Wilfred Lik-Man Mui

Prophylactic ilioinguinal neurectomy in open inguinal hernia repair: a double-blind randomized controlled trial.

Objective:We conducted a double-blinded randomized controlled trial to investigate the short- to mid-term neurosensory effect of prophylactic ilioinguinal neurectomy during Lichtenstein repair of inguinal hernia. Method:One hundred male patients between the age of 18 and 80 years with unilateral inguinal hernia undergoing Lichtenstein hernia repair were randomized to receive either prophylactic ilioinguinal neurectomy (group A) or ilioinguinal nerve preservation (group B) during operation. All operations were performed by surgeons specialized in hernia repair under local anesthesia or general anesthesia. The primary outcome was the incidence of chronic groin pain at 6 months. Secondary outcomes included incidence of groin numbness, postoperative sensory loss or change at the groin region, and quality of life measurement assessed by SF-36 questionnaire at 6 months. All follow-up and outcome measures were carried out by a designated occupational therapist at 1 and 6 months following surgery in a double-blinded manner. Results:The incidence of chronic groin pain at 6 months was significantly lower in group A than group B (8% vs. 28.6%; P = 0.008). No significant intergroup differences were found regarding the incidence of groin numbness, postoperative sensory loss or changes at the groin region, and quality of life measurement at 6 months after the operation. Conclusions:Prophylactic ilioinguinal neurectomy significantly decreases the incidence of chronic groin pain after Lichtenstein hernia repair without added morbidities. It should be considered as a routine surgical step during the operation.

IFSO-APC Consensus Statements 2011

AbstractAssociations of BMI with body composition and health outcomes may differ between Asian and European populations. Asian populations have also been shown to have an elevated risk of type 2 diabetes, hypertension, and hyperlipidemia at a relatively low level of BMI. New surgical indication for Asian patients should be discussed by the expert of this field. Forty-four bariatric experts in Asia-Pacific and other regions were chosen to have a voting privilege for IFSO-APC Consensus at the 2nd IFSO-APC Congress. A computerized audience-response voting system was used to analyze the agreement with the sentence of the consensus. Of all delegates, 95% agreed with the necessity of the establishment of IFSO-APC consensus statements, and 98% agreed with the necessity of a new indication for Asian patients.IFSO-APC Consensus statements 2011Bariatric surgery should be considered for the treatment of obesity for acceptable Asian candidates with BMI ≥ 35 with or without co-morbiditiesBariatric/GI metabolic surgery should be considered for the treatment of T2DM or metabolic syndrome for patients who are inadequately controlled by lifestyle alternations and medical treatment for acceptable Asian candidates with BMI ≥ 30The surgical approach may be considered as a non-primary alternative to treat inadequately controlled T2DM, or metabolic syndrome, for suitable Asian candidates with BMI ≥ 27.5. Other eight sentences are agreed with by majority of the voting delegates to form IFSO-APC consensus statements. This will help to make safe and wholesome the progress of bariatric and metabolic surgery in Asia.

Radiofrequency Ablation for Benign Aldosterone-Producing Adenoma: A Scarless Technique to an Old Disease

Objective: To evaluate the safety and efficacy of radiofrequency ablation (RFA) in treating primary aldosteronism (PA) due to aldosterone-producing adenoma (APA). Background: Radiofrequency ablation is an established technique for treating malignant solid organ neoplasm. Its application on benign functional adrenal adenoma has never been prospectively described. Methods: We prospectively evaluated a patient cohort with computed tomography (CT)-guided percutaneous RFA performed on functional APA of size 4 cm or less. Treatment success was defined as complete tumor ablation on follow-up CT scan plus normalization of serum aldosterone-to-renin ratio (ARR) at 3 to 6 months after RFA. Salvage laparoscopic adrenalectomy was offered to patients who had failed RFA and remained hypertensive. Results: Between August 2004 and August 2008, 28 patients were referred for the procedure. Radiofrequency ablation was not performed on 4 APA because of their close proximity to major vascular structures. Twenty-four patients (11 men and 13 women) with a median age of 51.5 (range = 34–63) years underwent RFA for 11 right and 13 left APA. The median tumor diameter was 16.0 (range = 4.0–25.0) mm. There was no periprocedure hypertensive crisis or major morbidity or mortality. Minor complications occurred in 4 patients (16.7%), including 1 small pneumothorax and 3 retroperitoneal hematomas (<3 cm), which all resolved on conservative treatment. At 3 to 6 months of follow-up, CT scan showed complete tumor ablation in all patients (100%). Primary aldosteronism was biochemically resolved in 23 patients (95.8%). Salvage adrenalectomy was not performed in the single failed patient, as she remained normotensive on repeated follow-up. The overall success rate of RFA was 95.8%. Conclusions: Computed tomography–guided percutaneous RFA is a safe and efficacious alternative to laparoscopic adrenalectomy in treating patients with PA due to small APA.

