Assanee Tongyoo, Aekkaphod Liwattanakun, Ekkapak Sriussadaporn, Palin Limpavitayaporn, Chatchai Mingmalairak

Background: Laparoscopic cholecystectomy (LC) is one of the most common abdominal operations. The difficult cases are still challenging for surgeons. There had been many studies providing several preoperative models to predict difficult LC or conversion. Randhawa's scoring system was a simple and practical predictive model for clinicians. The modification was reported to be more preferable for delayed LC. This study aimed to confirm the advantage of modified predictive model in larger sample size.

Materials and Methods: This retrospective cohort study reviewed medical records of patients who underwent LC since January 2017 to December 2021. The difficulty of operation was categorized into three groups: easy, difficult, and very difficult. Multivariate analysis was performed to define significant factors of very difficult and converted cases. The predictive scores were calculated by using the original Randhawa's model and the modification, then compared with actual outcome.

Results: There were 567 cases of delayed LC in this study, with 44 cases (7.8%) converted to open cholecystectomy. Four factors (previous cholecystitis, previous endoscopic retrograde cholangiopancreatography, higher ALP, and gallbladder wall thickening) for very difficult group and five factors (previous cholecystitis, previous cholangitis, higher white blood cell count, gallbladder wall thickening, and contracted gallbladder) for conversion were significant. The modification provided the better correlation and higher area of receiver operating characteristic (ROC) curve comparing with the original model.

Conclusion: The modification of Randhawa's model was supposed to be more preferable for predicting the difficulty in elective LC. Thai Clinical Trials Registry No. 20220712006.

Kanlerd A, Mahawongkajit P, Achavanuntakul C, Boonyasatid P, Auksornchart K.

Abstract Diagnosis of blunt esophageal injury is currently a challenging issue. Early surgical interventions still play as the mainstay of treatment. There was no consensus about appropriate treatment options. However, it was potential morbidity if delayed management. We report a 33-year-old man with a history of a motorcycle accident who presented with hematemesis and epigastrium pain. He was initially diagnosed with left pneumohemothorax and low-grade gastric injury. The patient developed a high-grade fever with complex left pneumohemothorax 72-h after admission. The diagnostic studies revealed a lower esophageal rupture. He was treated with trans-gastric primary repair and recovered well with no complications. We propose the trans-gastric intraluminal repair is one of the surgical options in a blunt lower esophageal rupture.

Chompoonut Achavanuntakul, Prasit Mahawongkajit , Saritphat Orrapin , Karikarn Auksornchat, Piyapong Boonyasatid, Nichakarn Waewsri , Alisa Moriguchi , Amonpon Kanlerd

Purpose: For more than two years since the COVID-19 pandemic, human lives have changed, including the healthcare system. Management of acute appendicitis, the most common emergency surgical disease, has been inevitably affected. This study aimed to assess the effect of the COVID-19 pandemic on the incident rate of complicated appendicitis, management, outcome, and complication of acute appendicitis. Patients and Methods. This study was a retrospective cohort study comparing 574 patients diagnosed with acute appendicitis before the COVID-19 outbreak and 434 patients diagnosed with acute appendicitis during the COVID-19 outbreak. Patient demographic data, type of appendicitis, type of treatment, time to surgery, length of stay, cost, and complications were collected and analyzed.

Results: During the COVID-19 pandemic, the number of patients diagnosed with acute appendicitis was reduced. CT scan usage for diagnosis was increased compared to pre-COVID-19. Most patients diagnosed with acute appendicitis received operative treatment in both groups. Median time to surgery was significantly longer during the COVID-19 pandemic, 11.93 hours compared to 9.62 hours pre-COVID-19, p-value <0.001 (relative risk 1.5, 95% CI 1.29-1.76, p value 0.041). The incidence of complicated appendicitis was not higher during COVID-19. Compared to pre-COVID-19, ICU admission rate, the use of a mechanical ventilator, length of stay, and cost increased in the univariate analysis but were not statistically significant in the multivariate analyses. Other treatment complications had no statistically significant difference.

