curative Stage IV colon and rectal cancer patients have
more options available to them. The combination of multi-
visceral resections, chemotherapy and/or radiotherapy has
improved disease free survival for these set of patients.

Enhanced Recovery After Surgery is set to revo-
lutionize how a patient is managed peri-operatively. The
changes include Pre-operatively: fuid and carbohydrate
loading, no prolonged fasting, no or selective bowel prepa-
ration, and use of antibiotic and thrombo-prophylaxis. Intra-
operatively: use of short acting anesthetic agents and mid-
thoracic epidural anesthesia, no routine placement of drains
and maintenance of normothermia. Post-operatively: no na-
sogastric tubes, early removal of foley catheter, early insti-
tution of oral nutrition, early mobilization, use of non-opioid
oral analgesia or NSAIDs and stimulation of gut motility are
Clinical Associate Professor
Division of Colorectal Surgery
Department of Surgery UP-PGH
The following are the modalities to manage hemorrhoids
Type of
Indication Success Recurrence Complica-
Band Liga-
Grade I, II,
III internal
65-85% 68% at 4 to
5 years
dal artery
Grade II and
III internal
90% 10%
Grade II,
III and IV
same as
al excisional
Long term
and pro-
neal sepsis,
fstula and
The main goals of treatment are cure of the disease, preven-
tion of recurrence and maintain anal function.
Below are the options in the management of complex anal
fstula, except for fstulotomy for simple anal fstulas.
Type of Proce-
Recurrence Incontinence
Seton Insertion 16% 17%
70% none
Fibrin Glue 60-70% 11%
Fibrin Plug 15-80% 13%
Ligation of
Fistula Tract
56-90% Usually inter-
Clinical Associate Professor
Division of Colorectal Surgery
Department of Surgery UP-PGH
The benefts of minimally invasive surgery includes
reduced pain after surgery, accelerates post-operative re-
turn of bowel function and mobility, shorten hospital stay,
reduced formation of adhesions and decreased incidence of
incisional hernias.
The use of laparoscopic and robotic surgery has
extended its utility not only to benign conditions but also to
oncologic resections with equivalent results as with con-
ventional open surgery. The challenge in laparoscopic and
robotic surgery in colorectal surgery is working in several
quadrants of the abdomen. The indications for the use of
minimally invasive surgery in colorectal surgery includes di-
agnostic laparoscopy to stage and create stomas, for diver-
ticular disease, for colon and rectal cancer.
The use of minimally invasive surgery for colorec-
tal surgery should follow the traditional surgery principles
and standards. For colon and rectal cancer surgeries, there
should be complete exploration of the abdomen, adequate
proximal and distal margins, ligation of the major vessels at
its respective origin.
Clinical Associate Professor
Division of Colorectal Surgery
Department of Surgery UP-PGH
Hyperthermic Intraperitoneal Chemotherapy in-
cludes cytoreductive surgery to remove visible tumors intra-
peritoneally, followed by infusion of a highly concentrated,
heated chemotherapy delivered directly in the abdomen dur-
ing surgery. Heating the solution improves the absorption of
the chemotherapy drugs and destroys microscopic cancer
cells remaining in the abdomen after tumor debulking.
HIPEC is a treatment option for people who have
advanced surface spread of cancer within the abdomen,
without disease involvement outside of the abdomen.
Advantages of this procedure includes:
1. Allows for high doses of chemotherapy
2. Enhances and concentrates chemotherapy
within the abdomen
3. Minimizes the rest of the bodys exposure to
the chemotherapy
4. Improves chemotherapy absorption and
susceptibility of cancer cells
5. Reduces some chemotherapy side effects
Caustic injuries are tissue injuries caused by chemi-
cal reactions resulting from ingestion of caustic agents. It is
a public concern since caustic agents are widely available
as household and industrial cleaning products and that its
ingestion may result in signifcant morbidity and mortality. In
the US, 5-15,000 caustic ingestions occur per year with bi-
modal age distribution. Ingestions occurring in the 1-5 years
age group are frequently accidental while those occurring in
the 21 years age group are commonly intentional in nature.
The true prevalence in the developing countries is diffcult
to estimate due to under-reporting. In the Philippine Gen-
eral Hospital from 2008-2012, there were 195 adult cases of
caustic ingestion with mean age of 37. It is more common
in males (60%) than females (40%) and were intentional in-
gestions in 87% of the time with major depressive disorder
as the most common psychiatric disorder. Half of the cases
were due to acid (muriatic) and only about 35 % from al-
kali (liquid sosa) ingestion. Majority (75%) of the cases were
treated conservatively and surgical intervention were done
in the remaining cases with esophago-gastrectomy as the
most common procedure done. Operative mortality rate was
23% and an overall mortality rate of 7.2%.

The ingestion of caustic substances may result to a
wide spectrum of injuries from mild with no acute or chronic
sequela to severe and potentially fatal. In the acute setting,
caustic injuries are true surgical emergencies in the setting
of bleeding, necrosis, and/or perforation. The systemic con-
sequences in the acute setting are formidable, with patients
prone to fuid and metabolic disturbances, acidosis, sepsis,
coagulopathy, hemolysis, respiratory distress, and hepatic
and renal failure. In the long-term, patients face the chal-
lenge of gastrointestinal reconstruction, stricture, and the
attendant nutritional, metabolic, functional, psychological
and overall quality of life issues.
The best management of caustic injuries is preven-
tion. Strategies to avoid these injuries altogether include
preventative packaging and labeling, restrictions on potency
and availability, and injury prevention programs.
Caustic substances are generally classifed as acids
(pH <7) and bases (pH >7). Bleaches are also considered
caustic substances although pH is typically neutral in com-
mercial preparations. The extent of caustic injuries are de-
termined by several factors including the identity or nature
of the agent which is largely defned by its pH, volume in-
gested, concentration, physical state, duration of exposure,
and to some extent, the gastric status.
The substances that pose the greatest concern are
acids with pH <2 and bases with pH >12. Sulfuric and hydro-
chloric acids are acids commonly found in toilet and swim-
ming pool cleaners, rust removers, and battery fuids. Lye is
a general term that refers to bases, usually sodium or potas-
sium hydroxide, used as household cleaning products.
Acids cause coagulation necrosis which leads to
formation of coagulum or eschar in the superfcial layers.
Alkalis, on the other hand, lead to liquefactive necrosis with
saponifcation of facts, dissolution of proteins, and emulsif-
cation of cell membranes. Due to these differences in patho-
physiology, it is generally held that acids produce injuries
with limited depth whereas alkalis produce deeper injuries.
However, while this may be true for mild acids and bases,
strong bases and acids may also lead to deep tissue injuries.
With acids, the formation of eschar leads to hypoperfusion
of surrounding tissues thereby predisposing to ischemia.
Alkalis cause thrombosis of adjacent vessels leading to
necrosis. Extent of injury with acids is usually determined
within 48 hours. Acids generally cause more injuries in the
stomach than the esophagus while the reverse is true for
bases. With acids, the formation of superfcial coagulum in
the esophagus and the partial neutralization by the alkaline
pH of the esophagus limit the injury to the esophagus. Acids
induce pylorospasm causing pooling in the stomach leading
to greater injury. The increased viscosity of bases increases
contact time with the esophagus causing more injury. Acids
are noxious, have poor taste, and tend to evoke protective
responses hence limiting the volume ingested. However,
they predispose to aspiration leading to more respiratory
complications. Alkalis are tasteless and odorless and do not
tend to evoke protective responses causing greater volume
to be ingested. Acids, having more systemic absorption,
have greater systemic complications including metabolic ac-
idosis, hemolysis, disseminated intravascular coagulation,
liver failure and renal failure. Hydrofuoric acid in particular
causes profound hypocalcemia and hypomagnesemia.

