New Proposed Classification of Difficulty in Laparoscopic Cholecystectomy.

Background: Difficult laparoscopic cholecystectomy (LC) has been challenging for surgeons. Randhawa's system used operative time, complications, and conversion to define three difficulty grades. However, using fixed numbers of operative time as dividers among three groups might not be applicable universally. This study aimed to propose new classification with more flexible parameters. Methods: This retrospective cohort study was conducted with patients who underwent LC because of gallstone-related diseases between January 2017 and December 2021 at Thammasat University Hospital. The exclusion criteria were (1) emergent LC for acute cholecystitis, (2) other procedures performed in the same setting of LC, (3) incomplete information, and (4) LC converted to open cholecystectomy. Patients were categorized into three groups using Randhawa's classification. Thereafter, new classification using mean and standard deviation was applied to reclassify patients into three new groups. The comparison between two grading results was performed to prove the advantage of new classification. Results: Total of 523 patients who underwent LC were included with median age 59.3 years old and 60.8% female. By Randhawa classification, proportions of easy, difficult, and very difficult groups were 39%, 53.7%, and 7.3%, respectively. Then, the new operative-time dividers among three groups were changed from 60 and 120 minutes to mean and mean + 2SD, respectively. Reclassified three difficult groups were 38.9%, 57.1%, and 4%. The comparison demonstrated new classification as more flexible and more compatible with each individual surgeon. Conclusions: New surgeon-referenced grading system of difficult LC included surgeon's factors, not only unfavorable operative findings. This classification should be more flexible than the previous criterion-referenced one. Thai Clinical Trials Registry at https://www.thaiclinicaltrials.org with Number TCTR20220426003.

Effectiveness of Lidocaine nasal drops versus placebo drops for reducing the discomfort of nasogastric tube insertion: a randomized controlled trial study.

PURPOSE: Nasogastric tube (NGT) insertion can be painful and distressing for the patient. Lidocaine nasal drops might be effective as a local anesthetic agent before the procedure. This study aimed to compare the effects of Lidocaine nasal drops versus placebo drops for reducing the discomfort of this procedure. METHODS: Patients indicated for NGT insertion were categorized into two groups randomly. The Lidocaine group had 2% Lidocaine instilled nasally 3 min before the procedure and the control group had normal saline drops instilled. We compared the pain scores (using a visual analog scale) and complications between the two groups. RESULTS: A total of 126 patients who required NGT insertion between September, 2021 and August, 2022 were enrolled in this study. The pain score of the Lidocaine nasal drops group was 1.41 ± 0.50 (range 1-2) and that of the control group was 4.54 ± 1.03 (range 3-7) (p < 0.01). The duration of the procedure in the Lidocaine and control groups was 1.52 ± 0.76 min and 3.38 ± 1.36 min, respectively (p < 0.01). The insertion was completed successfully within the first attempt in 98% of the Lidocaine group patients, whereas two or three attempts were needed in the control group. The incidence of complications such as vomiting, coughing, difficult breathing, and aspiration was lower in the Lidocaine group than in the control group (p < 0.01). CONCLUSION: Instilling Lidocaine nasal drops before NGT insertion alleviated discomfort and reduced procedure-associated complications.

Optimizing the Yield of Abnormal Preoperative Chest Radiographs in Elective Non-cardiothoracic Surgery: Development of a Risk Prediction Score and External Validation.

BACKGROUND: Guideline recommendations for preoperative chest radiographs vary to the extent that individual patient benefit is unclear. We developed and validated a prediction score for abnormal preoperative chest radiographs in adult patients undergoing elective non-cardiothoracic surgery. METHODS: Our prospective observational study recruited 703 adult patients who underwent elective non-cardiothoracic surgery at Ramathibodi Hospital. We developed a risk prediction score for abnormal preoperative chest radiographs with external validation using data from 411 patients recruited from Thammasat University Hospital. The discriminative performance was assessed by receiver operating curve analysis. In addition, we assessed the contribution of abnormal chest radiographs to perioperative management. RESULTS: Abnormal preoperative chest radiographs were found in 19.5% of the 703 patients. Age, pulmonary disease, cardiac disease, and diabetes were significant factors. The model showed good performance with a C-statistics of 0.739 (95% CI, 0.691-0.786). We classified patients into four groups based on risk scores. The posttest probabilities in the intermediate-, intermediate-high-, and high-risk groups were 33.2%, 59.8%, and 75.7%, respectively. The model fitted well with the external validation data with a C statistic of 0.731 (95% CI, 0.674-0.789). One (0.4%) abnormal chest radiograph from the low-risk group and three (2.4%) abnormal chest radiographs from the intermediate-to-high-risk group had a major impact on perioperative management. CONCLUSIONS: Four predictors including age, pulmonary disease, cardiac disease, and diabetes were associated with abnormal preoperative chest radiographs. Our risk score demonstrated good performance and may help identify patients at higher risk of chest abnormalities.

