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Background Fasting during Ramadan is one of the five pillars of the Muslim faith. Despite the positive effects of fasting on health, there are no guidelines or clear recommendations regarding fasting after metabolic/bariatric surgery (MBS). The current study reports the result of a modified Delphi consensus among expert metabolic/bariatric surgeons with experience in managing patients who fast after MBS. Methods A committee of 61 well-known metabolic and bariatric surgeons from 24 countries was created to participate in the Delphi consensus. The committee voted on 45 statements regarding recommendations and controversies around fasting after MBS. An agreement/disagreement ≥ of 70.0% was regarded as consensus. Results The experts reached a consensus on 40 out of 45 statements after two rounds of voting. One hundred percent of the experts believed that fasting needs special nutritional support in patients who underwent MBS. The decision regarding fasting must be coordinated among the surgeon, the nutritionist and the patient. At any time after MBS, 96.7% advised stopping fasting in the presence of persistent symptoms of intolerance. Seventy percent of the experts recommended delaying fasting after MBS for 6 to 12 months after combined and malabsorptive procedures according to the patient's situation and surgeon's experience, and 90.1% felt that proton pump inhibitors should be continued in patients who start fasting less than 6 months after MBS. There was consensus that fasting may help in weight loss, improvement/remission of non-alcoholic fatty liver disease, dyslipidemia, hypertension and type 2 diabetes mellitus among 88.5%, 90.2%, 88.5%, 85.2% and 85.2% of experts, respectively. Conclusion Experts voted and reached a consensus on 40 statements covering various aspects of fasting after MBS.

Bariatric surgery has been proven to be the most effective weight loss treatment for patients with morbid obesity. However, the alteration in the anatomy of the gastrointestinal structure, food aversion, and non-compliance to recommended dietary advice after bariatric surgery may cause food intolerance, which may affect the nutritional status and health-related quality of life (HRQOL). This study aims to determine the effects of bariatric surgery on food tolerance, nutritional status, and HRQOL among patients with morbid obesity in Malaysia.This prospective observational study screened a total of 97 patients with morbid obesity. Data on socio-demographic characteristic, food tolerance, nutritional status and HRQOL were collected and assessed at baseline, one month and three months after bariatric surgery. Food tolerance was evaluated using a validated quality of alimentation questionnaire. The anthropometry measurements, including the body mass index (BMI) and percent excess weight loss (EWL), were evaluated, and the dietary intake was collected using a three-day food record. The HRQOL was assessed using the World Health Organization Quality of Life-BREF (WHOQOL-BREF) questionnaire.This study recruited 90 patients with morbid obesity who underwent bariatric surgery with a response rate of 100%. There were 62 females (68.9%) and 28 male (31.1%) patients, with 50% of the patient age less than 40. The EWL one month and three months after surgery was 14.1% and 31.6%, respectively. There was a significant decrease in the total food tolerance score from 26.4 (SD = 0.8) at baseline to 17.7 (SD = 4.7) one month after bariatric surgery, but a gradual rise in the score to 21.7 (SD = 4.3) was observed three months after surgery. A similar pattern is seen in the dietary intake assessment where a significant reduction in the total energy from 1842 kcal (SD = 445) at baseline to 570 kcal (SD = 180) one month and an increase to 731 kcal (SD = 185) three months after bariatric surgery. The HRQOL of the study patients showed a statistically significantly increase in the domain of physical health (t = -7.253, p = 0.001), psychological (t = -7.692, p 0.001), social relationship (t = -5.767, p 0.001) and environment (t = -4.208, p 0.013) three months after bariatric surgery.The present study showed that bariatric surgery effectively reduces weight and improves overall HRQOL domains among patients with morbid obesity despite reduced food tolerance and energy intake after bariatric surgery. Future longitudinal studies or randomized controlled trial with a larger sample size is recommended to determine the cause and effect mechanism between food tolerance, weight loss, dietary intake, HRQOL and bariatric surgery in Malaysia.

