Timed barium esophagography to predict recurrent achalasia after peroral endoscopic myotomy: a retrospective study in Thailand.

Background/Aims: Achalasia is a rare esophageal motility disease, for which peroral endoscopic myotomy (POEM) has emerged as a promising treatment option; however, recurrence remains a challenge. Timed barium esophagography (TBE) is a useful diagnostic tool and potential outcome predictor of achalasia. This study aimed to determine predictive tools for recurrence after POEM. Methods: This retrospective study enrolled achalasia patients who underwent POEM between January 2015 and December 2021. Patients were categorized into two groups using the 1-month post-POEM Eckardt scores and TBE: the discordant group (Eckardt score improved >50%, TBE decreased <50%) and the concordant group (both Eckardt score and TBE improved >50%). Recurrence was defined as a reincrease in the Eckardt score to more than three during follow-up. Results: Complete medical records were available in 30 patients who underwent POEM. Seventeen patients (56.7%) were classified into the discordant group, while 13 patients (43.3%) were in the concordant group. The overall recurrence rate was 11.9% at 1-year, increasing to 23.8% during the extended follow-up. The discordant group had a 6.87 fold higher recurrence rate than the concordant group (52.9% vs. 7.7%, p=0.017). Conclusions: These results strongly suggest that combining the Eckardt score with TBE can effectively predict recurrent achalasia after POEM. Patients in the discordant group had an elevated risk.

Aerosol protection using modified N95 respirator during upper gastrointestinal endoscopy: a randomized controlled trial.

Background/Aims: The coronavirus disease 2019 pandemic has affected the worldwide practice of upper gastrointestinal endoscopy. Here we designed a modified N95 respirator with a channel for endoscope insertion and evaluated its efficacy in upper gastrointestinal endoscopy. Methods: Thirty patients scheduled for upper gastrointestinal endoscopy were randomized into the modified N95 (n=15) or control (n=15) group. The mask was placed on the patient after anesthesia administration and particles were counted every minute before (baseline) and during the procedure by a TSI AeroTrak particle counter (9306-04; TSI Inc.) and categorized by size (0.3, 0.5, 1, 3, 5, and 10 µm). Differences in particle counts between time points were recorded. Results: During the procedure, the modified N95 group displayed significantly smaller overall particle sizes than the control group (median [interquartile range], 231 [54-385] vs. 579 [213-1,379]×103/m3; p=0.056). However, the intervention group had a significant decrease in 0.3-µm particles (68 [-25-185] vs. 242 [72-588]×103/m3; p=0.045). No adverse events occurred in either group. The device did not cause any inconvenience to the endoscopists or patients. Conclusions: This modified N95 respirator reduced the number of particles, especially 0.3-µm particles, generated during upper gastrointestinal endoscopy.

Is fascial closure required for a 12-mm trocar? A comparative study on trocar site hernia with long-term follow up.

BACKGROUND: Despite the infrequency of trocar site hernias (TSHs), fascial closure continues to be recommended for their prevention when using a ≥ 10-mm trocar. AIM: To identify the necessity of fascial closure for a 12-mm nonbladed trocar incision in minimally invasive colorectal surgeries. METHODS: Between July 2010 and December 2018, all patients who underwent minimally invasive colorectal surgery at the Minimally Invasive Surgery Unit of Siriraj Hospital were retrospectively reviewed. All patients underwent cross-sectional imaging for TSH assessment. Clinicopathological characteristics were recorded. Incidence rates of TSH and postoperative results were analyzed. RESULTS: Of the 254 patients included, 70 (111 ports) were in the fascial closure (closed) group and 184 (279 ports) were in the nonfascial closure (open) group. The median follow up duration was 43 mo. During follow up, three patients in the open group developed TSHs, whereas none in the closed group developed the condition (1.1% vs 0%, P = 0.561). All TSHs occurred in the right lower abdomen. Patients whose drains were placed through the same incision had higher rates of TSHs compared with those without the drain. The open group had a significantly shorter operative time and lower blood loss than the closed group. CONCLUSION: Routine performance of fascial closure when using a 12-mm nonbladed trocar may not be needed. However, further prospective studies with cross-sectional imaging follow-up and larger sample size are needed to confirm this finding.