The Modification of a Preoperative Scoring System to Predict Difficult Elective Laparoscopic Cholecystectomy.

Background: Laparoscopic cholecystectomy (LC) is one of the most common abdominal operations. The difficult cases are still challenging for surgeons. There had been many studies providing several preoperative models to predict difficult LC or conversion. Randhawa's scoring system was a simple and practical predictive model for clinicians. The modification was reported to be more preferable for delayed LC. This study aimed to confirm the advantage of modified predictive model in larger sample size. Materials and Methods: This retrospective cohort study reviewed medical records of patients who underwent LC since January 2017 to December 2021. The difficulty of operation was categorized into three groups: easy, difficult, and very difficult. Multivariate analysis was performed to define significant factors of very difficult and converted cases. The predictive scores were calculated by using the original Randhawa's model and the modification, then compared with actual outcome. Results: There were 567 cases of delayed LC in this study, with 44 cases (7.8%) converted to open cholecystectomy. Four factors (previous cholecystitis, previous endoscopic retrograde cholangiopancreatography, higher ALP, and gallbladder wall thickening) for very difficult group and five factors (previous cholecystitis, previous cholangitis, higher white blood cell count, gallbladder wall thickening, and contracted gallbladder) for conversion were significant. The modification provided the better correlation and higher area of receiver operating characteristic (ROC) curve comparing with the original model. Conclusion: The modification of Randhawa's model was supposed to be more preferable for predicting the difficulty in elective LC. Thai Clinical Trials Registry No. 20220712006.

The pre-operative predictive model for difficult elective laparoscopic cholecystectomy: A modification.

BACKGROUND: Although LC is a common operation, difficult cases are still challenging. Several studies have identified factors for the difficulty and conversion. Many scoring systems have been established for pre-operative prediction. This study aimed to investigate significant factors and validity of Randhawa's model in our setting. METHODS: This prospective study enrolled LC patients in Hepato-Pancreato-Biliary Surgery unit between March 2018 and October 2019. The difficulty of operation was categorized into 3 groups by intra-operative grading scale. Multivariate analysis was performed to define significant factors of very-difficult and converted cases. The difficulty predicted by Randhawa's model were compared with actual outcome. Area under ROC curve was calculated. RESULTS: Among 152 patients, difficult and very-difficult groups were 59.2% and 15.1%, respectively. Sixteen cases needed conversion. Four factors (cholecystitis, ERCP, thickened wall, contracted gallbladder) for very-difficult group and 3 factors (obesity, biliary inflammation or procedure, contracted gallbladder) for conversion were significant. After some modification of Randhawa's model, the modified scoring system provided better prediction in terms of higher correlation coefficient (0.41 vs 0.35) and higher AUROC curve (0.82 vs 0.75) than original model. DISCUSSION: Randhawa's model was feasible for pre-operative preparation. The modification of this model provided better prediction on difficult cases.

Comparison of Introducer Percutaneous Endoscopic Gastrostomy with Open Gastrostomy in Advanced Esophageal Cancer Patients.

