ISSN 0125-6068
The Thai Journal of SURGERY
Official Publication of the Royal College of Surgeons of Thailand www.surgeons.or.th/ejournal
Volume 32 October-December 2011 Number 4
ORIGINAL ARTICLES 113 Related Factors in Necrotizing Enterocolitis after Gastroschisis Repair Arada Suttiwongsing, et al. 120 Si-Wa Hand Port for Hand-Assisted Laparoscopic Surgery: An Innovative Device Sirinuch Dulayaprapa, et al. 124 Incidence and Risk Factors or Early Postoperative Seizure in Patients with Intracranial Tumor Removal: Prasat Neurological Institute Experience Kullapat Veerasarn, Paveen Tadadontip 131 The Relationship between Carotid Plaque Calcification and Stability Kittipan Rerkasem, et al. 137 Effectiveness of Prophylaxis Antibiotic Used for Tension-free Hernioplasty: A Randomized Double-blinded Placebo-controlled Trial Wibun Phanthabordeekorn
CASE REPORT
141 Laparoscopic Excision of an Infected Urachal Cyst in an Adult Supoj Laiwattanapaisal
ABSTRACTS 145 Abstracts of the 36th Annual Scientific Meeting of the Royal College of Surgeons of Thailand, 14-17 July 2011, Ambassador City Jomtien Hotel, Jomtien, Pattaya, Cholburi, Thailand (Part II)
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Vol. 32 October - December 2011 No. 4
Original Article Related Factors in Necrotizing Enterocolitis after Gastroschisis Repair
Arada Suttiwongsing, MD Rangrong Sriworarak, MD Veera Buranakitjaroen, MD Rangsan Niramis, MD Department of Surgery, Queen Sirikit National Institute of Child Health (Children’s Hospital), Bangkok 10400, Thailand
Abstract Background/Objectives: Necrotizing enterocolitis (NEC) has been documented as a complication in infants after repair of gastroschisis. Previous studies showed that the etiology of NEC might be multi-factorial. The aim of this study was to review the experience in the management of neonates with gastroschisis and to identify the risk factors of NEC after gastroschisis repair. Methods: A retrospective case analysis was performed on neonates with gastroschisis treated at the Queen Sirikit National Institute of Child Health between 1998 and 2007. Information data including relevant demography, perioperative data, intravenous parenteral nutrition and enteral feeding were reviewed. The study focused on related factors that might induce NEC after gastroschisis repair. Data were analyzed by the Chi-square and student t-test. Statistically significant difference was considered at the level of a p-value less than 0.05. Results: Four hundred and sixty-six neonates with gastroschisis were treated by definitive operation during the study period. Forty cases died and 11 of these had evidence of NEC (27.5%). Of the total 466 patients, 44 cases (9.4%) developed NEC after gastroschisis repair. The mean of birth weight was significantly different between the NEC and non-NEC groups (2,016.4 ± 658.2g vs. 2,234.2 ± 1,165.5g, p = 0.001). Neonates in the NEC group underwent additional operation due to associated GI anomalies or complications more than the non-NEC group with statistical significance (9/44 vs. 17/422, p <0.001). Regarding sepsis complications, the NEC group had also more common than those of the non-NEC neonates (11/44 vs. 31/422, p = 0.003). There was no difference in associated GI abnormalities between both groups (4/44 vs. 32/422; p = 0.148), except for intestinal atresia. Surprisingly, neonates in the non-NEC group had significantly more early initiating enteral feeding than the NEC group (15.3 ± 11.2 days vs. 18.0 ± 10.5 days; p = 0.007) Conclusions: Low birth weight, underlying compromised bowel, additional operation due to complications and associated GI anomalies especially intestinal atresia were the important predisposing factors for NEC after gastroschisis repair. Delayed initiating enteral feeding is unable to prevent NEC after gastroschisis repair.
Key words: closure of abdominal wall defect, gastroschisis, necrotizing enterocolitis
Correspondence address : Rangsan Niramis, MD, Queen Sirikit National Institute of Child Health (Children’s Hospital), 420/8 Rajvithi Road, Bangkok10400, Thailand; Tel: +66 2354 8095; Fax: +66 2354 8095; E mail : [email protected]
113 114 Suttiwongsing A, et al. Thai J Surg Oct. - Dec. 2011
BACKGROUND between 1998 and 2007. The patients who had definitive The prevalence of gastroschisis has increased operation from other hospital were excluded from the significantly in recent years. Although the mortality of study. Information data including relevant demo- gastroschisis has decreased to less than 10 % but the graphics, perioperative data, intravenous parenteral morbidity is still very common; particularly infectious nutrition, enteral feeding and results of the treatment and gastrointestinal complications1-5. Intestinal atresia were reviewed. is a common anomaly associated with gastroschisis and is considered as a significant contributor to morbidity Treatment protocol and mortality. Necrotizing enterocolitis (NEC) is a Infants with gastroschisis were treated by primary well-recognized complication after gastroschisis repair closure whenever possible. Patients with major viscera- which may cause morbidity and occasional mortality6-8. abdominal disproportion due to large amount of Many authors reported risk factors of NEC after herniated abdominal viscera, marked swelling of the gastroschisis repair and showed that it might be multi- eviscerated bowel with serositis and marked narrowing factorial2,6-9. At our institute, timing of initiating enteral of the abdominal cavity were treated by staged closure feeding is considered as a risk factor of NEC after with an artificial sac or silo. This sac was prepared by gastroschisis repair. Therefore, some surgeons had using Steri-Drape® covering both surfaces of a stockinet attempted a delay in initiating enteral feeding tube which was described by Havanonda2,3 (Fig. 1, 2). postoperatively but NEC remained occurring. The The patients who had intestinal infarction, perforation, objective of this study was to review the experience in atresia or stenosis and other complications such as management of neonates with gastroschisis and to adhesive small bowel obstruction, septic arthritis or identify risk factors of NEC after gastroschisis repair wound dehiscence might undergo additional operation from a single institute for pediatric patients in Thailand. for intestinal resection, enterostomy or drainage, etc. All infants with gastroschisis received preoperative METHODS intravenous fluid resuscitation, nasogastric (NG) intubation with intermittent suction, preoperative and Patients postoperative antibiotics adjusted by clinical status After the proposal was approved by the and postoperative total parenteral nutrition (TPN) in Institutional Review Board, a retrospective case analysis every case. was performed on neonates with gastroschisis treated The patients who suspected NEC status underwent at the Queen Sirikit National Institute of Child Health investigations including complete blood count, serum
Figure 1 Creation of artificial sac or silo by suing Seri-Drape® covering both surfaces of a stockinette tube. Vol. 32 No. 4 Related Factors in Necrotizing Enterocolitis after Gastroschisis Repair 115
Figure 2 Application of an artificial sac above the abdominal wall defect and continuous suturing between this sac and the defect by No. 2-0, Ethylene.
electrolyte and abdominal roentgenography. Diagnosis RESULTS and staging of NEC were based on Bell’s criteria10. Stage I was described as “suspected NEC” and presented Demographic data with feeding intolerance, lethargy, abdominal During the study period, 466 neonates with distension, bilious vomiting, occult or gross blood in gastroschisis were admitted and treated by definitive stool and non-specific intestinal dilatation in abdominal operation. Male and female ratio was 236:234 (1:1). roentgenography. Stage II was classified as definite Seventy-five patients were born at Rajavithi Hospital NEC with clinical presentations similar to stage I and (the former name “Women’s Hospital”), while the association with one of radiological findings such as other 391 patients were born at other hospitals. From pneumotosis intestinalis, portal vein gas, persistent 1998 to 2007, 89,070 neonates were delivered at rigid bowel loop and peritoneal fluid. Stage III or Rajavithi Hospital. An incidence of gastroschisis among advanced NEC was categorized with stability of vital neonates born at Rajavithi Hospital was about 1: 1,200 signs, evidences of septic shock, peritonitis or live births. The average birth weight was 2,245.5 ± pneumoperitoneum in abdominal plain films. After 1,210.8 (range 1,000-3,600 g). Approximately 73% of definite diagnosis of NEC was decided, management the patients had the birth weight less than 2,500 g. One would be started including NPO approximately 10-14 half of patients (50%) had mothers who were under 20 days, retained NG tube with intermittent suction, years of age during delivery. Most of the patients intravenous antibiotics, observation of abdominal signs (74%) were born by vaginal delivery and 69% of and serial abdominal films. maternal pregnancies were primigravida.