Conclusion: The incidence of complicated appendicitis did not increase during the COVID-19 pandemic. The operation waiting time significantly increased but did not increase the rate of treatment complications in a well-prepared hospital system.

Sriussadaporn E, Tongyoo A, Pipatbouwornkul S, Limpavitayaporn P, Mingmalairak C

Background: In 2019, the American Society for Gastrointestinal Endoscopy (ASGE) revised their guidelines for endoscopic management of common bile duct stones (CBDS).

Objective: To evaluate the accuracy of the 2019 ASGE criteria in evaluation of CBDS and to identify additional predictive parameters that might improve the accuracy of those criteria.

Material and Methods: The present study design was a retrospective cohort study. Patients suspected of having CBDS and treated with ERCP by the Surgery Department of Thammasat University Hospital between January 2017 and January 2020 were enrolled. Clinical, laboratory, radiological, and endoscopic data were retrospectively collected by medical chart review.

Results: Five hundred sixty-five patients were enrolled, with 85.8% in the high-risk group by ASGE criteria. CBDS were found in 75.4% by ERCP. The overall high-risk criteria had sensitivity of 90.6%, and accuracy 75.4%. CBDS on imaging was the most powerful criterion with an odds ratio of 3.36 (p<0.01) with the highest sensitivity at 68.1%, specificity at 61.2%, and accuracy at 66.4%. Post-cholecystectomy, age, and elevated alkaline phosphatase (ALP) level were significant factors in finding of CBDS by multivariate analysis. The newly proposed high-risk condition of “TB 1.8 to 4.0 mg/dL, elevated ALP, and CBD dilatation” had improved sensitivity at 92.3%, accuracy at 76.4%, and odds ratio at 4.65 compared to the original high-risk criteria with an odds ratio of 3.90.

Conclusion: The high-risk criteria of the ASGE 2019 guideline is an effective evaluation for patients clinically suspected of having CBDS. Adding a new criterion of “TB 1.8 to 4.0 mg/dL and elevated ALP and CBD dilatation” could make the high-risk criteria more sensitive to CBDS and improve accuracy.

Prasit Mahawongkajit, Neranchala Soonthornkes

Background: Topical pharyngeal anesthesia has improved esophagogastroduodenoscopy (EGD) efficiency with smooth insertion, reducing pain and discomfort. Lidocaine spray is one of the safe and widely used methods. In practice, the patients walk, sit in a wheelchair, or lie on a trolley bed, and the lidocaine sprays are applied to those in sitting or supine positions for pre-endoscopic preparation. Although there is no current guidance technique, this study aims to compare the effects of lidocaine sprays between sitting (Group A; Gp A) and supine positions (Group B; Gp B) for patients undergoing unsedated EGD.

Methods: This study was a single-center prospective randomized controlled trial. Unsedated EGD patients were randomly allocated the lidocaine spray in sitting or lidocaine spray in the supine position.

Results: Lidocaine spray treatments were significantly different in the gag reflex (NRS; Gp A: 1.28 ± 0.67, Gp B: 1 ± 0.63, p = 0.0003), ease of esophageal instrumentation (NRS; Gp A: 7.68 ± 0.91, Gp B: 7.95 ± 0.66, p = 0.0042), and pain score (NRS; Gp A: 5.16 ± 2.08, Gp B: 4.53 ± 1.93, p = 0.0059). When considering modified Mallampati classification (MMC), MMC classes III and IV were significantly different in the same direction but MMC classes I and II were not.

Conclusion: The technique of spraying in the supine position was associated with less gagging, less pain, and easier esophageal instrumentation, especially in patients with MMC classes III and IV.

Prasit Mahawongkajit, Ajjana Techagumpuch, Kharikarn Auksornchat

Background and study aims The current practice of endoscopists is undergoing a dramatic revolution due to emerging endoscopy practices. Increasing use of gastrointestinal endoscopy has led to hospital budgets setting aside funds specifically related to damage to endoscopic instruments. Therefore, training in understanding endoscopic equipment, handling techniques, and equipment care can be helpful in addressing this issue. The aim of this study was to investigate the effects of educational courses and training about basic endoscopic handling and care in gastrointestinal endoscopic care and services.