The physical form of the caustic substance, whether
solid or liquid, determines the pattern and distribution of in-
jury to GI tract. Solids are more diffcult to swallow and tend
to adhere to mucosa. Hence, injuries are found more proxi-
mally (mouth, pharynx, and upper esophagus) and tend to
be focal and deep. Liquids tend to travel more distally hence
causing more injuries to the esophagus and stomach. Inju-
ries from liquids are usually circumferential and diffuse.
Concentration of acids and bases are directly pro-
portional to extent of injury. In rat esophagus model, ex-
posure to sodium hydroxide at 1.83% concentration causes
epithelial necrosis alone whereas concentration of 14.33%
leads to full thickness injury.
Similarly, the greater the quantity ingested, the
greater the injury. Several factors infuence the quantity in-
gested. Intentional ingestions, acids, and liquid substances
correlate with greater volume ingested.
Longer duration of exposure to the caustic sub-
stance likewise increases injury risk. Rapid transit of acid
through esophagus due coagulum contribute to limited es-
ophageal injury. The esophagus has increased exposure to
alkali due to repeated episodes of regurgitation. Acids in-
duce pylorospasm causing delayed emptying of acids from
the stomach, thereby increasing gastric injury and limiting
damage to the duodenum.
To some extent, the status of the stomach during
ingestion infuences extent of injury because of the buffering
effect of food. With an empty stomach, the gastric mucosa
along the lesser curvature and antrum are most at risk. With
a full stomach, gastric injury tends to be diffuse.
Burns of the GI tract due to caustic ingestion are
defned by degrees according to depth of injury. 1st degree
burns involve the mucosa only whereas 2nd degree burns
extend to the muscularis layer. 1st degree burns heal com-
pletely without stricture whereas 2nd degree burns have risk
for stricture formation. 3rd degree burns are full thickness
injuries with or without perforation. They are at highest risk
for perforation and stricture formation. Extent of injury is as-
sessed endoscopically using Zargars endoscopic grading.
Degree of esophageal injury at endoscopy is an accurate
predictor of systemic complications and death with each
increased injury grade correlated with a 9-fold increase in
morbidity and mortality. 30% of grade 2 and 80% of grade 3
injuries will develop strictures.
Oropharyngeal injury is not a reliable indicator of es-
ophageal involvement as 70% of those with oropharyngeal
burns have no esophageal burns and 10-30% of those with
esophageal burns have no oropharyngeal burns. Extensive
esophageal damage is usually coupled with laryngeal injury
and upper airway edema. Supraglottic or epiglottic burns are
harbingers of airway obstruction.
Caustic substances induce acid-base reactions that
cause injury by disruption of organic macromolecules, heat
generation, and further production of toxic chemicals such
as oxygen radicals, sulfdes, nitric/nitrous oxide, chlorine,
and others. There are 3 phases of caustic injury. In the ini-
tial phase, lasting 1-4 days, acute necrosis occurs with eo-
sinophilic necrosis, hemorrhagic congestion, lipid peroxida-
tion, and vascular thrombosis. At 4-7 days, granulation and
ulceration occurs. This phase is characterized by mucosal
sloughing, bacterial invasion, formation of granulation tis-
sues, and appearance of fbroblasts with fbrin formation. If
ulceration exceeds the muscle plane, perforation is likely to
occur. The last phase is characterized by cicatrization and
scarring. At 2 weeks, collagen deposition begins and at 1
month, ulcers start to epithelialize. Scar retraction begins as
early as 3 weeks and may last up to 6 months. 6-12 weeks
is the average time for full fbrosis to be achieved. Tissue
tensile strength is low during the frst 3 weeks and perfora-
tion can occur at any time during the frst 2 weeks. Hence,
endoscopy is avoided 5-15 days after injury. Strictures may
occur as early as 3 weeks or as late as 1 year. Majority
(80%) occur within 8 weeks. The resultant lower esophageal
sphincter pressure impairment and shortening of involved
esophagus increase gastroesophageal refux that further
contributes to stricture formation.

The anatomic areas of GI tract narrowing are most
at risk for acute and chronic injuries from caustic ingestion
due to delayed transit in the area thereby increasing contact
time. In the esophagus, these areas are the cricopharyn-
geus, level of aortic arch and left mainstem bronchus and
the lower esophageal sphincter. In children, injury in the
upper esophagus is more likely due to compression by the
thymus. In the stomach, injury commonly occurs in the py-
loroantral area.

The esophagus is unique from the rest of the GI
tract in that it lacks a serosal layer. It is located in the pos-
terior mediastinum with close anatomic relations to the tra-
chea, the L mainstem bronchus and aorta. Perforation of the
thoracic esophagus can cause life-threatening mediastinitis.
The adventitia of the anterior wall of the cervical and up-
per thoracic esophagus is attached to the connective tissue
of the posterior wall of the trachea which is membranous
due to the incomplete tracheal rings at its posterior aspect.
Extensive necrosis of the upper esophagus can involve the
trachea to cause necrosis and tracheoesophageal fstula.
The descending aorta is closely related to the posterolateral
aspect of the middle to lower thoracic esophagus. Extensive
necrosis of the esophagus in these areas can cause aortoe-
sophageal fstulas. Extreme care must be exercised when
mobilizing the thoracic esophagus during resective proce-
dures for strictures to avoid injuries to the tracheobronchial
tree and aorta.
Close proximity of the stomach to other intraab-
dominal organs such as the colon, pancreas, spleen , left
lobe of the liver, left kidney and left adrenal may necessitate
multivisceral resection in the setting of extensive necrosis
with extensions to these organs. With acid ingestions, the
duodenum is protected by pylorospasm and the alkaline pH.
However, in 34.6% of acid ingestions, grade I/II duodenal
injuries may occur. For injuries that extend beyond the py-
lorus, the ampulla of Vater may be involved hence concern
for drainage of the common bile duct and pancreatic duct.
The systemic complications of caustic injury are brought
about by complex interplay of interrelated pathways asso-
ciated with infammation. Central to the pathophysiology
of systemic complications in caustic injury is the systemic
infammatory response (SIRS) which can lead to multiple
organ dysfunction syndrome (MODS), and ultimately multi-
organ failure (MOF) in severe cases even in the absence
of infection. With infammation comes the activation of in-
fammatory cells, cytokine release, generation of free radi-
cals, and changes in vascular permeability and tone. Fluid
sequestration with third-spacing in addition to GI losses (e.g.
vomiting), bleeding, and inability to take fuids orally predis-
pose patient to hypovolemia and shock. Tissue ischemia
and necrosis lead to decrease in serum bicarbonate and in-
crease in lactate causing metabolic acidosis. Presence of
shock also contributes to acidosis. Ischemic and necrotic
tissues can promote bacterial translocation and overgrowth
which can lead to sepsis. Respiratory complications can
arise in the setting of direct injury, aspiration, or pulmonary
edema from third spacing. Systemic absorption particularly
with acids can lead to coagulopathy, hemolysis, acidosis,
and renal and liver failure.

Long-term complications are formidable and in-
clude strictures, gastroesophageal refux, fstulas (tracheoe-
sophageal, gastrocolic), and cancer. Recurrent pulmonary
infections should raise suspicion of tracheoesophageal fs-
tula. Risk of cancer, commonly esophageal squamous cell
carcinoma, is increased by 1000-3000 times relative to the
general population. The long latency period (10-25 years)
requires surveillance long after the caustic ingestion event
(15-20 years later).
Patient who ingest caustic substances have a di-
verse range of clinical presentations. The initial symptoms
upon presentation are not directly correlated to the degree of
injury. Patients may present with pain in the oropharyngeal,
retrosternal and epigastric areas. They may also complain
of dysphagia, odynophagia, drooling, excessive salivation,
vomiting and hematemesis. Severe retrosternal or back pain
may signal mediastinitis or esophageal perforation. There
may also be direct and rebound tenderness on abdominal
examination. Hoarseness, wheezing and shortness of breath
may occur with injury to the larynx and epiglottis. Fever and
hemodynamic instability indicate extensive injury. Morbidity
and mortality are proportional to the degree of injury.
