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Background Laparoscopic sleeve gastrectomy (LSG) has become the preferred bariatric procedure in many countries. However, there is one shortcoming of LSG in the long-term follow-up, and this is the onset of gastro-esophageal reflux disease (GERD) and erosive esophagitis (EE). Conversion to Roux-en-Y gastric bypass (RYGB) is considered an option in patients unresponsive to medical therapy. Currently, there is no evidence of EE improvement or resolution after conversion surgery. In this study, we objectively evaluate the effectiveness of RYGB in management of EE with upper endoscopy (EGD) to identify the significant variables in patients with GERD symptoms post LSG refractory to medical therapy and require conversion surgery. Methods Over a period of 11 years (2008–2019) at Singapore General Hospital, we retrospectively reviewed a prospectively collected database of a cohort of patients whom had conversion surgery to RYGB for refractory GERD and EE after LSG. Patient’s endoscopic findings and demographic and anthropometric data were analyzed. Results We identified a total of 14 patients who underwent LSG to RYGB conversions for endoscopic proven erosive esophagitis in our unit during the study period. Eight patients (57.1%) had concurrent hiatal hernia repaired. Nine (64.3%) patients were females. The median age of patients in this cohort was 44 (range 30–61) years. Mean weight and BMI were 87.7 kg (± 19.2) and 32.8 (± 3.09) kg/m2, respectively, on the day of conversion surgery. The median time between LSG and revision to RYGB was 36 (range 6–68) months. Seven patients (50%) had complete resolution of GERD symptoms after conversion, and 6 patients (42.9%) had partial resolution. Six out of 7 patients had complete resolution of EE. There were 4 anastomotic strictures (28.6%). Older patients, Indian ethnicity, present of hiatal hernia and lower weight loss after initial LSG were more likely to undergo conversion surgery. Conclusion Conversion to RYGB after LSG is clinically relevant and may be a feasible solution if patients have ongoing GERD refractory to medical therapy. Ninety-three percent of our patients achieved complete resolution of their GERD symptoms and significant improvement of erosive esophagitis with significant weight loss after conversion. This study has important implications as LSG is increasingly being performed and a proportion of these will need revision surgery for various reasons, particularly GERD which is extremely prevalent.

Anastomotic leak following Ivor Lewis oesophago-gastrectomy is a major complication with high morbidity and mortality. We report our experience with three such cases where endoscopically deployed double pigtail stents (DPT) were used to help manage the leaks. Methods Three patients from October 1, 2019 to February 29, 2020 experienced leakage from the oesophago-gastric anastomosis following minimally invasive Ivor Lewis oesophago-gastrectomy. These occurred on post-operative day 9, day 29 and day 7 respectively. All cases were managed with endoscopic deployment of double pigtail stents along with other adjunctive measures. Results To date all patients remain alive, with sepsis under control. One of the patients had been able to have his double pigtail stent removed at six weeks and he has been able to commence adjuvant chemotherapy. Another patient had a follow-up contrast study one week after DPT insertion which showed no further contrast extravasation and was able to recommence oral intake. The third patient has a left empyema (managed conservatively with a combination of internal DPT and external pigtail drainage) which is gradually resolving. Conclusion Endoscopically deployed DPTs are a useful tool in the armamentarium for managing oesophago-gastric anastomotic leaks in selected patients following Ivor Lewis oesophago-gastrectomy. They are advantageous in that stent migration does not appear to be an issue, nor is there any problem with leakage around the stent. Patients are mostly able to restart oral intake soon after insertion of DPTs. This reduces the morbidity associated with these anastomotic leaks, and reduces the number of interventions needed.

Background: Bile acids (BAs) are traditionally associated with lipid absorption and phase II detoxification by forming various BA conjugates. Recently, it has been discovered that BAs also regulate glucose metabolism, and the increase in BAs in patients following bariatric surgery may contribute to the post-surgery improvement in insulin resistance (IR). However, while Roux-en-Y gastric bypass can increase BA concentrations post-surgery, this may not be the case after laparoscopic sleeve gastrectomy (LSG). We hypothesized that the profiling of BAs that include the conjugated BA species could detect post-surgery BA changes after LSG. To test our hypothesis, we performed comprehensive profiling of BAs in Asian individuals with morbid obesity at baseline, and at 6 months following LSG. Methods: Fourteen subjects scheduled for LSG were recruited. Anthropometric measurements, oral glucose tolerance test, and biochemistry tests were performed at baseline and at 6 months after LSG. BAs were profiled using liquid chromatography–mass spectrometry. Results: At 6 months, subjects lost significant weight from 117.4±5.4 to 92.1±3.8 kg and demonstrated significant improvement in IR. HOMA-IR decreased from 6.2±0.7 to 2.0±0.2 and the Matsuda index increased from 1.9±0.3 to 3.3±0.3. We did not detect any significant post-operative change in the levels of total BAs (5237.1±1219.4 vs. 3631.7±457.9, p=0.181) or non-sulfated BAs after LSG. However, sulfated BA species increased significantly after LSG. Conclusion: Our study showed that the serum concentrations of sulfated BA species in morbidly obese Asian individuals increased significantly 6 months after LSG; the increase in sulfated BAs after LSG might contribute to the post-surgery improvement of metabolic health.

