Inguinal hernia repair: toward Asian guidelines.

Groin hernias are very common, and surgical treatment is usually recommended. In fact, hernia repair is the most common surgical procedure performed worldwide. In countries such as the USA, China, and India, there may easily be over 1 million repairs every year. The need for this surgery has become an important socioeconomic problem and may affect health-care providers, especially in aging societies. Surgical repair using mesh is recommended and widely employed in Western countries, but in many developing countries, tissue-to-tissue repair is still the preferred surgical procedure due to economic constraints. For these reason, the development and implementation of guidelines, consensus, or recommendations may aim to clarify issues related to best practices in inguinal hernia repair in Asia. A group of Asian experts in hernia repair gathered together to debate inguinal hernia treatments in Asia in an attempt to reach some consensus or develop recommendations on best practices in the region. The need for recommendations or guidelines was unanimously confirmed to help overcome the discrepancy in clinical practice between countries; the experts decided to focus mainly on the technical aspects of open repair, which is the most common surgery for hernia in our region. After the identification of 12 main topics for discussion (indication, age, and sex; symptomatic and asymptomatic hernia: type of hernia; type of treatment; hospital admission; preoperative care; anesthesia; surgical technique; perioperative care; postoperative care; early complications; and long-term complications), a search of the literature was carried out according to the five levels of the Oxford Classification of Evidence and the four grades of recommendation.

Outcomes of local excision for early rectal cancer: a 6-year experience from the largest university hospital in Thailand.

BACKGROUND: This study aimed to determine clinical outcomes of local excision for early rectal cancer from a University Hospital in Thailand. MATERIALS AND METHODS: We performed a retrospective review of 22 consecutive patients undergoing local excision for early rectal cancer (clinical and radiological T1/T2) from 2005-2010 at the Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok. Data were collected from patients' medical records, including demographic and clinical characteristics, pathological report and surgical outcomes. RESULTS: This study included 10 males and 12 females, with average age of 68 years. Nineteen patients (86%) underwent transanal excision and the others had trans-sacral excision. Median operative time was 45 minutes. Postoperative complications occurred in 2 patients (9%); 1 fecal fistula and 1 wound infection following trans-sacral excision. There was no 30-day postoperative mortality. Median hospital stay was 5 days. Pathological reports revealed T1 lesion in 12 cases (55%), T2 lesion in 8 cases (36%) and T3 lesion in 2 cases (9%). Eight patients received additional treatment; one re-do transanal excision, two proctectomies, and five adjuvant chemoradiation. During the median follow-up period of 25 months, local recurrence was detected in 4 patients (18%); two cases of T2 lesions with close or positive margins, and two cases of T3 lesions. Three patients with local recurrence underwent salvage abdominoperineal resection. No local recurrence was found in T1/T2 lesions with free surgical margins. CONCLUSIONS: Local excision is a feasible and acceptable alternative to radical resection only in early rectal cancer with free resection margins and favorable histopathology.

Long-term outcomes of emergency Lichtenstein hernioplasty for incarcerated inguinal hernia.

PURPOSE: To evaluate the long-term outcomes of emergency Lichtenstein hernioplasty for incarcerated inguinal hernia. METHODS: The subjects of this prospective, observational study were 24 patients who underwent emergency Lichtenstein hernioplasty for an incarcerated inguinal hernia between September 2002 and January 2006 at the Faculty of Medicine Siriraj Hospital, Thailand. Patients with bowel strangulation and recurrent hernia were excluded. We evaluated the long-term outcomes over at least a 2-year follow-up. RESULTS: Long-term follow-up was completed for 20 patients (83.3 %). All of the patients were men, with a median age of 60 years (range 19-78 years) at the time of surgery. The median time to resumption of normal daily activities was 3 weeks (range 1-8 weeks). None of the patients had inguinal paresthesia persisting beyond 1 month after the operation. One patient (5 %) experienced chronic groin pain, which subsided within 4 months after surgery. Clinical recurrence was detected in two patients (10 %) during a median follow-up period of 6 years (range 2.3-7.6 years). Contralateral inguinal hernia was found in two patients (10 %) during follow-up. CONCLUSIONS: Lichtenstein hernioplasty is a safe and effective operation for non-strangulated incarcerated inguinal hernia, with a recurrence rate of 10 % at the median follow-up time of 6 years. Chronic groin pain and inguinal paresthesia were rare in this series.

