The Bioenteric Intragastric Balloon (BIB) as a treatment for obesity: poor results in Asian patients.

INTRODUCTION: The Bioenteric Intragastric Balloon (BIB, Inamed Health, Santa Barbara, CA, USA) is an endoscopic method for achieving restriction of gastric intake in obese patients. It is less invasive and cheaper than bariatric surgery, but can only be left in the stomach for six months. We report our experience with the BIB in Singapore. METHODS: Since its introduction to our hospital in 2004, a prospective database has been kept of all patients undergoing BIB insertion. This database was used to retrieve the information for this study. RESULTS: 20 patients have undergone BIB insertion. Mean patient age was 40 (range, 28-52) years and 85 percent were female. Mean body weight was 79.6 (range, 67.6- 103.7) kg. Mean body mass index (BMI) was 31.5 (range, 27.8-38.8) kilogramme per square metre. Mean excess weight was 21.2 (range, 11.9-37.6) kg. The BIBs were inserted under conscious sedation. BIB intolerance was a major problem and four patients (20 percent) required early BIB removal due to refractive nausea and epigastric discomfort. All remaining BIBs were removed after six months under conscious sedation. The mean maximum weight loss during the six months was 5.9 (range, 1.4-13.4) kg. The mean maximum percentage of excess weight lost was 32.4 (range, 6.7-87). Weight loss was reasonably preserved at the end of the sixmonth period, but by one year, when all the patients had been without BIBs for at least six months, the mean weight loss for the group compared to pre-BIB weight was only 1.5 kg (range, weight gain 5.3 kg to weight loss 9 kg). The mean percentage excess weight loss at one year was 10.9 (range, 15.1 percent weight gain to 31.3 percent weight loss). Only four patients (20 percent) regarded their experience with the BIB as a success. CONCLUSION: The BIB is poorly tolerated by Asian patients, even when lower volumes are inserted into the balloon to compensate for the smaller Asian stature. Although temporary weight loss can be achieved, mandatory removal of the BIB at six months results in regain of the lost weight in the majority of patients. Eligible patients (BMI 32.5 and above) should be encouraged to undergo bariatric surgery rather than BIB to achieve long-term reliable weight loss. Patients who are ineligible for bariatric surgery may benefit from BIB, especially if they have severe comorbidities and have failed to lose weight by any other means in a validated weight management programme, but the chance of long-term success is poor.

Laparoscopic adjustable gastric banding for severe obesity.

INTRODUCTION: Severe obesity is an increasing problem in Singapore. Laparoscopic adjustable gastric banding (LAGB) was introduced at our hospital in 2001 as part of a comprehensive weight management programme. To assess the effectiveness of this procedure, our results to date have been reviewed. METHODS: A prospective database was kept of all patients undergoing LAGB and this was used to retrieve the information. RESULTS: 256 consecutive patients underwent LAGB from January 2001 up to December 2005. There were 163 females and 93 males, with a median age of 36 years (range 18-63 years). Median preoperative weight was 112.7 kg (range 71.5-204 kg) and median body mass index (BMI) was 41.9 (range 32-73). Three patients were converted from laparoscopic to open laparotomy (1.2 percent). 91 percent of patients were discharged home on the first postoperative day. There were seven hospital morbidities (2.7 percent) with one mortality (0.4 percent). During follow-up, 20 patients (7.8 percent) developed late complications requiring revision surgery. Ten were band complications, requiring revision or removal of the band. The other ten were minor access port or tubing complications. Median weight loss at one year was 27.6 kg (range 5.6-71.2 kg) and median excess weight loss, using a BMI of 23 as a baseline, was 51.7 percent (range 9-117.5 percent). Easily measurable comorbidities such as diabetes mellitus and hypertension improved or resolved in 85.4 percent of patients. CONCLUSION: There is a clear demand for LAGB in Singapore. This has increased since the BMI thresholds for severe obesity were reduced in Asian patients. The surgery provides effective, lasting weight loss with improvement or resolution of comorbidity for most patients. LAGB has the advantages of allowing controlled weight loss and life-long treatment while being easily reversible. When compared to other bariatric surgical procedures, low hospital morbidity has to be offset against the closer follow-up required and the need for secondary surgical procedures in some patients.

Symptomatic and radiological follow-up after para-esophageal hernia repair.