Methods A number of new endoscopists, nurses, and nurse assistants were enrolled in a course for training in basic endoscopic handling and care. Data on the type of damage, cause, cost, and timing of endoscopic repair were prospectively collected. Data from the post-training period then were compared with retrospective data from the pre-training period.

Results This study demonstrated that after training, there was less damage to endoscopes, lower costs associated with it, and repair times were shorter for endoscopes than before the training course. Post-training results indicated savings of a total of $ 40,617.21 or £ 29,539.78 and 102.6 days per damaged endoscope.

Conclusions Basic endoscopic handling and care training plays an important role for both endoscopists and nurses, as well as in endoscopy facilities, specifically in avoiding the nuisance of unwanted and broken endoscopes. This could be beneficial for both hospital finances and endoscopic services.

Prasit Mahawongkajit, Jirawat Swangsri

Assanee Tongyoo, Parm Chotiyasilp, Ekkapak Sriussadaporn, Palin Limpavitayaporn, Chatchai Mingmalairak

Background: Although LC is a common operation, difficult cases are still challenging. Several studies have identified factors for the difficulty and conversion. Many scoring systems have been established for pre-operative prediction. This study aimed to investigate significant factors and validity of Randhawa's model in our setting.

Methods: This prospective study enrolled LC patients in Hepato-Pancreato-Biliary Surgery unit between March 2018 and October 2019. The difficulty of operation was categorized into 3 groups by intra-operative grading scale. Multivariate analysis was performed to define significant factors of very-difficult and converted cases. The difficulty predicted by Randhawa's model were compared with actual outcome. Area under ROC curve was calculated.

Results: Among 152 patients, difficult and very-difficult groups were 59.2% and 15.1%, respectively. Sixteen cases needed conversion. Four factors (cholecystitis, ERCP, thickened wall, contracted gallbladder) for very-difficult group and 3 factors (obesity, biliary inflammation or procedure, contracted gallbladder) for conversion were significant. After some modification of Randhawa's model, the modified scoring system provided better prediction in terms of higher correlation coefficient (0.41 vs 0.35) and higher AUROC curve (0.82 vs 0.75) than original model.

Discussion: Randhawa's model was feasible for pre-operative preparation. The modification of this model provided better prediction on difficult cases.

Prasit Mahawongkajit, Nantawat Talalak, Neranchala Soonthornkes

Purpose: Esophagogastroduodenoscopy (EGD) under topical pharyngeal anesthesia has the advantage of avoiding the unwanted cardiopulmonary adverse events experienced following intravenous sedation. Lidocaine spray is a common anesthetic option and is safe for unsedated EGD. Although several studies have compared different topical anesthetic agents, their formulations, and delivery techniques, questions still remain concerning the optimal mode of administration. We have designed a lidocaine formulation in the form of an ice popsicle and compared its effectiveness and tolerability with lidocaine spray in patients undergoing unsedated EGD.

Methods: This was a single-center prospective randomized controlled trial. Unsedated EGD patients were randomly allocated the lidocaine spray [Group (Gp) A] or lidocaine ice popsicle (Gp B) formulation.

Results: In total, 204 unsedated EGD patients were evaluated. Compared to the spray, the lidocaine ice popsicle group showed better scores for effects in terms of endoscopist satisfaction (Gp A, 7.28±1.44; Gp B, 7.8±0.89; p=0.0022), gag reflex (Gp A, 1.3±0.66; Gp B, 1.02±0.61; p=0.0016), patient satisfaction (Gp A, 7.74±0.82; Gp B, 8.08±0.82; p=0.0039), discomfort (Gp A, 6.54±1.34; Gp B, 5.95±1.21; p=0.0012), and pain (Gp A, 5.38±1.85; Gp B, 4.51±2.01; p=0.0015).

Conclusion: Both the lidocaine spray and ice popsicle formulations are safe, effective options for diagnostic EGD with the ice popsicle exhibiting better performance. We propose the lidocaine ice popsicle formulation for topical pharyngeal anesthesia in patients undergoing unsedated diagnostic EGD and suggest it may be a suitable option during the COVID-19 pandemic.

