The Thai Journal of SURGERY

ISSN 0125-6068

Official Publication of The Royal College of Surgeons of Thailand www.tci-thaijo.org/index.php/ThaiJSurg/index

Volume 40 July-September 2019 Number 3

ORIGINAL ARTICLES

53 Superior Epigastric Artery: Safety Zones for Pedicle TRAM Flap Reconstruction: A Case Series Suragit Pornchai, Prakasit Chirappapha, Watoo Vassanasiri, Monchai Leesombatpaiboon, Panya Thaweepworadej, Chairat Supsamutchai, Thongchai Sukarayothin 58 The Association between Somatotype and Outcomes in Critically Ill Surgical Patients Thanakorn Yingruxpund, Kaweesak Chittawatanarat CASE REPORT

65 Novel Mutation of NR5A1 in A Case of 46,XY Disorder of Sexual Development: A Case Report Worapat Attawettayanon, Wison Laochareonsuk, Somchit Jaruratanasirikul, Wanwisa Maneechay, Surasak Sangkhathat SURGICAL TECHNIQUE

71 Breast Conserving Surgery with Random Rotation Flap Prakasit Chirappapha, Saowanee Kitudomrat ABSTRACTS

77 Abstracts of the 44th Annual Scientific Congress of The Royal College of Surgeons of Thailand, 13-16 July 2019, Ambassador City Jomtien Hotel, Jomtien, Pattaya, Cholburi, Thailand (Part I)

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Songchai Simaroj Representative of General Surgeons Monawat Ngerncham Representative of Pediatric Surgeons Sirachai Jindarak Representative of Plastic & Reconstructive Surgeons Sompop Prathanee Representative of Thoracic Surgeons Yodruk Prasert Representative of Neurosurgeons Chaiyong Nualyong Representative of Urological Surgeons Nopdanai Chaisomboon Representative of Colorectal Surgeons Thana Turajane Representative of Orthopedic Surgeons Thanyadej Nimmanwudipong Member Pornchai O-Charoenrat Member Supakorn Rojananin Member The THAI Journal of SURGERY Official Publication of The Royal College of Surgeons of Thailand

ISSN 0125-6068 Editorial Board

First Editor : Thongdee Shaipanich

Emeritus Editor : Soottiporn Chittmittrapap Nopadol Wora-Urai Pornchai O-charoenrat Editor-in-Chief : Panuwat Lertsithichai

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Editorial Team : Bunpot Sitthinamsuwan Doonyapat Sa-Nguanraksa Kaweesak Chittawatanarat Pornprom Muangman Potchavit Aphinives Prakasit Chirappapha Surasak Sangkhathat Thanyawat Sasanakietkul Thawatchai Akaraviputh Varut Lohsiriwat Advisory Board : Paisit Siriwittayakorn Pramook Mutirangura

Editorial Board: Chairat Supsamutchai Chaiyong Nuanyong Chaowanun Pornwaragorn Chayanoot Rattadilok Ittichai Sakarungchai Jule Namchaisiri Narongrit Kantathut Narong Rungsakulkij Nutsiri Kittitirapong Paisarn Vejchapipat Panya Thaweepworadej Phitsanu Mahawong Piya Samankatiwat Pornthep Pungrasmi Saritphat Orrapin Siripong Sirikurnpiboon Sompol Permpongkosol Suragit Pornchai Suravej Numhom Teerawut Rakchob Wiroon Laupattarakasem

Published quarterly by : The Royal College of Surgeons of Thailand The THAI Journal of SURGERY Official Publication of The Royal College of Surgeons of Thailand

INFORMATION FOR AUTHORS About the Journal consecutively in the order in which they are first mentioned in the text. The Thai Journal of Surgery is the official publication of The Identify references in text, tables, and legends by Arabic numerals (in Royal College of Surgeons of Thailand issued quarterly. superscript). The references must be verified by the author(s) against the The Thai Journal of Surgery invites concise original articles in original documents. Example forms of references are given below. clinical and experimental surgery, surgical education, surgical history, Journal surgical techniques and devices, as well as review articles in surgery and 1. Standard Journal Article: related fields. Papers in basic science and translational medicine related List all authors when three or less; when four or more, list only first to surgery are also welcome. The Thai Journal of Surgery is dedicated to three and add et al. serving the needs of the Members of The Royal College of Surgeons of Soter NA, Wasserman SI, Austen KF. Cold urticaria: release into the Thailand, specifically the younger researchers and surgeons in training circulation of histamine and eosinophil chemotatic factor of anaphylaxis who wish to have an outlet for their research endeavors. The Royal during cold challenge. N Engl J Med 1976; 294:687-90. College strives to encourage and help develop Thai Surgeons to become 2. Corporate Author: competent researchers in all their given fields. With an international The Committee on Enzymes of the Scandinavian Society for outlook, the Thai Journal of Surgery welcomes submissions from outside Clinical Chemistry and Clinical Physiology. Recommended method for of Thailand as well. the determination of gamma glutamyltransferase in blood. 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Vol. 40 July - September 2019 No. 3

The THAI Journal of SURGERY 2019;40:53-57. Official Publication of The Royal College of Surgeons of Thailand Original Article Superior Epigastric Artery: Safety Zones for Pedicle TRAM Flap Reconstruction: A Case Series Suragit Pornchai, MD* Prakasit Chirappapha, MD† Watoo Vassanasiri, MD† Monchai Leesombatpaiboon, MD† Panya Thaweepworadej, MD‡ Chairat Supsamutchai, MD† Thongchai Sukarayothin, MD† *Department of Surgery, Saraburi Hospital, Thailand †Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand ‡Department of Surgery, Bangkok Metropolitan Administration General Hospital, Bangkok, Thailand

Abstract Deep superior epigastric artery (DSEA) can be damaged in pedicled transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction. Current descriptions of the course of the DSEA do not provide surface landmarks that would be of help to the surgeon. Surface markings of the deep inferior epigastric artery (DIEA) with description safe zones of the TRAM flap are available in the literature, but this is not the case for the DSEA. This study aimed to map surface markings for the DSEA and identify the “danger zone”, which must be avoided during pedicled TRAM flap reconstruction. Keywords: Immediate autologous flap reconstruction, Deep superior epigastric artery, Transverse rectus abdominis musculocutaneous flap.

Introduction descriptions of the course of the DSEA do not provide Deep superior epigastric artery (DSEA) can be surface landmarks that would be of help to the surgeon. damaged in pedicled transverse rectus abdominis mus- Surface markings of the deep inferior epigastric artery culocutaneous (TRAM) flap reconstruction. Current (DIEA) with description safe zones of the TRAM flap

Correspondence address: Dr. Monchai Leesombatpaiboon, Department of Surgery, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; Telephone: +66 2201 1315, Fax: +66 2201 1316; E-mail: [email protected]. 53 54 Pornchai S, et al. Thai J Surg Jul. - Sept. 2019 are available in the literature, but this is not the case for arising from either the superior or inferior epigastric the DSEA. This study aimed to map surface markings for arteries, which send branches supplying muscle or the the DSEA and identify the “danger zone”, which must overlying skin9. be avoided during pedicled TRAM flap reconstruction. Superior epigastric veins follow alongside their corresponding arteries, and drain to the internal thoracic Anatomy vein. These structures, like the arteries, are present bi- The main arterial supply to the abdominal wall laterally almost symmetrically in the human body10. comes from the epigastric arteries. There are three epi- The regional lymphatic drainage follows the flow gastric arteries supply the abdominal wall–superior, of veins above the Scarpa fascia. The lymph nodes that inferior, and superficial epigastric arteries. The super- follow the superficial aspect of superior epigastric veins ficial epigastric artery supplies the superficial tissue of above the umbilicus drain toward the anterior (pectoral) the abdominal wall; the superior and inferior epigastric group of axillary lymph nodes. Lymph nodes that follow arteries make an anastomosis with each other and supply the deep aspect of superior epigastric veins drain back to the muscles of the abdominal wall. the parasternal lymph nodes along internal thoracic ves- Several anatomic studies of the superior epigastric sels11. There are no nerves that follow the path epigastric vascular system have been done1-5. Hallock2 was the arteries like veins and lymph nodes. first to describe a perforator flap based on the superior epigastric artery. At the level of sixth or seventh costal Patients and Methods cartilage, the internal thoracic artery divides into two This study was approved by the Hospital’s Research terminal branches. The first is the musculophrenic artery Ethics Committee. The anatomical observations were supplies the muscles of the diaphragm. The second ter- made at the right subcostal incision during open hepa- minal branch is the superior epigastric artery. According tobiliary surgery. The posterior surfaces of the anterior to some, it passes through a space medially by the sternal abdominal wall were dissected. The surface anatomy part of the diaphragm, laterally by the costal part of the of eight DSEAs and their branches was defined. The diaphragm, and anteriorly by the musculoaponeurotic position of the DSEA was measured from the xiphoid plane formed by transversus thoracis and transversus process to the first branch of DSEA. The danger zone abdominis (Larrey’s space or trigonum sternocostale). was identified by the position of DSEA, both medially Before entering the rectus sheath, it divides into a super- and laterally (Figure 1). ficial branch and a deep branch. The superficial branch pierces the rectus fascia directly under the xiphoid to- Results ward the skin. The deep branch (DSEA) enters the rectus A total of seven patients underwent dissection muscle on its deep surface, approximately 7 cm below (Table 1). One patient underwent bilateral subcostal the costal margin6. When entering the rectus sheath, it dissection. The mean age was 58.1 years. The mean will run behind the rectus abdominis muscle and give distance of the DSEA from the xiphoid process to the the perforating branch to supplying it. first branch of DSEA was 3.8 cm (range, 3.6-4.0 cm). The DSEA usually anastomoses with the deep We found the DSEA to be in the most lateral position branch of the inferior epigastric artery(DIEA) at um- in 1 case, while the rest were more towards the middle bilicus level or more inferiorly depending on different position of the rectus muscle. The DSEA was directed variations of the human body7. The perforator branch towards the posterior to the surface of rectus muscle in pierces the rectus muscle or sometimes pierces the 5 cases. sheath beside the lateral border of the muscle to supply the abdominal skin6. The artery supplies the diaphragm; Discussion on the right small branches reach the falciform ligament One popular technique of breast reconstruction to anastomose with the hepatic artery. A xiphoid branch for breast cancer is to use a pedicled TRAM flap with contributes to the supply to the lower sternal region and blood supplied by the DSEA12. The advantage of using may be of special importance when used as a conduit in a pedicled TRAM flap is that a very large amount of coronary artery by-pass grafts8. At the intersections of breast volume can be obtained, avoiding the need for the rectus abdominis muscle there are transverse arcades prostheses. The are several types of pedicled TRAM flap. Vol. 40 No. 3 Superior Epigastric Artery: Safety Zones for Pedicle TRAM Flap Reconstruction 55

Popular methods include the Whole Muscle Technique13 The preservation of rectus muscle makes the abdominal and the Split Muscle Technique14. The split muscle tech- wall stronger and the smaller pedicle looks better cos- nique aims to preserve a part of the rectus muscle, at metically15, But the major disadvantages is occurrence the medial and lateral side, 1 cm in width on each side. of DSEA injury16.

A B

Figure 1 A: Anatomy of the DSEA and DIEA. Distance of the DSEA refers to the distance from xiphoid process to the first branch of the DSEA (green double-ended arrow). B: Position of the DSEA is reported in accordance to the rectus muscle which is divided into 4 equal parts.

Table 1 Characteristics of the DSEA of seven patients who underwent dissection

The mean Size of the Position Patient number distance of the DSEA of the Direction of the DSEA DSEA (cm)* (mm) DSEA

1 3.9 2.5 Lateral 1/4 Posterior surface of rectus muscle Male, 59 y 2 3.7 1 Lateral 2/4 Middle of rectus muscle Male, 61 y 3 3.6 2.5 Medial 2/4 Middle of rectus muscle Female, 58 y 4 3.7 3 Medial 2/4 Posterior surface of rectus muscle Female, 57 y 5 4.0 2 Medial 2/4 Posterior surface of rectus muscle Female, 55 y 6 3.8 2 Lateral 2/4 Posterior surface of rectus muscle Female, 58 y 7 3.9 1.5 Medial 2/4 Posterior surface of rectus muscle Female, 59 y 3.7 2 Lateral 2/4 Middle of rectus muscle (bilateral subcostal incision)

* The distance of the DSEA was measured from the xiphoid process to the first branch of DSEA. 56 Pornchai S, et al. Thai J Surg Jul. - Sept. 2019

Injury to the DSEA may result in abdominal wall 2. “Safety” and “danger” zones hematoma formation, flap necrosis, infection, incisional “Safety” and “danger” zones have been defined in hernia formation, or major blood loss, depending on various studies on cadavers in different countries7, 20. At where the arterial transection occurs. Therefore, knowing the level of the xiphoid process, the safe zones are at the the anatomy of superior epigastric artery may reduce the midline, along with an adjacent area measuring 3 cm on 17 chance of arterial injury . either side. 1. Identification Technique Many surgeons use the transillumination technique to visualize important vessels coursing through the skin to help reduce DSEA injury. However, this is difficult to do in dark-skinned patients and patients with a thick subcutaneous tissue. A study by Quintet et al. showed that blood vessels were visualized using the transillumination technique in only 63% of 103 patients studied7. Some surgeons use both unidirectional Doppler flowmetry and colour Duplex scanning, which have been proved to be useful tools in evaluating vascular anatomy pre- operatively, improving surgical planning and reducing operating time and DSEA injury18. MDCT-based imaging has provided detailed information on the quality, course, and localization in three- dimensional images to map vessels pre-operatively. The high sensitivity and specificity make it possible to map vessels pre-operatively, effectively improving surgical strategy, reducing valuable operating time, intraoperative Figure 2 Showing the “safety” (green) and “danger” (pink) injury and postoperative complications19. zones of DSEA

A B Figure 3 A: The DSEA enters the middle of the rectus muscle and reaches the lateral 2/4 surface (left side muscle) B: The DSEA enters the posterior part of rectus muscle and reaches the lateral 1/4 surface (right side muscle). Vol. 40 No. 3 Superior Epigastric Artery: Safety Zones for Pedicle TRAM Flap Reconstruction 57

The danger zone starts from 3 cm from the mid- 4. Taylor GI. The angiosomes of the body and their supply to line, up to 5 cm from the midline, which should include perforator flaps. Clin Plast Surg 2003;30:331-42. the main stem of DSEA. The length of the DSEA lies 5. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J between the xiphoid process and umbilicus, and the Plast Surg 1987;40:113-41. danger zone at this site measures a strip starting from 3 6. McCraw JB. Perforator flaps: anatomy, technique, and clinical to 8.5 cm from the midline on either side. The remaining applications. Plast Reconstr Surg 2006;118:552-3. area is safe, as shown in green in Figure 2. By avoid- 7. Joy P, Prithishkumar IJ, Isaac B. Clinical anatomy of the ing these danger zones, the incidence of damage to the inferior epigastric artery with special relevance to invasive major trunks of the DSEA can be reduced. This will not procedures of the anterior abdominal wall. J Minimal Access Surg 2017;13:18-21. only have immediate benefits including avoidance of 8. Lachman N, Satyapal KS. Origin and incidence of xiphoid hematoma formation, but will also save the trans-rectus branch of the internal thoracic artery. Surg Radiol Anat 1999; abdominis flap for reconstruction. 21:351-4. In our study of “Safety” and “danger” zones (8 9. Whetzel TP, Huang V. The vascular anatomy of the tendinous DSEAs identified during hepatobiliary procedures), we intersections of the rectus abdominis muscle. Plast Reconstr found the point of first DSEA branching as measured Surg 1996;98:83-9. 10. Yurdakul M, Tola M, Ozdemir E, et al. Internal thoracic artery- from xiphoid process to range between 3.6 to 4 cm inferior epigastric artery as a collateral pathway in aortoiliac (mean, 3.8 cm) and 50% of the DSEA to lie at the medial occlusive disease. J Vasc Surg 2006;43:707-13 2/4 (Figure 1), which is consistent with other studies. 11. Al Talalwah W. A new concept and classification of corona The DSEA entered in the middle of rectus muscle in 3 mortis and its clinical significance. Chinese J Traumatol 2016; cases and posterior surface of rectus muscle in 5 cases 19:251-4. as shown in Figure 3A. In one case, the DSEA enters the 12. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric posterior part of rectus muscle and reaches the lateral system. Plast Reconstr Surg 1988;82:815-32. 1/4 surface (Figure 3B). 13. Slavin SA, Goldwyn RM. The midabdominal rectus abdominis myocutaneous flap: review of 236 flaps. Plast Reconstr Surg Conclusion 1988;81:189-99. The pattern of DSEA is variable. The Muscle Split- 14. Little JW. Breast reconstruction by the unipedicle tram operation: muscle splitting technique. In: Spear S, editor. Surgery of ting Technique in pedicled TRAM flaps may therefore the breast: principles and art. Philadelphia: Lippincott-Raven; risk injuring DSEA. Attempting to preserve the entire 1998. p. 521–33. fascia while harvesting the whole muscle may also be 15. Kroll SS, Marchi M. Comparison of strategies for preventing dangerous due to the superficial nature of the blood sup- abdominal-wall weakness after TRAM flap breast reconstruc- ply at the muscle surface. The vascular patterns of DSEA tion. Plast Reconstr Surg 1992;89:1045-51. are discussed in this article on an anatomical basis. We 16. Ducic I, Spear SL, Cuoco F, et al. Safety and risk factors for breast reconstruction with pedicled transverse rectus abdominis found the pattern of DSEA to be similar to that previ- musculocutaneous flaps: a 10-year analysis. Ann Plast Surg ously described, and the usual “safety” and “danger” 2005;55:559-64. zones can still be applied to Thai patients. 17. Vasquez JM, Demarque AM, Diamond MP. Vascular complications of laparoscopic surgery. J Am Assoc Gynecol Laparosc 1994;1:163-7. REFERENCES 18. Hallock GG. Doppler sonography and color duplex imaging 1. Boyd JB, Taylor GI, Corlett R. The vascular territories of the for planning a perforator flap. Clin Plast Surg 2003;30:347-57. superior epigastric and the deep inferior epigastric systems. Plast 19. Masia J, Clavero JA, Larranaga JR, et al. Multidetector-row Reconstr Surg 1984;73:1-16. computed tomography in the planning of abdominal perforator 2. Hallock GG. The superior epigastric (RECTUS ABDOMINIS) flaps. JPRAS 2006;59:594-9. muscle perforator flap. Ann Plast Surg 2005;55:430-2. 20. Nordestgaard AG, Bodily KC, Osborne RW, Jr., et al. Major 3. Miller LB, Bostwick J 3rd, Hartrampf CR Jr, et al. The superiorly vascular injuries during laparoscopic procedures. Am J Surg based rectus abdominis flap: predicting and enhancing its blood 1995;169:543-5. supply based on an anatomic and clinical study. Plast Reconstr Surg 1988;81:713-24. The THAI Journal of SURGERY 2019;40:58-64. Official Publication of The Royal College of Surgeons of Thailand Original Article The Association between Somatotype and Outcomes in Critically Ill Surgical Patients Thanakorn Yingruxpund, MD Kaweesak Chittawatanarat, MD, PhD Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Abstract Background: The somatotype is defined as the quantification of the present shape and composition of the human body. It can be simply categorized into 4 groups (Endomorphy, mesomorphy, ectomorphy and central group). Some studies show that mesomorphic component positively correlate to lean body mass which is acceptable proved that loss of lean body mass more than 25-30 % results in fatal outcomes in critically ill surgical patients. Because there is no study that prove the association between somatotype and outcomes in critically ill surgical patients. Therefore, the purpose of this study was to prove the association of the somatotype and the outcomes in critically ill surgical patients. Patients and Methods: A total of 200 critically ill surgical patients in surgical intensive care unit at Maharaj Nakorn Chiang Mai hospital were collected. Demographic data and outcomes (28-day mortality rate, Hospital length of stay, ICU length of stay and duration of ventilator use) were compared among 4 groups of somatotypes (endomorphy, mesomorphy, ectomorphy and central group) Results: There was no significant difference in outcomes of critically ill surgical patients between 4 groups of somatotypes (endomorphy, mesomorphy, ectomorphy and central group). The 28-day mortality rate are 0%, 16.7%, 14.9%, 8.6% (p = 0.15) in endomorphy, mesomorphy, ectomorphy and central group respectively. The median length of hospital stay was 15, 19, 31, 20 days (p = 0.21) respectively. The median length of ICU stay was 14, 7, 12, 8 days (p = 0.36) respectively. The median duration of ventilator use was 12, 5, 12, 7 days (p = 0.38) respectively. Conclusion: This study shows that no significant difference in outcomes of critically ill surgical patients between 4 groups of somatotypes. 28-day mortality rate, length of hospital stay, length of ICU stays and duration of ventilator use. Keywords: Somatotype, Endomorphy, Mesomorphy, Ectomorphy, Surgical intensive care unit