Upon consult at the ER for caustic ingestion, a thor-
ough evaluation is done. PGH has a unique set-up for the
multidisciplinary management of caustic ingestion and the
team is activated at the ER comprising of the Department
of Surgery, Section of Gastroenterology for endoscopy, De-
partment of Psychiatry for non-accidental cases and the Na-
tional Poison Management and Control Center. The patient
is kept on NPO, and an intravenous line is inserted for fuid
resuscitation. Acute care for caustic ingestion is similar to
management of other injuries. Patients with oropharyngeal
injury must be carefully assessed for airway obstruction; la-
ryngoscopy must be done to check for swelling of the larynx
and epiglottis. If these are present, it is recommended to
maintain the airway with a tracheostomy rather than by en-
dotracheal intubation. It is noteworthy, however, that the ab-
sence of pain does not preclude signifcant gastrointestinal
For stable patients not in surgical abdomen, a chest
X-Ray upright is done to evaluate for pneumomediastinum
and pneumoperitoneum, indicating esophageal or gastric
perforation. To confrm equivocal fndings, an esophago-
gastric or upper GI series with water soluble contrast may
be carefully attempted. Arterial blood gas analysis is done,
and if metabolic acidosis is present and surgery is indicated,
patient is given aggressive resuscitation, however, it is not
necessary to wait for the acidosis to be fully corrected since
this can be corrected only by removal of all necrotic tissues.
In general, there is no need for oral dilution of the
ingested acid or base. Neutralization of pH with acid or al-
kaline lavage must not be attempted as this may cause exo-
thermic reaction, and may cause further thermal injury. Blind
NGT insertion is also contraindicated.
Endoscopy is the gold standard for assessing depth
and extent of injury, and determining appropriate therapeu-
tic action. There are reports suggesting that asymptomatic
patients who have ingested low potency substances do not
require endoscopy. However, most adult patients who ingest
caustic material with suicidal intentions usually take very
potent substances, and therefore, emergent endoscopy is
recommended for all patients. Upper GI endoscopy must be
performed within 24 hours of ingestion of caustic substance.
EGD must be avoided during days 5-15 post ingestion due
to wound softening due to absence of collagen. Endoscopy
is contraindicated in the following conditions: hemodynami-
cally unstable patients, patients with suspicion of perfora-
tion, patients in severe respiratory distress, and patients with
severe pharyngolaryngeal edema or necrosis.
Zargars grading classifcation of mucosal injury
caused by ingestion of caustic substances
0 Normal
1 Superfcial mucosal edema and ery-
2 Mucosal and submucosal ulcerations
2A Superfcial ulcerations, erosions and
2B Deep discreet or circumferential ulcera-
3 Transmural ulcerations with necrosis
3A Focal necrosis
3B Extensive necrosis
4 Perforation
Minimal mucosal damage is associated with minimal
morbidity and mortality with low risk for developing strictures.
Injuries exceeding grade 2A are at higher risk of developing
serious complications. Grades 2B and 3 may warrant care-
ful observation, ideally in an ICU, and nutritional support. If
they remain stable with resolution of abdominal pain, feed-
ing may be gradually progressed starting with water intake
if they are able to swallow saliva after 48 hrs of ingestion.
Patients with clinical or radiologic evidence of perforation re-
quire immediate laparotomy.
Surgical management of caustic injury is affected
primarily by the severity and extent of injuries. However,
the corrosive properties of the ingested substance and its
amount and concentration as well as the duration of contact
in the gastrointestinal tract are all predictors of surgical out-
The main principle in the surgical management aims
to do an adequate resection or debridement thereby remov-
ing ALL necrotic tissue and preserving all viable tissues. A
comprehensive abdominal exploration is mandatory if signs
and symptoms of perforation and ongoing tissue necrosis
are evident. In patient with severe post corrosive injury or
with grade IIIB on endoscopy, prompt surgical intervention
in patients have shown to decrease morbidity and mortality.
Extent of surgical resection is based on the extent of injury.
Extensive debridement of necrotic tissue is required in pa-
tients with multiple and complex perforations.

A study conducted in UP-PGH from 2009-2013
which included 195 cases of caustic injury showed a major-
ity of non-surgical cases and only 28.7% were managed sur-
gically. Common surgical options in the acute setting include
the following 1) Exploration, Esophagogastrectomy with cer-
vical esophagostomy, 2) Exploration, Esophagogastroduo-
denojejunectomy with tube pancreatostomy, 3) Exploration,
gastrectomy with abdominal esophagostomy. Placement of
a tube jejunostomy after extensive surgery to initiate early
enteral feeding is recommended. Drain placement such as
bilateral tube thoracostomy in the chest and Jackson pratt
drain in the abdomen are routine and recommended.
The potential catastrophic presentation and lifelong
complications following caustic ingestion remains to be a
socioeconomic burden and a challenging encounter in the
surgical practice. Moreover, prevention plays a role in ad-
dressing this problem by means of preventive strategies and
early recognition of psychosocial distress since most of the
cases we have encountered are non-accidental
Chronic sequelae of caustic injuries include es-
ophageal stricture, gastric stricture, esophageal cancer, and
trachea-esophageal fstula.
Esophageal strictures are primarily seen in those
with grade 2B or 3 injury, with peak incidence of two months,
and occurs as early as two weeks or as late as years af-
ter ingestion. The management include balloon or bougie
dilatation, or in cases of refractory strictures, stents which
are kept in place for a period of time. Intraluminal steroids
also show some beneft in the management of esophageal
strictures. Surgical management includes esophagectomy
with reconstruction by colonic interposition graft, and gastric
Gastric stricture or gastric outlet obstruction usually
presents with early satiety and weight loss, observed from
5-6 week up to several years after ingestion. Feeding je-
junostomy can be used to improve the patients nutritional
status and ensure the success of surgery. Distal gastrecto-
my and gastrojejunostomy are usually done for antropyloric
strictures, subtotal gastrectomy or total gastrectomy usually
are done for those with extensive disease.
Caustic injuries usually present with 1000 to 3000-
fold increase in incidence of esophageal cancer with mean
latency of 41 years (13-71 years).
Tracheo-esophageal fstula are rare complications
of caustic ingestion. They present around 2 weeks post in-
jury. Diagnosis through chest CT and contrast studies can
confrm the fstula. Timing of surgery ranges from 6 months
to 1 year. Surgical management includes direct repair, clo-
sure of stricture, tracheal resection, and reconstruction, with
a mortality rate of 8.3% for single stage repair. Nonsurgical
management usually carries a poor prognosis.
Majority of the complications of caustic injury are de-
tected late. Diligent and timely follow up is required to ensure
such late appearing sequelae are caught early. The most
complications include esophageal stricture, gastric outlet
obstruction, esophageal neoplasm and tracheoesophageal
Timely evaluation and dilatation of strictures play a
central role in achieving good outcome. Late management
is usually associated with marked fbrosis rendering the pro-
cedure diffcult. Delayed intervention has been proven to be
strong predictor of future esophageal replacement.
The risk of developing carcinoma in a strictured es-
ophagus is 100-1000x higher than the general population
and is usually seem at the location of the stricture. Hence,
long term annual follow up is recommended. For patients
who have developed long term sequelae of caustic injury,
swallowing and speech rehabilitation are paramount strate-
gies to alleviate debilitating effects of caustic injury.
Each patient must be evaluated individually. And
although the late sequelae of caustic injury follow a predict-
able pattern, clinical picture varies widely. Both acute and
chronic phases of caustic injury require different approach-
es. Finally, great attention should be given even to low grade
injuries because of the potential devastating complications.