BACKGROUND Plasma concentrations of branched-chain amino acids (BCAAs) are elevated in obese individuals with insulin resistance (IR) and decrease after bariatric surgery. However, the metabolic mechanisms are unclear. OBJECTIVES Our objectives are to compare leucine kinetics between morbidly obese and healthy-weight individuals cross-sectionally, and to prospectively evaluate changes in the morbidly obese after sleeve gastrectomy. We hypothesized that leucine oxidation is slower in obese individuals and increases after surgery. METHODS Ten morbidly obese [BMI (in kg/m2) ≥32.5, age 21-50 y] and 10 healthy-weight participants (BMI

INTRODUCTION Obesity is a key risk factor in the development of Type 2 diabetes mellitus (T2DM). Bariatric surgery causes a large amount of durable weight loss in those with clinically severe obesity. We reported the effect of weight loss via bariatric surgery on DM prevention in those at high risk of developing DM. METHODS This was a retrospective cohort study of 44 patients with obesity (mean body mass index 43.8 kg/m2) and pre-DM who underwent bariatric surgery and were followed up for up to three years. We also reviewed a non-surgical cohort of patients with obesity and pre-DM seen at the weight management clinic. RESULTS 91% of patients attained normal glycaemic status at one year after bariatric surgery. At the three-year follow-up, 87.5% of the patients maintained normoglycaemia. None of the patients developed T2DM after surgery. 26.9% of patients achieved absolute weight loss at one year after bariatric surgery and maintained this at two and three years post surgery (p < 0.001 vs. baseline). The homeostatic model assessment-insulin resistance index in patients also decreased from 5.50 at baseline to 1.20, 1.14 and 1.44 at one, two and three years, respectively (p < 0.001). CONCLUSION Bariatric surgery produces significant weight loss, and leads to reversion from the pre-diabetic state to normal glycaemic status and reduction of the incident DM rate in those with pre-DM and morbid obesity.

Herein we review the management status of governmental financial support of bariatric surgeries in several Asia-Pacific areas of Japan, Singapore, and Australia, which were discussed in the 2016 International Congress on Obesity and Metabolic Syndrome (ICOMES). Patient's body mass index criteria of bariatric surgery for public support are different one another in the three countries. Whereas laparoscopic sleeve gastrectomy (LSG), Roux-en Y gastric bypass (RYGB), and laparoscopic adjustable gastric banding (LAGB) are applicable in both Singapore and Australia, the coverage of insurance is limited to LSG in Japan. In addition, the surgical fees and equipment costs are not fully covered by public health insurance for performing sleeve gastrectomy in Japan, but patients with morbid obesity can still use public health insurance. In Singapore, the waiting time for surgery in public hospitals is longer on average than for private hospitals. However, patients can obtain subsidies of up to 80% of the costs of surgery in public hospitals, while particularly needy patients may even be able to obtain completely free bariatric surgery through Medifund. In Australia, bariatric surgeries in public sectors are publicly funded, but most bariatric surgeries occur in the private sector and Medicare only reimburses surgical costs in the private sector. Although certain characteristics need to be improved, the access to bariatric surgery has shown steady progress through public support in each of these countries.

Background Laparoscopic vertical sleeve gastrectomy (LSG) is a popular bariatric procedure performed in Asia, as obesity continues to be on the rise in our population. A major problem faced is the development of de novo gastroesophageal reflux disease (GERD) after LSG, which can be chronic and debilitating. In this study, we aim to assess the relationship between the presence of small hiatal hernia (HH) and the development of postoperative GERD, as well as to explore the correlation between GERD symptoms after LSG and timing of meals. In doing so, we hope to gain a better understanding about the type of reflux that occurs after LSG and take a step closer towards effectively managing this difficult to treat condition. Methods We retrospectively reviewed data collected from patients who underwent LSG in our hospital from Dec 2008 to Dec 2016. All patients underwent preoperative upper GI endoscopy, during which the identification of hiatal hernia takes place. Patients' information and reflux symptoms are recorded using standardized questionnaires, which are administered preoperatively, and again during postoperative follow up visits. Results Of the 255 patients, 125 patients (74%) developed de novo GERD within 6 months post-sleeve gastrectomy. The rate of de novo GERD was 57.1% in the group with HH, and 76.4% in the group without HH. Adjusted analysis showed no significant association between HH and GERD (RR = 0.682; 95% CI 0.419 to 1.111; P = 0.125). 88% of the patients who developed postoperative GERD reported postprandial symptoms occurring only after meals, and the remaining 12% of patients reported no correlation between the timing of GERD symptoms and meals. Conclusion There is no direct correlation between the presence of small hiatal hernia and GERD symptoms after LSG. Hence, the presence of a small sliding hiatal hernia should not be exclusion for sleeve gastrectomy. Electing not to perform concomitant hiatal hernia repair also does not appear to result in higher rates of postoperative or de novo GERD.

