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History and Progress of Bariatric Surgery in Malaysia

Kosai NR, Rajan R

Obes Surg, 2018 08;28(8):2572-2577.
PMID: 29860561 DOI: 10.1007/s11695-018-3289-6

Bariatric surgery has become a popular treatment modality for obesity in Malaysia. However, the absence of a standardized national registry has led to paucity of information pertaining to quantity and quality of bariatric surgery in Malaysia. In the absence of a national registry, a nationwide survey was conducted with the aim of establishing a fair estimate of case volume based on type of procedure and to identify the total number of surgeons performing those procedures at their respective centers from 1st January 2010 to 31st December 2016. For this purpose, a questionnaire was designed and distributed to bariatric surgeons throughout Malaysia. The data along with a brief narrative of the history and progress of bariatric surgery in Malaysia is presented in this report.
Fulltext Creative treatment of early buried bumper syndrome

Taher MM, Kosai NR, Gendeh HS

Ann R Coll Surg Engl, 2014 Nov;96(8):621-2.
PMID: 25350188 DOI: 10.1308/rcsann.2014.96.8.621b
Fulltext A case of closed loop small bowel obstruction within a strangulated incisional hernia in association with an acute gastric volvulus

Kosai NR, Gendeh HS, Noorharisman M, Sutton PA, Das S

Acta Medica (Hradec Kralove), 2014;57(2):83-6.
PMID: 25257156 DOI: 10.14712/18059694.2014.45

Small bowel obstruction is a common clinical problem presenting with abdominal distention, colicky pain, absolute constipation and bilious vomiting. There are numerous causes, most commonly attributed to an incarcerated hernia, adhesions or obstructing mass secondary to malignancy. Here we present an unusual cause of a small bowel obstruction secondary to an incarcerated incisional hernia in association with an acute organoaxial gastric volvulus.
Misdiagnosed infected aneurysm presenting as pyrexia of unknown origin (PUO)

Abdikarim M, Shahari S, Idris MA, Hanafiah H, Kosai NR, Das S

Clin Ter, 2014;165(4):199-201.
PMID: 25203333 DOI: 10.7417/CT.2014.1733

Infected aneurysm is a life threatening clinical condition that is associated with significant morbidity and mortality. Early detection is essential for a rapid and efficacious initial treatment for better prognosis. Since the introduction of antibiotic therapy and concomitant decline of endocarditis, true mycotic aneurysms are rarely seen. The usual treatment consists of antibiotics along with aggressive surgical debridement of the infected tissue and vascular reconstruction, if needed. We here describe an infected aneurysm presenting as pyrexia of unknown origin and discuss the clinical features and challenges encountered in the treatment.
Refeeding syndrome: the danger of feeding a starving man

Anitha H, Lam YF, Sutton PA, Kosai NR, Srijit D

Clin Ter, 2014;165(4):203-5.
PMID: 25203334 DOI: 10.7417/CT.2014.1734

Refeeding syndrome is a potentially fatal clinical condition characterized by severe electrolyte and fluid shifts associated with metabolic abnormalities in severely malnourished or starved patients undergoing oral, enteral or parenteral refeeding. We here present a case of a 50-year-old Indian male with a background of depression and alcoholic liver disease presented with alleged ingestion of a detergent. He subsequently developed an oesophageal stricture resulting in severe malnutrition. He developed refeeding syndrome following commencement of TPN associated with clear biochemical alteration. This was immediately identified and rectified. This case report highlights the prevalence of refeeding syndrome in a typical hospital setting that can easily be overlooked and stresses the importance of early recognition as this is a preventable disorder.
A rare case of intussusception associated with metastasized small cell carcinoma of lung

