Outcome of endoscopic small-bore naso-jejunal tube stenting in early postoperative jejunal limb obstruction after gastrectomy.

BACKGROUND: Early postoperative jejunal limb obstruction is a rare complication following gastric surgery with jejunal reconstruction. The condition is mainly attributed to kinking of the jejunal limbs, gastrojejunal or jejunojejunal anastomosis. There has been currently limited information regarding the safety and efficacy of endoscopic treatment in patients with early postoperative jejunal obstruction. We aimed to investigate outcome of endoscopic small-bore naso-jejunal (N-J) tube stenting across the obstructed segment in patients with uncomplicated early postoperative partial jejunal limb obstruction. METHODS: All patients diagnosed of jejunal limb obstruction within 8 weeks after gastric-related surgery were reviewed. Patients with malignant obstruction, complete closed loop obstruction, sepsis, instability, intestinal strangulation, or perforation were excluded. All patients underwent endoscopic dekinking and stenting for 2 weeks with an N-J tube using 16-French single lumen plastic nasogastric tube across the obstruction segment after failed conservative therapy. Successful N-J tube placement across the obstruction point was confirmed by contrast study. Complications, technical, and clinical success were evaluated. RESULTS: Twenty-one patients met the criteria. The primary operations were 7 partial gastrectomies with Billroth-II reconstruction, 7 total or partial gastrectomies with Roux-en-Y reconstruction and 4 Whipple's operations, 2 bypass procedures, and 1 proximal gastrectomy. Most common site of obstruction was jejunojejunal anastomosis and gastrojejunal anastomosis following Roux-en-Y and Billroth-II reconstruction, respectively. Endoscopic N-J tube placement was technically successful in 20 out of 21 patients (95%). One patient had aspirated pneumonia. There was no procedure-related mortality. After N-J tube removal, clinical success was demonstrated in 19 out of 20 patients (95%) at the median duration of 6 months. One patient underwent reoperation due to repeated tube dislodgement. CONCLUSIONS: Endoscopic stenting with a 16-F naso-jejunal tube across the angulated segment is safe and effective for treatment of patients with uncomplicated early postoperative partial jejunal limb obstruction following gastric surgery with jejunal reconstruction.

Combination of EUS-FNA and elastography (strain ratio) to exclude malignant solid pancreatic lesions: A prospective single-blinded study.

BACKGROUND: Negative results of EUS-FNA for solid pancreatic lesions (SPL) can be false ones. Combination with strain ratio (SR) may ensure a correct benign diagnosis of SPL. AIMS: We prospectively evaluated the sensitivity rate of EUS-FNA and EUS elastography using the strain ratio method for diagnosing SPL. METHODS: Thirty-eight patients with SPL identified by CT or MRI between January 2013 and November 2013 were included in our prospective study. EUS diagnoses were made using SR by an endosonographer who was blinded to all clinical information. In SPL with adequate cellularity, the results of EUS-FNA were combined with strain ratio to diagnose SPL and the diagnostic value was calculated. RESULTS: Benign SPL were diagnosed in nine patients with surgical or guided-biopsy pathology (n = 3) and benign cells from FNA with stable disease during the 12-month follow-up time (n = 6). Using the best cut-off strain ratio level at 3.17, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy rate of EUS elastography were 86.2%, 66.7%, 89.3%, 60%, and 81.6%, respectively. For the 28 patients who underwent EUS-FNA with results of adequate cellularity; EUS-FNA alone versus combination of results of cytology and SR provided sensitivity, specificity, PPV, NPV, and accuracy rate at 90% versus 95.2, 100% versus 71.4%, 100% versus 90.9%, 80% versus 83.3, and 92.9% versus 89.3%, respectively. CONCLUSIONS: In this prospective single-blinded study, the negative results of both EUS-FNA and SR were more reliable to exclude malignant SPL. The sensitivity of EUS elastography by SR was not superior to EUS-FNA. © 2015 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.

Thoracoscopic approach for esophageal resection in chronic severe corrosive esophageal stricture: report of 2 cases.