Chatbadin Thongchuam, Prasit Mahawongkajit, Amonpon Kanlerd

Purpose: Since January 2020, the outbreak of COVID-19 coronavirus has impacted global mental health, daily activities, and economies, including Thailand. The essential strategy is the disease-preventing measure of "lockdown." Corrosive ingestion is one of the most common forms of self-harm and problems worldwide. This study aimed to evaluate the effect of corrosive ingestion in the COVID-19 situation.

Methods: This was a retrospective study of adult patients (≥18y) who had ingested corrosives and been admitted to surgical department, Thammasat University Hospital between June and December 2019 (pre-COVID-19) and January to June 2020 (COVID-19 period) and compared the epidemiological and clinical features between these two groups.

Results: Nine and 20 patients were admitted in the pre-COVID-19 and COVID-19 periods, for an increase of 122%; males numbered 15. A minority of ingestions, 8/29, were intentional of which 7 were in the COVID-19 period. The Zargar classification showed a trend towards more gastric injury in the COVID-19 vs pre-COVID-19 periods: 8/17 vs 1/9 (p=0.09). Because of the endoscopic grade 0 in stomach was significantly higher in pre-COVID-19 than COVID-19 case (pre-COVID-19; 8 patients (88.9%), COVID-19; 9 patients (45%); p value 0.011).

Conclusion: Data from this study suggest increasing trends of corrosive ingestion and greater gastric injury during the COVID-19 period.

Prasert W, Homvises B.

Prasert W, Achavanuntakul C, Lohitvisate W.

Patraithikul P, Prasert W, Lohitvisate W.

Suwatthanarak T, Prasert W.

Tangkullayanone W, Prasert W, Sujarittanakarn S.

Prasit Mahawongkajit

Gastroenterol Res Pract. 2020 Jan 30;2020:6873071.

Endoscopic submucosal dissection (ESD) was also considered a "high risk" at the starting point with skillful endoscopic techniques and terrible complications. Still, it remains challenging yet has become widespread among institutes in many parts of the world. This study is aimed at further investigating the feasibility, efficacy, and safety of ESD of gastric lesions and at evaluating clinical outcomes in early experience. The patient characteristics, postoperative outcomes, and results of histopathological examinations were reviewed retrospectively between January 2017 and May 2019. Thirteen patients' gastric ESD were included with all of en bloc resections without recurrence. The long duration was related to the large lesion, the upper part of the stomach, and previous treatment. In this study, the ESD procedure of the stomach is a feasible and safe minimally invasive treatment option with organ preservation. It requires training and experience with a learning approach where skill may be improved to prevent unwanted complications.

Sasithorn Sujarittanakarn, Wanwisa Himakhun, Worawarn Worasawate, Wilairat Prasert

Background: Nowadays, the adjuvant treatment for breast cancer patients chosen depends on immunohistochemical pattern of Estrogen receptor(ER), Progesterone receptor(PR) and HER2 status of primary breast tumor. Several retrospective studies showed significant discordance in receptor expression between primary and metastatic tumors. The objective of this research was to determine discordant rate of ER, PR and HER2 status between primary breast cancer and synchronous axillary lymph node metastasis of individual breast cancer patients in Thammasat University Hospital.

Methods: A prospective observational study of all breast cancer patients who have axillary metastasis and underwent surgery at Thammasat Hospital between January 2011 to December 2015. Tumor staging, ER, PR, and HER2 status on primary breast tumor were recorded. Synchronous axillary lymph node metastasis was evaluated with immunohistochemistry for ER, PR, and HER2.

Results: The ER-positive rate from primary tumor to synchronous axillary lymph node metastasis decreased from 74.7% to 71.7%; the HER2 overexpression rate was decreased from 26% to 24%. In contrast, PR positive rate were 71% in both primary tumor and synchronous axillary lymph node metastasis. In case to case comparison, discordance rate of ER, PR and HER2 status between primary breast cancer and synchronous axillary lymph node metastasis were 11.1%, 20.2% and 10.1%, respectively. Furthermore, the tumor staging was not significant associated with discordance of ER, PR and HER2.