Introduction ectomorphy is the relative linearity or slenderness of a The technique of somatotyping is used to appraise physique. The Heath-Carter method of somatotyping is body shape and composition. The somatotype is defined the most commonly used today and the anthropometric as the quantification of the present shape and composi- method has proven to be the most useful way to obtain tion of the human body. It is expressed in a three-number somatotype1. rating representing endomorphy, mesomorphy and Lean Body Mass is a component of body composi- ectomorphy components respectively, always in the tion, calculated by subtracting body fat weight from total same order. Endomorphy is the relative fatness, meso- body weight2. Lean body mass is used in many literatures morphy is the relative musculoskeletal robustness, and and proved that Lean body mass depletion results in

Correspondence address: Kaweesak Chittawatanarat, MD, PhD, FRCST, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Telephone: +66 5393 5533; E-mail: [email protected] 58 Vol. 40 No. 3 The Association between Somatotype and Outcomes in Critically Ill Surgical Patients 59 increased length of hospital stay and loss of lean body mass more than 25-30% in critically ill surgical patients results in fatal outcomes3,4. Some studies showed that mesomorphic component in somatotype positively correlate with lean body mass5- 7. However, there is no study that determine the association between somatotype and outcomes in critically ill surgical patients. Therefore, the purpose of this study was to determine the association between somatotype and ICU outcomes especially on the mortality.

Patients and Methods This study was an ambispective cohort study. The Figure 1 Holtain Tanner/Whitehouse Skinfold Caliper data of 200 critically ill surgical patients in surgical intensive care unit of Department of Surgery, Faculty of Medicine, Chiang Mai University, Maharaj Nakorn fingers of the left hand and allow them to exert their full Chiang Mai Hospital since 1 March 2012 to 31 March pressure before reading the thickness of the fold1,9. The 2014 were collected. Some detail data were retrieved measurer took all skinfolds on the right side of the body. from THAI-SICU study research which collected the The subjects stand or sit on bed with relaxed position. cases since 1 May 2012 to 31 October 20128. We col- The details of anthropometric dimension measurement lected age, sex, diagnosis, body mass index (BMI), Acute were demonstrated in Table 1. physiologic and chronic health evaluation II (APACHE Ten anthropometric data were calculated and ana- II) score, somatotype, length of hospital stays, length lyzed by software programmer named “Somatotype - of ICU stays, duration of ventilator uses and 28-day calculation and analysis” which is a software product of mortality outcome. The Ethic committee of Faculty of Sweat technologies. This software can be legally down- Medicine, Chiang Mai University approved this study loaded from website “somatotype.org”. It is expressed (SUR-2557-02120). in a three-number rating representing endomorphy, mesomorphy and ectomorphy components respectively, The Anthropometric Somatotype Method1,9 always in the same order. Endomorphy is the relative The anthropometric method of The Heath-Carter fatness, mesomorphy is the relative musculoskeletal ro- anthropometric somatotype (1990) was used in this bustness, and ectomorphy is the relative linearity or slen- study to obtain somatotype. Anthropometric equipment derness of a physical appearance1. The details of calcula- included a stadiometer or height scale and headboard, tion methods, rating method, equations for somatotype weighing scale, small sliding caliper, a flexible steel or analysis, and 2-dimensions somatochart were detail on fiberglass tape measure, and a skinfold caliper. Holtain The Heath-Carter Anthropometric Somatotype-Manual Tanner/Whitehouse Skinfold caliper was used in this (http://www.somatotype.org/Heath-CarterManual.pdf). study (Figure 1). Somatotype could be simply categorized into 4 Regarding the somatotype categorization, ten groups (endomorphy, mesomorphy, ectomorphy and anthropometric dimensions are needed to calculate the central group). anthropometric somatotype1: height, body weight, four 1) Central: no component differs by more than one skinfolds (triceps, subscapular, supra-spinale, medial unit from the other two. calf), two bone breadths (bi-epicondylar humerus and 2) Endomorph: endomorphy is dominant, meso- femur), and two limb girths (arm flexed and tensed, calf). morphy and ectomorphy are more than one-half unit Regarding the skinfolds measurement, the measurer rais- lower. es a fold of skin and subcutaneous tissue firmly between 3) Mesomorph: mesomorphy is dominant, endo- thumb and forefinger of the left hand and away from the morphy and ectomorphy are more than one-half unit underlying muscle at the marked site1,9. Apply the edge lower. of the plates on the caliper branches 1 cm below the 4) Ectomorph: ectomorphy is dominant. 60 Yingruxpund T, Chittawatanarat K Thai J Surg Jul. - Sept. 2019

Figure 2 Triceps skinfold measurement (From Chittawatanarat K. Anthropometric measurement in clinical applications: height, body weight and body composition prediction [Clinical epidemiology]. Chiang Mai: Chiang Mai University; 2012: With Permission)

Figure 3 Subscapular skinfold measurement (From Chittawatanarat K. Anthropometric measurement in clinical applications: height, body weight and body composition prediction [Clinical epidemiology]. Chiang Mai: Chiang Mai University; 2012: With Permission)

Figure 4 Supra-iliac skinfold measurement (From Chittawatanarat K. Anthropometric measurement in clinical applications: height, body weight and body composition prediction [Clinical epidemiology]. Chiang Mai: Chiang Mai University; 2012: With Permission) Vol. 40 No. 3 The Association between Somatotype and Outcomes in Critically Ill Surgical Patients 61

Table 1 The ten anthropometric dimension for defining the patient somatotypes1,9

Parameters Details of measurement

1. Stature (height) Taken against a height scale or stadiometer. Take height with the subject standing straight, against an upright wall or stadiometer, touching the wall with heels, buttocks and back. Orient the head in the Frankfort plane (the upper border of the ear opening and the lower border of the eye socket on a horizontal line), and the heels together. Instruct the subject to stretch up- ward and to take and hold a full breath. Lower the headboard until it firmly touches the vertex. In case who cannot stand, the height is recorded from the identification card. 2. Body mass (weight): The subject, wearing minimal clothing, stands in the center of the scale platform. Record weight to the nearest tenth of a kilogram. A correction is made for clothing so that nude weight is used in subsequent calculations 3. Triceps skinfold: With the subject’s arm hanging loosely in the anatomical position, raise a fold at the back of the arm at a level halfway on a line connecting the acromion and the olecranon processes. (Figure 2) 4. Subscapular skinfold Raise the subscapular skinfold on a line from the inferior angle of the scapula in a direction that is obliquely downwards and laterally at 45 degrees. (Figure 3) 5. Supraspinale skinfold: Raise the fold 5-7 cm (depending on the size of the subject) above the anterior superior iliac spine on a line to the anterior axillary border and on a diagonal line going downwards and medially at 45 degrees. (This skinfold was formerly called suprailiac, or anterior suprailiac. The name has been changed to distinguish it from other skinfolds called “suprailiac”, but taken at different locations). (Figure 4) 6. Medial calf skinfold: Raise a vertical skinfold on the medial side of the leg, at the level of the maximum girth of the calf. 7. Biepicondylar breadth The width between the medial and lateral epicondyles of the humerus, with the shoulder and of the humerus (right): elbow flexed to 90 degrees. Apply the caliper at an angle approximately bisecting the angle of the elbow. Place firm pressure on the crossbars in order to compress the subcutaneous tissue. 8. Biepicondylar breadth Seat the subject with knee bent at a right angle. Measure the greatest distance between the of the femur (right): lateral and medial epicondyles of the femur with firm pressure on the crossbars in order to compress the subcutaneous tissue. 9. Upper arm girth, elbow The subject flexes the shoulder to 90 degrees and the elbow to 45 degrees, clenches the flexed and tensed (right): hand, and maximally contracts the elbow flexors and extensors. Take the measurement at the greatest girth of the arm. 10. Calf girth (right): The subject stands with feet slightly apart. Place the tape around the calf and measure the maximum circumference

(Modified from The Heath-Carter Anthropometric Somatotype- Instruction Manual)

Statistical analysis Results Statistical analysis was carried out using STATA software version 12.0. For categorical variables, differ- Patient characteristics ences were analyzed with the chi-square test. All con- Anthropometric data of 200 critically ill surgical tinuous variables were compared using non-parametric patients were calculated and analyzed. Patients were Kruskal–Wallis one-way analysis of variance. Statistical simply categorized into each group of somatotypes significance was determined asP values of less than 0.05. (endomorphy, mesomorphy, ectomorphy and central group). four patients are in endomorph (Male 0, Female 4).24 patients are in mesomorph (Male 15, Female 9). 67 patients are in ectomorph (Male 44, Female 23). 62 Yingruxpund T, Chittawatanarat K Thai J Surg Jul. - Sept. 2019

96 patients are in central group (Male 67, Female 33). The causes of death were sepsis and hemorrhage. No significant difference in age p( = 0.16) and sex (p However, no significant difference of causes of death = 0.07). Average BMI in ectomorph is less than other was found among these groups (Table 3). groups (average BMI = 17.66 which is categorized in underweight) (p < 0.001). No significant difference in Secondary outcome albumin and APACHE II score in each group. (p = 0.79 Secondary outcomes in this study are length of and 0.53 respectively) Patients characteristics are shown hospital stay, length of ICU stay and duration of ventila- in Table 2. tor use. No significant difference was found as shown in Table 3. Primary outcome Primary outcome in this study is 28-day mortality rate. No significant difference was found in each group (p = 0.42).

Table 2 Patients characteristic

Endomorph Mesomorph Ectomorph Central P-value (N=4) (N=24) (N=67) (N=105) Median age (IQR) 75.5 68 69 63 0.160 (68.5-81) (51-80.5) (58-78) (56-75) Female (%) 4 9 23 38 0.070 (100.00) (37.50) (34.33) (36.19) Median BMI (IQR) 24.45 22.59 17.66 20.42 < 0.001 (23.58-6.16) (20.77-3.96) (16.61-8.69) (19.84-20.90) < 18.5(underweight) 0 0 49 7 < 0.001 (0.00) (0.00) (73.13) (6.67) 18.5-22.9 (normal) 0 16 18 90 (0.00) (66.67) (26.87) (85.71) 23.0-24.9 (overweight) 3 5 0 6 (75.00) (20.83) (0.00) (5.71) 25-29.9 (obese I) 1 2 0 2 (25.00) (8.33) (0.00) (1.90) ≥ 30.0 (obese II) 0 1 0 0 (0.00) (4.17) (0.00) (0.00) Median Albumin (IQR) 2.5 2.45 2.4 2.5 0.796 (2.05-2.95) (2-2.9) (1.8-2.9) (2.1-2.9) < 2.1 0 4 9 11 0.525 (0.00) (16.67) (13.43) (10.48) 2.1-2.6 1 2 8 21 (25.00) (8.33) (11.94) (20.00) 2.7-3.4 2 11 23 46 (50.00) (45.83) (34.33) (43.81) > 3.4 1 7 27 27 (25.00) (29.17) (40.30) (25.71) Median APACHE II (IQR) 13 24 18 18 0.535 (8-18) (9-28) (10-24) (12-24)

IQR: Interquartile range, BMI: Body mass index, APACHE II: Acute physiologic and chronic health evaluation II Vol. 40 No. 3 The Association between Somatotype and Outcomes in Critically Ill Surgical Patients 63

Table 3 Primary and secondary outcome

Endomorph Mesomorph Ectomorph Central P-value (N=4) (N=24) (N=67) (N=105)

Length of hospital stay 25 (13.5-36) 18.5 (8-36) 31 (16-53) 20 (11-34) 0.208 Length of ICU stay 14 (3.5-26.5) 6.5 (2-18) 12 (4-23) 8 (4-16) 0.362 Duration of ventilator 12 (2.5-24) 5 (1-18) 12 (3-21) 7 (3-15) 0.388 28-day mortality 0 (0.00) 4 (16.67) 10 (14.93) 9 (8.57) 0.422 Cause of death Sepsis 0 (0.00) 2 (8.33) 10 (14.92) 8 (7.62) 0.146 Hemorrhage 0 (0.00) 2 (8.33) 1 (1.49) 1 (0.95)

Discussion stay, duration of ventilator use and 28-day mortality rate Currently, it is acceptable that loss of lean body are high in ectomorphy who have lower BMI than other mass more than 25-30% results in fatal outcomes in criti- groups. So, in our opinion, the study may need more cally ill surgical patients2. Some studies showed positive sample size to make the significant difference. correlation between mesomorphic component and lean Although this study was the bedside of measure- body mass6. So, we expect that somatotype might relate ment to determine the patient somatotype which might to the outcomes in critically ill surgical patient. However, be extrapolated to the patient lean body mass or fat free no previous study was designed to prove these associa- mass. There were some inevitable limitations on this tions as well as there was no evidence that somatotype study: may be used as a tool to predict the outcomes in these 1) we did not measure the concomitant body com- patients. position on these patients. The Heath-Carter method of somatotyping is the 2) the limitation of rating form did not include most commonly used today to define present shape and some extreme value patients and the combination of body composition of human. This method has been used somatotypes in one person. in many literatures of sport medicine to study the body 3) Most of critically ill patient have been resusci- shape and composition in various type of sport mans. tated before admission and there was edematous status There was no study in critically ill surgical patients yet. at the first presentation. The measurement of skin fold Ten anthropometric parameters in the Heath-Carter in edematous patient was hardly to measure and error. method of somatotype can be simply measured by 4) The distribution of each somatotypes is differ- general physician or nurse. It can easily be analyzed ence, most of patients were central (52.5%), the outcome by software programmer that can be afforded from the difference might be not detected on the other group of official website “www.somatotype.org”. somatotypes in this study. The data from patient characteristics show that In our opinion, Although the body composition there is no significant difference in age, sex, albumin tools are expensive, the direct measurement of body and APACHE II score. BMI in ectomorphy is signifi- composition might lead to closely relation between the cant less than other groups. So, we initially assume that outcomes. Therefore, we suggest to use the body com- ectomorphy may have less lean body mass and worse position measurement method in the future of study. outcomes than other groups. The results showed no significant difference on Conclusion both primary outcome (28-day mortality rate) and sec- This study shows that there is no significant differ- ondary outcome (length of hospital stay, length of ICU ence in outcomes of critically ill surgical patients among stay, duration of ventilator use). Even though the results 4 groups of somatotypes including 28-day mortality rate, cannot show significant difference among these group, length of hospital stay, length of ICU stays and duration we notice that the length of hospital stay, length of ICU of ventilator. 64 Yingruxpund T, Chittawatanarat K Thai J Surg Jul. - Sept. 2019

REFERENCES 6. Slaughter MH, Lohman TG. Relationship of body composition 1. Carter JEL. The Heath-Carter Anthropometric Somatotype: San to somatotype. Am J Phys Anthropol 1976;44:237-44. Diego State University; 2002. 7. Slaughter MH, Lohman TG, Boileau RA. Relationship of Heath 2. Vestbo J, Prescott E, Almdal T, et al. Body mass, fat-free body and Carter’s second component to lean body mass and height mass, and prognosis in patients with chronic obstructive pulmo- in college women. Res Q 1977;48:759-68. nary disease from a random population sample: findings from 8. Chittawatanarat K, Chaiwat O, Morakul S, et al. A multi-center the Copenhagen City Heart Study. Am J Respir Crit Care Med Thai university - based surgical intensive care units study 2006;173:79-83. (THAI-SICU study): Methodology and ICU characteristics. J 3. Bolonchuk WW, Hall CB, Lukaski HC, Siders WA. Relationship Med Assoc Thai 2014;97 S45-S54. between body composition and the components of somatotype. 9. Chittawatanarat K. Anthropometric measurement in clinical ap- Am J Hum Biol 1989;1:239-48. plications: height, body weight and body composition prediction 4. Savalle M, Gillaizeau F, Maruani G, et al. Assessment of body [Clinical epidemiology]. Chiang Mai: Chiang Mai University; cell mass at bedside in critically ill patients. Am J Physiol En- 2012. docrinol Metab 2012;303:E389-96. 5. Bulbulian R. The influence of somatotype on anthropometric prediction of body composition in young women. Med Sci Sports Exerc 1984;16:389-97.

