A same day approach for choledocholithiasis using endoscopic stone removal followed by laparoscopic cholecystectomy: a retrospective study.

OBJECTIVE: The timing of minimally invasive approach of choledocholithiasis, using endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC), is challenging. The aim of the present retrospective study was to assess the feasibility and safety of endoscopic stone removal for choledocholithiasis followed by same-day LC. MATERIAL AND METHOD: Between October 2005 and February 2007, 27 patients diagnosed with choledocholithiasis were treated with this approach. Of these patients, nine (33%) had either pancreatitis or cholangitis. The mean age of the patients was 56 years (range, 29-78). ERCP was performed in the endoscopic unit, whereas LC was performed in the theater Success rate and clinical outcome were analyzed. RESULTS: Ninety-three percent clinical success was achieved. Two patients required conversion to opened cholecystectomy because of uncertain anatomy. There was no 30-day postoperative mortality. Two patients (7%) had postoperative complications (post-ERCP pancreatitis and superficial surgical site infection). The mean interval between the two procedures was 122 minutes (28-325). The mean operative time of ERCP was 25 minutes (15-30) and of LC was 83 minutes (30-140). The mean length of hospital stay was four days (range, 3-6). CONCLUSION: The management of choledocholithiasis using endoscopic stone removal, followed by same day laparoscopic cholecystectomy, is safe and has good clinical outcomes.

Antibiotic prophylaxis and incisional surgical site infection following colorectal cancer surgery: an analysis of 330 cases.

OBJECTIVE: To evaluate the rate of incisional surgical site infection (SSI) following colorectal cancer surgery in a university hospital and to determine whether duration of prophylactic antibiotic administration can affect the development of this complication. MATERIAL AND METHOD: The medical records of 330 patients with colorectal cancer undergoing elective oncological resection between 2003 and 2006 at Siriraj Hospital were reviewed. Patients were divided into two groups according to the duration of antibiotic administration; group A: prophylactic antibiotics were discontinued within 24 hours after surgery and group B: antibiotics administration was extended beyond 24 hours after surgery. Data including rate of incisional SSI were analyzed. RESULTS: There were 180 males and 150 females, with a mean age of 63 years. There were 126 patients (38%) in group A and 204 patients (62%) in group B. There was no statistical difference in patient characteristics and tumor-related variables between the two groups, except tumor location. Overall rate of incisional SSI was 14.5%. The rate of incisional SSI was not statistically different between the two groups (group A 11.1% vs. group B 16.7%, p = 0.22). Patients with incisional SSI had a significantly longer hospital stay than patients without incisional SSI (15.9 vs. 8.3 days, p < 0.001). CONCLUSION: This present study found the overall rate of incisional SSI following colorectal surgery to be 14.5%. There was no significant difference in the rate of this complication between the two groups. Thus, surgeons should be encouraged to use a shorter duration of antibiotics to prevent the emergence of antibiotic-resistant bacterial infection and reduce hospital expenditure.

Preoperative chemoradiation for locally advanced rectal cancer with capecitabine 2,000 mg/m2/day.

OBJECTIVE: Evaluate the efficacy and the tolerability of preoperative chemoradiation with high dose Capecitabine. MATERIAL AND METHOD: Fifteen patients with locally advanced resectable rectal cancer were treated with Capecitabine 2,000 mg/m2/day, orally 7 days/week concurrent with whole pelvic irradiation 45 Gy in 25 fractions/5 weeks. Patients underwent surgery in the following 4-6 weeks. RESULTS: After complete treatment, 11 patients (73%) underwent surgery. Ten patients (66%) had sphincter preservative surgery; three of them had primary tumors located in the lower rectum. Five patients had grade 2 and one patient had grade 3 diarrhea. No grade 4 toxicity was reported. CONCLUSION: Preoperative Capecitabine 2,000 mg/m2/day concurrent with whole pelvic irradiation were effective and well tolerated The potential dose limiting toxicity effect was the diarrhea.

Ambulatory anorectal surgery under perianal anesthetics infiltration: analysis of 222 cases.