OBJECTIVE: The authors reported the feasibility and safety of thoracoscopic approach for resection of the esophagus in two patients with diffuse corrosive esophageal stricture. BACKGROUND: The unrelenting corrosive strictures of esophagus merit esophageal substitution. Because of the risk of complications in the retained esophagus, such as malignancy, mucocele, gastroesophageal reflux, and bleeding, esophageal resection is deemed necessary. Transthoracic approach for esophageal resection is considered safe but requiring thoracotomy. Transhiatal resection of a scared esophagus could be associated with serious complications. Less was known regarding the safety and feasibility of thoracoscopic resection of the esophagus in corrosive stricture of the esophagus. MATERIAL AND METHOD: Thoracoscopic approach was used for mobilization of the scarred esophagus in two female patients. Laparotomy with colonic mobilization was performed in the second phase of the operation. Pharyngocolonic and esophagocolonic anastomosis were done via left neck incision in each patient. Intra-operative and post-operative complications were observed. Swallowing ability was assessed in the early postoperative period. RESULTS: Thoracoscopic esophageal mobilization was successfully performed without complications. Any adhesions around the esophagus could be clearly seen and divided using harmonic scalpel under direct vision. Operative duration of the thoracoscopic part was 104 and 120 minutes and total blood loss was 320 and 350 ml respectively. Postoperative period was uneventful. The patient could have regular diet on day 8 and 9 after surgery. CONCLUSION: Thoracoscopic approach for esophageal resection could be safely performed for the extirpation of diffuse esophageal stricture. Postoperative complication is being assessed in the authors' prospective trial.

Tele-control of an endoscopic surgical robot system between Japan and Thailand for tele-NOTES.

We describe our experience of the development of a endoscopic surgical robot system that can penetrate into the body through the esophagus and perform surgeries in the upper gastric tubes and several organs in the abdominal cavity. In this paper, we describe the results of an experiment using this robot. We describe the configuration of the control system using a gigabit ethernet system named JGN2 for the endoscopic surgical robot. We also describe the results of the first telesurgery experiment using the NOTES (natural orifice transluminal endoscopic surgery) procedure (tele-NOTES), performed at a distance of about 3,750 km.

Cost-Effectiveness Evaluation of Bariatric Surgery for Morbidly Obese with Diabetes Patients in Thailand.

Background: Bariatric surgery is a choice for treatment in morbidly obese patients with type 2 diabetes mellitus (DM type 2) who have inadequate diabetes control with only medical treatment. However, bariatric surgery requires highly sophisticated equipment, and thus the cost of surgery seems to be very high following the procedure compared with the cost of conventional diabetes care. This raises the question of whether bariatric surgery is cost-effective for morbidly obese people with diabetes in Thailand. Objective: To perform a cost-effectiveness evaluation of bariatric surgery compared with ordinary treatment for diabetes control in morbidly obese DM type 2 patients in Thailand. Methods: Cost-effectiveness study was conducted, using a combination of decision tree and Markov model in analysis. Treatment outcomes and healthcare costs were incurred by data from literature review and retrospective cohort in King Chulalongkorn Memorial Hospital from September 2009 to March 2016 for the conventional and bariatric surgery group, respectively. One-way sensitivity was used for analysis of the robustness of the model. Cost-effectiveness was assessed by calculating incremental cost-effectiveness ratios (ICERs). Monetary benefits at a threshold of 150,000 to 200,000 Thai baht (THB) per quality-adjusted life-year (QALY) based on the Thailand gross domestic products (GDP) value was regarded as cost-effectiveness of bariatric surgery. Results: Bariatric surgery significantly improves the clinical outcome including long-term diabetes remission rate, hemoglobin A1C, and body mass index (BMI). The incremental cost per QALY of bariatric surgery compared with the medication control is 26,907.76 THB/QALY which can consider bariatric surgery as a cost-effective option. Conclusions: Use of bariatric surgery in morbidly obese with DM type 2 patients is a cost-effective strategy in Thailand's context.

Walled-off Peripancreatic Fluid Collections in Asian Population: Paradigm Shift from Surgical and Percutaneous to Endoscopic Drainage.