Conclusion: ER, PR and HER 2 biomarkers showed significant concordance between primary tumor and synchronous axillary lymph node metastasis. Hence, if we cannot assess the ER, PR and HER2 status in primary tumor, then synchronous axillary lymph node metastasis can be studied instead. However, the repeat of biomarker testing in node-positive breast cancer patients may be beneficial for tailored adjuvant therapy, especially for patients with negative hormone receptor and/or HER2 profile on primary tumor.

Prasit Mahawongkajit, Prakitpunthu Tomtitchong 

Fluoropyrimidine plus platinum (FP) are chemotherapeutic drugs that are most frequently used to treat esophageal squamous cell carcinoma (ESCC). However, drug resistance often occurs, and the mechanisms of resistance to 5-FU is yet to be determined. The role of micro (mi)RNAs has been well established in a variety of human cancers. The aim of the present study was to investigate the expression profile of ESCC, revealing the differential expression between ESCC and 5-FU resistant ESCC. The establishment of a 5-FU resistant (5-FUR) cell lines model provides a way of analyzing the expression of miRNAs in drug resistance. The miRNA expression indicated 50 miRNAs that were upregulated in TE10-5-FUR compared with TE10, while 119 miRNAs were downregulated. The TE11-5-FUR demonstrated 140 miRNAs were upregulated compared with TE11, which exhibited 12 downregulated miRNAs. Both cell lines share the 2 candidate upregulated miRNAs (miR-146a and miR-483-5p) and 5 downregulated miRNAs (miR-34a, miR-141, miR-200b, miR-200c and miR-205). Further studies are required to analyze and evaluate the function of the miRNAs.

Prasit Mahawongkajit, Nuttorn Boochangkool

Colonic evaluation is an essential step before proceeding with esophagectomy to reconstruct by colonic interposition. Colonoscopy is the standard practice for colorectal cancer screening, but it has a chance of failing cecal intubation and carries a risk of horrific adverse events by colonic perforation. CT colonography is a less invasive alternative method reported as useful for colonoscopic screening in cases of average risk of colorectal cancer. This study set out to report our clinical experience and to evaluate CT colonography in the preoperative process for colonic interposition of esophagectomy patients. Data for esophagectomy with colonic interposition patients were retrospectively analyzed and compared the colonoscopy group with the CT colonography group. During eight years, 31 patients, 12 patients in the colonoscopy group and 19 patients in the CT colonography group, included in this study. In both groups, the patient demographic data, procedures, and outcomes were not different. After colonic interposition, endoscopy was performed, and no lesions of conduits were detected. CT colonography is a minimally invasive and reliable option for colonic evaluation method for the patient of average colorectal cancer risk who has undergone esophagectomy with colonic interposition.

Mahawongkajit P, Techagumpuch A, Limpavitayaporn P, Kanlerd A, Sriussadaporn E, Juntong J, Tongyoo A, Mingmalairak C.

In esophageal cancer treatment, nutrition by feeding tube has been demonstrated to improve patient tolerance of treatment, quality of life, and long-term outcomes. The open gastrostomy and percutaneous endoscopic gastrostomy (PEG) using introducer technique are procedures that avoid cancer cells seeding and also improve patient's nutritional status, hydration, and medication. The aim of this study is to compare the results of the introducer PEG and open gastrostomy in patients with advanced esophageal cancer. A retrospective study was analyzed in the advanced esophageal cancer patients who indicated and received feeding support between January 2016 and December 2017. Twenty-eight patients in introducer PEG and 36 patients in open gastrostomy presented the following comparative data: mean operative duration time shorter, less pain score, and shorter hospitalization in introducer PEG than open gastrostomy. Both groups showed no readmission or 30-day mortality. The adverse events of open gastrostomy demonstrated higher than introducer PEG group. Both introducer PEG and open gastrostomy were the safe options for advanced esophageal cancer patients indicating for enteral feeding and to avoid cancer cell seeding but the introducer PEG demonstrated the effective minimally invasive procedure with fewer complications.

