Bariatric surgery is expensive but improves co-morbidity: 5-year assessment of patients with obesity and type 2 diabetes.

BACKGROUND: Bariatric surgery can be effective in weight reduction and diabetes remission in some patients, but is expensive. The costs of bariatric surgery in patients with obesity and type 2 diabetes mellitus (T2DM) were explored here. METHODS: Population-based retrospectively gathered data on patients with obesity and T2DM from the Hong Kong Hospital Authority (2006-2017) were evaluated. Direct medical costs from baseline up to 60 months were calculated based on the frequency of healthcare service utilization and dispensing of diabetes medication. Charlson Co-morbidity Index (CCI) scores and co-morbidity rates were measured to compare changes in co-morbidities between surgically treated and control groups over 5 years. One-to-five propensity score matching was applied. RESULTS: Overall, 401 eligible surgical patients were matched with 1894 non-surgical patients. Direct medical costs were much higher for surgical than non-surgical patients in the index year (€36 752 and €5788 respectively; P < 0·001) mainly owing to the bariatric procedure. The 5-year cumulative costs incurred by surgical patients were also higher (€54 135 versus €28 603; P < 0·001). Although patients who had bariatric surgery had more visits to outpatient and allied health professionals than those who did not across the 5-year period, surgical patients had shorter length of stay in hospitals than non-surgical patients in year 2-5. Surgical patients had significantly better CCI scores than controls after the baseline measurement (mean 3·82 versus 4·38 at 5 years; P = 0·016). Costs of glucose-lowering medications were similar between two groups, except that surgical patients had significantly lower costs of glucose-lowering medications in year 2 (€973 versus €1395; P = 0.012). CONCLUSION: Bariatric surgery in obese patients with T2DM is expensive, but leads to an improved co-morbidity profile, and reduced length of hospitalization.

Long-term survival outcomes after definitive chemoradiation versus surgery in patients with resectable squamous carcinoma of the esophagus: results from a randomized controlled trial.

BACKGROUND: The aim of this study was to report on the 5-year survival outcomes of patients with resectable esophageal carcinoma who were treated by definitive chemoradiotherapy (CRT) or standard esophagectomy. PATIENTS AND METHODS: Between July 2000 and December 2004, 81 patients with resectable squamous cell carcinoma of the mid- or lower thoracic esophagus were randomized to receive esophagectomy or definitive CRT. The primary outcome was the overall survival and secondary outcomes included disease-free survival, morbidities and mortalities. RESULTS: Forty-five patients received esophagectomy and 36 patients were treated by definitive CRT. The overall 5-year survival favors CRT but the difference did not reach statistical significance (surgery 29.4% and CRT 50%, P=0.147). A trend to improved 5-year survival was observed for patients suffering from node-positive disease (P=0.061). The 5-year disease-free survival also showed a trend to significance favoring CRT (P=0.068), particularly for patients suffering from node-positive disease (P=0.017). Both the stage of the disease and albumin level were significant predictors to mortality and disease-free survival. CONCLUSIONS: Definitive CRT for squamous esophageal carcinoma resulted in comparable long-term survival to surgery. Further large-scale studies would be required to further investigate the role of CRT in node-positive patients. Clinicaltrials.gov identifier: NCT01032967.

Laparoscopic Heller's cardiomyotomy achieved lesser recurrent dysphagia with better quality of life when compared with endoscopic balloon dilatation for treatment of achalasia.

Achalasia is a rare primary motility disorder of esophagus; treatments include endoscopic balloon dilatation (EBD) and laparoscopic Heller's cardiomyotomy (LC). This study compared EBD versus LC for treatment of achalasia with focus on quality of life (QoL) and prevalence of post-treatment gastroesophageal reflux disease. This was a retrospective cohort study of all patients diagnosed with achalasia older than 16 treated with either EBD or LC from January 1998 to April 2008. Patients' demographic data, comorbidities, postintervention GERD symptoms, QoL, recurrence of dysphagia, reintervention rate, hospital stay, and time to resumption of diet were collected. Sixty-eight patients were recruited into the study (EBD n= 50; LC n= 18). A significant improvement in QoL was found in patients undergoing LC (0.917 vs. 0.807, P= 0.006). A higher proportion of patients treated with EBD developed post-treatment gastroesophageal reflux symptoms (60.5% vs. 43.8%) when compared with LC, although statistically insignificant (P= 0.34). Patients treated with balloon dilatation had a greater percentage of recurrence of dysphagia (55.1% vs. 26.7%; P= 0.235) and need of reintervention (42.1% vs. 9.1%; P= 0.045). However, these patients had a shorter median hospital stay (1d [range 0-4]) and earlier resumption of diet (0d [range 0-3]). Although EBD is associated with a quicker perioperative recovery, LC accomplished a better QoL, lower incidence of recurrence of dysphagia, and need of reintervention after treatment for achalasia.

