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.

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.

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.

Glucagonoma presenting with obstructive jaundice : A case report.

A case report of a 2-cm glucagonoma at head of pancreas in 48-year old woman presented with obstructive jaundice. She had no manifestation of the glucahonoma syndrome. She underwent bylorus preserving pancreaticoduodenectomy (PPPP). Immunohistochemical studies revealed that this tumor was a malignant glucagonoma. She made an uneventful recovery after the operation and was discharged from the hospital without complication. Six months later, she was found to have multiple liver metastases which did not response to chemotherapy and died 11 months after the operation with liver failure.

A young woman with rectal bleeding.

Rectal cancer is a common malignancy in Thailand. A case of 39-year-old female with rectal bleeding caused by adenocarcinoma of rectum is reported here. Successful treatment was achieved by preoperative chemoradiation therapy and low anterior resection. She is now symptom free and has good sphincter control. The history, physical examination, investigations, diagnosis and treatment are discussed.