Wei-Jei Lee

Hepatic progenitor cells (HPCs) activation, proliferative ductular reaction (DR), replicative arrest and Notch signaling have been demonstrated in a variety of human liver diseases. The relationships are poorly understood in morbid obesity. We investigated factors responsible for the HPCs/DR, replicative arrest and Notch signaling in non-NASH and NASH groups. Cytokeratin 7 (and 19), p21, CD34, Ki67 and different Notch receptors and ligands immunohistochemical stained biopsies from morbid obese patients with non-NASH (n=10) and NASH (n=25) were studied. These results were correlated with clinicopathological variables. NASH patients presented with abnormal liver function tests and had higher HbA1c percentage. Strong association between HPCs and DR was seen (r=0.785, p<0.000). BMI, interface activity and replicative arrest were associated with HPCs expansion and DR in NASH patients. A strong association between CD34 with HPCs and DR was found in non-NASH patients. In NASH group, Notch 3 was important in bile ductular proliferation; whereas Notch 4 was associated with sinusoidal neovessels proliferation and Kupffer cell activation. HPCs and DR played an important role in hepatic regeneration in fatty liver disease of morbid obesity. An altered replication pathway in NASH promotes HPCs activation and DR. Notch-3 and Notch-4 were significantly different between non-NASH and NASH groups.

Compared with conventional pharmacological therapies, bariatric surgery has been shown to cause greater and- sustained weight loss. It was aimed to evaluate weight loss in obese patients after laparoscopic adjustable gastric banding surgery using information typically available during the initial evaluation studied before bariatric surgery and genes. 74 patients undergoing laparoscopic adjustable gastric banding (LAGB) were enrolled. Artificial Neural Network technology was used to predict weight loss. We studied 74 patients consisting of 22 men and 52 women 2 years after operation. Mean age was 31.7 +/- 9.1 years. 27 (36.5%) patients had successful weight reduction (excess weight loss >50%) while 47 (63.5%) did not. ANN provided predicted factors on gender, insulin, albumin and two genes: re4684846_r, rs660339_r which were associated with success. Artificial neural network is a better modeling technique and the predictive accuracy is higher on the basis of multiple variables related to laboratory tests. Our finding gave demonstrated result that obese patients of successful weight reduction after laparoscopic adjustable gastric banding surgery were women, having little lower insulin and albumin, and carrying GG genotype on rs4684846 and with at least one T allele on rs660339. In these cases, weight loss will give better results.

Gastric cancer remains a leading cause of death worldwide. Post-operative complication is one important factor which causes mortality of gastric cancer patients after gastrectomy. Better prediction of post-operative complication before gastrectomy can significantly reduce post-operative mortality and morbidity. Therefore, 3 data mining techniques were applied in this study on improving prediction of post-operative complication. A retrospective study was performed on 521 patients from 3 over 2,000 acute-bed medical centers in Taiwan during February 2002 to October 2004. Pre- and post-operative clinical data were collected and analyzed by applying 3 data mining techniques, included Artificial Neural Networks (ANN), Decision Tree (DT) and Logistic Regression (LR). Results of this study indicated that ANN was a better technique than DT and LR in predicting post-operative complication. Nutritious status, pathological characteristics and operational characteristics were important predictors of post-operative complication. Further study on predicting postoperative complication in gastric cancer patients is still important. However, how to combine different data mining techniques to improve accuracies of prediction will be another important issue for clinicians and researchers.

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. 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. 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). 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. 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.

