Long-term effects of bariatric surgery on cardiovascular risk factors in Singapore

INTRODUCTION@#Bariatric surgery is considered an effective treatment for weight loss and for improving the metabolic profile of patients with obesity. Obesity-related comorbidities such as hyperlipidaemia and type 2 diabetes mellitus (DM) are significant cardiovascular risk factors. Additionally, prospective clinical trials have shown that statins increase the risk of development of DM, and many patients with obesity are on statins. We retrospectively examined the effect of bariatric surgery on lipid profile, DM control and weight loss at the five-year follow-up.@*METHODS@#In total, 104 patients undergoing bariatric surgery from 2008 to 2012 were retrospectively studied. 36 patients were on preoperative statins. Their lipid profile, DM control and weight loss were examined at the one-year and five-year follow-ups.@*RESULTS@#Both high-density lipoprotein and triglyceride levels showed significant improvement at the one-year and five-year follow-ups (p = 0.01). Total cholesterol showed significant improvement at the one-year follow-up (-0.30 mmol/dL, p = 0.0338); however, better control was not sustained at the five-year follow-up (-0.15 mmol/dL, p = 0.133). Low-density lipoprotein did not show any considerable improvement at the one- and five-year follow-ups (-0.27 mmol/dL, p = 0.150 and -0.24 mmol/dL, p = 0.138, respectively). A statistically significant improvement in DM control was observed in these patients and in those on preoperative statins. Weight loss was sustained at one and five years.@*CONCLUSION@#Bariatric surgery does not confer a uniform improvement in lipid profile in the long term. It does, however, induce efficient weight loss and improvement in diabetic profile, even in patients on preoperative statins.

Outcomes of oesophageal cancer treated with neoadjuvant compared with definitive chemoradiotherapy

INTRODUCTION@#We report outcomes of patients with oesophageal cancer treated with neoadjuvant chemoradiotherapy (NACRT) plus surgery or definitive chemoradiotherapy (chemoRT) at our institution.@*METHODS@#We retrospectively reviewed patients who underwent chemoRT from 2005 to 2017. The primary outcome was overall survival (OS). Secondary outcomes were disease-free survival (DFS) and toxicities.@*RESULTS@#We identified 96 patients with median age of 64 years and squamous cell carcinoma in 82.3%. Twenty-nine patients (30.2%) received NACRT plus surgery, 67 patients (69.8%) received definitive chemoRT. Median follow-up was 13.5 months. The 3/5-year OS were 26.4%/13.4%, and 59.6%/51.6% in the definitive chemoRT and NACRT plus surgery groups, respectively. The 3/5-year DFS were 19.3%/12.3%, and 55.7%/37.2% in the definitive chemoRT and NACRT plus surgery groups, respectively. NACRT plus surgery significantly improved OS (hazard ratio [HR] 0.40, 95% confidence interval [CI] 0.22-0.72, @*CONCLUSION@#NACRT plus surgery improved OS and DFS. However, in view of treatment-related complications, careful selection of patients is warranted. With the predominant histology of our cohort being squamous cell carcinoma (SCC), our results may be more relevant for those with SCC.

Laparoscopic sleeve gastrectomy for morbidly obese adolescents in Singapore

INTRODUCTION@#Laparoscopic sleeve gastrectomy (LSG) outcomes among adolescents and factors associated with adolescent obesity in Singapore were evaluated.@*METHODS@#Prospectively collected data of patients aged 16-19 years who underwent LSG was retrospectively reviewed. A lifestyle questionnaire, Berlin and Epworth scores, and Patient Health Questionnaire-9 scores were collected. Preoperative anthropometrics, comorbidities, weight loss and body composition outcomes were recorded.@*RESULTS@#Among 208 LSGs, 13 (6.3%) were performed on obese adolescents. Mean age and body mass index (BMI) at first presentation were 19.1 ± 0.9 (range 16.8-19.8) years and 46.2 ± 6.3 (range 36-57) kg/m, respectively. There was family history of obesity (n = 7) and regular consumption of high-calorie drinks (n = 12). Most patients had comorbidities (n = 12), including hypertension (n = 5), asthma (n = 4), diabetes mellitus (n = 3), hernia (n = 3) and obstructive sleep apnoea requiring continuous positive airway pressure support (n = 3). At one year, excess weight loss was 64.3% ± 34.7% (range 21.8%-101.5%), while BMI and fat mass dropped to 31.2 ± 7.6 (range 23-40) kg/m and 17.4 kg, respectively. Pain score was 2/10 at 24 hours after surgery. Mean postoperative stay was 2.7 days. No complications or readmissions occurred. Remission of diabetes mellitus and hypertension was reported in two of three and four of five adolescents, respectively, within one year of surgery.@*CONCLUSION@#LSG is a safe option for adolescents with good short-term weight loss outcomes and remission of metabolic comorbid conditions.

Is Laparoscopic Sleeve Gastrectomy for Asian Super Obese a Safe and Effective Procedure?

