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.

Laparoscopic distal pancreatectomy: a comparative study.

BACKGROUND/AIMS: This article aims to describe the different techniques of laparoscopic distal pancreatectomy and to compare the results of our series of 9 laparoscopic resections against the historical open control in the same institution. With the advent of laparoscopic surgery, there is an increasing number of patients with different pancreatic pathologies that can now be managed by minimal access surgery. The initial results of laparoscopic pancreatectomy are quite promising particularly for those small neuroendocrine and cystic neoplasms located at the body and tail of pancreas. METHODOLOGY: The different techniques of laparoscopic distal pancreatectomy are described in detail with special emphasis on the need of "hand assistance" and the different methods of splenic preservation. The perioperative data of 9 laparoscopic distal pancreatectomies are analyzed and compared against the 5 historical open controls in the same institution. RESULTS: There were 9 laparoscopic pancreatic resections performed in our institution since 1999. Indications for surgery included 5 cystic neoplasms (1 patient with concomitant splenic artery aneurysm), 1 chronic pancreatitis with pancreatic duct stricture and a small pseudocyst, 1 pseudopancreatic tumor secondary to seal off perforated posterior gastric ulcer, 1 pseudopapillary tumor and 1 neuroendocrine tumor. There were 6 females and 3 males with median age of 61 years (range 18-79). The majority of patients was of low anesthetic risk (ASA 1 or 2). Total laparoscopic resection was performed in 7 cases and 2 resections were performed using the hand-assisting technique. Out of the 4 cases with splenic preservation, only one patient had both splenic artery and vein successfully preserved, whereas the other 3 cases had to rely on the short gastric arcade. Median operating time was 180 minutes (range 120-250) and median blood loss was 100cc (range 50-500). Pancreatic leak occurred in two patients (22.2%) and 1 patient developed intraabdominal collection, all of which settled upon conservative treatment. In our series, clear resection margin was obtained for all the neoplastic cases. Median hospital stay was 7 days (4-53). Postoperatively, patients consumed an average of 15 tablets of dologesic. No other complications were observed upon a median follow-up of 15 months (1-50). When results were compared to the 5 historical open controls (excluding those malignant tumors), patients managed with this new approach had significantly less intraoperative blood loss (100 vs. 450 mL, P = 0.021). CONCLUSIONS: Our initial experience not only confirmed the feasibility oflaparoscopic pancreatectomy, but also demonstrated the promising results of this approach in selected patients.

An alternative gallbladder extraction technique in laparoscopic cholecystectomy.

In this era of minimally invasive surgery, the challenge remains in finding techniques to reduce access trauma in terms of fewer and smaller size trocar ports. Our new described technique will allow a smaller subxiphoid port to be used to achieve extraction of the gallbladder without the need to change to a 5 mm laparoscope. We believe this method is easy to learn, safe and with no observable complications from our experience.

Antegrade biliary stenting versus T-tube drainage after laparoscopic choledochotomy--a comparative cohort study.

BACKGROUND/AIMS: Laparoscopic exploration of the common bile duct (LECBD) has been proven to be an effective and preferred treatment approach for uncomplicated common bile duct stones. However there is still controversy regarding the choice of biliary decompression after laparoscopic choledochotomy. METHODOLOGY: This is a retrospective comparison between the use of antegrade biliary stenting and T-tube drainage following successful laparoscopic choledochotomy. During the period between January 1995 and July 2003, biliary decompression was achieved by either antegrade biliary stenting or T-tube drainage based on the discretion of the operating surgeon. For antegrade biliary stenting, a 10-Fr Cotton-Leung biliary stent was inserted through the choledochotomy and passed down across the papilla. The stent position was confirmed by on-table choledochoscopy before interrupted single-layered closure of the common bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) was performed to remove the stent 4 weeks after operation and at the same time to check for any residual stones or other complications like stricture or leak. In the T-tube group, a 16-Fr latex T-tube was used and the long limb was brought out through the subcostal trocar port followed by the same method of bile duct closure. Cholangiogram through the T-tube was performed on day 7 and the tube would be taken off 1 week later (about 2 weeks after operation) if the cholangiogram did not reveal any abnormality. The two groups were compared according to the demographic data, operation time, length of hospital stay and complication rates. RESULTS: During the study period, 108 laparoscopic explorations of the common bile duct were performed in our centre of which 95 were attempted laparoscopic choledochotomies and 13 were transcystic duct explorations. Of the 95 patients with attempted laparoscopic choledochotomy, there were 9 open conversions, 17 laparoscopic bilioenteric bypasses and 6 primary closures of the common bile duct. All of these patients together with those receiving transcystic duct explorations were excluded and the remaining 63 patients having postoperative bile diversion by either antegrade biliary stenting or T-tube drainage were included in this study. Bile diversion was achieved by antegrade biliary stenting in 35 patients whereas 28 patients had T-tube drainage. There was no difference between the two groups in terms of age, clinical presentation, bilirubin level, length of hospital stay, follow-up duration, common bile duct size, size of common bile duct stones, incidence of residual/recurrent stone and complication rate. It was observed that more patients in the stenting group developed bile leak (14.2% vs. 3.5%) and required more intramuscular pethidine injections (182.86 +/- 139.30 vs. 92.81+/-81.15mg, P=0.000). On the other hand, the T-tube group had longer operation time (141.4+/-45.1 vs. 11 1.1+/-33.9 minutes, P=0.006) and had a longer postoperative hospital stay (10.0+/-7.4 vs. 8.8+/-9.3 days, P=0.020) reaching statistical significance. CONCLUSIONS: Postoperative bile diversion by antegrade biliary stenting after laparoscopic choledochotomy is shown to shorten operation duration and postoperative stay as compared to T-tube drainage, but the problem of bile leak needs further refinement of insertion technique.