The Asia-Pacific Metabolic and Bariatric Surgery Society (APMBSS) held its congress in Tokyo at the end of March, 2018, and representatives from Asia-Pacific countries presented the current status of bariatric/metabolic surgery in the “National Reports” session. The data are summarized here to show the current status and problems in the Asia-Pacific region in 2017. A questionnaire including data of 2016 and 2017 and consisting of eight general questions was prepared and sent to representatives in 18 Asia-Pacific countries by e-mail before the congress. After the congress, the data were analyzed and summarized. Seventeen of 18 countries responded to the survey. The frequency of obesity (BMI ≥ 30) in the 4 Gulf countries was > 30%, much higher than that in the other countries. In total, 1640 surgeons and 869 institutions were engaging in bariatric/metabolic surgery. In many East and Southeast Asian countries, the indication for bariatric surgery was BMI ≥ 35 or ≥ 37, whereas in many Gulf countries and Australia, it was BMI ≥ 40 or ≥ 35 with obesity-related disease. Ten of the 17 countries (58.8%) but only one of the 5 Southeast Asian countries (20.0%) had public health insurance coverage for bariatric surgery. In 2017, 95,125 patients underwent bariatric/metabolic surgery, with sleeve gastrectomy accounting for 68.0%, bypass surgery for 19.5%, and others for 12.5%. Current problems included public insurance coverage, training system, national registry, and lack of awareness and comprehension. This summary showed that bariatric/metabolic surgery is rapidly developing along with various problems in Asia-Pacific countries.

Short bowel syndrome in adults occurs as a result of massive small intestinal resection commonly due to severe Crohn’s disease, volvulus or tumors. Diarrhea and weight loss are hallmarks of malabsorption which are aggravated if the colon is removed along with the small intestinal resection. Enteral nutrition autonomy is difficult to achieve in such cases of malabsorption where parenteral nutrition are required more often than not. We report a case of short bowel syndrome with severe malabsorption following extensive small bowel removal. The patient eventually underwent intestinal rehabilitation surgery and achieved independence from parenteral nutrition.

Objectives: Conventional bowel preparation for colonoscopy confines patient to clear liquid diet the day before and such non-nutritive dietary regimen often caused discomfort and hunger. The purpose of this study is to determine the feasibility of feeding patient with low-residue, lactose-free semi-elemental enteral formula (PEPTAMEN®) compare to conventional clear liquid diet during bowel preparation before colonoscopy. Methods: This was a randomised, endoscopist-blinded study. Patients were randomised into two groups, those receiving oral PEPTAMEN® and mechanical bowel preparation (A) and those receiving clear liquid while undergoing mechanical bowel preparation (B). Documentation was made with regard to the type of bowel cleansing agents used, completeness of the colonoscopy, cleanliness quality score, and hunger score. Results: A total of 97 patients were included in the study, A = 48 and B = 49. Eight patients, who were not compliant to the bowel-cleansing agent or had an incomplete colonoscopic examination, were excluded from the study. In terms of the overall cleanliness score, no statistical significant difference was seen (p = 0.25) between the two groups, A (fair or poor 37.5%, good or excellent 62.5%) and B (fair or poor 49%, good or excellent 51%) whereas the hunger score showed a significant difference (p = 0.016), A (no hunger 41.7%, slight hunger 12.5%, hungry 12.5%) and B (no hunger 24.5%, slight hunger 38.8%, hungry 36.7%). Conclusions: These data suggest that the addition of oral PEPTAMEN® as part of the bowel preparation regimen did not significantly alter the luminal cleanliness score during colonoscopy while alleviating hunger. Resumo: Objetivo: A preparação intestinal convencional para a colonoscopia confina o paciente à dieta líquida clara no dia anterior; esse regime dietético não nutritivo frequentemente causa desconforto e fome. O presente estudo teve como objetivo determinar a viabilidade de alimentar o paciente com fórmula enteral semielementar sem lactose e pobre em resíduos (PEPTAMEN®) em comparação com a dieta líquida clara convencional no preparo intestinal para colonoscopia. Métodos: Este foi um estudo randomizado no qual o endoscopista foi cego quanto ao tipo de preparo. Os pacientes foram randomizados em dois grupos: aqueles que receberam PEPTAMEN® oral e preparo intestinal mecânico (A) e aqueles que receberam dieta líquida clara e preparo intestinal mecânico (B). Os pacientes foram avaliados quanto ao tipo de agente de limpeza intestinal utilizado, a completude da colonoscopia, o escore de qualidade de limpeza e o escore de fome. Resultados: Um total de 97 pacientes foram incluídos no estudo, 48 no grupo A e 49 no grupo B. Oito pacientes foram excluídos por não aderirem ao agente de limpeza intestinal ou apresentarem um exame incompleto de colonoscopia. Quanto ao escore geral de limpeza, não se observou diferença estatisticamente significativa (p = 0,25) entre os grupos A (resultado regular ou ruim, 37,5%; bom ou excelente, 62,5%) e B (resultado regular ou ruim, 49%; bom ou excelente, 51%). Por outro lado, o escore de fome apresentou diferença significativa (p = 0,016) entre os grupos A (sem fome, 41,7%; fome leve, 12,5%; fome, 12,5%) e B (sem fome, 24,5%; fome leve, 38,8%; fome, 36,7%). Conclusões: Os dados sugerem que a adição de PEPTAMEN® oral como parte do regime de preparo intestinal não altera significativamente o escore de limpeza luminal durante a colonoscopia, mas alivia a fome. Keywords: Colonoscopy, Bowel preparation, Quality, Low residue, Enteral formula, Palavras-chave: Colonoscopia, Preparo intestinal, Qualidade, Pobre em resíduo, Fórmula enteral

