Surgical aspects of choledochal cyst in children and adults: an experience of 106 cases.

PURPOSE: To describe clinical features of choledochal cyst (CC) patients in terms of demographic data, clinical presentation, investigations, treatment, and outcomes among children and adults. METHODS: The medical records of patients undergoing choledochal cyst (CC) surgery from 2002 to 2021 at a university hospital were retrospectively reviewed. The patients were divided into two groups: children (< 15 years) and adults (≥ 15 years). Descriptive statistics were used. RESULTS: There were 106 cases of CC (Female/male = 88/18, children/adult = 53/53). Abdominal pain was the predominant presenting symptom, followed by jaundice in both groups. Adults were significantly more prone to present with abdominal pain compared to children (86.8% vs. 52.8%; p < 0.001), while children were more likely to experience acholic stool than adults (22.6% vs. 3.8%; p = 0.004). Ultrasound was the preferred investigation screening modality (75.5%). Most patients were presented with type I CC (71.7%). Laparoscopic-assisted approach was performed in 8.5%. CC excision with roux-en-y hepatico-jejunostomy was the main procedure (88.7%). Adults had a higher incidence of post-op complications, including stones, anastomosis stricture, abdominal collection, and cholangitis. Adults were significantly more likely to require intervention after surgery, compared to children (26.4% vs. 5.7%; p = 0.04). CONCLUSIONS: Ultrasound was the most common screening tool for diagnosis. Postoperatively, adults with CC experience more serious post-op complications compared to children. This could be attributed to long-standing cystic inflammation. Therefore, prompt definitive surgery is recommended for CC patients.

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.

Outcome of dilatation and predictors of failed dilatation in patients with acid-induced corrosive esophageal strictures.

Outcome of endoscopic dilatation in acid-induced corrosive esophageal stricture is less known. This study aims to determine the outcome of dilatation and predictors of failed dilatation in patients with acid-induced corrosive esophageal stricture. Patients diagnosed of corrosive esophageal strictures were included. Endoscopic dilatation with graded Savary-Gilliard dilator was performed as the first line treatment. Outcome of dilatation was considered favorable when patients were able to swallow solid without intervention at least six months after successful dilatation. Failure of dilatation was defined as one of the following; complete luminal stenosis, inability to perform safe dilatation, perforation, and inability to maintain adequate luminal patency. Surgery or repeated dilatation was indicated in failed dilatations. There were 55 patients with corrosive esophageal strictures. Of 55 patients, 41 (75%) had failed dilatation (38 having esophageal replacement procedure, two continue repeated dilatation and one unfit for surgery). Of 323 sessions of dilatations, eight out of 55 patients (14.5%) had perforations. There was no dilatation-related mortality. Patients with concomitant pharyngeal stricture (p = 0.0001), long (≥ 10 cm) stricture length (p < 0.0001), number of dilatation >6 sessions per year (p = 0.01) and refractory stricture (inability to pass a larger than 11 mm dilator within three sessions) (p = 0.01) were more likely to have failed dilatation. Thirty-two of 38 patients with surgery had good swallow outcome with one operative mortality (2.6%). At the median follow-up of 61 months, overall favorable outcome was 84% after surgery and 25% for dilatation (p < 0.0001). Majority of patients with acid-induced corrosive esophageal stricture were refractory to dilatation. Esophageal dilatations were ultimately failed in three-fourth of the patients. Concomitant cricopharyngeal stricture, long stricture length, requiring frequent dilatation, and refractory to >11 mm dilatation were factors associated with failed dilatation.

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.

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.

Incidence of corona mortis; preperitoneal anatomy for laparoscopic hernia repair.

The present study 66 half pelvis of cadaver for vascular structure called corona mortis, vessel that connect between external iliac and internal iliac system. The vessel was found 77.27% and the incidence of aberrant is 13.6%. The average distance from symphysis pubis to the vessel is 5.28 cm and distance above superior pubic rami is 1.37 cm.

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.

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.