Use of laparoscopic sleeve gastrectomy and adjustable gastric banding for suboptimally controlled diabetes in Hong Kong.

Bariatric surgery has recently been considered as an option for treatment of type 2 diabetes mellitus (T2DM). We assessed the effect of laparoscopic gastric banding and laparoscopic sleeve gastrectomy in a cohort of 39 T2DM Chinese patients with body mass index (BMI) over 30 kg/m(2) . Their mean body weights and BMI before surgery were 108 kg and 40 kg/m(2) , respectively, and 18 patients (46%) had suboptimal diabetic control (HbA1c >7%). After a mean follow-up of 27 months, 4 of 11 insulin-dependent patients (36%) were able to stop their insulin therapy, and 18 patients (46%) achieved remission of T2DM (HbA1c <6.5% without the use of medication). Glycaemic control remained poor in only nine other patients (27%). Logistic regression analysis showed that a short history of T2DM and high BMI could predict remission of diabetes after restrictive procedures. Our results suggest that restrictive surgery can significantly improve glycaemic control in obese T2DM patients.

Laparoscopic adjustable gastric banding for the treatment of morbidly obese patients: early outcome in a Chinese cohort.

OBJECTIVE: To evaluate the efficacy of laparoscopic adjustable gastric banding in the management of morbid obesity in a cohort of Chinese patients. DESIGN. Cohort study. SETTING: University teaching hospital, Hong Kong. PATIENTS: From August 2002 to September 2003, 10 patients (6 male, 4 female) with a median age of 34 years (range, 23-48 years) underwent laparoscopic adjustable gastric banding to treat morbid obesity. Considerable co-existing diseases were present in 90% of the cases. We instituted a team approach that allowed every patient to see our dietitian, physician, psychiatrist (if necessary), and surgeon prior to deciding on the procedure to be used. MAIN OUTCOME MEASURES: Excessive body weight loss, quality-of-life score (SF36), and co-morbidities improvement. RESULTS: The 10 patients had a median weight of 127 kg (range, 115-196 kg) and median body mass index of 47 kg/m(2) (range, 38-67 kg/m(2)). The operation was successful in all patients with a median operating time of 110 minutes (range, 75-240 minutes). The median hospital stay was 3 days (range, 3-4 days) and three of the patients required overnight observation in the intensive care unit because of severe sleep apnoea and asthma. The median follow-up period was 12 months (range, 1-18 months). The mean weight loss at 6, 12, and 18 months was 19.3, 22.4, and 25.9 kg, respectively. Mean percentage of excessive weight loss at 6, 12, and 18 months was 34.9%, 36.5%, and 40.5%, respectively. Unsatisfactory weight loss (<20 kg) occurred in three patients because of poor dietary compliance and non-follow-up. Surgery also considerably improved the patients' co-morbidities (hypertension, diabetes, and obstructive sleep apnoea) and the quality of life. CONCLUSION: In the short term, laparoscopic adjustable gastric banding is certainly an effective procedure for morbid obesity, which results in a substantial weight loss and improvement of co-existing morbidities. Longer follow-up will show whether this weight loss is maintainable.

Combined sinus tract endoscopy and endoscopic retrograde cholangiopancreatography in management of pancreatic necrosis and abscess.

BACKGROUND: We report our experience of sinus tract endoscopy (STE) and endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of pancreatic necrosis and abscess. METHODS: Thirteen patients with extensive pancreatic necrosis were firstly managed with either percutaneous drainage (PD group; n = 9) or open necrosectomy (ON group; n = 4). Debridement of necrotic tissue was subsequently performed via the drain tract by STE. ERCP was performed only when there was a suspicious of persistent pancreatic duct disruption or choledocholithiasis. RESULTS: In the PD group, the median number of STE sessions required was 3 (range 2-8). The median hospital and ICU stay were 84 days (range 29-163 days) and 0 day (range 0-64 days), respectively, with an overall success rate of 67%. In the ON group, the median number of STE sessions required was 6.5 (range 1-18). The median hospital and ICU stay were 82 days (range 58-194 days) and 19 days (range 4-24 days), respectively. No mortality or failure was noted in the latter group. ERCP was required in nine of 13 patients. CONCLUSION: Combined ERCP and STE is a useful adjunct in treating pancreatic necrosis or abscess.

