Efficacy of Erector Spinae Plane Block on Postoperative Analgesia for Patients Undergoing Metabolic Bariatric Surgery: A Randomized Controlled Trial.

BACKGROUND: Metabolic bariatric surgery (MBS) advocates multimodal analgesia, discouraging opioid use to minimize side effects, such as nausea and vomiting, during postoperative pain management for quicker recovery. Combining erector spinae plane block (ESPB) with multimodal analgesia aims to reduce opioid consumption, improving postoperative recovery. This study aimed to compare morphine consumption between patients with severe obesity undergoing laparoscopic MBS with and without ESPB. METHODS: This study enrolled 91 patients with severe obesity who underwent laparoscopic MBS involving either sleeve gastrectomy or Roux-en-Y gastric bypass. Of these, 63 patients were included in this study. The participants were randomly allocated to either the intervention group, which received an ESPB before the standard anesthesia protocol, or the control group, which did not receive pre-anesthesia block. The primary outcome measured was 24-h morphine consumption via a patient-controlled analgesia machine. Secondary outcomes included patients' satisfaction, postoperative numerical rating score, changes over time, and quality of recovery (QoR) using the Thai QoR-35 score. RESULTS: We found no statistically significant difference in morphine consumption between the intervention group and the control group. Furthermore, our analysis revealed no significant between-group differences in patient satisfaction, postoperative numeric rating score, or QoR across all five aspects evaluated using the Thai QoR-35 score. CONCLUSIONS: ESPB did not reduce morphine consumption or QoR following laparoscopic MBS. Further studies are required to confirm and identify the reasons for the ineffectiveness of ESPB.

Comparison of long-term outcomes after laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass for morbid obesity.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the two most bariatric procedures in Asia. However, a comparison of long-term outcomes is still limited. OBJECTIVES: To compare the degree of long-term weight loss, remission of comorbidities and complication rates after LRYGB and LSG procedures. METHODS: A retrospective analysis was conducted for all patients who underwent LSG or LRYGB between May 2005 and May 2018 at a single institute with at least 1-5 years of follow up. Demographic data were collected. RESULTS: Of the total 342 patients, 159 underwent primary LSG and 183 patients underwent LRYGB. Preoperative BMI in the LSG group was significantly higher than the LRYGB group (54.7 ± 12.6 kg/m2 vs 48.2 ± 8.2 kg/m2, P = 0.001). Comorbidities between LSG and LRYGB groups were similar. Mean percentage of total weight loss (%TWL) at 5 years after was 23.6 ± 1.7 % in the LSG group vs. 29.9 ± 1.3 % in the LRYGB group (P = 0.005) and LRYGB resulted in greater weight loss than LSG at all time points. The remission of comorbidities were similar in both groups, except that dyslipidemia was significantly better in the LRYGB group. Overall complications were 35.2 % in the LSG group vs. 20.8 % in the LRYGB group (P = 0.003). CONCLUSIONS: Our center revealed that LRYGB had better results than LSG in terms of percentage total weight loss at all time points. In the long term, LSG showed a higher overall complication rate compared to LRYGB.

Comparison of enoxaparin 40 mg versus 60 mg dosage for venous thromboprophylaxis in patients undergoing bariatric surgery: A randomized controlled trial.