The treatment of para-esophageal hernia by the laparoscopic approach has been described by a number of authors. The lower morbidity of the laparoscopic approach compared with the open approach holds some attraction, however, reservations regarding the durability of laparoscopic repair exist. There is a paucity of objective follow-up data in the literature with regard to repair durability and symptomatic outcome. A review was undertaken of 94 patients over a 7 year period undergoing attempted laparoscopic repairs of para-esophageal hernia. Preoperative and operative data was collected and patients underwent postoperative interview and barium meal. Laparoscopic repair was successfully completed in 86 patients. Symptomatic reherniation occurred in 12% (10/86) of patients undergoing laparoscopic repair. These patients underwent open reoperative surgery. There were no symptomatic recurrences in patients undergoing initial open repair. Symptomatic outcome was assessed by interview in 78% (73/94) of patients at a median of 27 months (3-93 months) postoperatively. Ninety-seven percent (71/73) of patients were satisfied with their ultimate symptomatic outcome however, this group included seven patients who had required reoperative surgery for symptomatic recurrence and were therefore laparoscopic failures. In order to determine the asymptomatic recurrence rate patients were requested to undergo a barium meal. A further nine small asymptomatic recurrences were diagnosed in 42 patients having had laparoscopic repair. This represents an asymptomatic radiographic recurrence rate of 21%. Laparoscopic repair in this series was associated with a 12% symptomatic recurrence rate. The majority of patients with symptomatic recurrence underwent open reoperation with good results. Strategies for reducing recurrences should be examined in prospective series.

Laparoscopic excision of a Brunner's gland hamartoma of the duodenum.

Brunner's gland hamartoma (adenoma) was first described in 1876. It is a rare hamartomatous lesion, with only 100 cases reported in the world literature. Treatment has been by endoscopic snaring. Open surgical excision was reserved for cases where snaring had failed. We report a case of a Brunner's gland hamartoma (2.4 cm) that was successfully resected by laparoscopic techniques. Postoperative hospital stay was brief (2 days), and there were no complications. This is the second reported case to be resected laparoscopically.

Esophagogastric fistula secondary to teflon pledget: a rare complication following laparoscopic fundoplication.

Laparoscopic fundoplication has become the standard operation for gastroesophageal reflux disease. In our service, a laparoscopic fundoplication is performed as a 2-cm floppy 360 degrees wrap with division of the short gastric vessels and the fundoplication is sutured using a prolene 2/0 mattress suture (Ethicon, USA) and buttressed laterally with two teflon pledgets (PTFE 1.85 mm; low porosity, Bard, USA). We report a patient with post-operative dysphagia due to an esophagogastric fistula caused by erosion of a teflon pledget. This is the first such case in 734 laparoscopic fundoplications performed between January 1991 and December 1998. Reoperation was required, resulting in a prolonged convalescence. A review of current literature has not revealed any similar cases. Causes for this rare complication are postulated.

Multiple tumour presentation of trichilemmal carcinoma.

Trichilemmal carcinoma is a rare skin tumour occurring in the sun-exposed areas of the elderly. It originates from the external root sheath of the hair follicle and is the malignant form of the trichilemmoma. Clinically, it may be mistaken for a squamous cell carcinoma, basal cell carcinoma, nodular melanoma or keratoacanthoma. It is distinct from the proliferating trichilemmal tumour. Trichilemmal carcinoma is usually a solitary lesion and an extensive literature search revealed no previously reported cases of multiple tumour presentation. We describe a case of trichilemmal carcinoma arising from three distinct sites in the same patient and discuss the differential diagnoses, histological features and probable aetiology of this rare tumour.

Sclerosing lipogranuloma of the scrotum following a laparoscopic herniorraphy and varicocelectomy--a case report.

"Sclerosing lipogranuloma" was first coined to describe a lesion of adipose tissue thought to be due to trauma. Later, analysis of the fat within these lesions showed the presence of exogenous paraffin hydrocarbons and a link with paraffin injection was postulated. In Japan, lipogranulomas without a history of trauma or paraffin injection have been described more frequently. Our patient, developed such a lesion in his scrotum following a laparoscopic left herniorrhaphy and varicocelectomy (intra-abdominal approach). He had no prior history of trauma or paraffin injection. A possible relationship is postulated.