Jarmin R, Azman A, Rahim R, Kosai NR, Das S

Acta Med Iran, 2012;50(11):782-4.
PMID: 23292632

Intussusception is common cause of bowel obstruction in the paediatric age group compared to the elderly population. Many times, the diagnosis may be difficult because of asymptomatic nature of this bowel disorder. We hereby describe the case of a 75-year-old male who presented with lethargy, weakness, loss of movement in the joints and was found to be anemic. The haemoglobin level was low so he was transfused with packed cells. On gastrointestinal (GI) endoscopy, upper GI bleed was observed. A mass was observed beyond ampulla at the 2nd and 3rd part of the duodenal junction. Computerized tomography (CT) scan also showed a mass at the head of pancreas and the lesion at the left lung. In view of persistent bleed, 'Whipple's procedure' was performed. Histopathological examination showed small cell carcinoma of the lungs with metastasis to the pancreas and the jejunum. We here discuss the case of intussusception with intestinal metastasis which presented with gastrointestinal bleeding.
Laparoendoscopic Transgastric Enucleation of an awkwardly sited Peri-Cardial Gastrointestinal Stromal Tumour (GIST): A Multi- Modal Approach

Kosai NR, Rajan R, Roslani EJ, Sutton PA, Mustafa M, Das S

Clin Ter, 2015 Nov-Dec;166(6):248-52.
PMID: 26794812 DOI: 10.7417/CT.2015.1896

In the modern era of surgery, minimally invasive surgery is increasingly applied for excision of gastrointestinal stromal tumors. Site, size and tumor location are important factors that affect the surgical approach and excision. We performed a laparoendoscopic transgastric enucleation of a 4-cm pericardial endophytic gastrointestinal stromal tumor (GIST) using an energy device. The surgery was successful and post-operative recovery uneventful. No tumor recurrence was detected on surveillance gastroscopy. In the safe hands of a well-trained laparoscopic upper gastrointestinal surgeon, pericardial GIST can be enucleated safely by this method. The avoidance of surgical staplers is not only cost-effective, but also reduces the risk of associated complications.
Resolution of Acanthosis Nigricans Following Curative Gastric Carcinoma Resection

Jagwani AV, Reynu R, Affirul CA, Mustafa MT, Kosai NR

Clin Ter, 2016;167(4):99-100.
PMID: 27598021 DOI: 10.7417/CT.2016.1937

We discuss a 48-year old, who presented with upper epigastrium pain associated with early satiety and significant weight loss. Physical examination revealed a thickening and darkening of skins around the skin folds, scalp, back and front of abdomen. A diagnosis of gastro-esophageal junction adenocarcinoma was confirmed by oesophagogastroduodenoscopy (OGDS) and biopsy. The biopsy of the skin lesion revealed a diagnosis of acanthosis nigricans, He underwent a total gastrectomy followed by adjuvant chemo-radiotherapy. Recovery is unremarkable. Interestingly, the skin lesions disappear following our therapy. We believe this may be attributed to the treatment of the malignancy. We highlight the interesting association, pathophysiology and therapy.
Tackers versus glue mesh fixation: an objective assessment of postoperative acute and chronic pain using inflammatory markers

Liew W, Wai YY, Kosai NR, Gendeh HS

Hernia, 2017 08;21(4):549-554.
PMID: 28417279 DOI: 10.1007/s10029-017-1611-1

PURPOSE: Laparoscopic hernioplasty has become a popular choice for inguinal hernia repair since its advent in 1990s. Postoperative pain is an undesirable clinical outcome impairing daily activity of 22.5% of patients. The aim of this study is to evaluate postoperative acute and chronic pain via inflammatory markers as an objective assessment following tacks or glue mesh fixation in TEP repair.
METHODS: Sixty-six (66) patients with unilateral uncomplicated inguinal hernia were randomized into 34 patients in the tacker and 32 patients in cyanoacrylate glue mesh fixation in TEP repair. The extent of surgical trauma was evaluated by measuring inflammatory markers of C-reactive protein, white blood cell count at 48 h, and ESR at 3 months postoperatively. Postoperative acute and chronic pain was assessed by recording the visual analogue scale scores and surgical complications were recorded over 3 months of the study period.
RESULTS: The median CRP and WBC levels at postoperative 48 h in both groups raised significantly from the baseline values (p 0.05). The median ESR level increased significantly at 3 months postoperatively from baseline in the glue mesh fixation group only (p 0.05). There was no significant difference for VAS scores at all timelines between the tacker and glue mesh fixation group (p > 0.05).
CONCLUSION: Cyanoacrylate glue mesh fixation technique as an alternative method to mechanical fixation in TEP repair is comparable to tacker and can be considered to be safe and feasible.
A prospective cohort study on quality of life after endoscopic thoracic sympathectomy for primary hyperhidrosis