OBJECTIVE: To assess the safety and early postoperative results of ambulatory anorectal surgery using perianal anesthetics infiltration. MATERIAL AND METHOD: This retrospective study included 222 elective ambulatory anorectal surgical patients under perianal anesthetics infiltration between March 2002 and September 2005. Perioperative pain, postoperative complications, and surgical outcomes were analyzed. RESULTS: The patients were 122 males and 100 females aged 16-84 (mean 43) years undergoing 150 closed hemorrhoidectomies, 55 lateral internal anal sphincterotomies, 28 fistulotomies, and 3 cauterizations for condyloma acuminata. Perianal block was effective, neither intravenous analgesics nor conversion to general anesthesia was needed. The average pain score was 3.4 +/- 2.3 on day 1 and 1.2 +/- 1.5 on day 7 postoperatively. Urinary retention was found in one case (0.5%). None of the patients needed hospital admission, except one emergency hospitalization (0.5%) due to bleeding. CONCLUSION: Perianal anesthetics infiltration allows the surgeons to perform anorectal surgery in a day-case regimen safely and effectively with a low incidence of urinary retention.

Vancomycin overuse in Siriraj Hospital.

OBJECTIVE: An emergence of vancomycin resistant organisms particularly vancomycin-resistant enterococci (VRE) has become a serious public health concern. To prevent and control the spread of vancomycin resistant organisms, the prudent use of vancomycin is strongly recommended by the Hospital Infection Control Practices Advisory Committee (HICPAC). MATERIAL AND METHOD: A 6-week prospective observational study of vancomycin use was conducted in hospitalized patients at Siriraj Hospital from February to March 2005. Indications of initiating and continuing vancomycin were categorized according to HICPAC recommendations. Factors related to the appropriateness of vancomycin use were also evaluated. RESULTS: At initiation, vancomycin was inappropriately and empirically prescribed 19/222 times (8.6%) and 166/222 times (74.8%), respectively. After microbiological results were obtained, the rate of inappropriate prescription continued 132/222 times (59.5%). Furthermore, inappropriate use was significantly correlated with the type of department. There was a higher rate in the Department of Pediatrics, Surgery and Ophthalmology when compared with that of the Department of Medicine (p = 0.001). The inappropriate use also correlated with topical use (p < 0.001), intravenous administration (p = 0.012) and no consultation with an infectious disease specialist (p = 0.001). The overuse did not improve the clinical outcome. CONCLUSION: A substantial rate of inappropriate use of vancomycin was found in Siriraj Hospital. Intervention to improve appropriateness of vancomycin use should be urgently implemented to prevent and control the emergence of vancomycin resistant organisms.

Epidemiology of Staphylococcus aureus infections and the prevalence of infection caused by community-acquired methicillin-resistant Staphylococcus aureus in hospitalized patients at Siriraj Hospital.

BACKGROUND: The CA-MRSA infections have emerged in many parts of the world over the past decade. To our knowledge, the prevalence of CA-MRSA infections in Thai patients is unknown. OBJECTIVE: To determine an epidemiology of Staphylococcus aureus (S. aureus) infections in hospitalized patients in Siriraj Hospital and the prevalence of infections caused by community-acquired methicillin-resistant S. aureus (CA-MRSA). MATERIAL AND METHOD: The study was carried out at Siriraj Hospital from January to May 2005. The eligible patients were hospitalized patients whom S. aureus were isolated from their clinical specimens submitted to Department of Microbiology. S. aureus isolate was classified into infection or colonization. S. aureus infections were further classified into methicillin-resistant S. aureus (MRSA) or methicillin-sensitive S. aureus (MSSA) infections, and hospital-acquired (HA) or community-acquired (CA) infections. CA-MRSA infection is defined as infection caused by MRSA isolated from the patient within 72-hour of hospitalization and has no features of HA MRSA infections. RESULTS: There were 669 S. aureus isolates from 448 patients. Two hundred and sixty two patients (58.5%) were MSSA whereas 186 (41.5%) were MRSA infections. CA-MRSA was found in three isolates (0.9% of total MRSA) from two patients. CONCLUSION: The prevalence of CA-MRSA infections in hospitalized patients in Siriraj Hospital was uncommon and these patients could probably be HA MRSA infections.