BACKGROUND AND OBJECTIVES: Drainage of symptomatic walled-off peripancreatic fluid collections (WPFCs) can be achieved by endoscopic, percutaneous, and surgical techniques. The aim of this study was to determine the current trends in management of WPFCs and the outcome of such modalities in Asian population. METHODS: In this retrospective analysis, all patients diagnosed with pancreatitis from 2013 to 2016 in King Chulalongkorn Memorial Hospital, Bangkok, Thailand, were analyzed. Relevant clinical data of all patients with peripancreatic fluid collections (PFCs) was reviewed. Clinical success was defined as improvement in symptoms after drainage. RESULTS: Of the total 636 patients with pancreatitis, 72 (11.3%) had WPFCs, of which 55 (8.6%) and 17 (2.7%) had pancreatic pseudocyst (PP) and walled-off necrosis (WON), respectively. The commonest etiologies of WPFCs were alcohol (38.9%) and biliary stone (29.2%). Post-procedure and pancreatic tumor related pancreatitis was found in 8.3% and 6.9% patients, respectively. PP was more common in chronic (27.8%) than acute (5.5%) pancreatitis. Of the 72 patients with WPFCs, 31 (43.1%) had local complications. Supportive, endoscopic, percutaneous, and surgical drainage were employed in 58.3%, 27.8%, 8.3%, and 5.6% with success rates being 100%, 100%, 50%, and 100%, respectively. Complications that developed after percutaneous drainage included bleeding at procedure site (n = 1), infection of PFC (n = 1), and pancreatic duct leakage (n = 1). CONCLUSION: Over the past few years, endoscopic drainage has become the most common route of drainage of WPFCs followed by percutaneous and surgical routes. The success rate of endoscopic route is better than percutaneous and comparable to surgical modality.

A case of coexistence of TSH/GH-secreting pituitary tumor and papillary thyroid carcinoma: Challenges in pathogenesis and management.

Co-existence of thyrotropin/growth hormone-secreting pituitary adenoma with differentiated thyroid carcinoma is exceedingly rare, with less than 15 cases having been reported. Its clinical presentation and treatment strategy are challenging. We report a case of pituitary macroadenoma, with clinical syndromes of acromegaly and hyperthyroidism, and a thyroid nodule, with cytologically confirmed to be a papillary thyroid carcinoma. Clinical implications, focusing on the strategy for proper management, and possible pathogenesis were discussed.

Management and outcome of severe acute pancreatitis.

BACKGROUND: The treatment of severe acute pancreatitis (SAP) varies among several institutes. It has been evolving from routine surgical management to conservative management in the early stages. The surgical management has a role in the later stages of the disease. OBJECTIVE: The purpose of the present study was to review the management and outcome of the patients with SAP at King Chulalongkorn Memorial Hospital, Bangkok, Thailand. MATERIAL AND METHOD: Two hundred and ten patients with a diagnosis of acute pancreatitis at King Chulalongkorn Memorial Hospital, Bangkok, Thailand from December 2001 to April 2005 were studied by retrospective chart review. RESULTS: Forty patients were diagnosed with SAP, 27 men and 13 women. SAP was most commonly caused by alcohol abuse (47.5%) and biliary tract disease (37.5%). Eighteen patients (45%) had pancreatic necrosis. Among them, seven patients (38.9%) had infected necrosis, and the rest had sterile necrosis. All patients with infected pancreatic necrosis underwent open pancreatic necrosectomy, and three of 7 died. Four of 11 patients with sterile necrosis died. The overall mortality was 25%. CONCLUSION: Patients with SAP have high morbidity and mortality rates. The patients with infected pancreatic necrosis may require surgical management, whereas those with sterile necrosis or SAP without local complications can be managed with conservative treatment and/or intervention. Post-operative complications might occur, thus require long term follow-up.