Statistical analysis Associated congenital anomalies Regarding risk factors related NEC after Additional congenital anomalies were noted in gastroschisis repair, the data including sex, birth weight, 67 patients (14.4%) and some cases had more than gestational age, modes of operation, associated one anomaly. Major associated anomalies included anomalies, septic complications, timing to start enteral gastro-intestinal (GI), cardiac, genitourinary (GU) feeding were extracted to analyze by using SPSS for and neuro-logical abnormalities. Intestinal atresia was Window version 13.0 with the Chi-square and student the most common GI anomalies (15 in 36 cases). t-test. Statistically significant differences were Jejunoileal, colonic and duodenal atresias were noted considered at the level of a p-value less than 0.05. in 12, 2 and 1 case, respectively. Common cardiac 116 Suttiwongsing A, et al. Thai J Surg Oct. - Dec. 2011
defects were patent ductus arteriosus (PDA - 8 cases), (ranged 5-50 days) in patients with primary closure, atrial septal defect (ASD - 3 cases), and ventricular compared to 21.0 ± 16.5days (ranged 7 - 84 days) in the septal defect (VSD - 1 case). Most of GU anomalies staged operation group (p < 0.05). Average length of were cryptor-chidism in 11 cases and other minor hospital stay in the primary closure group was shorter abnormalities in 4 cases. Neurological anomalies than those in the staged operation group (25.5 ± 18.7 included hydro-cephalus in 3 cases and congenital days vs. 40.0 ± 26.2 days, p < 0.05). facial palsy in one case. Seven patients developed Of the 466 patients, 192 cases (42.3%) developed intestinal necrosis at the first physical examination due postoperative complications. The major complications to compression of the eviscerated bowel with a narrow included sepsis (20.7%), NEC (13.2%) and wound abdominal wall defect during patient transfer. Two of infection (10.2%). Forty-seven cases (10%) underwent the 7 patients with bowel necrosis were noted to have additional operations due to associated anomalies and intestinal perforation. complications. Nine of the 47 patients underwent small bowel resection due to intestinal necrosis and Modes and results of treatment required reoperation because of complications Primary closure of abdominal wall defect was following the first operation. Seventeen patients performed in 193 patients (41.4%), while staged closure needed reoperations for small bowel resection after was performed in 273 cases (58.6%) with marked complete abdominal closure because of intestinal visceroabdominal disproportion. The mean duration atresia, anastomotic leaks and enterocutaneous fistula. of intravenous parenteral nutrition was 16.2 ± 12.7days The remaining 21 cases required other surgical
Table 1 Demographic data of gastroschisis with and without NEC
NEC group Non-NEC group Patient information p-value (n = 44) (n = 422) Male : female 20 : 24 212 : 210 0.656 Birth weight (g) < 1500 3 7 1500-2000 30 96 2000-2500 9 196 2500-3000 2 100 > 3000 0 23 Mean 2016.4 ± 658.2 2234.2 ± 1365.5 0.001 Range 1400-2800 1000-3600 Mean gestational age (w) 36.0 ± 4.8 36.2 ± 6.5 0.701 Range 31-40 24-42 Mean maternal age at delivery (y) 21.4 ± 6.1 21.0 ± 6.9 0.815 Range 16-38 14-39 Type of delivery Vaginal delivery 43 302 0.065 Cesarean section 1 120 0.137 Birth order of the mother First child 42 303 0.071 Second child 1 89 0.182 Third and over 1 30 0.347 Major associated anomalies Cardiovascular 0 12 0.526 Gastrointestinal 4* 32 0.138 Neurological 0 4 1.00
*intestinal atresia in all of 4 cases Vol. 32 No. 4 Related Factors in Necrotizing Enterocolitis after Gastroschisis Repair 117
Table 2 Comparison of results of the treatment between gastroschisis with NEC and non-NEC groups
NEC group Non-NEC group Information of the treatment p-value (n = 44) (n = 422) Modes of treatment Primary closure 10 (22.7%) 170 (40.3%) 0.004 Staged closure 34 (77.3%) 252 (59.7%) 0.023 Additional operations due to major associated GI anomalies and complications 9 17 0.0001 Sepsis 11 31 0.0003 Mortality 11 (25%) 29 (6.9%) 0.0002
Table 3 Comparison of time to the first oral feeding, TPN administration and length of hospital stay in the survivors between NEC and non-NEC groups
NEC group Non-NEC group Time interval p-value (n = 33) (n = 393) Time to the first oral feeding (days) Mean 18.0 ± 10.5 15.3 ± 11.2 0.007 Range 8-52 6-47 Duration of TPN administration (days) Mean 35.4 ± 21.3 19 ± 13.8 0.0001 Range 15-81 (7-149) Length of hospital stay (days) Mean 51.4 ± 31.5 28.7 ± 25.6 0.0001 Range 26-107 12-159
procedures for several complications including had birth weight higher than 2,000 gm (p < 0.001). replacement of artificial sac, exploratory laparotomy Twenty six patients required additional operative and lysis of adhesion, resuturing after wound procedures after complete gastroschisis repair due to dehiscence, arthrotomy and drainage, etc. complications or associated anomalies such as intestinal atresia, intestinal necrosis or perforation, anastomotic NEC after gastroschisis repair leak and enterocutaneous fistula. Nine of the 26 Forty-four of the 466 patients (9.4%) developed patients developed NEC later. The patients in staged NEC at the interval 2-6 weeks after gastroschisis repair. closure group had significantly developed NEC higher NEC occurred after initial enteral feeding in every than those in primary closure group (77.3% vs. 22.7%, case. These NEC patients were classified by Bell’s p < 0.001). Regarding sepsis and mortality, patients criteria[3] with stage I, II and III in 25, 11 and 8 cases, with NEC had a higher rate than those without NEC respectively. Comparison of demographic data and (Table 2). results of the treatment of those infants with NEC and Of the 466 patients with gastroschisis, 426 cases without NEC were shown in Table 1. Significant survived, including 33 cases of NEC group and 422 differences were observed in mean birth weight (2,016.4 cases of non-NEC group. Average time to the first oral ± 658.2 vs. 2,234.2 ± 1,365.5, p = 0.001) and receiving feeding in NEC group was 18.0 ± 10.5days, while this additional operation due to some GI associated average time in the non-NEC group was15.3 ± 11.2 days anomalies or complications (9/44 vs. 17/422, p < (p = 0.007). This study indicated that neonates in non- 0.001). Thirty-three patients with NEC (75%) NEC group had initiating enteral feeding earlier than comparison with 103 patients without NEC (24.4%) those in NEC group (Table 3). Average duration of 118 Suttiwongsing A, et al. Thai J Surg Oct. - Dec. 2011
TPN administration and length of hospital stay (LOS) GI anomalies were not significantly different between in the NEC group were significantly longer than those the patients with NEC and without NEC groups, except in the non-NEC group also. These longer durations for intestinal atresia. Many investigators reported that might be partly reflected more complications and gastroschisis association with intestinal atresia was found complexity of NEC treatment. ranging from 4% to 18% and had a high incidence of morbidity and mortality6,24,25. Patients with gastroschisis DISCUSSION and intestinal atresia require several operations The incidence of gastroschisis at the Queen Sirikit including invasive treatment for complications. These National Institute of Child Health is increasing in the induce stress condition to the patients and influence recent years, compared to the previous study of 1986- developing of NEC. 19972,3. From the literature review, the incidence of The concept of early initial enteral feeding is gastroschisis is increasing worldwide for unknown considered as a risk factor of NEC after gastroschisis reasons1-5,11-14. Some investigators described risk factors repair. Some surgeons managed postoperatively of gastroschisis including maternal smoking and using gastroschisis repair by attempted delay initial enteral decongestants or aspirin during pregnancy15-17. Our feeding at least 2 weeks. Our present study showed no results revealed fetal gastroschisis occurring mostly in correlation between early feeding and incidence of young mothers with low parity18. It seems to be an NEC after gastroschisis repair. In contrast, many cases association between gastroschisis and low birth weight. with delayed enteral feeding developed NEC higher Theoretically many factors such as nutritional deficits than those with early oral feeding similar to the study could play a role in the etiology of this condition. Most of Jayanthi et al26. Walter Nicollet 27 showed improved of the patients with gastroschisis had low birth weight outcome of infants with gastroschisis by early minimal and were borderline premature15-20. The present study feeding. Many reports suggested that glucagon-like revealed significantly increased incidence of NEC in peptide 2 (GLP-2) is a physiologically relevant hormonal low birth weight neonates after gastroschisis repair signal linked to the intestinal adaptation associated (Table 1). with enteral nutrition in neonates27-29. GLP-2 is a Regarding criteria for operative procedures at potent intestinal trophic peptide. Enteral feeding was our institute, patients with perinatal type of gastroschisis demonstrated to be the primary stimulus for intestinal who had more stable and less compromised bowel mucosal growth, producing secretion and increased were treated by primary closure. Patients with antenatal circulating concentration of GLP-2. Hence, GLP-2 type of gastroschisis who had marked swelling of may play a role in the regulation of blood flow for eviscerated bowels due to prolonged exposure to amnio- maintenance of intestinal function in conditions of tic fluid, marked visceroabdominal disproportion and ischemia26-28. Additionally, Jayanthi26 advocated early physiologic derangement, were treated by staged enteral feeding with maternal expressed breast milk in closure. It might be the results that NEC developed order to protect the infant from developing NEC after after staged closure significantly higher than those gastroschisis repair. after primary closure because of more inflammation, The present study recommended early enteral impairing absorption and delayed motility of the feeding by small amount of electrolyte solution and intestine. Patients with small abdominal wall defect maternal breast milk (trophic feeding) for stimulation without serious intestinal abnormalities can safely be of intestinal mucosal growth and bowel function. Early managed by primary closure to achieve earlier full enteral feeding may be protective against NEC after enteral feeding and shorten duration of hospital stay. gastroschisis repair. Infants who required more extensive surgery with possible intestinal resection or ostomy procedure had CONCLUSIONS a high risk of prolonged postoperative ileus and other complications12,21-23. Additional operations due to Etiologies of NEC after gastroschisis repair may associated anomalies and other septic complications be multifactorial. The important related factors in the were the important stress factors to develop NEC after present study included low birth weight neonates, gastroschisis repair. From the present study, congenital compromised bowel during gastroschisis repair, Vol. 32 No. 4 Related Factors in Necrotizing Enterocolitis after Gastroschisis Repair 119