บทคัดย่อ ความสัมพันธ์ระหว่างรูปร่างและผลการรักษาในผู้ป่วยศัลยกรรม ธนากร ยิ่งรักพันธุ์ พ.บ., กวีศักดิ์ จิตตวัฒนรัตน์ พ.บ. ภาควิชาศัลยศาสตร์ คณะแพทยศาสตร์ มหาวิทยาลัยเชียงใหม่ ความเป็นมา: รูปร่างสามารถประเมินได้จากการวัดและการดูสัดส่วนขององค์ประกอบของร่างกาย โดยทั่วไปมีการแบ่งเป็น 4 กลุ่ม (Endomorphy, mesomorphy, ectomorphy และ central) หลายการศึกษาพบว่า mesomorphy มีความสัมพันธ์กับมวลไร้ไขมัน ซึ่งเป็นที่ยอมรับกันโดยทั่วไปว่าการสูญเสียมวลไร้ไขมันมากกว่า ร้อยละ 25 – 30 ส่งผลต่อการเพิ่มอัตราการเสียชีวิตในผู้ป่วยหนักศัลยกรรม เนื่องจากไม่เคยมีการศึกษาที่พิสูจน์ ความสัมพันธ์ของรูปร่างกับผลการรักษาในผู้ป่วยหนักศัลยกรรม ดังนั้น การศึกษานี้จึงมีวัตถุประสงค์เพื่อพิสูจน์ ความสัมพันธ์ระหว่างรูปร่างของผู้ป่วยกับผลการรักษาในผู้ป่วยหนักศัลยกรรม ผู้ป่วยและวิธีการ: ผู้ป่วยจำ�นวน 200 คนในไอซียูศัลยกรรม โรงพยาบาลมหาราชนครเชียงใหม่ได้รับ คัดเลือกเข้าการศึกษา บันทึกลักษณะของผู้ป่วยและผลการรักษา (การเสียชีวิตใน 28 วัน ระยะเวลานอนใน โรงพยาบาล ระยะเวลานอนในไอซียู และระยะเวลาของการใช้เครื่องช่วยหายใจ) เปรียบเทียบในผู้ป่วยที่มีรูปร่าง แตกต่างกัน 4 กลุ่ม (Endomorphy, mesomorphy, ectomorphy และ central) ผลการศึกษา: ไม่พบความแตกต่างอย่างมีนัยสำ�คัญของผลการรักษาระหว่างรูปร่างต่างๆ ในผู้ป่วย ศัลยกรรม โดยอัตราการเสียชีวิตที่ 28 วันตามลำ�ดับ Endomorphy, mesomorphy, ectomorphy และ central คือ ร้อยละ 0, 16.7, 14.9 และ 8.6 (p = 0.15) ค่ามัธยฐานของการนอนโรงพยาบาลคือ 15, 19, 31 และ 20 วันตามลำ�ดับ (p = 0.21) ค่ามัธยฐานของการนอนในไอซียู คือ 14, 7 ,12 และ 8 วันตามลำ�ดับ (p = 0.36) ค่ามัธยฐานของการใช้ เครื่องช่วยหายใจคือ 12, 5, 12 และ 7 วัน ตามลำ�ดับ (p = 0.38) สรุปผลการศึกษา: การศึกษานี้พบว่าไม่มีความแตกต่างระหว่างรูปร่างและผลการรักษาอย่างมีนัยสำ�คัญ ทางสถิติในผู้ป่วยหนักศัลยกรรมระหว่างรูปร่างทั้ง 4 กลุ่ม ได้แก่ อัตราการเสียชีวิตใน 28 วัน ระยะเวลาในการ นอนโรงพยาบาล ระยะเวลานอนในไอซียู และระยะเวลาในการใช้เครื่องช่วยหายใจ The THAI Journal of SURGERY 2019;40:65-70. Official Publication of The Royal College of Surgeons of Thailand Case Report

Novel Mutation of NR5A1 in A Case of 46,XY Disorder of Sexual Development: A Case Report Worapat Attawettayanon, MD* Wison Laochareonsuk, MD* Somchit Jaruratanasirikul, MD† Wanwisa Maneechay, MSc‡ Surasak Sangkhathat, MD, PhD* *Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand 90110 †Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand 90110 ‡ Central Research Laboratory and Biological Banking Facility, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand 90110

Abstract 46,XY disorder of sexual differentiation (DSD) is a type of sexual ambiguity which a patient with male chromosome does not completely developed male sex phenotype. Although the condition is known as androgen insensitivity syndrome, its pathophysiology is not always such unresponsiveness to androgen. Defective androgen production caused by molecular pathology on steroidogenic hormone regulating genes explain the phenotypes in a number of cases. Herein, we report a case of 46,XY DSD with gonadal dysgenesis who had a heterozygous germline mutation of NR5A1 at the position 9:124500710. The mutation is predicted to result in a substitution of Arginine with Cysteine at the codon 84 (p.R84C) of NR5A1, which encodes for a DNA binding domain of the transcription factor SF1. On familial study, the mutation was found derived from the maternal side who also carried a heterozygous p.R84C. With this novel mutation, our evidence was consistent with previous studies which have suggested that mutations within NR5A1 are associated with 46,XY DSD and primary ovarian insufficiency. Keywords: Disorder of sexual development, NR5A1, SF1

Introduction the principal hormone that induces differentiation of Gender development is a continuous process, Wolffian duct system (epididymis, vas deferens and beginning from chromosomal derived biological sex seminal vesicles), AMH suppresses Müllerian structures to sexual organs development and personality trait. (uterus and adnexa). Apart from SRY defects, germline Each step requires combination of signals from various mutations in various genes were reported to be involved genes in both sex chromosomes and autosomes. Hu- in 46,XY disorder of sexual development (46,XY DSD) man male sex is primarily determined by SRY gene on including Steroid 5-alpha reductase 2 (SRD5A2), andro- Y chromosome. With presence of SRY, the primordial gen receptor (AR), Nuclear receptor subfamily 5 group gonad differentiates into testicular tissue that contains A member 1 (NR5A1), Bone morphogenetic protein 4 Leydig cells and Sertoli cells. Under influence of hu- (BMP4) and Wilms tumor 1 (WT1)2, 3. man chorionic gonadotropin (hCG) from the placenta, NR5A1 (9q33.3, MIM #184757) provides an es- Leydig cells produce testosterone while Sertoli cells sential transcription factor for male sex development, produce anti-Müllerian hormone (AMH)1. When T is the steroidogenic factor 1 (SF1).

Correspondence address: Surasak Sangkhathat, MD, PhD, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand 90110; Telephone: +66 7445 1401-3, Fax: +66 7445 1400; E-mail: [email protected]. 65 66 Attawettayanon W, et al. Thai J Surg Jul. - Sept. 2019

SF1 expresses in the urogenital ridge during early Case Report embryonic life and involves in the development of go- A female baby first presented to us on her 6-month nadal and adrenal tissue4, 5. In male mice model, targeted age with a problem of ambiguous external genitalia. The deletion of NR5A1 is associated with gonadal and adrenal girl was born term and was the first child of a mother agenesis together with persistent Müllerian structures. with long history of infertility, irregular menstruation and Animals with heterozygosity have a variety of subtle early menopause. The second child was a normal male. phenotypes such as testicular hypoplasia and abnormal On examination, the patient had female type external steroid hormone production during stress. In humans, genitalia with deep labioscrotal fold, enlarged phallus heterozygous mutations of NR5A1 were reported in that looked like a large clitoris and urogenital sinus (fu- 46,XY DSD with or without adrenal insufficiency. In sion of the urethra and the distal vaginal canal) (Figure addition, some mutations in NR5A1 were associated 1). There was no palpable gonad within the inguinal with ovarian insufficiency in 46,XX female6. canals. A chromosomal study by G-band karyotyping With advancement in genome sequencing tech- method showed 46,XY. Baseline testosterone was < 0.02 nique, rare mutations in human genome can be detected ng/ml and raised to 3.10 ng/ml after a single-dose hCG and the variant data is meaningful in understanding stimulation. A contrast genitogram showed urogenital pathophysiology of various rare diseases. In this report, sinus and grade 3 bilateral vesicoureteral refluxes. Dur- we demonstrate a case of 46,XY DSD with gonadal dys- ing voiding, the contrast retrograded into a posterior tract genesis in whom a genetic study found a novel mutation which was suspected to be a large vagina. Elongation of of NR5A1. posterior urethra was noted.

Figure 1 Appearance of the external genitalia in this 46,XY patient at 3 months old, showing cleft labioscortal fold without gonads and a small phallus (arrow) Vol. 40 No. 3 Novel Mutation of NR5A1 in A Case of 46,XY Disorder of Sexual Development 67

The patient was assigned to be female and under- the position 9:124500710 (DNA RefSeq NM 004959.3) went a transabdominal gonadectomy and genital size which had C to T mutation at 10/19 reads. The position reduction surgery when she was 4 years old. On lapa- belonged to codon 84 of the gene NR5A1 and the vari- rotomy, there was no uterus and both gonads were found ant led to substitution of Arginine (R) by Cysteine (C). in the pelvis near the internal inguinal rings. Pathology At the time of this manuscript preparation (September of the resected gonads reported gonadal dysgenesis. The 2019), the variant has never been annotated in the Single patient had regular follow-up visit with the endocrinolo- Nucleotide Polymorphism database (dbSNP) but a mis- gist and began to receive estrogen therapy when she was sense mutation in this same position causing different twelve. Her parents reported that the girl love to play out- amino acid substitution (p.R84H) is reported in a study8. door sports and did well at the secondary school. Body Validation by Sanger’s dideoxynucleotide sequenc- weight steadily gain at the percentile 25 and the height ing technique confirmed heterozygous mutation at the began to spurt from the percentile 25 to the percentile same point (Figure 2). Further study in both parents 50 around the age 12-14. An augmentation vaginoplasty found identical heterozygous mutation in the mother and was performed when the patient aged 17 years, by using wildtype sequence in the phenotypically normal father a U-flap ileal segment. and the brother. Genetic study was performed in 2017 under in- formed consent. Blood DNA was submitted for a Whole Discussion Exome Study (WES) using Illumina Hiseq-2000 (Il- Modern high throughput genome study has allowed lumina, San Diego, California, United States) platform novel approach in various human diseases, especially with 100bp runs at an average mean target depth of 100x rare diseases like endocrinological disorders. Previ- coverage. The raw sequence data in the FASTQ format ously, 46,XY DSD was categorized in a group of rare were mapped to the reference genome (GRCh38/hg7) conditions known as ‘androgen insensitivity’ which using the Lasergene 15.0 Bioinformatic suits (DNAstar, meant that although testosterone can be produced, the Wisconsin, United States). Annotation focused on the embryonic tissue does not respond to the hormone and, genes previously reported to be associated with 46,XY as a consequence, the male genital organs do not develop DSD according to a recent publication list7. The analysis well. With this pathophysiological paradigm, molecu- showed that the most likely pathogenic variant was at lar pathology in focus was at the receptor gene, AR6.

Figure 2 Electropherograms of the capillary electrophoresis, demonstrating heterozygous point mutation (C/T) at the position 9:124500710 68 Attawettayanon W, et al. Thai J Surg Jul. - Sept. 2019

Table 1 Structure of SF1 (NR5A1) protein (illustrated in the box below and positions of mutation reported in each category of disorders of sexual differentiation

Phenotypes Genotypes

46,XY DSD female external genitalia, p.G35E (Achermann JC 1999), p.R92O (Achermann JC 2002), p.R427Wa (Rocca MS persistent Mullerian structures 2018) with adrenal insufficiency

6,XY DSD female external genitalia, Del nt1058-1065 (Correa RV 2004), D6fsX74 (Hasegawa T 2004), p.V15M, p.M78I, without adrenal insufficiency p.G91S, p.L437Q (Lin L 2007), p.C16X (Mallet D 2004), p.C33S, p.R84H, p.Y138X (Kohler B 2008). p.L376F, p.G328V (Tantawy S 2014), p.K38*, p.S32N (de Andrade, JGR 2014), p.C65Y (Fabbri HC 2014), p.T03X, E07XQ299HfsX386 (Hussain S 2015), p.G26A, p.C283R, p.L384Rfs*7, p.E455* (Woo KH 2015), p.G90C, p.L298P, (Re- hkamper J 2017), p.T40R, p.T47C, p.G328W, p.A351E, p.Q460R (Rocca MS 2018), p.G212S (Wang H 2018), R39C, C247* (Fabbri-Scallrt H 2017) p.R84C (This study)

46,XY DSD micropenis and/or p.Q107X, c.103-2C>A, p.E11X (Kohler B 2009), R281P (Philibert P 2011), p.Y183X hypospadias and/or cryptorchidism (Warman DM 2011), p.G26A (Woo KH 2015), S32N, K396Rfs*34 (Fabbri-Scallrt H 2017) p.N44X, p.C283*, p.T29K, p.E148fsX105, p.G35V, p.C370Y, p.E367G, S430I (Wang H 2018)

46,XY infertility p.G165R, p.D257N, p.I323T (Ropke A 2013)

46,XX testicular/ovotesticular DSD p.P125Rfs*171 (Rehkamper J 2016), p.R92W (Bashamboo A 2016, Takasawa K 2017), aR427W had borderline level of cortisol (Rocca MS 2018), DSD: disorder of sex development

However, mutations of AR belong to minority group of 46,XY DSD individuals harboring NR5A1 is wide, from 46,XY DSD reported by large cohorts that used a high- isolated hypospadias to full female external genitalia, throughput genomic technique7, 9. there is no genotype-phenotype correlation22. Most XY NR5A1, synonym SF1 or adrenal 4-binding protein patients with NR5A1 reported in the literature had vary- (Ad4BP), encodes a nuclear receptor protein SF1 which ing degree of poor development of external genitalia with consists of 461 amino acids. The SF1 protein comprised or without undescended testicles22, 23. In addition, mis- of a DNA-binding domain (DBD), a ligand binding do- sense mutations of NR5A1 were also found in infertile main (LBD), 2 functional activation domains (named A males with normal genital organs24. In 46,XX, although box and AF2), and a hinge region (Illustrated in Table 1). phenotypes of NR5A1 mutated are subtle, varying from As a transcription factor, NR5A1 regulates expression of asymptomatic to primary ovarian insufficiency25, a recent several enzymes essential for testosterone biosynthesis, evidence suggested that p.R92W mutation is specifically AMH, SOX9 and several genes involving in cholesterol associated with 46,XX SRY-negative testicular DSD26-28. mobilisation and steroid hormone biosynthesis10, 11. Cru- Genotypes of NR5A1 reported in each category of DSD cial roles of NR5A1 is at the early stage of sexual organ are reviewed from Pubmed database and are summarized diversification, consisting of differentiation of Wolffian in Table 1. Interestingly, the same mutation in NR5A1 structures and regression of Müllerian organs3. More may give different severity of phenotype in siblings than 80 mutations of NR5A1 were reported in 46,XY which might be explained by uncovered genetic modi- DSD11-21 and NR5A1 mutations are estimated to contrib- fiers29, 30. ute 8-15% of the cases11. Although clinical spectrum of Vol. 40 No. 3 Novel Mutation of NR5A1 in A Case of 46,XY Disorder of Sexual Development 69