Early gastric cancer: the first case series in Thailand.

BACKGROUND: Early gastric cancer (EGC) defined as gastric cancer involving up to submucosal layer, regardless of lymph node metastasis, is increasingly found at Siriraj Hospital. Understanding the characteristic of EGC and result of surgical management for EGC can help to choose the optimal treatment. In the present study, the authors reported the first case series in Thailand. MATERIAL AND METHOD: The authors analyzed 21 consecutive EGC patients treated with gastrectomy with lymph node dissection between September 2001 and December 2009 at Minimally Invasive Surgery Center, Division of General Surgery, Department of Surgery, Siriraj Hospital, Mahidol University, Thailand. RESULTS: Ratio of EGC to total cases of gastric cancer was increasing yearly, from 1.8% in 2006 to 8.1% in 2009 at Siriraj Hospital. The most common type of EGC was type IIc (66.7%) while type III was found in 19%, and type I in 14.3%. The tumor invaded mucosal layer in 42.9% and submucosal layer in 57.1% of the patients. For N staging, 76.2% of the patients were N0 while N1 was 19% and N2 was 4.8%. Overall, lymph node metastasis was found in 23.8%. For mucosal cancer (m), no lymph node metastasis was seen while for submucosal cancer (sm) five cases (41.7%) had lymph node metastasis, especially in one patient that the metastasis was in N2 group. Lymphatic invasion was seen in 14.3% of cases. All cases with lymphatic invasion were all submucosal cancer. Overall staging was stage 1a in 76.2%, stage 1b in 19%, and stage 2 in 4.8%. Morbidity was seen in 14.3% of the cases. No mortality was seen. The survival was excellent with no recurrence found during the follow-up period of the present study (mean 30.53 months). CONCLUSION: Surgery for EGC has good results with minimal complications and excellent 5-year survival. Less invasive treatment has become the option for EGC. Understanding the characteristic of EGC and careful selection to assign appropriate treatment is important to improve the result in the treatment of EGC.

Comparison of the efficacy and safety between generic intravenous omeprazole (Zefxon) and original omeprazole (Losec) in the adjunct treatment of non-variceal upper gastrointestinal bleeding in Siriraj Hospital.

BACKGROUND: Clinical efficacy and safety of generic omeprazole have not been well studied in Thailand. OBJECTIVE: Determine whether generic omeprazole (Zefxon) is inferior to original omeprazole (Losec) in the treatment of non-variceal upper gastrointestinal bleeding (UGIB) in Siriraj Hospital. MATERIAL AND METHOD: Medical records of adult patients with the diagnosis of non-variceal UGIB receiving intravenous omeprazole (either Zefxon or Losec) in Siriraj Hospital between January 2006 and September 2010 were reviewed Noninferiority study was used to investigate whether the generic omeprazole was no more than 10% less effective than the original omeprazole. The primary endpoints were recurrent bleeding and mortality within seven and 30 days. Surgery, endoscopic retreatment, blood transfusions, length of hospital stay and safety were also analyzed RESULTS: Of 200 randomly selected patients in each group, there was no difference in age, gender co-morbidities, severity of UGIB, endoscopic findings and endoscopic intervention between patients receiving generic omeprazole and original omeprazole. Overall rate of recurrent bleeding, mortality, and surgical intervention within 30 days were 12.3%, 5.5% and 2.0%, respectively. The rates of recurrent bleeding, overall mortality, and non-variceal UGIB related mortality within seven and 30 days were not significantly different between the two groups. Neither were the rates of endoscopic retreatment and surgery. The incidence of adverse side effects was 3.5% in each group. Cox regression analysis showed no significant association between type of omeprazole and recurrent bleeding or mortality. Compared to the original omeprazole, the hazard ratio of recurrent bleeding, overall mortality, and non-variceal UGIB related mortality in patients receiving generic omeprazole was 1.44 (95% CI 0.82-2.53; p = 0.21), 2.12 (95% CI 0.90-5.43; p = 0.08) and 1.82 (95% CI 0.53-6.21; p = 0.34), respectively. CONCLUSION: Although the original omeprazole Losec tended to have more favorable outcomes in the treatment of non-variceal UGIB in the present study, non-inferiority test showed that the efficacy and safety of the generic omeprazole Zefxon was not inferior to those of the original omeprazole.