Dharmaraj B, Kosai NR, Gendeh H, Ramzisham AR, Das S

Clin Ter, 2016;167(3):67-71.
PMID: 27424505 DOI: 10.7417/CT.2016.1928

BACKGROUND: Hyperhidrosis is an excessive sweating disorder affecting quality of life. Endoscopic thoracic sympathectomy (ETS), introduced by Kux in 1951, is currently the gold standard surgical treatment for primary hyperhidrosis. 75% of patients with primary hyperhidrosis have seen improvement in quality of life within 30 days after surgery. Compensatory hyperhidrosis and pneumothorax (up to 75%) have been reported in patients after surgery. This study evaluates the functional status, self- esteem, compensatory hyperhidrosis and quality of life among patient with primary hyperhidrosis before and after undergoing ETS.
METHOD: Fifty (n=50) patients between the ages 18 to 30, with primary hyperhidrosis were recruited. Patients answered the quality of life questionnaire and Rosenberg self-esteem questionnaire prior to surgery and 30 days post surgery on follow up. Any post-operative complications were documented. Telephone interviews were held for patients who were unable to attend the clinics for follow-up.
RESULTS: Forty six patients (92%) had symptomatic relieve within 30 days of surgery. The incidence of compensatory sweating was 78% (39 patients), with 6 patients developing severe hyperhidrosis. Two patients who did not experience symptomatic relieve, developed compensatory hyperhidrosis. Pneumothorax was documented in 8 patients (16%), with 6 patients requiring chest tubes. Significant improvement in quality of life and self-esteem was seen among patients after surgery.
CONCLUSIONS: ETS has shown to significantly improve the quality of life and self-esteem of patients with primary hyperhidrosis within 30 days of surgery. However, the rate of compensatory hyperhidrosis still remains high (78%) which requires a long term evaluation.
KEYWORDS: Hyperhyrosis; Quality of life; Thoracoscopic Symphatectomy
Epidemiology and role of Helicobacter pylori virulence factors in gastric cancer carcinogenesis

Sukri A, Hanafiah A, Mohamad Zin N, Kosai NR

APMIS, 2020 Feb;128(2):150-161.
PMID: 32352605 DOI: 10.1111/apm.13034

Infection with Helicobacter pylori is associated with the development of gastric cancer. Although the prevalence of gastric cancer has declined throughout years due to improvement in early screening strategy, mortality due to gastric cancer has not changed. Incidence and mortality due to gastric cancer are higher in developing countries as compared to developed countries. Diagnosis and prognosis of gastric cancer are still poor with patients usually diagnosed with cancer at an advanced stage. Eradication of H. pylori is pertinent for the prevention of gastric cancer. However, the rise in antimicrobial resistance among H. pylori isolates has complicated the prevention strategy. H. pylori express multiple virulence factors for survival in the hostile acid gastric environment. The expression of oncogenic protein cytotoxin-associated gene A (CagA), vacuolating cytotoxin A (VacA), and outer inflammatory protein is essential for H. pylori to exert pathogenesis towards the host. Interestingly, <3% of H. pylori-infected subjects develop gastric cancer, suggesting a unique way of interaction between the host's immune response and H. pylori virulence factors. This article is aimed to review the epidemiology and role of H. pylori in gastric carcinogenesis. A better understanding of the interaction between H. pylori virulence factors and host is required for better gastric cancer prevention.
Distribution of gastric adenocarcinoma subtypes in different ethnicities in Kuala Lumpur, Malaysia