Management of aerosol generation during upper gastrointestinal endoscopy.

In the highly contagious coronavirus disease 2019 pandemic, aerosol-generating procedures (AGPs) are associated with high-risk of transmission. Upper gastrointestinal endoscopy is a procedure with the potential to cause dissemination of bodily fluids. At present, there is no consensus that endoscopy is defined as an AGP. This review discusses the current evidence on this topic with additional management. Prevailing publications on coronavirus related to upper gastrointestinal endoscopy and aerosolization from the PubMed and Scopus databases were searched and reviewed. Comparative quantitative analyses showed a significant elevation of particle numbers, implying that aerosols were generated by upper gastrointestinal endoscopy. The associated source events have also been reported. To reduce the dispersion, certain protective measures have been developed. Endoscopic unit protocols are recommended for the concerned personnel. Therefore, upper gastrointestinal endoscopy should be classified as an AGP. Proper practices should be adopted by healthcare workers and patients.

Laparoscopic surgery produced less surgical smoke and contamination comparing with open surgery: the pilot study in fresh cadaveric experiment in COVID-19 pandemic.

BACKGROUND: The SARS-CoV2 virus has been identified in abdominal cavity of the COVID-19 patients. Therefore, the potential viral transmission from any surgical created smoke in these patients is of concern especially in laparoscopic surgery. This study aimed to compare the amount of surgical smoke and surgical field contamination between laparoscopic and open surgery in fresh cadavers. METHODS: Cholecystectomy in 12 cadavers was performed and they were divided into 4 groups: laparoscopic approach with or without smoke evacuator, and open approach with or without smoke evacuator. The increased particle counts in surgical smoke of each group were analyzed. In the model of appendectomy, surgical field contamination under ultraviolet light and visual contamination scale between laparoscopic and open approach were compared. RESULTS: Open cholecystectomy significantly produced a greater amount of overall particle sizes, particle sizes < 5 µm and particle sizes ≥ 5 µm than laparoscopic cholecystectomy (10,307 × 103 vs 3738 × 103, 10,226 × 103 vs 3685 × 103 and 81 × 103 vs 53 × 103 count/m3, respectively at p < 0.05). The use of smoke evacuator led to decrease in the amount of overall particle sizes of 58% and 32.4% in the open and laparoscopic chelecystectomy respectively. Median (interquatile range) visual contamination scale of surgical field in open appendectomy [3.50 (2.33, 4.67)] was significantly greater than laparoscopic appendectomy [1.50 (0.67, 2.33)] at p < 0.001. CONCLUSIONS: Laparoscopic cholecystectomy yielded less smoke-related particles than open cholecystectomy. The use of smoke evacuator, abeit non-significantly, reduced the particles in both open and laparoscopic cholecystectomy. Laparoscopic appendectomy had a lower degree of surgical field contamination than the open approach.

Outcomes of Laparoscopic Common Bile Duct Exploration by Chopstick Technique in Choledocholithiasis.

BACKGROUND AND OBJECTIVES: Laparoscopic cholecystectomy with common bile duct exploration (LC with LCBDE) remains the preferred technique for difficult common bile duct stone (CBDS) removal. The chopstick method uses commonly available instruments and may be cost-saving compared to other techniques. We studied the outcome of LCBDE using the chopstick technique to determine if it could be considered a first-choice method. METHODS: Data from all patients that underwent LCBDE from January 1, 2012 to April 30, 2019 were retrospectively analyzed. A standard 4-port incision and CBDS permitted extraction with two laparoscopic instruments by chopstick technique via vertical choledochotomy. Demographic data, stone clearance rate, surgical outcomes, complications, and other associated factors were evaluated. RESULTS: Thirty-two patients underwent LCBDE. The mean number of preoperative endoscopic retrograde cholangiopancreatography (ERCP) sessions was 2.4. In 65.5% of cases, the CBDS was completely removed by the chopstick technique, while 96.9% of stones were removed after using additional tools. The need for additional instruments was associated with increased age, increased numbers of stones, longer period from the latest ERCP session, and previous upper abdominal surgery. The conversion rate to open surgery was 28.1% and was significantly associated with a history of upper abdominal surgery. CONCLUSION: The chopstick technique is a good alternative and could be considered as a first-line technique in LCBDE to remove the CBDS in cases with 1 to 2 large suprapancreatic CBDS due to instrument availability, cost-effectiveness, and comparable surgical outcomes.