Short-term and long-term results of endoscopic balloon dilation for achalasia: 12 years' experience.

BACKGROUND AND STUDY AIMS: This retrospective study reports 12 years' experience with pneumatic dilation treatment in patients with achalasia and attempts to define factors capable of predicting failure of endoscopic dilation. PATIENTS AND METHODS: Consecutive patients with achalasia who received endoscopic balloon dilation were studied retrospectively. Repeat dilation was carried out if dysphagia persisted or recurred. A structured symptom score questionnaire (the Eckardt score) was conducted by phone with patients who had received dilation and had been followed up for more than 2 years. Failure was defined as the presence of significant dysphagic symptoms after more than two repeat dilations. Data for the first 2 years (short-term) and for the subsequent follow-up (long-term) were analyzed. RESULTS: From 1989 to 2001, 66 patients underwent endoscopic balloon dilation for achalasia; three perforations (4.5 %) occurred, with no mortalities. Dysphagic symptoms significantly improved 12 weeks after the procedure ( P < 0.05). Fourteen patients (20 %) required a second dilation procedure within a median of 7 months (range 1 - 52 months), and 13 of them underwent repeat dilations within the first 2 years. Five patients (7.5 %) required further surgical or endoscopic therapy. Fifty-eight patients received pneumatic dilation for more than 2 years; 32 (55 %) responded to the questionnaire. The mean dysphagia score was 1.7 (SD 1.2), with only five patients (16 %) having significant dysphagic symptoms during a median follow-up period of 55 months (range 26 - 130 months). The cumulative success rates for pneumatic dilation after 5 and 19 years were 74 % and 62 %, respectively. Cox regression analysis identified small balloon size (30 mm) as the only significant factor capable of predicting failure of endoscopic dilation ( P = 0.009; relative risk 5.3; 95 % confidence interval, 1.7 to 40.9). CONCLUSIONS: Endoscopic balloon dilation is an effective treatment for achalasia, with minimal morbidity (60 % experience long-term benefit).

The safety, feasibility, and acceptability of patient-controlled sedation for colonoscopy: prospective study.

OBJECTIVE: To assess the safety, feasibility, and acceptability of patient-controlled sedation for elective day-case colonoscopy, and the factors predicting patients' unwillingness to use patient-controlled sedation for colonoscopy. DESIGN: Prospective, non-randomised study. SETTING: University-affiliated endoscopy centre, Hong Kong. PARTICIPANTS: Five hundred patients who underwent elective day-case colonoscopy were prospectively recruited from January 2001 to June 2002. INTERVENTION: Sedation for colonoscopy was a mixture of propofol and alfentanil, which was delivered by means of a patient-controlled syringe pump. Each bolus delivered 4.8 mg propofol and 12 microg alfentanil. No loading dose was used and the lockout time was set at zero. MAIN OUTCOME MEASURES: Cardiopulmonary complications, dose of patient-controlled sedation used, recovery time, satisfaction score, delayed side-effects, and the willingness to use the same sedation protocol for future colonoscopy. A multiple stepwise logistic regression model was used to assess which factors might predict unwillingness to use patient-controlled sedation for colonoscopy. RESULTS: The mean (standard deviation) age of patients was 53.0 (13.9) years. The mean dose of propofol consumed was 0.93 (0.69) mg/kg. Forty-three (8.6%) patients developed hypotension during the procedure. The mean satisfaction score was 7.2 (2.6). Sixteen (3.2%) patients developed delayed side-effects. The median (interquartile range) recovery time was 0 (0-5) minutes. Approximately 78% of patients were willing to use patient-controlled sedation for future colonoscopy if needed. Younger age (<50 years), female sex, a higher mean dose of sedatives used, a lower satisfaction score, and the presence of delayed side-effects were independent factors that were associated with patients' unwillingness to use patient-controlled sedation for colonoscopy. CONCLUSION: . The use of patient-controlled sedation for elective colonoscopy is safe, feasible, and acceptable to most patients.

Can visual distraction decrease the dose of patient-controlled sedation required during colonoscopy? A prospective randomized controlled trial.