Radical esophagectomy for esophageal cancer: results in Thai patients.

BACKGROUND: Radical esophagectomy was reported to have prolonged survival in patients with esophageal cancer However, it is associated with high morbidity and mortality. Controversy still exists regarding value of radical esophagectomy MATERIAL AND METHOD: The authors analyzed the results, including complications and survival in 68 consecutive patients with esophageal cancer who were treated with transthoracic radical esophagectomy at the Department of Surgery, Siriraj hospital, Mahidol University between June 2002 and June 2008. RESULTS: There were 57 males and eight females with a mean age of 59.28 +/- 11.25 years. Regarding T staging, 81.5% of the patients were in T3 stage while 1.5% of the patients had Ti stage, 15.4% had T2 stage, and 1.5% had T4 stage. Lymph node metastasis (NI) was found in 63.1% of the patients and NO was in 36.9%. Most of the patients were in advanced stages with 53.8% in stage III, 44.6% in stage II, and 1.5% in stage I. The 5-year survival rate of the patients with node positive was significantly lower than the patients with node negative (p = 0.018). The survival was significantly better in stage Ilcompared to stage III (p = 0.012). Overall 5-year survival rate was 28. 5%. Most common complications were from pulmonary causes (22.1%), anastomotic leakage (8.8%), and wound infection (8.8%). Mortality rate was 4.41%. CONCLUSION: Radical esophagectomy was associated with relatively low mortality and acceptable survival. It should be considered in surgical treatment of patients with esophageal cancer

Lymph node metastasis in gastric cancer: result of D2 dissection.

BACKGROUND: Extent of lymph node dissection still remains one of the most controversial issues regarding radical gastrectomy. Knowledge of the pattern and incidence of lymph node metastasis may help to define the optimal extent of lymph node dissection. MATERIAL AND METHOD: The authors analyzed lymph node metastasis and survival rate in 130 consecutive gastric cancer patients who underwent radical gastrectomy with D2 dissection between June 2001 and October 2008 at the Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand. RESULTS: For N staging, 28.5% of the patients were N0 while N1 was 40% and N2 was 31.5%. 44% of the patients with lymph node positive had metastasis up to group 2 lymph nodes. The patients with node positive had 5 year survival of 39% while the patients with node negative had survival of 73% (p = 0.003). Tumor at the middle part of the stomach had the most widespread lymph node metastasis compared to other regions. Lymph node group 7, 8 and 9 had a high incidence of lymph node metastasis especially for distal cancer while lymph node group 10, 11, 12 had lower incidence of metastasis. No mortality was seen in the present study. CONCLUSION: N staging, number of metastatic node > 5 and angiolymphatic invasion were the lymph node related factors contributing to survival. For radical gastrectomy, D2 dissection is required for adequate clearance of metastatic lymph nodes, which can be done without mortality.

Incidence and factors influencing the development of fistula-in-ano after incision and drainage of perianal abscesses.