Our patient carried heterozygous mutation of 7. Gomes NL, Lerario AM, Machado AZ, et al. Long-term outcomes NR5A1 at the codon 84 (R84C) which was located at the and molecular analysis of a large cohort of patients with 46,XY DNA binding domain of the protein. Functional study disorder of sex development due to partial gonadal dysgenesis. Clin Endocrinol (Oxf) 2018. of the position R84 has been studied by Köhler and col- 8. Kohler B, Lin L, Ferraz-de-Souza B, et al. Five novel mutations leagues since 2008. In their experiment, p.R84H showed in steroidogenic factor 1 (SF1, NR5A1) in 46,XY patients with reduced binding affinity with Cyp11a promotor when severe underandrogenization but without adrenal insufficiency. subcellular localization did not significantly change. The Hum Mutat. 2008;29:59-64. same study also showed reduced transcriptional activity 9. Wang H, Zhang L, Wang N, et al. Next-generation sequenc- of the cells transfected with p.R84H mutated NR5A1. ing reveals genetic landscape in 46, XY disorders of sexual development patients with variable phenotypes. Hum Genet Although our mutation p.R84C was not exactly identical 2018;137:265-77. to theirs, we assume that loss of arginine in this position 10. Luo X, Ikeda Y, Parker KL. A cell-specific nuclear receptor is impacts the transcription activity in the same way. The essential for adrenal and gonadal development and sexual dif- phenotypes in KÖhler’s patient were similar to our case ferentiation. Cell 1994;77:481-90. in that the patient had female type external genitalia with 11. Hussain S, Amar A, Najeeb MN, et al. Two novel mutations in testicular dysgenesis and absence of the uterus. Although the NR5A1 gene as a cause of disorders of sex development in a Pakistani cohort of 46,XY patients. Andrologia 2016;48: hormonal study had not been performed in the mother, 509-17. irregular menstruation and early menopause suggested 12. Achermann JC, Ito M, Hindmarsh PC, et al. A mutation in the primary ovarian insufficiency that was related to a carrier gene encoding steroidogenic factor-1 causes XY sex reversal state of the mutation. and adrenal failure in humans. Nat Genet 1999;22:125-6. In summary, we report a case of 46,XY DSD with 13. Achermann JC, Ozisik G, Ito M, et al. Gonadal determination gonadal dysgenesis without adrenal dysfunction. The and adrenal development are regulated by the orphan nuclear receptor steroidogenic factor-1, in a dose-dependent manner. J case inherited a point mutation of NR5A1 from a mother Clin Endocrinol Metab 2002;87:1829-33. who was likely to have primary ovarian insufficiency. 14. Philibert P, Polak M, Colmenares A, et al. Predominant Sertoli Our evidence supports the role of NR5A1 in the devel- cell deficiency in a 46,XY disorders of sex development patient opment of 46,XY females and also supports the role with a new NR5A1/SF-1 mutation transmitted by his unaffected of a whole exome study in an annotation of germline father. Fertil Steril 2011;95:1788 e5-9. pathology in a patient with ambiguous genitalia. 15. Ciaccio M, Costanzo M, Guercio G, et al. Preserved fertility in a patient with a 46,XY disorder of sex development due to a new heterozygous mutation in the NR5A1/SF-1 gene: evidence cknowledgement A of 46,XY and 46,XX gonadal dysgenesis phenotype variability Dave Patterson edited English language in the in multiple members of an affected kindred. Horm Res Paediatr manuscript. 2012;78:119-26. 16. Fabbri HC, de Andrade JG, Soardi FC, et al. The novel p.Cys65Tyr mutation in NR5A1 gene in three 46,XY siblings with normal testosterone levels and their mother with primary ovarian insuf- REFERENCES ficiency. BMC Med Genet 2014;15:7. 1. MacLaughlin DT, Donahoe PK. Sex determination and differ- 17. Gabriel Ribeiro de Andrade J, Marques-de-Faria AP, Fab- entiation. N Engl J Med 2004;350:367-78. bri HC, et al. Long-Term Follow-Up of Patients with 46,XY 2. Achermann JC, Ozisik G, Meeks JJ, et al. Genetic causes of human Partial Gonadal Dysgenesis Reared as Males. Int J Endocrinol reproductive disease. J Clin Endocrinol Metab 2002;87:2447-54. 2014;2014:480724. 3. Parker KL, Schimmer BP. Genes essential for early events in 18. Tantawy S, Mazen I, Soliman H, et al. Analysis of the gene gonadal development. Ann Med 2002;34:171-8. coding for steroidogenic factor 1 (SF1, NR5A1) in a cohort of 4. Parker KL, Rice DA, Lala DS, et al. Steroidogenic factor 1: 50 Egyptian patients with 46,XY disorders of sex development. an essential mediator of endocrine development. Recent Prog Eur J Endocrinol 2014;170:759-67. Horm Res 2002;57:19-36. 19. Fabbri HC, Ribeiro de Andrade JG, Maciel-Guerra AT, et al. 5. Buaas FW, Gardiner JR, Clayton S, et al. In vivo evidence for NR5A1 Loss-of-Function Mutations Lead to 46,XY Partial the crucial role of SF1 in steroid-producing cells of the testis, Gonadal Dysgenesis Phenotype: Report of Three Novel Muta- ovary and adrenal gland. Development 2012;139:4561-70. tions. Sex Dev 2016;10:191-9. 6. Camats N, Pandey AV, Fernandez-Cancio M, et al. Ten novel 20. Rehkamper J, Tewes AC, Horvath J, et al. Four Novel NR5A1 mutations in the NR5A1 gene cause disordered sex development Mutations in 46,XY Gonadal Dysgenesis Patients Including in 46,XY and ovarian insufficiency in 46,XX individuals. J Clin Frameshift Mutations with Altered Subcellular SF-1 Localiza- Endocrinol Metab 2012;97:E1294-306. tion. Sex Dev 2017;11:248-53. 70 Attawettayanon W, et al. Thai J Surg Jul. - Sept. 2019

21. Rocca MS, Ortolano R, Menabo S, et al. Mutational and functional 26. Bashamboo A, Donohoue PA, Vilain E, et al. A recurrent studies on NR5A1 gene in 46,XY disorders of sex development: p.Arg92Trp variant in steroidogenic factor-1 (NR5A1) can act identification of six novel loss of function mutations. Fertil Steril as a molecular switch in human sex development. Hum Mol 2018;109:1105-13. Genet 2016;25:5286. 22. Domenice S, Machado AZ, Ferreira FM, et al. Wide spectrum 27. Grinspon RP, Rey RA. Disorders of Sex Development with of NR5A1-related phenotypes in 46,XY and 46,XX individuals. Testicular Differentiation in SRY-Negative 46,XX Individuals: Birth Defects Res C Embryo Today 2016;108:309-20. Clinical and Genetic Aspects. Sex Dev 2016;10:1-11. 23. Kohler B, Lin L, Mazen I, et al. The spectrum of phenotypes 28. Saito-Hakoda A, Kanno J, Suzuki D, et al. A Follow-Up from associated with mutations in steroidogenic factor 1 (SF-1, Infancy to Puberty in a Japanese Male with SRY-Negative 46,XX NR5A1, Ad4BP) includes severe penoscrotal hypospadias in Testicular Disorder of Sex Development Carrying a p.Arg92Trp 46,XY males without adrenal insufficiency. Eur J Endocrinol Mutation in NR5A1. Sex Dev 2019. 2009;161:237-42. 29. Warman DM, Costanzo M, Marino R, et al. Three new SF-1 24. Ropke A, Tewes AC, Gromoll J, et al. Comprehensive sequence (NR5A1) gene mutations in two unrelated families with multiple analysis of the NR5A1 gene encoding steroidogenic factor 1 in affected members: within-family variability in 46,XY subjects a large group of infertile males. Eur J Hum Genet 2013;21: and low ovarian reserve in fertile 46,XX subjects. Horm Res 1012-5. Paediatr 2011;75:70-7. 25. Biason-Lauber A, Schoenle EJ. Apparently normal ovarian 30. Woo KH, Cheon B, Kim JH, et al. Novel Heterozygous Muta- differentiation in a prepubertal girl with transcriptionally inac- tions of NR5A1 and Their Functional Characteristics in Patients tive steroidogenic factor 1 (NR5A1/SF-1) and adrenocortical with 46,XY Disorders of Sex Development without Adrenal insufficiency. Am J Hum Genet 2000;67:1563-8. Insufficiency. Horm Res Paediatr 2015;84:116-23. The THAI Journal of SURGERY 2019;40:71-76. Official Publication of The Royal College ofSurgeons of Thailand Surgical Technique

Breast Conserving Surgery with Random Rotational Flap

Prakasit Chirappapha, MD, FRCST (Oncology)* Saowanee Kitudomrat, MD, FRCST† *Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University Bangkok, Thailand †Department of Surgery, Police General Hospital, Bangkok, Thailand

Abstract The random rotation flap in breast conserving surgery relies on a volume replacement concept using the random skin flaps from the lateral chest wall to cover the wide excisional defects to decrease deformity. The advantage of this operation is its simplicity, and requires a short operating time with a satisfying aesthetic outcome. However, a too wide random rotational flap may lead to a higher incidence of necrosis. In conclusion, this is an interesting and simple option to substitute for a latissimus dorsi musculocutaneous flap with a good aesthetic result. Keywords: Breast-conserving surgery, Random rotational flap, Local flap, Reconstructive procedure, Breast deformity

Introduction ume replacement is an important technique. This article Recently, the role of oncoplastic surgery in breast mentions how to use local flap from the lateral chest wall cancer treatment has been changed from the past, which to cover wide excisional defects at the lateral site. focused more on survival of the patient. Currently, quality of life and aesthetics are perceived to be just as Materials and Methods important.1 Some cases are eligible for breast-conserving therapy whereas others require mastectomy with a recon- Basic Principles and Step-by-Step Procedure structive procedure to improve their quality of life and Random flap from the lateral chest wall uses the self-esteem. There are many types of surgery to remove rotational flap concept to cover the subcutaneous gap breast cancer which depend on various factors such as and skin defect and to prevent twisted skin suturing by patient’s demand, tumor burden, and breast shape1,2. rotating skin and subcutaneous tissue from the lateral Here, we focus on breast conserving surgery. side of the breast to replace the removed skin and soft Oncoplastic breast-conserving surgery can be tissue area3. categorized into two types2,3. The first one uses volume The initial step is preparing a patient who comes displacement which reshapes residual breast tissue to with a breast mass with suspicious skin involvement at minimize deformity. Another is volume replacement the lateral side of the breast. (Figure 1,2) which uses local or musculocutaneous flap rotation to 1. Draw incision line over the tumor area that close the defect. Tumor removal in Asian women with mostly is circular or elliptical shape, extend this and small breasts often results in breast deformity, thus vol- create a lateral rotational flap in which the aspect ratio

Correspondence address: Prakasit Chirappapha1, MD, FRCST, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University Bangkok, Thailand; Telephone +66 84 457 4059; Email: [email protected]. 71 72 Chirappapha P, Kitudomrat S Thai J Surg Jul. - Sept. 2019

of the width to the length of the flap is less than 1:1. In the case of a flap with its feeding vessel, the length can be longer. (Figure 3) 2. Incise skin along the line around the tumor area deep through all layers of skin and subcutaneous tissue and then excise the mass in a cylindrical shape. (Figure 4) 3. Mark specimen with metallic clips to facilitate orientation. (Figure 5)

Figure 1 The tumor locates on the lateral side of the right breast with skin dimpling.

Figure 3 Drawing the lines for removing a mass and creating a random flap

Figure 2 The lateral side view shows that the tumor locates on the lateral side of the right breast with skin dimpling. (The dotted circle shows tumor area.) Figure 4 Incisions following the preoperative drawing Vol. 40 No. 3 Breast Conserving Surgery with Random Rotational Flap 73

Figure 5 Suturing metallic clips for tumor orientation Figure 6 After tumor removing, the metallic clip was placed

4. Place metallic clips at the tumor bed. (Figure 6) Simple defect closure without any technique could result in breast deformity. (Figure 7, 8) 5. Incise along the marked lines for the flap, through the skin and subcutaneous tissue, respecting its blood supply. (Figure 9) 6. Rotate flap to replace the excisional gap, and close the wound by suturing layer by layer. (Figure 10, 11) 7. Obtain specimen mammogram for evaluating surgical margin adequacy. (Figure 12 A-B) Discharge the patient home 2 to 3 days after the operation. (Figure 13 A-D)

Results and Discussion Random skin flap from lateral chest wall is appropriate for the following indications: 1. A single lesion with suspicious skin involvement 2. No contraindication for breast-conserving therapy 3. Tumor location at the lateral side of the breast 4. Not too wide skin defect Figure 7 Simple closure causes a deformity (Lateral view) 74 Chirappapha P, Kitudomrat S Thai J Surg Jul. - Sept. 2019

Figure 8 Simple closure causes a deformity (Anterior view)

Figure 10 Rotation of the flap to the defect

Figure 9 Dissecting the skin and subcutaneous tissue of the flap

The main advantage of this technique lies in its simplicity. The operative time is short and may be appropriate for elderly or high-comorbidity patients. Using the lateral local skin and subcutaneous tissue flap does Figure 11 Final appearance after a complete operation not result in a deformity at the donor site. This might result in a faster recovery time, a shorter hospital stays, of necrosis, so that large defects, and suturing with ex- and the wounds might even heal faster. cessive tension, should be avoided. However, one limitation is that there are no named Our limited experience with this flap has been quite or fixed vessels supplying the flap, thus the name random satisfactory. No major complications have occurred and flap. The wider the skin flap, the a higher the incidence the cosmetic results have been adequate so far. Vol. 40 No. 3 Breast Conserving Surgery with Random Rotational Flap 75

Figure 12 The specimen A: The specimen with tissue orientation B: Specimen mammogram shows the tumor and surrounding breast tissue B

A B

C D Figure 13 After breast-conserving therapy with a random skin flap from the lateral chest wall shows no deformity A: Lateral view, 1-week post-surgery B: Anterior view, 1-week post-surgery C: Lateral view, 1-month post-surgery D: Anterior view, 1-month post-surgery 76 Chirappapha P, Kitudomrat S Thai J Surg Jul. - Sept. 2019

Conclusion REFERENCES Oncoplastic techniques have an important role in 1. Baum M. Is it time for a paradigm shift in the training of breast breast-conserving therapy. The random lateral chest wall surgeons as a subspecialty? Breast 2003;12:159-60. flap is one such technique, and has good esthetic results. 2. Skillman JM, Humzah MD. The future of breast surgery: a new This is a simple technique able to replace latissimus dorsi subspecialty of oncoplastic breast surgeons? Breast 2003;12:161- 2. musculocutaneous flap in certain situations, especially 3. Prakasit Chirappapha, Panuwat Lertsithichai, Thongchai Su- those in which tumors are located at the outer part of the karayothin, et al. Oncoplastic techniques in breast surgery for breast. special therapeutic problems. Gland Surgery 2016;5:75-82 The THAI Journal of SURGERY 2019;40:77-96. Official Publication of The Royal College of Surgeons of Thailand

Abstracts of the 44th Annual Scientific Congress of The Royal College of Surgeons of Thailand, 13-16 July 2019, Ambassador City Jomtien Hotel, Pattaya, Chon Buri, Thailand (Part I)

GENERAL SURGERY

increased complications. Most procedures were done by fel- A 5-YEAR RETROSPECTIVE REVIEW ON ACUTE lows, by which the complication rate and number of attempts COMPLICATIONS AND ASSOCIATED FACTORS OF were higher than by residents or staffs; however, there were THOSE COMPLICATIONS OF CENTRAL VEIN CATH- no statistical significance. ETERISATION IN THE DEPARTMENT OF SURGERY, Conclusions: Overall complication rate was 3.7%, SIRIRAJ HOSPITAL which required intercostal chest drainage for pneumothorax in 1 case (0.8%), which was about the same as Parienti JJ (0.5% of Bounleua Litdang, Sasima Tongsai, Chainarong jugular vein and 1.5% for SCV insertions). Multiple attempts to Phalanusitthepha, Vitoon Chinswangwatanakul catheterisation was the only independent factor that was signifi- Department of Surgery, Faculty of Medicine, Siriraj Hospital, cant to complications. The interventions for acute complications Mahidol University, Bangkok Noi, Bangkok 10700, Thailand were intercostal chest drainage and vascular repair. Keywords: Central venous catheterisation, Hemothorax, Background: Central venous catheterisation has been Pneumotharax, Intercostal chest drainage used frequently in the hospital setting for various reasons. Objectives: To estimate the acute complication rates in central venous catheterisation in patients treated at the depart- A COMPARISON BETWEEN SODIUM PHOSPHATE ment of surgery, Siriraj Hospital and to determine the factors AND POLYETHYLENE GLYCOL FOR BOWEL associated with those complications. PREPARATION FOR COLONOSCOPY AT VAJIRA Materials and Methods: This is a retrospective chart HOSPITAL review for central venous catheterisation by surgeons in the operation room in Siriraj hospital from the 1st of January 2012 Thanacom Thapananon, to the 31st of December 2016; which has shown that there are Rangsima Thiengthiantham, Natthaphon Santrakul very few complications from this procedure. Department of Surgery, Vajira Hospital, Bangkok 10300, Results: There were a total of 22 reported complica- Thailand tion cases, which are mainly arterial cannulations and hemo/ pneumothorax. Arrhythmia had been noted by the anesthsiolo- Background: Bowel preparation is usually required be- gist, but were rarely noted or reported in the operative notes. fore colonoscopy. Bowel preparation agents at Vajira hospital Patient characteristics such as BMI, gender, diabetes or cancer included Sodium Phosphate (NaP) and Polyethylene glycol patients had no clinical correlation to complications; however, (PEG). However, PEG is often used for in-patients, since the use of anti-coagulation and/or anti-platelet medications has NaP is an osmotic laxative which may lead dehydration and a P-value of 0.05. The timing of operation was not related to electrolyte imbalance. 77 78 Abstracts Thai J Surg Jul. - Sept. 2019