Preoperative capecitabine with pelvic radiotherapy for locally advanced rectal cancer (phase I trial).

OBJECTIVE: Phase I multicenter study defined the maximal tolerated dose (MTD), dose-limiting toxicity (DLT) and safety profile of capecitabine in combination with preoperative radiation for patients with locally advanced rectal cancer (LARC). MATERIAL AND METHOD: Patients were treated with oral capecitabine (700, 800, 900, 1000, 1100 and 1200 mg/m2 twice daily continuously) plus preoperative whole pelvic irradiation (45-46 Gy in 23-25 fractions over 5-6 weeks). Surgery was performed at the median of 42 days after chemoradiation treatment. RESULTS: Twenty-seven patients were in this trial. Eighteen patients (3 per dose level) had received capecitabine from 700 mg/m2 twice daily to the highest dose level of 1200 mg/m2 twice daily. There were no grade 3/4 DLTs during dose escalation, a further nine patients were included at the highest capecitabine dose. Two of the twelve patients (16%) receiving capecitabine 1200 mg/m2 twice daily developed grade 3 diarrhea and discontinued treatment. There were no other grade 3/4 adverse events. After capecitabine chemoradiation, 24 of 27 patients (89%) received definite surgery. Primary and lymph node down staging occurred in ten patients (42%). Sphincter-sparing surgery was performed in seven patients (26%) and abdominal-perineal resection was performed in 17 patients (63%). CONCLUSION: Preoperative capecitabine chemoradiation based on continuous daily capecitabine is very well tolerated in patients with LARC. The authors did not reach the MTD in the present study.

Does preoperative chemoradiation therapy in locally advanced rectal cancer increase rate of sphincter preserving surgery: A prospective clinical trial.

Objective: To evaluate the influence of preoperative chemoradiation in locally advanced rectal cancer on ability to perform sphincter preserving surgery. Methods: Between 1998 and 2005, a prospective clinical trial of preoperative chemoradiation therapy (CTX/XRT) that delivered 45 Gy in 25 fractions over 5 weeks with bolus infusion of 5-fluorouracil (200 mg/m2/day) or capecitabine (2000mg/m2/day) was given to 42 rectal cancer patients admitted to the Department of Surgery, Siriraj Hospital, Bangkok, Thailand. The pretreatment stage distribution, as determined by endorectal ultrasonography and computed tomography of the pelvis, included uT3N0 in 90.48% and uT3N1 in 9.52% of cases. Approximately 6 weeks after completion of CTX/XRT, surgery was performed in every patient. The choice of the surgical procedure was based on the surgeon’s discretion. Results: The patient population consisted of 25 males (59.52%) and 17 females (40.48%) who had a median age of 57 years (range 32-79 years). Distal border of the tumors were located at a median of 5 cm (range 2-10 cm) above the anal verge. Thirty cases (71.43%) had distal border of the tumors within 6 cm from the anal verge. The pathological tumor stages were T1N0 in 2 cases (4.76%), T2N0 in 9 cases (21.43%), T2N1 in 4 cases (9.52%), T3N0 in 12 cases (28.57%), T3N1 in 8 cases (19.05%), T3N2 in 2 cases (4.76%) and T4N0 in 1 case (2.38%). The results included 9.52% pathological complete response, 42.86% downstaging and 50% sphincter preservation rate. Of the tumors located < 6 cm from the anal verge, sphincter preservation was accomplished in 30% of the patients. The pretreatment location of distal border of the tumors (< 6 cm vs. > 6 cm from anal verge) was the only factor predictive of sphincter preservation (p < 0.001). No local recurrence was detected during the period of follow up (median 23 months). Conclusion: The administration of preoperative chemoradiation for locally advanced rectal cancer is associated with tolerable toxicity and high rates of tumor downstaging. The preoperative chemoradiation and tumor downstaging do not increase rate of sphincter preservation in locally advanced rectal cancer.

Endoscopic endoprosthesis insertion in unresectable hilar cholangiocarcinoma patient.