OBJECTIVE: The aims of the present study were to evaluate the incidence offistula-in-ano following incision and drainage of acute perianal abscess and to determine factors influencing the fistula formation. MATERIAL AND METHOD: Patients with a first-time perianal abscess or intersphincteric abscess who underwent incision and drainage at Siriraj Hospital from January 2005 to June 2008 were reviewed Patients with coexisting fistula or perianal Crohn's disease were excluded. Incidence and risk factors for fistula formation were analyzed. RESULTS: Sixty-four patients were reviewed (50 males, 14 females). The average age of the patients was 44 years (range 19-82). The average follow-up period was 30 months (range 10-53). Twenty patients (31%) developed fistula-in-ano following incision and drainage. Gender; smoking, alcohol consumption, fever; leukocytosis, and location of abscess were not predictive of fistula formation. Univariate analysis showed that patients aged under 40 years and non-diabetic patients tended to have a higher risk for developing the fistula (43% vs. 21%, OR 2.95, 95% CI 0.98-8.85; p = 0.05 and 38% vs. 13%, OR 4.2, 95% CI 0.85-20.83; p = 0.071, respectively). However, patients receiving perioperative antibiotics (ATB) were less likely to develop subsequent fistula in both univariate and multivariate analysis. The FIA rate in non-ATB group was 48% and only 17% in ATB group (OR 4.5, 95% CI 1.44-14.13; p = 0.01). CONCLUSION: The incidence of fistula-in-ano following incision and drainage of perianal abscess was 31%. Patients aged under 40 years and non-diabetic patients appeared to have a higher risk for fistula formation. Administration of perioperative antibiotics significantly reduced the rate of subsequent fistula formation.

Impact of metabolic syndrome on the short-term outcomes of colorectal cancer surgery.

PURPOSE: The purpose of this study was to determine the effects of metabolic syndrome on the short-term outcomes of colorectal cancer surgery. METHODS: A prospective, observational study of colorectal cancer patients who underwent elective oncological resection was conducted between June 2007 and August 2008 at the Faculty of Medicine, Siriraj Hospital, Bangkok. Each patient received preoperative screening for metabolic syndrome using the criteria of the American Heart Association and the National Heart, Lung, and Blood Institute. Factors influencing 30-day postoperative morbidity and mortality were analyzed. RESULTS: The study included 114 patients with colorectal cancer, with an average age of 61 years (range 29-91). Forty-two (36.8%) patients had metabolic syndrome. There was no significant difference in age, sex, tumor, or operative parameters between patients with or without metabolic syndrome. There was no postoperative mortality, and overall postoperative morbidity was 21.9%. Patients with metabolic syndrome had a higher rate of complications and a longer length of hospital stay than those without metabolic syndrome (40.5% vs 11.1%, P < .001 and 11.2 vs 8.1 day, P = .006, respectively). The presence of metabolic syndrome, tumor location, American Society of Anesthesiologists' score III, elevated blood pressure, and high triglycerides level were risk factors for postoperative complications in the univariate analysis; however, in the multivariate analysis, the presence of metabolic syndrome and rectal cancer surgery were the only 2 independent factors for the development of complications. CONCLUSIONS: Patients with metabolic syndrome had a higher rate of postoperative complication and a longer length of hospital stay than patients without metabolic syndrome.

The surgical outcome of preoperative chemoradiation therapy for ultra low rectal cancer.

OBJECTIVE: To evaluate the surgical outcome of preoperative long-course chemoradiation therapy (PCRT) in patients with ultra low rectal cancer. MATERIAL AND METHOD: Medical records of patients with rectal adenocarcinoma located within the length of 5 cm from the anal verge, who underwent elective oncological resection between 2003 and 2006 at Siriraj Hospital, were reviewed. PCRT was performed in some patients based on tumor characteristics and surgeon's decision. Rate of sphincter preservation and other surgical outcomes were assessed. RESULTS: Ninety-three patients with an average age of 60 years were studied. Twenty-seven (29%) received PCRT. There was no difference in demographic data and location of the tumor between PCRT and non-PCRT group. Patients with PCRT had a smaller size of tumor (2.6 vs. 5.0 cm, p < 0.001) and better tumor staging (p < 0.001). Complete pathological response was found in four patients with PCRT (15%). However, there was no significant difference in SPP rate between PCRT and non-PCRT group (37% vs. 36%, p = 0.95). Other surgical outcomes between the two groups were also not different. CONCLUSION: PCRT did not increase rate of sphincter preservation in patients with low rectal cancer.