Background: There is a world-wide epidemic of overweight, obesity and morbid obesity. Bariatric surgery today, as the only effective therapy for morbid obesity, is expanding exponentially to meet the global epidemic of morbid obesity. Bariatric surgeons in the Asia-Pacific region had founded the Asia-Pacific Bariatric Surgery Group (APBSG) at Seoul, Korea on October 6, 2004. Methods: E-mail requests for information were sent to the national bariatric surgery leaders. These requests were followed, if necessary, by second e-mail requests and communications seeking clarification. The summary data was also discussed at the 1st Asia-Pacific Bariatric Consensus Meeting held in Taipei, February 27, 2005. Results: 11 countries or areas in Asia had started bariatric surgery and responded to the general questions. In 2004, 636 bariatric operations were performed by 61 bariatric surgeons. The earliest data for starting bariatric surgery was in 1974 in Taiwan. Following the development of gastric partition, Taiwan performed the first case in 1981, Japan in 1982 and Singapore in 1987. In 2004, 11 countries have started bariatric surgery. The APBSG was founded in 2004. In 2004, 12.1% of operations were open and 87.9% laparoscopic. The 6 most popular operations were: laparoscopic adjustable banding 42.3%; laparoscopic gastric bypass 34.2%; open vertical banded gastroplasty 7.5%; laparoscopic vertical banded gastroplasty 6.3%; laparoscopic sleeve gastrectomy 6.3%; open gastric bypass 4.2%. Pooling open and laparoscopic procedures, relative percentages were gastric banding 42.3%; gastric bypass 38.4%; vertical banded gastroplasty 13.8%. The APBSG consensus meeting recommended bariatric surgery in Asian patients with BMI >37 or >32 with diabetes or two other obesity-related co-morbidities. Conclusions: Bariatric surgery is expanding rapidly in Asia to meet rapidly increasing obesity. The modification of the indications for bariatric surgery in the Asian is proposed.

Individuals with the metabolic syndrome (MS), a clustering of risk factors (high levels of triglycerides and serum glucose, low level of high-density-lipoprotein cholesterol, high blood pressure, abdominal obesity) defined by the Third Report of the National Cholesterol Education Program Expert Panel of Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) (ATPIII), are at high risk of developing coronary heart disease and type 2 diabetes mellitus and may benefit from surgically induced weight loss. Prospectively controlled clinical study. A tertiary referral center. From December 1, 1999, to March 31, 2002, 645 consecutive morbidly obese patients were enrolled in a surgically supervised weight loss program, and the efficacy of weight loss 1 year after surgery was examined. Laparoscopic weight reduction surgery. Prevalence of the MS as defined by the ATPIII (>3 of the following): waist circumference greater than 102 cm in men and 88 cm in women; serum triglyceride level of at least 150 mg/dL (1.70 mmol/L); high-density lipoprotein cholesterol level less than 40 mg/dL (1.04 mmol/L) in men and 50 mg/dL (1.30 mmol/L) in women; blood pressure of at least 130/85 mm Hg; and serum glucose level of at least 110 mg/dL (6.11 mmol/L). Of 645 individuals, 337 (52.2%) met the ATPIII definition of the MS. Individuals with the MS had significant differences in age (31.5 years vs 28.1 years), sex (127 [37.7%] of 337 men vs 81 [26.3%] of 308 women), and many metabolic abnormalities compared with patients without the MS. Laparoscopic vertical banded gastroplasty was performed in 528 patients (81.9%) and laparoscopic gastric bypass in 117 (18.1%). A significant decrease in weight was found in both groups, but individuals who underwent laparoscopic gastric bypass lost significantly more weight (mean +/- SD, 38.4 +/- 14.4 kg vs 35.1 +/- 16.8 kg) and achieved a lower body mass index (29.3 +/- 4.8 vs 32.0 +/- 5.4) than individuals who underwent laparoscopic vertical banded gastroplasty. Substantial mean weight reduction (31.9%) of patients with the MS resulted in a substantial reduction of systolic (11.0 mm Hg) and diastolic (11.4 mm Hg) blood pressure and levels of glucose (46.1 mg/dL [2.56 mmol/L]), triglycerides (196.6 mg/dL [2.22 mmol/L]), and total cholesterol (33.7 mg/dL [0.88 mmol/L]) 1 year after surgery. These improvements resulted in a 95.6% resolution of the MS 1 year after surgery. There was no difference between operations (laparoscopic vertical banded gastroplasty or laparoscopic gastric bypass) in the resolution rate of the MS 1 year after surgery (95.0% vs 98.4%, respectively). The MS is prevalent in 52.2% of morbidly obese individuals enrolling in an obesity surgery program. Significant weight reduction 1 year after surgery markedly improved all aspects of the MS and resulted in a cure rate of 95.6%. Obesity surgery performed by laparoscopic surgery is recommended for obese patients with the MS.

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, PPPPPP<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 patient's decision.