Introduction: Obesity increases the risk of incident chronic kidney disease (CKD), being one of the strongest risk factors for new-onset CKD even in the metabolically normal obese. Weight loss has been shown to reduce renal hyperfiltration and proteinuria. Metabolic Bariatric Surgery (MBS) remains an effective treatment for obesity and its metabolic related complications. However, literature on its impact on long term renal function remains limited. Methods: This was an observational retrospective study in a tertiary centre in Singapore. MBS cases performed at the centre between 2008 and 2019 were included. The primary outcome measure was estimated Glomerular Filtration Rate (eGFR), calculated using the CKD Epidemiology Collaboration equation, and albuminuria (defined as urine Albumin-Creatinine Ratio (uACR) >3.5 mg/mmol) at baseline and at one-year post surgery. Results: 557 patients were included. Baseline parameters are as follows: mean age 41.7 ±10.1 years; female 65.4%; ethnic composition: Chinese (35.2%), Malay (33.0%), Indian (26.9%); BMI 42.5 ±7.9 kg/m²; glycaemic status: Diabetes Mellitus (34.5%), Pre-diabetes (13.5%), Non-diabetic (52.1%); Hypertensive status: Hypertension (55.2%), Pre-Hypertension (1.9%), Normotensive (42.9%). Median eGFR was 110.9 (92.4 - 121.5) mL/min/1.73 m² and median uACR was 1.00 (0.40 - 3.55) mg/mmol. At one-year post surgery, patients achieved statistically significant reductions in mean BMI (-11.3 ±4.2 kg/m2), systolic BP (-3.24 ±19.3 mmHg), diastolic BP (-5.23 ±13.8 mmHg), fasting glucose (-1.95 ±2.89 mmol/L) and improvement in HDL (0.29 ±0.26 mmol/L). In addition, statistically significant reductions in the proportion of patients on anti-hypertensive (48.8% to 14.4%), anti-diabetic (34.1% to 12.7%) and lipid-lowering medications (37.8% to 20.4%) were seen. In particular, ACE-inhibitor and/or angiotensin receptor blocker (32.9% to 9.2%, p< 0.001) usage was reduced. At one-year post surgery, median eGFR increased by 1.66 mL/min/1.73 m² (p Conclusions: Metabolic bariatric surgery had a positive impact on renal function as shown by the improvement in eGFR in the non-diabetic group, and the reduction in albuminuria in the diabetes and pre-diabetes group at one-year post surgery. More adequately powered, longer-term data is required to investigate the durability of this impact.

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.

Post-operative bleeding is a major but infrequent complication in laparoscopic sleeve gastrectomy (LSG). There is paucity in the literature on management of this complication. This paper seeks to review the presentation of post-operative bleeding complications after LSG in a single cohort of patients and highlight the surgical and non-surgical methods of treatment. A retrospective study of 409 LSG patients performed in a tertiary hospital, Singapore General Hospital (SGH) since 2008. Patients who encountered post-operative bleeding complications, defined as requiring blood transfusion or re-laparoscopy for haemostasis, were identified from a prospectively recorded database. The presentation, source of bleeding and management were recorded and presented. Five out of 409 (1.2%) patients were diagnosed with post-operative bleeding. Two patients were treated conservatively requiring only blood transfusion and 3 patients were surgically explored with laparoscopy, 2 were from staple line bleeding (SLB) and suture haemostasis performed. In 1 patient, the source of bleeding was not identified intraoperatively and CT angiography performed post-operatively showed active contrast bleeding near short gastric arteries and gastroepiploic artery. Gel foam and coil embolization was performed and the bleeding was controlled. Average hospitalization stay due to post-operative bleeding was 7.3 days compared to 2.3 days for those without. Post-operative bleeding after LSG occurred at the staple line and branches of the right gastro-epiploic artery and short gastric arteries. Bleeding may stop spontaneously or require haemostasis by operative or endovascular means. CT angiogram is proposed to locate the source of bleed and subsequent embolization of bleeding arteries maybe possible, avoiding the need for re-operation. Bleeding from the staple line requires surgical haemostasis.

I’m not ashamed, I admit it. I used to be an F.O.B. No I was never one of those “fresh off the boat” Chinese guys you see all the time in Flushing now. No, I was a Fat Oriental Boy. Oh yeah, and it was “oriental” not “Asian” during the pre-politicallycorrect days of 1972. And being a fat oriental boy of Chinese persuasion what do you think they called me in P.S. 214? . . . A chunk. THE FLUSHING CYCLE excerpts from memoir-monologue plays

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.