BACKGROUND AND STUDY AIMS: We previously demonstrated that audio distraction using relaxation music could lead to a decrease in the dose of sedative medication required and improve patient satisfaction during colonoscopy. This prospective randomized controlled trial was designed to test the hypotheses that visual distraction may also decrease the requirement for sedatives and that audio and visual distraction may have additive beneficial effects when used in combination. PATIENTS AND METHODS: 165 consecutive patients who underwent elective colonoscopy were randomly allocated into three groups to receive different modes of sedation: group 1 received visual distraction and patient-controlled sedation (PCS); group 2 received audiovisual distraction and PCS; group 3 received PCS alone. A mixture of propofol and alfentanil, delivered by a Graseby 3300 PCA pump, was used for PCS in these groups. Each bolus of PCS delivered 4.8 mg propofol and 12 micro g alfentanil. Measured outcomes included the dose of PCS used, complications, recovery time, pain score, satisfaction score, and willingness to use the same mode of sedation if the procedure were to be repeated. RESULTS: Eight patients were excluded after randomization. The mean+/-SD dose of propofol used in group 2 (0.81 mg/kg +/- 0.49) was significantly less than the dose used in group 1 (1.17 mg/kg +/- 0.81) and that used in group 3 (1.18 mg/kg +/- 0.60) ( P < 0.01, one-way analysis of variance). The mean +/- SD pain score was also lower in group 2 (5.1 +/- 2.5), compared with the pain scores in group 1 (6.2 +/- 2.2) and group 3 (7.0 +/- 2.4) ( P < 0.01, one-way analysis of variance). The mean +/- SD satisfaction score was higher in groups 1 (8.2 +/- 2.4)) and 2 (8.4 +/- 2.4), compared with the score in group 3 (6.1 +/- 2.9) ( P < 0.01, one-way analysis of variance). A majority of patients in groups 1 (73 %) and 2 (85 %) said that they would be willing to use the same mode of sedation again, compared with only 53 % in group 3 ( P < 0.01, chi-squared test). CONCLUSIONS: Visual distraction alone did not decrease the dose of sedative medication required for colonoscopy. When audio distraction was added, both the dose of sedative medication required and the pain score decreased significantly. Both visual and audiovisual distraction might improve patients' acceptance of colonoscopy.

Minimal invasive approach of gastric and esophageal mobilization in total pharyngolaryngoesophagectomy: total laparoscopic and hand-assisted laparoscopic technique.

BACKGROUND: To evaluate early results in total pharyngolaryngoesophagectomy (PLE) by minimally invasive approaches for patients suffered from pharyngoesophageal tumor. METHODS: Between April 1998 and September 2001, 12 consecutive patients underwent either total laparoscopic (n = 9) or hand-assisted laparoscopic (n = 3) gastric mobilization plus transhiatal esophageal resection in total PLE. The operative data and postoperative outcomes were evaluated. RESULTS: Total PLE by minimally invasive approach was successfully performed in 11 patients, and 1 patient required conversion due to uncontrolled bleeding. The median total operative time was 8.5 h (range, 5-11 h) and the abdominal laparoscopic stage usually took less than 4 h. The median time for extubation was 2 days (range, 1-4 days) and the median ICU stay was 2 days (range, 1-20 days). There was no 30-day mortality, and major complications occurred in 5 patients (42%). CONCLUSION: Minimally invasive PLE is a feasible and safe alternative to conventional open surgery for patients with pharyngoesophageal carcinoma.

Through-the-scope stent for malignant gastric outlet obstruction.

This report is of the technique and results for through-the-scope stent in palliating malignant gastric outlet obstruction for 17 patients. All procedures were done using conscious sedation and fluoroscopy. Enteral Wallstents with a diameter of 20 mm or 22 mm and length 60 mm or 90 mm were used and delivered over a guidewire through an endoscope with an operating channel of at least 3.7 mm. A total of 18 stents were placed. One stent failed to be deployed. One stent migrated and required insertion of a second stent. One patient required repeat endoscopy to stop bleeding from the tumour. Through-the-scope stent relieved obstructive symptoms for 14 (82%) patients. The median dysphagia score improved from 4 to 2 after through-the-scope stent (P=0.001). The median overall survival and hospital-free survival time was 6 weeks (interquartile range, 3-9 weeks) and 4 weeks (interquartile range, 1-7 weeks), respectively. To conclude, through-the-scope stent was safe and feasible, offering an alternative minimal invasive method to palliate obstructive symptoms for patients with inoperable tumours causing gastric outlet obstruction.