Tongyoo A, Boonyasatid P, Sriussadaporn E, Limpavitayaporn P, Mingmalairak C

Background: Surgical site infection (SSI) is a common complication after abdominal operation which may cause disability or mortality. One of the factors associated with SSI was the abdominal wall thickness ≥20 mm. Therefore, the drainage of collection within subcutaneous tissue may decrease SSI rate.

Siribumrungwong B, Chunsirisub T, Limpavitayaporn P, Tongyoo A, Sriussadaporn E, Mingmalairak C, Thowprasert W, Thakkinstian A

BACKGROUND: Transumbilical incision has been applied in single-incision laparoscopy. Evidence for the effect of transumbilical incision on postoperative pain compared with infraumbilical incision is still lacking.

METHODS: A randomized controlled trial (RCT) was conducted in a university hospital. Patients who underwent conventional laparoscopic cholecystectomy were randomized to have transumbilical or infraumbilical incision. Postoperative pain was measured using visual analog score at 6, 24 h, and 7 days post operation. Secondary outcomes were analgesic usage, length of stay, superficial surgical site infection (SSI), wound numbness, and hypersensitivity. Risk ratio and mean difference (MD) along with their 95% confidence intervals (CIs) were estimated. Adjusted analysis was done, if clinical unbalanced characteristics presented. The study was registered at http://ClinicalTrial.gov (ID NCT02738710).

RESULTS: A total of 102 patients were enrolled in which 51 patients were randomized to each interventional group. Postoperative pain was not significantly different between the groups with the MD of - 0.07 (95% CI - 0.47, 0.35). Paracetamol usage was significantly 1 tab (95% CI - 1.9, - 0.1) less after transumbilical incision, but this was not significant after adjusting for unbalanced characteristics. Superficial SSI rate was much higher in the transumbilical than the infraumbilical group, i.e., 16 versus 4%, but this was not significant (p = 0.070). Satisfaction scores at 3 months were not different between the groups, with the corresponding means of 8.9 [standard deviation (SD) 1.3] and 9.0 (SD 1.0).

CONCLUSIONS: Transumbilical incision had non-significant different pain compared to infraumbilical incision. Most patients in both groups were satisfied with the operation at 3 months. A further large RCT is required for comparing SSI between the two incisions.

Tongyoo A, Thamwongskul C , Sriussadaporn E , Limpavitayaporn P , Mingmalairak C

Extrahepatic bile duct malignancy is mostly an adenocarcinoma cell type. The squamous cell carcinoma is scarcely reported in the literature. The authors are presenting an interesting case of this rare tumor. A 36-year-old man with obstructive jaundice and epigastric pain was referred to the authors hospital. Blood tests showed direct hyperbilirubinemia and elevated ALP. Imaging studies demonstrated dilated bilateral intrahepatic bile ducts with disproportional fusiform dilatation of extrahepatic bile duct compatible with choledochal cyst type 1. There was also the abrupt narrowing of distal CBD associated with enhancement of irregular periductal soft tissue that suggested a malignant feature. After biliary drainage, the patient underwent pancreaticoduodenectomy with bile duct excision to remove the choledochal cyst and tumor-involved periampullary area, then followed with reconstruction. The pathologic specimen consisted of large polygonal cells with vesicular to fine chromatin nucleus, irregular nuclear membrane, and abundant eosinophilic cytoplasm. There were also extracellular keratin materials and presence of intercellular bridges between tumor cells. This morphology was compatible with squamous cell carcinoma. Therefore, the primary squamous cell carcinoma of distal CBD was diagnosed. Concurrent chemoradiation was administered for adjuvant therapy after post-operative recovery. The patient had been doing well for five months after surgery.