Endoscopic ultrasound-guided needle-based confocal laser endomicroscopy for diagnosis of solid pancreatic lesions (ENES): a pilot study.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasound-guided needle-based confocal laser endomicroscopy (EUS-nCLE) has been shown to aid in the diagnosis of cystic pancreatic lesions. This is a pilot project to study its findings in patients with solid pancreatic lesions (SPLs) with a prospective single-blinded study design. METHODS: Patients with SPLs undergoing trans-gastric EUS fine needle aspiration (EUS-FNA) from July 2013 to March 2014 were prospectively enrolled. The nCLE diagnoses were compared with the final diagnoses. Researchers learned about the EUS-nCLE findings from previously published studies and applied it to diagnose SPLs. In the meantime, the findings were recorded. RESULTS: In total, 22 patients were recruited (mean age 62.7 years, SD 13.8 years; 14 men and eight women). The mean maximal tumor diameter was 36.0 mm (SD 10.9 mm). EUS-nCLE yielded satisfactory images in all patients during the first EUS procedure and diagnosed benign and malignant SPLs in 3 and 19 patients, respectively. Final diagnoses of malignant SPLs were made in 19 patients. Benign SPLs were eventually diagnosed in three patients, with confirmed the cytology and disease stability during the 12-month follow-up period. At the end of the project, based on the results of this current study, EUS-nCLE findings for malignant SPLs were dark clumping with or without dilated vessels (> 40 µm). There were two criteria for diagnosing benign lesions which were white fibrous bands and normal acini cells. The accuracy rate of EUS-nCLE was 90.9 % (20/22). One falsely diagnosed malignant SPL was an inflammatory mass from a recent acute pancreatitis. Another one with a pancreatic neuroendocrine tumor presenting with a symptomatic pseudocyst was incorrectly diagnosed as an inflammatory mass. This was likely from sampling error of the EUS-nCLE probe in an inflammatory area. Only one patient had post EUS-FNA bleeding but did not require a blood transfusion. The inter-observer agreement among three blinded endoscopists was almost perfect (Kappa 0.82). CONCLUSION: EUS-nCLE is a promising technique for the diagnosis of SPLs with good inter-observer agreement. Study registration : TCTR20140402001.

Can a single dose corticosteroid reduce the incidence of post-ERCP pancreatitis? A randomized, prospective control study.

BACKGROUND: Acute pancreatitis is one of the complications after Endoscopic retrograde cholangio pancreatography (ERCP) and it could be fatal. Several drugs were used to prevent or decrease this complication. Corticosteroid is one of the medications which may have such potential. It is affordable and available everywhere. OBJECTIVES: To compare the incidence of post-ERCP pancreatitis in patients receiving single dose corticosteroid prior to the procedure with that of the control group . RESEARCH DESIGN: A prospective randomized controlled double-blinded study. MATERIAL AND METHOD: A total of 120 patients were randomized to receive either intravenous hydrocortisone 100 mg. or normal saline 1 hour prior to the procedure. The serum amylase levels were recorded 4 and 24 hours after the procedure. Abdominal pain and back pain were also recorded. Patients were diagnosed as having post-ERCP pancreatitis if ones had new or worsened epigastric pain with or without radiation to the back combined with elevation of serum amylase more than 2.5 times the upper limit. RESULTS: The overall incidence of pancreatitis was 6.67% with 1.64% in the study group compared with 11.86% in the control group (p = 0.031). The groups were similar with regard to age, gender, type of procedure performed (diagnostic or therapeutic), difficulty of cannulation, concentration of contrast media and pre operative amylase level. CONCLUSION: The results of the present trial indicate that hydrocortisone could reduce the risk of post-ERCP pancreatitis.

Minimally invasive surgery training in soft cadaver (MIST-SC).

OBJECTIVES: The purpose of this study was to evaluate the surgical anatomy, tissue plane, organ consistency of soft cadaver and the possibility of minimally invasive surgery training in soft cadaver. SETTING: Surgical Training Center. Department of Anatomy and Department of Surgery Faculty of Medicine, Chulalongkorn University. DESIGN: Prospective descriptive study. MATERIAL AND METHOD: 2 soft cadavers were scheduled for fully laparoscopic surgery in upper gastrointestinal, colorectal, hepatopancreatobiliary and solid organs surgery. All the procedures were performed by the experienced surgical staffs and assisted by surgical staffs and/or surgical residents. The surgical anatomy, tissue plane, organ consistency and the satisfactory in performing the procedures were recorded for evaluation. RESULTS: The surgical anatomy, the tissue consistency the anatomical plane were very well preserved with mean score of 4.72 +/- 0.45. All the surgeons were satisfied with the findings, the mean score was 4.97 +/- 0.18. All the plan procedures were completely performed with great satisfactory results. CONCLUSION: The Minimally Invasive Surgery Training in Soft Cadaver (MIST-SC) was feasible with great satisfactory. This successful integration of basic and advanced laparoscopic procedures into the soft cadaver setting would be the next step in evolution of MIS training.