Predictive significance of cancer related-inflammatory markers in locally advanced rectal cancer.

BACKGROUND: Locally advanced rectal cancer is treated using neoadjuvant chemoradiation (nCRT), followed by total mesorectal excision (TME). Tumor regression and pathological post-treatment stage are prognostic for oncological outcomes. There is a significant correlation between markers representing cancer-related inflammation, including high neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte (MLR) and unfavorable oncological outcomes. However, the predictive role of these markers on the effect of chemoradiation is unknown. AIM: To evaluate the predictive roles of NLR, MLR, and PLR in patients with locally advanced rectal cancer receiving neoadjuvant chemoradiation. METHODS: Patients (n = 111) with locally advanced rectal cancer who underwent nCRT followed by TME at the Minimally Invasive Surgery Unit, Siriraj Hospital between 2012 and 2018 were retrospectively analyzed. The associations between post-treatment pathological stages, neoadjuvant rectal (NAR) score and the pretreatment ratios of markers of inflammation (NLR, MLR, and PLR) were analyzed. RESULTS: Clinical stages determined using computed tomography, magnetic resonance imaging, or both were T4 (n = 16), T3 (n = 94), and T2 (n = 1). The NAR scores were categorized as high (score > 16) in 23.4%, intermediate (score 8-16) in 41.4%, and low (score < 8) in 35.2%. The mean values of the NLR, PLR, and MLR correlated with pathological tumor staging (ypT) and the NAR score. The values of NLR, PLR and MLR were higher in patients with advanced pathological stage and high NAR scores, but not statistically significant. CONCLUSION: In patients with locally advanced rectal cancer, pretreatment NLR, MLR and PLR are higher in those with advanced pathological stage but the differences are not significantly different.

Randomized controlled trial comparing the effects of usual gas release, active aspiration, and passive-valve release on abdominal distension in patients who have undergone laparoscopic cholecystectomy.

INTRODUCTION: Residual, intra-abdominal CO2 contributes to abdominal distension and pain after laparoscopic surgery. The study was designed to assess recovery after gas release in patients who have undergone laparoscopic cholecystectomy (LC). METHODS: A total of 142 patients undergoing laparoscopic cholecystectomy were randomly divided into three groups: (i) group 1 (control group), gas release from the surgical wound without port release (n = 47); (ii) group 2, active gas aspiration via a subdiaphragmatic port (n = 48); and (iii) group 3, passive-valve release via a subdiaphragmatic port valve opening (n = 47). Abdominal distension and shoulder pain levels were assessed postoperatively. RESULTS: The active aspiration group had significantly reduced postoperative abdominal distensions at 30 min, 4, and 24 h compared with the control group (50.0% vs 80.9%, 43.8% vs 76.6%, 33.3% vs 57.4%, respectively; P < 0.05). Similarly, the passive-valve release group had significantly reduced postoperative abdominal distensions at 4 and 24 h compared with the control group (51.1% vs 76.6%, 57.4% vs 36.2%; P < 0.05). Both intervention groups had significantly reduced postoperative shoulder pain at 4 and 24 h compared with the control group (P < 0.001). In addition, the postoperative ambulation times for the active aspiration group were significantly shorter than those for the control and passive-valve release groups (P < 0.001). CONCLUSION: Releasing residual CO2 from the intra-abdominal cavity at the end of laparoscopic cholecystectomy by either the active aspiration or passive-valve release technique is an effective way to reduce postoperative abdominal distension and shoulder pain.

