Alvin Kim Hock Eng

Five-year long-term clinical outcome after bariatric metabolic surgery: A multi-ethnic Asian population in Singapore

Bariatric surgery is an effective treatment for morbid obesity and its metabolic related comorbidities; type 2 diabetes, hypertension and hyperlipidaemia.1 However, the literature is scarce regarding the long‐term outcome after bariatric surgery, especially among multi‐ethnic Asian populations. Considering the growing number of bariatric metabolic surgeries in Asia, we have attempted to provide a regional perspective on 5‐year long‐term clinical outcomes post bariatric surgery in Singapore. Between 2010 and 2016, all bariatric operative cases were included, and these comprised: laparoscopic sleeve gastrectomy (LSG), 393; laparoscopic Roux‐En‐Y gastric bypass (RYGB), 125; laparoscopic mini‐gastric bypass (MGB), 43. The primary outcome measure was the percentage of excess weight loss (% EWL) at 6 months, 1, 2, 3, 4 and 5 years, with % remission of type 2 diabetes mellitus (T2DM) at 1 year following LSG (49.7%, 61.2%, 56.1%, 47.8%, 40.8% and 47.3%; 82.2%), RYGB (60.2%, 62.1%, 57.6%, 50.1%, 48.7% and 47.7%; 86.9%) and MGB (58%, 68.1%, 62.7%, 66.2%, 64.0%, 65.2%; 71.9%). In conclusion, MGB and RYGB showed the greatest % EWL at 5 years and are recommended for moderate T2DM. LSG is an effective bariatric operation with a high % EWL up to 2 years, and a high remission rate of mild T2DM. The remission rate of T2DM was equally high in all 3 surgical groups, independent of ethnic differences.

Clinical features of paraduodenal hernia

Paraduodenal hernia (PDH), though uncommon, is a surgical emergency associated with high risk of strangulation and incarceration. Diagnosis of PDH remains challenging due to its non-specific presentation. We report the presentation and management of PDH in our hospital. All PDHs diagnosed from 2003 to 2014 were identified from a hospital database. Diagnosis of PDH was based on either radiological imaging or intraoperative surgical findings. Eight PDHs were identified during the study period. Median age was 48.5 (24–63) years and five occurred in females. All were left-sided PDHs. Six patients experienced recurrent symptoms prior to presentation. The commonest presenting symptoms were recurrent abdominal pain (four patients) and intestinal obstruction (four patients). Five patients were treated conservatively either because they had no obstructive symptoms or they declined surgery. All of them remained well up to a median of 27 (16–45) months’ follow-up. In contrast, three patients with obstructive symptoms underwent surgical repair (laparotomy, hernia repair and adhesiolysis). One patient had sub-acute intestinal obstruction after surgical repair and required re-exploratory surgery. All three PDH patients with obstructive symptoms remained well on follow-up (median 61 (range: 27–114) months) after surgery. In conclusion, PDH is an uncommon cause of intestinal obstruction. A high index of suspicion is required to diagnose PDH.

Endoscopic self‐expandable metallic stenting for palliation of malignant gastric outlet obstruction in Southeast Asia

Malignant gastric outlet obstruction (GOO) is a pre‐terminal event in the natural history of gastric and pancreaticobiliary cancers. The use of endoscopic placement of self‐expandable metallic stents (SEMS) is a less invasive alternative palliative option for these patients. This is the first study in Southeast Asia to evaluate the clinical efficacy and safety of endoscopic SEMS placement in patients with malignant GOO.

Totally Laparoscopic D2 Subtotal Gastrectomy with Hepatectomy and Cholecystectomy for Gastric Neuroendocrine Tumor with Liver Metastases

Synchronous resection of primary neuroendocrine tumors (NET) with liver metastases remains controversial, although recent studies have demonstrated its safety in select patients. Synchronous laparoscopic gastric and liver resection has been rarely reported. We report the case of a 65-year-old man who underwent successful simultaneous D2 subtotal gastrectomy with hepatectomy and cholecystectomy for metastatic gastric NET. This is the first reported case of totally laparoscopic simultaneous D2 gastrectomy with hepatectomy and cholecystectomy for metastatic gastric NET. Laparoscopic simultaneous gastrectomy and hepatectomy is feasible and safe in select patients with metastatic gastric NET.

Molecular Genetics of Gastric Adenocarcinoma

Gastric carcinoma is the second leading cause of cancer deaths in the world. Its aetiology is closely linked to the bacterial pathogen Helicobacter pylori which is believed to induce a state of chronic inflammation that predisposes to a cascade of molecular and cellular alterations leading to carcinogenesis. Although the exact process of gastric carcinogenesis has yet to be elucidated fully, the interaction of the genetic factors with environmental factors is likely to be a significant consideration. Numerous genes and molecular pathways have been discovered to be associated with gastric adenocarcinoma and more importantly, it is now becoming possible to use some of these as means of prognostication and targeted therapy. This review will outline our current understanding of the aetiology and molecular genetics of gastric adenocarcinoma and its current clinical applications.