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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.

Residual, intra-abdominal COA 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.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).Releasing residual CO

Background: There is no study of circumferential EMR in patients with Barrett's esophagus containing early stage malignant lesions. This study investigated the effectiveness and safety of circumferential EMR by using a simple snare technique without cap. Method: Patients with Barrett's esophagus containing multifocal high-grade intraepithelial neoplasia or intramucosal cancer, and patients with endoscopically nonidentifiable early stage malignant mucosal changes incidentally detected in random biopsy specimens were included in the study. A 30 × 50-mm polypectomy snare made of monofilament 0.4-mm steel wire was used without any additional device or submucosal injection. Results: Twelve patients (10 men, 2 women; median age 63.5 years, range 43-88 years) underwent circumferential EMR; 5 had multifocal lesions, and 7 had no visible lesions. Segments of Barrett's epithelium were circumferential (median length 5 cm) and completely removed. The median number of EMR sessions was 2.5. The median number of snare resections per EMR session was 5. The medial total area of mucosa in resected specimens per session was 3.8 cm 2 . Two patients developed strictures that were successfully treated by bougienage. Minor bleeding occurred during 4 of 31 EMR sessions. During a median follow-up of 9 months, no recurrence of Barrett's esophagus or malignancy was observed. Conclusions: Circumferential EMR with a simple snare technique is feasible, safe, and effective for complete removal of Barrett's epithelium with early stage malignant changes. (Gastrointest Endosc 2003;57:854-9.)

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.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 analyzedIn 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.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.

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.

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.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.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.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.

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.

Early gastric cancer (EGC) defined as gastric cancer involving up to submucosal layer, regardless of lymph node metastasis, is increasingly found at Siriraj Hospital. Understanding the characteristic of EGC and result of surgical management for EGC can help to choose the optimal treatment. In the present study, the authors reported the first case series in Thailand.The authors analyzed 21 consecutive EGC patients treated with gastrectomy with lymph node dissection between September 2001 and December 2009 at Minimally Invasive Surgery Center, Division of General Surgery, Department of Surgery, Siriraj Hospital, Mahidol University, Thailand.Ratio of EGC to total cases of gastric cancer was increasing yearly, from 1.8% in 2006 to 8.1% in 2009 at Siriraj Hospital. The most common type of EGC was type IIc (66.7%) while type III was found in 19%, and type I in 14.3%. The tumor invaded mucosal layer in 42.9% and submucosal layer in 57.1% of the patients. For N staging, 76.2% of the patients were N0 while N1 was 19% and N2 was 4.8%. Overall, lymph node metastasis was found in 23.8%. For mucosal cancer (m), no lymph node metastasis was seen while for submucosal cancer (sm) five cases (41.7%) had lymph node metastasis, especially in one patient that the metastasis was in N2 group. Lymphatic invasion was seen in 14.3% of cases. All cases with lymphatic invasion were all submucosal cancer. Overall staging was stage 1a in 76.2%, stage 1b in 19%, and stage 2 in 4.8%. Morbidity was seen in 14.3% of the cases. No mortality was seen. The survival was excellent with no recurrence found during the follow-up period of the present study (mean 30.53 months).Surgery for EGC has good results with minimal complications and excellent 5-year survival. Less invasive treatment has become the option for EGC. Understanding the characteristic of EGC and careful selection to assign appropriate treatment is important to improve the result in the treatment of EGC.

Radical esophagectomy was reported to have prolonged survival in patients with esophageal cancer However, it is associated with high morbidity and mortality. Controversy still exists regarding value of radical esophagectomyThe authors analyzed the results, including complications and survival in 68 consecutive patients with esophageal cancer who were treated with transthoracic radical esophagectomy at the Department of Surgery, Siriraj hospital, Mahidol University between June 2002 and June 2008.There were 57 males and eight females with a mean age of 59.28 +/- 11.25 years. Regarding T staging, 81.5% of the patients were in T3 stage while 1.5% of the patients had Ti stage, 15.4% had T2 stage, and 1.5% had T4 stage. Lymph node metastasis (NI) was found in 63.1% of the patients and NO was in 36.9%. Most of the patients were in advanced stages with 53.8% in stage III, 44.6% in stage II, and 1.5% in stage I. The 5-year survival rate of the patients with node positive was significantly lower than the patients with node negative (p = 0.018). The survival was significantly better in stage Ilcompared to stage III (p = 0.012). Overall 5-year survival rate was 28. 5%. Most common complications were from pulmonary causes (22.1%), anastomotic leakage (8.8%), and wound infection (8.8%). Mortality rate was 4.41%.Radical esophagectomy was associated with relatively low mortality and acceptable survival. It should be considered in surgical treatment of patients with esophageal cancer