Mahawongkajit P, Tomtitchong P, Boochangkool N, Limpavitayaporn P, Kanlerd A, Mingmalairak C, Awsakulsutthi S, Havanond C

BACKGROUND AND PURPOSE:

Publications document the risk of developing esophageal stricture as a sequential complication of esophageal injury grades 2b and 3a. Although there are studies describing the risk factors of post-corrosive stricture, there is limited literature on these factors. The aim of this study was to evaluate the different factors with post-corrosive esophageal stricture and non-stricture groups in endoscopic grades 2b and 3a of corrosive esophageal injuries.

METHODS:

Data were retrospectively analyzed in the patients with esophageal injury grades 2b and 3a between January 2011 and December 2017.

RESULTS:

One hundred ninety-six corrosive ingestion patients were admitted with 32 patients (15.8%) in grade 2b and 12 patients (6.1%) in grade 3a and stricture was developed in 19 patients (61.3%) with grade 2b and in 10 patients (83.3%) with grade 3a. The patients' height of the non-stricture group was greater than that of stricture groups (2b stricture group, 1.58 ± 0.08 m; 2b non-stricture group, 1.66 ± 0.07 m; p < 0.004; 3a stricture group, 1.52 ± 0.09 m; 3a non-stricture group, 1.71 ± 0.02 m; p < 0.001). Omeprazole was more commonly used in the non-stricture than stricture group (26.3% in the 2b stricture group, 69.2% in the 2b non-stricture group, p = 0.017; 50% in the 3a stricture group, 100% in the 3a non-stricture group, 1.71 ± 0.02 m, p = 0.015).

CONCLUSIONS:

The height of patients may help to predict the risks and the prescription of omeprazole may help to minimize the risks of 2b and 3a post-corrosive esophageal stricture.

Mahawongkajit P, Tomtitchong P

This study shows the first survey of patterns about surgeons' approaches and current practices in early and advanced gastric cancer in Thailand. Gastric cancer is a significant health problem worldwide. International guidelines for treatment differ in their recommendations including the accompanying therapy, but the condition is potentially curable. Surgeons have played an important role in Thailand but the limitation of institutional resources and the practices for gastric cancer vary between treatment options. The aim of this study is to investigate the current practices and approaches of Thai surgeons in relation to early and advanced gastric cancer treatment. A survey was conducted on 112 surgeons who claimed to have performed clinical practice upon gastric cancer patients. Information was collected on participant demographic data, the practices approaches in early and advanced stage without metastasis and the preferable adjuvant chemotherapy. The majority of participants were 100 general surgeons (89.4%). The preferred early gastric cancer treatment proved to be endoscopic resection 83.9%, cT1bN0 group preferred laparoscopic surgery 75.9%, cT2-T4aN0 group preferred open surgery 67.8%, cT4bN0 group preferred open surgery with En bloc resection 85.7% and cN+ group preferred open surgery 70.5%. For adjuvant treatment with chemotherapy, the study showed the surgeons who prescribed and treated by themselves was 41.9%. The preferred adjuvant regimens were S-1 50.9% and capecitabine and oxaliplatin 31.3%. This study is the first survey of the patterns of surgeons' approaches and current practices in early and advanced gastric cancer in Thailand.

Mahawongkajit P, Techagumpuch A, Chanswangphuvana P.

--not available abstract--

Mahawongkajit P, Techagumpuch A, Suthiwartnarueput W.

Complete surgical resections are crucial for permanently curing patients with gastrointestinal stromal tumors (GISTs). Laparoscopic wedge resection is a widely accepted surgical treatment, but identifying the tumor margin from a serosal laparoscopic view is challenging when using this technique. Non-exposed endoscopic wall-inversion surgery (NEWS) for patients with gastric GISTs is a novel, minimally invasive surgical technique that may aid in complete resection of the tumor margin by endoscopy and laparoscopy methods, removing the whole layer of the gastric wall and the entire tumor, with decreased risk of peritoneal contamination or tumor spread to the peritoneum. To the best of our knowledge, the present study reports the first use of NEWS for a patient with small gastric GIST in Thailand. A 61-year old female presented with jaundice and was diagnosed with acute viral hepatitis A. At 4 months, the severity of the symptoms had decreased but the serum transaminase in the liver function tests remained elevated. The computed tomography scans incidentally demonstrated a gastric mass that protruded into the lumen. Endoscopic examination revealed a 2.5×2.0-cm sub-epithelial tumor located in the posterior wall of the upper gastric body. The patient was informed and consented to undergo NEWS. No intraoperative or immediate postoperative complications were detected. The patient was discharged 5 days following the surgery. In a follow-up visit 4 weeks subsequent to the surgery, the patient was healthy and without complications.