Objective: Hilar cholangiocarcinoma is one of the most common causes of biliary tract obstruction in Thailand. However, in most patients, the tumors are unresectable. Endoscopic retrograde cholangiopancreatography (ERCP) with endoprosthesis insertion can provide effective internal biliary drainage in these patients; however, there are still some controversy regarding the complications, success rate and technical aspect of this approach. The aim of this study was to report results of palliative endoscopic endoprosthesis insertion using plastic stents in unresectable hilar cholangiocarcinoma. Methods: We analyzed 72 sessions of ERCP with plastic stent insertion in 61 patients with unresectable hilar cholangiocarcinoma, treated at the Endoscopic Unit, Department of Surgery, Siriraj Hospital from 1999-2001. Statistical analysis were done using chi – square test. Results: In 72 sessions of ERCP with plastic stent insertion, overall successful drainage was 48 %. Early complication was found in 13 sessions (18%) with cholangitis 13.9%, pancreatitis 2.8%, bleeding 2.8% and intra-abdominal collection 2.8%. Unilateral stent insertion was done in 94% (right side 43.4%, left side 49.1%) and bilateral stent insertion was performed in 7.5%. The success rate of right duct stent insertion was 63.1% while that of left duct stent insertion was 36.4% (p<0.01). Mortality rate was 2.98%. Conclusion: Endoscopic endoprosthesis insertion using plastic stent is an effective method for palliative biliary drainage in patients with unresectable hilar cholangiocarcinoma with acceptable morbidity and mortality rate.

Outpatient hemorrhoidectomy under perianal anesthetics infiltration.

BACKGROUND: Hemorrhoidectomy is the most effective long-term treatment for hemorrhoids, mostly done in an inpatient setting requiring general or spinal anesthesia. OBJECTIVE: To assess the safety and early post-operative results of outpatient closed hemorrhoidectomy under perianal anesthetics infiltration. MATERIAL AND METHOD: A retrospective study of outpatient closed hemorrhoidectomy under perianal block during March 2002 and May 2003 in an ambulatory facility of the Department of Surgery, Siriraj Hospital, Bangkok. RESULTS: Fifty-five patients with third-degree or fourth-degree internal hemorrhoids underwent outpatient closed hemorrhoidectomy under perianal block, including 40 males and 15 females. The mean age was 44.4 +/- 12.2 years (21-72 years). Sites of hemorrhoidectomy at each operation were single 53%, double 42% and triple 5%. Mean operative time was 20.7 +/- 9.9 minutes (5-60 minutes). Additional anal procedures were performed in 6 cases. Severity of early postoperative pain were mild in 35% of the patients, moderate in 40% of the patients and severe in 25% of the patients which could be relieved by oral analgesic drug, mostly lasting less than three days. No postoperative urinary retention occurred. The patients could pass their stool in 1.2 +/- 0.8 days postoperatively (0-4 days). No postoperative complications were found in the present study. All patients needed no hospital admission or an emergency department visit. CONCLUSION: Outpatient hemorrhoidectomy under perianal anesthetics infiltration is effective and well tolerated. It should be an alternative approach in the treatment of hemorrhoidal disease.

Surgical management of adult choledochal cysts.

OBJECTIVES: Results of the surgical management of 17 choledochal cysts in adults at the Department of Surgery, Siriraj Hospital, Mahidol University, are presented MATERIAL AND METHOD: All the patients who underwent diagnosis and were surgically managed during the period between October 1990 and January 1999 were analyzed retrospectively. Cysts were classified anatomically according to the descriptions of Todani et al. The authors assessed the clinical features, operative procedure and outcome of the patients. RESULTS: There were 15 females and 2 males, with ages ranging from 16-45 years. Only 2 patients (11.8%) had the clinical triad: jaundice, abdominal pain and mass. Clinical pancreatitis was presented in 3 patients (17.6%). There were 10 type 1 (58.8%), 6 type IVa (35.3%) and one type V (5.9%) according to Todanis classification. Cholangiocarcinoma was found in one patient (5.9%). Extrahepatic cyst excision with a Roux-en-Y hepatico-jejunostomy was performed on 16 patients with type I or IVa cysts (94.1%). There were no surgical deaths or complications. Ten survivors are well. The authors lost contact with 6 patients during follow-up (35.2%). The median follow up was 3.2 years. The patient with cholangiocarcinoma died 2 years after treatment. CONCLUSION: This experience recommends total extra-hepatic cyst excision with Roux-en-Y hepaticojejunostomy as the treatment of choice for adult choledochal cyst type I and IV to eliminate the risk of recurrent cholangitis and malignancy.

