Impact of nutritional status on surgical patients.

OBJECTIVE: This study aimed to compare cost and length of hospital stay of malnourished and well-nourished surgical patients. METHODS: A total of 6821 surgical patients were enrolled from January to December 2014 and were divided into 11 groups according to their disease diagnosis: soft tissue; upper gastrointestinal tract; colorectal; hepato-pancreato-biliary; vascular; head-neck breast; urology; cardio-vascular-thoracic surgery; neurology; plastic surgery; and trauma. The patients in each group were categorized as having either malignant or benign disease. All patients received nutritional screening and subjective global assessment, and details of length of hospital stay and cost were collected and analyzed. RESULTS: There were 4052 benign and 2769 malignant cases. In the benign category, patients with malnutrition in all subdivisions had longer hospital stays than those who were well-nourished. Significantly longer hospital stay was found in hepato-pancreato-biliary, neurology and cardio-vascular-thoracic surgery (p < 0.01, p = 0.01, p < 0.001). Hospital cost was also higher in malnourished patients in all subdivisions, and the differences were significant in the hepato-pancreato-biliary, upper gastrointestinal tract, colorectal, soft tissue, urology and head-neck-breast groups (p < 0.001, p = 0.01, p = 0.01, p = 0.03, p < 0.01, p < 0.01). In the malignant category, patients in all groups with malnutrition had longer hospital stay than those who were well nourished. Significantly longer hospital stay was found in the hepato-pancreato-biliary, upper gastrointestinal tract, colorectal, urology and neurology groups (p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001). Hospital cost was also higher with malnourished patients in all groups and significant differences were found in the hepato-pancreato-biliary, upper gastrointestinal tract, colorectal, urology, head-neck-breast and cardio-vascular-thoracic surgery groups (p < 0.001, p < 0.001, p < 0.001, p < 0.01, p < 0.01, and p = 0.02). CONCLUSION: Malnourished patients, both with benign and malignant disease, incurred higher costs and had longer hospital stays.

The Impact of Transarterial Chemoembolization for Advanced Stage Hepatocellular Carcinoma: A Single Center Experience.

Objective: The present study aimed to study survival and complications of hepatocellular carcinoma (HCC) patients with Barcelona Clinic Liver Cancer (BCLC) stage C who received transarterial chemoembolization (TACE) at Rajavithi Hospital, Thailand. Material and Method: The method used was a descriptive retrospective study using data collected from patient medical records from 2008 to 2012. The general information, complications, and causes of death of the patients were presented with descriptive statistics. Survival was analyzed using the Kaplan-Meier method. Results: During the 5-year period, our institution performed TACE on 396 patients. While 57 cases were classified as BCLC stage C, only 44 cases had complete records. The mean age of the patients was 56.3 years with an age range from 30 to 75 years. Thirty-six cases or 81.8% were male. Twenty-six cases or 59.1% had hepatitis B infections. Thirty-five cases or 79.5% were Child-Pugh A. The median survival time was 7.1 months. The most common complication was post-embolization syndrome which occurred in 39 patients (88.6%). Liver failure was a major procedural-related complication which occurred in 8 patients (18.2%) and was responsible for three deaths (6.8%). Conclusion: TACE in HCC patients with BCLC stage C at Rajavithi Hospital was an effective and safe palliative treatment.

Chronic venous disease treated with endovenous microwave ablation: long-terms results and quality of life.

BACKGROUND: Microwave ablation is considered to be safe for treatment in chronic venous disease patients, but data is lacking about its long-terms results. The present study aimed to evaluate the effectiveness of endovenous microwave ablation. MATERIAL AND METHOD: From January 2009-June 2012, 100 patients underwent endovenous microwave ablation. Demographic data, post-operative complication, and CIVIQ-2 questionnaire scores were recorded. Microwave energy was set at 50-65 watts and the pull back speed was 3 cm/minute. RESULTS: C2 was a common finding, (59.6%). Mean follow-up time was 25.2 months and the most immediate complication was numbness (32.1%) with permanent numbness at 3.8%. Quality of life as determined by CIVIQ-2 score changedfrom 32 before operation to 24 after operation (p<0.001). Complete venous occlusion rate was 79.8% and the rate of partial venous occlusion with no venous reflux was 8.7%. CONCLUSION: Endovenous microwave ablation can be used safely. It could be an alternative treatment for patients with chronic venous disease.

