Ming Te Huang

Effect of Laparoscopic Mini-Gastric Bypass for Type 2 Diabetes Mellitus: Comparison of BMI >35 and <35 kg/m2

BackgroundLaparoscopic gastric bypass resulted in significant weight loss and resolution of type 2 diabetes mellitus (T2DM). The current indication for bariatric surgery is mainly applied for patients with body mass index (BMI) >35xa0kg/m2 with comorbidity status. However, little is known concerning T2DM patients with BMI <35xa0kg/m2. Recent studies have suggested that T2DM patients with BMI <35xa0kg/m2 might benefit from gastric bypass surgery.MethodsFrom Jan 2002 to Dec 2006, 820 patients who underwent laparoscopic mini-gastric bypass were enrolled in a surgically supervised weight loss program. We identified 201 (24.5%) patients who had impaired fasting glucose or T2DM. All the clinical data were prospectively collected and stored. Patients with BMI <35xa0kg/m2 were compared with those of BMI >35xa0kg/m2. Successful treatment of T2DM was defined by HbA1C <7.0%, LDL <100xa0mg/dl, and triglyceride <150xa0mg/dl.ResultsAmong the 201 patients, 44 (21.9%) had BMI <35xa0kg/m2, and 114 (56.7%) had BMI between 35and 45, 43 (21.4%) had BMI >45xa0kg/m2. Patients with BMI <35xa0kg/m2 are significantly older, female predominant, had lower liver enzyme and C-peptide levels than those with BMI >35xa0kg/m2. The mean total weight loss for the population was 32.1, 33.4, 31.9, and 32.8% (at 1, 2, 3, 5xa0years after surgery), and percentage to change in BMI was 31.9, 34.2, 32.2, and 29.5% at 1, 2, 3, and 5xa0years. One year after surgery, fasting plasma glucose returned to normal in 89.5% of BMI <35xa0kg/m2 T2DM and 98.5% of BMI >35xa0kg/m2 patients (pu2009=u20090.087). The treatment goal of T2DM (HbA1C <7.0%, LDL <150xa0mg/dl and triglyceride <150xa0mg/dl) was met in 76.5% of BMI <35xa0kg/m2 and xa092.4% of BMI >350xa0kg/m2 (pu2009=u20090.059).ConclusionLaparoscopic gastric bypass resulted in significant and sustained weight loss with successful treatment of T2DM up to 87.1%. Despite a slightly lower response rate of T2DM treatment, patients with BMI <35 still had an acceptable DM resolution, and this treatment option can be offered to this group of patients.

Laparoscopic Mini-gastric Bypass: Experience with Tailored Bypass Limb According to Body Weight

BackgroundGastric bypass surgery is an effective and long-lasting treatment of morbidly obese patients. However, the bypass limb may need to be tailored in morbidly obese patients with a wide range of obesity. The aim of the present study was to report clinical result of tailored bypass limb in a group of patients receiving laparoscopic mini-gastric bypass surgery.MethodsFrom Jan 2002 to Dec 2006, laparoscopic mini-gastric bypass was performed in 644 patients [469 women, 175 men: mean age 30.5u2009±u20098.1xa0years; mean body mass index (BMI) 43.1u2009±u20096.0] in our department. The gastric bypass limb was tailored according to the preoperative BMI. The clinical data and outcomes were analyzed. All the clinical data were prospectively collected and stored.ResultsTwo hundred eighty-six patients belonged to lower BMI (BMIu2009<u200940; mean 36.0), 286 patients moderate BMI (BMI 40–50; mean 43.2), and 72 patients higher BMI (BMIu2009>u200950; mean 55.4). All procedures were completed laparoscopically. Mean operative time was 130xa0min, and mean hospital stay was 5.0xa0days. Twenty-three minor early complications (4.3%) and 13 major complications (2.0%) were encountered, with one death occurred (0.016%). There was no significant difference in operation time and complication rate between the groups. The mean bypass limb was 150xa0cm for the lower BMI group, 250xa0cm for moderate BMI group, and 350xa0cm for the higher BMI group. The mean BMI reduction 2xa0years after surgery was 10.7, 15.5, and 23.3 for the lower, moderate, and higher BMI group. The weight loss curves and resolution of obesity related comorbidities were compatible with the tailored bypass limbs between the groups. However, the lower BMI patients had more severe anemia than the other two groups.ConclusionMorbidly obese patients receiving gastric bypass surgery may need to tailor the bypass limb according to BMI. The application of gastric bypass in lower BMI patients should be more carefully.