Clinical Associate Professor
Division Plastic and Reconstructive Surgery
Department of Surgery UP-PGH
Microtia is a term that encompasses a condi-
tion that presents as a congenitally small external ear or
auricle. It may occur in different variations ranging from
just a small ear to complete absence of the ear or anotia.
A brief description of the pathogenesis, prevalence and
different types of microtia, as well as history of the develop-
ment of current techniques in reconstructive plastic sur-
gery of the external ear shall be discussed. At present, the
major options of reconstruction are: 1) Autologous - using
the patients own rib cartilage for the framework, usually
completed in 2 stages and 2) Alloplastic using porous
polyethylene implant, done in a single stage. In addition,
innovations such as the use of 3dMD technology (for ear
template fabrication) and future directions in the feld of
tissue engineering (prefabricated biologic ear frameworks)
shall be presented.
General Objectives:
To be able to identify and classify different types of microtia/
congential ear deformities.
To be able to provide microtia patients different reconstruc-
tive options (autologous/ alloplastic) aside from the use of a
prosthetic device.
To know current innovations and future directions of ear
Clinical Associate Professor
Division of Trauma
Department of Surgery UP-PGH
The Division of Trauma of the UP-PGH, since its
establishment in September 1989, as the frst Trauma Unit
dedicated to the care of the injured patients in the country,
has had a rich track record of leadership in innovations and
local adaptations of various approaches in Trauma Care.
From specifc management of injuries to the neck, chest,
and abdomen, to innovative perspectives and exploratory
approaches in resuscitation, to endeavours in promoting
various advocacies in injury prevention and trauma care,
the session discussants will describe and look back on the
signifcant innovations of the Division, as well as move for-
ward to expound on current novel issues.
Clinical Associate Professor
Division of Transplant Surgery
Department of Surgery UP-PGH
In recent years, we have witnessed increasing clini-
cal experience with intestinal transplantation with concomi-
tant improved results. Several important advances have led
to improved outcomes which include newer immunosuppres-
sive drugs, improved technical skills and perioperative care.
As a result, the rate of patient survival at 1 year now exceeds
90% at experienced centers. Although long-term follow-up
data are still lacking, the role of intestinal transplantation in
the treatment of patients with gut failure is becoming clearer.
This presentation will touch on the essential principles and
concepts, indications as well as common complications of
intestinal transplantation and will be highlighted by discuss-
ing the frst case of isolated intestinal transplantation in the

Living donor organ transplantation (LDOT) has
made headway in many Asian countries because of the
con- stant undersupply of grafts from deceased donors. Al-
though deceased donor organ transplantation was started
relatively early in Asia, deceased donor organ rates in this
region are among the lowest in the world.1 The reasons for
this low deceased donor organ donation rate are multifac-
torial. As a natural response, increas- ing applicability was
found for LDOT in solid organ transplantation as the need
for alternative sources of organs increased because of the
exponential demand for organ replacement.
With the development of organ transplantation in
Asia, problems, mainly focused on ethical concerns about
the use of live donors, have arisen. The Council of Europe
recognized the rapid increase in the demand for organ do-
nation and its attendant concerns not only in continental Eu-
rope but also throughout the world. Or- gan traffcking has
become a primary concern for both deceased donor organ
transplantation and LDOT. Eth- ical, moral, and social ques-
tions arise as a result of poverty woes that condone organ
and human traffck- ing. This disapproval was heralded by
the Uniform An- atomical Gift Act of 1984 (as amended in
1987) and again reiterated by the World Health Organization
in 1994.
What makes Asia different from its Western coun-
ter- parts? For most Asian countries, religion, society, and
organ donation are intertwined. Because of its existen- tial
character, organ transplantation is strongly con- nected to a
persons view of life, which infuences deci- sions in trans-
plantation medicine. These decisions would beneft from a
consideration of the complexity of religious views when we
are striving for informed con- sent as participative involve-
ment.2 As the worlds major religions and those practicing
religious belief are found in Asia, the peoples resilience
against breaking away from centuries-old traditions and cul-
ture may, in part, contribute to the current problems. Reli-
gion is a very infuential aspect of human life in Asia and
continues to play a major role in issues of health, safety, and
mor- tality. Understanding religious beliefs in Asia is one of
the many issues that ethicists in organ transplantation must
resolve. Buddhists largely believe that organ do- nation is a
matter left to the individuals conscience. Hindus, although
not prohibited from donating their organs, likewise believe
that organ donation is a matter of personal choice. In Ja-
pan, where Shinto is the na- tional religion, the dead body is
considered impure and dangerous, and thus injuring a dead
body is a serious crime. It is diffcult to obtain consent from
bereaved families for organ donation, dissection for medi-
cal ed- ucation, or pathological anatomy because Shintos
re- late donation to injuring a dead body. This is one reason
for the very low deceased donor organ donation rate in Ja-
pan. For many religious Muslims, a sigh of relief came only
in 1988 when the Islamic Fiqh Academy (Majmaal-Fiqh al-
Islami) approved in principle guide- lines that would permit
organ transplants. However, some traditionalists question
these guidelines as it is a well-established principle of Sha-
riah that all organs of the human body, whether the person
is Muslim or not, are sacred and must not be tampered with.
In Egypt, for example, brain death criteria are not accepted,
and only organs acquired from living donors can be used
for transplants3; in Iran, legislation accepting brain death
and allowing deceased donor organ transplantation was
passed only in April 2000.4 For most ethnic Chi- nese, the
Confucian view on social relations, which focuses on self-
cultivation, may relegate the virtues of love and compassion
to organ donation. For most Christians, the largely Catholic
Philippines is a para- dox. Although people are encouraged
by the Vatican to view organ donation as an act of charity,
deceased do- nor organ donation remains low in the Phil-
ippines. In great contrast, deceased donor organ donation
thrives in Western countries in which religious beliefs may
play secondary roles.
Taiwan is an example among Asian countries in
which legislation has played a signifcant part in the matura-
tion of transplantation. The frst successful deceased donor
liver transplant in Asia, performed by Chao-Long Chen in
1984, stirred discussions about what consti- tutes a defni-
tion of death.5 The debate eventually ended with the frst
organ transplant law in Asia with a defnition of brain death
in 1987.6 Legislation and ed- ucation play important roles
in promoting and safe- guarding organ donation. There are
only a few coun- tries in Asia in which laws pertaining to or-
gan donation are in effect (Table 1).
However, legislation may not be the obligatory an-
swer. In a survey of ethical issues of organ transplan- ta-
tion in Taiwan and mainland China, Shih and col- leagues7
identifed 7 major ethical dilemmas, including diffculties in
touching the heart of the public, chal- lenges in helping do-
nors and their families, the compe- tence and availability of
health professionals, question- able social farewell or death
for deceased donors, recipients, and their families, the ques-
tionable legiti- macy of prisoners motivations with death
penalties, worry about public discrimination, and challenges
to families taking care of the recipients. Understanding these
dilemmas and working through the networks of legal and so-
cial procedures will make the public appre- ciate the value of
organ donation. In Korea, sociocul- tural barriers attributed
to Confucianism, clarity con- cerning the defnition of brain
death, and myths about selling spare organs contribute to
low deceased donor organ donation rates. These barriers
are compounded by bureaucratic problems due to policy
changes con- cerning organ procurement and insurance
coverage.8 The same problem is also true in most regions
of East Asia. In China, Malaysia, and Vietnam, sociolegal
fac- tors have a greater impact on organ donation. The Vice
Minister of Health of China reiterated this concern when
he admitted that shortcomings in legislation, dis- parities in
technical competency, a lack of a well-orga- nized adminis-
trative system, and cost had resulted in rampant disenfran-
chisement of would-be recipients and donors.9 Malaysias
development of organ trans- plantation is hampered by its
conservative outlook, cul- ture and value system, historical
background and reli- gious convictions, and lack of legisla-
tion.10,11 The Health Ministry of Vietnam has acknowledged
the need for a separate organ transplant law, and its parlia-
ment is debating the core issues.