Prasert W.

Tongyoo A, Chatthamrak P, Sriussadaporn E, Limpavitayaporn P, Mingmalairak C.

BACKGROUND:

The surgical site infection (SSI) is a common complication of abdominal operation. It relates to increased hospital stay, increased healthcare cost, and decreased patient's quality of life. Obesity, usually defined by BMI, is known as one of the risks of SSI. However, the thickness of subcutaneous layers of abdominal wall might be an important local factor affecting the rate of SSI after the abdominal operations.

OBJECTIVE:

The objective of this study is to assess the importance of the abdominal wall thickness on incisional SSI rate.

MATERIAL AND METHOD:

The subjects of the present study were patients who had undergone major abdominal operations at Thammasat University Hospital between June 2013 and May 2014, and had been investigated with CT scans before their operations. The demographic data and clinical information of these patients were recorded. The thickness ofsubcutaneous fatty tissue from skin down to the most superficial layer of abdominal wall muscle at the surgical site was measured on CT images. The wound infectious complication was reviewed and categorized as superficial and deep incisional SSIfollowing the definition from Centersfor Disease Control and Prevention (CDC) guidelines. The significance ofeach potentialfactors on SSI rates was determined separately with student t-test for quantitative data and χ2-test for categorical data. Then all factors, which had p < 0.10, were included into the multivariate logistic regression analysis and were analyzed with significance at p < 0.05.

RESULTS:

One hundred and thirty-nine patients were included in this study. They all underwent major abdominal surgery and had had pre-operative CTscans. Post-operative SSI was 25.2% (35/139), superficial and deep types in 27 and 8 patients, respectively. The comparison of abdominal wall thickness between patients with and without infection was significantly different (20.0 ± 8.4 mm and 16.0 ± 7.2 mm, respectively). When the thickness at 20 mm was used as the cut-off value, 43 of 139 patients had abdominal wall thickness ≥ 20 mm. The incidence of SSI of the thickness ±20 mm group was 37.2% (16/43) and of the less thickness group was 19.8% (19/96), with p < 0.05. The univariate analysis revealed that abdominal wall thickness ≥ 20 mm, body weight ≥ 60 kg, and wound classification were the important factors related to SSI after the abdominal operation. However, only abdominal wall thickness and wound classification were still significant by multivariate analysis.

CONCLUSION:

The findings of this study confirmed the significance of the subcutaneous thickness of abdominal wall at the surgical site on the incidence of incisional SSI. The thickness ≥ 20 mm had an effect on increasing post operative SSI rate especially in contaminated operations. These findings could be helpful in making healthcare providers fully aware and thus exercise special attention in wound care or even develop new modalities to prevent SSI in patients with the aforementioned risks.

Tongyoo A, Sriussadaporn E, Limpavitayaporn P, Mingmalairak C.

Sodium polystyrene sulfonate (Kayexalate) and calcium polystyrene sulfonate (CPS, Kalimate) are commonly used to reduce serum potassium. There were some published evidences of severe gastrointestinal complications from the administration of these agents such as colonic necrosis with or without perforation and acute obstruction. The authors reported a 52-year-old male patient being critically ill from severe soft tissue infection of the right leg and sepsis. Hyperkalemia had occurred due to renal insufficiency and required several doses of Kalimate to reduce the serum potassium level. Subsequently, the patient developed complete intestinal obstruction and an exploratory laparotomy was performed. The intra-operative findings were distended stomach and the small bowel contained a large amount of intraluminal affected Kalimate that was removed via gastrotomy and enterotomy. These findings suggested that the inspissated Kalimate could lead to significant obstruction of the gastrointestinal tract in some groups of patient.