BACKGROUND: Venous thromboembolism (VTE) is a common cause of morbidity and mortality after bariatric surgery. Morbid obesity is an independent risk factor for VTE, with goals of prophylactic anti-factor Xa levels within 0.2-0.5 IU/mL. The recommended dosing regimen of enoxaparin for VTE prophylaxis in patients with morbid obesity is lacking in available guidelines. OBJECTIVES: To evaluate the achieving prophylactic anti-factor Xa levels with different dosages of enoxaparin for morbid obesity patients. SETTING: We conducted a study at Chulalongkorn Bariatric and Metabolic Institute, King Chulalongkorn Memorial Hospital. METHODS: We conducted a randomized controlled trial comparing anti-factor Xa levels 4 h after the administration of enoxaparin. All recruited patients randomly received 40 mg or 60 mg of enoxaparin 12 h before the operation. Blood specimens were collected 4 h after the administration of enoxaparin. RESULTS: In total, 56 patients who presented between April 2019 and March 2020 at King Chulalongkorn Memorial Hospital were recruited. Of these patients, 28 received 40 mg and 28 received 60 mg of enoxaparin. In both groups, the rates of achieving target levels were 53.57% and 78.57%, respectively (p-value = 0.048). The mean anti-factor Xa levels were 0.19 IU/mL ± 0.06 IU/mL and 0.28 and 0.28 ± 0.10 IU/mL, respectively (p < 0.001). No significant difference was found in the estimated blood loss between the groups. No patient obtained anti-factor Xa levels exceeding 0.5 IU/mL. In both groups, no symptomatic VTE occurred. CONCLUSIONS: A 60 mg of enoxaparin regimen achieved more prophylactic anti-factor Xa levels than 40 mg in obese patients undergoing bariatric surgery without any adverse events.

Gut Microbiota in Patients with Non-Alcoholic Fatty Liver Disease without Type 2 Diabetes: Stratified by Body Mass Index.

The relationship between gut dysbiosis and body mass index (BMI) in non-diabetic patients with non-alcoholic fatty liver disease (NAFLD) is not adequately characterized. This study aimed to assess gut microbiota's signature in non-diabetic individuals with NAFLD stratified by BMI. The 16S ribosomal RNA sequencing was performed for gut microbiota composition in 100 patients with NAFLD and 16 healthy individuals. The differential abundance of bacterial composition between groups was analyzed using the DESeq2 method. The alpha diversity (Chao1, Shannon, and observed feature) and beta diversity of gut microbiota significantly differed between patients with NAFLD and healthy controls. However, significant differences in their diversities were not observed among subgroups of NAFLD. At the phylum level, there was no trend of an elevated Firmicutes/Bacteroidetes ratio according to BMI. At the genus level, patients with lean NAFLD displayed a significant enrichment of Escherichia-Shigella and the depletion of Lachnospira and Subdoligranulum compared to the non-lean subgroups. Combining these bacterial genera could discriminate lean from non-lean NAFLD with high diagnostic accuracy (AUC of 0.82). Non-diabetic patients with lean NAFLD had a significant difference in bacterial composition compared to non-lean individuals. Our results might provide evidence of gut microbiota signatures associated with the pathophysiology and potential targeting therapy in patients with lean NAFLD.

Effect of Preoperative Very Low-Calorie Diets on Hepatic Steatosis, Fibrosis, and Perioperative Outcomes of Bariatric Surgery.

Introduction: Preoperative weight loss through a very low-calorie diet (VLCD) has been shown to reduce liver volume and technical difficulty in patients undergoing metabolic and bariatric surgery (MBS). However, the effect of preoperative VLCD on liver histology and other outcomes is not well demonstrated. Our study aimed to explore the effect of a 2-week preoperative VLCD, compared with no-dietary intervention, on hepatic steatosis, fibrosis, weight loss, and other postoperative outcomes of MBS. Materials and Methods: This retrospective study was conducted at the Chulalongkorn Bariatric and Metabolic Institute, King Chulalongkorn Memorial Hospital, Bangkok, Thailand. The medical records of patients with severe obesity (body mass index ≥50 kg/m2) attending the clinic from January 2005 to December 2020 were reviewed. Clinical data and laboratory investigations were collected at baseline and at each follow-up visit, up to 5 years postoperatively. Hepatic steatosis and fibrosis were assessed by liver biopsy intraoperatively. Results: A total of 181 patients were included in this study. Preoperative VLCD was prescribed in 65 patients (VLCD group) and 116 patients received their usual diet (control group). Mean preoperative weight loss was 9.1 ± 6.1 kg in the VLCD group versus 0.0 ± 0.0 kg in the control group (P = .000). The VLCD group had significantly less number of patients with moderate and severe liver steatosis from the liver biopsy specimens (16.2% versus 46.3%; P = .008). However, there was no significant difference in fibrosis grade between those with VLCD and control (≥F2-fibrosis; 2.7% versus 7.5%; P = .118). Moreover, preoperative VLCD could reduce operating time in patients who underwent both laparoscopic Roux-en-Y gastric bypass (LRYGB; VLCD 163.4 ± 38.2 minutes versus control 215.1 ± 67.4 minute, P = .000) and laparoscopic sleeve gastrectomy (LSG; VLCD 110.8 ± 20.0 minutes versus control 131.0 ± 38.1 minutes, P = .004). During the 5-year follow-up, there were a significant difference of HbA1C between the VLCD and the control group (coefficient: -0.24 with 95% confidence interval [CI]: -0.44 to -0.04, P = .019), particularly in patients who underwent LRYGB (Coefficient: -0.26 with 95% CI: -0.49 to -0.03, P = .028), but not LSG. However, long-term weight loss outcomes and other biochemical outcomes were not different between the VLCD and the control group. Conclusion: Preoperative VLCD was associated with reduced liver steatosis and operative time in patients who underwent LRYGB and LSG. Moreover, preoperative VLCD significantly decreased HbA1C during a 5-year follow-up period. Therefore, it should be considered in patients with severe obesity, who will undergo MBS.

