The influence of stone size on spontaneous passage of common bile duct stones in patients with acute cholangitis: A retrospective cohort study.

BACKGROUND: The common bile duct (CBD) stones passage in patients with cholangitis was unclear.This study aimed to evaluate the effect on CBD stone sizes and predicting factors on spontaneous passage in patients with cholangitis. METHOD: The medical records of cholangitis at Her Royal Highness Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University from January 2014 to December 2019 were retrospectively reviewed. Patients with acute cholangitis from CBD stones underwent ERCP in the same admission were enrolled. RESULT: Of the 96 patients, The rate of spontaneous passage of CBD stones was 19.8%. By univariate analysis, factors significantly associated with a predictor of spontaneous CBD stone passage in patient with cholangitis were single CBD stone (p = 0.001), CBD stone diameter < 5 mm (p < 0.001), and clinical symptom improved before ERCP procedure (p = 0.004). Multivariate logistic regression analyses also revealed that these three factors were significantly associated with spontaneous passage. From ROC curve analysis, stone size of less than 4.85 mm was more likely to pass spontaneously with acceptable sensitivity (81.8%) and specificity (78.9%). CONCLUSIONS: CBD stone diameter < 5 mm, single CBD stone and improved clinical symptom before ERCP procedure are key predictors of spontaneous CBD stone passage in cholangitis.

Safety of Laparoscopic Oncologic Resection in Elderly Patients with Colorectal Cancer: A Multicenter Retrospective Study Based on Perioperative Short-Term Outcomes.

Objectives: Over the last century, unthinkable goals have been achieved in health care and medical sciences, leading to longer life expectancy. Although cancer affects all ages, it disproportionately targets older individuals. Thus, surgical oncologists are confronted with increasing numbers of older patients presenting with multiple chronic conditions. We intended to investigate the safety of oncologic resection in older patients with colorectal cancer (CRC) based on perioperative outcomes. Materials and Methods: We retrospectively collected and analyzed data from older patients (>85 years) who underwent curative resection for stage II or III CRC between January 2007 and August 2017 at four hospitals (St. Vincent's Hospital, Incheon St. Mary's Hospital, Seoul St. Mary's Hospital, and Yeouido St. Mary's Hospital). Results: A total of 140 patients were enrolled in this study. The mean age was 87.1, the mean stay in the intensive care unit after surgery was 1.6 ± 3.8 days, and the mean postoperative hospital stay was 10.5 ± 3.8 days, D3 lymph node dissection was performed in 67.0% of patients, and D2 lymph node dissection was performed in 33.0%. Postoperative complications occurred in 38 patients (27.9%). In the univariate analysis, the risk factors for postoperative complications were the omission of mechanical bowel preparation (P = .039) and open surgery (P = .031). Conclusions: Oncologic resection in selected older patients with CRC might be a relatively safe treatment option. In particular, a laparoscopic approach might be a safer surgical method than open surgery in older patients with CRC.

Intrahepatic Sarcomatous Cholangiocarcinoma: Case Report and Review of the Literature.

The authors report a case of a patient with intrahepatic sarcomatous cholangiocarcinoma. A 45-year-old Thai man presented with a 3-month history of right upper abdominal pain. CT scan revealed hepatomegaly with a 6.5 cm hypovascular soft tissue density mass in the right lobe and showed mild delayed enhancement. On exploratory laparotomy, the tumor adherent to right diaphragm was found. We performed right hepatectomy, partial resection of right diaphragm, and cholecystectomy. The immunohistological results suggested "sarcomatous intrahepatic cholangiocarcinoma." The tumor was recurrent in 5 months after operation and unresectable. Therefore, the treatment in this patient was supportive care. He died 11 months after his initial presentation. The literature reviews showed that intrahepatic sarcomatous cholangiocarcinoma is aggressive malignant with poor prognosis. Early detection, radical resection, and careful follow-up would be the treatment for the favorable prognosis.

Video and Photographic Documentation for the Critical View of Safety: A Method for Improving Quality Control in Laparoscopic.