Does Extending the Waiting Time of Low-Rectal Cancer Surgery after Neoadjuvant Chemoradiation Increase the Perioperative Complications?

Background. Traditionally, rectal cancer surgery is recommended 6 to 8 weeks after completing neoadjuvant chemoradiation. Extending the waiting time may increase the tumor response rate. However, the perioperative complication rate may increase. The purpose of this study was to determine the association between extending the waiting time of surgery after neoadjuvant chemoradiation and perioperative outcomes. Methods. Sixty patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiation followed by radical resection at Siriraj hospital between June 2012 and January 2015 were retrospectively analyzed. Demographic data and perioperative outcomes were compared between the two groups. Results. The two groups were comparable in term of demographic parameters. The mean time interval from neoadjuvant chemoradiation to surgery was 6.4 weeks in Group A and 11.7 weeks in Group B. The perioperative outcomes were not significantly different between Groups A and B. Pathologic examination showed a significantly higher rate of circumferential margin positivity in Group A than in Group B (30% versus 9.3%, resp.; P = 0.04). Conclusions. Extending the waiting to >8 weeks from neoadjuvant chemoradiation to surgery did not increase perioperative complications, whereas the rate of circumferential margin positivity decreased.

Colonic stenting for malignant colonic obstruction with pneumatosis intestinalis: A case report.

INTRODUCTION: Pneumatosis intestinalis is one of serious conditions following mechanical bowel obstruction. Emergency surgery is generally required to be a definite treatment in these patients of pneumatosis intestinalis, because of its risk of bowel ischemia and perforation. Since the operation in unprepared colon usually resulted in unfavorable outcome, the use of colonic stent is considered one of potential options as a bridge to definitive surgery. Presently, there is no widely published report of using colonic stent in these patients, particularly for stepping to curative surgery. Therefore, we herein report a case of obstructing sigmoid cancer with pneumatosis intestinalis who underwent successfully emergency metallic stent placement to convert from emergency to elective surgery. PRESENTATION OF CASE: A 50-year-old woman presented with 3-day history of abdominal pain and obstipation. Abdominal computed tomography demonstrated a short segment of circumferential luminal narrowing at sigmoid colon, the presence of pneumatosis intestinalis at cecum, including ascending colon, and no extraluminal air. We performed colonoscopy and placed the metallic stent. The patient was then improved. After 1 week, the patient underwent elective hand-assisted laparoscopic sigmoidectomy and was discharged 5days later. Pathological report showed stage IIa sigmoid cancer. The patient had no local recurrence or distant metastasis in 1year follow up. CONCLUSION: In obstructing colonic patient with pneumatosis intestinalis, nonsurgical treatment by colonic stenting can be used in selected patient as a bridge to definitive surgery. This will result in decreased morbidity and mortality and lower rate of stoma formation.

Cost-Effective and Potential Benefits in Three-Port Hand-Assisted Laparoscopic Sigmoidectomy.

OBJECTIVE: To demonstrate potential benefits of three-port hand-assisted laparoscopic sigmoidectomy (HALS) compared with open sigmoidectomy (OS) in terms of short-term outcomes and cost-benefit. MATERIAL AND METHOD: A retrospective review of a database of cases that matched 100 sigmoid cancer patients treated with sigmoidectomy at the Department of Surgery, Siriraj Hospital was performed. Short-term outcomes and costs of treatment were collected and analyzed. RESULTS: There were no differences in age, gender body mass index, American Society of Anesthesiologists' score, Charlson comorbidity index score, and previous surgery between OS and HALS groups. The three-port HALS group had significantly less blood loss (50 (5-400) mL vs. 120 (10-1,000) mL, p<0.001), faster time to regular diet (64.6±20.7 hours vs. 97.6±52.5 hours, p<0.001), and lower pain score (4.3±1.7 vs. 5.3±1.6, p = 0.008). The hospital-stay related cost was sign icantly lower in HALS group ($114 ($47-$789) vs. $190 ($57-$1,462), p

Simplified technique of laparoscopic cholecystectomy in a patient with situs inversus: a case report and review of techniques.