Comparison of Body Composition Variables between Post-Bariatric Surgery Patients and Non-Operative Controls.

Background: Since bariatric surgery results in massive weight loss, it may be associated with a disproportionate decrease in lean body mass. Objective: To evaluate body composition in post-bariatric surgery patients who had a successful weight loss at 12 months (>50% excess weight loss) with comparisons to healthy controls who were matched for age, sex and BMI. Methods: This is an observational analytic study using data from post-bariatric surgery patients who had laparoscopic Roux-en-Y gastric bypass (RYGB) or laparoscopic sleeve gastrectomy (SG) at King Chulalongkorn Memorial Hospital. Patients who had percentage excessive weight loss (%EWL) >50% and achieved a BMI of <30 kg/m2 within 12 months after the surgery were included. Non-operative healthy controls matched for sex, age, and BMI (1:1) were recruited. The 12-month post-bariatric surgery BMI was used to match the BMI of the control subjects. A single bioelectrical impedance analysis (BIA) (Inbody 770) machine was used for the entire study. Results: Sixty participants were included in this study. There are 30 post-bariatric surgery patients (female n = 19, male n = 11) and 30 non-operative controls (female n = 19, male n = 11). The 12-month post-bariatric surgery patients had lower percentage of body fat (PBF) (30.6% vs 35.9%, P-value .001) and trunk fat mass (10.3 vs 12.4 kg, P-value .04) than non-operative controls. The 12-month post-bariatric surgery patients also were found to have more soft lean mass (SLM) (47.7 vs 39.9 kg, P-value .001), fat free mass (FFM) (51.1 vs 42.3 kg, P-value .001), skeletal muscle mass (SMM) (27.5 vs 23 kg, P-value .003), and trunk lean mass (21.2 vs 19 kg, P-value .02). Conclusion: Despite the significant reductions in all body composition variables in post-bariatric surgery patients at 12-month follow-up, both fat free mass and skeletal muscle mass were found to be higher in the surgical patients compared to the control group. Clinical trials: Thai Clinical Trials Registry, https://thaiclinicaltrials.org/ID:TCTR20200223003.

Skin manifestations and biophysical changes following weight reduction induced by bariatric surgery: A 2-year prospective study.