Intragastric Balloon in Ethnic Obese Chinese: Initial Experience

Background: We evaluated the effectiveness and safety of intragastric balloon (IGB) for the treatment of obesity in ethnic Chinese in Hong Kong. Methods: 15 Chinese patients (10 females; median age 40 years (range 21-58)) completed IGB treatment over a 10-month period since November 2004. Median baseline body weight (BW) and BMI were 100.1 (range 78.5-170.3) kg and 39.4 (range 29.6-56.9) kg/m2 respectively. Coexistent obesity-related morbidities were present in 80% of patients. The Bioenterics Intragastric Balloon (BIB®) was employed, and all placement and removal were performed endoscopically under intravenous conscious sedation. A restricted balanced diet (∼1200 kcal/day) and 150 minutes/week of moderate-intensity exercise were prescribed after balloon placement in a multidisciplinary approach. Outcome measures were collected and assessed in a prospective manner. Results: Median procedure time was 25 (range 19-45) minutes and median hospital stay was 2 (range 1-6) days. Median BW and BMI loss were 15.3 (range 5.3-30.9) kg and 5.6 (range 1.9-12.5) kg/m2 after IGB. The median waist circumference (WC) loss was 9 (range 4-23) cm, and 66.7% of patients were highly satisfied with the treatment. No serious complication related to IGB was observed. Conclusion: IGB is a safe and effective device that achieves moderate weight loss in obese ethnic Chinese patients.

Laparoscopic sleeve gastrectomy with loop bipartition: A novel metabolic operation in treating obese type II diabetes mellitus

INTRODUCTION We report the first case of laparoscopic sleeve gastrectomy with loop bipartition (a modified form of Santoros operation) in the treatment of type II diabetes mellitus associated with obesity. PRESENTATION OF CASE A 46-year-old gentleman (baseline BMI 32.9; BW 98.5 kg) with 7-year history of type II diabetes mellitus (DM) underwent the procedure in Hong Kong. The control of DM was poor even with intensive medical therapy before the operation. Standard laparoscopic sleeve gastrectomy (SG) was performed and a loop gastroileostomy was fashioned at the antrum 250 cm from the ilececal valve without division of the 1st part of duodenum after SG. The resultant gastric tube has two outlets, one to the first part of duodenum and the other to the ileum with preferential passage of food through the gastroileostomy as shown on subsequent contrast study. The patients recovery was uneventful. The excess BMI loss was 97% with complete normalization of all metabolic parameters at 1-year follow-up. DISCUSSION This new surgical procedure (sleeve gastrectomy with loop bipartition: SG+LB) was evolved and derived from the combined concepts of sleeve gastrectomy with transit bipartition (SG+TB), single anastomosis duodenal-ileostomy (SADI), mini-gastric bypass (MGB) and duodenal-jejunal bypass (DJB) with less nutritional and surgical complications. CONCLUSION Sleeve gastrectomy with loop bipartition may be a very effective and simple operation to treat uncontrolled DM associated with obesity with a lot of apparent advantages over most current metabolic procedures available at the moment.

