Recommendations for eligibility criteria concerning bariatric and metabolic surgical and endoscopic procedures for obese Hong Kong adults 2024: Hong Kong Society for Metabolic and Bariatric Surgery Position Statement.

The surgical management of obesity in Hong Kong has rapidly evolved over the past 20 years. Despite increasing public awareness and demand concerning bariatric and metabolic surgery, service models generally are not standardised across bariatric practitioners. Therefore, a working group was commissioned by the Hong Kong Society for Metabolic and Bariatric Surgery to review relevant literature and provide recommendations concerning eligibility criteria for bariatric and metabolic interventions within the local population in Hong Kong. The current position statement aims to provide updated guidance regarding the indications and contraindications for bariatric surgery, metabolic surgery, and bariatric endoscopic procedures.

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.

Appropriate timing for surgery after neoadjuvant chemoradiation for esophageal cancer.

Optimal interval between neoadjuvant chemoradiotherapy (CRT) and surgery is not elucidated for esophageal squamous carcinoma. The aim of this study is to evaluate the impact of this time interval on patient outcome. Patients treated with neoadjuvant CRT followed by surgery between 2002 and 2009 were analyzed. Patients were divided into two groups based on the median interval to surgery (64 days): A  64 days (n = 53). A second analysis was performed by re-classifying patients into three interval groups: A* ≤ 40 days (n = 16); B* 41-80 days (n = 60); C* > 80 days (n = 31). Operative outcome, pathological data, and long-term survival were analyzed. One hundred and seven (n = 107) patients were analyzed. Five patients (9.4%) in group B had an anastomotic leak compared with no leakage from group A (P < 0.021). The complete pathological response was comparable in groups A and B (35% vs. 24.5%, p = 0.23). R0 was significantly lower in group A* (A*: 56.3%, B*: 90%, C*: 74.2%, P = 0.006). In patients with R0 resection, 5-year survival was significantly better in group A than B (71.7% vs. 51%, P = 0.032) and in group A* (A* 100% vs. B* 60.2% & C* 48.3%; A* vs. B*, P = 0.036; A* vs. C*, P = 0.019). Complete pathological response was an independent predictor of survival. Early surgery with R0 resection following neoadjuvant CRT may lead to a better outcome. Further prospective studies are still necessary to provide better insight into the issue. At present, timing of surgery should be individualized and performed at the earliest opportunity.

Post-esophagectomy gastric conduit cancers: treatment experiences and literature review.

Esophagectomy remains the mainstay of treatment for esophageal cancer. The stomach is the commonest organ used to restore intestinal continuity after esophagectomy. Metachronous gastric cancer in the gastric conduit after esophagectomy is rare; the etiology remains unclear. Possible risk factors include Helicobacter pylori infection, biliary or pancreatic reflux and prior radiotherapy. Prognosis of these patients remains poor. Treatment of this particular entity poses unique challenges to the surgeon and oncologist. Early diagnosis by endoscopy may allow endoscopic excision such as endoscopic mucosal resection or endoscopic submucosal dissection. In more advanced cancers, surgery is difficult, reconstruction is complicated, and further radiation may not be feasible because of previous neoadjuvant therapy. In this report, four patients who developed gastric conduit cancers are presented. They were treated with either surgery alone or combined with chemoradiotherapy. All four patients were still alive after at least 21 months, with three patients currently still alive (21-48 months). The literature is also reviewed, in particular addressing the incidence, possible underlying causes, prognosis and options of treatment for this specific clinical scenario.

Post-oesophagectomy anastomotic-bronchial fistula.

Anastomotic leakage after oesophagectomy is a dreaded complication. It has a wide range of presentations ranging from the patient being totally asymptomatic to septic with multi-organ failure. From the literature, in general, cervical anastomoses have a higher leakage rate than those that are intra-thoracic, but leaks from the latter confer greater morbidity. Cervical anastomotic leaks that are truly confined to the neck can be managed conservatively, but can extend into the mediastinum and result in more serious complications. Herein, we report on a patient with an oesophago-gastric anastomosis constructed in the neck but with extension into the mediastinum. Subsequently, the patient developed a fistulous erosion into the tracheobronchial tree, which was successfully managed endoscopically.

The use of self-expanding metallic stents (SEMS) is effective in symptom palliation from recurrent tumor after esophagogastrectomy for cancer.

The efficacy of using self-expanding metallic stent (SEMS) for palliation of symptoms because of tumor recurrence after prior esophagogastrectomy has not been properly assessed despite the well recognized use of SEMS in patients without prior surgery. The aim of this study is to evaluate the efficacy and safety of using SEMS in patients who had prior esophagogastrectomy. The study group included 35 patients with carcinoma of esophagus or cardia documented to have loco-regional recurrence after esophagogastrectomy and in whom SEMS were placed for palliation. The median age was 67 (ranged 41-85). The indications for stenting were dysphagia caused by recurrence at the esophageal anastomosis (n= 4) and in the esophageal remnant (n= 5), or extrinsic compression from mediastinal nodal disease (n= 7); gastric outlet obstruction produced by extrinsic tumor compression (n= 13); and tracheo-esophageal fistulae (n= 6). Forty-three stenting procedures were performed, and the technical success rate was 97.6%. The dysphagia score improved from 4.66 to 2.54 (P < 0.001). All patients with tracheo-esophageal fistula had their symptoms successfully palliated. The immediate complication rate was 14% (n= 5); two patients had stent malpositioning, two had inadequate opening of their stents, and one had a failed stenting procedure. On follow-up, 15 (42.8%) patients required a total of 22 re-intervention procedures for various reasons: endoscopic dilatation (five dilatations in three patients), removal of foreign bodies (nine procedures in four patients), and insertion of a second SEMS related to tumor growth (eight stents in eight patients). There was no procedure-related mortality. The median survival was short at 42 days (range 5-290 days), mostly related to advanced disease stage. SEMS in patients with recurrent tumor after esophagogastrectomy is safe and effective.

Outcome of laparoscopic colorectal resection.

It has been nearly two decades since the first laparoscopic colectomy was reported. However, the wide application of the procedure in various colorectal diseases, particularly colorectal malignancy, has been slow. With the recent reports ofoncological outcomes from randomised controlled trials, the oncological safety of laparoscopic colectomy has been proven and the long-term outcome is at least not inferior to open resection. The application of laparoscopic resection should not be regarded as a contraindication against management of colon cancer, but instead it appears the preferred treatment when the short-term benefits are considered. Regarding rectal cancer, the CLASICC (Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer) trial showed equal oncological outcome in patients who underwent laparoscopic and open resection for rectal cancer in a randomised trial. The application of laparoscopic resection for rectal cancer should be accepted, though cautions are still needed to scrutinise more data from high quality studies.