Skin manifestations and biophysical changes are observed in patients with morbid obesity. However, reports of changes after significant weight loss, particularly through post-bariatric surgery (BaS), are limited. The aim of this 2-year prospective study was to evaluate the prevalence of skin signs and their changes in patients with morbid obesity who underwent BaS. Thirty-one patients were recruited for the study, with a mean age of 38.35 (SD 10.61) years and a male preponderance (male = 19 [61.29%], female = 12 [38.71%]). Patients were scheduled for multiple visits at months 0, 3, 6, 12, 18, and 24 post-BaS. Each subject had a thorough skin examination, biophysical measurements, and laboratory tests at each visit. Striae, acanthosis nigricans (AN), and plantar hyperkeratosis were the most common skin findings (n = 30 [96.77%], 29 [93.55%], 29 [93.55%], respectively). BaS provided improvements in many skin manifestations, namely striae, AN, acrochordons, plantar hyperkeratosis, hirsutism, lymphedema, pruritus, acne, finger pebbles, and chronic venous insufficiency with varied cumulative rates of improvements. However, acute telogen effluvium was observed in 17 (54.84%) patients. Regarding skin biophysical properties, transepidermal water loss, skin hydration, and pH did not change, while sebum production on the face significantly decreased at months 3 and 6, and elasticity decreased at months 6 and 24. In conclusion, weight reduction by BaS provided improvements in various skin signs, although telogen effluvium was a common sequelae.

Laparoscopic approach in chronic posttraumatic diaphragmatic hernia.

Chronic posttraumatic diaphragmatic hernia is an unusual disease with challenging diagnosis and treatment. Surgery represents the treatment of choice which can be transabdominal, transthoracic, or combined approach. The principles of surgery consist of herniated visceral organs reduction and diaphragmatic defect closure. This video demonstrates the steps of chronic posttraumatic diaphragmatic hernia repair via a laparoscopic approach and concerning points during the operation.

Ten Years of Change in Bariatric/Metabolic Surgery in the Asia-Pacific Region with COVID-19 Pandemic: IFSO-APC National Reports 2021.

BACKGROUND: On November 25, 2021, the IFSO-Asia-Pacific Chapter (IFSO-APC) Virtual Meeting 2021 was held online, and the representatives from the Asia-Pacific region presented 10 years of change in bariatric/metabolic surgery and the influence of COVID-19 in the special session of "IFSO-APC National Reports 2010-2020". We herein report the summarized data. METHODS: National bariatric/metabolic surgery data, which included the data of 2010 and 2020, were collected from the representatives using a questionnaire that consisted of 10 general questions. At the congress, the data were calculated and summarized. RESULTS: Thirteen of the 14 national societies responded to the survey. From 2010 to recent years, the populations of individuals with obesity (BMI ≥ 30 kg/m2) and individuals with diabetes both significantly increased. Eight countries and regions expanded the lower limit of criteria for bariatric surgery by 2-5 kg/m2 (BMI), and 5 countries newly established criteria for metabolic surgery in the last ten years. Sixty-nine percent of the countries currently run public health insurance systems, which doubled from 2010. The number of bariatric surgeons and institutions increased more than threefold from 2010. In 2010, 2019, and 2020, surgeons in IFSO-APC societies performed 18,280, 66,010, and 49,553 bariatric/metabolic surgeries, respectively. Due to the COVID pandemic, restriction policies significantly reduced access to surgery in South and Southeast Asian countries. The biggest changes included increased numbers of bariatric surgeons and institutions, operation numbers, public insurance coverage, raising awareness, and national registry systems. CONCLUSION: For the last 10 years, bariatric/metabolic surgery has rapidly grown in the Asia-Pacific region.

International Delphi Expert Consensus on Safe Return to Surgical and Endoscopic Practice: From the Coronavirus Global Surgical Collaborative.

OBJECTIVE: The aim of this work is to formulate recommendations based on global expert consensus to guide the surgical community on the safe resumption of surgical and endoscopic activities. BACKGROUND: The COVID-19 pandemic has caused marked disruptions in the delivery of surgical care worldwide. A thoughtful, structured approach to resuming surgical services is necessary as the impact of COVID-19 becomes better controlled. The Coronavirus Global Surgical Collaborative sought to formulate, through rigorous scientific methodology, consensus-based recommendations in collaboration with a multidisciplinary group of international experts and policymakers. METHODS: Recommendations were developed following a Delphi process. Domain topics were formulated and subsequently subdivided into questions pertinent to different aspects of surgical care in the COVID-19 crisis. Forty-four experts from 15 countries across 4 continents drafted statements based on the specific questions. Anonymous Delphi voting on the statements was performed in 2 rounds, as well as in a telepresence meeting. RESULTS: One hundred statements were formulated across 10 domains. The statements addressed terminology, impact on procedural services, patient/staff safety, managing a backlog of surgeries, methods to restart and sustain surgical services, education, and research. Eighty-three of the statements were approved during the first round of Delphi voting, and 11 during the second round. A final telepresence meeting and discussion yielded acceptance of 5 other statements. CONCLUSIONS: The Delphi process resulted in 99 recommendations. These consensus statements provide expert guidance, based on scientific methodology, for the safe resumption of surgical activities during the COVID-19 pandemic.