BACKGROUND: Situs inversus is a rare and silent autosomal recessive disorder occurring in 1:5,000 to 1:20,000 individuals. Laparoscopic cholecystectomy, a standard treatment for gallbladder disease in the general population, is very challenging in patients with situs inversus, especially for right-handed surgeons. We herein report a case involving our modified laparoscopic cholecystectomy technique for right-handed surgeons in a Thai patient with situs inversus who developed a symptomatic gallstone. We also include a short review of the literature. CASE PRESENTATION: A 39-year-old female patient with dextrocardia presented with a 5-month history of episodic biliary colic. Abdominal ultrasonography revealed a left-sided gallbladder with gallstones. We performed laparoscopic cholecystectomy with our modified technique including port relocation. The operation went well, and our patient recovered satisfactorily. CONCLUSION: Laparoscopic cholecystectomy in patients with a left-sided gallbladder is not often confidently performed by right-handed surgeons. However, some modifications of "mirror image" ports focused on the more ergonomic port position are the keys to successful completion of this operation. The patient will thus still obtain benefits from this standard minimally invasive technique.

Giant inguinal hernia: Report of a case and reviews of surgical techniques.

INTRODUCTION: Inguinal hernia is one of the most surgical common diseases. Giant inguinal hernia is more unusual and significantly challenging in terms of surgical management. It is defined as an inguinal hernia that extends below the midpoint of inner thigh when the patient is in standing position. PRESENTATION OF CASE: A 67-year-old male presented with giant right-side inguinal hernia with symptoms of partial colonic obstruction and significant weight loss. Barium enema revealed ascending colon, cecum and ileum contained in hernia sac without significant lesions of large bowel. He underwent hernia repair with omentectomy. Hernioplasty with polypropylene mesh was performed without any complications. He recovered uneventfully. DISCUSSION: There were several repair techniques suggested by published articles such as resection of the content and increased intraabdominal volume procedure. Many key factors for management of the giant inquinal hernia were discussed. A new classification of the giant inquinal hernia was described. CONCLUSION: Surgical repair for the giant inquinal hernia is challenging and correlated with significant morbidity and mortality due to increased intra-abdominal pressure.

Outcomes of endoscopic sphincteroplasty using large balloon dilatation for difficult common bile duct stone removal: a single endoscopist experience.

OBJECTIVE: Endoscopic sphincteroplasty (ESPT) using a large CRETM Wireguided balloon dilatation is an alternative technique in removing a difficult common bile duct (CBD) stone. However the outcome and complications of endoscopic difficult CBD stone removal using ESPT have not been well demonstrated. The present study revealed the outcome of the technique which done by a single endoscopist. MATERIAL AND METHOD: Between January 2003 and December 2009, the retrospective study of ninety-three patients with CBD stones that underwent endoscopic retrograde cholangiopancreaticography (ERCP) for stone removal and had difficulty were enrolled. ESPT using a large CRE Wireguided balloon dilatation was performed in 62 patients. The success rate of complete stone clearance and post ERCP complications were analyzed RESULTS: In the aspect of complete stone removal, the success rate was 88.7%. Seven patients (11.3%) required adjunctive mechanical lithotripsy (ML) for complete stone clearance. This technique was associated with low complication rate (3.2%). Post ERCP bleeding was found in one patient (1.6%) with ESPT using a large CRE balloon dilatation. Mild post-ERCP pancreatitis occurred in only one patient. CONCLUSION: ESPT using large diameter CRE Wireguided balloon dilatation after biliary sphinctertomy is an effective technique for a difficult CBD stone removal associated with a lower rate of complications. This procedure can avoid unnecessary surgical CBD exploration for stone removal.

Platysma myocutaneous flap interposition in surgical management of large acquired post-traumatic tracheoesophageal fistula: A case report.