Sukri A, Hanafiah A, Kosai NR, Taher MM, Mohamed Rose I

Malays J Pathol, 2017 Dec;39(3):235-242.
PMID: 29279585 MyJurnal

The multiracial population in Malaysia has lived together for almost a century, however, the risk of gastric cancer among them varies. This study aimed to determine the distribution of different gastric adenocarcinoma subtypes and Helicobacter pylori infection status among gastric adenocarcinoma patients. Patients with gastric adenocarcinoma were enrolled from November 2013 to June 2015. Blood samples were collected for detection of H. pylori using ELISA method. Gastric adenocarcinoma cases were more prevalent in the Chinese (52.8%), followed by the Malays (41.7%) and least prevalent in the Indians (5.6%). Gastric adenocarcinoma located in the cardia was significantly more prevalent in the Malays (66.7%) compared to the Chinese (26.3%), whereas non-cardia cancer was diagnosed more in the Chinese (73.7%) compared to the Malays (33.3%) [P = 0.019; OR = 5.6, 95 CI: 1.27 to 24.64]. The Malays also had significantly higher prevalence of gastric tumour located at the cardia or fundus than other gastric sites compared to the Chinese (P = 0.002; OR: 11.2, 95% CI: 2.2 to 56.9). Among the cardia gastric cancer patients, 55.6% of the Malays showed intestinal histological subtype, whereas all the Chinese had the diffuse subtype. More than half of the patients (55.3%) with gastric adenocarcinoma were positive for H. pylori infection and among them, 66.7% were Chinese patients. The risk of gastric adenocarcinoma in our population is different among ethnicities. Further studies on host factors are needed as it might play an important role in gastric cancer susceptibility in our population.
The Impact of Laparoscopic Intraperitoneal Instillation of Ropivacaine in Enhancing Respiratory Recovery and Reducing Acute Postoperative Pain in Laparoscopic Sleeve Gastrectomy: a Double-Blinded Randomised Control; RELiEVE Trial

Zheng LQ, Kosai NR, Ani MFC, Maaya M

Obes Surg, 2023 Oct;33(10):3141-3146.
PMID: 37667104 DOI: 10.1007/s11695-023-06777-y

PURPOSE: Laparoscopic intraperitoneal instillation of local anaesthetic in bariatric surgery proven to reduce postoperative pain. Limited data are available regarding the use of instillation ropivacaine and its impact on the recovery of respiratory effort. This study aims to evaluate the efficacy of laparoscopic intraperitoneal instillation of ropivacaine in reducing acute postoperative pain and enhancing the recovery of respiratory effort in laparoscopic sleeve gastrectomy.
MATERIALS AND METHODS: This double-blinded RCT enrolled 110 patients who underwent laparoscopic sleeve gastrectomy at Hospital Canselor Tuanku Muhriz UKM from November 2020 to May 2021. Any patients with previous abdominal surgery, chronic kidney disease, or liver disease were excluded. The patients were randomised into two groups: (i) the IPLA group which received ropivacaine intraperitoneal instillation at the dissected left crus and (ii) the placebo group (sterile water instillation). Perioperative analgesia was standardised. The first 24-h postoperative pain was assessed using a VAS. The respiratory effort was assessed using incentive spirometry simultaneously.
RESULTS: Total of 110 patients were recruited. The VAS score was lower with an enhanced recovery of respiratory effort in the local anaesthetic group compared to the placebo group (P < 0.05) within the first 24 h postoperatively. In addition, the placebo group required additional postoperative analgesia (P < 0.05). No side effects were reported with the use of intraperitoneal instillation of ropivacaine.
CONCLUSION: The use of intraperitoneal instillation of ropivacaine in laparoscopic sleeve gastrectomy is recommended as it is safe, effectively reduces acute postoperative pain, and enhances the recovery of respiratory effort postoperatively.
Fulltext Prolapsing Gastric Polyp Causing Intermittent Gastric Outlet Obstruction

Kosai NR, Gendeh HS, Norfaezan AR, Razman J, Sutton PA, Das S

Int Surg, 2015 Jun;100(6):1148-52.
PMID: 25578789 DOI: 10.9738/INTSURG-D-14-00205.1