Extent of lymph node dissection still remains one of the most controversial issues regarding radical gastrectomy. Knowledge of the pattern and incidence of lymph node metastasis may help to define the optimal extent of lymph node dissection.The authors analyzed lymph node metastasis and survival rate in 130 consecutive gastric cancer patients who underwent radical gastrectomy with D2 dissection between June 2001 and October 2008 at the Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand.For N staging, 28.5% of the patients were N0 while N1 was 40% and N2 was 31.5%. 44% of the patients with lymph node positive had metastasis up to group 2 lymph nodes. The patients with node positive had 5 year survival of 39% while the patients with node negative had survival of 73% (p = 0.003). Tumor at the middle part of the stomach had the most widespread lymph node metastasis compared to other regions. Lymph node group 7, 8 and 9 had a high incidence of lymph node metastasis especially for distal cancer while lymph node group 10, 11, 12 had lower incidence of metastasis. No mortality was seen in the present study.N staging, number of metastatic node5 and angiolymphatic invasion were the lymph node related factors contributing to survival. For radical gastrectomy, D2 dissection is required for adequate clearance of metastatic lymph nodes, which can be done without mortality.

To evaluate the surgical outcome of preoperative long-course chemoradiation therapy (PCRT) in patients with ultra low rectal cancer.Medical records of patients with rectal adenocarcinoma located within the length of 5 cm from the anal verge, who underwent elective oncological resection between 2003 and 2006 at Siriraj Hospital, were reviewed. PCRT was performed in some patients based on tumor characteristics and surgeon's decision. Rate of sphincter preservation and other surgical outcomes were assessed.Ninety-three patients with an average age of 60 years were studied. Twenty-seven (29%) received PCRT. There was no difference in demographic data and location of the tumor between PCRT and non-PCRT group. Patients with PCRT had a smaller size of tumor (2.6 vs. 5.0 cm, p0.001) and better tumor staging (p0.001). Complete pathological response was found in four patients with PCRT (15%). However, there was no significant difference in SPP rate between PCRT and non-PCRT group (37% vs. 36%, p = 0.95). Other surgical outcomes between the two groups were also not different.PCRT did not increase rate of sphincter preservation in patients with low rectal cancer.

The advantage of a transverse incision over a midline incision for open right hemicolectomy remains controversial.To compare the short-term surgical outcomes of right hemicolectomy through midline incision (RHML) and right hemicolectomy through right transverse incision (RHTR) for right-sided colon cancer.This retrospective study included 74 patients with right-sided colon cancer who underwent elective right hemicolectomies through midline or right transverse incision between February 2004 and June 2006 at the Department of Surgery, Faculty of Medicine Siriraj Hospital. Operative details, postoperative requirement of narcotics, recovery of bowel function, and oncological parameters were analyzed.Fifty-four patients underwent RHML and 20 patients underwent RHTR. Both approaches achieved adequate oncological resection of the tumor. The RHTR group were characterized by shorter operative times (105 vs. 140 minutes; p = 0.001), less blood loss (70 vs. 125 ml,; p = 0.004), faster discontinuation of intravenous narcotics (1.2 vs. 1.8 days; p = 0.03), and shorter length of hospital stay (6.0 vs. 7.9 days,; p = 0.02). Postoperative complications and time to recovery of bowel function were not significantly different.The authors suggest that RHTR is a safe and effective operation for right-sided colon cancer; which results in a significant reduction in operative time, duration of intravenous narcotics administration, and hospital stay compared with RHML. However, there is no difference in postoperative recovery of bowel function and complication rate.