additional operation due to complications and 12. Abdullah F, Arnold MA, Nabaweesi R, et al. Gastroschisis in associated GI anomalies, especially intestinal atresia. the United States 1988-2003: analysis and risk categorization of 4344 patients. J Perinatol 2007;27:50-5. Delayed enteral feeding could not prevent NEC 13. Eggink BH, Richardson CJ, Malloy MH, et al. Outcome of occurrence post gastroschisis repair. gastroschisis : a 20-year review of infants with gastroschisis born in Galveston,Texas. J Pediatr Surg 2006;41:1103-8. 14. Penman DG, Fisher RM, Noblett HR, et al. Increase in ACKNOWLEDGEMENT incidence of gastroschisis in the South West of England in The authors would like to thank Dr. Siraporn 1995. Br J Obstet Gynaecol 1998;105:328-31. 15. Goldbaum G, Dailing J, Milham S. Risk factors for gastroschisis. Sawasdivorn, the Director of Queen Sirikit National Teratology 1990;42:397-403. Institute of Child Health, for permission to publish 16. Torfs CP, Katz EA, Bateson TF, et al. Maternal medications this paper and Dr.Vichao Kojaranjit for support of and environmental exposures as risk factors for gastroschisis. statistical analysis. Teratology 1996;54:84-92. Ethical approval : Approval by Institutional Review 17. Werler MM, Sheehan JE, Mitchell AA. Maternal medication Board, document No. 51-053. use and risks of gastroschisis and small intestinal atresia. Am Conflict of interest : None J Epidemiol 2002;155:26 -31. 18. Nichols CR, Dickinson JE, Pemberton PJ. Rising incidence of gastroschisis in teenage pregnancies. J Matern Fetal Med 1997;6:225-9. 19. Snyder CL. Outcome analysis for gastroschisis. J Pediatr Surg1999;34:1253-6. REFERENCES 20. Vilela PC, Ramos de Amorim MM, Falbo GH, et al. Risk 1. Jager CL, Heij H. Factor determining outcome in gastroschisis: factors for adverse outcome of newborns with gastroschisis clinical experience over 18 years. Pediatr Surg Int 2007;23: in a Brazilian hospital. J Pediatr Surg 2001;36:559-64. 731-6. 21. Morrison JJ, Klein N, Chitty LS, et al. Intra-amniotic 2. Niramis R, Watanatittan S, Anuntkosol M, et al. Abdominal inflammation in human gastroschisis: possible aetiology of wall defect: a 12-year experience. Thai J Surg 1998;19:121- postnatal bowel dysfunction. Br J Obstet Gynaecol 1998; 8. 105:1200-4. 3. Havanonda S. Omphalocele and gastroschisis. Bangkok: 22. Api A, Olguner M, Hakgqder G, et al. Intestinal damage in Unity Publication; 1989. p. 39-42 (in Thai). gastroschisis correlates with the concentration of 4. Lewis JE Jr, Kraeger RR, Danis RK. Gastroschisis: ten-year intraamniotic meconium. J Pediatr Surg 2001;36:1811-5. review. Arch Surg 1973;107:218-2. 23. Correia-Pinto J, Tavares ML, Baptista MJ, et al. Meconium 5. DiLorenza M, Yazbeck S, Duchame JC. Gastroschisis: an 18- dependence of bowel damage in gastroschisis. J Pediatr year review. J Pediatr Surg 1987;22: 710-2. Surg 2002;37:31-5. 6. Jayanthi S, Seymour P, Puntis JWL, et al. Necrotizing 24. Fleet MS, de la Hunt MN. Intestinal atresia with gastroschisis enterocolitis after gastroschisis repair: a preventable : a selective approach to management. J Pediatr Surg complication. J Pediatr Surg 1998; 33 :705-7. 2000;35:1323-5. 7. Amoury RA, Goodwin CD, McGill CW, et al. Necrotizing 25. Snyder CL, Miller KA, Sharp RJ, et al. Management of enterocolitis following operation in the neonatal period. J intestinal atresia in patients with gastroschisis. J Pediatr Surg Pediatr Surg 1980;15:1-8. 2001;36:1542-5. 8. Oldham KT, Coran AG, Drongowski RA, et al. The 26. Jayanthi S, Seymour P, Puntis JWL, et al. Necrotizing development of necrotizing enterocolitis following repair of enterocolitis after gastroschisis repair : a preventable gastroschisis : a surprisingly high incidence. J Pediatr Surg complication? J Pediatr Surg 1998;33:705-7. 1988;23:945-9. 27. Walter-Nicolet E , Rousseau V, Kieffer F, et al. Neonatal 9. Sangkhathat S, Patrapinyokul S, Chiengkriwate P, et al. outcome of gastroschisis is mainly influenced by nutritional Infectious complications in infants with gastroschisis: an 11- management. J Pediatr Gastroenterol Nutr 2009;48:612-7. year review from a referral hospital in southern Thailand. J 28. Burrin D, Guan X, Stoll B, et al. Glucagon-like peptide 2: a key Pediatr Surg 2008;43:473-8. link between nutrition and intestinal adaptation in neonates. 10. Bell MJ, Ternberg JL, Feigin RD, et al. Neonatal necrotizing J Nutr 2003;133:3712-6. enterocolitis : therapeutic dieision based on clinical staging. 29. Vogler SA, Fenton SJ, Scaife ER, et al. Closed gastroschisis : Ann Surg 1978;187:1-7. total parenteral nutrition - free survival with aggressive 11. Baerg J, Kaban G, Pahwa TP, et al. Gastroschisis : a sixteen- attempts at bowel preservation and intestinal adaptation. year review. J Pediatr Surg 2003;38:771-4. J Pediatr Surg 2008;43:1006-10. The THAI Journal of SURGERY 2011;32:120-123. Original Article Official Publication of the Royal College of Surgeons of Thailand
Si-Wa Hand Port for Hand-Assisted Laparoscopic Surgery: An Innovative Device
Sirinuch Dulayaprapa, PN* Warisara Tuvayanon, RN* Thawatchai Akaraviputh, MD** *Nursing Department, Minimally Invasive Surgery Unit, **Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
Abstract Objective: To demonstrate a newly invented inexpensive hand port device and to evaluate its performance in the Hand-Assisted Laparoscopic Surgery [HALS]. Materials & Methods: We invented a new reusable hand port named“ Si-Wa (Sirinuch -Warisara)” Hand Port from used, impaired commercial hand port and inexpensive materials. The technique of assembly was described. The device was evaluated with the satisfactory questionnaire by five gastrointestinal surgeons in the Department of Surgery, Faculty of Medicine Siriraj Hospital after using this new device. Results: From the satisfactory questionnaire acquiring from the surgeons who used this new device for Hand-Assisted Laparoscopic Colectomy in 40 patients, the statistic analysis indicated that the device was effective for maintaining the pneumoperitoneum condition, safety for the patients and saving cost. All of these answers were ranked in the “Very Good” level. Conclusion: Si-Wa hand port is an effective and inexpensive device for using in Hand-Assisted Laparoscopic Surgery.
Key words: Laparoscopic Surgery, Hand Port, Laparoscopic Colectomy
BACKGROUND At present, advanced laparoscopic colectomy can Colon cancer is the fourth most common cancer be performed by two methods. The first one is total in the world with the annual mortality rate of 655,0001. laparoscopic surgery. The second one is Hand-Assisted Currently the most popular treatment for colon cancer Laparoscopic Surgery [HALS]. In HALS, surgeons is laparoscopic colectomy due to the advantage of inserted one hand through a special device (hand having small wounds and less pain compared to open port) for manipulating intra-abdominal organs while surgery. The outcome can bring about shorter recovery it could preserve pneumoperitoneum state resulting time hence patients can go back to work sooner. in shorten duration of the operation2. In the
Correspondence address : Thawatchai Akaraviputh, MD, Dr.med. (Hamburg), Minimally Invasive Surgery Unit, Department of Surgery, Faculty of Medicine Siriraj Hospital, Bangkok 10700, Thailand; Telephone: +66 2419 8005; Fax : +66 2412 1370; E-mail: [email protected]
120 Vol. 32 No. 4 Si-Wa Hand Port for Hand-Assisted Laparoscopic Surgery 121
Department of Surgery, Faculty of Medicine Siriraj First, the silicone part of the impaired Hand Port Hospital, we adopted both methods for the treatment was unpeeled to get a big plastic ring, a small plastic of colorectal cancer patients. However, the hand port ring and a silicone ring (Figure 1). The finger parts of equipment is not yet popular because it is very expensive the new glove were cut off by measuring 12 inches from (approximately 20,000 Thai baht or 700 US Dollars) the edges. The edge of the glove was tied with the small and a disposable device. The materials are delicate plastic ring. The glove’s edge was inside of the ring and and easily torn. Moreover, it is difficult to be cleaned then tied with a rubber band (Figure 2). Another edge thoroughly which could cause infections if reuse in of the glove was inserted through the big plastic ring another patient. This could increase the costs for the and tied tightly with rubber band by letting the band be patient and for the hospital. inside the ring. The first ring was left 1.5 cm away from The authors have invented a new hand port the second ring (Figure 3). Using another new glove, device named, “Si-Wa (Sirinuch -Warisara)” Hand Port, the side with no edge was tied to the big ring then tied which is made from cheaper materials already existed in the operating room together with some parts from impaired and previously used, commercial hand port. Those materials can be adapted effectively to each patient’s physical condition. It is also easily dissembled and cleaned thoroughly before the next use. As a result, it could save an extra budget for the hospital. The present study described experiences in invention of this new hand port for HALS and assessed the satisfactory outcome among surgeons using this device.