Skin manifestations after bariatric surgery.

BACKGROUND: Skin signs observed in morbid obesity may change as the weight reduces, especially post-bariatric surgery (BaS). Data concerning the skin findings exclusively in post-BaS patients remain limited. METHODS: Seventy post-BaS patients were examined for cutaneous abnormalities. The patients were divided into those with successful weight loss (% excessive body weight loss (EBWL) of at least 50%) and a non-successful group (%EBWL < 50%). RESULTS: Forty-six patients with successful weight loss demonstrated a significantly lower prevalence of acanthosis nigricans on the neck, axillae and inguinal areas, keratosis pilaris (KP) and pebble fingers. However, a higher prevalence of alopecia was observed. After adjustment with patients' factors, KP (adjusted odds ratio (aOR) = 0.21, 95%CI 0.06-0.74, p = 0.02) and pebble fingers (aOR = 0.09, 95%CI 0.01-0.89, p = 0.04) remained significantly less likely in patients with successful weight loss. Laboratory results comparing pre- and post-surgery values revealed significant decreases in fasting plasma glucose, hemoglobin A1c, and triglyceride and an increase of high-density lipoproteins in both groups. However, significant decreases of liver aminotransferases (AST and ALT) were observed only in the successful group (p = 0.04, 0.003). Nonetheless, a decrease in vitamin B12 (p = 0.01) was observed in the successful group. CONCLUSION: Weight loss after BaS provided an improvement for metabolic profiles. Successful weight reduction resulted in better skin improvement. However, nutritional supplements may be necessary. TRIAL REGISTRATION: Thai Clinical Trials Registry TCTR20171003002 . Registered October 3. 2017, retrospectively registered.

Changes in plasma aldosterone level after weight loss by bariatric surgery in morbidly obese patients.

BACKGROUND: Overactivation of renin-aldosterone-angiotensin system (RAS) is part of the pathogenesis of obesity-associated hypertension. Evidences have shown that weight loss can result in reduction in blood pressure and RAS. This study was aim to investigate changes of plasma aldosterone concentration (PAC) after bariatric surgery. METHODS: A prospective study was done in 14 morbidly obese patients undergoing bariatric surgery. Patients who were taking medications that can interfere with PAC and renin levels were excluded. Collection of blood samples were done at baseline and at 3 and 6-month post-bariatric surgery. RESULTS: Four out of 14 patients had hypertension at baseline. Mean body mass index (BMI) was 56.7 ± 13.5 kg/m2. PAC were significantly decreased at 3-and 6-month post-bariatric surgery from 14.3 ± 8.0 to 7.5 ± 5.5 [reduction of 36% from baseline (P < 0.01)] and 8.0 ± 6.6 ng/dl [reduction of 32% from baseline (P < 0.05)] respectively. The reduction of PAC at 3-month post-surgery was correlated with the reduction of body weight (r = 0.46, P < 0.05), waist circumference (r = 0.73, P < 0.05) and percent of body fat (r = 0.58, P < 0.05). CONCLUSIONS: Maximal reduction of PAC in obese patients underwent bariatric surgery occurred during the first 3 months after bariatric surgery. The reduction of PAC was associated with the reduction of body weight, waist circumference and percent of body fat suggesting the link between RAS and obesity-mediated hypertension.

Immediate return of fertility function following a bariatric surgery: A case report.