Efficacy and safety of parenteral amoxycillin/ clavulanate for prevention of surgical site infection following abdominal surgery.

OBJECTIVE: The aim of the present study was to evaluate the efficacy and safety of parenteral amoxycillin/ clavulanate for the prevention of surgical site infection (SSI) following intra-abdominal surgery. MATERIAL AND METHOD: This prospective opened non-comparative clinical trial was conducted in the Department of Surgery, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand between 1 April 2004 and 30 September 2004. Prophylactic amoxycillin/clavulanate (Cavumox) at a dose of 1.2 gram was given intravenously to all patients who underwent emergency or elective intra-abdominal procedures. All patients were scheduled to follow-up visits at 7, 14 and 30 days post operatively for monitoring the occurrence of SSI. RESULTS: Thirty emergency appendectomies (85.7%) and other 5 elective surgical procedures (14.3%) were performed in 35 patients including 14 males and 21 females with a mean age of 37 (range, 18-72) years. No SSI or drug allergy was observed. CONCLUSION: Parenteral amoxycillin/clavulanate is a safe and effective antibiotic as the monotherapy for prevention of SSI following intra-abdominal surgery.

What are the risk factors of colonoscopic perforation?

BACKGROUND: Knowledge of the factors influencing colonoscopic perforation (CP) is of decisive importance, especially with regard to the avoidance or minimization of the perforations. The aim of this study was to determine the incidence and risk factors of CP in one of the endoscopic training centers accredited by the World Gastroenterology Organization. METHODS: The prospectively collected data were reviewed of all patients undergoing either colonoscopy or flexible sigmoidoscopy at the Faculty of Medicine Siriraj Hospital, Bangkok, Thailand between January 2005 and July 2008. The incidence of CP was evaluated. Eight independent patient-, endoscopist- and endoscopy-related variables were analyzed by a multivariate model to determine their association with CP. RESULTS: Over a 3.5-year period, 10,124 endoscopic procedures of the colon (8,987 colonoscopies and 1,137 flexible sigmoidoscopies) were performed. There were 15 colonic perforations (0.15%). Colonoscopy had a slightly higher risk of CP than flexible sigmoidoscopy (OR 1.77, 95%CI 0.23-13.51; p = 1.0). Patient gender, emergency endoscopy, anesthetic method, and the specialty or experience of the endoscopist were not significantly predictive of CP rate. In multivariate analysis, patient age of over 75 years (OR = 6.24, 95%CI 2.26-17.26; p < 0.001) and therapeutic endoscopy (OR = 2.98, 95%CI 1.08-8.23; p = 0.036) were the only two independent risk factors for CP. CONCLUSION: The incidence of CP in this study was 0.15%. Patient age of over 75 years and therapeutic colonoscopy were two important risk factors for CP.

Comparison between midline and right transverse incision in right hemicolectomy for right-sided colon cancer: a retrospective study.

BACKGROUND: The advantage of a transverse incision over a midline incision for open right hemicolectomy remains controversial. OBJECTIVE: To compare the short-term surgical outcomes of right hemicolectomy through midline incision (RHML) and right hemicolectomy through right transverse incision (RHTR) for right-sided colon cancer. MATERIAL AND METHOD: This retrospective study included 74 patients with right-sided colon cancer who underwent elective right hemicolectomies through midline or right transverse incision between February 2004 and June 2006 at the Department of Surgery, Faculty of Medicine Siriraj Hospital. Operative details, postoperative requirement of narcotics, recovery of bowel function, and oncological parameters were analyzed. RESULTS: Fifty-four patients underwent RHML and 20 patients underwent RHTR. Both approaches achieved adequate oncological resection of the tumor. The RHTR group were characterized by shorter operative times (105 vs. 140 minutes; p = 0.001), less blood loss (70 vs. 125 ml,; p = 0.004), faster discontinuation of intravenous narcotics (1.2 vs. 1.8 days; p = 0.03), and shorter length of hospital stay (6.0 vs. 7.9 days,; p = 0.02). Postoperative complications and time to recovery of bowel function were not significantly different. CONCLUSION: The authors suggest that RHTR is a safe and effective operation for right-sided colon cancer; which results in a significant reduction in operative time, duration of intravenous narcotics administration, and hospital stay compared with RHML. However, there is no difference in postoperative recovery of bowel function and complication rate.