MATERIALS & METHODS
The following materials in operating theater were needed to prepare: 1. New rubber glove No. 8 Figure 2 The glove was cut to be 12 inches (A) and use the 2. Some parts from impaired Hand Port edge of the glove to tie with the small plastic ring, 3. Scissors & ruler fixed with a rubber band (B). 4. Rubber band
Figure 3 Another edge of the fixed glove was inserted through the big plastic ring (A), fixed with a rubber band (B) Figure 1 The impaired commercial Hand Port was unpeeled and left the first ring 1.5 cm away from the second to three silicone rings. ring (C). 122 Dulayaprapa S, et al. Thai J Surg Oct. - Dec. 2011
Figure 4 Another cut glove was fixed with the second ring by Figure 5 The edges of both gloves were inside the third the rubber band (A & B). silicone ring (A&B). Then, the edges of the gloves were reverse to cover the ring (C). Finally the “Si- Wa” hand port could be used in HALS (D).
Table 1 The questionnaire used for the satisfactory evaluation of Si-Wa hand port
Very good Good Fair Improvement Satisfaction criteria (4) (3) (2) needed (1) 1. Effectiveness to hold pneumoperitoneum status 2. Patient safety 3. Quality of the device 3.1 Equipment flexibility 3.2 No pressure on both of the surgeon’s wrists 3.3 Durability of the equipment to use until completing the surgery 4. Saving cost 5. Overall satisfaction towards the equipment tightly with the rubber band with the band inside the The results from the questionnaire for performance ring. The last glove was brought to top the finished one evaluation of the device were separated into four and then the same steps were done (Figure 4). Both levels: Very Good (4), Good (3), Fair (2), and gloves were inserted using the sides that had edges into Improvement needed (1) (Table 1). Analyzing from the silicone ring. The edges of the gloves were reversed the question-naire’s statistics, the average value of to cover the silicone (Figure 5). Finally the materials performance was categorized into four levels: very were sterilized with ethylene oxide gas before use. good (3.5-4.0), good (2.5-3.49), fair (1.5-2.49), and improvement needed (≤ 1.49). After collecting and analyzing the data on the usage of Si-Wa hand port, the RESULTS satisfaction level of all criteria was in very good level The newly invented hand port “Si-Wa” had been (Table 2). used in the Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital since DISCUSSION 2007. Between October 2007 and February 2008, the data were prospectively collected from five surgeons We have described the technique to produce the who used this hand port in 40 cases of HALS colectomy. “Si-Wa” hand port. With “Si-Wa” hand port, the Vol. 32 No. 4 Si-Wa Hand Port for Hand-Assisted Laparoscopic Surgery 123
Table 2 The results of the evaluation of Si-Wa hand port in 40 HALS operations
Satisfaction criteria X ± S.D. Level 1. Effectiveness to hold pneumoperitoneum status 3.6 ± 0.54 Very Good 2. Patient safety 4.0 ± 0.00 Very Good 3. Quality of the device 3.8 ± 0.39 Very Good 3.1 Equipment flexibility 3.8 ± 0.39 3.2 No pressure on both of the surgeon’s wrists 3.8 ± 0.39 3.3 Durability of the equipment to use until completing the surgery 3.8 ± 0.39
4. Saving cost 3.8 ± 0.39 Very Good 5. Overall satisfaction towards the equipment 3.8 ± 0.39 Very Good technique of peritoneal insertion is slightly more CONCLUSION difficult than the other hand port because of its elasticity. In summary, the satisfaction level of surgeon in However, it is suitable for different size of surgeons’ operating room toward the “Si-Wa” hand port is in the wrist and is more comfortable than the commercial “very good” level. This reveals that the new device is one. For cleaning process, it is very easy and more effective, safe and cost saving for use in case of HALS effective than the other hand ports because all of its in advanced laparoscopic surgery. parts can be removed except three remaining plastic loops for disinfection process and reproducing a new REFERENCES “Si-Wa” hand port. In this study, there were few 1. Parkin DM, Pisani P, Ferlay J. Estimates of the worldwide surgeons completed the questionnaires for the incidence of eighteen major cancers in 1985. Int J Cancer efficiency evaluation of “Si-Wa” hand port. Therefore 1993;54: 594-606. the result may be not adequate to proof “Si-Wa” hand 2. Nagajima K, Lee SW, Cocilovo C, Foglia C, Sonada T, Milsam JW. Laparoscopic total colectomy hand assisted VS standard port’s efficiency. technique. Surgery Endosc 2004;18 (4) : 582-6. The THAI Journal of SURGERY 2011;32:124-130. Original Article Official Publication of the Royal College of Surgeons of Thailand
Incidence and Risk Factors or Early Postoperative Seizure in Patients with Intracranial Tumor Removal: Prasat Neurological Institute Experience
Kullapat Veerasarn, MD Paveen Tadadontip MD Prasat Neurological Institute, Bangkok, Thailand
Abstract Objectives: To evaluate the incidence and to identify the risk factors of early postoperative seizure (POSz) (within one week after surgery) in patients underwent intracranial tumor removal. Methods: Medical records of patients who had their brain tumor removed during June 2006 - May 2007 were reviewed. Data of demography, clinical presentation, operative records and pathology reports were recorded. The incidence of early POSz was calculated in total number and in subgroup differentiated by location. Univariate chi square and logistic regression analyses were used to analyze association between variables and seizure outcome. Results: The incidence of early POSz for intracranial tumor removal surgery was 9.7 % (21/216) with 13.16 % for convexity lesion, 16.07 % for subcortical location, 2.08 % for posterior fossa location, and 13.89 % for sella and parasellar location. In univariate analysis, male gender, history of pre-operative seizure and location of tumor were found to relate with early POSz. In multivariate analyses male gender and history of preoperative seizure were statistically related with early POSz. Role of antiepileptic drug prophylaxis was also studied and showed a benefit in high risk group with no statistical significance. In patients with early POSz, seizure occurred mostly on the day 0, day 1 and day 2 after surgery and correctable cause could be identified in some cases (evacuation of intracranial hematoma in one case, low antiepileptic drug level in two cases). Conclusions: Early POSz had a high incidence in surgery for tumor located at the locations of convextity, subcortex and sella parasella. History of preoperative seizure and male gender were the risk factors for early POSz. Close observation in these groups of patients during the postoperative period and the prescription of antiepileptic drugs would be necessary.
Key words: brain tumor removal, early postoperative seizure
INTRODUCTION operation2,3. But the incidence of early POSz (within Postoperative seizure (POSz) is a common one week after operation) in patients who had complication in neurosurgical practice. It affects the craniotomy for brain tumor removal was rarely recovery of nervous systems and may cause morbidity mentioned in literature4. and mortality. Incidence of POSz was estimated around There have been many attempts to reduce the 15-20% in supratentorial operation in non- trauma occurrence of postoperative seizure, one common group1 and varied between 1-5% for infratentorial method is anti-epileptic drug prophylaxis. However
Correspondence address : Kullapat Veerasarn, MD, Prasat Neurological Institute, 312 Ratchavithi Road, Ratchathewi, Bangkok 10400, Thailand; Telehone: +66 2354 7007 Fax: +66 2354 7085; E-mail: [email protected]
124 Vol. 32 No. 4 Early Postoperative Seizure in Patients with Intracranial Tumor Removal 125
the role of antiepileptic prophylaxis is still contro- ventricle), and cavernous sinus lesion. Sphenoid versial4,5. Recently, the study of seizure prophylaxis in meningioma and other extra axial skull base growth brain tumor patient clearly demonstrated that were grouped as skull base lesion. Pathology reports antiepileptic medication had no benefit in primary were reviewed. Prophylactic antiepileptic prescription prophylaxis6. Currently, we do not have a standard were reviewed and recorded in details (drug, dose, guideline for seizure prophylaxis in tumor surgery timing (relate with operation) and route of adminis- patients. Neurosurgeons usually prescribe antiepileptic tration). medication in patients considered “high risk” and Postoperative course of patients were reviewed. continue medication around one to three weeks and Seizure was declared and recorded if any clinical tapering off if patients have no seizure. This measure seizure was noted in physician’s progress note or nurse’s is based on the review benefit of anticonvultsant in note. Details of seizure were recorded including neurosurgical patients4. postoperative date occurred, investigation performed Many factors were studied and shown a correlation and clinical course. with early POSz such as history of previous seizure, lesion involve motor cortex, degree of cortical injury, Statistical Analysis postoperative brain edema, hemorrhage and Data was reported as descriptive statistics. hyponatremia7. But some factors such as location and Correlation between factors and early POSz were tested pathology of tumor had rarely been studied. Boarini by Chi square and Mann-Whitney U test for difference et al reported incidence of postoperative seizure in of age between two groups. Factors correlated with glioma patient 39% in non medical prophylaxis group early POSz in univariate analysis were analyzed by and 21% in prophylaxis group8. The objectives of this multiple regression analysis models. Data was calculated study were to identify the incidence and the risk factors by SPSS version 15.0. correlated with early POSz.
