Wei Jei Lee

Laparoscopic Roux-en-Y versus mini-gastric bypass for the treatment of morbid obesity: A prospective randomized controlled clinical trial

Objectives:This prospective, randomized trial compared the safety and effectiveness of laparoscopic Roux-en-Y gastric bypass (LRYGBP) and laparoscopic mini-gastric bypass (LMGBP) in the treatment of morbid obesity. Summary Background Data:LRYGBP has been the gold standard for the treatment of morbid obesity. While LMGBP has been reported to be a simple and effective treatment, data from a randomized trial are lacking. Methods:Eighty patients who met the NIH criteria were recruited and randomized to receive either LRYGBP (n = 40) or LMGBP (n = 40). The minimum postoperative follow-up was 2 years (mean, 31.3 months). Perioperative data were assessed. Late complication, excess weight loss, BMI, quality of life, and comorbidities were determined. Changes in quality of life were assessed using the Gastro-Intestinal Quality of Life Index (GIQLI). Results:There was one conversion (2.5%) in the LRYGBP group. Operation time was shorter in LMGBP group (205 versus 148, P < 0.05). There was no mortality in each group. The operative morbidity rate was higher in the LRYGBP group (20% versus 7.5%, P < 0.05). The late complications rate was the same in the 2 groups (7.5%) with no reoperation. The percentage of excess weight loss was 58.7% and 60.0% at 1 and 2 years, respectively, in the LPYGBP group, and 64.9% and 64.4% in the LMGBP group. The residual excess weight <50% at 2 years postoperatively was achieved in 75% of patients in the LRYGBP group and 95% in the LMGBP group (P < 0.05). A significant improvement of obesity-related clinical parameters and complete resolution of metabolic syndrome in both groups were noted. Both gastrointestinal quality of life increased significantly without any significant difference between the groups. Conclusion:Both LRYGBP and LMGBP are effective for morbid obesity with similar results for resolution of metabolic syndrome and improvement of quality of life. LMGBP is a simpler and safer procedure that has no disadvantage compared with LRYGBP at 2 years of follow-up.

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.

Hand-assisted laparoscopic hepatectomy for solid tumor in the posterior portion of the right lobe: Initial experience

Objective: To prove the feasibility of hand-assisted laparoscopic liver resection for tumors located in the posterior portion of the right hepatic lobe. Summary Background Data: Use of laparoscopic liver resection remains limited due to problems with technique, especially when the tumor is located near the diaphragm, or in the posterior portion of the right lobe. Methods: Between October 2001 and June 2002, a total of 7 patients with solid hepatic tumors involving the posterior portion of the right lobe of liver underwent hand-assisted laparoscopic hepatectomy with the HandPort system at our hospital. Surgical techniques used included CO2 pneumoperitoneum and the creation of a wound on the right upper quadrant of the abdomen for HandPort placement. The location of tumor and its transection margin were decided by laparoscopic ultrasound. The liver resection was performed using the Ultrashear without portal triad control, with the specimens obtained then placed in a bag and removed directly via the HandPort access. Results: The 5 male and 2 female patients ranged in age from 41 to 76 years (mean 62.3 ± 14.4). Surgical procedures included partial hepatectomy for 6 patients and segmentectomy for one, all successfully completed using a variant of the minimally invasive laparoscopic procedure without conversion to open surgery. The mean duration of the operation was 140.7 ± 42.2 minutes (90–180). The blood loss during surgery was 257.1 ± 159 mL (250–500), without any requirement for intraoperative or postoperative transfusion. Pathology revealed hemagioma (n = 2), colon cancer metastasis (n = 2), and hepatocellular carcinoma (n = 3). There were no deaths postoperatively, with 1 patient suffering bile leakage. Mean hospital stay was 5.3 ± 1.3 days postsurgery. Conclusion: The results of this study suggest that laparoscopic liver resection using the HandPort system is feasible for selected patients with lesions in the posterior portion of the right hepatic lobe requiring limited resection. Individuals with small tumors may benefit; because a large abdominal incision is not required, the wound-related complication rate might be reduced.