A randomized controlled trial of staple fixation versus N-butyl-2-cyanoacrylate fixation in laparoscopic inguinal hernia repair.

BACKGROUND: There has been paramount concern among most surgeons over complications caused by staples in the form of pubic injury and nerve entrapment leading to chronic pain in laparoscopic inguinal hernia repair OBJECTIVE: The present study aimed to compare the use of N-butyl-2-cyanoacrylate (Histoacryl) with that of staples in fixation of mesh in totally extraperitoneal laparoscopic inguinal hernia repair in terms of acute and chronic pain, complications, and recurrence within 1 year MATERIAL AND METHOD: 60 patients were allocated into 2 groups. The same protocol of general anesthesia was applied in both groups. In the staple group, Ultrapro mesh was used to cover the myopectineal orifice and was transfixed with staples. In the glue group, Histoacryl was sprayed to fix the mesh at the same area as in the staple group and also at the triangle of pain. Demographic data collected included fentanyl use, operation time, visual analogue pain score (VAS), chronic pain, complications and recurrence. RESULTS: Demographic data and complications showed no significant difference in the two groups. VAS in the staple group was significantly greater than that in the glue group after 24 hours (1.6 +/- 1.33 vs. 2.35 +/- 1.32) (p = 0.037). The incidence of chronic pain after 3 months and 1 year was higher in the staple group (33.0%, 33.0%, vs. 23.0%, 16.0%) (p = 0.390, 0.360). One patient in the staple group had a hernia recurrence eight months after the operation. CONCLUSION: N-butyl-2 cyanoacrylate might be an alternative choice of mesh fixation in TEP since overall complications and recurrence of hernia were not significantly different compared to staple fixation.

Long-term outcome of patients undergoing liver transplantation at Rajavithi Hospital, Thailand.

OBJECTIVE: Examine long-term outcome and survival of patients with liver transplantation at Rajavithi Hospital, a small-volume transplant center in Bangkok, Thailand. MATERIAL AND METHOD: Between May 1996 and December 2010, 21 liver transplantations were performed Piggyback technique and portal vein flushing with one liter of cold normal saline was used to prevent reperfusion injury. Color Doppler ultrasound was performed routinely. Data collection included demographic data, complications, operation time, ischemic time, duration of stay in intensive care unit (ICU), hospitalization period, and survival. RESULTS: There were two cases withdrawn from immunosuppressant drugs due to loss of follow-up and recidivism. Late death in three patients was from bleeding after hemiarthroplasty, chronic rejection, and lymphoma. Overall, 5-year and 10-year survival were 62% and 42% respectively Biliary complication rate was 9.5%. Two cases were under early reoperation due to bleeding from hepatic artery and retrohepatic vein. Hepatic vein occlusion was found in one case that had underlying Budd Chiari. One case with hepatocellular carcinoma, 10 nodules in both lobes of liver had survived more than three years after transplantation. CONCLUSION: Liver transplantation is a high-cost procedure. Good long-term results depend on expensive drugs, skilled surgeons, state-of-the-art equipment, and good team work. Policy and support from the government play an important role for successful transplantation, especially in developing countries.

Novel technique of mesh fixation with cyanoacrylate in totally extraperitoneal laparoscopic hernia repair: early experience.

Totally extraperitoneal laparoscopic hernioplasty (TEP) is an alternative surgery for inguinal hernia repair, but chronic pain is still a problem. The authors proposed the use of cyanoacrylate for mesh fixation instead of staples which might be the cause of chronic groin pain. The authors also innovated an instrument for delivery of cyanoacrylate for mesh fixation. The present article reported early experience in the first 15 patients who were treated with this technique. Early post-operative pain was comparable to a previous study, no recurrence and no chronic groin pain was detected after surgery.

Evaluation of the white test for the intraoperative detection of bile leakage.

