Appropriate Timing of Bariatric Surgery in Obese Type 2 Diabetes Patients

To combat the associated pandemics of obesity and type 2 diabetes mellitus, clinicians need every tool they can get. Currently, bariatric/metabolic surgery is widely accepted as the most effective treatment for weight loss and glycemic control. Nonetheless, the impact noted in clinical studies seems to have predominantly been on the numerical reductions of bodyweight and blood glucose level after surgery. Past and recent evidence about the role of bariatric surgery in the different stages of the clinical course of type 2 diabetes were presented in this paper. Given the evidence on the efficacy of bariatric surgery for obese patients with type 2 diabetes ranging from pre-diabetes through a long-standing diabetic state with established or end-stage macro- and micro-vascular complications, the overall conclusions are that end organ damage is expected to either stabilize or improve postoperatively in most cases. However, some of these clinical outcomes have not been assessed with a robust method, and many cases are not supported by randomized clinical trials. Available evidence strongly advocates in favor of bariatric surgery in the early phase of this course, possibly in the pre-diabetic or very early diabetic stages. To reserve surgery to more advanced and complicated stages of the disease seems to confer fewer benefits in the clinical course of diabetes and might expose these more frail patients to the possible side effects of a rapid weight loss.

Early experiences of minimally invasive surgery to treat gastroesophageal reflux disease / 대한외과학회지

PURPOSE: There are fewer patients with gastroesophageal reflux disease (GERD) in Korea compared with Western countries. The incidence of GERD has increased in recent years however, concerning many physicians. Here, we report our early experiences of using a recently introduced method of laparoscopic antireflux surgery for the treatment of GERD in Korean patients. METHODS: Fifteen patients with GERD were treated using antireflux surgery between May 2009 and February 2012 at the University of Ulsan College of Medicine and Asan Medical Center. Laparoscopic Nissen fundoplication with 360degrees wrapping was performed on all patients. RESULTS: Eleven male and four female patients were evaluated and treated with an average age of 58.1 +/- 14.1 years. The average surgical time was 118.9 +/- 45.1 minutes, and no complications presented during surgery. After surgery, the reflux symptoms of each patient were resolved; only two patients developed transient dysphagia, which resolved within one month. One patient developed a 6-cm hiatal hernia that had to be repaired and reinforced using mesh. CONCLUSION: The use of laparoscopic surgery for the treatment of GERD is safe and feasible. It is also an efficacious method for controlling the symptoms of GERD in Korean patients. However, the use of this surgery still needs to be standardized (e.g., type of surgery, bougienage size, wrap length) and the long-term outcomes need to be evaluated.

Improvement of Type 2 Diabetes after Bariatric Surgery in a Patient with Severe Obesity / 임상당뇨병

The prevalence of obesity is steadily increasing worldwide and is commonly associated with metabolic diseases including hypertension, hyperlipidemia, and type 2 diabetes as well as increased mortality. Bariatric surgery is an effective treatment modality for patients with severe obesity and type 2 diabetes that are refractory to conventional treatments. We performed bariatric surgery (biliopancreatic diversion with duodenal switch) in a 23-year-old man with severe obesity and uncontrolled type 2 diabetes. Before surgery, the patient experienced continuous weight gain and aggravated glycemic control despite dietary restrictions, exercise, and medications including high dose insulin. After surgery, his weight was reduced by 17 kg and he was able to stop insulin treatment. This case suggests that bariatric surgery is an effective therapeutic option when severe obesity and type 2 diabetes are refractory to usual treatments.

The Learning Curve of Laparoscopy-assisted Distal Gastrectomy (LADG) for Cancer

PURPOSE: Laparoscopic surgery for gastric cancer was introduced in the past decade because it was considered less invasive than open surgery, and this results in less postoperative pain, faster recovery and an improved quality of life. Several studies have demonstrated the safety and feasibility of this procedure. We examined the outcome of performing laparoscopic surgery for gastric cancer over the last two year. MATERIALS AND METHODS: From April 2004 to December 2006, 329 patients with gastric adenocarcinoma underwent a laparoscopy-assisted distal gastrectomy with lymph node dissection. The data was retrospectively reviewed in terms of the clinicopathologic findings, the perioperative outcomes and the complications. RESULTS: The total patient group was comprised 196 men (59.6%) and 133 women (40.4%). The mean BMI was 23.6 and the mean tumor size was 2.7 cm. The mean number of harvested lymph node was 22.7, and this was 18.6 before 30 cases and 23.1 after 30 cases, and the difference was significant (P=0.02). The mean operation time was 180.9 min, and this was than 287.9 min before 30 cases and 170.2 min after 30 cases. After 30 cases, there was a significant improvement of the operation time (P<0.01). The mean incision length after 30 cases was shorter than that before 30 cases (P<0.01). Postoperative complications occurred in 24 (7.3%) of 329 patients and there was no conversion to open surgery. CONCLUSION: Even though the LADG was accompanied by a difficult learning curve, we successfully performed 329 LADG procedures over the past 2 years and we believe that LADG is a safe, feasible operation for treating most early gastric cancers (EGC).

Mucinous Adenocarcinoma of the Colon and Rectum

PURPOSE: This study was to evaluate and compare the clinical characteristics of a mucinous adenocarcinoma with those of a non-mucinous adenocarcinoma in colorectal cancer patients. METHODS: Data were retrospectively reviewed on 3,232 colorectal cancer patients, including 221 mucinous adenocarcinoma patients (6.1%), who received surgery between 1990 and 2003. RESULTS: The mean tumor size (6.5 cm) of the mucinous adenocarcinomas was bigger than that (5.2 cm) of the non-mucinous adenocarcinomas. The locations of the mucinous adenocarcinomas were 95 (48.2%) in the proximal colon, 35 (17.8%) in the distal colon, and 67 (34.0%) in the rectum whereas those of the non-mucinous adenocarcinomas were 559 (18.9%) in the proximal colon, 861 (29.2%) in the distal colon, and 1,533 (51.9%) in the rectum. Stage distribution was as follows: In mucinous adenocarcinomas, 7 stage A (3.3%), 84 stage B (39.3%), 76 stage C (35.5%), and 47 stage D (21.9%). In non-mucinous adenocarcinomas, 447 stage A (15.2%), 1,036 stage B (35.1%), 997 stage C (33.8%), and 469 stage D (15.9%). In the univariate analysis, the overall 5-year survival rate of patients with a mucinous adenocarcinoma was lower than that of patients with a non-mucinous adenocarcinoma (60% vs. 65%, P=0.016), but survival rates for each stage were not significantly different. The difference in recurrence rates was not statistically significant (33.3% vs. 24.2%, P=0.258). A multivariate analysis showed that the mucinous histologic type was not useful as an independent prognostic factor. CONCLUSIONS: Mucinous colorectal adenocarcinomas tend to be large, exist in a proximal location, have an advanced stage at diagnosis. The difference in survival rates for each stage was not statistically significant. A mucinous histologic type was not an independent prognostic factor.