Premedication with Intravenous Ketorolac Trometamol (Toradol ® ) in Colonoscopy: A Randomized Controlled Trial

OBJECTIVE:We conducted a prospective double-blinded placebo-controlled randomized trial to investigate the effect of ketorolac trometamol (KT) administered intravenously as premedication in colonoscopy.METHODS:One hundred and forty patients undergoing colonoscopy were randomized to receive either 60 mg of KT (KT group (KTG), n = 70) or placebo (normal saline group (NSG), n = 70) intravenously as premedication 30 min prior to procedure. Patient-controlled sedation (PCS) was used as the mode of sedation. Outcome measures included patient self-assessed pain score in a 10-cm unscaled visual analog scale (VAS), endoscopist assessment of patient pain score in VAS, patients willingness to repeat colonoscopy, administered and demanded doses of PCS, patient satisfaction score in VAS, and hemodynamic changes during and after the procedure.RESULTS:The mean patient self-assessed pain score (SD) during procedure was significantly lower in KTG than NSG: 5.08 (2.74) vs 6.62 (2.45); p = 0.001. The mean endoscopist assessment of patient pain score (SD) was significantly lower in KTG than NSG as well: 3.99 (2.80) vs 5.28 (2.71); p = 0.006. More patients in KTG were willing to repeat procedure as compared with NSG (80.0% vs 57.1%; p = 0.004). No significant difference was found in the administered and demanded doses of PCS, mean satisfactory scores and hemodynamic changes in both groups. No serious complication related to intravenous (IV) KT was noted.CONCLUSIONS:Premedication with IV KT (Toradol®) improves pain control during colonoscopy with no associated serious complications.

Perigastric lymph node metastasis does not affect the survival of squamous cell carcinoma of the oesophagus treated with two‐field oesophagectomy

Aim:  There are some discrepancies as to the prognostic value of perigastric lymph node (LN) metastasis in the survival of squamous oesophageal carcinoma. The present study aimed to compare survival following standard oesophagectomy in the treatment of squamous oesophageal carcinoma with or without perigastric abdominal LN metastasis.

Effect of Repeated Bolus Injection, Low or High Dose Continuous Infusion of Omeprazole on Intragastric pH in Patients With Bleeding Peptic Ulcer v a Dose-Titration Study

Effect of Repeated Bolus Injection, Low or High Dose Continuous Infusion of Omeprazole on Intragastric pH in Patients With Bleeding Peptic Ulcer v a Dose-Titration Study Philip Wai Y., Simon Kin Hung Wong, Justin Chi Yuen Wu, Man Yee Yung, Wilfred Mui, Enders Kwok Wai Ng, James Yun Wong Lau, Joseph Sung Aim: From our previous study, we have shown that the adjunctive use of high dose omeprazole infusion reduced the rate of recurrent bleeding after endoscopic hemostasis for bleeding peptic ulcers. The appropriate dose of omeprazole to achieve optimal pH profile for clot stability is unknown. The aim of this study is to define the gastric acid suppression profile among various regimens of adjunctive omeprazole. Patients and Method: We included patients that presented with bleeding peptic ulcers and had endoscopic stigmata of either red dot or clean base that do not required endoscopic treatment. We excluded those that received regular antisecretory medications, NSAID/aspirin users, previous gastric surgery and moribund patients. All patients were randomly assigned to receive various dosage protocol of proton pump inhibitor for 24 hours, including 1. Omeprazole 80 mg bolus, then 8 mg/hr infusion (192 mg/d); 2. Omeprazole 80 mg bolus, then 4 mg/hr infusion (96 mg/d); or 3. Omeprazole intravenous 40 mg bolus 6 hourly (160 mg/d). We measured the 24 hour fasting gastric pH with the electrode positioned at 10 cm below the gastroesophageal junction. We collected the median pH, % time pH O 4 and % time pH O 6 at intervals of 1 hour, 4 hour, 12 hour and 24 hours after the start of therapy. We also analyzed the time needed to attain pH O 4 and pH O 6. Results: We included 30 patients with bleeding peptic ulcers that had endoscopic stigmata of either red dot or clean base. 11 patients received omeprazole 40 mg every 6 hourly, 10 patients received omeprazole 4mg/hr and 9 patients received omeprazole 8 mg/hr. The three groups were comparable in terms of age, body weight, ulcer size, initial blood pressure and hemoglobin level. There was no difference in the % time pH O 4 or 6 at 1, 4, 12 and 24 hours between the three groups. However, we found that those patients receiving omeprazole 8 mg/hr could reach pH O 4 in a significantly shorter time (Kruskal-Wallis test p Z 0.04) (Figure 1). Conclusion: Patients receiving a regime of high dose omeprazole infusion at 8mg/hr attained an intragastric pH profile of more than 4 in a significantly shorter period of time. A high dose regimen may be more effective in prevention of early recurrent rebleeding by early clot stabilization.