Palliative esophageal stent or surgery in advanced esophageal malignancy.

Esophageal malignancy is one of the most aggressive malignancies. Unfortunately, the majority of patients present with incurable disease. Then palliative treatment to relieve dysphagia is the mainstay of treatment. We compared the mortality, procedure-related complications, hospital stay, intervention time, improvement of dysphagia and survival time between esophageal stent and surgery. There were twenty patients who underwent esophageal stent and twenty-three patients underwent surgical treatment. Pretreatment characteristics were similar between the two groups. The mortality between the surgical group and the esophageal stent group was 30.43 per cent (7/23) and 5 per cent (1/20) (p<0.05). The complications in the surgical group included anastomotic leakage 39.13 per cent (9/23), wound dehiscence 4.35 per cent (1/23), small bowel obstruction 4.35 per cent (1/23) and late anastomotic stricture 37.5 per cent (6/16). In the esophageal stent group, the complications were severe chest pain 10 per cent (2/20), stent displacement 10.52 per cent (2/19), stent obstruction from food impaction 15.78 per cent (3/19) and tumor overgrowth leading to stent obstruction 5.26 per cent (1/19). More intervention time and hospital stay (post intervention period and ICU period) was spent in the surgical group (320.43+/-133.84 mins vs 57.5+/-23.98 mins p<0.001, 30.39+/-20.69 days vs 4.9+/-2.61 days p<0.001, 9.79+/-16.64 days vs 0 days p<0.05). The improvement of dysphagia was 1.00+/-1.03 vs 1.75+/-0.72 (p<0.05). Survival between the two groups was not statistically different (p>0.05).

The incidence of K-ras codon 12 mutations in cholangiocarcinoma detected by polymerase chain reaction technique.

In the study, to analyse a K-ras oncogene mutated at codon 12 in 24 patients with cholangiocarcinomas, four (16.67%) of them contained this point mutation. One of 4 was peripheral and the others were hilar tumors. There was no significant relationship between mutation and clinical features in terms of age, sex, endemic area, tumor location, tumor grading and pathological features. In our study, the incidence of K-ras codon 12 mutation in Thai patients with cholangiocarcinoma was lower than that found in British and Japanese patients. The discrepancy of incidence and type of the mutations, in different races and environment probably indicates that there is/are different etiologic mechanism(s) in the pathogenesis of cholangiocarcinoma.

Laparoscopic transperitoneal lumbar sympathectomy: a new approach.

A report of five sympathectomies for the treatment of vasospastic symptoms of coldness, rest pain and trophic lesions at the affected feet. Three patients had a right-sided sympathectomy done and the other two had left-sided done via laparoscopic surgery. This report has advocated original techniques: Under general anesthesia, a patient is put into a lateral position with the table broken between the ribs and iliac crest. The telescope port is inserted horizontally at the edge of the rectus sheath in line with the umbilicus. Two secondary ports (5 mm, 10 mm) are inserted under direct vision in the midclavicular line. The peritoneal reflection lateral to the colon is incised down to the pelvic brim. The use of the lateral position facilitates medial displacement of the colon and the kidney by virtue of gravity. The L2, L3, L4 sympathetic ganglia are then doubly clipped and divided between clips. When such a small piece of the sympathetic trunk has been removed, a laparoscopic transperitoneal lumbar sympathectomy should be a very reasonable, safe, minimally invasive alternative to the traditional operation.

Inferior segmentectomy IV: a surgical approach for hilar cholangiocarcinoma.

To access the proximal dilated bile duct of hilar cholangio-carcinoma, an inferior segmentectomy IV was proposed to be a beneficiary means of exposure of the whole length of the confluence of the hepatic duct. This method consists of partial resection of the quadrate lobe along the inferior sulcus, between the mid-axis of the gallbladder fossa and the falciform ligament. Eleven patients were enrolled into this study. In addition to removal of all the tumor mass, the author could access four secondary confluences and restore bilio-enteric bypasses. Six of them with curative resection had 24 months of mean survival (range 1 to 48 months: median 26 months). The remaining five patients with palliative resection had 7.2 months of mean survival (range 1 to 15 months: median 8 months). Regarding operative mortality, two patients died from massive intraoperative bleeding during the resection of the tumor. Successful approaches to perform a hilar resection and biliary bypass, an inferior segmentectomy IV are required for better access.