Objective: This study was designed to compare the conversion from laparoscopic to open ventral hernia repair. efficacy and adverse effects between using NaP and PEG. Conclusions: The present study suggests that laparo- Materials and Methods: Data of in-patients who were scopic ventral hernia repair may result in a shorter length of given either NaP or PEG for bowel preparation in Vajira hos- hospital stay compared to open ventral hernia repair, perhaps pital was collected from January to December 2016. due to less postoperative drainage and fewer surgical site infec- Results: There was no significant differences between tions. Laparoscopic ventral hernia repair should be considered NaP and PEG in terms of efficacy of bowel preparation, but the procedure of choice in selected patients. NaP was significantly associated with increased serum sodium (+1.74 mmol/L) and decreased serum potassium (-0.52 mmol/L) concentrations, compare with PEG. However, the ACCURACY FOR DIAGNOSIS OF ACUTE APP ENDI- cost of bowel preparation was lower with NaP (-184 Baht, or CITIS BY RIPASA SCORE AND ALVARADO SCORE a 42% reduction per person). Conclusion: NaP can be used, with caution, for bowel Panika Thawatchaimangmee1, Kanikar Laohavichitra2 preparation for in-patients, with minimal adverse effects to 1Department of surgery, Rajavithi Hospital, Bangkok, Thailand the serum electrolytes level. 2Department of surgery, Rajavithi Hospital, College of Keywords: Sodium Phosphate, Polyethylene glycol, Medicine, Rangsit University, Bangkok 10400, Thailand Bowel preparation, Efficacy, Electrolytes Background: Acute appendicitis is one of the most common emergency surgical condition. Diagnosis of acute A COMPARISON OF LENGTH OF HOSPITAL STAY appendicitis mostly use clinical evaluation and some labo- BETWEEN OPEN AND LAPAROSCOPIC VENTRAL ratory investigation. There are two clinical scoring system HERNIA REPAIR has been used in diagnosis. The Alvarado score is the most popular one but has been reported low accuracy among the Tatree Janpatompong, Suppa-ut Pungpapong Asian population in some studies. Later, RIPASA score has Department of General Surgery, King Chulalongkorn Memo- been developed with better accuracy compared to Alvarado rial Hospital, Bangkok, Thailand score in Asian group. Therefore, this study aimed to compare diagnostic accuracy between Alvarado score and RIPASA Background: The superiority of laparoscopic ventral score in the Thai population. hernia repair over the conventional open ventral hernia repair Materials and Methods: 163 consecutive patients who has been well documented. However, the existing literature have clinical suspected of acute appendicitis were included do not compare the length of hospital stay between the two to the study. Both Alvarado score and RIPASA score were operations in Thailand. applied to all patients prospectively. The histopathology of Objectives: To determine whether there is a difference appendix in case of underwent appendectomy or clinical fol- in length of hospital stay between open and laparoscopic low up one month without surgery was been used to analyzed ventral hernia repair. with both scoring systems by cut off 7 for Alvarado score and Materials and Methods: A retrospective review of 7.5 for RIPASA score which indicates a probable for acute patients who underwent open and laparoscopic ventral hernia appendicitis. Sensitivity, specificity, positive predictive value repair at King Chulalongkorn Memorial Hospital from Janu- (PPV), negative predictive value and accuracy of both scoring ary 2013 to June 2018 was performed. Length of hospital stay systems were evaluated. was defined as the period between date of operation and date Results: Of 163 patients, 127 underwent appendectomy of discharge from the hospital. which 115 patients had histopathological confirmed diagnosis Results: A total of 146 patients underwent ventral hernia but 12 normal appendixes were reported and 36 patients were repair during the study period. Fifty patients (34%) underwent observed by clinical. Sensitivity, specificity, NPV, PPV and open ventral hernia repair and 96 patients (66%) underwent accuracy of Alvarado score were 83.5%, 62.5%, 61.2%, 84.2% laparoscopic ventral hernia repair. The mean length of hospi- and 80.2% respectively meanwhile they were 92.2%, 50%, tal stay was 6.2 days in the open ventral hernia repair group 72.8%, 81.5% and 78.6% respectively for RIPASA score (p- (range 2 to 14 days) and 3.6 days in the laparoscopic ventral value <0.001 in all modalities) hernia repair group (range 2 to 6 days). No patient underwent Conclusions: RIPASA score provided more sensitive Vol. 40 No. 3 Abstracts 79 than Alvarado score but gave less accuracy in diagnosis of aneurysmal change in AVF was 5.7%. The aneurysmal change acute appendicitis in the Thai population. rates at 15, 30, 45, 60 months were 2.1%, 3.3%, 21.2%, and Keywords: RIPASA score, Alvarado score, Acute ap- 32.2%, respectively. The risk factors of aneurysmal change pendicitis were inconclusive due to retrospective review of incomplete data from medical record and the low incidence of events. Keywords: Hemodialysis, Aneurysmal change, Arte- ANEURYSMAL CHANGE IN ARTERIOVENOUS FIS- riovenous fistula, Thailand TULAS: RETROSPECTIVE ANALYSIS FROM SINGLE INSTITUTE IN THAILAND EARLY OUTCOME AND FEASIBILITY OF AMBU- Praphasinee Simarangsan, Kritaya Kritayakirana LATORY GROIN HERNIORRHAPHY IN SINGLE Department of Surgery, Faculty of Medicine, Chulalongkorn INSTITUTE University, Pathum Wan, Bangkok 10330, Thailand Tanapol Siewseng1, Pusit Fuengfoo2, Sermsak Hongjinda2, Background: Aneurysmal change is one of the most Annuparp Thienhiran2, Krisana Nongnuang3 common complication in arteriovenous fistula (AVF). The 14th year General Surgery resident, Phramongkutklao Hospital, cut off size for aneurysm in this study was 2 centimeters or Bangkok 10400, Thailand aneurysmal change that needs intervention. 2Department of Surgery, Phramongkutklao Hospital, Bangkok Objectives: To evaluate the incidence, the onset, and 10400, Thailand the risk factors of aneurysmal change in arteriovenous fistula 3Department of Anesthesiology, Phramongkutklao Hospital, (AVF). Bangkok 10400, Thailand Materials and Methods: This retrospective observation study was carried out in King Chulalongkorn Memorial Hos- Background: Inguinal hernia is one of common sur- pital in patients who underwent surgical AVF creation between gical disease in Thailand. Ambulatory herniorrhaphy might January 2013 and December 2017. Patient’s demographics, be conventional procedure in some hospitals, but not in our comorbidities, vascular access characteristics were analyzed. practice currently. This day-case surgery has been proved to Results: Two hundred ten end stage renal disease pa- be an alternative standard approach and continued growing tients underwent AVF surgery, most were female 115 (54.8%) due to lower hospital cost and more satisfied personalized with a mean age of 60.9 ± 14.5 years. AVF sites were 77 patient care. (36.7%) radiocephalic, 56 (26.6%) brachiocephalic, 1 (0.5%) Objectives: This study intent to determine the success radiobasilic, 1 (0.5%) unspecified anticubital, 75 (35.7%) rate and feasibility of ambulatory or day-case hernia surgery unspecified location which were 151 (71.9%) left side and in our center. The standard Lichtenstein repair under local 59 (28.1%) right side. The incidence of aneurysmal change anesthesia technique (ambulatory group) was also compared in AVF was twelve cases (5.7%). The aneurysmal change to conventional approach (control group) which repair under rates at 15, 30, 45, 60 months were 2.1%, 3.3%, 21.2%, and spinal anesthesia or general anesthesia in term of early opera- 32.2%, respectively. By using Cox Regression, the age did tive outcomes. not influence the incidence of aneurysmal change p( = 0.079, Materials & Methods: This study was designed as 95% CI 0.930-1.004). By using Log-rank test, the gender did prospective cohort study by enrollment of all patients with not influence the incidence of aneurysmal change (OR 1.039 unilateral inguinal hernia who obtained surgery between p = 0.308). Twelve patients that developed aneurysmal change October 2018 to April 2019. The inclusion criteria were pa- had comorbidities included 11 (91.7%) hypertension (HT), tients with Nyhus classification 1-3B, voluntary consent and 2 (16.7%) diabetic mellitus (DM), 7 (58.3%) dyslipidemia surgeon preference technique. They were purposive sampling (DLP). By using Log-rank test, the median onset to aneurysm assigned to either ambulatory group or conventional groups. change for HT was 38 months and non HT patients were 4 Ambulatory hernia protocol composed of preemptive pain months (p = 0.038), DM and non DM patients were 2 and 38 control, local inguinal nerve block, optional deep sedation months (p = 0.017), DLP and non DLP patients were 31 and and post anesthetic discharge score (PADS) evaluation before 45 months (p = 0.054). discharge. The predetermined PADS score higher than 9 was Conclusions: From this single study, the incidence of the criteria for hospital discharge and the system of fast tract 80 Abstracts Thai J Surg Jul. - Sept. 2019 readmission was established. Outcome variables monitored between September 2017 and November 2018 were carried included: duration of surgery, early postoperative complica- out. Silk sutures (size 2-0) were used in Group A, while Group tion, length of hospital stay, hospital cost, resumed normal B received non-absorbable polymer clips. Demographic and activities of daily living and any complication at 30 days. intra-operative data were recorded. Post-operative complica- Results: During study, 29 of 125 patients (23.2%) were tions such as bile leakage, surgical site infection or pancreatitis ambulatory group while 96 patients (76.8%) were treated as were noted if present. Liver function tests were repeated 2 usual approach. Postoperative evaluation revealed a case of weeks and 3 months after surgery. If patients experienced lower than 9-PADS score and a case asthmatic attack neces- post-operative abdominal pain, constipation, fever or jaundice; sitated overnight observation resulted in 93.1% success rate. ultrasound was recommended. The ambulatory group are younger in age (p = 0.012), shorter Results: No statistically significant difference were duration of surgery (75 vs 90 mins, p = 0.005), resumed normal observed in post-operative complications, hospital stays, activities of daily living (5 vs 7 days, p < 0.001) were observed. operating times and intra-operative blood loss between silk No significant difference was found in early postoperative sutures and non-absorbable polymer clips. None of LC pro- complication within the first week and hospital cost. cedures were converted into open cholecystectomy and none Conclusion: This study offers evidence to prove that of post-operative complications had bile leakage. Only 1 case ambulatory inguinal hernia is a safe, cost-effective and prac- was re-admitted during follow up 2 weeks after surgery that tically alternative to conventional inguinal hernia surgery in was diagnosed dyspepsia. our hospital. Conclusion: Ligating cystic duct and artery with silk Keywords: Ambulatory, Groin herniorrhaphy sutures during LC proved to be as successful and effective as that of non-absorbable polymer clips, in terms of safety, operative times, post-operative complications and costs. EFFICACY OF SILK SUTURES COMPARED WITH Keywords: Laparoscopic cholecystectomy, Hem-o-lok NON-ABSORBABLE POLYMER CLIPS FOR CYSTIC clips, Silk sutures, Bile leakage DUCT LIGATION IN LAPAROSCOPIC CHOLE- CYSTECTOMY: A PROSPECTIVE RANDOMIZED CONTROLLED STUDY FACTORS INFLUENCING THE EARLY AND LATE OVERALL SURVIVAL AFTER ENDOVASCULAR Rapeephan Na Nan, Akkaraphorn Deeprasertvit ANEURYSM REPAIR FOR RUPTURED ABDOMINAL Department of General Surgery, Police General Hospital, AORTIC-ILIAC ANEURYSM Pathumwan, Bangkok 10330, Thailand Chinapath Vuthivanich1, Khamin Chinsakchai1, Background: Laparoscopic cholecystectomy (LC) Suneerat Kongsayreepong2, Chumpol Wongwanit1, is the gold standard in gallbladder removal surgery. Despite Nuttawut Sermsathanasawadi1, Kiattisak Hongku1, the drastic improvement LC has to offer, there is still much Suteekhanit Hahtapornsawan1, Nattawut Puangpunngam1, debate regarding the most effective method in ligating cystic Tossapol Prapassaro1, Chanean Ruangsetakit1, duct and cystic artery during LC. Non-absorbable polymer Pramook Mutirangura1 clips (Hem-o-lok) are easy to use and do not cause artifacts 1Division of Vascular Surgery, Department of Surgery, Faculty during CT/MRI scans but the cost is very high. This study has of Medicine, Siriraj Hospital, Mahidol University, Bangkok, suggested to use non-absorbable suture materials (silk sutures) Thailand for ligation as surgical knots are easy to apply, secure and the 2Department of Anesthesiology, Faculty of Medicine Siriraj cost is significantly lower. Hospital, Mahidol University, Bangkok, Thailand Objective: To evaluate the efficacy of silk sutures in ligating the cystic duct comparison post-operative bile leakage Background: Ruptured abdominal aortic-iliac aneurysm with non-absorbable polymer clips. Furthermore, operative (ruptured AAIA) is one of the most fatal conditions requiring times, post-operative complications and the cost were into emergency surgical intervention. Endovascular aneurysm consideration. repair (EVAR) is a minimally invasive procedure for ruptured Materials & Methods: A prospective randomized con- AAIA and now widely acceptable in vascular anatomically trolled trial study of 90 patients who had indications for LC suitable cases. There is still controversy regarding the factors Vol. 40 No. 3 Abstracts 81 related to overall survival following emergency EVAR. pressure (IAP). Objective: To determine risk factors influencing the Objectives: To obtain IAP data in patients with abdomi- early and late overall survival following emergency EVAR nopelvic injury at Thammasat University Hospital (TUH), for ruptured AAIA. Thailand, and to identify risk factors associated with IAH/1o Materials and Methods: Data of ruptured AAIA ACS, and other outcomes following the development of patients treated with EVAR from August 2010 to December IAH/1o ACS. 2017 were retrospectively reviewed. Patient’s characteristics, Materials and Methods: The present study was a retro- pre-operative data, intra-operative findings, and post-operative spective review of abdominopelvic injury patients who were outcomes were analyzed. Factors associated with 1-month and admitted at the intensive care unit (ICU) of TUH between 1-year overall survival were analyzed in this study. 1st January to 31st December 2018. Information on age, sex, Results: 73 patients (84% male, mean age 71±12 body weight, height, initial vital signs, initial laboratory data years) were included in the study. Aneurysm morphologies and imaging, mechanism of injury, organ-specific injury, ab- were infrarenal in 43 cases (59%), aorto-iliac in 18 cases breviated injury scales (AIS) and injury severity scores (ISS), (25%) and iliac in 12 cases (16%). The majority of cases operations, interventions, IAP of the patient, and results of were performed with aorto-uniliac graft 38 cases (52.1%). In treatment was collected and analyzed to determine the inci- addition, 21 cases (28.8%) required aortic balloon occlusion dence of, and risk factors associated with, IAH /1o ACS. to maintain hemodynamic stability. Secondary interventions Results: Thirty-eight abdominopelvic injury patients were required in 20 cases (27.4%). The 1-month and 1-year were identified. Most of the patients were young (mean, overall survival rates were 81.7% and 53.5% respectively. 32 years), male (65%), and had blunt trauma (90%). The Multiple Cox regression analysis showed that independent incidence of IAH and 1o ACS are 16% (6 cases) and 3% (1 predictive factors for 1-month and 1-year overall survival case), respectively. Patients who presented with abdominal were post-operative myocardial infarction [adjusted HR 5.90, distention, organ evisceration, pelvis fracture, colonic injury, (95% CI 1.42 – 24.46); P 0.014 and adjusted HR 4.28, (95% multiple abdominal organ injuries, high serum creatinine, CI 1.67-10.97); P 0.002 respectively] and abdominal compart- low serum bicarbonate, elevated INR, high AIS (abdominal ment syndrome [adjusted HR 12.07, (95% CI 1.60 – 91.08); P injury including pelvis, lower extremity injury including 0.016 and adjusted HR 4.21, (95% CI 1.08 – 16.34); P 0.038, pelvis), and high ISS had significantly higher risks p<0.05( ) respectively]. of developing IAH. Patients with IAH had a significantly Conclusion: Emergency EVAR in ruptured AAIA is fea- increased use of blood components, increased need for sible in anatomical suitable patient. Post-operative myocardial abdominopelvic operations, need for intervention radiology, infarction and abdominal compartment syndrome indicated LOS, and mortality. poor early and late survival prognosis of the patients. Conclusion: Awareness of IAH and 1oACS in abdominopelvic injury patients is important, and early intervention may prevent complications and death. INCIDENCE AND RISK FACTORS ASSOCIATED Keywords: Abdominopelvic injury, Intraabdominal WITH INTRAABDOMINAL HYPERTENSION AND pressure, Intraabdominal hypertension, Abdominal compart- PRIMARY ABDOMINAL COMPARTMENT SYN- ment syndrome DROME IN ABDOMINOPELVIC INJURY

Krisada Nakornchai, Amonpon Kanlerd INCIDENCE OF TREATMENT FAILURE IN ESOPHA- Department of Surgery, Faculty of Medicine, Thammasat GEAL PERFORATION: A RETROSPECTIVE STUDY University Kanokwan Boonprachern, Vor Luvira, Ekkapong Satitkanmanee Background: Intraabdominal hypertension (IAH) Department of Surgery, Faculty of Medicine, Khon Kaen and primary abdominal compartment syndrome (1oACS) University, Khon Kaen 40002, Thailand are a consequence of abdominopelvic injury. The overall Background: Esophageal perforation is a fatal surgical incidence of IAH and ACS may vary from 30 to 70% and 10 emergency. Treatment varies, tailored by the status of the indi- to 35%, respectively. According to current guidelines, intra- vidual patient; however, treatment failure remains a problem. vesicular pressure is used to as a substitute for intraabdominal Objectives: Our study aimed to identify the incidence 82 Abstracts Thai J Surg Jul. - Sept. 2019 of treatment failure and so evaluated the factors associated Obstructed rectal cancer requires pre-multidisciplinary with treatment failure. therapy diversion colostomy. Because of technical difficulties Materials and Methods: We retrospectively reviewed to perform primary rectal cancer resection in poorly bowel the medical record of 23 patients with esophageal perforation preparation in near-completely obstructing rectal cancer treated between January 2006 and March 2017. Failure was (T4) which found in most Thai patients in referral system, defined as ‘needs secondary intervention’, ‘the occurrence of stoma usually performs without resection and anastomoses leakage’ and/or fistula. Clinical data were analyzed. in one setting. Results: Median age was 45 years (range, 3–78). There Objective: In Minimal access surgery (MAS) era, with were 15 males and 8 females. Iatrogenic perforation-occurring newly appropriate instruments and accumulation of expertise, in 65.2% of the patients–was the most frequent cause of this we found that laparoscopic procedure gives us better surgical condition; while Boerhaave’s syndrome was detected in 5 approach for TME in rectal cancer compare to open surgery, patients (21.7%). Median time for diagnosis was 30 h (range, even in conditions of obstructing rectal cancer obviated usual 0–384). Four patients (17.4%) underwent conservative treat- bowel preparation. We present early surgical outcomes to ment. Three patients (13%) received endoscopic treatment confirm the safety and efficiency of Laparoscopic LAR in (clipping, stent); surgery was performed in 16 (69.6 %) with non-bowel preparation obstructing rectal cancer cases. primary repair, esophagectomy, debridement, exclusion and Materials & Methods: We present 5 cases of rectal diversion. Failed esophageal perforation treatment occurred cancer cases presented with circumferential rectal mass, in 9 patients (39.1%). Univariate analyses revealed malnutri- without obvious distant metastasis by preoperative MRI, need tion (p=0.02), mechanical ventilator (p=0.001), and primary diversion colostomy before multidisciplinary treatment. We repair (0.007) were associated with treatment failure. None of performed Laparoscopic LAR with distal colonic washout these, however, were significant in the multivariate analysis. and diversion stoma for all. Technically details of procedure Neither delayed diagnosis (> 24 h) nor etiology had any effect will present. on failure of treatment. One patient died (4.3 %). Results: All 5 cases were ASA class I and II. Age dis- Conclusions: Since esophageal perforation is quite a tributions were 50, 55, 62, 68 and 76 years old. Male -female rare condition at our center. Our study was unable to deter- ratio was 1/4. No operative morbidity-mortality for all. mine the risk factor(s) for failure of treatment of perforation. Conclusion: These early surgical outcomes confirm Further study needs to follow the single guideline prospec- the safety and efficiency of laparoscopic LAR in non-bowel tively in order to evaluate the precise risk factors for, and preparation-partial obstructing rectal cancer cases. outcomes of, treatment.

