Singaporean Asian Patients have paradoxically higher rates of vitamin D deficiency compared to WesternPatients

1

Department of Endocrinology, Singapore General Hospital, Singapore 2Department of Surgery, Singapore

General Hospital
Daniel C. Wai1,Shanker Pasupathy2,Sonali Ganguly1,Kwang W. Tham1

Background: Vitamin D deficiency has been reported in between 57% to 65% of patients in Western countries
before bariatric surgery and can drop further after surgery, resulting in metabolic bone disease. Nostudies have however reported vitamin D (vit-D) levels in patients before bariatric surgery in tropical
Singapore. Aims of Study: To retrospectively investigate vit-D and intact parathyroid hormone (iPTH)
levels in obese patients immediately before undergoing bariatric surgery in a tertiary hospital.Methods:
Baseline patient characteristics, preoperative Vit-D and iPTH levels were studied together with its
relationship to race, gender and body mass index (BMI). Results were presented as mean (standarddeviation).Results: 46 patients underwent bariatric surgery. 61% were female. There were 44% Chinese,
26% Malay, 24% Indian, and 7% were of other ethnicity. 78% had laparoscopic sleeve gastrectomy, 20%
Roux-en-Y gastric bypass, and 2% bilio-pancreatic diversion. The mean age was 39 (10.6) and the mean
BMI was 43.6 (9.8). The mean of vit-D was low at 17.4 ng/ml (8.6). 75% were deficient (<21 ng/ml), 21%
were insufficient (21-29 ng/ml), and only 4% had sufficient vit-D (>29 ng/ml). Mean iPTH was low at 6.5
pmol/l (3.5). 50% of the patients had raised iPTH. Vit-D levels were inversely correlated with BMI(r2=0.242, p=0.008). Non-Chinese patients had higher BMI (46.3 vs 40.0, p=0.032), lower vitamin D levels(13.6 vs 23.2 ng/ml, p=0.002) and higher iPTH (8.7 vs 4.4 pmol/l, p=0.007). Those were not different
between males and females.

Conclusion: The majority of obese patients, especially Malays and Indians,

had deficient and insufficient vit-D levels even before bariatric surgery. Alarmingly the proportionof patients deficient was higher than in Western countries despite the fact that Singapore has sunshine
all year round. Physicians in tropical countries therefore should routinely screen for its deficiency
preoperatively with appropriate repletion.

A Simple Clinical Scoring System to Identify Patients at Risk of NASH Before the Development of NASH

1

Department of General and Digestive Surgery, Flinders Medical Centre, Adelaide, Australia 2Department

of Digestive Surgery, Osaka Medical Centre for Cancer and Cardiovascular Diseases, Osaka, Japan
Jacob A Chisholm1,Yosuke Seki2,James Toouli1,Jurgen Stahl1,Jane Collins1,Lilian Kow1

Background

Nonalcoholic fatty liver disease (NAFLD) is common in the morbidly obese. It is a condition

that can lead to progressive fibrosis and cirrhosis. A clinical scoring system to identify patients
predisposed

tofibrosis

wouldassistinselectingpatients

forliverbiopsyandfurthermanagement.Methods Liver biopsies were taken from 370 consecutive patients who underwent laparoscopic
bariatric surgery. Clinical and biochemical parameters were then assessed for correlation withhistological features of non-alcoholic fatty liver disease.Results Sixty eight patients (18%) were foundto have non-alcoholic steatohepatitis (NASH). Raised insulin resistance, ALT and total bilirubin wereindependently associated with NASH. The presence of at least 2 of the 3 provided the best combinationof sensitivity (0.71) and specificity (0.71) for predicting NASH.Conclusion Raised insulin resistance,
ALT and total bilirubin are clinical indicators for the presence of NASH prior to the development offibrosis.

Bariatric surgery improves arterial stiffness of the patient with metabolic syndrome1

Department of Rehabilitation, Kamagaya General Hospital, Chiba, Japan 2Department of Diabetes andEndocrinology, Saitama Medical University, Saitama, Japan
Juntendo University Graduate School of Medicine, Tokyo, Japan3

Department of Ageing Control Medicine,
4

Department of obesity surgery, Kamagaya

General Hospital, Chiba, JapanYuichi

Shinoda1,Ikuo

Inoue2,Takuji

Shirasawa3,Isao

Kawamura4

Obesity is an independent predictor of cardiovascular risk. Increased arterial stiffness, as reflectedby an increased pulse wave velocity (PWV), is significantly and independently associated with higher
risk for cardiovascular morbidity and mortality. According to recent reports, individuals with obesity
are likely to have an increase in aortic stiffness, independent of blood pressure (BP) level, ethnicity,and age.

A 60-year-old Japanese woman with obesity (BMI 45.5) and metabolic syndrome was referred tous. Her diabetic status is under control after bariatric surgery. The PWV decreased significantly aftertreatment (1528 vs 1211cm/sec) with reduction of visceral fat (100 vs 52 cm2). The bariatric surgery
could improve arterial wall stiffness in patients with metabolic syndrome. The pathophysiologic
mechanisms that link abdominal adiposity to arterial stiffening are should be investigated.

Case study : Partial Situs Inversus in a Morbidly Obese Female.
Sanjay Borude
Introduction
A 32 years old female presented with off & on mid chest pain and Morbid Obesity (BMI 41.41Sq.
Mtrs) & secondary infertility. One FTND & she had a h/o ? liver problem.
MethodCT Chest/Abd/Pelvis showed Enlarged Mediastinal Lymph nodes and Partial Situs Inversus since
there was no Dextr-Cardia.
Ba Meal FT also showed Situs Inversus. Haematology, Biochemistry, ECG, 2D Echo, Chest X-ray
were normal.
Patient planned for a Sleeve Gastrectomy in a supine reverse Trendenburg’s position. Primary
surgeon stood on the left of the patient. Camera 12 mm port in the supra-umbilical region, 12mm port in the line of umbilicus in (L) mid-clavicular line, 5 mm port right epigastrium forliver retraction, another two 5 mm working ports either side of the mid abdomen.
Intra-operative findings: Large stomach on the right of abdomen, Liver extending from left toright, Spleen in the RHC region. Devascularisation of the greater curvature started fromabout 6 cms from the Pylorus to the right crus. Stomach resected with 32 F Bougie in thestomach. Staple line burried with 2-0 Ethibond suture. Abdominal drain placed. Ryles tube
placed in the stomach.
ResultPatient’s recovery was uneventful. Patient started on oral liquids 20 hours after thesurgery. Ryles tube was removed after 24 hours and drain after 30 hours.
Conclusion
Patient was totally asymptomatic so far GI tract was considered. It was only the surgicaltask for the surgeon because of the “Mirror-Image” effect.