Short-term Results of Laparoscopic Mini-Gastric Bypass

Background: The laparoscopic mini-gastric bypass (MGB) is a modification of Masons loop gastric bypass, but with a long lesser curvature tube. With weight loss results similar to laparoscopic Roux-en-Y gastric bypass (LRYGBP), the MGB is a simpler operation with a low complication rate. Controversy exists concerning the efficacy and side-effects of this procedure. This report presents the technique of laparoscopic MGB and its results in 423 patients. Methods: From October 2001 to October 2004, 423 consecutive patients (87 males and 336 females) underwent laparoscopic MGB (LMGB) for morbid obesity. Mean age was 30.8 years, preoperative mean weight 120.3 kg and mean BMI 44.2 kg/m2. Results: All procedures were completed laparoscopically. Mean operative time was 130.8 minutes, and mean hospital stay was 5.0 days. 18 minor early complications (4.3%) were encountered, and 7 major complications (1.7%) occurred. Marginal ulcers were noted in 34 patients (8.0%) during follow-up, and anemia was found in 41 patients (9.7%). Mean BMI decreased to 29.2 and 28.4 kg/m2 at 1-year and 2-year follow-up, with mean excess weight loss 69.3% and 72.2%. The Gastrointestinal Quality of Life Index improved significantly 1 year after the operation. Conclusions: LMGB has a low complication and mortality rate. The learning curve is less steep than for LRYGBP, whereas the efficacy is similar.

Laparoscopic Vertical Banded Gastroplasty and Laparoscopic Gastric Bypass: a Comparison

Background: Vertical banded gastroplasty (VBG) and gastric bypass (GBP) are the two bariatric procedures recommended by NIH consensus conference. Recent advancement in laparoscopic (L) techniques has made LVBG and LGBP alternatives for the conventional open approach. Methods: From December 2000 to February 2002, 80 patients (24 men and 56 women; mean age 32 years, range 18-57) with morbid obesity (mean BMI 43.2 kg/m2, range 36-59.8) were enrolled in a prospective trial and randomly assigned to LVBG or LGBP. Changes in quality of life were assessed using the Gastro-intestinal quality of life index (GIQLI). Results: The conversion rate was zero for LVBG and 2.5% (1/40) for LGBP. There has been no mortality. Surgical time was significantly longer for LGBP (209 minvs 126 min for LVBG, P<0.001).Mean hospital stay was 3.5 days for the LVBG vs 5.7 days for LGBP (P<0.001). Postoperative analgesic usage was also less for LVBG patients (mean dose 1.4 vs 2.4, P<0.05). Early complication rate was higher in the LGBP group (17.8% vs 2.5%, P<0.001). All 3 major complications were in the LGBP group, of which 2 were related to anastomotic leakage (5%). Late complications consisted of upper GI bleeding, stenosis and others observed in 4 LGBP patients (10%) and 2 LVBG patients (5%). Mean follow-up was 20 months (range 18 to 30). BMI fell significantly in both groups, with significant improvement of obesity-related co-morbidities. LGBP had significantly better excess weight loss than LVBG (62.9% vs 55.4% at 1 year and 71.4% vs 53.1% at 2 years), as well as lower BMI than LVBG (29.6 vs 31.1 at 1 year and 28.5 vs 31.9 at 2 years). There was no difference in the reduction of obesity-related laboratory abnormalities at 1 year except a lower hemoglobin in LGBP (11.8 vs 13.8, P<0.05). Preoperative GIQLI scores were similar between the groups; however, at 1 year, LGBP patients had better GIOLI scores than LVBG patients (121 vs 106, P<0.01). LVBG had improvement in physical condition, social function and emotional conditioning but deterioration in GI symptoms which resulted in no increase in total GIQLI score. Conclusion: LGBP was a time-consuming demanding technique with a higher early complication rate compared with LVBG. Although both operations resulted in significant weight reduction and decrease in obesity-related co-morbidities, LGBP had a trend of greater weight loss and significantly better GIQLI than LVBG at the cost of a significant long-term trace element deficiency state. Each patient should be individualized for the operations according to the patients decision.

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.

Breast cancer vascularity: color Doppler sonography and histopathology study.

SummaryIn this prospective study, the authors examined 50 patients with breast tumors (malignant, n = 32; benign, n = 18) to investigate the correlation between color Doppler flow mapping and histopathological findings and to evaluate the clinical significance of color Doppler mapping. Among the 32 patients with breast cancer, color Doppler signals were detected in 24 patients (75%). The maximum flow velocities varied from 5 to 34 cm/sec, with 16 (67%) of them above 15 cm/sec. Among the 18 patients with benign tumors, color Doppler signals could be detected in 7 (39%). The maximum flow velocity varied from 3 to 30 cm/sec but was over 15 cm/sec in only two patients (28%). Histological studies revealed that color Doppler signals detected by Doppler sonography correlated with disordered neovascularization penetrating the lesion from its periphery, consisting of thin-walled blood vessels and large arteriovenous shunts. Although large tumors tend to have high Doppler flow, there is no significant correlation between the maximum flow velocity and tumor size. There is also no significant correlation between the detection of high flow color Doppler signals and the age, receptor status, tumor size, lymph node metastases, or clinical stage of patients with breast cancer. However, there is a positive association (p < 0.05) between nodal metastases and higher tumor flow velocity in T1 (≤ 2 cm) breast tumors, but not in larger tumors. It is concluded that color Doppler is useful in the assessment of tumor vascularity but is of limited value in the differentiation of benign from malignant lesions. However, the presence of color Doppler signals in Tl breast cancer suggesting early dissemination of the cancer might be of important clinical significance in detecting those small, apparently early, but aggressive tumors with poor prognosis.