Obesity in women of childbearing age is linked to lower fertility rates due to chronic oligoovulation and anovulation. Effective weight loss treatment such as bariatric surgery can improve fertility potential. However, pregnancy during the first 12 months after bariatric surgery should be avoided due to an active catabolic state and may increase the potential risk of fetal growth restriction. Here, we report a case with an immediate return of fertility function following a bariatric surgery with favorable outcomes. A 30-year-old woman with obesity, history of polycystic ovarian syndrome and infertility become pregnant within 2-month period following bariatric surgery. She first recognized her pregnancy at the gestational age of 8 weeks. Micronutrient laboratory results at baseline were normal except for low 25-OH vitamin D level of 18.7 ng/dL. She continued to lose her weight during the first trimester but was able to gain some weight during the second and third trimesters. Close fetal ultrasonography monitoring was done during each trimester. The fetal ultrasonography showed an appropriate fetal weight, a normal Doppler study and no abnormality detected in the fetus. Finally, at 36 weeks of gestation, a 2380-g female baby was delivered successfully.

Cost-Effectiveness Evaluation of Bariatric Surgery for Morbidly Obese with Diabetes Patients in Thailand.

Background: Bariatric surgery is a choice for treatment in morbidly obese patients with type 2 diabetes mellitus (DM type 2) who have inadequate diabetes control with only medical treatment. However, bariatric surgery requires highly sophisticated equipment, and thus the cost of surgery seems to be very high following the procedure compared with the cost of conventional diabetes care. This raises the question of whether bariatric surgery is cost-effective for morbidly obese people with diabetes in Thailand. Objective: To perform a cost-effectiveness evaluation of bariatric surgery compared with ordinary treatment for diabetes control in morbidly obese DM type 2 patients in Thailand. Methods: Cost-effectiveness study was conducted, using a combination of decision tree and Markov model in analysis. Treatment outcomes and healthcare costs were incurred by data from literature review and retrospective cohort in King Chulalongkorn Memorial Hospital from September 2009 to March 2016 for the conventional and bariatric surgery group, respectively. One-way sensitivity was used for analysis of the robustness of the model. Cost-effectiveness was assessed by calculating incremental cost-effectiveness ratios (ICERs). Monetary benefits at a threshold of 150,000 to 200,000 Thai baht (THB) per quality-adjusted life-year (QALY) based on the Thailand gross domestic products (GDP) value was regarded as cost-effectiveness of bariatric surgery. Results: Bariatric surgery significantly improves the clinical outcome including long-term diabetes remission rate, hemoglobin A1C, and body mass index (BMI). The incremental cost per QALY of bariatric surgery compared with the medication control is 26,907.76 THB/QALY which can consider bariatric surgery as a cost-effective option. Conclusions: Use of bariatric surgery in morbidly obese with DM type 2 patients is a cost-effective strategy in Thailand's context.

Outcome of endoscopic small-bore naso-jejunal tube stenting in early postoperative jejunal limb obstruction after gastrectomy.

BACKGROUND: Early postoperative jejunal limb obstruction is a rare complication following gastric surgery with jejunal reconstruction. The condition is mainly attributed to kinking of the jejunal limbs, gastrojejunal or jejunojejunal anastomosis. There has been currently limited information regarding the safety and efficacy of endoscopic treatment in patients with early postoperative jejunal obstruction. We aimed to investigate outcome of endoscopic small-bore naso-jejunal (N-J) tube stenting across the obstructed segment in patients with uncomplicated early postoperative partial jejunal limb obstruction. METHODS: All patients diagnosed of jejunal limb obstruction within 8 weeks after gastric-related surgery were reviewed. Patients with malignant obstruction, complete closed loop obstruction, sepsis, instability, intestinal strangulation, or perforation were excluded. All patients underwent endoscopic dekinking and stenting for 2 weeks with an N-J tube using 16-French single lumen plastic nasogastric tube across the obstruction segment after failed conservative therapy. Successful N-J tube placement across the obstruction point was confirmed by contrast study. Complications, technical, and clinical success were evaluated. RESULTS: Twenty-one patients met the criteria. The primary operations were 7 partial gastrectomies with Billroth-II reconstruction, 7 total or partial gastrectomies with Roux-en-Y reconstruction and 4 Whipple's operations, 2 bypass procedures, and 1 proximal gastrectomy. Most common site of obstruction was jejunojejunal anastomosis and gastrojejunal anastomosis following Roux-en-Y and Billroth-II reconstruction, respectively. Endoscopic N-J tube placement was technically successful in 20 out of 21 patients (95%). One patient had aspirated pneumonia. There was no procedure-related mortality. After N-J tube removal, clinical success was demonstrated in 19 out of 20 patients (95%) at the median duration of 6 months. One patient underwent reoperation due to repeated tube dislodgement. CONCLUSIONS: Endoscopic stenting with a 16-F naso-jejunal tube across the angulated segment is safe and effective for treatment of patients with uncomplicated early postoperative partial jejunal limb obstruction following gastric surgery with jejunal reconstruction.