Transmural migration of a retained surgical sponge into the intestinal lumen: an experimental study.

A retained surgical sponge in the peritoneal cavity is an occasional misadventure in modern surgery. Such a sponge can migrate into the intestinal lumen, but its mechanism is still unknown. A piece of surgical sponge, measuring 4 x 4 centrimetres, was placed at different sites of the abdominal cavity of Wistar rats. Inspite of the absence of infection, entry of the sponge into the intestinal lumen was shown microscopically in 10 out of 36 rats. Parallel statistical analysis by Cutler-Ederer estimation was found to be 0.58 of condition probability at 6 months. Transmural migration of a retained surgical sponge was not only associated with different sites placing in the abdominal cavity (P = 0.680), but also whether a seromuscular incision was made or not (P = 0.306). A hypothesis, based on a study of microscopic and macroscopic pathology, is proposed as four stages: foreign body reaction, secondary infection, mass formation and remodeling.

Recent approach for common bile duct stone.

One hundred and thirty-nine patients underwent cholecystectomy from 1992 through 1994. Twenty-seven patients demonstrated preoperative risk factors for common bile duct (CBD) stones and underwent endoscopic retrograde cholangiopancreatography (ERCP). ERCPs were successful in 25 (92.6%) patients and there were two failures, due to pyloric obstruction and duodenal diverticulum. Of 25 patients suspected of harboring CBD stones, 48 per cent had bile duct stones on preoperative ERCP. In contrast, 3 of 112 patients (2.7%) thought not to have stones indeed had choledocholithiasis. Laparoscopic cholecystectomies (LC) were performed on 19 (76%) of 25 patients. Of these 19, 13 (68%) had negative ERCP, 5 (26.3%) had stones removed by endoscopic sphincterotomy (ES), and only one was accomplished with laparoscopic choledochoduodenostomy. Open exploration of CBD was performed on 3 patients who had complex CBD stones and bilio-enteric bypasses in 2 patients who had multiple impacted stones in the left main duct. Overall, three endoscopic failures (2 ERCPs and 1 ES) were managed by open biliary surgery. We suggest that patients with complex CBD stones who are not successful in stone extraction via ES should undergo open CBD surgery. LC following successful ES has been accepted as the gold standard for the treatment of simple CBD stones.

Totally extraperitoneal laparoscopic lumbar sympathectomy: an initial case report.

A 27-year-old man with a diagnosis of Buerger's disease presented with vasospastic symptoms of coldness and pain at rest of his right foot. Physical examination of his affected limb revealed absent popliteal pulse, cool skin hyperhidrosis and dry gangrene of the big toe. He had been operated on for a ruptured liver and liver abscess 20 years ago. He was scheduled for totally extraperitoneal laparoscopic lumbar sympathectomy on July 26, 1994. The technique was performed under general anesthesia and the patient was put in a supine position with slight extension between the rib and the iliac crest. The working space was created by digital blunt dissection and direct insufflation of carbon dioxide. The right sympathetic trunk was found between the medial edge of the psoas muscle and inferior vena cava. The L2, L3, L4 sympathetic ganglia were identified above the vertebral column and meticulously dissected cephalocaudally. Based on the concept of traditional approach, we believe that this laparoscopic technique is relatively safe and should become the procedure of choice in the future.

Leukocytic count in the diagnosis of acute appendicitis.

Two hundred and thirty-three patients with a pathological diagnosis of acute appendicitis from 1989 to 1990 were reviewed. A comparative series of 235 elective cases who were admitted during the same period, was similarly reviewed. Using these data, the binary tables could be constructed and the cutoff point was obtained by plotting the positive and negative predictive values. This series yielded the clinically significant laboratory findings that the cutoff point of total leukocytic count, percentage of neutrophils and total neutrophilic count were 11,500 mm3, 75 per cent and 8,000 mm3 respectively. Combined specificity of all three tests is higher (95.74%), but the sensitivity is lower (61.55%).