INTRODUCTION: Acquired post-traumatic tracheoesophageal fistula (TEF) is an uncommon entity requiring early diagnosis. Among the many strategies in surgical management, we report a case successfully treated with a single-stage tracheal resection and esophageal repair with platysma myocutaneous interposition flap. PRESENTATION OF CASE: A 24-year-old man had a motor vehicle accident with head injury and cerebral contusion who required mechanical ventilation support. Three weeks later, he developed hypersecretion, and recurrent episodes of aspiration pneumonia. The chest computed tomography, esophagogastroduodenoscopy, and bronchoscopy revealed a large TEF diameter of 3cm at 4.5cm from carina. Single-stage tracheal resection with primary end-to-end anastomosis and esophageal repair with platysma myocutaneous interposition flap was performed. A contrast esophagography was done on post-operative day 7 and revealed no leakage. He was discharged on post-operative day 10. Esophagogastroduodenoscopy at 1 month revealed patient esophageal lumen. At present he is doing well without any evidence of complications such as esophageal stricture or fistula. DISCUSSION: There are many choices of myocutaneous muscle flaps in trachea and esophageal closure or reinforcement. The platysma myocutaneous flap interposition is simple with the advantage of reduced bulkiness. Concern on the vascular supply is that flap should be elevated with the deep adipofascial tissue under the platysma to ensure that the flap survival is not threatened. CONCLUSION: The treatment of acquired TEF with platysma myocutaneous flap is an alternative procedure for a large uncomplicated TEF as it is effective, technically ease, minimal donor site defect and yields good surgical results.

Asia-Pacific consensus recommendations for endoscopic and interventional management of hilar cholangiocarcinoma.

Hilar cholangiocarcinoma (HCCA) is one of the most common types of hepatobiliary cancers reported in the world including Asia-Pacific region. Early HCCA may be completely asymptomatic. When significant hilar obstruction develops, the patient presents with jaundice, pale stools, dark urine, pruritus, abdominal pain, and sometimes fever. Because no single test can establish the definite diagnosis then, a combination of many investigations such as tumor markers, tissue acquisition, computed tomography scan, magnetic resonance imaging/magnetic resonance cholangiopancreatography, endoscopic ultrasonography/intraductal ultrasonography, and advanced cholangioscopy is required. Surgery is the only curative treatment. Unfortunately, the majority of HCCA has a poor prognosis due to their advanced stage on presentation. Although there is no survival advantage, inoperable HCCA managed by palliative drainage may benefit from symptomatic improvement. Currently, there are three techniques of biliary drainage which include endoscopic, percutaneous, and surgical approaches. For nonsurgical approaches, stent is the most preferred device and there are two types of stents i.e. plastic and metal. Type of stent and number of stent for HCCA biliary drainage are subjected to debate because the decision is made under many grounds i.e. volume of liver drainage, life expectancy, expertise of the facility, etc. Recently, radio-frequency ablation and photodynamic therapy are promising techniques that may extend drainage patency. Through a review in the literature and regional data, the Asia-Pacific Working Group for hepatobiliary cancers has developed statements to assist clinicians in diagnosing and managing of HCCA. After voting anonymously using modified Delphi method, all final statements were determined for the level of evidence quality and strength of recommendation.

Unusual penetration of plastic biliary stent in a large ampullary carcinoma: A case report.

Endoscopic biliary stenting is a well-established treatment of choice for many obstructive biliary disorders. Commonly used plastic endoprostheses have a higher risk of clogging and dislocation. Distal stent migration is an infrequent complication. Duodenum is the most common site of a migrated biliary stent. Intestinal perforation can occur during the initial insertion or endoscopic or percutaneous manipulation, or as a late consequence of stent placement. A 52-year-old male who presented with obstructive jaundice underwent endoscopic retrograde cholangiopancreatography (ERCP) with plastic stent placement. However, jaundice did not improve and he then underwent ERCP which revealed the plastic stent penetrating the ampullary tumor into the duodenal wall causing malfunction of the stent. A new plastic stent was inserted and the patient underwent Whipple's operation. He is currently doing well after the operation.