RESULTS MATERIALS AND METHODS Two hundred and sixteen consecutive cases of Operative registration records during June 2006 brain tumor surgery were reviewed during June 2006 - May 2007 were retrospectively reviewed. All patients - May 2007. There were 93 males and 123 females. The who underwent craniotomy with tumor removal youngest patient was 1 yr old while the oldest one was procedure were enrolled in this study. Exclusion 75 yrs old. The total incidence of POSz was 9.7% (21/ criteria were patients with biopsy alone and patients 216) (Table 1). The incidence of POSz in convexity who had more than two procedures within one week. lesion, subcortical lesion, sellar-parasellar lesion, There are nine attending surgeons practicing during intraventricular lesion was higher than total incidence that time. Clinical records during admission were (13.16%, 16.07%, 13.89%, 14.29%) whereas posterior reviewed. Histories of preoperative clinical seizure fossa group had only 1 of 48 case seizure (2.08%) and were obtained. Operative records were reviewed. no seizure in cavernous sinus and sphenoid wing Timings of operation were obtained and classified as lesions. Only three pineal tumor operations were less than six hours or more than six hours. Whether performed in that year and no early postoperative the patients underwent corticotomy procedure was seizure found. recorded. Locations of tumor were classified into Factors including age, gender, tumor histology, seven groups; namely convexity group (extra axial location of tumor, corticotomy procedure, duration of tumor had center or mainly involve cerebral convexity operation (< 6 hrs or > 6hrs), history of preoperative cortex), subcortical lesion group (intra axial tumor clinical seizure and perioperative antiepileptic had center at subcortical region), sellar & parasellar prophylaxis were analyzed with the occurrence of early group, posterior fossa group (including all tumor in POSz (Table 2). Only three factors were found to posterior fossa - brainstem, cerebellopontine angle, 4th correlate with early POSz: history of preoperative ventricle, cerebellar tumor), pineal region group, clinical seizure (p = 0.001), male gender (p = 0.021) intraventricular group (tumor in lateral and 3rd and tumor location (p = 0.036). Corticotomy procedure 126 Veerasarn K and Tadadontip P Thai J Surg Oct. - Dec. 2011
Table 1 Incidence of early postoperative seizure differentiated showed higher incidence of POSz but not reached by tumor location. statistical significance (p = 0.057). Perioperative Tumor location Incidence (%) antiepileptic prophylaxis showed no correlation with seizure (p = 0.228). Using multivariate regression Convexity: extra axial mass 5/38 (13.16) Subcortical lesion: intra axial mass 9/56 (16.07) analysis, male gender and history of preoperative seizure Posterior fossa 1/48 (2.08) were independently correlated with early POSz while Sellar / parasellar lesion 5/36 (13.89) location of tumor failed to show statistical signification Pineal location 0/3 (0) correlation (p = 0.284) (Table 4). Peri-operative Intraventricular lesion 1/7 (14.29) antiepileptic drugs used in the study were phenytoin Skull base area: cavernous, sphenoid, or valproic acid in a standard loading and maintenance extra axial mass at skull base 0/28 (0) dose11. The timing for prophylaxis was peri-operative
Table 2 The correlation between various factors and early post operative seizure
Early post operative seizures Factors P value Yes no
Pathology 0.101 Glioma group 5 (23.8%) 33 (16.9%) Meningioma 5 (23.8%) 79 (40.5%) Metastasis 2 (9.5%) 14 (7.2%) Schwannoma 1 ( 4.8%) 21 (10.7%) Pituitary adenoma 1 (4.8%) 11 (5.6%) Craniopharyngioma 4 (19.0%) 7 (3.6%) Other 3 (14.3%) 30 (15.4%) Location of tumor 0.036 Cortical surface 5 (23.8%) 33 (16.9%) Subcortical lesion 9 (42.9%) 47 (24.1%) Posterior fossa 1 (4.8%) 47 (24.1%) Sellar, Parasellar region 5 (23.8%) 31 (15.9%) Other: pineal, intravent, skull base 1 (4.8%) 37 (19.0%) Age 46 (25-59) 44 (34-54) > 0.05 Male gender 14 (66.7%) 79 (40.5%) 0.021 Corticotomy procedure 10 (47.6%) 54 (27.7%) 0.057 Timing of operation (0-6 hrs / > 6 hrs) 10 (47.6%) 126 (64.6%) 0.125 Preoperative seizure 11 (52.4%) 35 (17.9%) 0.001 No Perioperative seizure prophylaxis 4 (19.0%) 62 (31.8%) 0.228
Table 3 Number of antiepileptic prophylaxis prescribed differentiated by location of tumor and their seizure outcome.
Prophylaxis Seizure Location Total case Yes No Prophylaxis No prophylaxis
Convexity 38 36 2 5 (13.9%) 0 Subcortical lesion 56 52 4 8 (15.4%) 0 Posterior fossa 48 16 32 0 1 Sellar parasellar 35 21 14 2 ( 9.5% ) 3 (21.4%) Pineal region 3 2 1 0 0 Intraventricular lesion 7 3 4 1 (33.3%) 0 Skull base 29 19 10 0 0 Vol. 32 No. 4 Early Postoperative Seizure in Patients with Intracranial Tumor Removal 127
Table 4 Regression analysis to identify correlation between or immediate postoperative depended on each male gender, history of clinical preoperative seizure neurosurgeon. and location of tumor with early postoperative seizure. Although there was no correlation between Factors Odd ratio P value antiepileptic prophylaxis and early POSz, higher Male sex 2.735 0.047 percentage of seizure occurred in patients receiving History of clinical preoperative seizure 3.757 0.009 no prophylaxis with tumors in sellar and paresellar Location of tumor 1.261 0.284 location (21.42% and 9.52%). This did not reach statistical significance due to too small sample size
Table 5 Characteristics of patients who had early POSz.