Management of posttraumatic diaphragmatic injury (DI) is still challenging. In suspected patients with stable hemodynamic, laparoscopy may aid in the diagnosis and treatment of DI.To analyze and determine the role of laparosocopy in diagnosis and treatment of suspected diaphragmatic injury patients at Trauma Centre, Faculty of Medicine Siriraj Hospital.A prospective descriptive study was conducted between 2001 and 2008 in Division of Trauma Surgery, Siriraj Hospital, Mahidol University, Thailand. Twenty-four suspected DI patients with stable hemodynamic were reviewed and analyzed Laparoscopy was performed in all patients.Of the patients, 95.8% were men with a mean age of 27.3 years (range, 14-54 yr). Twenty-three patients (95.8%) had a penetrating injury. Five patients (20.8%) presented with tachypnea and decreased breath sound Pneumohemothorax occurred in five patients (20.8%). Chest x-ray revealed diaphragmatic elevation in one patient (4.2%). Five cases (20.8%) were found DI. In one patient with right-sided DI, thoracoscopic repair was performed There were no procedure related complications. All patients were discharged 72 hours after the operation.Laparoscopy is an excellent diagnostic and therapeutic tool in hemodynamically stable patients. Left-sided DI can be successfully treated with laparoscopic repair However right-sided DI may be better with thoracoscopic repair.

AIM: To determine the efficacy of perioperative parecoxib injection on postoperative pain relief after laparoscopic cholecystectomy. METHODS: A prospective, double-blind, randomized, placebo-controlled study was conducted on 70 patients who underwent elective laparoscopic cholecystectomy under general anesthesia at Siriraj Hospital, Bangkok, from January 2006 to December 2007. Patients were randomized to receive either 20 mg parecoxib infusion 30 min before induction of anesthesia and at 12 h after the first dose (treatment group), or normal saline infusion, in the same schedule, as a placebo (control group). The degree of the postoperative pain was assessed every 3 h in the first 24 h after surgery, and then every 12 h the following day, using a visual analog scale. The consumption of analgesics was also recorded. RESULTS: There were 40 patients in the treatment group, and 30 patients in the control group. The pain scores at each time point, and analgesic consumption did not differ between the two groups. However, there were fewer patients in the treatment group than placebo group who required opioid infusion within the first 24 h (60% vs 37%, P = 0.053). CONCLUSION: Perioperative administration of parecoxib provided no significant effect on postoperative pain relief after laparoscopic cholecystectomy. However, preoperative infusion 20 mg parecoxib could significantly reduce the postoperative opioid consumption.

Foreign body (FB) in the upper gastrointestinal tract (UGIT) is a common clinical problem in endoscopic practice. At present, many physicians recommend endoscopy for both diagnosis and treatment. To date, few have report endoscopic findings and management of FB in UGIT.To report the authors' experience and outcome of the endoscopic management of foreign body ingestion at Siriraj Hospital.Medical records of patients with FB ingestion in the UGIT, who underwent endoscopic management between January 2004 and January 2008 at Siriraj Hospital, were reviewed.The analysis included 34 patients of which 58.82% were men. The mean age of the group was 18.26 years (range 10 months - 86 years). 58.82% of patients were younger than 5 years. Esophagogastroduodenoscopy (EGD) was performed in 100% of cases, under general anesthesia (GA) in 85.29%, and under transintravenous anesthesia (TIVA) in 14.71%. Endoscopic management was successful in all cases. The extractions were done with rat-tooth forceps, polypectomy snare, dormia basket, or tripods. There were no procedure related complications.The ingested FB varied widely according to the underlying medical condition and age. In a tertiary care center endoscopic removal of FB in UGIT could be safely performed with a very good result.

The timing of minimally invasive approach of choledocholithiasis, using endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC), is challenging. The aim of the present retrospective study was to assess the feasibility and safety of endoscopic stone removal for choledocholithiasis followed by same-day LC.Between October 2005 and February 2007, 27 patients diagnosed with choledocholithiasis were treated with this approach. Of these patients, nine (33%) had either pancreatitis or cholangitis. The mean age of the patients was 56 years (range, 29-78). ERCP was performed in the endoscopic unit, whereas LC was performed in the theater Success rate and clinical outcome were analyzed.Ninety-three percent clinical success was achieved. Two patients required conversion to opened cholecystectomy because of uncertain anatomy. There was no 30-day postoperative mortality. Two patients (7%) had postoperative complications (post-ERCP pancreatitis and superficial surgical site infection). The mean interval between the two procedures was 122 minutes (28-325). The mean operative time of ERCP was 25 minutes (15-30) and of LC was 83 minutes (30-140). The mean length of hospital stay was four days (range, 3-6).The management of choledocholithiasis using endoscopic stone removal, followed by same day laparoscopic cholecystectomy, is safe and has good clinical outcomes.