MAMMOGRAPHIC MICROCALCIFICATION AND LAPAROSCOPIC LOW ANTERIOR RESECTION BREAST CANCER: A RADIO-PATHOLOGIC COR- FOR OBSTRUCTING RECTAL CANCER WITHOUT RELATION BOWEL PREPARATION Chompoonut Achavanuntakul, Wilairat Prasert, Saipan Khunpugdee, Hathaiwan Moungthard, Wanrudee Lohitvisate Chayanit Sirisai, Worapong Anuponganant 1 Department of Surgery, Faculty of Medicine, Thammasat Gastrointestinal Division, National Cancer Institute of University, Pathumtani 12120, Thailand Thailand, Bangkok 10400, Thailand 2 Department of Radiology, Faculty of Medicine, Thammasat University, Pathumtani 12120, Thailand Background: When discussing treatment options for rectal cancer with patients preoperatively, both surgeons and Background: Breast cancer is the most common can- patients’ preferences play a role in the decisions about treat- cer in women and is responsible for the most cancer-related ment options. Multidisciplinary treatments are standard for deaths worldwide. Patients with breast cancer may not show all rectal cancer therapy. Most patients prefer primary cancer noticeable symptoms but may be diagnosed from combined resection with anastomoses in addition to diversion colos- screening with mammography and ultrasound. One important tomy at first operation even defecation problems following mammographic finding is abnormal microcalcification. How- a low anastomosis, such as fecal incontinence and urgency. ever, the positive predictive value of malignancy for each type Vol. 40 No. 3 Abstracts 83 of abnormal microcalcification is still uncertain. tients. There were 29 laparoscopic procedures (9 insertions Objectives: To determine the positive predictive value and 25 revisions) and 177 opened procedures (161 insertions of malignancy for each type of mammographic abnormal and 11 revisions). Forty-eight percent of cases were female. microcalcification. Average age of patients is 55.49 years old. In opened insertion Materials & Methods: The present study was a retro- procedures catheters survival is 20.52 months compared to lap- spective review of 62 women with abnormal microcalcifica- aroscopic insertion, means catheter survival is 19.75 months tions who underwent mammography-guided needle localized (p=0.964). In opened revision procedures, means catheter excision between September 2011 and December 2018. survival is 18.52 months compared to laparoscopic revision, Results: There were 72 lesions with various morpho- means catheter survival is 15.82 months (p=0.875). The lapa- logic types of abnormal microcalcifications in 62 patients. roscopic revision was performed in cases with multiple time of The positive predictive values of malignancy were as follows: catheter malfunction, the operative findings were malposition coarse heterogeneous 25%, amorphous 38%, fine pleomorphic (39.13%), omental wrap (34.78%), intraperitoneal organs wrap 42% and fine linear/linear branching 33%. (8.7%) and fibrin coat (4.35%). Operative procedures were Conclusion: Abnormal microcalcifications on mam- laparoscopic repositioning with adjunct procedures; fixation mography (BI-RADS classification 4 to 5) have high positive (47.83%), fibrin removal (13.04%), omentopexy (13.04%), predictive values, indicating the need for tissue diagnosis. adhesiolysis (8.7%) and omentectomy (4.35%). Keywords: Breast cancer, Mammography, Microcal- Conclusion: Between all groups, there was no statistic cification, Radio-pathologic correlation, Needle localized significant of catheter survival rate. In laparoscopic revision excision group, there were difficult cases which need adjunct procedure to correct causes of catheter malfunction.

MANAGEMENT OF PERITONEAL DIALYSIS CATHE- TER MALFUNCTION: OPENED OR LAPAROSCOPIC MORTALITY RATE AND ASSOCIATED FACTOR OF TECHNIQUE? NECROTIZING FASCIITIS

Chatiyaporn Manomayangoon, Patchareeya Poonyasanthan, Thitipong Setthalikhit Phuphat Vongwattanakit, Sopark Manasnayakorn Department of surgery, Surin hospital, Surin 32000 Department of surgery, King Chulalongkorn memorial hospital, Bangkok 10330, Thailand Background: Necrotizing fasciitis (NF) is a serious and fatal condition where there is rapid progression of inflamma- Background: Peritoneal dialysis (PD) was recom- tion of skin, subcutaneous tissue, and superficial fascia. The mended by the national policy for end state renal disease rapidly progressive in nature and if not promptly treated leads patients since 2007. Second most common problem of PD to significant morbidity or mortality. catheter is mechanical malfunction that can be corrected by Objectives: This study was designed to explore surgery. In last two decades, there has been increased use of the mortality rate and associated factors of necrotizing laparoscopic technique to correct extraluminal obstruction or fasciitis malposition of PD catheters. However, there is lacking data Materials & Methods: Observational prospective co- to conclude which technique is recommended. hort study conduct in Surin hospital, from February 2018 to Objectives: To compare between opened and laparo- March 2019. Patient was diagnosed necrotizing fasciitis by scopic techniques for insertion and revision of PD catheter clinical manifestations and/or diagnosis after surgical debride- in 10 years in King Chulalongkorn Memorial Hospital. ment. Then follow up clinical outcome are amputation, length Materials and Methods: Between January 2008 and of stay and dead. December 2017, all patients who underwent operation of Results: Total of 176 patients, the mortality rate of PD catheter were identified in the local database. Demo- necrotizing fasciitis was 21.59% (95% CI 15.76–28.41). graphics data, operative findings, procedure, catheter survival Mean age was 67.63±14.34 in mortality group, 63.28±14.67 were collected and analyzed by statistic software SPSS in survival group. Most common comorbidities were DM version 22. (23.86%) and CKD (17.61%), but in immunocompromised Results: There were 206 procedures done in 187 pa- patient (5.11%) are high-risk group to mortality (p-value = 84 Abstracts Thai J Surg Jul. - Sept. 2019

0.0110). On admissions SBP < 90 mmHg, DBP < 60 mmHg, analysis showed that independent adverse prognostic factors MAP < 65 mmHg, use of inotropic drug, qSOFA score ≥ 2 are were perineural invasion (HR: 3.94, 95% CI: 1.90-6.40, p < associated in mortality. Significant risk factors from Simple 0.01), N2 nodal status (HR: 2.98, 95% CI: 1.16-7.64, p = 0.23), and multiple logistic regression analysis for association with positive resection margin (HR: 1.93, 95% CI: 1.19-3.14, p = mortality of necrotizing fasciitis were qSOFA score ≥ 2 (p 0.047), lymphovascular invasion (HR: 1.73, 95% CI: 1.03-2.9, = < 0.0001), INR > 1.3 (p = 0.0230), BUN > 20 mg/dl (p = p = 0.03) and pre-operative albumin < 3.5 g/dl (HR: 1.71, 95% 0.0180). Mortality rate according by bacteriology results in CI: 1.09-2.67, p = 0.02). Tumor with perineural invasion also mortality group are gram-positive bacteria (73.68%), gram had higher rate of lymphovascular invasion. Patient with low negative bacteria (13.16%), polyorganism (7.89%) and fungus albumin level had higher proportion of T3 and T4 staging, and (2.63%). Most common organism is group A. beta-hemolytic poorly differentiated tumor. Notably, pre-operative biliary streptococcus that seen in both groups. drainage and total bilirubin were not significant predictive Conclusion: Present of SBP < 90 mmHg, DBP < 60 factors. mmHg, MAP < 65 mmHg on admissions, the use of inotropic Conclusion: Poor prognostic factors for periampullary drug, qSOFA score ≥ 2, INR >1.3 and BUN >20 mg/dl were carcinoma after PD included N2 nodal status, perineural inva- associated factor for mortality of NF sion, lymphovascular invasion, positive resection margin and Keywords: Necrotizing fasciitis, Mortality low albumin level. Therefore, pre-operative nutritional status should not be overlooked. Keywords: Periampullary cancer, Pancreaticoduode- OUTCOME AND PROGNOSTIC FACTORS FOR PERI- nectomy, Prognostic factor, Overall survival AMPULLARY CARCINOMA AFTER PANCREATICO- DUODENECTOMY: A SINGLE TERTIARY CENTER EXPERIENCE OUTCOMES COMPARISON BETWEEN BASILIC VEIN TRANSPOSITION AND ARM STRAIGHT Tunyaporn Kumjornkijbovorn, Prawat Kositamongkol, GRAFT FOR HEMODIALYSIS IN END STAGE RENAL Chutiwichai Tovikkai, Prawej Mahawithitwong, DISEASE Wethit Dumronggittigule, Pholasith Sanserestid, Somchai Limsrichamrern, Yongyut Sirivatanauksorn Boonying Siribumrungwong, Kesanan Prajumsukh, Department of Surgery, Faculty of Medicine Siriraj Hospital, Saritphat Orrapin, Kanoklada Srikuea Mahidol University, Thailand Division of Vascular and Endovascular Surgery, Department of Surgery, Faculty of Medicine, Thammasat University Hospital, Background: Pancreaticoduodenectomy (PD) remains Pathum Thani, 12120, Thailand the standard treatment archiving long term outcome for peri- Background: According to current guideline, primary ampullary carcinoma. option for vascular access is autogenous AVF and distal Objective: To evaluate outcome and prognostic factors autogenous AVF is recommended because of minimum of of PD in large tertiary center in Thailand. complication, less revisions and less hospital admissions. Materials and Methods: This is a single-center, ret- However, in some case that cephalic vein is smaller than 2 rospective study of patients who underwent PD for periam- mm or failure of previous distal AVF, the guideline suggests pullary carcinoma at Siriraj Hospital from 2011 to 2015. Brachiobasilic AVF (BBAVF) and arm straight graft (ASG) Univariate and multivariate analyses were performed to iden- as the alternative access. But the results of upper arm vascular tify poor clinicopathological prognostic factors for survival access between BBAVF and ASG for hemodialysis are still after PD. controversial. Results: The total of 128 patients who underwent PD Objective: This study aimed to compare relevant out- for periampullary carcinoma at Siriraj Hospital between comes between BBAVF and ASG. 2011 and 2015 were included. Five-year overall survival was Materials and Methods: All BBAVF and ASG cases 16% with median survival time of 23 months. Patients with from August 2014 to November 2018 were reviewed. Base- ampullary-cancer (25.7%) and duodenal cancer (21.1%) had line characteristics were collected and compared. Outcomes longer 5-year survival than pancreatic cancer (13.3%) and included operative outcomes (i.e., operative time, length of distal cholangiocarcinoma (0%) (p < 0.001). Multivariate stay), postoperative complications (i.e., wound infection, Vol. 40 No. 3 Abstracts 85 seroma, hematoma), and functional outcomes (i.e. maturation retrospectively evaluated patients that had undergone MDCT rate, time to successful first cannulation, reintervention and liver in Songklanagarind Hospital between January 2016 and 1-year primary patency rate) were compared between groups December 2016. Two experienced hepatobiliary surgeons using multivariable linear, logistic regression analysis and interpreted the image and classified type of variation inde- Cox proportional hazard model for continuous, categorical pendently. and time to event outcomes, respectively. Results: Classical portal vein branching (type 1) were Results: Twenty-eight (30%; 21 primary and 7 second- observed in 73 patients (81%). The most frequent type of ary) and 66 (70%) patients had BBAVF and ASG respectively. portal vein variation was type 4 (Segment VII branch separate All baseline characteristics are not significantly different branch of RPV) which was observed in 7 (8%) of the patients. between groups except ASG had more hypertensive patients The second most common variation was a type 5 (Segment VI (94% vs 75%; p = 0.015) and less previous ipsilateral access branch separate branch of RPV) which was noted in 4 (4%) (11% vs. 43%; p < 0.001) than BBAVF. Operative times and of the patients. Other unusual variations in this study are one postoperative complications were not significantly different (1%) of the patient had type 2 (trifurcation), and three of the between groups. Eighteen (86%) and 42 (81%) were ma- patients (3%) had type 3 (Right posterior vein as the first tured after BBAVF and ASG respectively (p = 0.745). ASG branch of MPV) anatomy. had about 30 days’ shorter time for successful first cannula- Conclusion: Common variation of the hepatic portal tion but with significant worst 1-year primary patency rate vein in Thai people is segment VII branch separate branch [78% (95% CI: 64, 87) vs. 96% (95% CI: 76, 99); hazard from RPV. The variant hepatic portal vein is important. We ratio of 5.7 (95% CI: 1.2, 27.3; p = 0.030)]. Seven patients should understand and recognize before making an operation. (11%) in ASG had reintervention for complications at Keywords: Hepatectomy, Portal vein, Variation, Liver 1 year follow up whereas none in BBAVF but not signi- resection ficant. Conclusion: BBAVF had significant better primary patency rate and might had lower rate of complications than RANDOMIZED CONTROLLED TRIAL COMPARING ASG. Therefore, it should be considered first in anatomical BETWEEN OUTPATIENT BOWEL PREPARATION suitable cases. VERSUS BOWEL PREPARATION IN HOSPITAL FOR COLONOSCOPY

PREVALENCE AND CLINICAL APPLICATION TO Sasithon Ajjimarangsi, Jirat Jirathammaopas LIVER SURGERY OF THE PORTAL VEIN VARIATION Hatyai Surgical Endoscopic Excellent Center, Department of surgery, Hatyai hospital, Hatyai, Songkhla, 90110, Thailand Jakkaput Changsiriwattanathamrong, Nanak Wiboonkwan, Tortrakoon thongkan Background: Bowel preparation is important for a Department of Surgery, Faculty of Medicine, Prince of Song- complete high-quality colonoscopy. We observe that, the kla University, Hat Yai, Songkhla 90110, Thailand patient who drank the laxative drug by own self at home has Background: The Couinaud classification divides the poor bowel preparation and has many problems such as forget liver segment into eight functionally independent segments. to drink or cannot drink complete dose. The functional segment needs its own portal vein, hepatic Objectives: To study quality of bowel preparation in artery, venous outflow, and biliary drainage. Understanding admission vs. OPD before colonoscopy and to development of portal vein variation is the fundamental knowledge using the result of colonoscopy. in preoperative planning, portal vein embolization, and trans- Materials and Methods: We study grade of quality plantation. The portal vein variation if it is not recognized may bowel preparation in 260 patients by separate to two groups. result in hepatic failure. Lack of study of portal vein variation The first, 130 patients were drinking the laxative drug at home in Thailand was identified. by own self preparation we call, “OPD group”. The second, Objective: The aim of this study was to determine 130 patients were drinking the laxative drug in hospital by the types, prevalence rates, and clinical implication of PV the nurse whom prepared the laxative, we called “Admission variations. group”. The colonoscopy was performed by surgeon and was Materials and Methods: The study included 151 grading the bowel preparation. Primary outcome is grading 86 Abstracts Thai J Surg Jul. - Sept. 2019 of bowel preparation. derwent non-curative surgery or endoscopy (Non-curative Results: A total of 260 patients were in the study with a group) and 56 (25.4%) patients received best supportive care mean age 61. There were males 35% and female 65%. Admis- (BSC group). There was significant higher overall survival sion group had a higher rate of quality of bowel preparations (OS) in curative surgery group (p < 0.001). 5-year OS was than the OPD group (73.1% vs. 55.4%, p value < 0.01), a low 22.5% and median survival time was at 32 months (95% CI grade of poor bowel preparations (35.8% vs. 44.6%, p value 10.7-53.3). Older aged did not significantly impact survival < 0.01). The inadequate grade of the Admission group was outcome in all patients although they were over 80 years old. lower (0.4% vs. 1.9%). The time was shortly in the Admission Significant better survival outcome was observed in earlier group (9.8% vs. 12.5%). There was no difference between the stage of disease than advanced stage (p = 0.02). 14 patients rates of polyps, diverticulum and mass detected. had severe complication after curative or non-curative pro- Conclusions: The good bowel preparation has affected cedures. Postoperative mortality rate was 3%. Presence of on the complete high-quality of the colonoscopy. The patient coronary artery disease was an independent risk factor for who drank the laxative at home by own self has low grade severe postoperative complications (p = 0.001) and 30-days of clearance bowel than whom drank the laxative in hospital postoperative mortalities (p = 0.034). by the nurse preparation. This result suggests that, the best Conclusions: Curative surgical resection in elderly colonoscopy should be performed on the admission. patients should be considered regardless of old age. Even Keywords: Colonoscopy, Bowel preparation, Outpatient non-curative treatment also offered better survival than best vs. in hospital supportive care alone. Patients with coronary artery disease might have higher risk of severe postoperative complications. Keywords: Stomach neoplasms, Gastrectomy, Aged, RETROSPECTIVE STUDY OF DIFFERENT MANAGE- Mortality, Esophagogastric junction MENT FOR ELDERLY PATIENTS WITH CANCER OF STOMACH AND ESOPHAGOGASTRIC JUNCTION RISK FACTORS ASSOCIATED WITH BILIARY COM- Thammawat Parakonthun, Chawisa Nampoolsuksan, PLICATIONS AFTER DECEASED DONOR LIVER Jirawat Swangsri, Asada Methasate TRANSPLANTATION Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand Channasa Promyarat, Bunthoon Nonthasoot Department of Surgery, King Chulalongkorn Memorial Background: Surgery is the main modality of treat- Hospital, Bangkok 10330, Thailand ment for cancer of stomach and esophagogastric junction. For patients who cannot tolerate surgery such as elderly patients, Background: Liver transplantation is the curative treat- best supportive care is also a preferable choice. ment for cirrhotic and early hepatocellular carcinoma patients. Objective: To compare survival outcomes and com- The surgical outcomes have been gradually improved, but plications in elderly patients who received different types of biliary complications are still common that affects the graft treatments. function, patient survival and quality of life after liver trans- Materials and Methods: Medical records of 220 plantation. ed adenocarcinoma of stomach or esophagogastric junction Objective: To explore the factors associated with biliary during January 2005 to December 2016 at Siriraj Hospital complications in deceased donor liver transplantation (DDLT) were reviewed and analyzed. All patients were divided into at King Chulalongkorn Memorial hospital. three groups; curative surgery (Curative), non-curative treat- Materials and Methods: Retrospective study in DDLT ment (Non-curative) and best supportive care (BSC) group. at KCMH between January 1st 2007 – December 31st 2017. Survival outcomes and post-treatment complications were The demographic data and factors include type of biliary compared. anastomosis, ischemic time, pre-operative treatment for Results: 102 (46.4%) patients underwent curative HCC, blood loss, blood transfusion and donor age were intended surgery (Curative group), 62 (28.2%) patients un- studied. Vol. 40 No. 3 Abstracts 87

