Laparoscopic Adrenalectomy: 6 Years Experience in Srinagarind Hospital.

BACKGROUND AND OBJECTIVE: Laparoscopic adrenalectomy has become the procedure of choice to treat benign functioning and non-functioning adrenal tumors. This study aims to present our single unit experience of laparoscopic adrenalectomy. MATERIAL AND METHOD: Review of all recorded clinical data was performed in patients who underwent laparoscopic adrenalectomy for adrenal neoplasm, between January 2008 and December 2013 in Srinagarind Hospital. Patients' demographic data, lesion size, operation time, blood loss, conversion rate, length of postoperative stay, morbidity and mortality were collected and analyzed. RESULTS: Forty-six adrenalectomy were done. 11 men and 35 women, with a mean age of 44 years (range 20-69) were enrolled. A right adrenal gland tumor in 14 cases (30.43%) and left adrenal gland tumor in 32 cases (69.57%). Overall mean operative time was 97 minutes and mean blood loss was 61.73 ml. Conversion to open surgery was necessary in 6 of 46 patients (13.04%). Mean length of post operative hospital stay of conversion to open surgery group (9.83 days) was longer than laparoscopic group (4.67 days) significantly p<0.05 (95% CI: -7.28 to -3.03). Tumor mean size was of 2.6 cm and most was cortical adenoma. Morbidity rate was 2.17% and no mortality. CONCLUSION: Laparoscopic adrenalectomy is the procedure of choice for benign adrenal gland tumor. Current review confirms that it has been a safe and feasible procedure associated with minimal morbidity. Surgical skill and laparoscopic experience are important factors to achieve consistently good outcomes.

Management of blunt renal trauma in Srinagarind Hospital: 10-year experience.

BACKGROUND: Renal trauma is the most common injury in the urogenital system. In the last decade the management has beer shifted f rom a mandatory exploration to conservative treatment. So, the present study was conducted to evaluate the result f, renal trauma patients. MATERIAL AND METHOD: The data of renal trauma patients treated at Srinagarind Hospital since 1 January 1998 to 31 December 2007 was collected. Clinical data and trauma score were obtained via medical record review. RESULTS: Sixty-nine patients were included; 59 were male (82%). Mean age was 29.8 years (1-68 years). Forty-nine patiens: (80%) were injured by traffic accident. Eighteen percents of patients also had splenic injury. Fifty-five patients (80%) of blunt renal injury patients were treated by Non-Operative Management (NOM). In this group, most patients had grade I injury (39%). Mean injury severity score (ISS), revised trauma score (RTS), trauma and injury severity score (TRISS) were 20, 7.3 and 0.93, respectively. Successful rate of non-operative management was 87.2%. Mean hospital stay was 11.8 days and urinary tract infection was the most frequent complication (10%). Fourteen patients (20%) underwent surgery. Mean ISS, RTS, TRISS were 20.8, 5.5, and 0.72, respectively. In the operative group, 71% were grade 5 injury and almost all were treated by nephrectomy. Mean hospital stay was 9 days. CONCLUSION: Blunt injury is the major cause of renal trauma and the main mechanism is traffic accident. The success rate of Non-Operative Management in Srinagarind Hospital was high. However operative management is still the standard treatment in unstable patients.

A comparison of the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Trauma-Injury Severity Score (TRISS) for outcome assessment in Srinagarind Intensive Care Unit trauma patients.