Seizure type Perioperative Post Drug Post op Case AE op day level imaging Preop Post op prophylaxis 1. Atypical meningioma, Occipital 1 - Generalized Yes - Surgical site convexity hematoma 2. Meningioma, parietal convexity 5 - Generalized Yes Adequate Surgical site hematoma 3. Meningioma, parietal parasagital 0 - Motor Yes - Negative study 4. Planum meningioma 5 Generalized Generalized Yes Low level Negative study 5. Planum meningioma 1 - Generalized Yes Adequate Negative study 6. DNET, Temporal 0 Generalized Generalized Yes - Negative study 7. Frontal mixed oligoastrocytoma 4 Generalized Motor Yes Adequate No imaging 8. Lymphoma, parietal 2 Motor Generalized Yes Adequate Brain edema 9. Gemistocytic astrocytoma, frontal 0 Generalized Generalized Yes - Epidural hematoma, need surgical evacuation 10. Metastasis, frontal 3 Motor Motor Yes Adequate No imaging 11. Frontal mixed oligoastrocytoma 0 Generalized Generalized Yes - No imaging 12. Metastasis, parietal 0 Motor Motor Yes Adequate No imaging 13. Frontal GBM 2 Generalized Motor Yes - Brain edema 14. Frontotemporal astrocytoma 1 Generalized CPS Yes - No imaging 15. Vestibular schwannoma (with 1 - Generalized No - No imaging hydrocephalus and intraop ventriculostomy) 16. Craniopharyngioma 6 - Generalized Yes - Negative study 17. Craniopharyngioma 0 Generalized Generalized No - Negative study 18. Craniopharyngioma 0 Generalized Generalized No - Negative study 19. Craniopharyngioma 1 - Generalized No - Negative study 20. Pituitary adenoma 2 - Generalized Yes Adequate Surgical site hematoma 21. Pinealoblastoma, intraventricular 0 - Generalized Yes Low Negative study (lateral ventricle bilateral, 3rd ventricle)
● In CT imaging, negative study means image was normal during postoperative period. No imaging means image was not sent by attending physician. ● For drug level “-” didn’t investigate; “adequate” adequate blood level (10-20 mg/ml for phenytoin and 50-100 mg/ml for valproic acid; “low” below therapeutic level. 128 Veerasarn K and Tadadontip P Thai J Surg Oct. - Dec. 2011
8 7th postoperative day; three patients among these had 7 deterioration of consciousness and could not rule out 6 non-convulsive seizure but no EEG record to confirm 5 before they died. 4 3 DISCUSSION 2 Numberpatients of 1 The incidence of early POSz was 9.7% in total: 0 13.16% for convexity group, 16.07% for subcortical Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 group, 13.89% for sellar and parasellar group, and Postoperative day 2.08% for posterior fossa group. For the intraventricular and pineal region and skull base lesion, the numbers Figure 1 Graph showed the number of patients who developed seizure and post operative day of cases were too few. This is the first study that identified the incidence of early POSz in Thai patients who underwent craniotomy for tumor removal. The incidence of POSz in the convexity group, subcortical (Table 3). Most patients in the convexity and subcortical group and sellar region group were comparable to the group (88/94) and in the sellar and parasellar group non trauma group 1 around 15-20%, and the incidence (21/35) received antiepileptic prophylaxis whereas of POSz in the posterior fossa group (1.8%) was similar those in the posterior fossa group did not. In the to the reported suboccipital craniectomy for all diseases cortical surface and subcortical group, all seizure cases without antiepileptic prophylaxis2,3. occurred in patients with antiepileptic prophylaxis. In this study, we found three factors that correlated The characteristics of patients who had early with early POSz as follows: POSz were shown in Table 5. Details included date of 1) Male gender This study showed a correlation seizure, seizure characteristic at pre and post operative between male gender and early POSz in patients with periods, antiepileptic prophylaxis, drug level when craniotomy for tumor removal. Extensive literature seizure occurred, CT imaging when seizure occurred. review showed no prior report on the correlation Most patients who had early POSz were controlled by between gender and postoperative seizure1-3. Although adequate intravenous antiepileptic therapy except for statistical significance was found on univariate and one case (Patient No. 2 in Table 5) who developed multivariate analysis, a reasonable explanation could generalized tonic clonic seizure on the postoperative not be made on this finding and most of literatures day 5. After being given adequate intravenous showed different outcomes. Conclusion of this finding antiepileptic therapy, he regained conscious but still should be awaited for further study. From practical had epilepsia partialis continuae of right upper view point this finding may not have an influence on extremity. He was treated as status epilepticus and patient care. seizure was controlled but remained comatose for two 2) History of preoperative clinical seizure A weeks. Later on he regained conscious and fully strong correlation between this factor and POSz has recovered with some right hand weakness. been shown in many literatures.7,9 This study showed Most of the early POSz were generalized seizure that correlation was also found in early postoperative (14/21; 66.7%). CT brain was positive in 6/15 (40%) period. It might provoke seizure or for most of the cases and one patient needed surgical intervention. In cases it improved seizure control in the long term. nine cases, blood samplings for anti-epileptic drug 3) Location of tumor The present results showed level were sent for investigated and two of them (22.2%) that there was a different incidence in early POSz in were low. Serum sodium was also evaluated and was various locations of tumors. In univariate analysis, this within normal limit in all cases. Most patients developed factor was statistically significant correlated with early seizure as early as the day of surgery and 13/21 (61.9%) POSz but no statistical significance in multivariate had seizure within the first postoperative day. In this analysis. Difference between the incidences of POSz in study we excluded five patients who expired before the supratentorial and infratentorial procedures of non- Vol. 32 No. 4 Early Postoperative Seizure in Patients with Intracranial Tumor Removal 129
traumatic patients1-3 has been well documented. This a long time4,5,10. By now, there was no standard protocol study investigated a specific tumor surgery group of for the use of AE prophylaxis in patients undergoing patients and found the same trend. Furthermore we craniotomy with tumor removal at our institute. AE found that some areas of supratentorial region might medication is usually prescribed for high risk patients have lower incidence of early postoperative seizure and tapered off a few weeks postoperatively if the (cavernous sinus, sphenoid wing area). However, this patient has no postoperative seizure. In the present study was done in retrospective manner. When patients study, the early POSz occurred very early especially on were categorized into subgroups, the number of day 0 and 1 implying the inadequate dose of AE patients in some groups was very few leading to an medication and the true incidence of POSz. In some invalid comparison. But this study at least has shown cases, the seizure attacked during the ICU stay prior to a trend and may guide us in patient’s care and suggest the first dose of an AE. Therefore, the AE prophylaxis for further study. should be given prior to the procedure. The following factors showed no correlation with When the seizure occurred it might be from early POSz but should be mentioned: correctable causes, such as low drug level or hematoma. 1) Pathology of tumor This study showed a This study showed the importance of imaging and correlation between early POSz and tumor location drug level to evaluate postoperative seizure patients. rather than tumor pathology. For example, patients Among our 21 cases of early POSz, 15/21 had a post with meningioma in convexity location had seizure in seizure CT scan and only 9/21 had their blood AE level 5 of 34 cases (14.7%) whereas no seizure occurred in checked. Forty percent of CTs were abnormal and other areas. This results had the same trend with other 22% of blood sample were at low levels of an AE. study in supratentorial meningioma patients9. But in The major flaw of this study was in its retrospective sellar and parasellar groups, almost all cases that had nature. Data such as clinical presentation of seizure seizure were craniopharyngioma with the risk of POSz was difficult to notice and might be missed in clinical was 4/11 (36.4 %) compared with 1/12 (8.3%) for record. A prospective study on AE prophylaxis in high pituitary adenomas. Since the number of cases was risk patients should be carried out in a larger population small, this result needed confirmation in further study. group. 2) Corticotomy procedure Many literatures showed that cortical injury might cause POSz7. In this CONCLUSION study, univariate analysis showed high proportion of patients in the corticotomy group with seizure but The incidence of early POSz varied among value did not reach statistical significance. The extent different locations of tumors. Patients undergoing of cortical dissection was not recorded and therefore craniotomy for tumor removal who have preoperative was unable to analyze. The POSz in posterior fossa clinical seizure, tumor located in cortical surface, surgery was related to shunt or ventriculostomy subcortical, or sellar parasellar area should be procedure3. In our posterior fossa group, patients who considered high risk for early POSz. Male gender may had seizure underwent intraoperative ventriculostomy have a higher risk for unknown reason. The role and procedure. benefit of prophylactic AE drug cannot be concluded 3) Anti-epileptic (AE) medication prophylaxis but may have benefit in high risk patients. Although the use of AE drugs was related with early POSz on univariate analysis, the result could not be interpreted due to selection bias from surgeons. In REFERENCES subgroup analysis, the correlation between seizure 1. Foy PM, Copeland GP, Shaw MDM. The incidence of and AE medication varied among different locations. postoperative seizures. Acta Neurochir 1981;55:253-64. In the sellar and parasellar group, the incidence of 2. Suri A, Mahapatra AK, Bithal P. Seizure following posterior fossa surgery. Br J Neurosurgery 1998;12:41-4. POSz was reduced to 11.9% in the prophylactic group 3. Lee ST, Lui TN, Chang CN, et al. Early postoperative seizure but did not reach statistical significance. after posterior fossa surgery. J Neurosurgery 1990;73:541-4. Issues of perioperative AE medication in term of 4. Temkin NR. Current review. Prophylactic anticonvulsants timing, duration and efficacy have been discussed for after neurosurgery. Epilepsy Currents 2002;4:105-7. 130 Veerasarn K and Tadadontip P Thai J Surg Oct. - Dec. 2011
5. Santis AD, Villani R, Sinisi M, et al. Add - on Phenytoin fails to Neurosurgery 1985;16:290-2 prevent early seizures after surgery For supratentorial brain 9. Chozick BS, Reinert SE, Samual H, et al. Incidence of seizures tumor: A randomized controlled study. Epilepsia 2002;43:175- after surgery of supratentorial meningiomas: a modern 82. analysis. J Neurosurgery 1996;84:382-6. 6. Sirven JI, Wingerchuk DM, Drazkowski JF, et al. Seizure 10. Temkin NR, Dikmen SS, Wilensky AJ, et al. A randomized, prophylaxis in patients with brain tumors: a Meta-analysis. double - blind study of phenytoin, for the prevention of Mayo Clinic Pro 2004;79:1489-9. posttraumatic seizures. N Engl J Med 1990;323:497-502. 7. Warnick RE. Surgical complication and their avoidance. In: 11. Beenen LF, Lindeboom J, Kasteleijn- Nolst Trenite’ DG, et al. Winn HR, editor. Youmans neurological surgery. 5th ed. USA: Comparative double blind clinical trial of phenytoin and Saunder; 2004. p. 937-8. sodium valproate as anticonvulsant prophylaxis after 8. Boarini DJ, Beck DW, Vangilder JC. Postoperative prophy- craniotomy: efficacy, tolerability, and cognition effects. J lactic anticonvulsant therapy in cerebral gliomas. Neurol Neurosurg Psychi 1999;67:474-80. The THAI Journal of SURGERY 2011;32:131-136. Original Article Official Publication of the Royal College of Surgeons of Thailand
The Relationship between Carotid Plaque Calcification and Stability
Kittipan Rerkasem, MD, PhDa,b Patric J Gallagher, PhDc Robert F Grimble, PhDd Philip C Calder, PhDd Clifford P Shearman, FRCS, MSe aDepartment of Surgery, Faculty of Medicine, Chiang Mai University, Thailand bCenter for Applied Science, Research Institute for Health Sciences, Chiang Mai University, Thailand cDepartment of Pathology, Southampton General Hospital, Southampton, UK d Institute of Human Nutrition, University of Southampton, Southampton, UK eDepartment of Vascular Surgery, Southampton General Hospital, Southampton, UK
Abstract Aim: The study aimed to examine the hypothesis that advanced plaques with calcification are more stable (lower proportion of lipid component and higher proportion of fibrous tissue) compared to plaques without calcification. Methods: Carotid endarterectomy (CEA) specimens from 141 consecutive patients were studied. The specimens were analyzed histologically for fibrous tissues, smooth muscle cells, macrophage, lymphocyte, hemorrhage and lipid, according to the methods of European Carotid Plaque Study Group; plaques were also graded according to American Heart Association (AHA) consensus and its modification. Clinical data was recorded and the plasma concentrations of cholesterol and inflammatory markers were measured. Results: Thirty five out of 141 plaque specimens were identified to have advanced atherosclerosis (type V according to AHA criteria) and these were analyzed further. There were 29 type Va (non-calcified) plaques and 6 type Vb (calcified) plaques. Calcified plaques had significantly less lipid than non-calcified plaques (p < 0.0001): the mean percentage of lipid for non-calcified and calcified plaques was 61.29% and 23.48%, respectively. Also calcified plaques had more fibrous tissue than non-calcified plaques (p = 0.004): the mean percentage of fibrous tissue for non-calcified and calcified plaques was 23.74% and 59.37%, respectively (P<0.0001). The 6 calcified plaques showed no inflammatory cell infiltrate and did not exhibit thin fibrous cap atheroma which are the characteristics indicating high risk for plaque rupture. Conclusion: Calcified plaques had significantly less lipid and more fibrous tissue than non-calcified plaques. These findings might suggest indirectly that plaque calcification is a marker of plaque stability. This may be a useful clinical tool to identify asymptomatic carotid stenosis patients with high risk plaques, which could improve benefit of CEA.