Poverty is number 1 among the reasons for selling
organs in the Philippines and Pakistan. The concept of altru-
ism is challenged in the Philippines, as a recent study showed
that 25% of the surveyed population ac- cepted the idea of
compensated donation, and giving compensation does not
ultimately equate with commer- cialization.12,13 As early as
1988, Iran adopted a com- pensated living unrelated donor
transplantation pro- gram, mainly for kidney transplants. In
this program, many ethical problems that were associated
with paid kidney donation were prevented. Currently, Iran is
the only country with no renal transplant waiting lists, and
more than 50% of patients with end-stage renal disease
have functioning grafts.4 However, even developed coun-
tries have their problems. In Japan, there is still a cultural
confict due to a lack of understanding and acceptance of
organ donation for transplantation on account of health pro-
fessionals lack of specifc educa- tion and low confdence in
donation-related tasks and disbelief in the concept of brain
death.14,15 In the 10 years since legislation on brain death
and organ dona- tion was passed in Japan, fewer than 60
deceased do- nor organs have been used.
We take, for example, the growing need for liver
transplantation. Rates of living donor liver transplantation
have increased exponentially, whereas rates of de- ceased
donor liver transplantation have remained low1,16 except in
China in the last 2 years with the promulgation of new Chi-
nese organ transplantation laws in 2007. Recent reports of
donor deaths have drawn heavy criticism about sacrifcing
healthy donors in an attempt to save acutely ill patients. This
is the reason that donor safety should remain the highest
priority in any living donor liver transplantation proce- dure.
The Vancouver Forum was specifcally held to present de-
fnitive and timely statements regarding the responsibility of
the transplant community to the live organ donor.
The ethical principles governing live donor organ
dona- tion rest on 2 major issues: the autonomy of the deci-
sion to donate based on informed consent and the safety
of the operation. There should be no coercion of the donor
in any form. The ethical dimension of equi- poise mandates
that with risk-beneft analysis, the risk to the donor must
balance the beneft to the recipient, the urgency of the re-
cipients need, and the resultant donor satisfaction from the
long-term survival of the recipient. The objective of avoid-
ing and minimizing any potential risk to the donor can be
summarized in 2 centuries-old sayings: primum non nocere
(frst, do no harm) and primum succurrere (frst, do help).
A thin line will always remain between donor safety and live
donor transplantation. The risks to the donor are mainly
physiological and psychological in nature and include risks
associated with any surgical procedure, insuffcient physio-
logical function after donation, the possibility of life-threaten-
ing complications, risks asso- ciated with blood transfusion,
and unknown long-term risks.
Center surgical expertise, adequate resources, es-
tab- lishment of an appropriate informed consent process,
and foresight are prerequisites for starting an LDOT pro-
gram. Surgical expertise and adequate resources make
living donation safe with minimal mortality and acceptable
morbidity and thus justifable in societies in which the de-
mand for transplantation is great and the deceased donor
organ donation rate remains low. The ethical justifcation for
living donation may become eth- ically unacceptable and un-
thinkable for competent centers if they deny this access to
needy patients.
To act conscientiously within the boundaries of what
is ethically, morally, and legally acceptable in society re-
quires vigilance. To improve ethical standards and increase
organ donation rates, we need to promulgate new laws and
amend existing laws to be in tune with current practices, im-
plement and regulate these laws, educate and disseminate
information, advocate for na- tional registries, adhere to in-
ternationally accepted standards, and promote advocacy
groups in both gov- ernment and private sectors. These pri-
mary principles and concerns are outlined in the Declaration
of Istan- bul on Organ Traffcking and Transplant Tourism.
The ethical principle of utility is enhanced by LDOT
because it has the potential to optimize the effcient use of
organs and to increase the availability of de- ceased donor
organs.20 In most countries, living do- nation is regulated by
law to include only relatives, spouses, or in-laws. In Western
countries, even close friends can be solicited as donors.21
Most Asian countries follow the former norm, except for Hong
Kong and Korea, in which a close relationship be- tween the
live donor and recipient may be accepted as a reason for do-
nation. Living paired-exchange dona- tion is also acceptable
in Korea. Taiwans legislation on human organ transplanta-
tion, for example, is strict, specifcally defning those eligible
for living do- nor organ donation and including the recipients
spouse and relatives within a ffth degree of consan- guinity.
Furthermore, it defnes a spouse to be one who has given
birth to at least one child with the potential recipient or one
who has a legal marriage with the recipient for at least two
years. However, if the indication for transplantation is diag-
nosed at a time when a legal marriage has existed for more
than one year the spouse is eligible for organ donation.
Some believe that a regulated market is an ethical
vehicle for shortening waiting lists and decreasing illegal or-
gan sales. This concept forms the basis for compensated
living donation in Sweden,2 3 nondi- rected kidney donation
from living unrelated donors in the Philippines,24 and com-
pensated and regulated unrelated living donor transplanta-
tion in Iran.4 With increasing interest in reimbursement for
living organ donation, altruism may become an unsuccessful
doc- trine as patients and healthcare providers are looking
for a pragmatic approach. The approach is strikingly seri-
ous in Europe; a study conducted in Cyprus, Ger- many,
the Netherlands, and Sweden on values con- cerning the
commercialization of organ donation showed that different
models of fnancial incentives played crucial roles in the par-
ticipants values and ideas about organ donation and drew
particular at- tention to the central role of reciprocity.
Even transplant coordinators face ethical concerns.
In a study comparing Japan and the United Kingdom, trans-
plant coordinators in the 2 countries were found to share
common dilemmas regarding potential is- sues of coercion
as well as compensation and rewards in living related and
living unrelated donations.
In summary, the ethics of live organ donation in
Asian countries are dictated by their needs. In a region in
which the supply of deceased donor organs is low, LDOT
will continue. The highest medical and ethical standards in
its practice must be continually empha- sized.
Clinical Associate Professor
Division Thoracic and Cardiovascular Surgery
Department of Surgery UP-PGH
Liver transplantation (LT) is not just a medical is-
sue but a social interest as well. The number of manpower
hours lost due to frequent hospitalizations, infections, and
disease progression by a working class patient who needs
liver transplant translates to millions of dollars. It is also not
just a private matter between physician and patient but be-
comes a social responsibility because of the involvement
of a third party-the donor. Whether the liver allograft comes
from a deceased or living donor, the state or society has the
responsibility of promoting as well as protecting the source
because it is for the common good.
The frst successful LT with extended survival in
Asia was performed in an adolescent with Wilsons disease
complicated by end-stage liver cirrhosis in 1984. The longest
Asian survivor, also with Wilsonian cirrhosis, has now been
living for 25 years. Initially, living donor liver transplantation
(LDLT) was performed only in pediatric recipients using a
left lateral segment graft. With experience, the indications
for LDLT have been extended to adults where a right lobe
graft is mainly used due to volume requirement.
Hepatitis virus-related liver cirrhosis with or without
hepatocellular carcinoma (HCC) is now the most common
indication for adult LT. Protocols in preventing posttransplant
hepatitis B virus (HBV) recurrence by using pretransplant
lamivudine and/ or adefovir or entecavir, preventing de novo
HBV posttransplant when using HBV core antibody positive
donors by lamivudine and immunization, and preventing
hepatitis C virus recurrence by using pegalyted interferon
and ribavirin are widely used. The Australasian Liver Trans-
plant Study has shown the effcacy of low-dose hepatitis B
immumnoglobulin in preventing HBV re-infection posttrans-
plant thus decreasing total cost in the management of these
LT now offers the best chance for cure for selected
patients with unresectable HCC. But not all patients with un-
resectable HCC are suitable to be transplanted. Improved
outcome of LT for HCC greatly depends on recipient selec-
tion and accurate tumor staging. Both rely heavily on diag-
nostic imaging. The role of adjuvant and neoadjuvant treat-
ments needs further evaluation in the overall objective of
disease removal and liver replacement.