OBJECTIVE: To assess the ability of the Acute Physiology and Chronic Health Evaluation (APACHE II) system and Trauma-Injury Severity Scoring (TRISS) system in predicting group mortality in intensive care unit (ICU) trauma patients. MATERIAL AND METHOD: The trauma patients admitted to ICU at Srinagarind Hospital between June 2008 and December 2010 were studied. For each patient, demographic data, mechanism of injury and surgical status were collected. The probability of death was calculated for each patient based on the APACHE II and TRISS equations. The ability to predict group mortality for APACHE II and TRISS was assessed by receiver operating characteristic curve analysis, two by two decision matrices and calibration curve analysis. RESULTS: One hundred and thirty-two trauma patients were admitted to the ICU. Twenty-seven (20%) patients died and hundred and five (80%) survived. There were significant differences between survivors and non-survivors in Glasgow Coma Scale, Revised Trauma Score, Injury Severity Score and APACHE II score. By receiver operating characteristic (ROC) curve analysis, the areas under the curves (+/- SEM) of APACHE II and TRISS were 0.89 +/- 0.04 and 0.83 +/- 0.04, respectively. Using two by two decision matrices with a decision criterion of 0.5, the sensitivities, specificities and percentages correctly classified were 44.4%, 98.1% and 87.1%, respectively for APACHE II and 25.9%, 98.1% and 83.3%, respectively, for TRISS. From the calibration curves, the r2 value was 0.99 (p = 0.0001) for APACHE II and 0.98 (p = 0.0001) for TRISS. CONCLUSION: Both APACHE II and TRISS scores were shown to accurately predict group mortality in ICU trauma patients. APACHE II and TRISS may be utilized for quality assurance in ICU trauma patients. However, neither APACHE II nor TRISS provides sufficient confidence for prediction of outcome of individual patients.

Laparoscopic appendectomy: results of a new technique for stump management.

OBJECTIVE: The purpose of the present study was to review a new laparoscopic technique for treatment of appendicitis. An earlier pilot study indicated the safety of the technique in addition to saved time and cost. MATERIAL AND METHOD: The electronic records were analyzed on appendix surgeries performed at our hospital between January 1, 2007 and December 31, 2011. RESULTS: The 91 patients who had an appendiceal stump closure using clips (viz., the Hem-o-lock clip) had a significantly shorter surgery and hospitalization than those whose appendiceal stump was closed using the standard loop strap (Endo-loop). CONCLUSION: The complications between groups were not significantly different and were treated in both groups using conservative management.

Treatment Outcome of Traumatic Subclavian Artery Injuries.

BACKGROUND: Traumatic subclavian artery injuries are associated with high morbidity and mortality. Thoracic cage and clavicle provide a well protection of the underlying subclavian vessels and nerves and also cause a very limited operation space during open surgery. The endovascular modality is less invasive and alternative to conventional open surgical reconstruction. PURPOSE: The purpose of this study was to analyze the different therapeutic effects on limb salvage. METHODS: A retrospective review of patients who presented with blunt or penetrating injuries to the subclavian arteries between March 2012 and March 2021. RESULTS: Endovascular and open repairs were both effective for traumatic subclavian artery injury. There was no statistical difference in the limb salvage, mortality, procedure-related complication, reintervention rate and in-hospital medical complications. Intraoperative blood loss, red blood cell transfusion requirement and length of hospital stay were significantly lower in the endovascular intervention group. CONCLUSION: Endovascular treatment represents an attractive alternative to the traditional surgical approach for the treatment of traumatic injuries in the subclavian.

A Life Saving Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) with Open Groin Technique.

A 53-year-old male pedestrian was hit by a car and arrived at our hospital with a blunt abdominal injury and hemorrhagic shock. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) was performed in a timely fashion using the open groin technique in the emergency room. The procedure resulted in rapid improvement of hemodynamic status while the bleeding source was controlled. Recently, REBOA is a proper adjunctive procedure in major non-compressible torso hemorrhage patients. The procedure requires a portable X-ray or fluoroscopic machine in the ER to confirm the balloon's position. This method has likely limited the use of REBOA in developing countries. The procedure with open groin technique, using anatomical landmarks and physiologic change to confirm the position of the balloon, has been developed to address these concerns. Here we report on the treatment's success with this technique and believe that it can benefit trauma patient care.

A Life Saving Emergent Temporary External Carotid Artery Controlled in Extensive Craniofacial Injury.

INTRODUCTION: Craniofacial trauma may potentially have significant blood loss which may lead to death in some trauma patients. CASE REPORT: We report a case of a 43-year-old male who had a lethal noncompressible arterial hemorrhage from a penetrating wound on his left frontotemporal and preauricular region. Extensive bleeding was successfully temporarily controlled by external carotid artery (ECA) occlusion. The definitive operation was completed in a staged fashion following a computed tomography angiography assessment extension of the injury. CONCLUSION: Temporarily controlling the bleeding from the carotid artery should be considered as a life saving procedure in a lethal craniofacial injury.

What are the strongest indicators of intracerebral hemorrhage in mild traumatic brain injury?