Gastrointestinal Quality of Life Following Laparoscopic Adjustable Gastric Banding in Asia

Background: Laparoscopic adjustable gastric banding (LAGB) is a safe and effective treatment for morbid obesity. Previous studies in Western countries disclosed a significant improvement in co-morbidities and health-related quality of life. Data from Asia and regarding the specific GI quality of life following LAGB are lacking. Methods: From May 2002 to May 2005, 107 consecutive patients – 48 men and 59 women, with mean age 31.4 years (range 17-57 years) with morbid obesity (mean weight 115.8 kg, range 81-174 kg; mean BMI 41.3 kg/m2, range 32.0-59.8 kg/m2) underwent LAGB in a prospective trial. All bands were placed via the pars flaccida technique. Quality of life was measured by the Gastrointestinal Quality of Life Index (GIQLI), a 36item questionnaire before LAGB, and at 3, 6, 12 and 24 months after surgery. Results: All procedures were performed laparoscopically with no conversions. There was neither intra-operative complications nor major postoperative complications. Minor complications occurred in 3 patients (2.8%); all were transient stoma obstruction. At follow-up, only one band (0.94%) was removed at 3 months postoperatively because of the patients intolerance. No gastric slippage occurred. 4 patients (3.7%) had tubing problems and required revision surgery for port adjustment. Mean BMI decreased from 41.3 to 33.1 after 2 years. Percent excess BMI loss averaged 48.1% at 2 years (range 6.7-139.2). All co-morbidities were eliminated significantly. 80% of patients were satisfied with the results at 2 years. However, the GIQLI score remained similar before and after surgery. Preoperative score was 110.8+15 points. The score became 116.2+13, 114.7+13, 108.5+14 and 107.2+17 at 3, 6, 12 and 24 months. The patients had improvement in 3 domains of general health (social, physical and emotional functions), but decrease in the domain of symptoms. Conclusion: Although LAGB was successful in weight loss and resolution of co-morbidities in morbidly obese patients, the GIQLI did not improve. This feature will be the major disadvantage of LAGB.

Improved renal function 12 months after bariatric surgery

BACKGROUNDnObesity is a risk factor for developing chronic kidney disease (CKD) that may be improved with bariatric surgical weight reduction. The objective of this study was to investigate changes in the glomerular filtration rate (GFR) in severely obese patients 1 year after bariatric surgery.nnnMETHODSnGFR was measured in 233 severely obese patients before and more than 12 months after bariatric surgery. Patients were separated by baseline GFR: hyperfiltration (GFR>125 mL/min), normal (GFR 125-90 mL/min), CKD stage 2 (GFR 89-60 mL/min), and CKD stage 3 (59-30 mL/min). The groups were reanalyzed 12 months after bariatric surgery.nnnRESULTSnOf the 233 patients, 61 (26.2%) had hyperfiltration, 127 (54.5%) were normal, 39 (16.7%) had CKD stage 2, and 6 (2.6%) had CKD stage 3. The mean GFR was 146.4±17.1 mL/min in the hyperfiltration group, 105.7±9.6 mL/min in the normal group, 76.8±16.7 mL/min in the CKD stage 2 group, and 49.5±6.6 mL/min in the CKD stage 3 group. The mean GFR 1 year after weight loss surgery decreased to 133.9±25.7 mL/min in the hyperfiltration group, increased to 114.2±22.2 mL/min in the normal group, increased to 93.3±20.4 mL/min in the CKD stage 2 group, and increased to 66.8±19.3 mL/min in the CKD stage 3 group.nnnCONCLUSIONSnAbnormal renal function was common in severely obese patients. Bariatric surgery-induced weight loss had positive effects on renal function at 1 year after surgery.

Laparoscopic drainage of pyogenic liver abscesses

PurposeTo report our experience of performing laparoscopic drainage of liver abscesses in patients who failed to respond to conservative treatment.MethodsWe retrospectively compared the results and complications of 18 patients who underwent laparoscopic liver abscess drainage with those of 5 patients who underwent open drainage between June 1999 and October 2002.ResultsThe operation times were shorter and oral intake was recommenced earlier in the laparoscopic group, which also tended to have less blood loss and shorter hospitalization. One case of recurrence, which developed 1 month postoperatively, was successfully treated with percutaneous drainage. There was no mortality in either group.ConclusionLaparoscopic drainage of liver abscesses, combined with intravenous antibiotics, is a safe alternative for patients requiring surgical drainage when medical treatment has failed.