Because the Milan criteria have been considered
restrictive criteria whereby transplantation may be denied
to an HCC transplant candidate whose outcome may oth-
erwise be acceptable, the University of California San Fran-
cisco (UCSF) and Pittsburg criteria were developed. The
Japanese experience in LDLT for HCC has shown that
some patients transplanted for HCC beyond Milan criteria
have survival rates similar to those within Milan; and spe-
cialists argue that tumor biologic behavior is more important
rather than size and number which are often over-estimated
by imaging methods. Specialists advocate to an expanded
criteria. Novel approaches to down-staging tumors initially
beyond the Milan criteria are now being evaluated using
loco-regional therapies like transarterial embolization, per-
cutaneous ethanol injection, and radiofrequency ablation or
a combination of strategies.
LDLT is now an acceptable treatment modality for
HCC. There are no concensus accepted criteria for the use
of LDLT for HCC. Centers offering LDLT use currently ac-
cepted criteria in deceased donor LT or adopted their own
criteria. The Milan criteria have been expanded to UCSF,
Pittsburgh, Tokyo, Kyoto, Asan, and Hangzhou criteria.
Cumulative data in the past 20 years have shown an
increasing survival after pediatric solid organ transplantation.
In LT, the most common indication for transplant is biliary
atresia followed by metabolic diseases of the liver. Survival
rate in excess of 80% at 2 years is a common achievement
with current transplantation practices. In LT, judicious re-
cipient and donor selection, careful preoperative planning,
excellent anesthesia management, prompt detection and
treatment of complications and improved use of immuno-
suppresion have resulted to long-term survival among trans-
planted children. As a result, we are becoming more aware
of the late complications of LT in children. As compared to
adults, children have much less morbidity and mortality from
recurrent disease, but, because they require immunosup-
pression throughout the critical phases of growth and devel-
opment, the spectrum of late complications is dominated by
consequences of long-term immunosuppression.
However, data from the U.S. Organ Procurement
and Transplant Network showed that better early patient
and graft survivals do not equally translate to late patient
and graft survivals. This is due to a. immunosuppression
choice that affects the graft, b. late graft failure mechanism
unrelated to immune injury, and c. inadequate immunosup-
pression due to minimization strategies and non-adherence.
Renal dysfunction remains to be the foremost concern in
liver transplantation that affects survival pre- and posttrans-
plant because a. pretransplant renal dysfunction correlates
with post LT outcome, b. pre renal dysfunction may dictate
post LT immunosuppression, and c. early introduction of cal-
cineurin inhibitors may worsen long-term renal dysfunction.
The other critical care unit concerns that infuence
recipient survival in the ICU include: 1. induction therapy with
basiliximab, 2. choice of calcineurin inhibitor, including dose
reduction, 3. management of gastrointestinal disorders, 4.
mechanical ventilator use, 5. replacement of inadequate cir-
culating volume, 6. treatment of infections, and 7. early iden-
tifcation of surgically correctable problems (hepatic artery
thrombosis, portal vein thrombosis, bile duct stenosis and
leakage, hepatic vein stenosis).
Late posttransplant period should focus on adverse
effects of calcineurin inhibitors (dyslipidemia, proteinuria,
pulmonary toxicity, oral ulcers), development of new-onset
diabetes mellitus, cardiovascular events and hypertension.
Clinical Associate Professor
Division of Transplant Surgery
Department of Surgery UP-PGH
Intestinal and multivisceral transplantation has
evolved from an experimental procedure to the treatment of
choice for patients with irreversible intestinal failure and seri-
ous complications related to long-term parenteral nutrition.
Increased numbers of transplant recipients and improved
survival rates have led to an increased prevalence of this
patient population in intensive care units. Management of
intestinal and multivisceral transplant recipients is uniquely
challenging because of complications arising from the high
incidence of transplant rejection and its treatment. Long-
term comorbidities, such as diabetes, hypertension, chronic
kidney failure, and neurological sequelae, also develop in
this patient population as survival improves. Herein we pre-
sent the essential principles in the intensive care manage-
ment of intestinal transplant recipients.

Clinical Associate Professor
Division of Thoracic and Cardiovascular Surgery
Department of Surgery
For over a century since the frst thoracotomy was
performed in 1891 by Theodore Tuffer, open thoracotomy
has been the norm in the diagnosis and management of tho-
racic surgical diseases. Over the past two decades since
its description, minimally invasive thoracic surgery and in
particular VATS lobectomy has undergone a revolution. This
session aims to give the participants an overview of the his-
tory, rationale, current practice and future directions of mini-
mally invasive thoracic surgery. Video presentations of the
more common procedures are also presented in an interac-
tive manner.
Total Number of Participants 244
Pre-Registered 76
On-site 168
Profle of Participants
Consultants 118
Alumni 26
Residents 100
Participants by Region
NCR 49
Luzon 96
Visayas 42
Mindanao 57
Participants by Hospital Affliation
Government Hospital 108
Private Hospital 125
Both Govt and Private 6
Not Specifed 5
Participants Profle
Event Pictures
The Registration Team
Dr. Tablan, Dr. Tiongco, Dra. Baltazar, Mrs. Tablan and Mrs. Ditas Panopio
Dr. Tiongco poses with collegues Dr. and Mrs. Tablan and Dra. Almonte
Dr. Porong Gana and Dr. Ed Bautista
Dra. Almonte and Sister Eva
Dr. Monroy,, Dr. Espiritu, Dr. Cabaluna, Dr. Bisquera and Dra. Moreno
Chief Resident Dr. Poy Ng with ACRs Dr. Dave Resoco, Dr. Mab Moreno,
Dr. Krista delos Santos and Dr. Bjay Pasco
The AV Team: Dr. Mac Onglao, Dr. Pao Amante, Dr. Nino Lucero and Dr. Ge Abesamis
Dr. Arjel Ramirez leads the singing of the Philippine National Anthem
Dr. Dante Ang (right) leads the ceremony and introduces Dr. Porong Gana (left), President of
FASE Inc., who gives a masterful Welcome Remarks
Opening Ceremony
UP-PGH Department of Surgery Chair Dra. Wilma Baltazar delivering her message
UPCM Associate Dean for Planning and Research Dr. Crisostomo delivers a message in
behalf of UPCM Dean Dr. Agnes Mejia
Dr. Tony Perez and Dr. Noneng Monroy
PGH Director and former Department of Surgery Chair Dr. Jose Gonzales delivers his message
UP Manila Chancellor Dr. Manuel Agulto delivers his message to all particpants
Dr. Gana and Dra. Baltazar sign a memorandum of agreement between the Department of
Surgery and MDPie, making the PGH Surgery Postgraduate Course contents available online
Dr. Eric Berbarabe as the Master of Ceremony Dr. Mon de Vera introduces the
14th ATR Memorial Lecturer
14th ATR Memorial Lecture
Dr. Porong Gana, Mrs. Bella Yan-Ramirez and Dra. Wilma Baltazar honors Dr. Tiongco with a plaque
Dr. Jose M. Tiongco delivering his 14th ATR Memorial Lecture
Surgery and Mountain Climbing
Session 1: Panel Discussion - Trainers in Surgery: Role and Legal Liabilities
Part II with Panelists Dr. Armand Crisostomo, Dr. Regina Berba, Dr. Tony
Perez and Dr. Jojo Arcilla, moderated by Dr. Bok Ocampo
Session 2: Pediatric Surgery Lecture - Pediatric Lymphangiomas and Hemangiomas
by Dra. Celine Villegas (L), moderated by Dra. Esther Saguil (R)
RBGM Lunch Symposium delivered by Dr. Noneng Monroy
Session 3: GS2 Lectures - (clockwise) Dr. Manuel Roxas, Dr. Armand Crisostomo,
Dr. Noneng Monroy and Dr. Ancoy Lopez, moderated by Dr. Cathy Co
Session 4: GS2 Panel Discussion - Dr. Manuel Roxas (moderator), (L-R) Dr. Noneng Monroy, Dr.