BACKGROUND: Although there are eight factors known to indicate a high risk of intracranial hemorrhage (ICH) in mild traumatic brain injury (TBI), identification of the strongest of these factors may optimize the utility of brain CT in clinical practice. This study aimed to evaluate the predictors of ICH based on baseline characteristics/mode of injury, indications for brain CT, and a combination of both to determine the strongest indicator. METHODS: This was a descriptive, retrospective, analytical study. The inclusion criteria were diagnosis of mild TBI, high risk of ICH, and having undergone a CT scan of the brain. The outcome of the study was any type of ICH. Stepwise logistic regression analysis was used to find the strongest predictors according to three models: (1) injury pattern and baseline characteristics, (2) indications for CT scan of the brain, and (3) a combination of models 1 and 2. RESULTS: There were 100 patients determined to be at risk of ICH based on indications for CT of the brain in patients with acute head injury. Of these, 24 (24.00%) had ICH. Model 1 found that injury due to motor vehicle crash was a significant predictor of ICH, with an adjusted OR (95% CI) of 11.53 (3.05 to 43.58). Models 2 and 3 showed Glasgow Coma Scale (GCS) score of 13 to 14 after 2 hours of observation and open skull or base of skull fracture to be independent predictors, with adjusted OR (95% CI) of 11.77 (1.32 to 104.96) and 5.88 (1.08 to 31.99) according to model 2. DISCUSSION: Open skull or base of skull fracture and GCS score of 13 to 14 after 2 hours of observation were the two strongest predictors of ICH in mild TBI. LEVEL OF EVIDENCE: III.

Trauma care audit using Srinagarind hospital's audit filter.

BACKGROUND: To audit trauma care (including the mortality rate and obstacles faced by the authors) at Srinagarind (University) Hospital using the trauma audit filter. MATERIAL AND METHOD: Conduct a prospective, descriptive, study of trauma patients who received trauma medical care at Srinagarind Hospital, Khon Kaen University, Thailand, between January and May 2006. Srinagarind Hospitals trauma audit filter was used to audit trauma care. The audit filter comprised 14 criteria (i.e., 1) emergency medical service; 2) accident and emergency out-patient service; 3) in-patient service). Any filter that generated a "Yes" response was investigated to find the reason(s). The obstacles and mortality were also recorded. RESULTS: The authors enrolled 3209 patients. The mortality rate was 0.5% (95% CI 0.3-0.8). Emergency medical service, accident and emergency out- and in-patient service were rated satisfactorily. The reported obstacles were lack of hospital beds, inappropriate locale for trauma care, financial process, admission process, and lack of equipment. CONCLUSIONS: Srinagarind Hospital's audit filter had the capability to audit trauma care. Overall trauma care at Srinagarind Hospital was satisfactory albeit improvements are needed.

Sixty-one cases of obturator hernia in Chiangrai Regional Hospital: retrospective study.

OBJECTIVE: To review the patient characteristics and clinical symptoms, intraoperative finding and management, including morbidity and mortality rate of obturator hernia cases. MATERIAL AND METHOD: A retrospective study was performed in 61 patients diagnosed as obturator hernia at Chiangrai Regional Hospital between January 2000 and December 2005. RESULTS: The incidence of obturator hernia is 61 of 2,828 cases (2.2%) of all hernias, female:male 6.6:1. The mean age was 72.85 years. The mean body weight was 35.72 Kg. Howship-Romberg's sign were positive in eight patients (13.11%). Thirty-five patients (57.38%) were Richter type hernia, left:right side 3:2. Strangulation of bowel occurred in 41 patients (67.21%) Mortality rate was 11.47%. All patients with postoperative complications and all deaths showed bowel strangulation and all were more than 70 years of age. CONCLUSION: In the present study, the authors found a high incidence of obturator hernia (2.2% of all hernias) compared with a previous report (0.05%-1.4% of all hernias). This high incident rate might relate to the specific local life style of people in Chiangrai as most patients had a habit of smoking. Chronic obstructive pulmonary disease (COPD), old age, and low body weight were possible contributing factors. Bowel strangulation and age more than 70 years old were associated with morbidity and mortality.

Outcome of in-patient trauma cases: Accident and Emergency Unit, Khon Kaen University.

