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.

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.

Establishment of Highly Transplantable Cholangiocarcinoma Cell Lines from a Patient-Derived Xenograft Mouse Model.

Cholangiocarcinoma (CCA) is a deadly malignant tumor of the liver. It is a significant health problem in Thailand. The critical obstacles of CCA diagnosis and treatment are the high heterogeneity of disease and considerable resistance to treatment. Recent multi-omics studies revealed the promising targets for CCA treatment; however, limited models for drug discovery are available. This study aimed to develop a patient-derived xenograft (PDX) model as well as PDX-derived cell lines of CCA for future drug screening. From a total of 16 CCA frozen tissues, 75% (eight intrahepatic and four extrahepatic subtypes) were successfully grown and subpassaged in Balb/c Rag-2-/-/Jak3-/- mice. A shorter duration of PDX growth was observed during F0 to F2 transplantation; concomitantly, increased Oct-3/4 and Sox2 were evidenced in 50% and 33%, respectively, of serial PDXs. Only four cell lines were established. The cell lines exhibited either bile duct (KKK-D049 and KKK-D068) or combined hepatobiliary origin (KKK-D131 and KKK-D138). These cell lines acquired high transplantation efficiency in both subcutaneous (100%) and intrasplenic (88%) transplantation models. The subcutaneously transplanted xenograft retained the histological architecture as in the patient tissues. Our models of CCA PDX and PDX-derived cell lines would be a useful platform for CCA precision medicine.

Palliative surgical bypass versus percutaneous transhepatic biliary drainage on unresectable hilar cholangiocarcinoma.

OBJECTIVE: To compare the survival probability of unresectable hilar cholangiocarcinoma patients who have been managed by palliative surgical bypass versus percutaneous transhepatic biliary drainage (PTBD). MATERIAL AND METHOD: A historical (retrospective) cohort study was performed by retrospective and prospective data collection. From January 1, 2000 to December 31, 2002, all unresectable hilar cholangiocarcinoma patients who received only one type of palliative surgical bypass or PTBD in Srinagarind Hospital, Khon Kaen University were included in the present study. The patients were followed until December 31, 2004. Survival analysis was completed for all of the patients. STATISTIC ANALYSIS: Survival analysis was analyzed with the Kaplan-Meier method, Cox regression analysis, and Log-rank test. A p-value of less than 0.05 was considered significant. RESULTS: During the study period, 83 patients were included. Palliative surgical bypass was performed in 42 patients and PTBD was performed in 41 patients. Demographic data, peri-operative complication rate, and late complication rate were comparable. The median survival time of the palliative surgical bypass group was 160 days,(95% CI: 85.33, 234.67) and 82 days (95% CI: 29.76, 134.24)for PTBD group. Comparing survival experience by Log-rank test gave statistical significant diference (p = 0.0276). Hazard ratio was 0.599 (p = 0.03) CONCLUSION: Survival rate of the palliative surgical bypass group was higher than the PTBD group. The survival rate of both groups was comparable to previous reports.

Outcome of curative resection for perihilar cholangiocarcinoma in Northeast Thailand.

AIM: To examine survival outcomes of perihilar cholangiocarcinoma (PCCA) resection including mortality, morbidity and prognostic factors. METHODS: Multivariate analyses were carried out based on the survival data of all patients with histologically confirmed PCCA who underwent curative resection at Srinagarind Hospital from January 2006 to December 2011. RESULTS: There were 29 (19%) cases of intrahepatic CCA that involved hilar and 124 (81%) with hilar bile-duct cancer. R0 resection was carried out on 66 (43.1%) patients of whom 50 (32.7%) also had lymph node metastasis. The other patients underwent R1 resection. The overall 5-year survival rate was 20.6% (95%CI: 13.8-28.4) and median survival time was 19.9 mo. Postoperative mortality was 2%, and 30% of patients had complications. Patients without lymph node metastasis were 60% less likely to die than those with metastasis. Achieving R0 led to a 58% reduction in the chance of mortality as compared to R1. CONCLUSION: To achieve a better survival outcome, focus should center on performing radical surgery and detection of patients with early stage cancer.

Clinical value of biliary alkaline phosphatase in non-jaundiced cholangiocarcinoma.

PURPOSE: Measurement of the activities of alkaline phosphatase isoenzyme has been used for the identification and monitoring of diseases associated with the isoenzyme. Biliary alkaline phosphatase (BALP), an isoform of liver-ALP, has been found in the serum of patients with biliary obstruction and metastatic liver cancer. This study compared the BALP isoform in the serum of patients with cholangiocarcinoma (CCA) with that of non-jaundiced benign hepatobiliary disease, other cancers, and healthy persons. METHODS: ALP isoforms were separated using cellulose acetate electrophoresis and the activity was demonstrated using indolyl blue reagent. RESULTS: The BALP isoform was demonstrated in 65% of CCA patients independently of jaundice condition or histological grading of the tumor. The level of serum BALP in non-jaundiced CCA was significantly lower than that of jaundiced CCA, and not correlated with serum bilirubin. No BALP was detected in healthy persons. In the patients with high serum ALP (> 147U/l), BALP can differentiate non-jaundiced CCA patients from other non-jaundiced carcinoma patients with 85% sensitivity, 79% specificity, and positive and negative predictive values of 81% and 83%, respectively. CONCLUSION: The demonstration of serum BALP, in particular in non-jaundiced patients with high serum ALP, may indicate the presence of tumor in the bile duct.

Methionine aminopeptidase 2 over-expressed in cholangiocarcinoma: potential for drug target.

Methionine aminopeptidases (MetAP) are proteases which remove the N-terminal methionine from newly synthesized proteins. Associations of MetAP2 with tumor progression of different cancers have been repeatedly reported. We aim to determine if MetAP2 is expressed in cholangiocarcinomas (CCA) and investigate to see if it would be a useful therapeutic target. We evaluated MetAP2 expression by immunohistochemistry in 82 patients of intrahepatic CCA. MetAP2 was expressed in bile ducts to various degrees. It was occasionally expressed with weak staining in normal bile duct epithelium but was strikingly over-expressed in dysplastic bile duct epithelia, primary and metastatic CCA tissues (p < 0.001). The increased expression of MetAP2 in proliferating bile duct was evident. All metastatic tumors had stronger expression of MetAP2 than the corresponding primary tumors. Fumagillin, a MetAP2 specific inhibitor, significantly inhibited cell proliferation in dose dependent manner and the degree of growth inhibition was dependent on the amount of cellular enzyme. The present study highlights the involvement of MetAP2 in an early event of carcinogenesis of CCA. The findings represent the first description of increased MetAP2 expression in CCA. The inhibition of enzyme activity using MetAP2 inhibitors may be a potential strategy for long-term control of tumor development and progression in CCA patients.