To determine the incidence of colonoscopic perforation (CP), and evaluate clinical findings, management and outcomes of patients with CP from the World Gastroenterology Organization (WGO) Endoscopy Training Center in Thailand.All colonoscopies and sigmoidoscopies performed between 1999 and 2007 in the Endoscopic unit, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok were reviewed. Incidence of CP, patients' characteristics, endoscopic information, intra-operative findings, management and outcomes were analyzed.A total of 17357 endoscopic procedures of the colon (13699 colonoscopies and 3658 flexible sigmoidoscopies) were performed in Siriraj hospital over a 9-year period. Fifteen patients (0.09%) had CP: 14 from colonoscopy and 1 from sigmoidoscopy. The most common site of perforation was in the sigmoid colon (80%), followed by the transverse colon (13%). Perforations were caused by direct trauma from either the shaft or the tip of the endoscope (n = 12, 80%) and endoscopic polypectomy (n = 3, 20%). All patients with CP underwent surgical management: primary repair (27%) and bowel resection (73%). The mortality rate was 13% and postoperative complication rate was 53%.CP is a rare but serious complication following colonoscopy and sigmoidoscopy, with high rates of morbidity and mortality. Incidence of CP was 0.09%. Surgery is still the mainstay of CP management.

The aims of this study were to evaluate the efficacy and safety of precut sphincterotomy in relation to the experience of a single endoscopist, and to establish the number of procedures required before achieving an effective and safe precut sphincterotomy.A total of 200 consecutive patients underwent precut sphincterotomy carried out by a single endoscopist (T.A.) between January 2003 and December 2005. All of the procedures were divided into four chronological groups of 50 (Group I, II, III, and IV). Medical records and patient data were retrospectively reviewed and included procedure indications, outcomes, and complications. All patients were admitted for observation after the procedure in case of complications.A total of 200 patients (23.3%) (mean age 58.5 years; 101 men) underwent precut sphincterotomy (161 with needle-knife technique, 32 with septotomy technique, and seven with Erlangen technique). There was no mortality. The success rates of prompt bile duct cannulation after precut sphincterotomy were 88%, 86%, 94%, and 82%, respectively ( P0.05). Immediate bleeding requiring a submucosal adrenaline injection was observed in combined group I - II (28%) and combined group III - IV (7%) ( P0.05). One patient (2%) from each of group I, III, and IV required further endoscopic treatment for rebleeding. Duodenal perforation (2%) was detected and conservatively treated in one patient from group II. Mild pancreatitis was found in one patient (2%) in group III.The success rates of bile duct cannulation by precut sphincterotomy were not associated with the experience of the endoscopist. The postprocedural complications significantly decreased after the first 100 procedures. An experience of at least 100 procedures is suggested to achieve a safe precut sphincterotomy.

Background/Aims: To evaluate the outcomes of sphincter-saving operation for rectal cancer without protective stoma and pelvic drain and to determine factors influencing anastomotic leakage. Methods: We investigated 170 patients undergoing elective sphincter-saving operation without protective stoma and pelvic drain during 2003–2006 in a single institution. Early postoperative outcomes were evaluated. 17 independent patient-, tumor-, and treatment-related variables were analyzed by a multivariate model to determine their association with anastomotic leakage. Results: The patients’ median age was 64 years. Median tumor height was 8 cm (range 3–15) from the anal verge. Overall 30-day mortality rate was 1.2%. Postoperative complications were diagnosed in 38 patients (22%) including 14 cases of anastomotic leakage (8.2%), of which 10 cases (71%) required surgical intervention. Tumor height within 5 cm from the anal verge was the only independent factor for leakage (OR 4.04; 95% CI 1.25–13.08). Conclusion: A sphincter-saving operation without a protective stoma and pelvic drain can be performed safely in the vast majority of rectal cancer patients. Tumor height within 5 cm from the anal verge is an independent risk factor for anastomotic leakage. Thus, the routine use of a protective stoma and pelvic drainage might be unnecessary.