OBJECTIVES: To study and report the outcome of in-patient trauma cases based on the Trauma and Injury Severity Scoring (TRISS) method and compare the outcome with the registry data from the Major Trauma Outcome Study (MTOS). MATERIAL AND METHOD: A descriptive study was performed by retrospective data collection. From 1 January 2002 to 31 December 2002, all admitted trauma patients in the Accident and Emergency Unit, Department of Surgery, Faculty of Medicine, Khon Kaen University were included in the present study. Survival analysis was completed for all of the patients. STATISTICAL ANALYSIS: TRISS method and W, M and Z-statistics (Z-score) on the basis of definitive outcome-based evaluation (DEF) method for comparing with MTOS data. RESULTS: The majorities of patients were men (76.85%) and mean age was 30.81 years. One hundred and ninety five patients (96.06%) sustained blunt trauma, the vast majority resulting from motor vehicle crashes. The observed survivors were 182, whereas the expected survivors were 183.582. The W, M and Z-statistics were -0.779, 0.843 and -0.493 respectively. CONCLUSION: Z-score -0.493 indicated no statistical difference between observed and expected survivors.

A comparison of letrozole and anastrozole followed by letrozole in breast cancer patients.

BACKGROUND: We previously studied the noninferiority of anastrozole (ANZ) versus ANZ followed by letrozole (A-LTZ) due to reimbursement policy. We found that patients with A-LTZ had better overall survival (OS) than did patients with ANZ alone. This study aimed to prove that patients with A-LTZ also had better OS than patients with letrozole (LTZ) alone. METHODS: All medical records of the breast cancer patients taking LTZ with or without ANZ between 2004 and 2013 were reviewed. All patients were divided into two groups: the LTZ group included patients treated with LTZ alone, and the A-LTZ group included patients treated with ANZ who were automatically changed to LTZ due to change of the reimbursement policy. RESULTS: From 359 cases, there were 179 cases in the LTZ group and 180 cases in the A-LTZ group. The mean age of patients in the LTZ group was 53.7 years and in the A-LTZ group was 54.2 years. The distribution of clinical stages among the LTZ group versus the A-LTZ group was 21 versus 4 (stage 1), 86 versus 116 (stage 2), 55 versus 46 (stage 3), and 17 versus 14 (stage 4), respectively. Among the LTZ patients, 63.7% took aromatase inhibitor monotherapy and 36.3% had a switching strategy, while in the A-LTZ group, 53.9% took AI monotherapy and 46.1% had a switching strategy. OS of the A-LTZ group was longer than that of the LTZ group. CONCLUSION: The patients in A-LTZ, taking ANZ followed by LTZ had better OS than those in LTZ, taking LTZ alone.

Effects of switching from anastrozole to letrozole, due to reimbursement policy, on the outcome of breast cancer therapy.

BACKGROUND: Endocrine therapy is one of the standard treatments for estrogen-receptor-positive breast cancer patients. Letrozole is the only aromatase inhibitor (AI) included in Thailand's essential drug list since the change of reimbursement policy in 2008, when patients had to change their AIs (other than letrozole) to letrozole. This study aimed to prove that the efficacy of anastrozole plus letrozole is not less than anastrozole alone. METHODS: All medical records of breast cancer patients taking anastrozole between 2004 and 2013 were reviewed. Some patients were initially treated with anastrozole and then changed to letrozole (A-LTZ group), whereas the other patients were continuously treated with anastrozole until completion of therapy (ANZ group). RESULTS: In a total of 180 (55.9%) out of the 322 cases, anastrozole was replaced with letrozole. The mean age of patients in the ANZ group was 54.9 years and that of those in the A-LTZ group was 54.2 years. Clinical stages (1-4) of the ANZ versus A-LTZ patients were four versus four, 76 versus 116, 46 versus 46, and 16 versus 14, respectively. ANZ patients took AI monotherapy (46.5%) and switching strategy (53.5%), while A-LTZ patients took AI monotherapy (53.9%) and switching strategy (46.1%). The overall survival (OS) of A-LTZ patients was longer than that of ANZ patients. Stage 2 and 4 patients in the A-LTZ group also had better OS than those in the ANZ group, but stage 3 patients had similar OS in both groups. CONCLUSION: Anastrozole can be replaced by letrozole any time during endocrine therapy. The patients taking anastrozole plus letrozole surprisingly seemed to have better OS than patients taking anastrozole alone.