Gastric polyps are often an incidental finding on upper gastrointestinal endoscopy, with an incidence up to 5%. The majority of gastric polyps are asymptomatic, occurring secondary to inflammation. Prior reviews discussed Helicobacter pylori (H pylori)-associated singular gastric polyposis; however, we present a rare and unusual case of recurrent multiple benign gastric polyposis post H pylori eradication resulting in intermittent gastric outlet obstruction. A 70-year-old independent male, Chinese in ethnicity, with a background of diabetes mellitus, hypertension, and a simple renal cyst presented with a combination of melena, anemia, and intermittent vomiting of partially digested food after meals. Initial gastroscopy was positive for H pylori; thus he was treated with H pylori eradication and proton pump inhibitors. Serial gastroscopy demonstrated multiple sessile gastric antral polyps, the largest measuring 4 cm. Histopathologic examination confirmed a benign hyperplastic lesion. Computed tomography identified a pyloric mass with absent surrounding infiltration or metastasis. A distal gastrectomy was performed, whereby multiple small pyloric polyps were found, the largest prolapsing into the pyloric opening, thus explaining the intermittent nature of gastric outlet obstruction. Such polyps often develop from gastric ulcers and, if left untreated, may undergo neoplasia to form malignant cells. A distal gastrectomy was an effective choice of treatment, taking into account the polyp size, quantity, and potential for malignancy as opposed to an endoscopic approach, which may not guarantee a complete removal of safer margins and depth. Therefore, surgical excision is favorable for multiple large gastric polyps with risk of malignancy.
Transarterial angioembolization versus surgery after failed endoscopic therapy for non-variceal upper gastrointestinal bleeding

Jailani RF, Kosai NR, Yaacob NY, Jarmin R, Sutton P, Harunarrashid H, et al.

Clin Ter, 2014;165(6):294-8.
PMID: 25524184 DOI: 10.7417/CT.2014.1771

BACKGROUND AND OBJECTIVE: To compare the outcome of transarterial angioembolization (TAE) and surgery with endoscopically unmanageable non-variceal hemorrhage of the upper gastrointestinal tract.

MATERIALS AND METHODS: A case note review of all patients treated for non-variceal upper gastrointestinal bleeding from January 2006 till January 2012 was performed.

RESULTS: Fifty-four of 667 patients with non-variceal bleeding did not respond to endoscopic treatment. Nine of the 54 patients had incomplete data, leaving 45 patients in the study; 24 had angiography and another 21 had surgery. The two groups were broadly similar in terms of relevant clinical variables. Nineteen of 24 having angiography had embolisation. Re-bleeding recurred in 8 patients (33%) in the TAE group and 6 patients (28.6%) in the surgery group (p = 0.28). There was no statistically significant difference in post procedural complications (81% vs 62.5%, p = 0.17), 30-day mortality (33% vs 29.1%, p = 0.17 ) units of blood transfused (12.24 vs 8.92, p = 0.177) and mean hospital stay (30.7 vs 22.9 days, p = 0.281) observed in patients undergoing surgery as compared to TAE.

CONCLUSIONS: TAE and surgery have similar outcomes in patients with endoscopically unmanageable non-variceal upper gastrointestinal haemorrhage.
Single incision laparoscopic surgery (SILS) inguinal hernia repair - recent clinical experiences of this novel technique

Yussra Y, Sutton PA, Kosai NR, Razman J, Mishra RK, Harunarashid H, et al.

