Pancreaticobiliary ductal anatomy in Thai people.

The complex anatomy of the pancreaticobiliary duct was studied to demonstrate basic data in Thai people. Fresh specimens of the pancreas, common bile duct, and duodenum were obtained en bloc from the autopsies of 103 patients who had died of causes not related to trauma or disease of these organs. The length of the pancreas, the location of the pancreatic ducts in relation to the surface of the pancreas, the length and types of the common channels, as well as the anatomy of the ampulla, were studied, using methylene blue infusion via the pancreatic duct cannulation and careful dissection. Ninety-three male and 10 female patients were included. Their ages ranged from 15 to 76 years (mean 31.38 +/- 12.98 years). The length of the pancreas ranged from 10.9-19 cm (mean, 15.60 +/- 1.80 cm). The intrapancreatic portion of the common bile duct showed patterns of three types; most common (90/103; 87.38%) was type A, in which the anterior surface of the common bile duct was totally covered, while its posterior surface was partially covered, by the pancreatic parenchyma. On dissection of the accessory duct of Santorini in the pancreatic substance, the accessory duct was traceable to the duodenal wall in 59 specimens (57.26%). The anatomy of the Wirsung-choledochus confluence was grouped into five different types. The common channel (junction of the common bile duct and pancreatic duct) was found in 76.70% of specimens and its length varied from just a common junction (so-called "V-type" anatomy) to 15 mm (Y-type-b). Separate papillae (so-called "II-type") were found in 12. 62% of specimens. Separate openings in the same papilla (so-called "U-type") were found in 10.68% of specimens. The Wirsung duct at the pancreatic neck was most often located posterior and superior in relation to the surface of pancreas. This study demonstrated several important points regarding the anatomy of the pancreaticobiliary junction and pancreatic ductal system in a Thai population. Some of these data were different from those reported in the literature for other population groups.

The impact of laparoscopic cholecystectomy on the practice and training of gallbladder surgery in Thailand.

The objective of this study was to find out the impact laparoscopic cholecystectomy had on the practice and training of cholecystectomy in Thailand. This study involved prospective interviewing by questionnaires, of patients who had had cholecystectomies by laparoscopic cholecystectomy (LC) and open cholecystectomy (OC) techniques starting from their immediate postoperative days, comparison of the length of hospital stay and the costs of LC and OC, and the surveillance of Thai laparoscopic surgeons' experience and surgical residents' attitude towards this procedure. The results revealed that laparoscopic surgeons offered LC to most of their patients with gallstones but in each institution the proportion of cholecystectomies performed was below 70%. Patients' satisfaction was higher and postoperative pain was less after LC. Complications occurred in 2.12% (37 in 1744 patients). The length of hospital stay was slightly shorter (2.68 +/- 0.62 versus 3.30 +/- 0.95 days) and the expenses were only slightly higher for LC. Most residents were interested to learn this procedure only after they have finished their formal surgical training; they still felt that LC was suitable only for patients with a higher economic status and that it was associated with a higher complication rate. This study suggest that LC did have an impact on the practice of cholecystectomy and future planning of trainings should take into account the necessity to change residents' misunderstanding about the suitability of this procedure in appropriate patients.

Endoscopic laser therapy for stage III and IV esophageal cancer.

Patients with esophageal cancer frequently present with advanced-stage disease. Many surgeons have adopted a policy of recommending esophagectomy to all patients who are fit enough to withstand major surgery, even if it provides no survival benefit. Only those patients who are too ill are referred for endoscopic laser therapy (ELT) or merely gastrostomy. In this study we investigated the short- and long-term results of esophagectomy and ELT in patients with Stages III and IV squamous cell carcinoma of the thoracic esophagus between January 1989 and April 1993. Thirty-three patients (12 at Stage III and 21 at Stage IV) underwent esophagectomy, while 22 patients (4 at Stage III and 18 at Stage IV) had ELT during the same period. Concurrent diseases were more prevalent in the ELT group. In the esophagectomy group, mortality was 19% and 16.7% in patients with Stage III and IV disease, respectively. Major complications were respiratory problems and leakage. Patients who developed major complications stayed an average of almost 100 days in hospital and succumbed shortly after discharge. Patients given ELT had a high mortality due to their severe pre-treatment status. However, those who survived the initial treatment stayed only a few days in hospital with a median survival of 159.5 days. The survival of patients in the two groups did not differ. ELT had the benefit of providing a shorter and cheaper hospital stay even in very advanced cases. It remains to be determined whether ELT patients would have had a final outcome comparable to that of patients offered resection if they had been treated at an earlier stage.

Ultrasound-guided liver biopsy: accuracy, safety and sonographic findings.

An experience of 97 liver biopsies performed under the guidance of a portable ultrasonographic procedure was reviewed. Of the 88 cases in which the results of biopsy were available, 73 malignant and 7 benign liver diseases were correctly diagnosed by the procedure, an accuracy of 90.9 per cent. There was no mortality. Significant complication was observed in 5 cases and consisted of 3 cases of intraperitoneal bleeding that required only blood transfusion, one case of upper gastrointestinal bleeding presumed to be hemobilia and one case of persistent fever of 38 degrees C that subsided after antibiotic administration. Ultrasound-guided liver biopsy can be an effective and safe outpatient procedure for pathological diagnosis of liver diseases. Analysis of sonographic and histologic correlation revealed that the types of sonographic appearance could not be significantly correlated to the histologic nature of the masses. Therefore, accurate prediction of pathology of liver masses from their sonograms is not possible.

Occurrence of intestinal metaplasia of the stomach in Thai patients with gastritis, benign ulcer, and gastric cancer.

Pathological sections of gastrectomized specimens of 74 patients with benign gastric ulcer and 79 with gastric cancer were reviewed. Intestinal metaplasia was found in 26 specimens with benign ulcer (35.1%) and in 43 with cancer (54.4%), a difference that is statistically significant. Further analysis of age groups showed that rate of occurrence of metaplasia in cancer patients older than 60 years was 70.3%, which was significantly higher than that of their younger counterparts (40.5%) and of patients with benign ulcer of either age group. A survey was also conducted by taking biopsies of mucosa of antrum and body of the stomach of 250 patients who underwent gastroscopic examinations. Acute and chronic gastritis was found in 22 and 156 patients, respectively. Intestinal metaplasia was found to be associated with acute gastritis in 2 (9.1%) and with chronic gastritis in 25 (16%) patients. In conclusion, intestinal metaplasia was associated with higher proportion than it was with benign gastric ulcer and gastritis among Thai patients.