Current practices in rectal cancer surgery: a survey of Thai colorectal surgeons.

OBJECTIVE: Surgical techniques and management of rectal cancer have been rapidly evolving. The aim of the present study was to assess current practices in rectal cancer surgery among Thai colorectal surgeons. MATERIAL AND METHOD: Descriptive study was set between July and September 2008, a questionnaire was distributed to members (board-certified colorectal surgeons) of the Society of Colon and Rectal Surgeons Thailand regarding their current practices in rectal cancer including pre-operative management, surgical techniques, and postoperative surveillance protocol. Their perception of laparoscopic surgery was also emphasized. RESULTS: Forty questionnaires were returned (80% response rate). Of the respondents, 45% worked in a university hospital. Surgeons were in broad agreement (>75 percent agree) on the routine preoperative use of carcinoembryonic antigen, CT or MRI of the pelvis for cancer staging, mechanical bowel preparation, pelvic drainage after colorectal anastomosis, and postoperative surveillance in patients with curative resection. Opinion was divided (<75 percent agreement) on the use of neoadjuvant therapy for locally advanced rectal cancer, lateral pelvic node dissection, rectal irrigation prior to bowel resection, air-testing after bowel anastomosis, the need of protective stoma, and duration of prophylactic antibiotics. Thirty-three surgeons (82.5%) believed that laparoscopic surgery achieved the same oncological outcomes of open surgery; however only 40% of surgeons have experience in laparoscopic resection for rectal cancer. CONCLUSION: There is a considerable diversity of clinical practice for rectal cancer surgery, particularly in preoperative chemoradiation in locally advanced rectal cancer and to perform protective stoma after colorectal anastomosis. Meanwhile, postoperative surveillance protocol is quite uniform, and laparoscopic rectal surgery has gained attention among Thai colorectal surgeons.

Value of routine histopathologic examination of three common surgical specimens: appendix, gallbladder, and hemorrhoid.

BACKGROUND: The purpose of this study was to assess the need for a routine histopathologic examination of three common surgical specimens (appendix, gallbladder, hemorrhoid) and its impact on the further management of the patients. METHODS: Histopathologic reports of patients undergoing appendectomy, cholecystectomy, or hemorrhoidectomy performed between 1998 and 2006 in the Faculty of Medicine, Siriraj Hospital were reviewed. The reports were excluded if patients had a clinical diagnosis or suspicion of malignancy. The incidence of unexpected pathologic diagnoses and their impact on postoperative management were evaluated. RESULTS: Of 4545 appendectomy specimens, 44 (0.97%) revealed incidental unexpected pathological diagnoses, including one adenocarcinoma and one primary appendiceal lymphoma. About one-fifth of such unexpected appendiceal findings had an impact on postoperative treatment. Unexpected pathologic gallbladder findings were found in 88 (2%) of 4317 cholecystectomy specimens. Gallbladder cancer (GBC) was detected in 24 specimens (0.56%). A clinical diagnosis of empyema and patient's age over 60 years were two significant risk factors for an unexpected GBC [odds ratio (OR) 11.0, 95% confidence interval (CI) 4.2-29.2 and OR 6.2, 95% CI 2.1-18.2, respectively]. About one-fourth of patients with unexpected gallbladder findings required further management. Of 914 hemorrhoidectomy specimens, there were 13 (1.4%) histologic abnormalities other than the usually expected lesions in hemorrhoids. None of these altered postoperative management. CONCLUSIONS: The routine histopathology examination of the appendix and gallbladder, particularly in cases of empyema and patient's age over 60 years, is of value for identifying unsuspected conditions requiring further postoperative management. However, routine histopathologic evaluation of the hemorrhoid seems unnecessary.