Results: There were 171 DDLT. The overall biliary to 11.5, and OR = 8.68; 95% CI: 1.9 to 39.6, respectively). complication rate was 6.4%, including bile leakage of 0.6 % Conclusion: Risk factors for duodenal perforation post- and biliary stricture of 5.8 %. Type of biliary anastomosis, ERCP included the female patient and presence of duodenal ischemic time, pre-operative treatments for HCC, blood loss, diverticulum. blood transfusion and donor age were not related with biliary Keywords: Duodenal perforation, Risk factors, ERCP complications. But the only factor that was associated with biliary complications significantly was intraoperative cryoprecipitate transfusion (p = 0.029). RISK FACTORS OF IN-HOSPITAL MORTALITY Conclusions: The biliary complications were still the AFTER SURGERY FOR ACUTE AORTIC DISSEC- common surgical complication after DDLT. In our institute TION STANFORD TYPE A IN SONGKLANAGARIND the incidence was 6.4% and the only associated risk factor HOSPITAL was intraoperative cryoprecipitate transfusion. Kawinnooch Boonpipattanapong, Voravit Chittithavorn, Pongsanae Duangpakdee, RISK FACTORS OF DUODENAL PERFORATION Surasak Sangkhathat POST-ENDOSCOPIC RETROGRADE CHOLANGIO- Department of Surgery, Faculty of Medicine, Prince of Songkla PANCREATOGRAPHY University, Hat Yai, Songkhla 90110, Thailand

Wantun chotsamitkul, Ekapobe kittivaraku1 Background: Acute aortic dissection Stanford type A is Department of surgery, Chiangraiprachanukroh hospital, a severe disease, which can cause life-threatening complica- Chiangrai 57000, Thailand tions. Patients who received surgery, have significantly lower in-hospital mortality than a non-operated group, therefore Background: Endoscopic retrograde cholangiopancrea- surgery becomes the gold standard treatment. Previous studies tography (ERCP) is a frequently used procedure for managing have demonstrated several factors associated with mortality. biliary tract diseases. ERCP is less invasive and safer than open However, the significance of each factor varies among studies, operations, but duodenal perforation post-ERCP is a serious which could be caused by the diversities of different centers and life-threatening complication. as well as ethnic populations. Objective: To determine the risk factors for duodenal Objective: The aims of this retrospective study were to perforation post-ERCP. analyze the data of the patients with acute aortic dissection Materials and Methods: The present design was a Stanford type A, that received surgery at Songklanagarind case-control study. During the period between October 2013 hospital, Thailand, in terms of operation and risk factors to to September 2018, we included patients who were admitted in-hospital mortality, so as to find out the postoperative infor procedure codes 5100, 5188, 5187 of the ICD-9. We iden- hospital mortality; for a lead into the risk modifications and tified cases who had duodenal perforation post-ERCP from improvements of surgical techniques for better outcomes. medical records as well as imaging evidence. The controls Materials and Methods: Eighty-eight patients, who were selected from patients who underwent ERCP without had acute aortic dissection type A whom received operative complications, in the ratio of 4:1 for controls versus cases. treatment at Songklanagarind hospital, between January Results: There were 1,160 patients who underwent 2007 and December 2016, were retrospectively evaluated in ERCP during the study period. Duodenal perforation post- terms of: demographic, pre-operative, intra-operative, post- ERCP was identified in 20 patients. A control group 80 patients operative data and outcomes. Multivariate cox regression was chosen. On univariable analysis, presence of duodenal analysis was performed to identify the influence of different diverticulum was significant associated with duodenal per- related-variables on in-hospital mortality. foration post-ERCP (OR = 8.14; 95% CI 2.03 to 32.6). On Results: The in-hospital mortality of 88 surgically multivariable analysis, the female gender as well as presence treated acute aortic dissection type A patients was 22.7 %. of duodenal diverticulum were significantly associated with Overall, the mean age was 53.1 (13.8) years, and the duodenal perforation post-ERCP (OR = 3.45; 95% CI: 1.23 elderly group (age > 70 years old), made up 10% overall. There 88 Abstracts Thai J Surg Jul. - Sept. 2019 were more men than women (67% VS 33%). The significant in the resection group, and 68.8, 45.6 and 24.4 percent in the risk factors for in-hospital mortality were: ASA class 5 [HR RFA group (p = 0.008). The complication rate was 6 percent 12.6359 p-value 0.0024], serum creatinine at higher than 1.3 in RFA group and 22.7 percent in resection group. mg/dL [HR 11.1162 p-value 0.0007], total arch replacement Conclusions: There was no difference in overall survival [HR 21.8094 p-value 0.0004], descending aorta replacement between RFA and surgical resection. However, disease free [HR 25.8479 p-value 0.0094]. FFP transfusion >1500 ml were survival was lower in resection group. the protective factors [HR 0.0476 p-value 0.0336]. Keywords: Radiofrequency ablation, Surgical resection, Conclusion: Even though being uncommon, acute aor- Small hepatocellular carcinoma tic dissection Stanford type A is a life-threatening condition, with a high in-hospital mortality. The significance of each factor varies among previous studies, this could be due to the THE ACCURACY OF PROGNOSTIC SCORING SYSTEMS diversities of centers along with different ethnic populations. FOR POST-OPERATIVE MORBIDITY AND MORTALI- Therefore, this present study provided a local profile, and TY IN PATIENT WITH PERFORATED PEPTIC ULCER facility analysis of patients with surgically treated acute aortic IN BUDDHACHINARAJ PHITSANULOK HOSPITAL dissection Stanford type A. Juthamad Pattom, Thanakorn Rodsakan Deparment of Buddhachinaraj Phitsanulok Hospital, SURGICAL RESECTION VERSUS RADIOFREQUEN- Phitsanulok 65000 Thailand CY ABLATION FOR SMALL HEPATOCELLULAR CARCINOMA Background: The peptic ulcer perforate often present with acute, severe illness that carries a high risk for morbidity Sarat Sanguanlosit, Wipusit Taesombat and mortality. The aim of this study was to compare known Department of Surgery, Faculty of Medicine, Chulalongkorn clinical factors and the four-scoring system’s [American Soci- University, Bangkok 10330, Thailand ety of Anesthesiologists (ASA), Boey, Peptic Ulcer Perforation Background: Radiofrequency ablation (RFA) is now (PULP) and P-POSSUM score] ability to predict mortality one of the curative treatments for small hepatocellular carci- in Perforated Peptic Ulcer (PPU) and its use for screening noma according to Barcelona Clinical Liver Cancer (BCLC) patient’s pre-operative care at intensive care unit. guideline. RFA is widely performed in Asia-Pacific region with Objective: This study aimed to evaluate accuracy of comparable outcome to surgical resection but undetermined prognostic scoring systems for post-operative morbidity and outcome in Thailand. mortality in peptic ulcer perforate patients. Objectives: To evaluate the efficacy of surgical re- Materials and Methods: Retrospective study of pa- section (SR) and radiofrequency ablation (RFA) for single tients undergoing emergency surgery for PPU between 2012 hepatocellular carcinoma (HCC) 3 cm or less. and 2016 were done at Buddhachinaraj Phitsanulok Hospital. Materials & Methods: Between 2008 and 2017, a total Clinical and surgical out comes were analyzed through ad- of 131 (SR, 47; RFA, 84) patients with single, less than 3 cm justed odds ratio (OR) and model AUC. hepatocellular carcinoma with child turcotte pugh (CTP) A Results: Study included 480 patients (Female 22.5%, which first treatment with SR and RFA were enrolled. Their Male 77.5%) with mean age of 61 year. The most common overall survival (OS) and recurrence-free survival (RFS) were site of peptic ulcer perforate were at pre-pyloric area 36.6% compared. with size about 5 mm diameter and post-operative transfer to Results: Mean follow up time of this study was 4.9 ICU about 74 (15.41%). The AUC morbidity prediction for years. At baseline, portal hypertension was found more in RFA scoring systems were as followed: ASA score 0.711; PULP group while tumor size was larger in resection group. The 1-, score 0.720; Boey score 0.696 and P-possum score 0.505. The 3-, 5-overall survival rates were 93.2, 81.8 and 76.4 percent AUC mortality prediction was 0.826 for ASA score, 0.735 for respectively in the resection group, compared with 93.8, 85.2 PULP score, 0.692 for Boey score and 0.552 for P-possum and 67.9 percent in the RFA group (p = 0.667). However, the score. disease-free survival rates were 79.5, 65.8 and 52.4 percent Conclusions: The ASA score may be the better prognos- Vol. 40 No. 3 Abstracts 89 tic scoring system for post-operative morbidity and mortality in Siriraj Hospital during 2014-2016 and were follow up for of PPU patient than PULP,Boey score, and P-POSSUM score. 1 year. The parameter of this study is integrated relaxation However, in case of ASA scoring, there wasn’t sufficient pressure (IRP)Eckardt score, Timed Barium Esophagography number and distribution of information to be used from the compare POEM and 1 year after POEM. data base. Boey score having ROC cure value of 0.69 has Results: This study revealed that the height of barium good distribution of data and easier to keep information when column is relatively decrease both at 1 and 5 min compare to compared with PULP score with more data. IRP. The decrease of IRP value is significantly decrease (r = Keywords: Scoring system, Perforated peptic ulcer 0.283, p = 0.033, and r = 0.35, p = 0.007). In contrast, Eck- (PPU), Morbidity, Mortality ardt’s score and the width of barium column do not significant relation with IRP. From our study, there is significant relation between THE COMPARISON OF TIME BARIUM ESOPHA- the height of barium column and IRP. We suggested that the GOGRAPHY TO ECKARDT’S SCORE FOR AC- Timed Barium Esophagography was recommended for follow CESSING RESPONSE TO PERORAL ENDOSCOPIC up and predict the success of achalasia treatment in patient MYOTOMY IN ACHALASIA PATIENT who underwent POEM. Conclusion: TBE and esophageal HRM were compa- Bunyarit Thongpisitsombut1, rable in assessing efficacy of POEM in treatment of achalasia. Chainarong Phalanusitthepha2 However, Eckardt score do not predictive the decrease of IRP. 1 Gerneral Surgery Division, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand 2 Minimal Invasive Surgery Unit, General Surgery Division, THE RELATIONSHIP BETWEEN INTRAINCI- Department of Surgery, Faculty of Medicine, Siriraj Hospital, SIONAL ANALGESIC INFILTRATION AND OPIOID Mahidol University, Thailand PRESCRIPTION AFTER OPEN INGUINAL HERNIA REPAIR Background: Achalasia is rare neuromotor disease of the esophagus. Even the standard treatment of achalasia is Papawee Chennavasin1, Supparerk Prichayudh2, Laparoscopic Heller Myotomy with fundoplication (LHM), Danita Weerachareonkul3 But recently the new procedure, Peroral Endoscopic Myotomy 1 Department of Surgery, Faculty of Medicine, Chulalongkorn (POEM), have obvious evidence for equivalent outcome for University, Pathumwan, Bangkok 10330, Thailand treatment. The High Resolution Manometry is standard tool 2 Department of Surgery, Faculty of Medicine, Chulalongkorn for follow up and surveillance to predict the success of treat- University, Pathumwan, Bangkok 10330, Thailand ment outcome. Due to the lack of instruments in Thailand, 3 Department of Anesthesiology, Faculty of Medicine, Chul- those were ignorish and Eckardt’s clinical score play signifi- alongkorn University, Pathumwan, Bangkok 10330, Thailand cant role during follow up period. In contrast, Timed Barium Esophagography also one of the tools for access the severity. Background: Open inguinal hernia repair is one of the It is a simple contrast study technique and widely spread all most common surgeries performed, nowadays. Treatment of over the country, but it is rarely use in clinical practice. The postoperative pain control plays an important role in improved objective of this study is to focus on the comparison of both recovery of patients and may decrease chronic postoperative tool for predict the success of the treatment in the hospital pain. which lack of high resolution manometry. Objectives: The aim of the study was to investigate Objective: To compare prediction’s efficacy of Eckardt’s whether a local anesthesia injection into the operated site has score, Timed Barium Esophagrography to High resolution an effect on the opioid consumption besides acute postopera- manometry in result of achalasia treatment with Peroral En- tive pain and persistent pain at 1 year after open inguinal hernia doscopic Mytomy in Siriraj Hospital. repair Materials and Methods: This cohort study in 57 acha- Materials & Methods: This is a retrospective study lasia patients who treated with Peroral Endoscopic Myotomy that collected the data from patients who underwent elec- 90 Abstracts Thai J Surg Jul. - Sept. 2019 tive open inguinal hernia repair between October 2017 and matched control patients. Demographic data, information March 2018. There were 99 patients included in this study, about relevant risk factors, and VCSS were collected. Duplex 19 patients (19.20%) were applied local bupivacaine injection ultrasonography was performed on all patients. intraoperatively and 80 patients (80.80%) that weren’t applied Results: There were 59 new varicose vein patients. local anesthesia injection. Each patient’s age, sex, type of The majority, 46 patients (73%), were female. Twenty-four anesthesia, technique of hernia repair, length of hospital stays, patients (40.7%) were over 60 years old. The mean body mass total opioid consumption and pain score at recovery room, at index (BMI) of the cohort was 25.1 kg/m2. Pain was the most 24 hours and pain score upon discharge were recorded. Only common presenting symptom (49%), followed by edema of 72 patients from 99 patients were assessed pain score at 1 year the legs (29%), and cosmetic concerns (27%). Most of the after their surgery with DN4 questionnaire weather they had patients had had symptoms for more than one year (92%). chronic postoperative pain after surgery or not. The 95 limbs with visible varicose veins were categorized Results: The two groups were matched in sex, age, into CEAP (Clinical, Etiology, Anatomy and Pathophysiol- and type of hernia repair. The local bupivacaine injection ogy) clinical stages: C2 69%, C3 12%, C4 12%, C5 5%, and was performed more in patient who underwent general anes- C6 2%. The mean VCSS was 5.9. Refluxes of different types thesia compare to patient with spinal anesthesia [9 from 20 were found: at the saphenofemoral junction (SFJ) (33%), sa- (45%) versus 10 from 79 (12%)]. There were no different in phenopopliteal junction (SPJ) (1%), perforators reflux (3%), postoperative complication, total opioid consumption, and and the great saphenous vein (GSV) reflux 16%. The mean postoperative pain score. Four people still have persistent diameter of GSV was 6.9 ± 2.6 mm. The risk factors that were pain, but no one was considered to have neuropathic pain. found to be significant when compared with the control group Conclusion: Local analgesia injection is safe to perform were age between 51-60 years old [odds ratio (OR) = 5.2, without any complications, but it is not associated with the 95% CI = 1.21-22.2], age over 60 years old (OR = 31.1, 95% reduction of postoperative pain, total opioid consumption or CI = 5.7-169.7), varicose veins in family history (OR = 10.1, persistent postoperative pain in patients who underwent open 95% CI = 2.3-45.0), and prolonged standing posture (> 50% inguinal hernia repair. of working hours) (OR = 3.8, 95% CI = 1.4-10.6). It should Keywords: Local analgesia, Open inguinal hernia repair, be noted that, among females, oral contraception, hormonal Postoperative pain therapy, and number of pregnancies were not significant risk factors. Conclusions: This study revealed that risk factors for VARICOSE VEINS: RISK FACTORS AND PATTERNS varicose veins include increasing age, especially above 50 OF VENOUS REFLUX IN THAI PATIENTS years old, varicose veins in family history, and prolonged standing posture. Pain, edema and cosmetic concerns com- Kachornvitaya Pattharasai, Kritayakirana Kritaya, prised common presentations. The venous reflux was most Apinan Uthaipaisanwong, Narueponjirakul Natawat commonly found in SFJ, and there was no deep vein reflux Department of Surgery, Faculty of Medicine, Chulalongkorn identified in any patients. University, Bangkok, Thailand Background: The disorder of varicose veins is a common disease among the Thai population, however the VENOUS THROMBOEMBOLISM IN TRAUMA published studies in Thai patients are still limited. PATIENTS, THE FIRST REPORT FROM A PRIVATE Objectives: To investigate the risk factors, patterns of TERTIARY CARE HOSPITAL venous reflux, and venous clinical severity scores (VCSS) in Thai patients afflicted with varicose veins. Wittawas Sriprayoon, Ekkit Surakarn, Materials and Methods: A prospective comparative Wassana Siriwanitchaphan case-control study was performed for patients with varicose Bangkok Trauma Center, Bangkok Hospital, Bangkok 10310, veins in a vascular surgery clinic at a single institute between Thailand February 2018 and January 2019. The patients were enrolled, interviewed and compared with the same number of sex- Background: Trauma patients are at increased risk of Vol. 40 No. 3 Abstracts 91 developing venous thromboembolism (VTE), one of the pre- deep vein thrombosis (DVT) and 2 patients had both DVT ventable fatal complication. Study of VTE in trauma patients and pulmonary embolism (PE). Four patients had been should enhance awareness and appropriate intervention to diagnosed for VTE prior to admission. Thirteen patients in improve clinical outcome in every healthcare facility. VTE group were diagnosed within 48 hours after admission. Objectives: This study assessed the incidence Fourteen major trauma patients had VTE (incidence 3.88%) and characteristic of VTE in adult trauma patients receiving There were twenty-one male patients and ten female patients care at Bangkok Hospital Headquarters. Relationship between in VTE group. Fifteen patients in VTE group were older than VTE, patient demography and severity of injury were also 65 years (48% of VTE group). Nine patients developed VTE studied. despite prophylaxis. The higher ISS, the higher incidence of Materials & Methods: Trauma registry of Bangkok VTE (p<0.001). There was no VTE related mortality in this Hospital Headquarters (BHQ) during 2016 to 2018 was ret- study. rospectively reviewed. Detail of in-patients aged ≥ 15 years Conclusions: The incidence of VTE in adult trauma were collected, including gender, age, injury severity score patients at BHQ is 1.14%, which is comparable with 1% in the (ISS), VTE risk and clinical outcome. USA (National Trauma Data Bank, US 2016). The presence Results: A total of 2,548 adult trauma patients were of VTE in early admission and the strong association between admitted at BHQ from January 1, 2016 to December 31, ISS and VTE development (P<0.001) suggest that we should 2018. Of these, 31 patients had VTE (1.1%), 29 patient had start intervention early, especially in high ISS patients.