Fatty Liver Disease: Predictors of Nonalcoholic Steatohepatitis and Gallbladder Disease in Morbid Obesity

BackgroundNonalcoholic steatohepatitis (NASH) and gallbladder disease (GD) are members of metabolic syndrome in morbidly obesity. Insulin resistance is a risk factor for NASH and GD. The aim of the present study was to investigate the relationship between insulin resistance (HOMA-IR), liver fibrosis, NASH and GD in morbidly obese patients who presented with fatty liver during preoperative abdominal ultrasonography examination.MethodsWe studied 152 morbid obese patients with fatty liver disease including 54 with NASH, 11 with GD and two with concurrent NASH and GD that were undergoing laparoscopic bariatric surgery. Clinical data (gender, age, body mass index [BMI], and associated diseases), laboratory evaluation, and histopathology were obtained from the patient databases. We analyzed the relationship between clinical characteristics, histological parameters, HOMA-IR, and fibrosis stage associated with NASH and GD in morbid obese patients.ResultsAmong the 152 patients with fatty liver disease, 93 were females and 59 were males. The mean age was 30.3u2009±u20098.9xa0years and the mean BMI was 44.9u2009±u20095.4xa0kg/m2. Fifty-four patients (54/152, 35.5%) were diagnosed as NASH and 11 patients (11/152, 7.2%) received concomitant laparoscopic cholecystectomy because of gallbladder disease (GD). Morbidly obese patients with fatty liver disease and GD were significantly older (Pu2009=u20090.020), had higher serum levels of cholesterol (Pu2009=u20090.020) and low-density lipoprotein (LDL)-cholesterol (Pu2009=u20090.044), and had lower serum levels of total bilirubin (Pu2009=u20090.044), C-peptide (Pu2009=u20090.023), and insulin (Pu2009=u20090.039) than the NASH group. Histopathology factors of hepatic steatosis (Pu2009=u20090.012), ballooning degeneration (Pu2009=u20090.001), lobular inflammation (Pu2009=u20090.019), fibrosis (Pu2009=u20090.026), and glycogenated nuclei (Pu2009=u20090.028) were significantly different between NASH and GD groups. However, further multivariate analysis failed to demonstrate any independent clinicopathological factor. The prevalence of chronic hepatitis B and NASH was the same (18%) in all 11 GD patients. Besides, when we compared NASH patients (nu2009=u200954) with concurrent NASH-GD patients (nu2009=u20092), we found that waist (Pu2009=u20090.016), waist/hip (Pu2009=u20090.039), and HOMA-IR (Pu2009=u20090.040) were independent associated factors. We further assessed the HOMA-IR distribution and the relationship between fibrosis stage in patients with NASH and GD. In the NASH group, HOMA-IR distribution progressively decreased when the severity of fibrosis was plotted as a function of insulin resistance.ConclusionThe prevalence of NASH in gallbladder disease was 18% in morbid obese population. We concluded that age, serum cholesterol, and low-density lipoprotein cholesterol levels were risk factors associated with gallbladder disease and fatty liver disease. Insulin resistance was more common in concurrent NASH and gallbladder disease. The mechanism between insulin resistance, fibrosis stage, NASH, and gallbladder disease is unknown.

A Series of Laparoscopic Liver Resections with or without HALS in Patients with Hepatic Tumors

BackgroundDifferences were compared between laparoscopic surgery with and without hand-assisted laparoscopic technique (HALS) in order to assess whether HALS is a safe and feasible alternative to laparotomy and to determine what factors contributed to successful laparoscopic liver surgery.MethodFrom a total of 416 liver resections, 45 patients with 46 hepatic tumors were chosen for laparoscopic liver resection with or without a hand-assisted technique. For each patient, her/his surgical duration, intraoperative blood loss, tumor size and location, hospital stay after surgery, mortality, and morbidity were recorded for analysis.ResultsThe 45 surgical laparoscopic liver resections included 19 left lateral lobectomies, three hemihepatectomies, three segmentectomies, and 21 partial hepatectomies. A HALS was used more frequently in the right posterior group (14/16) than in the anterior group (6/29). There was no notable difference between these two groups in terms of tumor size, mean surgical time, blood loss during surgical procedure, hospital stay after surgery, and occurrence of complication.ConclusionSurgical results between HALS and non-HALS usage were similar except for higher blood loss with HALS, higher use of HALS when liver cirrhosis was present, and less likelihood of using HALS when there was a superficial location of the tumor or lesion.

