Laparoscopic sleeve gastrectomy with loop bipartition: A novel metabolic operation in treating obese type II diabetes mellitus.

INTRODUCTION: We report the first case of laparoscopic sleeve gastrectomy with loop bipartition (a modified form of Santoro's operation) in the treatment of type II diabetes mellitus associated with obesity. PRESENTATION OF CASE: A 46-year-old gentleman (baseline BMI 32.9; BW 98.5kg) with 7-year history of type II diabetes mellitus (DM) underwent the procedure in Hong Kong. The control of DM was poor even with intensive medical therapy before the operation. Standard laparoscopic sleeve gastrectomy (SG) was performed and a loop gastroileostomy was fashioned at the antrum 250cm from the ilececal valve without division of the 1st part of duodenum after SG. The resultant gastric tube has two outlets, one to the first part of duodenum and the other to the ileum with preferential passage of food through the gastroileostomy as shown on subsequent contrast study. The patient's recovery was uneventful. The excess BMI loss was 97% with complete normalization of all metabolic parameters at 1-year follow-up. DISCUSSION: This new surgical procedure (sleeve gastrectomy with loop bipartition: SG+LB) was evolved and derived from the combined concepts of sleeve gastrectomy with transit bipartition (SG+TB), single anastomosis duodenal-ileostomy (SADI), mini-gastric bypass (MGB) and duodenal-jejunal bypass (DJB) with less nutritional and surgical complications. CONCLUSION: Sleeve gastrectomy with loop bipartition may be a very effective and simple operation to treat uncontrolled DM associated with obesity with a lot of apparent advantages over most current metabolic procedures available at the moment.

Laparoscopic greater curve plication in Asia: initial experience.

BACKGROUND: This study aimed to evaluate the effectiveness and safety of laparoscopic greater curve plication (LGCP) for the treatment of obesity in ethnic Chinese in Hong Kong. METHODS: Twenty-seven consecutive Chinese patients (23 females; mean age 37.6 ± 8.9 years) received LGCP for the treatment of obesity from September 2010 to December 2011. Mean baseline body weight (BW) and body mass index (BMI) were 84.6 ± 17.5 kg and 31.2 ± 4.7 kg/m(2), respectively. RESULTS: All procedures were performed laparoscopically with conversion to open surgery in one patient. There was neither mortality nor any postoperative complications. Mean follow-up was 10.6 ± 6.5 months. Mean procedure time was 117.9 ± 22.3 min and mean hospital stay was 2.6 ± 0.7 days. Mean BMI loss was 4.1 ± 1.6, 4.8 ± 2.0 and 5.2 ± 2.5 kg/m(2) at 3, 6 and 12 months. Mean % EBL was 67.3 ± 42.1, 66.4 ± 35.9 and 60.2 ± 25.5 % at 3, 6 and 12 months. Mean % EBL in BMI >35 group (n = 7) was 38.2 ± 11.1, 43.5 ± 14.0 and 50.6 ± 21.6 % at 3, 6 and 12 months. Mean % EBL in BMI <35 group (n = 20) was 76.5 ± 44.2, 76.5 ± 38.2 and 65.0 ± 27.0 % at 3, 6 and 12 months. CONCLUSIONS: LGCP is safe and effective in achieving significant weight loss in obese ethnic Chinese patients. However, weight loss in BMI <35 is more pronounced. It is a very valid alternative to other procedures in Asian population.

Radiofrequency ablation for benign aldosterone-producing adenoma: a scarless technique to an old disease.

OBJECTIVE: To evaluate the safety and efficacy of radiofrequency ablation (RFA) in treating primary aldosteronism (PA) due to aldosterone-producing adenoma (APA). BACKGROUND: Radiofrequency ablation is an established technique for treating malignant solid organ neoplasm. Its application on benign functional adrenal adenoma has never been prospectively described. METHODS: We prospectively evaluated a patient cohort with computed tomography (CT)-guided percutaneous RFA performed on functional APA of size 4 cm or less. Treatment success was defined as complete tumor ablation on follow-up CT scan plus normalization of serum aldosterone-to-renin ratio (ARR) at 3 to 6 months after RFA. Salvage laparoscopic adrenalectomy was offered to patients who had failed RFA and remained hypertensive. RESULTS: Between August 2004 and August 2008, 28 patients were referred for the procedure. Radiofrequency ablation was not performed on 4 APA because of their close proximity to major vascular structures. Twenty-four patients (11 men and 13 women) with a median age of 51.5 (range = 34-63) years underwent RFA for 11 right and 13 left APA. The median tumor diameter was 16.0 (range = 4.0-25.0) mm. There was no periprocedure hypertensive crisis or major morbidity or mortality. Minor complications occurred in 4 patients (16.7%), including 1 small pneumothorax and 3 retroperitoneal hematomas (< 3 cm), which all resolved on conservative treatment. At 3 to 6 months of follow-up, CT scan showed complete tumor ablation in all patients (100%). Primary aldosteronism was biochemically resolved in 23 patients (95.8%). Salvage adrenalectomy was not performed in the single failed patient, as she remained normotensive on repeated follow-up. The overall success rate of RFA was 95.8%. CONCLUSIONS: Computed tomography-guided percutaneous RFA is a safe and efficacious alternative to laparoscopic adrenalectomy in treating patients with PA due to small APA.