Background: Currently, Laparoscopic cholecystectomy (LC) is the gold standard surgical treatment of stones in the gall bladder. However, the disadvantage of LC was increases in the incidence of bile duct injury up to 0.20-3.40%. The critical view of safety (CVS) technique has been developed in an attempt to prevent the complication. Objective: To verify the adequacy of performing CVS technique by auditing the operative note, video record and photographic documentation. Material and Method: From January until December 2015, we investigated the accuracy of CVS establishment on video and photo prints. Two experienced laparoscopic surgeons were independent analyzer of the documentations, which classified into conclusive, probably, inconclusive and not established. Results: A twenty-four patients underwent an elective LC. The video records provide a superior quality to prove the CVS than the photo prints (90-95% versus 75-80%). However, a combination of documenting modality including operative note, video and photo print proved that a conclusive CVS establishment could be achieved in all cases. There was no postoperative complication occurred in this study. Conclusion: Mandatory use of the imaging documentation methods for assessment of adequate CVS generally facilitates a good quality control in surgical practice and patient care.

Predictive Factors for Choledocholithiasis in Symptomatic Gallstone Patients.

Background: Complications of common bile duct stones (choledocholithiasis) can vary from simple biliary colic to lifethreatening conditions. Approximately 10-25% of symptomatic gallstone patients may be associated common bile duct stone (CBDS) at the time of diagnosis. Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for diagnosis and treatment of CBDS but this procedure is invasive and has high morbidity and mortality rate. Moreover, routine preoperative ERCP is not cost-effectiveness. Objective: This study aimed to determine the predictive factors for predicting CBDS in symptomatic gallstone patients. Material and Method: Between March 2008 and February 2011, 149 symptomatic gallstone patients who underwent preoperative ERCP or intraoperative cholangiography (IOC) during laparoscopic cholecystectomy at Her Royal Highness Princess Mahachakri Sirindorn Medical Center (MSMC) were evaluated by clinical presentations, biochemical blood test and transabdominal ultrasonography. The preoperative predictive factors for choledocholithiasis were determined by univariate and multivariate analysis. Results: Age morethan 55 years, history of jaundice, history of cholangitis, total bilirubin >2.0 mg/dL, Aspartate aminotransferase >2 times the normal value, Alanine aminotransferase >3 times the normal value, Alkaline phosphatase >300 U/L, Gamma glutamyltranspeptidase >90 U/L, sized of CBD >8 mm and visualized CBD stones by ultrasonography were found to be associated with CBD stones by univariate analysis. For multivariate analysis, history of cholangitis (p-value 0.027), sized of CBD >8 mm (p-value 0.003) and detected CBD stones by ultrasonography (p-value 0.000) were found to be predictive factors for choledocholithiasis. Conclusion: This study presented that the helpful preoperative predictive factors for choledocholithiasis were history of cholangitis, dilatation of CBD >8 mm and visualized CBD stone by ultrasonography.

The Effects of Single-Dose Preoperative Intravenous Dexamethasone on Clinical Outcome after Laparoscopic Cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy is one of the most common procedures in surgery. Post-operative pain and post- operative nausea and vomiting (PON) are frequently events after laparoscopic cholecystectomy and cause distress to patients. Dexamethasones are known for analgesic, anti-inflammatory, immune-modulating and anti-emetic effects. Therefore, preoperative dexamethasone administration may reduce postoperative pain and postoperative nausea vomiting after laparoscopic cholecystectomy. OBJECTIVE: This study aims to determine the effects of single-dose preoperative intravenous dexamethasone on clinical outcome such as postoperative pain nausea and vomiting in patients undergoing laparoscopic cholecystectomy. MATERIAL AND METHOD: This is a prospective randomized controlled trial study. Eighty patients undergoing elective laparoscopic cholecystectomy were randomized to dexamethasone group and control group. Dexamethasone group received 8 mg (2 ml) of intravenous dexamethasone 60-90 minute before surgery whereas control group received 2 ml of normal saline 60-90 minute before surgery. Patients received a similar standardized anesthesia, surgical and multimodal analgesic treatment. The pain score, nausea and vomiting at 1, 6, 24 hours after surgery and before discharge including analgesic consumption and antiemetic required was recorded in both groups. Preoperative and postoperative erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were measured. RESULTS: No significant difference existed between two groups regarding age, sex, previous operation, operation time and hospital stays. All of the patients had no postoperative complication. Postoperative pain score, nausea and vomiting at 1st and 6th hours in dexamethasone group were significantly reduced in comparison with control group. Analgesic consumption, antiemetic requirement and CRIP postoperative were significantly decreased in dexamethasone group. CONCLUSION: Single-dose preoperative dexamethasone 8 mg 60-90 minute before induction of anesthesia improved clinical outcome in terms of significantly less nausea, vomiting, pain at first 6 hours and less inflammatory response after laparoscopic cholecystectomy compared to placebo. The preoperative dexamethasone should be used as routine in patients undergoing laparoscopic cholecystectomy.