We assess whether the White test is better than the conventional bile leakage test for the intraoperative detection of bile leakage in hepatectomized patients. This study included 30 patients who received elective liver resection. Both the conventional bile leakage test (injecting an isotonic sodium chloride solution through the cystic duct) and the White test (injecting a fat emulsion solution through the cystic duct) were carried out in the same patients. The detection of bile leakage was compared between the conventional method and the White test. A bile leak was demonstrated in 8 patients (26.7%) by the conventional method and in 19 patients (63.3%) by the White test. In addition, the White test detected a significantly higher number of bile leakage sites compared with the conventional method (Wilcoxon signed-rank test; P < 0.001). The White test is better than the conventional test for the intraoperative detection of bile leakage. Based on our study, we recommend that surgeons investigating bile leakage sites during liver resections should use the White test instead of the conventional bile leakage test.

Prognostic relevance of circulating CK19 mRNA in advanced malignant biliary tract diseases.

AIM: To determine the role of circulating tumor cells (CTCs) in prediction of the overall survival of patients with advanced malignant biliary tract obstruction. METHODS: We investigated the prognostic value of CTCs by examining two markers, cytokeratin (CK) 19 and human telomerase reverse transcriptase (hTERT) mRNA, in 40 patients diagnosed with advanced malignant biliary tract diseases. Quantitative real-time reverse transcription polymerase chain reaction was used to detect CK19 and hTERT mRNA in the peripheral blood of these patients. Overall survival was analyzed using the Kaplan-Meier method and Cox regression modeling. RESULTS: Positive CK19 and hTERT mRNA expression was detected in 45% and 60%, respectively, of the 40 patients. Univariable analysis indicated that positive CK19 mRNA expression was significantly associated with worse overall survival (P = 0.009). Multivariable analysis determined that positive CK19 mRNA expression, patient's age and serum bilirubin were each independently associated with overall survival. CONCLUSION: CK19 mRNA expression levels in peripheral blood appear to provide a valuable marker to predict the overall survival of patients with advanced malignant biliary tract obstruction.

Serum AFP and AFP-L3 in clinically distinguished hepatocellular carcinoma from patients with liver masses.

OBJECTIVE: To determine the ability of alpha fetoprotein (AFP) and AFP-L3% serum level in discriminating hepatocellular carcinoma (HCC) from other types of liver mass. MATERIAL AND METHOD: This study was performed according to a prospective-specimen-collection, retrospective-blinded-evaluation (PRoBE) design. A total of 109 HCC patients and 51 patients with other types of liver mass were consecutively selected. The levels of AFP and AFP-L3% in their sera were measured. RESULTS: AFP levels in serum significantly elevated while AFP-L3% levels significantly decreased in HCC patients (AFP: p < 0.001, AFP-L3%: p < 0.001). The area under the curve (AUC) of a receiver operating characteristic (ROC) curve analysis for the diagnosis of HCC of AFP and AFP-L3% was 0.71 and 0.67, respectively. In addition, the serum level of AFP-L3% was significantly different between the small (mass occupying lesser than 50% of liver volume) and large (mass occupying more than 50% of liver volume) HCC (p = 0.040). CONCLUSION: The diagnostic accuracy of serum AFP and AFP-L3% could provide them as candidate biomarkers to discriminate patients with HCC from patients with other types of liver mass. Serum AFP-L3% as a prognostic factor for HCC should be further evaluated in more details.

Strong expression of CD133 is associated with increased cholangiocarcinoma progression.

AIM: To determine the role of CD133 in cholangiocarcinoma progression. METHODS: CD133 protein expression was evaluated by immunohistochemistry in 34 cholangiocarcinoma specimens. In addition, proliferation, chemoresistance and invasive properties of CD133-enriched (CD133(+)) and CD133-depleted (CD133(-)) RMCCA1 cholangiocarcinoma cells were studied and compared. RESULTS: Strong CD133 expression was observed in 67.6% (23/34) of the cholangiocarcinoma specimens. Strong expression of CD133 was significantly associated with nodal metastasis (P = 0.009) and positive surgical margin status (P = 0.011). In the in vitro study, both the CD133(+) and CD133(-) cells had similar proliferation abilities and resistance to chemotherapeutic drugs. However, the CD133(+) cells had a higher invasive ability compared with CD133(-) cells. CONCLUSION: CD133+ cells play an important role in the invasiveness of cholangiocarcinoma. Targeting of the CD133+ cells may be a useful approach to improve treatment against cholangiocarcinoma.