To compare the results and complications of early pre-cutting technique with standard technique.From January 2003 to December 2004, a total of 416 consecutive therapeutic biliary ERCP procedures were performed by one endoscopist (T.A.). Data were retrospectively collected according to procedure indication and results. Of these, 293 procedures (70.4%) were done with standard technique (group A) and 123 procedures (29.6%) with early pre-cutting technique in case of difficult cannulation (group B). The results and complications of ERCP were compared.Success rate of first attempt cannulation was 98.0% in group A and 87.8% in group B. The overall incidence of post-ERCP pancreatitis, hemorrhage, perforation and cholangitis was 0%, 0.2%, 0.5% and 0.5%, respectively. Morbidity rate was not significantly different. No procedure-related mortality was occurred.For an experienced hand, the early pre-cutting technique for biliary cannulation is safe and effective as standard technique.

To determine the relationship between preoperative serum albumin and postoperative bowel function as well as surgical outcomes in right-sided colon cancer patients.This retrospective study in a university hospital included 84 patients who underwent elective right hemicolectomy for adenocarcinoma of the right-sided colon between January 2004 and December 2005. The patients had a preoperative serum albumin assessment. Serum albumin less than 3.5 g/dL was regarded as hypoalbuminemia. Postoperative outcomes were classified into mortality, morbidity (infectious and noninfectious complications), time to first bowel movement, time to resume normal diet, and hospital stay.Forty males (48%) and forty-four females (52%) with a mean age of 64 (range, 27-89) years were included. Forty-eight patients (57%) had hypoalbuminemia. No 30-day postoperative mortality occurred. All 14 postoperative complications occurred in hypoalbuminemic cases. Therefore, 29% of the hypoalbuminemics had complications whereas none occurred in nonhypoalbuminemics (p=0.001). In univariate analysis, hypoalbuminemia and postoperative complications were the risk factors for delayed postoperative recovery of bowel function and prolonged length of hospital stay. In multivariate analysis, hypoalbuminemia was the significant risk factor for postoperative complications (p0.001) and delayed time to first bowel movement (p=0.018) whereas postoperative complications were the significant risk factor for delayed time to resume normal diet (p0.001) and prolonged hospital stay (p0.001).Hypoalbuminemia is a potential predictor of delayed recovery of bowel function postoperatively and significantly associated with postoperative complications in right-sided colon cancer patients undergone right hemicolectomy.

Background Laparoscopically-assisted right hemicolectomy (LRH) is an acceptable alternative to open surgery for right-sided colon cancer which offers patients less pain and faster recovery. However, special equipment and substantial surgical experience are required. The aim of the study is to compare the short-term surgical outcomes of LRH and open right hemicolectomy through right transverse skin crease incision (ORHT) for right-sided colon cancer. Patients and methods This retrospective study included 33 patients with right-sided colon cancer who underwent elective right hemicolectomy by laparoscopic or open approaches through right transverse skin crease incision between March 2004 and September 2006 at the Department of Surgery, Faculty of Medicine Siriraj Hospital. Operative details, postoperative requirement of narcotics, recovery of bowel function, and oncological parameters were analyzed. Results Thirteen patients underwent LRH and 20 patients underwent ORHT. Both approaches achieved adequate oncological resection of the tumor. The laparoscopic group were characterized by shorter average incision lengths (7.7 vs 10.3 cm; p < 0.001), but longer average operating times (208 vs 105 min; p < 0.001). There was no significant difference in the time to first bowel movement, time to defecation, and time to resumption of normal diet between both groups (59 vs 64 hr; p = 0.64, 3.2 vs 3.7 d; p = 0.25 and 3.9 vs 4.3 d; p = 0.39). There was no statistically significant difference in the time to discontinuation of intravenous nacrotics and the length of hospital stay (1.0 vs 1.4 d; p = 0.25 and 6.2 vs 7.1 d; p = 0.3). Conclusion LRH and ORHT for right-sided colon cancer resulted in the same short-term surgical outcomes including postoperative bowel function, narcotics consumption and length of hospital stay. However, LRH required a significantly longer operating time.