Novel, high-definition 3-D endoscopy system with real-time compression communication system to aid diagnoses and treatment between hospitals in Thailand.

INTRODUCTION: Traditionally, laparoscopy has been based on 2-D imaging, which represents a considerable challenge. As a result, 3-D visualization technology has been proposed as a way to better facilitate laparoscopy. We compared the latest 3-D systems with high-end 2-D monitors to validate the usefulness of new systems for endoscopic diagnoses and treatment in Thailand. METHODS: We compared the abilities of our high-definition 3-D endoscopy system with real-time compression communication system with a conventional high-definition (2-D) endoscopy system by asking health-care staff to complete tasks. Participants answered questionnaires and whether procedures were easier using our system or the 2-D endoscopy system. RESULTS: Participants were significantly faster at suture insertion with our system (34.44 ± 15.91 s) than with the 2-D system (52.56 ± 37.51 s) (P < 0.01). Most surgeons thought that the 3-D system was good in terms of contrast, brightness, perception of the anteroposterior position of the needle, needle grasping, inserting the needle as planned, and needle adjustment during laparoscopic surgery. Several surgeons highlighted the usefulness of exposing and clipping the bile duct and gallbladder artery, as well as dissection from the liver bed during laparoscopic surgery. In an image-transfer experiment with RePure-L®, participants at Rajavithi Hospital could obtain reconstructed 3-D images that were non-inferior to conventional images from Chulalongkorn University Hospital (10 km away). CONCLUSION: These data suggest that our newly developed system could be of considerable benefit to the health-care system in Thailand. Transmission of moving endoscopic images from a center of excellence to a rural hospital could help in the diagnosis and treatment of various diseases.

Endoscopic transaxillary thyroid lobectomy: flexible vs rigid laparoscope.

BACKGROUND: The use of the endoscopic procedure for thyroid lobectomy in benign solitary thyroid nodule has been developed rapidly and increasingly refined in recent years. The early results are technically feasible, safe and mainly provide promising cosmetic results, some show a quicker recovery. The authors wanted to know if this procedure can be performed via rigid laparoscope which is simple, less expensive and widely available in many surgical centers. OBJECTIVES: The aims of this study were to evaluate operative time, blood loss, complication of flexible compared to 30 degrees rigid laparoscope in endoscopic transaxillary thyroid lobectomy for solitary thyroid nodule. METHOD: From February 2004 to June 2004, 13 cases of benign solitary thyroid nodule underwent the endoscopic transaxillary thyroid lobectomy. Flexible laparoscope techniques were performed in 9 cases and 30 degrees rigid laparoscope in the other 4 cases. Port site, number of ports and dissected method were the same in both procedures by the same surgeon. Operative time, blood loss, post-operative results were measured for evaluation. RESULTS: From 13 cases, 9 in the flexible laparoscope group and 4 in the rigid laparoscope group. All but one in the flexible group with torn internal jugular vein were successful. The mean operation time was 165.42 +/- 35.06 minutes, which was 175.63 +/- 35.70 minutes for flexible laparoscope group and 145 +/- 26.45 minutes for rigid laparoscope group. There was no recurrent laryngeal nerve injury and no subcutaneous emphysema. The patients were satisfied with the cosmetic results. CONCLUSION: On the basis of early experience with these 13 patients, the authors believe that endoscopic thyroidectomy using the rigid laparoscope has proved to be no different in the intra-operative results, so the authors do aimed to show that with the rigid laparoscope which is available in many surgical centers, less expensive and easy in maintenance will provide another surgical option for treatment of thyroid nodule, with maximized cosmetic effect.