A randomized control trial of levobupivacaine, bupivacaine versus placebo extraperitoneal infusion in totally extraperitoneal laparoscopic inguinal hernioplasty.

BACKGROUND: Totally extraperitoneal (TEP) laparoscopic inguinal hernioplasty procedure is significantly less painful than open repair, but it is not completely painless. The aim of this study was to compare the effect of extraperitoneal infusion of 0.25% levobupivacaine, 0.25% bupivacaine, and placebo in patients undergoing TEP procedure in terms of pain reduction. METHODS: Twenty patients were included in each group for TEP procedure. Group A received 40 mL of 0.9% normal saline, group B received 40 mL of 0.25% bupivacaine, and group C received 40 mL of 0.25% levobupivacaine infused into the extraperitoneal space before closing. Postoperative pain was assessed at 4, 8, 12, 24, 36, and 48 h postoperatively. Analgesic requirement, complications, and overall satisfaction were also recorded. RESULTS: The demographic and surgical characteristics of the patients did not significantly differ among groups. There were no statistical differences among groups in postoperative pain scores, total IV-PCA morphine requirement, complications, and overall satisfaction. CONCLUSION: Extraperitoneal infusion 40 mL of 0.25% bupivacaine or 0.25% levobupivacaine following TEP procedure did not show any benefit over placebo in terms of pain reduction.

Endovenous microwave ablation of varicose veins: in vitro, live swine model, and clinical study.

AIM: This study aims to investigate the application of the microwave generator to treat the patients with varicose veins. MATERIALS AND METHODS: Phase 1: Explanted saphenous veins in subcutaneous layer of the pork meat were ablated at 0, 40, 50, 60, and 70 W. Phase 2: The forelimb veins and the hindlimb arteries of a 40-kg swine were ablated at 50 and 60 W. Phase 3: The patients were treated with endovenous microwave ablation at 50 W. RESULTS: Phase 1: Perivenous tissue injury was found in groups 50, 60, and 70 W. Phase 2: Less perivenous tissue injury was found in group 50 W. Phase 3: Complete venous occlusion rate was 65% and venous reflux-free was 85% in 1 year. No severe complication was found. CONCLUSIONS: The microwave generator with 50-W power setting could be used to ablate the varicose veins safely.

Role of ciprofloxacin in patients with cholestasis after endoscopic retrograde cholangiopancreatography.

AIM: To determine the role of ciprofloxacin in reducing cholangitis in cholestatic patients with adequate biliary drainage after endoscopic retrograde cholangiopancreatography (ERCP). METHODS: A randomized, controlled trial was performed in 48 cholestatic patients at Rajavithi Hospital (Tertiary Referral Center for ERCP: 600 cases per year). All the 48 patients received 200 mg ciprofloxacin intravenous injection for 30 min before starting any procedures, and then were randomly divided in two groups. Twenty-two patients in study group continually received ciprofloxacin until 48 h after ERCP. Causes of biliary obstruction, bacteriology of bile and blood (in cholangitis) and clinical cholangitis were recorded. RESULTS: Forty-eight patients were enrolled and divided into continuous ciprofloxacin treatment group (n = 22) and discontinuous ciprofloxacin treatment group (n = 26). During ERCP, stones were found in 22 patients, malignant diseases in 24 patients and other pathologic lesions in 5 patients. One (4.5%) of the 22 patients who received ciprofloxacin and 2 (6.3%) of the 26 patients who discontinued ciprofloxacin after ERCP developed cholangitis (relative risk = 0.71; 95% CI = 0.14-3.65; P = 0.88). Bacterobilia was found in 27 (56.3%) out of 48 patients. E. coli and Streptococcus viridans were the most common organisms. CONCLUSION: Continual use of ciprofloxacin in patients with cholestasis after adequate biliary drainage procedures plays no role in reducing cholangitis.

Establishment and characterization of a cholangiocarcinoma cell line (RMCCA-1) from a Thai patient.