Background: This prospective observational study aimed to determine the impact of bariatric surgery on the protein-energy intake, sleep quality and quality of life (QOL) of bariatric surgery patients in Malaysia. Methods: The study evaluated 52 morbidly obese patients who underwent bariatric surgery. The short version of the World Health Organization Quality of Life questionnaire (WHOQOL-BREF), Epworth Sleepiness Scale (ESS) questionnaire and three days 24-hour diet recall were used to evaluate the health-related QOL, sleep quality and protein-energy intake of patients. Patients were interviewed before and 3 months after surgery. Results: The mean age was 42 years and 69.2% of them were female. The mean BMI was 42 kg/m2. Patients with morbid obese had significantly lowered QOL scores, mean intake of 1898 kilocalories and 75 g protein per day before the surgery. The reduction of weight after bariatric surgery showed an increase in QOL score in all areas (P < 0.05) and a decrease on ESS score from 6.3 ± 4.0 to 2.9 ± 2.3 (p < 0.00). The mean intake 3 months after surgery was 718 kilocalories, 39g protein per day. Conclusion: Bariatric surgery is proven effective in achieving significant weight loss, improving sleep quality and QOL among Malaysian obese patients within 3 months of surgery. However, the newly restricted stomach after bariatric surgery significantly reduces food intake in the first 3 months. Therefore, a more careful follow-up with patients is required.

Background: Colonoscopy is an indispensable investigative and therapeutic tool in colorectal conditions. The accuracy of colonoscopic diagnosis is dependent on the effectiveness of the bowel preparation and the visibility of the colonic mucosa. Objective: This study compares the efficacy of split-dosing bowel preparation compared to the conventional the single-day timing of bowel preparation, by measuring the quality of colonoscopy performed using a validated bowel cleanliness score. Methods: An endoscopist-blinded clinical trial was conducted over a period of three months through convenient sampling at the Surgery Out-Patient Clinic at a secondary referral hospital in Malaysia. Data were recorded prospectively on the timing of bowel preparation, colonoscopic view of bowel cleanliness, age, and gender. Results: There was a total of 110 subjects for both conventional and test groups. Demographic studies showed 63 (57.3%) patients were under 60 years old, 61(55.5%) were male, and 48 (44%) were Malays. For the patients undergoing colonoscopy, the majority of the 86 (78.2%) had good bowel preparation and 96 (87.3%) of them with high efficacy of bowel preparation. The timing of bowel preparation is significantly associated with the efficacy of the bowel preparation and the quality of the colonoscopy (p

Buerger’s disease or thromboangiitis obliterans causes pain, ulceration, or gangrene in the lower or upper extremity. It is associated with chronic cigarette smoking and is believed to be an immune mediated vasculitis. The pathogenesis is still unknown but recent postulate of its association with odontal bacteria has generated much renewed interest. Despite its recognition more than a century ago, little progress has been made in its treatment. Until the pathogenesis is elucidated, abstinence from cigarette is the only effective therapy.