Bariatric/Metabolic Surgery in the Asia-Pacific Region: APMBSS 2018 Survey.

INTRODUCTION: The Asia-Pacific Metabolic and Bariatric Surgery Society (APMBSS) held its congress in Tokyo at the end of March, 2018, and representatives from Asia-Pacific countries presented the current status of bariatric/metabolic surgery in the "National Reports" session. The data are summarized here to show the current status and problems in the Asia-Pacific region in 2017. METHODS: A questionnaire including data of 2016 and 2017 and consisting of eight general questions was prepared and sent to representatives in 18 Asia-Pacific countries by e-mail before the congress. After the congress, the data were analyzed and summarized. RESULTS: Seventeen of 18 countries responded to the survey. The frequency of obesity (BMI ≥ 30) in the 4 Gulf countries was > 30%, much higher than that in the other countries. In total, 1640 surgeons and 869 institutions were engaging in bariatric/metabolic surgery. In many East and Southeast Asian countries, the indication for bariatric surgery was BMI ≥ 35 or ≥ 37, whereas in many Gulf countries and Australia, it was BMI ≥ 40 or ≥ 35 with obesity-related disease. Ten of the 17 countries (58.8%) but only one of the 5 Southeast Asian countries (20.0%) had public health insurance coverage for bariatric surgery. In 2017, 95,125 patients underwent bariatric/metabolic surgery, with sleeve gastrectomy accounting for 68.0%, bypass surgery for 19.5%, and others for 12.5%. Current problems included public insurance coverage, training system, national registry, and lack of awareness and comprehension. CONCLUSION: This summary showed that bariatric/metabolic surgery is rapidly developing along with various problems in Asia-Pacific countries.

Prevalence and associated factors of obstructive sleep apnea in morbidly obese patients undergoing bariatric surgery.

PURPOSE: Our goal in this study is to determine the prevalence and associated factors of obstructive sleep apnea (OSA) in morbidly obese patients undergoing bariatric surgery. METHODS: This descriptive study was conducted at King Chulalongkorn Memorial Hospital from 2007 to 2015. Data of morbidly obese patients who underwent bariatric surgery were included using ICD-10 code for principle diagnosis "morbid obesity" (E668) and ICD-9 code for "bariatric surgery" (4389, 4438, 4439). RESULTS: Baseline characteristics of 238 patients who met the inclusion criteria demonstrated 49.2% male, mean age of 33.9 ± 10.8 years, and mean BMI of 52.6 ± 11.6. Sleeve gastrectomy and Roux-en Y gastric bypass surgery were performed in 51.5 and 48.5%; respectively. High risk for OSA using STOP-Bang as a screening questionnaire (≥3 points) was 92.7%. The prevalence of OSA using respiratory disturbance index (RDI) ≥ 5 was demonstrated at 85.7%. Mild, moderate, and severe OSA was observed in 8.8, 15.3, and 75.9%, respectively. Snoring, STOP-Bang score ≥ 3, fatty liver, and BMI were significantly correlated with OSA compared to the group without OSA with the odds ratio of 17.04 (p = <0.0001, 95% CI = 6.67-43.49), 16 (p = 0.01, 95% CI = 1.95-131.11), 4.75 (p = 0.001, 95% CI = 1.82-12.37), and 1.04 (p = 0.045, 95% CI = 1.0009-1.09), respectively. Comparison between non-severe and severe OSA groups demonstrated dyslipidemia and BMI to be correlated with OSA severity (odds ratio = 3.06, 95% CI 1.36-6.89, p = 0.007 and odds ratio = 1.07, 95% CI 1.03-1.13, p = 0.001, respectively). CONCLUSIONS: Obstructive sleep apnea is frequently observed in morbidly obese patients undergoing bariatric surgery and the severity tends to be severe. Snoring, STOP-Bang score ≥ 3, fatty liver, and BMI were significantly correlated with OSA. Dyslipidemia and BMI were demonstrated to be associated factors for severity of OSA in this population.

