Effect of bariatric surgery on glycemic profiles in multiethnic obese nondiabetic Asians.

BACKGROUND: The effect of bariatric surgery on improvement and remission of type 2 diabetes (T2D) is well studied. The effect of surgery on glycemic profiles of obese, but nondiabetic individuals is unknown. OBJECTIVES: We aimed to study changes in glycemic indices in obese nondiabetics undergoing bariatric surgery and correlate fat mass loss with changes in glycemic profiles. SETTING: University Hospital, Singapore. METHODS: A prospective database of nonT2D patients who underwent bariatric surgery between April 2009 and December 2014 was analyzed. Changes in weight, fat mass, and glycemic profiles, including glycated hemoglobin, C-peptide levels, and the homeostasis model assessment of insulin resistance were studied at 1- and 3-year follow-up. RESULTS: One hundred thirty-three nondiabetics underwent bariatric surgery in the study period. Twenty-nine (21.8%) patients were found to have impaired fasting glycemia. We observed reductions in mean fat mass from 47.4 ± 12.2 kg preoperatively to 27.8 ± 11.6 kg at 1 year. Despite mean fat mass regain to 33.9 ± 19.6 kg at 3 years, homeostasis model assessment of insulin resistance improved from severe insulin resistant state of >5.00 (7.13 ± 11.5) preoperatively to normal ranges of <3.00 (1.55 ± .91) at 3 years. CONCLUSION: Bariatric surgery results in significant sustained weight loss in obese nondiabetics and normalizes glycated hemoglobin and homeostasis model assessment of insulin resistance after surgery. It is a promising modality to prevent or delay the onset of T2D in obese nondiabetic patients. Further studies should be conducted in nondiabetics to assess the efficacy of bariatric surgery in prevention of T2D onset in the longer term.

Switching from Ticagrelor to Clopidogrel in Asian Patients with ST-Elevated Myocardial Infarction - A Time Dependent Analysis Study.

BACKGROUND: Ticagrelor is initially prescribed after an ST-elevated myocardial infarction (STEMI) and this may be followed by a switch to clopidogrel. However, studies involving antiplatelet switching have been conflicting and only assessed at a specific switch point. The objective of this study was to investigate switching from ticagrelor to clopidogrel in an Asian population, after accounting for various switch points as in a real-world environment. METHODS: A retrospective cohort of 349 STEMI patients started on ticagrelor and aspirin were followed-up for 1 year after a percutaneous coronary intervention that was performed between June 2014 and November 2016. Patients who switched to clopidogrel were compared with those who remained on ticagrelor. Outcomes measured were major adverse cardiac and cerebrovascular events (MACCEs) and clinically significant bleeding (CSB). Cox regression analysis with switch status as a time-dependent covariate was performed. RESULTS: The switched group was not associated with MACCEs or CSB [10.0% vs. 13.8%; hazard ratio (HR) = 0.484; 95% confidence interval (CI): 0.196-1.191; p = 0.114]. There was also no significant difference when MACCEs were analyzed alone (2.3% vs. 7.7%; HR = 0.518; 95% CI: 0.137-1.957; p = 0.332). For CSB, the switched group was less likely to have an event (7.8% vs. 8.5%; HR = 0.298; 95% CI: 0.091-0.982; p = 0.047). CONCLUSIONS: This study showed no significant difference between staying on ticagrelor and switching to clopidogrel. Switching might decrease the incidence of CSB. De-escalation from ticagrelor to clopidogrel could translate to cost savings for Asian patients without compromising safety and efficacy.