Colorectal cancer screening and surveillance: a survey among Thai general surgeons.

PURPOSE: A significant reduction in colorectal cancer (CRC) mortality is attributed to CRC screening and surveillance. However, there is no national consensus on CRC screening and surveillance in Thailand. The aim of this study was to assess current practice in CRC screening and surveillance among Thai general surgeons. METHODS: Between July and November 2008, a questionnaire was randomly sent to general surgeons nationwide, mainly to those who worked in the General Province Hospital or University Hospital. Their responses were analyzed. RESULTS: One hundred and twelve general surgeons completed questionnaires (56% response rate); about 39% of them were colorectal surgeons. Ninety-four surgeons (84%) routinely offered CRC screening to an asymptomatic, average-risk population. Most surgeons started CRC screening in an average-risk patient at the age of 50 years and did no screening in populations with age above 80 years. Colonoscopy is the most popular investigation used in CRC screening, followed by fecal occult blood testing and double contrast barium enema. When the surgeons themselves were subjected to CRC screening, colonoscopy was also the favorite investigation used. About 3-18% of surgeons showed interest in CRC screening with computed tomographic colonography. After curative CRC resection, most surgeons set up a surveillance program with examinations every 3 months in the first 2 years and performed post-CRC resection surveillance by colonoscopy at 1 year. CONCLUSIONS: There is a wide variation in CRC screening and surveillance among Thai surgeons. These results highlight the need to establish evidence-based and cost-effective CRC screening and surveillance in Thailand.

Incidence of synchronous appendiceal neoplasm in patients with colorectal cancer and its clinical significance.

BACKGROUND: The aims of this study were to evaluate the incidence of synchronous appendiceal neoplasm in patients with colorectal cancer, and to determine its clinical significance. METHODS: Pathological reports and medical records were reviewed of patients with colorectal adenocarcinoma who underwent oncological resection of the tumor together with appendectomy at the Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand between September 2000 and April 2008. RESULTS: This study included 293 patients with an average age of 62 years (range 19-95) and 51 percent were male. Of the patients studied, 228 (78 percent) had right hemicolectomy, whereas the others (22 percent) had surgery for left-sided colon cancer or rectal cancer. One patient (0.3 percent) had epithelial appendiceal neoplasm (mucinous cystadenoma) and 3 patients (1.0 percent) had metastatic colorectal cancer in the mesoappendix. However, the presence of synchronous appendiceal tumors and/or metastasis did not alter postoperative management, as these patients had received adjuvant therapy and were scheduled for surveillance program because of nodal involvement. CONCLUSION: The incidence of synchronous primary appendiceal neoplasm and secondary (metastatic) appendiceal neoplasm in colorectal cancer patients was 0.3 and 1.0 percent, respectively. However, these findings did not change the postoperative clinical management.

Antibiotic prophylaxis and incisional surgical site infection following colorectal cancer surgery: an analysis of 330 cases.

