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.

A multicenter prospective study of immunochemical fecal occult blood testing for colorectal cancer detection.

BACKGROUND: Colorectal cancer (CRC) screening by guaiac fecal occult blood test (gFOBT) can reduce the mortality of CRC. The new immunochemical fecal occult blood test (iFOBT) has possibly improved sensitivity and specificity without any dietary restriction. OBJECTIVE: The present study aimed to evaluate the sensitivity, specificity, positive and negative predictive values of iFOBT for CRC detection compared to the colonoscopic and pathologic findings in known CRC cases. MATERIAL AND METHOD: A multicenter prospective study was conducted in three university hospitals in Bangkok, Thailand, between May and August 2006. Stool samples from 100 histologically-proven CRC patients and 64 control cases with normal colonoscopic findings were collected for iFOBT (OC-Light, Nagase, Singapore) without dietary restriction. RESULTS: The results showed the sensitivity, specificity, positive and negative predictive values of iFOBT for CRC detection to be 91.0% (95% CI: 83.8-95.2), 93.8% (95% CI: 85.0-97.5), 95.8% (95% CI: 89.7-98.4) and 87.0% (95% CI: 77.0-93.0) respectively. The sensitivity for CRC according to Dukes'stage was 71.4% (Dukes' A), 88.0% (Dukes' B), and 96.7% (Dukes' C or D). The sensitivity was 84.2% for proximal colon and 92.6% for distal colon and rectum. CONCLUSION: The iFOBT revealed high sensitivity, specificity, positive and negative predictive values for CRC detection without dietary restriction. It should be considered as a noninvasive tool for CRC detection.

Fraud and deceit in published medical research.

Medical research casts a great impact on health of the entire human population so it must be conducted and publicized without dishonesty or bias. Any misrepresentation can have extremely serious consequences for patients and clinical practice. Unfortunately, fraud and deceit have increasingly been detected and have become a problem in today's research. They are falsification, fabrication, plagiarism, and deliberate use of inappropriate statistical analysis. It is sometimes difficult to differentiate fraud from incompetence, errors, bias, and misunderstanding. Many fraudulent articles are still undercover. The question is how to detect and prevent the fraud and deceit in medical research. In addition, the system of handling research misconduct is still lacking. Critical audit and inspection are required to diagnose it. There is no standard guideline to treat fraud. Prevention is the best way of treatment. This relies on research institutions, editors of journals, citing authors, and, most of all the researchers who must adhere strictly to medical professionalism, which is solely based on honesty and ethics to self-regulate and conduct only ethical and genuine research.

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.

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.