Whipple's operation without an operative mortality in 37 consecutive patients: Thai surgeons' experiences.

OBJECTIVE: Pancreaticoduodenectomy (Whipple's operation) represents a considerable surgical challenge. The operative mortality rate after Whipple's operation is still less than 5%. Recent studies show pancreaticojejunostomy (PJ) anastomosis is the "Achilles heel" of the procedure. The authors present the results of Whipple's operation without mortality which were performed in the Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. MATERIAL AND METHOD: From January 1991 to December 2003, thirty-seven consecutive patients who underwent Whipple's operation were enrolled in the present study. The ages ranged from 33 to 79 years (mean 57.13). There were 19 male and 18 female patients. Twenty-nine of them underwent a pylorus preserving pancreaticoduodenctomy (PPPD). Construction of the PJ anastomosis was mostly performed by a dunking technique, that is, the invagination of the pancreatic resected end into the jejunum. RESULTS: There was no postoperative mortality from anastomotic leakage. Surgical wound infections occurred in 7 patients, gastric atony in 2 patients, and PJ anastomosis leakage which created a fistula in 1 patient. All 37 patients were discharged in an improved condition following surgery. The median follow-up was 2 years (range: 4 month-11 years). Eighteen patients died from liver failure. Until now 19 patients are doing well. CONCLUSION: The authors demonstrated that the dunking technique used for PJ anastomosis in Whipple's operation provided a good result without any mortality rate.

Isospora belli infection associated with chronic cholecystitis and sclerosing cholangitis in immuncompetent host : A case report.

Isospora belli (I. belli) is a spore-forming protozoa that primarily infects enterocyte. The clinical manifestation may very from asmptomatic to self-limited diarrhea in healthy persons. Rarely, in the normal hosts,5 chronic persistent or intermittent symptom may continue for many years.1,2 Treatment with cotrimoxazole is usually effective in both normal patients19 and patients with AIDS20,21 Nevertheless, relapse is common and is believed to be associated with the presence of extraintestinal infection.3,4,17 Few cases of extraintestinal I. belli infection have been documented in patients with AIDS,3-5 and one case in an immuncompetent patient.24 This report presents a unique case of isosporiasis in a 58-year-old anti-HIV negative Thai female suffering from chronic recurrent diarrhea due to I. belli, despite two episodes of complete 4-week cotrimoxazole and another course of nitazoxanide. Abdominal computer tomographic examination and ultrasonography identified sclerosing cholangitis and chronic cholecstitis. Histologic examination of the cholecystectomy specimen recovered schizonts and merozoites in the parasitophorous vacuoles located in gallbladder epithelium.

Pancreatic adenocarcinoma: A 10-year-experience in Siriraj Hospital.

Carcinoma of the pancreas is not a common disease in Thailand, and is not included in the list of the 10 leading cancers in the country. One hundred and sixty-eight patients with this cancer were treated at the Siriraj Hospital during January 1987 till December 1996. Ninety-five patients (56.6%) were male and the male to female ratio was 1.3 : 1. The mean age was 61.9 years (range 27-86 years). Back pain and/or abdominal pain was the most common presenting symptom (59.5%), followed by anorexia and weight loss (56.6%). Jaundice was found in 88 patients (52.4%), and the mean serum billirubin among these icteric patients was 18.2 mg/dl. Eighty-two per cent of the patients had tumour at the head of pancreas, and nearly 60% of the patients already had metastatic disease at the time of operation. Histological confirmation was obtained in only 49 patients (29.2%). Majority of the patients underwent some forms of palliative surgery, and the resectability rate was approximately 14%. Because of the low resectability rate and high incidence of metastasis, pancreatic cancer is still a disease with poor prognosis.