OBJECTIVE: To evaluate the rate of incisional surgical site infection (SSI) following colorectal cancer surgery in a university hospital and to determine whether duration of prophylactic antibiotic administration can affect the development of this complication. MATERIAL AND METHOD: The medical records of 330 patients with colorectal cancer undergoing elective oncological resection between 2003 and 2006 at Siriraj Hospital were reviewed. Patients were divided into two groups according to the duration of antibiotic administration; group A: prophylactic antibiotics were discontinued within 24 hours after surgery and group B: antibiotics administration was extended beyond 24 hours after surgery. Data including rate of incisional SSI were analyzed. RESULTS: There were 180 males and 150 females, with a mean age of 63 years. There were 126 patients (38%) in group A and 204 patients (62%) in group B. There was no statistical difference in patient characteristics and tumor-related variables between the two groups, except tumor location. Overall rate of incisional SSI was 14.5%. The rate of incisional SSI was not statistically different between the two groups (group A 11.1% vs. group B 16.7%, p = 0.22). Patients with incisional SSI had a significantly longer hospital stay than patients without incisional SSI (15.9 vs. 8.3 days, p < 0.001). CONCLUSION: This present study found the overall rate of incisional SSI following colorectal surgery to be 14.5%. There was no significant difference in the rate of this complication between the two groups. Thus, surgeons should be encouraged to use a shorter duration of antibiotics to prevent the emergence of antibiotic-resistant bacterial infection and reduce hospital expenditure.

Perforated peptic ulcer: clinical presentation, surgical outcomes, and the accuracy of the Boey scoring system in predicting postoperative morbidity and mortality.

BACKGROUND: The purposes of this study were to determine clinical presentations and surgical outcomes of perforated peptic ulcer (PPU), and to evaluate the accuracy of the Boey scoring system in predicting mortality and morbidity. METHODS: We carried out a retrospective study of patients undergoing emergency surgery for PPU between 2001 and 2006 in a university hospital. Clinical presentations and surgical outcomes were analyzed. Adjusted odds ratio (OR) of each Boey score on morbidity and mortality rate was compared with zero risk score. Receiver-operating characteristic curve analysis was used to compare the predictive ability between Boey score, American Society of Anesthesiologists (ASA) classification, and Mannheim Peritonitis Index (MPI). RESULTS: The study included 152 patients with average age of 52 years (range: 15-88 years), and 78% were male. The most common site of PPU was the prepyloric region (74%). Primary closure and omental graft was the most common procedure performed. Overall mortality rate was 9% and the complication rate was 30%. The mortality rate increased progressively with increasing numbers of the Boey score: 1%, 8% (OR=2.4), 33% (OR=3.5), and 38% (OR=7.7) for 0, 1, 2, and 3 scores, respectively (p<0.001). The morbidity rates for 0, 1, 2, and 3 Boey scores were 11%, 47% (OR=2.9), 75% (OR=4.3), and 77% (OR=4.9), respectively (p<0.001). Boey score and ASA classification appeared to be better than MPI for predicting the poor surgical outcomes. CONCLUSIONS: Perforated peptic ulcer is associated with high rates of mortality and morbidity. The Boey risk score serves as a simple and precise predictor for postoperative mortality and morbidity.

Colonoscopic perforation: A report from World Gastroenterology Organization endoscopy training center in Thailand.

AIM: To determine the incidence of colonoscopic perforation (CP), and evaluate clinical findings, management and outcomes of patients with CP from the World Gastroenterology Organization (WGO) Endoscopy Training Center in Thailand. METHODS: All colonoscopies and sigmoidoscopies performed between 1999 and 2007 in the Endoscopic unit, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok were reviewed. Incidence of CP, patients' characteristics, endoscopic information, intra-operative findings, management and outcomes were analyzed. RESULTS: A total of 17357 endoscopic procedures of the colon (13699 colonoscopies and 3658 flexible sigmoidoscopies) were performed in Siriraj hospital over a 9-year period. Fifteen patients (0.09%) had CP: 14 from colonoscopy and 1 from sigmoidoscopy. The most common site of perforation was in the sigmoid colon (80%), followed by the transverse colon (13%). Perforations were caused by direct trauma from either the shaft or the tip of the endoscope (n = 12, 80%) and endoscopic polypectomy (n = 3, 20%). All patients with CP underwent surgical management: primary repair (27%) and bowel resection (73%). The mortality rate was 13% and postoperative complication rate was 53%. CONCLUSION: CP is a rare but serious complication following colonoscopy and sigmoidoscopy, with high rates of morbidity and mortality. Incidence of CP was 0.09%. Surgery is still the mainstay of CP management.