<p><b>INTRODUCTION</b>Outcomes of bariatric surgery for super obese Asians are not well reported. We aimed to compare short-term outcomes of laparoscopic sleeve gastrectomy (LSG) in Asian patients with body mass index (BMI) <47.5 kg/m to those with BMI •••••• ≥47.5 kg/m.</p><p><b>MATERIALS AND METHODS</b>A total of 272 patients from Singapore university hospital who underwent LSG from 2008 to 2015 with a follow-up of at least 6 months were included in the study. Primary endpoint was weight loss at 1-year and 3-years. Morbid obesity (Group 1, G1) was defined as BMI <47.5 kg/m and super obesity (Group2, G2) was defined as BMI ≥47.5 kg/m.</p><p><b>RESULTS</b>There were 215 patients in G1 and 57 patients in G2 (mean preoperative weight: 107.3 kg and 146.8 kg; mean follow-up: 27.9 and 26.8 months, respectively). Mean total weight loss at 3-year of 41.9 kg for G2 was significantly higher ( = 0.003) than 27.2 kg for G1. Mean percentage excess weight loss (EWL) did not differ at 3-years. There was no difference in operating time, blood loss, length of stay, 30-day morbidity and readmission. There were no conversions and mortality in both groups. Remission of herpertension ( - 0.001) and dyslipidaemia ( = 0.038) were significantly associated with achieving EWL percentage (%EWL) >50 in G1.</p><p><b>CONCLUSION</b>LSG is an equally safe and effective operation in Asians with BMI ≥47.5 kg/m2 when compare to patients with BMI <47.5 kg/m in achieving significant weight loss and improvement in comorbidities. Super obese lose more weight but have lower %EWL.</p>

Attitudes and Concerns of Diabetic Patients towards Bariatric Surgery as Treatment of Diabetes

<p><b>INTRODUCTION</b>Bariatric surgery is increasingly recognised as an effective treatment for type 2 diabetes that significantly improves glycaemic control, even achieving remission. This study examined perceptions and concerns of diabetic patients towards bariatric surgery as a treatment option for diabetes.</p><p><b>MATERIALS AND METHODS</b>A total of 150 patients were recruited from a specialised diabetic outpatient clinic and completed a questionnaire (items were rated on a Likert scale from slightly important [lowest score of 1] to extremely important [maximum score of 5]). Logistic regression was performed to identify factors influencing decision for surgery.</p><p><b>RESULTS</b>The 74 males and 76 females had mean age of 50 (range 20 to 78) and body mass index (BMI) of 29.6 kg/m(range 18.1 to 51); 61% considered surgery favourably. Predictive factors for interest in surgery: higher educational levels (OR = 2.3; 95% CI, 1.2 to 4.4), duration of diabetes (OR = 0.4; 95% CI, 0.2 to 1.0) and use of insulin (OR = 2.1; 95% CI, 1.1 to 4.1). Reasons for surgery: desire for remission (Likert scale 4.7 ± 0.7), to prevent complications (Likert scale 4.5 ± 0.9) and to reduce medications (Likert scale 4.3 ± 1.1). For those not keen on surgery, main reasons were fear of surgery (Likert scale 4 ± 1.5) and satisfaction with current therapy (Likert scale 3.7 ± 1.6).</p><p><b>CONCLUSION</b>Many diabetic patients would consider surgery as an option to improve their metabolic disorder (greater interest in patients with higher educational levels, currently using insulin and with shorter duration of diabetes). Surgical complications, length of recovery and duration of benefits were the main concerns.</p>

Perforated Early Gastric Cancer: Uncommon and Easily Missed a Case Report and Review of Literature

Gastric carcinoma rarely presents as a perforation, but when it does, is perceived as advanced disease. The majority of such perforations are Stage III/IV disease. A T1 gastric carcinoma has never been reported to perforate spontaneously in English literature. We present a 56 year-old Chinese male who presented with a perforated gastric ulcer. Intra-operatively, there was no suspicion of malignancy. At operation, an open omental patch repair was performed. Post-operative endoscopy revealed a macroscopic Type 0~III tumour and from the ulcer edge biopsy was reported as adenocarcinoma. Subsequently, the patient underwent open subtotal gastrectomy and formal D2 lymphadenectomy. The final histopathology report confirms T1b N0 disease. The occurrence of a perforated early gastric cancer re-emphasises the need for vigilance, including intra-operative frozen section and/or biopsy, as well as routine post-operative endoscopy for all patients.

Surgical management of obesity - National University Hospital experience

<p><b>INTRODUCTION</b>The Singapore National Survey of 2004 reported the prevalence of obesity to have increased to 6.9%, thus reflecting the profound changes in our society's lifestyle and eating habits. Bariatric surgery has steadily been increasing to counter the ill effects of obesity.</p><p><b>MATERIALS AND METHODS</b>We audited our prospective series of 31 patients who had laparoscopic adjustable gastric banding (LABG) for morbid obesity performed by our multidisciplinary team at the National University Hospital, Singapore, between August 2004 and December 2006.</p><p><b>RESULTS</b>The median age at presentation was 40 years old including 6 males and 25 females. Their median BMI was 42.35 kg/m(2). At a median follow-up of 26 months, the median percentage of excess weight loss (%EWL) was 41.95%. The positive impact of gastric banding on comorbidities are evident whereby 15 (94%) of the diabetics had improved glycaemic control with HbA(1)C of 7.7% preoperatively improving to 5.9% postoperatively, and also 8 (58%) now take smaller doses of oral hypoglycaemic agents. Hypertension improved in 4 patients and 2 (11%) were cured. All our patients with dyslipidaemia had their statin doses reduced with marked lowering of serum lipid levels. We had 2 patients (6.45%) with band erosion and another 2 with reflux oesophagitis. Our article also summarises the available surgical procedures while discussing the pros and cons of each.</p><p><b>CONCLUSION</b>Our results showed that a multidisciplinary programme can achieve significant weight loss for obese patients in Singapore. To achieve long-term weight loss, a commitment of both the medical team and the patient is necessary. Laparoscopy has revolutionised the practice of bariatric surgery worldwide. LAGB is an effective and safe procedure.</p>