In esophageal cancer treatment, nutrition by feeding tube has been demonstrated to improve patient tolerance of treatment, quality of life, and long-term outcomes. The open gastrostomy and percutaneous endoscopic gastrostomy (PEG) using introducer technique are procedures that avoid cancer cells seeding and also improve patient's nutritional status, hydration, and medication. The aim of this study is to compare the results of the introducer PEG and open gastrostomy in patients with advanced esophageal cancer. A retrospective study was analyzed in the advanced esophageal cancer patients who indicated and received feeding support between January 2016 and December 2017. Twenty-eight patients in introducer PEG and 36 patients in open gastrostomy presented the following comparative data: mean operative duration time shorter, less pain score, and shorter hospitalization in introducer PEG than open gastrostomy. Both groups showed no readmission or 30-day mortality. The adverse events of open gastrostomy demonstrated higher than introducer PEG group. Both introducer PEG and open gastrostomy were the safe options for advanced esophageal cancer patients indicating for enteral feeding and to avoid cancer cell seeding but the introducer PEG demonstrated the effective minimally invasive procedure with fewer complications.

Outcomes of extended-spectrum beta-lactamases producing Enterobacteriaceae colonization among patients abdominal surgery patients.

Preoperative enteric screening for extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae was conducted in 360 patients prospectively observed for surgical site infection (SSI). ESBL colonization (adjusted odds ratio [aOR], 2.4) and dirty wound classification (aOR, 3.6) were associated with SSI; no association between carbapenem prophylaxis and reduction in SSI was detected.

Comparison of postoperative pain at umbilical wound after conventional laparoscopic cholecystectomy between transumbilical and infraumbilical incisions: a randomized control trial.

BACKGROUND: Transumbilical incision has been applied in single-incision laparoscopy. Evidence for the effect of transumbilical incision on postoperative pain compared with infraumbilical incision is still lacking. METHODS: A randomized controlled trial (RCT) was conducted in a university hospital. Patients who underwent conventional laparoscopic cholecystectomy were randomized to have transumbilical or infraumbilical incision. Postoperative pain was measured using visual analog score at 6, 24 h, and 7 days post operation. Secondary outcomes were analgesic usage, length of stay, superficial surgical site infection (SSI), wound numbness, and hypersensitivity. Risk ratio and mean difference (MD) along with their 95% confidence intervals (CIs) were estimated. Adjusted analysis was done, if clinical unbalanced characteristics presented. The study was registered at http://ClinicalTrial.gov (ID NCT02738710). RESULTS: A total of 102 patients were enrolled in which 51 patients were randomized to each interventional group. Postoperative pain was not significantly different between the groups with the MD of - 0.07 (95% CI - 0.47, 0.35). Paracetamol usage was significantly 1 tab (95% CI - 1.9, - 0.1) less after transumbilical incision, but this was not significant after adjusting for unbalanced characteristics. Superficial SSI rate was much higher in the transumbilical than the infraumbilical group, i.e., 16 versus 4%, but this was not significant (p = 0.070). Satisfaction scores at 3 months were not different between the groups, with the corresponding means of 8.9 [standard deviation (SD) 1.3] and 9.0 (SD 1.0). CONCLUSIONS: Transumbilical incision had non-significant different pain compared to infraumbilical incision. Most patients in both groups were satisfied with the operation at 3 months. A further large RCT is required for comparing SSI between the two incisions.

Risk Factors for Esophageal Stricture in Grade 2b and 3a Corrosive Esophageal Injuries.

BACKGROUND AND PURPOSE: Publications document the risk of developing esophageal stricture as a sequential complication of esophageal injury grades 2b and 3a. Although there are studies describing the risk factors of post-corrosive stricture, there is limited literature on these factors. The aim of this study was to evaluate the different factors with post-corrosive esophageal stricture and non-stricture groups in endoscopic grades 2b and 3a of corrosive esophageal injuries. METHODS: Data were retrospectively analyzed in the patients with esophageal injury grades 2b and 3a between January 2011 and December 2017. RESULTS: One hundred ninety-six corrosive ingestion patients were admitted with 32 patients (15.8%) in grade 2b and 12 patients (6.1%) in grade 3a and stricture was developed in 19 patients (61.3%) with grade 2b and in 10 patients (83.3%) with grade 3a. The patients' height of the non-stricture group was greater than that of stricture groups (2b stricture group, 1.58 ± 0.08 m; 2b non-stricture group, 1.66 ± 0.07 m; p < 0.004; 3a stricture group, 1.52 ± 0.09 m; 3a non-stricture group, 1.71 ± 0.02 m; p < 0.001). Omeprazole was more commonly used in the non-stricture than stricture group (26.3% in the 2b stricture group, 69.2% in the 2b non-stricture group, p = 0.017; 50% in the 3a stricture group, 100% in the 3a non-stricture group, 1.71 ± 0.02 m, p = 0.015). CONCLUSIONS: The height of patients may help to predict the risks and the prescription of omeprazole may help to minimize the risks of 2b and 3a post-corrosive esophageal stricture.