Results of the surgical management of 17 choledochal cysts in adults at the Department of Surgery, Siriraj Hospital, Mahidol University, are presentedAll the patients who underwent diagnosis and were surgically managed during the period between October 1990 and January 1999 were analyzed retrospectively. Cysts were classified anatomically according to the descriptions of Todani et al. The authors assessed the clinical features, operative procedure and outcome of the patients.There were 15 females and 2 males, with ages ranging from 16-45 years. Only 2 patients (11.8%) had the clinical triad: jaundice, abdominal pain and mass. Clinical pancreatitis was presented in 3 patients (17.6%). There were 10 type 1 (58.8%), 6 type IVa (35.3%) and one type V (5.9%) according to Todanis classification. Cholangiocarcinoma was found in one patient (5.9%). Extrahepatic cyst excision with a Roux-en-Y hepatico-jejunostomy was performed on 16 patients with type I or IVa cysts (94.1%). There were no surgical deaths or complications. Ten survivors are well. The authors lost contact with 6 patients during follow-up (35.2%). The median follow up was 3.2 years. The patient with cholangiocarcinoma died 2 years after treatment.This experience recommends total extra-hepatic cyst excision with Roux-en-Y hepaticojejunostomy as the treatment of choice for adult choledochal cyst type I and IV to eliminate the risk of recurrent cholangitis and malignancy.

Pancreaticoduodenectomy (Whipple's operation) represents a considerable surgical challenge. The operative mortality rate after Whipple's operation is still less than 5%. Recent studies show pancreaticojejunostomy (PJ) anastomosis is the "Achilles heel" of the procedure. The authors present the results of Whipple's operation without mortality which were performed in the Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.From January 1991 to December 2003, thirty-seven consecutive patients who underwent Whipple's operation were enrolled in the present study. The ages ranged from 33 to 79 years (mean 57.13). There were 19 male and 18 female patients. Twenty-nine of them underwent a pylorus preserving pancreaticoduodenctomy (PPPD). Construction of the PJ anastomosis was mostly performed by a dunking technique, that is, the invagination of the pancreatic resected end into the jejunum.There was no postoperative mortality from anastomotic leakage. Surgical wound infections occurred in 7 patients, gastric atony in 2 patients, and PJ anastomosis leakage which created a fistula in 1 patient. All 37 patients were discharged in an improved condition following surgery. The median follow-up was 2 years (range: 4 month-11 years). Eighteen patients died from liver failure. Until now 19 patients are doing well.The authors demonstrated that the dunking technique used for PJ anastomosis in Whipple's operation provided a good result without any mortality rate.

Background: Biliary leakage is a problematic complication of hepatobiliary surgery. A novel alternative method is described that can obviate the need for reoperation for refractory biliary fistula. Methods: Nine patients with large biliary leaks unresponsive to endoscopic drainage underwent N-butyl-2-cyanoacrylate glue occlusion at ERCP. Results: In 7 patients, occlusion was successful with prompt control of the fistula in a single session, averting reoperation. In 1 patient there was a partial response and in another the treatment was unsuccessful. No procedure-related complication occurred over a median follow-up of 35 months (range: 1.6-160 months). Conclusion: N-butyl-2-cyanoacrylate glue occlusion is a safe and effective endoscopic method for control of refractory bile leaks that eliminates the need for surgical reintervention.

For Choledochal cyst type I, complete excision of cyst with Roux-en-Y hepaticojejunostomy anastomosis is the treatment of choice. It has been performed laparoscopically with the advancement of laparoscopic skill. Recently, a telemanipulative robotic surgical system was introduced, providing laparoscopic instruments with wrist-arm technology and 3-dimensional visualization of the operative field. We present a case of robot-assisted total excision of a choledochal cyst type I and biliary reconstruction in a 14-year-old girl. No intraoperative complications or technical problems were encountered. An intraabdominal collection occurred and was successfully treated with continuous percutaneous drainage. At one-year follow-up, she is doing well without evidence of recurrent cholangitis.