Stapled technique for acute thrombosed hemorrhoids: a randomized, controlled trial with long-term results.

PURPOSE: This study was designed to compare stapled vs. conventional hemorrhoidectomy for patients with acute thrombosed hemorrhoids. METHODS: Forty-one patients with acute thrombosed hemorrhoids were randomized into: 1) stapled hemorrhoidectomy (PPH group; n = 21), and 2) open hemorrhoidectomy (open group; n = 20). Emergency surgery was performed with perioperative data and complications were recorded. Patients were followed up by independent assessors to evaluate pain, recurrence, continence function, and satisfaction at regular intervals. RESULTS: The median follow-up for the PPH group and open group were 59 and 56 weeks, respectively. There was no significant difference in terms of the hospital stay, complication rate, and continence function; however, the mean pain intensity in the first postoperative week was significantly less in the PPH group (4.1 vs. 5.7, P = 0.02). Patients in the PPH group recovered significantly faster in terms of the time to become analgesic-free (4 vs. 8.5 days, P < 0.01), time to become pain-free (9 vs. 20.5 days, P = 0.01), resumption of work (7 vs. 12.5 days, P = 0.01), and time for complete wound healing (2 vs. 4 weeks, P < 0.01). On long-term follow-up, significantly fewer patients in the PPH group complained of recurrent symptoms (0 vs. 5, P = 0.02). The overall symptom improvement and patients' satisfaction were significantly better in the PPH group (90 vs. 80 percent, P = 0.03 and +3 vs. +2, P < 0.01 respectively). CONCLUSIONS: Stapled hemorrhoidectomy is safe and effective for acute thrombosed hemorrhoids. Similar to elective stapled procedure, emergency stapled excision has greater short-term benefits compared with conventional excision: diminished pain, faster recovery, and earlier return to work. Long-term results and satisfaction were excellent.

Non-operative management of small cell carcinoma of esophagus.

Primary small cell carcinoma of the esophagus (SmCC) is an uncommon aggressive tumor characterized by early systemic dissemination and poor prognosis, regardless of the methods of treatment. The optimal treatment strategy remains uncertain. A retrospective study was conducted to review the results of non-operative treatment for patients with limited and metastatic esophageal SmCC. Between 1993 and 2003, 10 patients were diagnosed to have primary esophageal SmCC in our institution. Six of them had disseminated diseases, whereas the other four had limited disease upon diagnosis. All patients were managed non-operatively by either chemotherapy and/or radiotherapy. The overall median survival was 8 months (range, 2-62 months). The survival was 4-62 months for patients with limited disease, whereas it was 2-10 months for patients with disseminated disease at initial diagnosis. In summary, the current study demonstrated satisfactory palliation could be achieved with chemo-radiation for patients with limited disease; however, the ultimate role of primary chemo-radiation for esophageal SmCC must await results from randomized trials.

Laparoscopic abdominoperineal resection revisited: are there any health-related benefits? A comparative study.

BACKGROUND: Laparoscopic colectomy is associated with less overall morbidity and improved survival for patients with colonic cancers. There are unfortunately limited clinical reports on laparoscopic abdominoperineal resection. We therefore designed this study to compare laparoscopic abdominoperineal resection with conventional open surgery, with emphasis on health-related issues from the patients' perspective in order to justify its role in the management of low rectal or anal canal tumours. METHODS: We carried out a non-randomized, prospective comparative study on a cohort of patients who underwent either laparoscopic or open abdominoperineal resection between March 1994 and December 2003. Patient demographics, tumour characteristics, operative morbidity and mortality, as well as overall survival were considered. The standard endpoints of last follow-up date and deaths were used. Data was analyzed according to intention-to-treat principle. RESULTS: A total of 102 patients were recruited: 31 patients underwent conventional open abdominoperineal resection (OAPR) and 71 patients were treated laparoscopically. Patient demographics, median follow-up period, as well as tumour characteristics were similar between groups. The median operating time was similar among groups (145 min in laparoscopic group vs. 156 min in open group; p=0.62). Patients in the laparoscopic group had significantly less blood loss (p=0.01) and fewer requirements for blood transfusion (p=0.01). Despite similar overall morbidity, the laparoscopic group had a reduced incidence of abdominal wound infections (p=0.01) and chest infections (p=0.01). Overall survival was significantly better in the laparoscopic group (p=0.01). CONCLUSIONS: Laparoscopic abdominoperineal resection confers definite health-related benefits the over open approach in terms of reduced septic complications and fewer requirements for blood transfusion. It should be considered the procedure of choice for patients with low rectal or anal canal tumour in whom sphincter excision proved inevitable.