Venous ulcer as a complication of ankle arteriovenous fistula for hemodialysis is rarely reported. It poses a challenge between ulcer healing and fistula preservation. We report our experience in the management of venous ulcers secondary to an ankle arteriovenous fistula in a hemodialysis patient.

Wounds following stoma closures are at a high risk of infection due to the presence of the intestinal flora. Hence a wound breakdown after a primary stoma closure is common. In anticipation of such a surgical site infection, stoma closure wounds can be treated with antimicrobial agents while allowing the wound to heal with a secondary intention. While most skin antiseptics have similar efficacies, silver dressing has the advantage of patient convenience with its less frequent need of dressing change.

There has been much progress made in the management of peripheral arterial disease (PAD) in the past two decades. Progress in the understanding of the endothelial-platelet interaction during health and disease state have resulted in better antiplatelet drugs that can prevent platelet aggregation, activation and thrombosis during angioplasty and stenting. Collaborative effort by different international societies has resulted in a consensus guideline that recommends the modality of intervention in certain disease states. Progress in perioperative care has reduced the morbidity and mortality associated with peripheral vascular reconstruction surgery. Nevertheless, the advances in percutaneous peripheral intervention (PPI) have made a paradigm shift in the current management of patients. The procedure is safe and effective and is emerging as the first choice revascularization procedure.

Idiopathic chronic anal fissure is believed to be a consequence of a traumatic acute anodermal tear followed by recurrent inflammation and poor healing due to relative tissue ischaemia secondary to internal sphincter spasm. This pilot trial compared the efficacy of a novel manufactured ano-coccygeal support attached to a standard toilet seat (Colorec) to the standard procedure of lateral internal sphincterotomy (LIS) for chronic anal fissure. Fifty-three patients with confirmed chronic anal fissures were enrolled and assigned, based on their preference, to the test group and the control group. Each patient was reviewed after therapy, and follow-up was scheduled at 4, 6 and 8 weeks and at 6 months. The fissure healing rate was 100 % in both groups. There were no statistically significant differences between the test group (n = 30, median age 42 years; range 20–71 years) and the control group (n = 22, median age 38 years; range 23–60 years) with regards to resolution of rectal bleeding at defaecation after 4 weeks (86.6 vs 72.7 %, p = 0.698), and by week 6, bleeding had resolved in 100 % of patients in both groups. There was no statistically significant difference between the test group and the control group with regards to pain scores at 4, 6 and 8 weeks (4.30 ± 0.79, 2.03 ± 0.80, 0.43 ± 0.50 vs 3.50 ± 0.74, 1.68 ± 0.56, 0.50 ± 0.51, p = 0.054) and to time until complete healing of fissures (5.60 ± 1.52 weeks vs 5.91 ± 1.57 weeks, p = 0.479). After continuous use of the ano-coccygeal support over 6 months, no patients in the test group had recurrent fissures. No complications were observed during the trial. Results of both methods were comparable and demonstrated that the ano-coccygeal support is at least as effective as LIS, without any short-term complications. Larger and randomised trials on the use of ano-coccygeal support for chronic anal fissures are awaited.

Perforation with extravasation of barium is a rare complication of contrast enema examination of the large bowel with a high associated mortality rate. The experience of performing a re-laparotomy in a patient previously exposed to barium peritonitis is even less common. We describe an elderly male patient with a Hartmann's procedure performed a year previously, presenting with peritonitis following barium enema evaluation of the proximal colon via an end descending colon stoma. Emergency laparotomy, segmental bowel resection and liberal peritoneal toilet resulted in a satisfactory outcome. The patient had a subsequent successful reversal of his Hartmann's procedure nine months later despite the presence of dense barium induced adhesions. This potentially preventable iatrogenic complication is discussed in this report, which is supplemented by a brief review of the English literature.