AIM: To characterize clinical features, surgery, outcome, and survival of malignant melanoma (MM) of the gastrointestinal (GI) tract in a surgical training center in Bangkok, Thailand. METHODS: A retrospective review was performed for all patients with MM of the GI tract treated at our institution between 1997 and 2007. RESULTS: Fourteen patients had GI involvement either in a metastatic form or as a primary melanoma. Thirteen patients with sufficient data were reviewed. The median age of the patients was 66 years (range: 32-87 years). Ten patients were female and three were male. Seven patients had primary melanomas of the anal canal, stomach and the sigmoid colon (5, 1 and 1 cases, respectively). Seven patients underwent curative resections: three abdominoperineal resections, two wide local excisions, one total gastrectomy and one sigmoidectomy. Six patients had distant metastatic lesions at the time of diagnosis, which made curative resection an inappropriate choice. Patients who underwent curative resection exhibited a longer mean survival time (29.7 mo, range: 10-96 mo) than did patients in the palliative group (4.8 mo, P = 0.0006). CONCLUSION: GI MM had an unfavorable prognosis, except in patients who underwent curative resection (53.8% of cases), who had a mean survival of 29.7 mo.

AIM: To determine the relationship between pre-operative hypoalbuminemia and the development of complications following rectal cancer surgery, as well as postoperative bowel function and hospital stay. METHODS: The medical records of 244 patients undergoing elective oncological resection for rectal adenocarcinoma at Siriraj Hospital during 2003 and 2006 were reviewed. The patients had pre-operative serum albumin assessment. Albumin less than 35 g/L was recognized as hypoalbuminemia. Postoperative outcomes, including mortality, complications, time to first bowel movement, time to first defecation, time to resumption of normal diet and length of hospital stay, were analyzed. RESULTS: The patients were 139 males (57%) and 105 females (43%) with mean age of 62 years. Fifty-six patients (23%) had hypoalbuminemia. Hypoalbuminemic patients had a significantly larger tumor size and lower body mass index compared with non-hypoalbuminemic patients (5.5 vs 4.3 cm; P < 0.001 and 21.9 vs 23.2 kg/m2; P = 0.02, respectively). Thirty day postoperative mortality was 1.2%. Overall complication rate was 25%. Hypoalbuminemic patients had a significantly higher rate of postoperative complications (37.5% vs 21.3%; P = 0.014). In univariate analysis, hypoalbuminemia and ASA status were two risk factors for postoperative complications. In multivariate analysis, hypoalbuminemia was the only significant risk factor (odds ratio 2.22, 95% CI 1.17-4.23; P < 0.015). Hospitalization in hypoalbuminemic patients was significantly longer than that in non-hypoalbuminemic patients (13 vs 10 d, P = 0.034), but the parameters of postoperative bowel function were not significantly different between the two groups. CONCLUSION: Pre-operative hypoalbuminemia is an independent risk factor for postoperative complications following rectal cancer surgery.

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.

Background Knowledge of the factors influencing colonoscopic perforation (CP) is of decisive importance, especially with regard to the avoidance or minimization of the perforations. The aim of this study was to determine the incidence and risk factors of CP in one of the endoscopic training centers accredited by the World Gastroenterology Organization. Methods The prospectively collected data were reviewed of all patients undergoing either colonoscopy or flexible sigmoidoscopy at the Faculty of Medicine Siriraj Hospital, Bangkok, Thailand between January 2005 and July 2008. The incidence of CP was evaluated. Eight independent patient-, endoscopist- and endoscopy-related variables were analyzed by a multivariate model to determine their association with CP. Results Over a 3.5-year period, 10,124 endoscopic procedures of the colon (8,987 colonoscopies and 1,137 flexible sigmoidoscopies) were performed. There were 15 colonic perforations (0.15%). Colonoscopy had a slightly higher risk of CP than flexible sigmoidoscopy (OR 1.77, 95%CI 0.23-13.51; p = 1.0). Patient gender, emergency endoscopy, anesthetic method, and the specialty or experience of the endoscopist were not significantly predictive of CP rate. In multivariate analysis, patient age of over 75 years (OR = 6.24, 95%CI 2.26-17.26; p < 0.001) and therapeutic endoscopy (OR = 2.98, 95%CI 1.08-8.23; p = 0.036) were the only two independent risk factors for CP. Conclusion The incidence of CP in this study was 0.15%. Patient age of over 75 years and therapeutic colonoscopy were two important risk factors for CP.