Armand Crisostomo, Dr. Ancoy Lopez and Dr. Dione Sacdalan
Session 5: GS1 Mini Symposium on Caustic Injury - Dr. Jun Bisquera, Dr. Gemma Uy,
Dr. Nelson Cabaluna, Dr. Rodney Doftas and Dr. Tito Espiritu, moderated by Dr. Mark Kho
GS1 Consultants: Dr. Rodney Doftas, Dr. Mark Kho, Dr. Nelson Cabaluna, Dra. Gemma Uy,
Dr. Tito Espiritu and Dr. Jun Bisquera
GS1 Residents, Fellows, Alumni and Consultants
Session 6: Plastic Surgery Lecture - Microtia: Tenga Ko, Tenga Mo Rin by Dr. Jay Lizardo,
moderated by Dr. Bernie Tansipek
Session 7: Urologic Surgery Lecture - Robotics in Urologic Surgery by Dr. Dennis Serrano,
moderated by Dr. Linnie Cabungcal
Session 8: Transplant Surgery Lecture - Short Bowel Syndrome: Hopeless No More by
Dr. Don Paloyo, moderated by Dr. Junico Visaya
Johnson and Johnson Lunch Symposium delivered by Dr. Tony Perez
Session 10: Mini Symposium on Critical Care Management of Transplant Patients
by Dr. Allan Concejero and Dr. Don Paloyo, moderated by Dr. Ed Bautista
Session 9: Trauma Surgery Lectures and Panel Discussion by Dr. Ed Ayuste, Dr. Eric Talens, and
Dr. Bok Ocampo
Session 11: TCVS Lecture on Minimally Invasive Thoracic Surgery
by Dr. Rus Querol, moderated by Dr. Gisel Catalan
Session 12: GS3 Panel Discussion - Multidisciplinary Approach in the Management of Malignant
Liver Disease, with panelists: Dr. J. Catibog, Dr. Mon De Vera, Dr. Janus Ong and Dra. Sandoval-
Tan, moderated by Dr. Jojo Arcilla
Session 13: Research for Surgeons by Dr. Mela Lapitan, moderated by Dr. Eric Berberabe
Session 14: Endosurgery Lecture - Innovations and Advances in Hernia Surgery by Dr. Macky
Faylona and Dr. Tony Perez, moderated by Dr. Dante Ang
Meet the
The Fellowship
Dra. Wilma Baltazar and Dr. Allan Concejero registering for the Fellowship Night
The Surgery Band: Dr. Raphy Arada, Dr. Armand Crisostomo, Dr. Aneza Maglangit, Dr. Marc
Bueser and Dr. Poy Ng
Dr. Serrano giving a toast
for the night
The Scientifc
GS3 Workshop: Choledochoscopy
TCVS Workshop: Thoracic,
Cardiac and Vascular Trauma
Burn Workshop: Wound Care:
Updates in Wound Management
GS1 Workshop: Principles of
Breast Cancer Management
Residents &
September 4, 2014: Day 2 Scientifc Sessions
Dr. Rus Querol, Dr. Dominic Bichara & Dr. Don Paloyo
Women surgeons: Dr. Krista delos Santos, Dr. Tine Paguirigan, Dr. Donna Dy-Abalajon,
Dr. Apple Valparaiso, Dr. Gemma Uy, Dr. Janneth Tan, Dr. Cheche Tayag
Dr. Jay Lizardo giving his lecture on Microtia
Surgery residents trying out
the 3D laparoscopic machine
The Postgraduate Courses Committee 2014-2015
Offcers of the Foundation for the Advancement of Surgical Education, Inc.
Executive Director
Department of Surgery Offcers
Executive Vice-Chair
Executive Assistant
Finance Offcer
Assistant Chair for Academic Affairs
Assistant Chair for Training
Assistant Chair for Services
Assistant Chair for Special Projects
Assistant Chair for Research
Division Chiefs of the Department of Surgery
Surgical Oncology, Head & Neck, Breast,
Skin & Soft Tissue, & Esophagogastric Surgery
Colorectal Surgery
Hepatobiliary and Pancreatic Surgery
Surgical Critical Care
Thoracic and Cardiovascular Surgery
Pediatric Surgery
Plastic Surgery
Organ Transplant
Postgraduate Courses Committee
Chair Orlino C. Bisquera, Jr., MD
Co-Chair Jose Macario V. Faylona, MD
Mark Richard C. Kho, MD, Catherine S. Co, MD, Dante G. Ang, MD,
Edgardo G. Gonzales, MD, Ana Melissa H. Cabungcal, MD, Leoncio L. Kaw, MD,
Ma. Celine Isobel A.Villegas, MD, Bernard U.Tansipek, MD,
Allan Dante M. Concejero, MD, Junico T.Visaya, MD, Anthony R. Perez, MD,
John Paulo B. Ng, MD, Dave R. Resoco, MD, Gerald Marion M. Abesamis, MD,
Florencio Angelo C. Lucero, MD, Ms. Eleanor R. Mercado and Ms. Juvy M. Concepcion
Telesforo E. Gana, Jr., MD
Jaime F. Esquivel, MD
Gerardo G. Germar, MD
Dennis P. Serrano, MD
Ms. Teresita T. Venturina
Wilma A. Baltazar, MD
Nelson D. Cabaluna, MD
AEricson B. Berberabe, MD
Dennis P. Serrano, MD
Eduardo R. Bautista, MD
Anthony R. Perez, MD
Jose Macario V. Faylona, MD
Nikko J. Magsanoc, MD
Marie Carmela M. Lapitan, MD
Rodney B. Doftas, MD

Hermogenes DJ Monroy, MD
Ramon L. de Vera, MD
Anthony R. Perez, MD
Eric SM Talens, MD
Eduardo R. Bautista, MD
Adrian E. Manapat, MD
Dennis P. Serrano, MD
Antonio DR. Catangui , MD
Gerardo G. Germar, MD
Glenn Angelo S. Genuino, MD
Dennis P. Serrano, MD
Joel Patrick A. Aldana, M.D.
Josefna R. Almonte, M.D.
Dante G. Ang, M.D.
Crisostomo E. Arcilla, Jr., M.D.
Eric Perpetuo E. Arcilla, M.D.
Eduardo C. Ayuste, Jr., M.D.
Jeane J. Azarcon, M.D.
Wilma A. Baltazar, M.D.
Eduardo R. Bautista, M.D.
AEricson B. Berberabe, M.D.
Orlino C. Bisquera, Jr., M.D.
Brian Samuel S. Buckley, M.D.
Alvin B. Caballes, M.D.
Nelson D. Cabaluna, M.D.
Gisel T. Catalan, M.D.
Antonio D.R. Catangui, M.D.
Catherine S. Co, M.D.
Allan Dante M. Concejero, M.D.
Rafael Isidro DJ. Consunji, M.D.
Armando C. Crisostomo, M.D.
Jose Joven V. Cruz, M.D.
Jose Luis L. Danguilan, M.D.
Jose Dante P. Dator, M.D.
Ferri P. David-Paloyo, M.D.
Ramon L. de Vera, M.D.
Daniel A. dela Paz, Jr., M.D.
Arturo S. dela Pea, M.D.