Laparoscopic antireflux surgery for the elderly: A surgical and quality-of-life study

PurposeLaparoscopic antireflux surgery (LARS) has long been introduced as an alternative method for the treatment of gastroesophageal reflux disease (GERD) in young adults. However, the safety of this procedure and the associated improvement in the quality of life for the elderly are rarely discussed. This study compared the results between young and elderly patients who underwent laparoscopic fundoplication for the treatment of GERD.MethodsFrom January 1999 to January 2006, there were 231 adult patients who underwent LARS for GERD at a single institute. Among all patients, 33 patients were older than 70 years old (14.3%, 73.0 ± 1.9, range 70–76), 198 patients were younger than 70 years old (85.7%, 46.6 ± 11.5, range 20–69). The clinical characteristics, operation time, postoperative hospital stay, surgical complications, and quality of life were retrospectively analyzed.ResultsThe mean operation time had no significant difference between the younger group and the elderly group. The mean postoperative hospital stay in the elderly group was slightly longer than the younger group (4.1 ± 2.5 days vs 3.4 ± 1.3 days, P = 0.19). There were no mortalities and no major complications found in each group. No patients required conversion to an open procedure. Four patients had minor complications (three in the elderly group, rate: 9.0%; one in the younger group, rate: 0.5%, P < 0.05). There were two patients in the nonelderly group who had recurrence. A comparison of the preoperative and postoperative Gastro-Intestinal Quality of Life Index (GIQLI) scores showed significant improvements (99.3 ± 19.2 points, and 110.2 ± 20.6 points, respectively, P < 0.05) with no significant difference between the two groups.ConclusionLaparoscopic antireflux surgery thus appears to provide an equivalent degree of safety and symptomatic relief for elderly patients with GERD as that observed in young patients.

Severe Peritonitis due to Streptococcus viridans Following Adjustable Gastric Banding

AbstractsLate postoperative intra-abdominal infections after laparoscopic gastric banding are extremely rare and may or may not be associated with the device following uncomplicated adjustable gastric banding procedures. The spectrum of pathogens associated with intra-abdominal infections is diverse and depends on the origin of the infection. Streptococci is a significant cause of peritoneal dialysis peritonitis (6% to 16% of the cases), and S. viridans is reported to account for up to 93% of streptococci infections. However, peritonitis due to S. viridans in patients following adjustable gastric banding is very rare. We herein report a non-uremic case of a 38-year-old male patient with severe peritonitis due to S. viridans 5xa0years after an uneventful primary gastric banding procedure.

Clinical Characteristics and Outcome of Morbidly Obese Bariatric Patients with Concurrent Hepatitis B Viral Infection

BackgroundBariatric surgery is the only effective and long-lasting treatment of morbidly obese patients. However, the safety and efficacy of bariatric surgery in patients with hepatitis B viral (HBV) infection is not clear. The aim of the present study is to investigate weather HBV infection influences clinic features and outcomes of bariatric surgery.MethodsThe preoperative seropositivity of HBV surface antigen (HBsAg) using radioimmunoassay was determined in 592 patients (481 female, 111 male: mean age 30.5u2009±u20098.1xa0years; mean body mass index [BMI] 43.1u2009±u20096.0) who had undergone bariatric surgery (209 banding and 383 gastric bypass) for their morbid obesity in the past 5xa0years. All the clinical data were prospectively collected and stored.ResultsThe overall seroprevalence of HbsAg was 18.8%. Morbidly obese patients positive for HBV infection were associated with older age and higher diastolic blood pressure, but not with sex, BMI, liver enzyme, blood lipid, and glucose levels. Although minigastric bypass (MGB) had a better weight reduction than gastric banding, there was no difference in weight reduction between patients who were positive and negative for HBV infection. The weight loss curves and resolution of obesity-related comorbidities were similar between the two groups except the postoperative aspartate transaminase (AST) and alanine transaminase (ALT) were significantly higher in patients who were positive for HBV infection. During follow-up, two patients developed fulminating hepatitis after MGB with one mortality.ConclusionMorbidly obese patients with the existence of HBV infection do not influence the outcome of bariatric surgery, but continuing monitor of the liver function is indicated.