AIM: To establish and characterize a new cell line derived from peripheral cholangiocarcinoma of a Thai patient. METHODS: The peripheral cholangiocarcinoma specimen surgically obtained from the patient was aseptically processed by washing and mincing before culturing in Ham's F12 medium containing 10% fetal bovine serum. After 3 mo, when the cell line has become homogeneous and stabilized, several features were investigated, including growth characteristics, immunofluorescence staining for cytokeratins, expression of tumor markers, chromosomal analysis by G-banding and multicolour fluorescence in situ hybridization (mFISH), in vitro migration and invasion characteristics. RESULTS: The RMCCA-1 cell line has been established. These cells proliferated as a monolayer with a population doubling time of 48 h. Immunofluorescence staining showed positive staining for human cytokeratin 7 and 19 verifying the biliary epithelial origin. RMCCA-1 secreted carbohydrate antigen 19-9 (CA19-9), but insignificant levels of carcinoembryonic antigen (CEA) and alpha-fetoprotein (AFP). Chromosome analysis identified aneuploidy karyotypes with a modal chromosome number of 59. RMCCA-1 exhibited a low level of in vitro invasiveness, but a high degree of motility. The cell line exhibited a significant number of chromosomal aberrations as shown by mFISH and G-banding methods. CONCLUSION: A new cell line derived from peripheral cholangiocarcinoma of a Thai patient has been established. This cell line shows a low level of in vitro invasiveness, but a high degree of motility. It will serve as a valuable tool for further studies on tumor biology, molecular pathogenesis, metastatic mechanism and response to therapeutic drugs of cholangiocarcinoma.

Simple technique in the measurement of liver volume.

The measurement of liver volume is considered to be a highly effective prediction of postoperative liver failure in hepatectomized patients and selection of the proper size of the liver obtained from a living donor. The aim of the paper was therefore, to develop a simple, inexpensive and practical technique for the measurement of liver volume. Computerized tomography (CT) imaging sections were used to measure sectional areas of liver sections via a graphic program. The volumes of livers were then calculated from the combined sectional areas using mean-area, end-area, and prismodial methods. The calculated volumes of livers obtained were compared to those manually measured in a water replacement technique. The findings of the results indicated that the liver volume could be estimated from CT scan films with typically less than 5 per cent difference compared to the manual method.

Outcome of inguinal hernia repair total extraperitoneal laparoscopic hernia repair versus open tension free repair (Lichtenstein technique).

BACKGROUND: Result and efficacy of laparoscopic hernioplasty has been controversial. Many techniques have been performed and evaluated. Totally extraperitoneal laparoscopic hernia repair (TEP) technique has been used for laparoscopic hernioplasty in this center. Complications, benefit and efficacy in terms of recurrence were studied and compared with open tension free repair (Lichtenstein). METHOD: Fifty-five patients with 4 recurrent, 16 bilateral and 35 unilateral groin hernia underwent laparoscopic hernioplasty by the TEP technique. The other twenty-four patients with I recurrent 2 bilateral and 21 unilateral groin hernia underwent Lichtenstein hernioplasty (OH). Operative time, complications, hospital stay and recurrence after 1 year follow-up were recorded. RESULT: Mean operative time was 67.85 +/-21.66 and 55.85 +/- 10.60 minutes. Mean difference was 12.00, 95 per cent CI (1.83, 22.16) p-value 0.02 (TEP and OH). Mean hospital stay was 2.71 +/- 1.29 and 2.38 +/- 0.58 days. Mean difference was 0.33, 95 per cent CI (-0.26, 0.93) p-value 0.27 (TEP and OH) complication rate 12.7 per cent and 12.5 per cent p-value 0.64 (TEP and OH). Most complications were minor such as seroma, hematoma, neuralgia, one case of pubic osteitis needed to remove staples and some parts of the mesh. There was one conversion to open repair due to large sac and large bowel adherence. There was one recurrence after one year follow-up in the laparoscopic group, no major morbidity or mortality in this study. CONCLUSION: This study demonstrated that complications of the TEP technique were minimal and it was safe to perform. Although the operative time was longer and there was one recurrence in the TEP group, that might be because of the early learning period for a new surgical procedure