A Multimodal Analgesic Protocol Reduces Opioid-Related Adverse Events and Improves Patient Outcomes in Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed procedures for the treatment of obesity. Patients with obesity are more prone to experience opioid-related adverse events (ORAE). OBJECTIVES: The objective of this study is to determine if a multimodal analgesia protocol (MAP) reduces ORAE and provides effective pain relief for patients after LSG. SETTING: This study was conducted at University Hospital, Singapore. METHODS: The MAP consists of mandatory pre-operative etoricoxib, intra-operative acetaminophen, and post-operative acetaminophen with optional post-operative tramadol. We identified and collected data for patients who underwent LSG between May 2010 and November 2015 and compared patients before and after the implementation of the MAP. RESULTS: One hundred fifty-eight patients were included and 68 patients were treated with the MAP. There were no differences in age, gender, body mass index, ethnicity, or comorbidities between the two groups except for the incidence of hypertension (p = 0.015). There was a significant reduction in the incidence of ORAE from 33.3 to 8.8% (p < 0.001) after the implementation of the MAP. There was also a significant reduction in the use of opioids intra-operatively from 58.2 to 43.6 mg (p < 0.001) and post-operatively from 23.7 to 0.7 mg (p < 0.001). Pain scores were similar at 1, 6, and 48 post-operatively, while pain scores were significantly reduced at 12 (p = 0.033) and 24 h (p = 0.02) post-operatively. Multivariate analysis showed that these results remained significant. CONCLUSION: Our study suggests that a MAP reduces ORAE and provides effective pain relief for patients undergoing LSG.

Comparative study and systematic review of laparoscopic liver resection for hepatocellular carcinoma.

AIM: To compare the surgical outcomes between laparoscopic liver resection (LLR) and open liver resection (OLR) as a curative treatment in patients with hepatocellular carcinoma (HCC). METHODS: A PubMed database search was performed systematically to identify comparative studies of LLR vs OLR for HCC from 2000 to 2014. An extensive text word search was conducted, using combinations of search headings such as "laparoscopy", "hepatectomy", and "hepatocellular carcinoma". A comparative study was also performed in our institution where we analysed surgical outcomes of 152 patients who underwent liver resection between January 2005 to December 2012, of which 42 underwent laparoscopic or hand-assisted laparoscopic resection and 110 underwent open resection. RESULTS: Analysis of our own series and a review of 17 high-quality studies showed that LLR was superior to OLR in terms of short-term outcomes, as patients in the laparoscopic arm were found to have less intraoperative blood loss, less blood transfusions, and a shorter length of hospital stay. In our own series, both LLR and OLR groups were found to have similar overall survival (OS) rates, but disease-free survival (DFS) rates were higher in the laparoscopic arm. CONCLUSION: LLR is associated with better short-term outcomes compared to OLR as a curative treatment for HCC. Long-term oncologic outcomes with regards to OS and DFS rates were found to be comparable in both groups. LLR is hence a safe and viable option for curative resection of HCC.

Post-operative aspirin use and colorectal cancer-specific survival in patients with stage I-III colorectal cancer.

BACKGROUND: Recent observational studies suggest that postoperative aspirin use may improve Colorectal cancer (CRC)-specific survival and overall survival (OS). In this study, we aimed to assess the effects of aspirin use on outcomes in a predominantly Asian cohort of patients with CRC. PATIENTS AND METHODS: Case records of patients undergoing curative resection for stage I-III CRC were retrieved for clinical data and patterns of aspirin use and vital data were determined from hospital electronic prescription records, hospital pharmacy dispensing records, national clinical and prescription databases. CRC-specific and recurrence-free survival (RFS) amongst aspirin users and non-users were analyzed and compared using the Cox proportional hazards model. RESULTS: Out of 726 patients with CRC, 103 were regular aspirin users and 623 were non-users. The median age of the cohort was 65 years (range=22-94 years) and the majority of patients were Chinese (90%). Nineteen percent, 31% and 47% had stage I, II and III CRC respectively; tumor staging was unknown for 3%. After adjusting for prognostic factors (age, stage, lymph node stage, grade, lesion site, perineural invasion, lymphvascular invasion), the risk of CRC relapse or death from CRC was approximately 60% lower compared to patients who were not postoperative aspirin users (Hazard Ratio=0.38, 95% Confidence Interval=0.17-0.84, p=0.017). No benefit was observed for preoperative use of aspirin. CONCLUSION: In this single-Institution study, with long-term follow-up of patients with stage I-III-resected CRC, postoperative aspirin use was associated with reduced risk of relapse of and death from CRC.