Impact on obesity-related illnesses and quality of life following intragastric balloon.

BACKGROUND: The impact of intragastric balloon (IGB) on obesity-related illnesses and quality of life (QOL) has not been previously investigated. METHOD: One hundred and nineteen consecutive obese patients (86 females; mean age 37.8; mean body weight (BW) 103.7 +/- 24.1 kg; mean BMI 38.4 +/- 8.0 kg/m(2)) who underwent IGB were evaluated for improvement on obesity-related illnesses and QOL after weight reduction in a multidisciplinary university referral center. Bioenterics Intragastric balloon (BIB system was employed in the study. RESULTS: Mean treatment period was 169.9 +/- 34.8 days. Mean BW, BMI, and excess body weight loss were 12.4 +/- 6.9 kg, 4.6 +/- 2.7 kg/m(2), and 45.1 +/- 35.3%. Mean waist circumference and biceps fold and triceps fold loss were 10.5 +/- 8.3, 9.8 +/- 8.5, and 8.7 +/- 7.4 cm respectively. Metabolic syndrome was decreased from 42.9% to 15.1% after IGB (p < 0.0005). Improvement of obesity-related illnesses were significant in fasting glucose, cholesterol, triglyceride, C-reactive protein, and blood pressure (p < 0.005).In 28 diabetes patients, HBA1C level was significantly decreased as compared to baseline (7.4 vs. 5.8%; p < 0.0005). The QOL of patients was significantly improved after IGB (p < 0.05). No serious complication related to IGB was observed. Four patients (3.3%) had intolerance and required early removal of balloon. Thirty-one patients (26%) received further bariatric surgery after IGB. CONCLUSIONS: IGB produces meaningful weight loss and significantly improves obesity-related illnesses and quality of life.

Laparoscopic sleeve gastrectomy in ethnic obese Chinese.

BACKGROUND: The aim of this study was to evaluate the effectiveness and safety of laparoscopic sleeve gastrectomy (LSG) for the treatment of obesity in ethnic Chinese in Hong Kong. METHODS: Seventy consecutive Chinese patients (49 females; mean age 34.7+/-8.8 [range 18-56] years) received LSG for the treatment of obesity from May 2006 to Nov 2007 as a stand-alone procedure for weight reduction. Mean baseline body weight (BW) and body mass index (BMI) were 108.9+/-22.1 kg (range 71.0-164.9 kg) and 40.7+/-7.8 kg/m(2) (range 27.4-68.4 kg/m(2)), respectively. Outcome measures were collected and assessed in a prospective manner. RESULTS: All procedures were performed laparoscopically with no conversion. There was neither mortality nor any postoperative complications that required reoperation. Major complication occurred in two patients (2.9%; esophagogastric junction [EGJ] leak and stomach tube stricture). Mean follow-up was 7.1+/-5.0 months. Mean procedure time was 90.6+/-39.4 min, and mean hospital stay was 3.8+/-2.3 days. Mean BMI loss was 6.3+/-2.5, 9.0+/-3.4 and 12.3+/-4.5 kg/m(2) at 3, 6, and 12 months. Mean percent of excess BW loss was 48.5+/-28.4, 69.7+/-31.7, and 63.5+/-29.4 at 3, 6, and 12 months. CONCLUSION: LSG is safe and effective in achieving significant weight loss in obese ethnic Chinese patients.

[Effectiveness and safety of intragastric balloon for treatment of morbid obesity].

OBJECTIVE: To evaluate the effectiveness and safety of intragastric balloon (IGB) for the treatment of obese Chinese. METHODS: IGB was placed into the stomachs of 48 Chinese patients in Hong Kong, 13 males and 35 females; aged 39 +/- 9 (18 - 65), with the mean baseline body weight (BW) of 106 +/- 26 kg and mean body mass index (BMI) of (40 +/- 9) kg/m(2), 34 (70.8%) with coexistent obesity-related morbidities, who failed to respond to other weight reducing treatment, via routine gastroscopy under intravenous conscious sedation. Restricted balanced diet with 1200 kcal/day and exercise of 150 minutes/week were prescribed after the balloon placement. The IGB was removed endoscopically after at most 180 days. Follow-up was conducted once a week during the first month and then once a month. RESULTS: The median hospital stay and treatment duration were 1 (IQR 1:2.25) day and 174 (IQR 166:181) days respectively. The BW, BMI, and waist circumference were significantly decreased after the IGB placement (all P < 0.01) with the mean BW loss of (13 +/- 7) kg, mean BMI loss of (5 +/- 3) kg/m(2), mean excessive body weight loss of (45 +/- 36)%, and mean waist circumference loss of (12 +/- 8) cm. 66.7% of the patients were satisfied with the treatment. No serious complication related to IGB was noted. CONCLUSION: IGB is a safe and effective device that achieves moderate weight loss in obese Chinese.