Key words: calcification, carotid, plaque, atherosclerosis, instability
Correspondence address : Kittipan Rerkasem, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; Telephone: +66 5394 5532; Fax: +66 5394 6139; E-mail: [email protected]
131 132 Rerkasem K, et al. Thai J Surg Oct. - Dec. 2011
INTRODUCTION concentrations of soluble E-selectin (sE-selectin) were Carotid stenosis is a cause of stroke. Carotid measured using Quantikine ELISA kits from R & D endarterectomy (CEA) can reduce stroke risk in Systems Europe (Abingdon, UK). The limit of detection patients especially those with symptomatic severe was 0.1 ng/mL; inter- and intra-assay coefficients of carotid stenosis1. However the benefit of CEA in variation were less than 10% and 5%, respectively. asymptomatic patients is still controversial, because in Plasma soluble intercellular adhesion molecule-1 these patients CEA shows only marginal benefit2,3. It is (sICAM-1) and soluble vascular cell adhesion molecule- estimated that 85 patients with asymptomatic severe 1 (sVCAM-1) concentrations were measured using carotid stenosis need to be operated on to prevent one Cytoscreen ELISA kits from BioSource (Nivelles, disabling stroke or death in one year2, whereas six Belgium). Limits of detection were 0.04 ng/mL patients with symptomatic severe carotid stenosis need (sICAM-1) and 0.5 ng/mL (sVCAM-1). Inter- and to be operated on to prevent one stroke in one year1. intra-assay coefficients of variation were less than 5% Therefore, an ability to identify asymptomatic carotid for both assays. Total plasma cholesterol and low- stenosis patients who have a high risk plaque (i.e. density lipoprotein concentrations were measured vulnerability to rupture, known as plaque instability) using commercially available, enzyme-based diagnostic could improve the efficacy of CEA in asymptomatic kits (Sigma Chemical Co., Poole, UK). patients and could reduce the number of unnecessary Specimens of carotid plaque obtained during operations in this group of patients. CEA were immediately washed with saline in operating In common with coronary plaques, unstable theatre. Serial transverse 2 mm sections were taken. carotid plaques have a high lipid content, a thin These sections were then labeled alphabetically, starting fibrous cap, a high inflammatory cell content, and from the distal end of the internal carotid artery and increased protease activity4. Calcification is a feature ending at the common carotid artery. Alternate sections of advanced plaques, but the relation between of the plaque were cut from each block. We fixed calcification and other plaque components remains sections in formaldehyde and then embedded them in uncertain and the relation of calcification to plaque paraffin wax and stained with haematoxylin and eosin stability is not clear. Here, we investigated association (H & E). These stained sections were viewed with a between calcification and other plaque features microscope under 10 x magnification in random order; characteristic of plaque instability. they were graded blindly and independently by KR and PJG, using criteria of American Heart Association (AHA) concensus6 and its modification7. Also the MATERIALS AND METHODS amount of different plaque components (histomor- The study was approved by the Southampton and phometry) was measured according to the European South West Hampshire Research Ethics Committee, Carotid Plaque Study Group guidelines, which were and written informed consent was obtained from all developed and validated in our unit for a previous patients recruited. This was a prospective study and study of carotid atherosclerosis8. 141 consecutive patients undergoing CEA were The AHA classification has six grades or types6: recruited and their medical history was recorded5. type I (initial lesion); type II (early lesion or fatty Patients’ records were also checked. On pre-operative streak); type III (intermediate lesion or preatheroma); visits venous blood samples were taken into vacutainer type IV (atheroma or atheromatous plaque); type V (r) tubes containing 0.12 ml of 15% EDTA. Plasma was (fibroatherma or fibrotic lesion); and type VI (lesion isolated by centrifugation at 2500 rpm for 10 minutes with surface defect, hemorrhage, thrombotic deposit, and then stored at -70 ˚C. The plasma concentration or a combination of these). The modification of this of high sensitivity C-reactive protein (hs-CRP) was classification entails a series of descriptive grades of measured by an immunoturbidimetric technique, using increasing severity: pathological intimal thickening a commercially available kit, made by Wako (smooth muscle cells in the matrix with areas of Laboratories and available from Alpha Laboratories extracellular lipid accumulation but no necrosis or (Eastleigh, UK). Inter- and intra-assay coefficients of thrombus); fibrous cap atheroma (a well-formed variation were 6.4% and 3.4% respectively. Plasma necrotic core with an overlying fibrous cap; no Vol. 32 No. 4 Plaque Stability in Carotid Plaque Calcification 133
thrombus); thin fibrous cap atheroma (a thin fibrous using Student’s t-test, and non-normally distributed cap infiltrated by macrophages and lymphocytes with data were compared using the Mann-Whitney Rank rare smooth muscle cells and an underlying necrotic sum test. Categorical data were compared by Chi- core; no thrombus); erosion (luminal thrombosis); square test or Fisher’s exact test. A p value of less than plaque rupture (fibroatheroma with disruption; 0.05 was considered significant. luminal thrombus communicating with necrotic core); and calcified nodule and fibrocalcific plaque7. For the RESULTS histomorphometry measurement, the contribution of fibrous tissue, lipid, hemorrhage, macrophages, 35 out of 141 plaque specimens were identified to lymphocytes, smooth muscle cells, and new blood have severe atherosclerosis (type V according to AHA vessels was measured volumetrically with a standard criteria) and these were analysed further. They were light microscope with a reticule, which superimposed classified as 29 type Va (non-calcified) plaques and 6 as a grid of many equally-sized squares on the field of type Vb (calcified) plaques. The mean period between view8. This was done by identifying and recording for symptom and surgery was 41 days. There were no each field of view the type of tissue at the 36 reticule statistically significant differences between patients points (intersections of two reticule lines). The field of with non-calcified and calcified plaques in baseline view was scanned carefully to ensure that no areas of characteristics, blood lipid concentrations or plasma the section were missed or counted more than once. inflammatory markers (Tables 1 and 2). In an analysis From 6 to 20 fields were examined to cover the surface of histomorphometry (plaque composition) (Table area of each section. The percentage contribution of 3), calcified plaques had significantly more fibrous each constituent was calculated. Inter-observer tissue and less lipid than non-calcified plaques. The agreement of histomorphometry was 92%. mean percentage of fibrous tissue for non-calcified and calcified plaques was 23.74% and 59.37%, Statistical analysis respectively, while the mean percentage of lipid for Normally distributed ordinal data were compared non-calcified and calcified plaques was 61.29% and
Table 1 Baseline characteristics of patients undergoing carotid endarterectomy according to whether the AHA type V plaque was calcified or non-calcified
Non-calcified plaque Calcified plaque Risk factors P value (n = 29) (n = 6) Mean age, y (SEM) 70.21 (1.9) 69.00 (4.0) 0.79 Male, n (%) 16 (55.2) 2 (33.3) 0.40 Hypertension, n (%) 20 (69.0) 3 (50.0) 0.36 Diabetes, n (%) 3 (10.3) 2 (33.3) 0.20 Current smoker, n (%) 24 (82.8) 5 (83.3) 1.00 Mean body mass index, kg/m2 (SEM) 25.43 (3.4) 25.92 (1.7) 0.76 Coronary artery disease,n (%) 9 (31.0) 3 (50.0) 0.15 Peripheral artery disease, n (%) 3 (10.3) 1 (16.7) 1.00 Clinical history Asymptomatic 8 (27.6) 2 (33.3) 0.44 Amaurosis fugax 3 (10.3) 2 (33.3) Transient ischemic attack 13 (44.8) 0 Stroke 5 (17.2) 2 (33.3) Severe stenosis (70-99%) 24 (82.8) 5 (83.3) 0.85 Eversion carotid endarterectomy (%) 8 (27.6) 1 (16.7) 1.0
SEM, Standard error of the mean; n = total number 134 Rerkasem K, et al. Thai J Surg Oct. - Dec. 2011
Table 2 Blood lipid and inflammatory marker concentrations in patients according to whether the AHA type V plaque was calcified or non-calcified