Risk Assessment of Abdominal Wall Thickness Measured on Pre-Operative Computerized Tomography for Incisional Surgical Site Infection after Abdominal Surgery.

BACKGROUND: The surgical site infection (SSI) is a common complication of abdominal operation. It relates to increased hospital stay, increased healthcare cost, and decreased patient's quality of life. Obesity, usually defined by BMI, is known as one of the risks of SSI. However, the thickness of subcutaneous layers of abdominal wall might be an important local factor affecting the rate of SSI after the abdominal operations. OBJECTIVE: The objective of this study is to assess the importance of the abdominal wall thickness on incisional SSI rate. MATERIAL AND METHOD: The subjects of the present study were patients who had undergone major abdominal operations at Thammasat University Hospital between June 2013 and May 2014, and had been investigated with CT scans before their operations. The demographic data and clinical information of these patients were recorded. The thickness ofsubcutaneous fatty tissue from skin down to the most superficial layer of abdominal wall muscle at the surgical site was measured on CT images. The wound infectious complication was reviewed and categorized as superficial and deep incisional SSIfollowing the definition from Centersfor Disease Control and Prevention (CDC) guidelines. The significance ofeach potentialfactors on SSI rates was determined separately with student t-test for quantitative data and χ2-test for categorical data. Then all factors, which had p < 0.10, were included into the multivariate logistic regression analysis and were analyzed with significance at p < 0.05. RESULTS: One hundred and thirty-nine patients were included in this study. They all underwent major abdominal surgery and had had pre-operative CTscans. Post-operative SSI was 25.2% (35/139), superficial and deep types in 27 and 8 patients, respectively. The comparison of abdominal wall thickness between patients with and without infection was significantly different (20.0 ± 8.4 mm and 16.0 ± 7.2 mm, respectively). When the thickness at 20 mm was used as the cut-off value, 43 of 139 patients had abdominal wall thickness ≥ 20 mm. The incidence of SSI of the thickness ±20 mm group was 37.2% (16/43) and of the less thickness group was 19.8% (19/96), with p < 0.05. The univariate analysis revealed that abdominal wall thickness ≥ 20 mm, body weight ≥ 60 kg, and wound classification were the important factors related to SSI after the abdominal operation. However, only abdominal wall thickness and wound classification were still significant by multivariate analysis. CONCLUSION: The findings of this study confirmed the significance of the subcutaneous thickness of abdominal wall at the surgical site on the incidence of incisional SSI. The thickness ≥ 20 mm had an effect on increasing post operative SSI rate especially in contaminated operations. These findings could be helpful in making healthcare providers fully aware and thus exercise special attention in wound care or even develop new modalities to prevent SSI in patients with the aforementioned risks.

Acute intestinal obstruction due to Kalimate, a potassium-lowering agent: a case report and literature review.

Sodium polystyrene sulfonate (Kayexalate) and calcium polystyrene sulfonate (CPS, Kalimate) are commonly used to reduce serum potassium. There were some published evidences of severe gastrointestinal complications from the administration of these agents such as colonic necrosis with or without perforation and acute obstruction. The authors reported a 52-year-old male patient being critically ill from severe soft tissue infection of the right leg and sepsis. Hyperkalemia had occurred due to renal insufficiency and required several doses of Kalimate to reduce the serum potassium level. Subsequently, the patient developed complete intestinal obstruction and an exploratory laparotomy was performed. The intra-operative findings were distended stomach and the small bowel contained a large amount of intraluminal affected Kalimate that was removed via gastrotomy and enterotomy. These findings suggested that the inspissated Kalimate could lead to significant obstruction of the gastrointestinal tract in some groups of patient.