Background: The Ligasure™ Vessel Sealing System is a haemostatic device designed primarily for use in abdominal surgery. Randomized trials have demonstrated that it is safe and quick for haemorrhoidectomy, but there is no evidence that it confers any advantage in complicated gastrointestinal surgery. The aim of the present study was to examine the value of the Ligasure™ system in extended lymph node dissection (D2) during gastrectomy for cancer in a randomized clinical trial. Methods: D2 gastric resection performed with the Ligasure™ system was compared with resection using conventional haemostatic methods in a prospective randomized trial. Central randomization (40 patients in each group) was performed after a staging laparotomy. The main outcome measures were operating time, intraoperative blood loss, postoperative course and complications. Results: Ligasure™ was associated with less intraoperative blood loss (mean(s.d.) 142(73) versus 239(124) ml; P = 0·001) and a shorter operating time (mean(s.d.) 169(25) versus 222(28) min; P = 0·001) than conventional operation. Postoperative drainage fluid volumes were greater in the Ligasure™ group (mean(s.d.) 1577(940) versus 886(542) ml; P = 0·020). There were no differences in postoperative complications or hospital stay. Conclusion: The Ligasure™ Vessel Sealing System is safe for use in extended lymph node dissection for gastric cancer, and is associated with a shorter operating time and decreased blood loss compared with conventional haemostatic techniques. Copyright © 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

The inverse relation between life expectancy and obesity is in large part due to multiple metabolic and cardiovascular comorbidities. Metabolic syndrome (MS) is defined as a cluster of these comorbidities. The prevalence of MS in obesity is not clear. This investigation assessed the prevalence and inter-relationships of MS with various demographic and clinical characteristics in patients with severe obesity. A total of 534 obese patients referred to a surgical center for weight reduction surgery were included in this retrospective study. Data collected included blood pressure, anthropometric measurements, and biochemical parameters associated with metabolic comorbidities and MS. The prevalence of MS in various subgroups was analyzed. The frequency of metabolic comorbidities included hypertension in 29.8%, hyperglycemia in 29.0%, hyperlipidemia in 61.0%, hyperuricemia in 57.9%, and abnormal liver function in 60.9%. The presence of any of these 4 metabolic comorbidities in the absence of others was uncommon. Only 28 patients (5.2%) had no metabolic comorbidities. The criteria for MS were met by 217 patients (50.7%). Patients with MS were significantly older (32.9 years vs 29.5 years), more likely to be male (31.9% vs 20.5%) and more likely to have metabolic comorbidities compared with patients without MS. In the multivariate analysis, male gender, age, and abnormal liver function remained significantly associated with the development of MS, while body mass index (BMI) was not. Metabolic comorbidities were common in the obese patients referred for weight reduction surgery. The cluster of metabolic comorbidities in MS was significantly associated with male gender, and increased age but not with BMI.

Laparoscopic antireflux surgery has recently been introduced as an alternative to laparotomy for the treatment of gastroesophageal reflux disease (GERD) at National Taiwan University Hospital. This study compared the results of traditional open and laparoscopic fundoplication for the treatment of GERD. The surgical records and medical charts of 29 adult patients who were surgically treated for GERD between 1980 and 2001 were retrospectively reviewed. The clinical characteristics, indications for surgery, and surgical findings and procedures were analyzed. Laparotomy and Nissen fundoplication were carried out on 20 of the patients between 1985 and 2000. Laparoscopic Nissen or Toupet fundoplication was performed on nine patients between 1997 and 2001. Patients in the laparoscopic group were younger than those in the laparotomy group (46.7 +/- 15.9 vs 58.3 +/- 18.5 yr). The incidence of associated prominent hiatal hernia was significantly higher in the laparotomy group (60 vs 33%). The mean operation time was 164.5 +/- 25.5 minutes in the laparotomy group and 182.2 +/- 52.2 minutes in the laparoscopy group (p = 0.6129). The mean hospital stay in the laparotomy group was significantly longer than that in the laparoscopy group (8.7 vs 3.4 days). Postoperative complications included three ventral hernias and one ileus in the laparotomy group. Results were good or excellent in 78.9% (15/19) of patients undergoing laparotomy (one patient was lost to follow-up 2 months later), and in 77.7% (7/9) of those undergoing laparoscopy. Symptomatic and endoscopic recurrence was recorded in two patients in the laparotomy group and one in the laparoscopy group. Laparoscopic fundoplication is as effective as traditional laparotomy for treating GERD. More GERD patients in Taiwan, even the young and those without associated hiatal hernia, would rather undergo the less invasive and cosmetically better laparoscopic surgery than require medication throughout their lives.