Clin Ter, 2013;164(5):425-8.
PMID: 24217830 DOI: 10.7417/CT.2013.1608

Inguinal hernia remains the most commonly encountered surgical problem. Various methods of repair have been described, and the most suitable one debated. Single port access (SPA) surgery is a rapidly evolving field, and has the advantage of affording 'scarless' surgery. Single incision laparoscopic surgery (SILS) for inguinal hernia repair is seen to be feasible in both total extraperitoneal (TEP) and transabdominal pre-peritoneal (TAPP) approaches. Data and peri-operative information on both of these however are limited. We aimed to review the clinical experience, feasibility and short term complications related to laparoscopic inguinal hernia repair via single port access. A literature search was performed using Google Scholar, Springerlink Library, Highwire Press, Surgical Endoscopy Journal, World Journal of Surgery and Medscape. The following search terms were used: laparoscopic hernia repair, TAPP, TEP, single incision laparoscopic surgery (SILS). Fourteen articles in English language related to SILS inguinal hernia repair were identified. Nine articles were related to TEP repair and the remaining 5 to TAPP. A total of 340 patients were reported within these studies: 294 patients having a TEP repair and 46 a TAPP. Only two cases of recurrence were reported. Various ports have been utilized, including the SILS port, Tri-Port and a custom- made port using conventional laparoscopic instruments. The duration of surgery was 40-100 minutes and the average length of hospital stay was one day. Early outcomes of this novel technique show it to be feasible, safe and with potentially better cosmetic outcome.
Arterial embolization of a bleeding gastric Dieulafoy lesion: a case report

Mohd Rizal MY, Kosai NR, Sutton PA, Rozman Z, Razman J, Harunarashid H, et al.

Clin Ter, 2013;164(1):25-7.
PMID: 23455738 DOI: 10.7417/T.2013.1506

Dieulafoy's lesion is one of an unusual cause of upper gastrointestinal bleeding (U GIB). Endoscopic intervention has always been a preferred non-surgical method in treating UGIB including bleeding from Dieulafoy's lesion. Owing to recent advances in angiography, arterial embolization has become a popular alternative in non- variceal UGIB especially in cases with failed endoscopic treatment. However, managing bleeding Dieulafoy's with selective arterial embolization as the first line of treatment has not been exclusively practiced. We hereby, report a case of bleeding Dieulafoy lesion which had been primarily treated with arterial embolization.
The sequelae of barium aspiration

Gendeh HS, Hashim ND, Mohammad Yunus MR, Gendeh BS, Kosai NR

ANZ J Surg, 2018 09;88(9):937-938.
PMID: 27122196 DOI: 10.1111/ans.13624
Surface Antigen Profiling of Helicobacter pylori-Infected and -Uninfected Gastric Cancer Cells Using Antibody Microarray

Sukri A, Hanafiah A, Kosai NR, Mohamed Taher M, Mohamed Rose I

Helicobacter, 2016 Oct;21(5):417-27.
PMID: 26807555 DOI: 10.1111/hel.12295

Comprehensive immunophenotyping cluster of differentiation (CD) antigens in gastric adenocarcinoma, specifically between Helicobacter pylori-infected and -uninfected gastric cancer patients by using DotScan(™) antibody microarray has not been conducted. Current immunophenotyping techniques include flow cytometry and immunohistochemistry are limited to the use of few antibodies for parallel examination. We used DotScan(™) antibody microarray consisting 144 CD antibodies to determine the distribution of CD antigens in gastric adenocarcinoma cells and to elucidate the effect of H. pylori infection toward CD antigen expression in gastric cancer.
Pregnant and severe acute abdominal pain: A surgical diagnostic dilemma

Kosai NR, Amin-Tai H, Gendeh HS, Salleh S, Reynu R, Taher MM, et al.

Clin Ter, 2015;166(3):110-3.
PMID: 26152617 DOI: 10.7417/CT.2015.1839

Acute abdominal pain in pregnancy remains a surgical conundrum. A 25-year-old primigravid at 29 weeks gestation presented with a two-week history of epigastric pain, nausea and vomiting. She had a distended abdomen consistent with a full term gravid uterus; tender at the epigastric and right hypochondrium suggestive of small bowel obstruction or acute appendicitis. Abdominal ultrasound was inconclusive but abdominal Computed Tomography (CT) suggested small bowel volvulus. An exploratory laparotomy revealed a segmental jejunal volvulus and small bowel diverticulum contributing to the volvulus. A short segmental bowel resection was performed. Histopathology confirmed a Meckel's Diverticulum. The patient recovered well but underwent premature labour 10 days later. Small bowel obstruction secondary to Meckel's diverticulum is rare in pregnancy. In an acute gestational abdomen, clinical examination is key. Radiological imaging may be helpful, whilst surgical intervention is confirmatory and therapeutic in the event of an obstructive volvulus.

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