Changes in Testosterone Levels and Sex Hormone-Binding Globulin Levels in Extremely Obese Men after Bariatric Surgery.

Objective. Obesity is a risk factor for hypogonadotropic hypogonadism in men. Weight loss has been shown to improve hypogonadism in obese men. This study evaluated the early changes in sex hormones profile after bariatric surgery. Methods. This is a prospective study including 29 morbidly obese men. Main outcomes were changes in serum levels of total testosterone (TT), free testosterone (cFT), SHBG, estradiol, adiponectin, and leptin at 1 and 6 months after surgery. Results. The mean age of patients was 31 ± 8 years and the mean BMI was 56.8 ± 11.7 kg/m2. Fifteen patients underwent Roux-en-Y gastric bypass and 14 patients underwent sleeve gastrectomy. At baseline, 22 patients (75.9%) had either low TT levels (<10.4 nmol/L) or low cFT levels (<225 pmol/L). Total testosterone and SHBG levels increased significantly at 1 month after surgery (p ≤ 0.001). At 6 months after surgery, TT and cFT increased significantly (p ≤ 0.001) and 22 patients (75.9%) had normalized TT and cFT levels. There were no changes in estradiol levels at either 1 month or 6 months after surgery. Conclusions. Increases in TT and SHBG levels occurred early at 1 month after bariatric surgery while improvements in cFT levels were observed at 6 months after bariatric surgery.

Thoracoscopic approach for esophageal resection in chronic severe corrosive esophageal stricture: report of 2 cases.

OBJECTIVE: The authors reported the feasibility and safety of thoracoscopic approach for resection of the esophagus in two patients with diffuse corrosive esophageal stricture. BACKGROUND: The unrelenting corrosive strictures of esophagus merit esophageal substitution. Because of the risk of complications in the retained esophagus, such as malignancy, mucocele, gastroesophageal reflux, and bleeding, esophageal resection is deemed necessary. Transthoracic approach for esophageal resection is considered safe but requiring thoracotomy. Transhiatal resection of a scared esophagus could be associated with serious complications. Less was known regarding the safety and feasibility of thoracoscopic resection of the esophagus in corrosive stricture of the esophagus. MATERIAL AND METHOD: Thoracoscopic approach was used for mobilization of the scarred esophagus in two female patients. Laparotomy with colonic mobilization was performed in the second phase of the operation. Pharyngocolonic and esophagocolonic anastomosis were done via left neck incision in each patient. Intra-operative and post-operative complications were observed. Swallowing ability was assessed in the early postoperative period. RESULTS: Thoracoscopic esophageal mobilization was successfully performed without complications. Any adhesions around the esophagus could be clearly seen and divided using harmonic scalpel under direct vision. Operative duration of the thoracoscopic part was 104 and 120 minutes and total blood loss was 320 and 350 ml respectively. Postoperative period was uneventful. The patient could have regular diet on day 8 and 9 after surgery. CONCLUSION: Thoracoscopic approach for esophageal resection could be safely performed for the extirpation of diffuse esophageal stricture. Postoperative complication is being assessed in the authors' prospective trial.