Rodney B. Doftas, M.D.
Neresito T. Espirito, M.D.
Jaime F. Esquivel, M.D.
Jose Macario V. Faylona, M.D.
Telesforo E. Gana, Jr., M.D.
Eduardo R. Gatchalian, M.D.
Glenn Angelo S. Genuino, M.D.
Gerardo G. Germar, M.D.
Edgardo G. Gonzales, M.D.
Jose C. Gonzales, M.D.
Teodoro J. Herbosa, M.D.
Serafn C. Hilvano, M.D.
Ana Melissa F. Hilvano-Cabungcal, M.D.
Reynaldo O. Joson, M.D.
Leoncio L. Kaw, Jr., M.D.
Mark Richard C. Kho, M.D.
Marie Carmela M. Lapitan, M.D.
Adriano Victor G. Laudico, M.D.
Marc Paul J. Lopez, M.D.
Felixberto S. Lukban, M.D.
Sheila S. Macalindong, M.D.
Joel U. Macalino, M.D.
Nikko J. Magsanoc, M.D.
Francisco C. Manalo, M.D.
Adrian E. Manapat, M.D.
Alvin D.B. Marcelo, M.D.
Hermogenes D.J. Monroy III, M.D.
Maria Adela A. Nable-Aguilera, M.D.
Richard S. Nicolas, M.D.
Orlando O. Ocampo, M.D.
Siegfredo R. Paloyo, M.D.
Marie Dione A. Parreno-Sacdalan, M.D.
Anthony R. Perez, M.D.
Racel Ireneo Luis C. Querol, M.D.
Maria Eliza M. Raymundo, M.D.
Derek C. Resurreccion, M.D.
Leandro L. Resurreccion III, M.D.
Alberto B. Roxas, M.D.
Manuel Francisco T. Roxas, M.D.
Esther A. Saguil, M.D.
Dennis P. Serrano, M.D.
Eric S.M. Talens, M.D.
Bernard U. Tansipek, M.D.
Gemma Leonora B. Uy, M.D.
Ma. Celine Isobel A. Villegas, M.D.
Junico T. Visaya, M.D.
Consultant Staff 2014-2015
UP-PGH Department of Surgery
Resident Staff 2014-2015
UP-PGH Department of Surgery
John Paulo Ng, M.D.
Senior Subspecialty Residents
Bernice Navarro, M.D. (GS1 - Surgical Oncology)
Apple Valparaiso, M.D. (GS1 - Surgical Oncology)
Rainier Lutanco, M.D. (GS1 - Head and Neck Surgery)
Al Radjid Jamiri, M.D.(GS2 - Colorectal Surgery)
Vienna Encila, M.D. (GS2 - Colorectal Surgery)
Neil Bacaltos, M.D. (GS3 - Hepatobiliary Surgery)
J. Kristoffer Zubiri, M.D. (Plastic Surgery)
Margarita Elloso, M.D. (Plastic Surgery)
Pinky Dirain-Beran, M.D. (Plastic Surgery)
Sabrina Anne Gonzalez, M.D. (TCVS)
Patrick Louie Maglaya, M.D. (TCVS)
Patrick Joseph Matias, M.D. (Urology)
Al Melkins Peco, M.D. (Urology)
Robert Christian Bravo, M.D. (Urology)
Dorothy Anne Dumlao, M.D. (Pediatric Surgery)
Jason Castro, M.D. (Pediatric Surgery)
Fifth Years
Nathaniel Carl Tan, M.D.
Janneth Tan, M.D.
Neil Gollaba, M.D.
Donna Marie Dy-Abalajon, M.D.
Jason Rafael Maddumba, M.D.
John Paulo Ng, M.D.
Lesley Anne Dominique Cua-Pardo, M.D.
Rochelle Elizabeth Tayag, M.D.
Maria Jenica So, M.D.
Jeffrey Michael Wong, M.D.
Kathleen Rose Descallar-Mata, M.D.
John Paul Emerson Marinas, M.D.
Mark Brian Roa, M.D.
Fourth Years
Mark Floren Bueser, M.D.
Jan Paolo Cruz, M.D.
Krista de los Santos, M.D.
Anthony Doftas, M.D.
Amabelle Moreno, M.D.
Caryl Joy Nonan, M.D.
Bayani Pasco, Jr., M.D.
Dave Resoco, M.D.
Gerald Marion Abesamis, M.D.
Alexandra Monica Tan, M.D.
Jobelle Joyce Anne Baldonado, M.D.
Kathleen Cruz, M.D.
Ly-Ann Diwa, M.D.
Chito Semblante, M.D.
Third Years
Juan Carlos Abon, M.D.
Jan Miguel Deogracias, M.D.
Mark Augustine Onglao, M.D.
Kristine Paguirigan, M.D.
Jose Miguel Verde, M.D.
Emmanuel Hao II, M.D.
Mayou Martin Tampo, M.D.
Marie Shella de Robles, M.D.
Dax Carlos Pascasio, M.D.
Ana Patricia Villanueva, M.D.
Alvin Anthony Anastacio, M.D.
Ivan Lemuel de Grano, M.D.
Second Years
Angel Paulo Amante, M.D.
Leonard Christopher Sena, M.D.
Arjel Ramirez, M.D.
Carlos Miguel Perez, M.D.
Leona Bettina Dungca, M.D.
Sittie Aneza Camille Maglangit, M.D.
Raymond Joseph De Vera, M.D.
Mario Emmanuel Lopez de Leon, M.D.
Justin Leo Carpio, M.D.
Arthur Gallo, M.D.
Raphael Benjamin Arada, M.D.
Ray Joseph Badulis, M.D.
First Years
Enrique Chua III
Emmeline Elaina Cua
Ma Cesar Del Rosario
Antonio Miguel Dela Paz
Michelle Francisco
Maureen Elvira Villanueva
Ma. Katrina Guillermo
Sylvia Karina Alip
Joshua Anton Yabut
Florencio Angelo Lucero
Paul Gerald Santos
Gianina Kasandra Grey
Ostomy Care &
Supply Center



HD Autoclavable Camera Head
- Olympus CH-S190-XZ-E
- Olympus CH-S190-XZ-Q
Visera Elite Xenon Light Source (CLV-S190)
45L High Flow Insufflation Unit (UHI-4)
Image Management Hub (IMH-10 / IMH-20)
High Definition LCD Monitor (OEV262H)

Dynamic silver release
rapid destruc,on, sustained protec,on
Transparent Waterproof
Dressing with Absorbent Pad
For your laparoscopic
hand instruments needs
please contact:
Ms. Mengie Cabanlit
(02)8290175, (02)3963691,
50th Postgraduate Course Secretariat
Teresita T. Venturina
Administrative Offcer
Eleanor R. Mercado
Special Assistant for the Postgraduate Course
Staff Members:
Mercedita A. Panopio
Juvy M. Concepcion
Mary Grace P. Apines
Edwin Z. Bacalla
Delia San Diego
Glycerine Manalo
Emily Dizon
Ma. Victoria Martinez
Regielyn W. Reforzado
Wound Care Products
Jeremiah Drug (Metro Manila, Luzon)
22 San Andres St., San Beda Village, Q.C., 1106
Tel. No. 455-1283
EC Zuric Biotherapies (Visayas, Mindanao)
22 San Andres St., San Beda Village, Q.C., 1106
Suprasorb A
Suprasorb A + Ag
Suprasorb X + PHMB
Suprasorb C
Suprasorb H
Suprasorb F
Suprasorb G
Vliwaktiv Ag
Mollelast Haft
Curapor Transparent
Solvaline N



Department of Surgery
University of the Philippines Manila - Philippine General Hospital
Taft Avenue, Manila
Phone: 554-8472 / 554-8400 loc. 2250
Copyright 2014