Prophylactic ilioinguinal neurectomy in open inguinal hernia repair: a double-blind randomized controlled trial.

OBJECTIVE: We conducted a double-blinded randomized controlled trial to investigate the short- to mid-term neurosensory effect of prophylactic ilioinguinal neurectomy during Lichtenstein repair of inguinal hernia. METHOD: One hundred male patients between the age of 18 and 80 years with unilateral inguinal hernia undergoing Lichtenstein hernia repair were randomized to receive either prophylactic ilioinguinal neurectomy (group A) or ilioinguinal nerve preservation (group B) during operation. All operations were performed by surgeons specialized in hernia repair under local anesthesia or general anesthesia. The primary outcome was the incidence of chronic groin pain at 6 months. Secondary outcomes included incidence of groin numbness, postoperative sensory loss or change at the groin region, and quality of life measurement assessed by SF-36 questionnaire at 6 months. All follow-up and outcome measures were carried out by a designated occupational therapist at 1 and 6 months following surgery in a double-blinded manner. RESULTS: The incidence of chronic groin pain at 6 months was significantly lower in group A than group B (8% vs. 28.6%; P = 0.008). No significant intergroup differences were found regarding the incidence of groin numbness, postoperative sensory loss or changes at the groin region, and quality of life measurement at 6 months after the operation. CONCLUSIONS: Prophylactic ilioinguinal neurectomy significantly decreases the incidence of chronic groin pain after Lichtenstein hernia repair without added morbidities. It should be considered as a routine surgical step during the operation.

Intragastric balloon in ethnic obese Chinese: initial experience.

BACKGROUND: We evaluated the effectiveness and safety of intragastric balloon (IGB) for the treatment of obesity in ethnic Chinese in Hong Kong. METHODS: 15 Chinese patients (10 females; median age 40 years (range 21-58)) completed IGB treatment over a 10-month period since November 2004. Median baseline body weight (BW) and BMI were 100.1 (range 78.5-170.3) kg and 39.4 (range 29.6-56.9) kg/m2 respectively. Coexistent obesity-related morbidities were present in 80% of patients. The Bioenterics Intragastric Balloon (BIB) was employed, and all placement and removal were performed endoscopically under intravenous conscious sedation. A restricted balanced diet (approximately 1200 kcal/day) and 150 minutes/week of moderate-intensity exercise were prescribed after balloon placement in a multidisciplinary approach. Outcome measures were collected and assessed in a prospective manner. RESULTS: Median procedure time was 25 (range 19-45) minutes and median hospital stay was 2 (range 1-6) days. Median BW and BMI loss were 15.3 (range 5.3-30.9) kg and 5.6 (range 1.9-12.5) kg/m2 after IGB. The median waist circumference (WC) loss was 9 (range 4-23) cm, and 66.7% of patients were highly satisfied with the treatment. No serious complication related to IGB was observed. CONCLUSION: IGB is a safe and effective device that achieves moderate weight loss in obese ethnic Chinese patients.

Premedication with intravenous ketorolac trometamol (Toradol) in colonoscopy: a randomized controlled trial.

OBJECTIVE: We conducted a prospective double-blinded placebo-controlled randomized trial to investigate the effect of ketorolac trometamol (KT) administered intravenously as premedication in colonoscopy. METHODS: One hundred and forty patients undergoing colonoscopy were randomized to receive either 60 mg of KT (KT group (KTG), n=70) or placebo (normal saline group (NSG), n=70) intravenously as premedication 30 min prior to procedure. Patient-controlled sedation (PCS) was used as the mode of sedation. Outcome measures included patient self-assessed pain score in a 10-cm unscaled visual analog scale (VAS), endoscopist assessment of patient pain score in VAS, patient's willingness to repeat colonoscopy, administered and demanded doses of PCS, patient satisfaction score in VAS, and hemodynamic changes during and after the procedure. RESULTS: The mean patient self-assessed pain score (SD) during procedure was significantly lower in KTG than NSG: 5.08 (2.74) vs 6.62 (2.45); p=0.001. The mean endoscopist assessment of patient pain score (SD) was significantly lower in KTG than NSG as well: 3.99 (2.80) vs 5.28 (2.71); p=0.006. More patients in KTG were willing to repeat procedure as compared with NSG (80.0%vs 57.1%; p=0.004). No significant difference was found in the administered and demanded doses of PCS, mean satisfactory scores and hemodynamic changes in both groups. No serious complication related to intravenous (IV) KT was noted. CONCLUSIONS: Premedication with IV KT (Toradol) improves pain control during colonoscopy with no associated serious complications.