Clinical characteristics, endosonographic findings and etiologies of gastroduodenal subepithelial lesions: a Thai referral single center study.

OBJECTIVE: The present study was undertaken to evaluate the demographic data, endoscopic ultrasonography (EUS) characteristics of the sub-epithelial lesions, pathology results, complications and long-term follow-up of the patients whom referred for EUS evaluation at Siriraj Hospital. MATERIAL AND METHOD: From January 2008-June 2011, a total of 61 cases was referred for EUS evaluation due to subepithelial lesions. The endoscopic reports, pathology results and the patients' medical records were reviewed. The present study was approved by Siriraj Institutional Review Board. RESULTS: A total of 61 patients were referred for evaluation of subepithelial lesions, 6 of them were excluded. Thus, 55 cases were analyzed. The mean age was 57.7 +/- 13.8 years (27-87 years). Sixty seven percent were female. Only one-third of the patients had symptoms. The provisional diagnosis of the sub-epithelial lesions, regarding only clinical and endosonographic characteristics were GIST neuroendocrine tumor (NET), pancreatic rest, lipoma, granular cell tumor and others (70.9%, 9.1%, 9.1%, 3.6%, 3.6% and 3.6% respectively). All the lesions were diagnosed as GIST originating from either the forth layer (97.4%) or the second layer (2.6%) of gastric or duodenal wall. Fine needle aspiration (FNA) was performed in 13 patients (23.6%). The positive predictive value, negative predictive value and accuracy of diagnosis of GIST made by endosonographers based on only endosonographic characteristics were 85, 100 and 86% (95% CI: 62.4%-94.4%) respectively. CONCLUSION: Most of the subepithelial lesions which were referred for EUS evaluation at Siriraj Hospital were GISTs. The diagnosis of GISTcan be accurately made by using the EUS based on only endosonographic characteristics. FNA should be done for the large sized GIST. For small sized GIST (< 3 cm), FNA might not be beneficial but a 1year interval follow-up with EUS is recommended.

Single-incision laparoscopic colectomy without using special articulating instruments: an initial experience.

BACKGROUND: Single-incision laparoscopic colectomy (SILC) was introduced as a novel minimally invasive technique. The benefits of this technique include reducing number of the incision and cosmetic improvement. Unlike the conventional laparoscopic colectomy, majority of previously reported SILC need to be performed using special curved or articulated instruments. The purpose of this study is to demonstrate our initial experience of SILC, which could be performed using the standard laparoscopic instruments. MATERIAL AND METHODS: Retrospective review of 14 patients who underwent SILC at Siriraj Hospital from May to December 2010, patient's demographic data, perioperative outcomes, early postoperative complications and pathological data were collected and analyzed. RESULTS: The mean age of all patients was 60 years. The most common operation with SILC was sigmoidectomy (n = 9), followed by right hemicolectomy (n = 2), left hemicolectomy (n = 1), anterior resection (n = 1), and total colectomy (n = 1). The trocar insertion techniques were multi-fascial incision using regular port (n = 11) and GelPOINT(®) (n = 3). The mean operative time was 155 minutes (range 90-280) and the mean estimate blood loss was 32.1 mL (range 10-100). All patients were successfully operated without conversion. The mean length of hospital stay was 9 days (range 5-20). There was no mortality. The pathological results revealed colorectal cancer (n = 12), neoplastic polyp (n = 1) and Familial adenomatous polyposis (FAP) (n = 1). The mean number of lymph nodes retrieval was 16.6 (range 3-34). CONCLUSION: SILC can successfully and safely be performed with standard laparoscopic instruments. This technique might be an alternative procedure to conventional laparoscopic colectomy with better cosmetic result.

Endoscopic tattooing of colorectal lesions: Is it a risk-free procedure?

Endoscopic tattooing is one of the most useful tools for the localization of small colorectal lesions especially in the laparoscopic setting. This is a minimally invasive endoscopic procedure without risk of major complications. However, many studies have revealed complications resulting from this procedure. In this article, several topics are reviewed including the accuracy, substance preparation, injected techniques and complications related to this procedure.