PEDIATRIC SURGERY

EVALUATION OF INITIAL RESULTS OF inguinal orifice at VietDuc University Hospital from January LAPAROSCOPIC INGUINAL HERNIA REPAIR 2017 to June 2018. IN CHILDREN AT VIETDUC UNIVERSITY Results: In 153 patients: 10 bilateral hernias (6.5%), 31 HOSPITAL unilateral hernias were diagnosed with contralateral hernia by laparoscopic (20.3%), 112 unilateral hernias (73.2%). Nguyen Viet Hoa, Dang Thi Huyen Trang, The mean surgical time was 25.2 minutes (30.1 minutes with Vu Hong Tuan, Chu Minh Phuc, bilateral hernia, 22.9 minutes with unilateral hernia). Hospital Nguyen Duy Gia, Hong Quy Quan, Vo Ta Chung stay duration 1.6 day. No case of surgical catastrophe. Post- Department of Pediatric and Neonatal Surgery, Viet Duc operation: 2 patients were bleeding in position of the umbilical University Hospital trocar and 3 patients were mild swelling of the groin, scrotum. Post-operation follow-up 3 months: no recurrence, no testicu- Objective: To evaluate the early outcomes of totally lar atrophy. intra-peritoneal laparoscopic inguinal hernia repair in chil- Conclusion: Laparoscopy that use trocar 3 mm to dren by stitching herniated sac in the deep inguinal orifice at treat inguinal hernia in children is safe, feasible, effective VietDuc University Hospital. methods. The opportunity to diagnose a bilateral hernia when Materials and Methods: Prospective and retrospective non-diagnosed before surgery, or in case of recurrence after study, 153 patients over 2 years old that were diagnosed with an inguinal approach, are the main advantages for laparo- inguinal hernia based on clinical symptoms and ultrasound scopy. and treated with laparoscopic technique that use 3 trocars (1 Keywords: Pediatric inguinal hernia, Laparoscopic trocar 5mm, 2 trocars 3mm) to stitch hernia sac in the deep inguinal hernia 92 Abstracts Thai J Surg Jul. - Sept. 2019

examination to confirm microscopically free margins and 3) OUTCOMES OF SACROCOCCYGEAL TERATOMA: long-term follow-up. 18-YEAR EXPERIENCE AT A TERTIARY CARE Keywords: Sacrococcygeal teratoma, Survival rate, HOSPITAL Recurrence, Functional outcomes

Prapaporn Uthedphonrattanagul, Nutnicha Suksamanapan, RADIOLOGIC PATTERNS ASSOCIATED WITH Monawat Ngerncham, SURGICAL NECROTIZING ENTEROCOLITIS AND Mongkol Laohapensang DIAGNOSTIC INDEXES AMONG DEPARTMENTS Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok Sireekarn Chantakhow1, Pannee Visrutaratna2, 10700, Thailand Shanika Kosarat3, Jiraporn Khorana1 1 Division of pediatric surgery, Department of surgery, Faculty Background: Pediatric germ cell tumor, though a rare of medicine, Chiang Mai University, Chiang Mai, Thailand tumor, is the most common solid tumor among neonates. Al- 2 Department of radiology, Faculty of medicine, Chiang Mai most 70% of germ cell tumors involve sacrococcygeal area. University, Chiang Mai, Thailand The management of sacrococcygeal teratomas (SCTs) depends 3 Department of pediatrics, Faculty of medicine, Chiang Mai on their histology, location, and staging. University, Chiang Mai, Thailand Objectives: To determine the overall survival rate, tumor recurrence rate and risk factors for recurrence disease. Com- Background: Necrotizing enterocolitis (NEC) is the plications related to treatment of SCTs were also evaluated. most common cause of moribund in neonates, especially in Materials and Methods: A retrospective chart review surgical NEC. There are few recent studies reported on risk of patients admitted to Siriraj Hospital with SCTs between factors of surgical NEC, like several important risk factors 2000 and 2018 was performed. Data on demographics, clini- associated with the development of NEC. From previous cal presentation, size, type and histology of tumors, operative study in Chiang Mai University (CMU) Hospital found treatment, and complications, were collected and analyzed for some radiologic finding associated with surgical NEC. The the association with outcomes, including survival and tumor detail of radiologic patterns associated with NEC was not recurrence. well classified. Results: A total of 40 patients were included. There were Objectives: The main objective of this study was to 14 (35%) male and 26 (65%) female patients. Sixteen (40%) evaluate risk factors of surgical NEC, especially radiologic were Altman type I, 17 (43%) were type II, 3 (7%) were type finding from first diagnostic and follow up films for early III, and 4 (10%) were type IV. The overall three-year survival detection. Another objective was to identify diagnostic index was 98%. One patient died due to massive hemorrhage during of radiologic patterns interpretation among departments in the perinatal period. Three patients (7%) developed recurrenc- CMU Hospital. es which were significantly associated with microscopically Materials and Methods: This study is the nested incomplete resection margin, malignant teratoma histology, case-control study reviewed patients from CMU NEC cohort and Altman type IV. Long term bowel complications (soiling between 2009-2016. The patients were divided into two in 1 patient and constipation in 4 patients) were all found in groups, surgical NEC as a case group and non-surgical NEC patients with Altman type II. Two patients, one with type I patients as a controlled group, matching by gestational age and the other with type III, developed neurogenic bladder. (week + 3) and birth weight (gram + 150). NEC patients with No risk factors were found to be associated with functional no complete abdominal films were excluded. The radiologic complications in the present study. signs of first diagnostic and follow up films of patients were Conclusion: The overall 3-year survival in SCTs was read by one pediatric surgeon, one neonatologist and one high. There was a 7% recurrence rate, which did not adversely pediatric radiologist. Reference standard was the consensus influence the survival rate. Attention should be paid to 1) among departments. Nosologic diagnostic indexes were complete tumor removal, including the coccyx 2) pathological analyzed. Vol. 40 No. 3 Abstracts 93

Results: A total of 44 patients were divided to 22 The medical records were missed in 31 patients, so 107 pa- patients for each group. Multivariable logistic regression tients were included to this study. Then they were categorized analysis under multilevel model for radiologic signs reader into pleural effusion and no pleural effusion group. Pre and showed persist and progress of intraperitoneal fluid were perioperative data including age, body weight at transplan- significant associated with surgical NEC after adjusted by tation, etiology, pre-operative albumin level, lung disease, general characters (OR = 7.65, 4.78, 95% CI = 1.82-32.19, Pediatric End-Stage Liver Disease score (PELD)/Model 1.15-19.84 respectively). After interpreted diagnostic index For End-Stage Liver Disease score (MELD), intraoperative of radiologic patterns interpretation among departments, ascites, liver graft characteristics, length of stay in ICU/ neonatologist had high sensitivity (94.95%), pediatric surgeon hospital and O2 dependence time were compared between 2 had high specificity (97.27%) and radiologist had high both groups by multivariable logistic regression analysis. sensitivity (84.04%) and specificity (94.78%) for diagnosis Results: Post-transplant pleural effusion occurred in 64 NEC from plain abdominal films. (59.8%) patients. PELD score ≥ 25, presence of intraoperative Conclusions: This study showed intraperitoneal fluid ascites, LDLT (left lateral segment donor grafts) were signifi- or ascites had association with surgical NEC, but the progres- cant factors for postoperative pleural effusion. Prolonged length sion of radiologic pattern by time was more important. So, we of stay in ICU (p = 0.013) / hospital (p = 0.018) and oxygen recommended close follow up plain abdominal film in these dependence time (p = 0.001) were significant outcomes in patients. Multidisciplinary care team could improve accuracy pleural effusion group following liver transplantations. of radiologic diagnosis of NEC. Conclusions: Pleural effusion following Pediatrics liver Keywords: Necrotizing enterocolitis, Surgical NEC, transplantations incidence is high. Pre-operative risk factor Risk factors, Radiologic findings assessment can use to predict the prognosis of post-transplant pleural effusion. Consequently, this may diminish morbidity and length of stay in hospital. RISK FACTORS FOR PLEURAL EFFUSION Keywords: Pleural effusion, Pediatrics liver transplanta- FOLLOWING PEDIATRICS LIVER TRANSPLANTA- tions, Pulmonary complications after liver transplantations TIONS IN RAMATHIBODI HOSPITAL

Prapatsorn Srina, Chollasak Thirapattaraphan, SURGERY FOR DISORDER OF SEXUAL DEVELOP- Sani Molagool, Pornsri Thanachatchairattana, MENT: A RETROSPECTIVE DESCRIPTIVE STUDY Ampaipan Boonthai Division of Pediatric Surgery, Department of Surgery, Sethaphol Rojanaratanangoon, Faculty of Medicine Ramathibodi Hospital, Mahidol Somboon Roekwibunsi University, Bangkok,10400, Thailand Pediatric Surgery Unit, Department of Surgery, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Background: Pediatrics liver transplantations have Memorial Hospital, Bangkok, Thailand 10330 been accepted as definitive treatment for end stage liver disease. Pleural effusion is the most common of pulmonary Background: Disorder of sex development (DSD) is complications following liver transplantation in children. It defined as a congenital condition in which development of can affect high morbidity including prolong oxygen depen- chromosomal, gonadal, or anatomic sex is atypical. DSD dence and hospitalization. is a rare disorder requiring a multidisciplinary approach. Objectives: To identify the risk factors associated Surgical management plays an important role in treating with posttransplant pleural effusion and patients’ outcomes in this condition. Ramathibodi hospital in order to predict the prognosis after liver Objective: To describe the characteristics of DSD transplantations. patients who underwent genital surgical procedures. Materials & Methods: This is a retrospective review of Materials and Methods: Data of DSD patients (0-15 140 patients who underwent pediatrics liver transplantations years of age) between January 2002 and December 2017 were between March 2001 and June 2018 in Ramathibodi hospital. retrospectively reviewed. 94 Abstracts Thai J Surg Jul. - Sept. 2019

Results: One-hundred and five patients underwent respectively. The most common post-operative complication genital surgical procedures during the studied period. There among male patients with DSD undergoing urethroplasty were 13 cases (12%) of sex chromosome DSD, 41 cases (39%) was urethrocutaneous fistula (25/51 cases, 49%). All patients of 46XY DSD, and 51 cases (49%) of 46XX DSD. For sex having genital procedures were pre-operatively evaluated and chromosome DSD, mix gonadal dysgenesis was the most com- approved by DSD team and their parents. Finally, it was the mon (11 cases, 85%). For 46XY DSD, androgen insensitivity surgeon who would make the decision regarding the possible syndrome was the most common (19 cases, 41%). For 46XX surgical procedures. DSD, congenital adrenal hyperplasia was the most common Conclusions: Surgery of genital structures plays an (43 cases, 84%). In all male patients with DSD, urethroplasty important role in treating DSD patients. Although the treat- was the most common procedure (51 cases, 91%). However, ment of this condition needs multidisciplinary approach, the in female patients with DSD, clitoroplasty is the most com- types of surgery for these patients were designated by the mon (36 cases, 73%). The median age for urethroplasty and surgeon. Awareness of the types of surgery, its complications, clitoroplasty were 3 years 4 months and 3 years 11 months, and life-long effects are helpful in the therapeutic strategy.

PLASTIC SURGERY

A LITTLE THING THAT IS IMPORTANT IN wet-to-dry gauzes for the primary dressing to a hydrofiber with WOUND CARE: A PERIWOUND silver dressing and from gauze and Micropore as a secondary dressing to an adhesive sodium carboxymethylcellulose foam Apinut Wongkietkachorn1, dressing. This resolved all complaints. The patient’s satisfac- Palakorn Surakunprapha1, tion score using visual analog scale increased from 2 to 10 Attapol Titapun1, (out of 10 points). This example shows how even small details Nuttapone Wongkietkachorn2, can make a significant difference in wound care. Because Supawich Wongkietkachorn3 periwound care is often neglected, therapeutic algorithm that 1 Department of Surgery, Faculty of Medicine, integrates major challenges in periwound care into wound Khon Kaen University, Khon Kaen, Thailand healing strategies is proposed. 2 Division of Plastic and Reconstructive Surgery, Video link: https://1drv.ms/vs!AqzA8KxTww0 Department of Surgery, Chulabhorn Hospital, WgccvaBl36jCLpzv6IQ Bangkok, Thailand 3 Department of Surgery, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand ARTERIOVENOUS OF THE HEAD AND NECK: TREATMENT AND OUTCOME In wound care, we usually focus nearly all of our ef- forts on the wound area while paying little attention to the Do Thi Ngoc Linh1, Tran Thiet Son2, periwound area. Although the periwound area may seem Nguyen Hong Ha1 unimportant, it matters to patients. A female patient was ad- 1 Department of Maxillofacial and Plastic Surgery Department, mitted with a wound at the perianal area. Wound dressing was Viet Duc University Hospital, Hanoi, Vietnam performed using standard wet-to-dry gauzes. The patient had 2 Division of Plastic Surgery, Hanoi Medical University, several small complaints including irritant contact dermatitis, Hanoi, Vietnam skin maceration, pain during dressing change, and fecal con- tamination to the wound. In this case, we ended up switching Background: Arteriovenous malformations (AVMs) to a different method of wound dressing. We went from using are fast-flow vascular malformations that comprise a complex Vol. 40 No. 3 Abstracts 95 network of primitive vessels directly connecting feeding rence. The best chance for long-term control is early and total arteries to draining veins. AVM is an aggressive disease with resection. a high tendency to recur; its treatment is complex and very challenging, especially in the anatomically delicate head and neck area and requires extensive experience and an interdis- PENILE REPLANTATION: THE FIRST THREE SUC- ciplinary approach. CESSFUL CASES IN VIETNAM Objectives: This study evaluated the outcome after treatment and analyzed the correlation between the pattern Trung-Truc Vu, Mai-Anh Bui, Hong-Ha Nguyen, Quang of head and neck AVM and the frequency of recurrence. Nguyen Materials and Methods: We retrospectively assessed Department of Maxillofacial - Plastic - Aesthetic Surgery, Viet the outcome and recurrence of head and neck AVM after treat- Duc University Hospital, Hanoi, Vietnam ment by embolization and resection. Recurrence is defined as expansion following embolization or resection. The effect Penile amputations are uncommon injuries, that requir- of sex, age, size, location, stage and treatment modalities on ing urgent microsurgical intervention. Accidental trauma can recurrence of head and neck AVM were analyzed. be caused by genital self-amputation in patients with mental Results: This study includes of 60 patients. All patients disorders, circumcision injury inflicted by a partner following were treated by embolization and then resection. Of these, we marital discord. Other reasons are results of farming or work- have follow-up information of at least 6 months after treatment place accidents, gunshot wounds and human or animal bites. on 55 patients. The outcome was excellent in 73%, good in Currently, microsurgical replantation helps to reduce skin, 20%, fair in 5% and poor in 2% (mean follow-up time, 38.6 urethra constricted and glans loss but these complications months). Of the 55 patients, 14 had recurrences after treatment is still occurring. This report describes a series of the first (long-term recurrence rate, 26%). Recurrence was less likely three successful replantation cases with penile amputation in for lower-staged or small lesions, and did not correlate with Vietnam (all complete, from 2007 to 2016) and the outcomes age or location. are discussed. Conclusions: AVM of the head and neck is a one of Keywords: Penile replantation, Genital self-amputation, the most challenging diseases and has a high risk of recur- Microsurgery

THORACIC SURGERY

longevity and durability after right ventricular outflow tract DURABILITY OF RV-PA HOMOGRAFT AT reconstruction using homograft in pulmonic position. PULMONIC POSITION IN CONGENITAL HEART Materials & Methods: We retrospectively reviewed PROCEDURES AT RAJAVITHI HOSPITAL patients underwent right ventricular outflow tract reconstruction using homograft in pulmonic position between 1st January Chanokporn Daowan, Kumpoo Foofuengmonkolkit, Pirapat 1998 and 31st December 2016 in Rajavithi Hospital. There Mokarapong are four major operations including Rastelli’s operation, Cardiovascular Thoracic Surgery Unit, Rajavithi Hospital, Ross procedure, Trancal repair and RV-PA reconstruction. Bangkok, Thailand Two methods of homograft preservation used in our study, one from Rajavithi-preserved homograft and one from Thai Background: A homograft considered as a standard national bank preparation. conduit in right ventricular outflow tract reconstruction. Results: A total of 138 patients with right ventricular Objectives: To determine long-term outcome, conduit outflow tract reconstruction using homograft in pulmonic 96 Abstracts Thai J Surg Jul. - Sept. 2019 position in this study. 58.7% were male with mean age of was the only predictor for homograft degeneration in multi- 8.90 ± 5.72 years. The major diagnosis of pulmonary atresia variate analysis (p = 0.003). Freedom from explantation was with a ventricular septal defect was 39.86%, congenital aortic 97.22%, 88.89% and 75.0% at 5, 10 and 15 years. There are valve disease 23.91%, complex transposition 15.22%, double no patients explanted or died with complication of homograft outlet right ventricle 10.87%, tetralogy of Fallot 6.52% and endocarditis. truncus arteriosus 3.62%. Rastelli’s operation performed in Conclusions: RV-PA homograft implantation in the 71.7%, Ross procedure 23.0%, truncal repair 3.6% and RV-PA pulmonic position can perform with good long-term freedom reconstruction 0.7%. Homograft using in our study was har- from explantation and provide excellently outcome. Factors vest from aortic origin 73.91% and pulmonic origin 26.09%. affect homograft durability include a patient with truncus Among this homograft, Rajavithi-preserved homograft was arteriosus, homograft from the pulmonic origin and Rajavithi 49.3% and from Thai national bank preparation 50.7%. The preserved homograft. overall 5-year survival was 93.48%, and 10-year survival Keywords: Right ventricular outflow tract, Valve con- was 91.30%. Homograft harvested from pulmonic origin duit, Homograft, Congenital heart