Non-calcified plaque Calcified plaque P value (n = 29) (n = 6) LDL, mmol/L 1.97 (0.1) 2.67 (0.8) 0.23 Total cholesterol, mmol/L 4.80 (0.2) 5.90 (1.0) 0.35 hs-CRP (mg/L) 6.02 (1.8) 19.16 (13.2) 0.37 sICAM-1 (ng/mL) 310.93 (15.0) 343.10 (53.6) 0.42 sVCAM-1 (ng/mL) 693.01 (51.5) 683.28 (87.9) 0.93 sE-selectin (ng/mL) 36.32 (4.3) 46.95 (7.3) 0.24
Data are mean with SEM shown in parentheses. n = total number LDL, low-density lipoprotein; hs-CRP, high-sensitivity C-reactive protein; sICAM, soluble intercellular adhesion molecule; sVCAM, soluble vascular adhesion molecule; sE-selectin, soluble E selectin
Table 3 The percentage of the content of fibrous tissue, lipid, hemorrhage, lymphocyte, macrophage, smooth muscle cells, and new blood vessels according to whether the AHA type V plaque was calcified or non-calcified
Non-calcified plaque Calcified plaque Plaque component P value (n = 29) (n = 6) Fibrous tissue 23.74 (3.5) 59.37 (7.6) < 0.0001 Lipid 61.29 (3.7) 23.48 (8.1) 0.004 Hemorrhage 1.30 (0.4) 0.52 (0.4) 0.38 Lymphocytes 3.88 (1.4) 1.05 (0.6) 0.35 Macrophages 1.11 (0.6) 0 0.38 Smooth muscle cells 2.28 (0.7) 7.67 (6.3) 0.43 New blood vessels 0.07 (0.03) 0.04 (0.03) 0.61
Data are mean percentage with SEM shown in parentheses, n = total number of plaques in each type
Table 4 The number and percentage of plaque morphology of non-calcified and calcified plaques according to the modified AHA classification
Non-calcified plaque Calcified plaque P value (n = 29) (n = 6) Fibrous cap atheroma 2 (6.9) 0 Thin fibrous cap atheroma 27 (93.1) 0 < 0.0001 Calcified nodule 0 4 (66.7) Fibrocalcific plaque 0 2 (33.3)
Data are number of plaque with percentage shown in parentheses, n = total number of plaques in each type
23.48% respectively. Calcified plaques showed no fibrous cap and a large lipid core are at high risk for macrophage infiltration and did not exhibit thin fibrous rupture, increasing likelihood of thrombosis and cap atheroma which are the characteristics indicating stroke7. We found that calcified plaques showed no high risk for plaque rupture (Table 4). macrophage infiltration and no calcified plaques were classified as thin fibrous cap atheromas. It was considered that thin fibrous cap atheromas are most DISCUSSION likely to rupture7. Together, our findings indicate that Here we show that calcified plaques have more calcification is associated with plaque stability. In a fibrous tissue and less lipid content than non-calcified previous study, Wahlgren et al. showed that calcified plaques. It is well known that plaques with a thin plaques had fewer macrophages in the fibrous cap Vol. 32 No. 4 Plaque Stability in Carotid Plaque Calcification 135
than non-calcified plaques9. Shaalan et al. investigated lowering agents not only reduce the amount of lipid in plaque calcification by CT scan and plaque charac- the plaque but increase plaque calcium20. teristics by immunohistochemistry10. They found Although we believe our data is valid, the sample calcified plaques to have a less inflammatory character size was small, meaning that the number of calcified and to be associated with fewer ischemic symptoms plaques was small (n = 6), which was prone to have type than non-calcified plaques. Similarly Nandalur et al. II error in the analyses. However, our study result is still reported that the proportion of carotid plaque consistent with other studies in terms of inflammatory calcification is associated with plaque stability in patients cells and plaque stability.9-11 Also the mean duration with carotid stenosis and they proposed plaque between symptom and surgery was 41 days, that might calcification of 45% of the total volume according to have time to heal plaque. This might partly explain no CT scan that might represent a clinically useful cutoff11. correlation between symptom and plaque stability Li and colleague reported the importance of the criteria was found. location of calcification in plaques by magnetic resonance imaging study. They found when CONCLUSION calcification locates in fibrous cap especially in thin fibrous cap, it creates a very high stress concen-tration Plaques with calcification demonstrate less lipid on plaque and consequently increases risk of plaque and more fibrous components, compared to plaques rupture12,13. Also a recent systematic review found without calcification. These findings might suggest symptomatic plaques have a lower degree of indirectly that plaque calcification is a marker of plaque calcification than asymptomatic plaques14. Our study stability. This needs to be tested in bigger studies. If adds novel information on the relationship between that is the case, this will benefit enormously because plaque calcification and plaque instability in terms of plaque calcification is readily identified on non-invasive the morphologic characteristics i.e. no thin fibrous testing such as ultrasound and this may be a useful cap atheroma in calcified plaque. Overall, our findings clinical tool to identify patients with lower risk plaques. suggested that calcification is associated indirectly with stable plaques. ACKNOWLEDGEMENTS The mechanisms of the association between calcification and plaque stability are not clear. Our We would like to thank Dr. Chulakadabba for study together with others found that calcified plaque assisting in data collection. The authors would like to had fewer macrophages9. It is recognised that thank the Food Standards Agency (UK) for its financial macrophages play a role which makes plaques more support. unstable through many machanisms namely excessive inflammatory cytokine and matrix metalloproteinases production15,16, apoptosis17 and potent initiators of thrombosis18. Plaque calcification may be applied to select REFERENCES patients with asymptomatic carotid stenosis who have 1. Rerkasem K, Rothwell PM. Carotid endarterectomy for high risk for strokes. Calcification can be identified by symptomatic carotid stenosis. Cochrane Database Syst Rev 2011;13:CD001081. many available investigations such as ultrasound, CT 2. Endarterectomy for asymptomatic carotid artery stenosis. 19 scanning and magnetic resonance imaging . If the Executive Committee for the Asymptomatic Carotid significance of calcification in this study is confirmed, Atherosclerosis Study. JAMA 1995;273:1421-8. by a prospective randomized controlled trial, patients 3. Prevention of disabling and fatal strokes by successful carotid with asymptomatic carotid stenosis with calcification endarterectomy in patients without recent neurological might need medical treatment alone. Also calcification symptoms: randomised controlled trial. MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Lancet might be a marker to monitor the effectiveness of 2004;363:1491-502. medical treatment to make plaques more stable, such 4. Virmani R, Finn AV, Kolodgie FD. Carotid plaque stabilization as by lipid lowering agents or by antihypertensive and progression after stroke or TIA. Arterioscler Thromb Vasc drugs. Interestingly, Zhao et al. reported that lipid Biol 2009;29:3-6. 136 Rerkasem K, et al. Thai J Surg Oct. - Dec. 2011
5. Rerkasem K, Gallagher PJ, Grimble RF, Calder PC, Shearman 13. Li ZY, Howarth S, King-Im J, Gillard J. Atheroma: is Calcium CP. Sex difference in composition of plaques of patients important or not? A modelling study of stress within the undergoing carotid endarterectomy. Vascular 2010;18:77- atheromatous fibrous cap in relation to position and size of 81. calcium deposits. Conf Proc IEEE Eng Med Biol Soc 2005;3: 6. Stary HC, Chandler AB, Dinsmore RE, et al. A definition of 2236-9. advanced types of atherosclerotic lesions and a histological 14. Kwee RM. Systematic review on the association between classification of atherosclerosis. A report from the Committee calcification in carotid plaques and clinical ischemic on Vascular Lesions of the Council on Arteriosclerosis, symptoms. J Vasc Surg 2010;51:1015-25. American Heart Association. Arterioscler Thromb Vasc Bio 15. Geng YJ, Wu Q, Muszynski M, Hansson GK, Libby P. Apoptosis 1995;15:1512-31. of vascular smooth muscle cells induced by in vitro stimulation 7. Virmani R, Kolodgie FD, Burke AP, Farb A, Schwartz SM. with interferon-gamma, tumor necrosis factor-alpha, and Lessons from sudden coronary death: a comprehensive interleukin-1 beta. Arterioscler Thromb Vasc Biol 1996;16:19- morphological classification scheme for atherosclerotic 27. lesions. Arterioscler.Thromb Vasc Biol 2000;20:1262-75. 16. Libby P. Molecular bases of the acute coronary syndromes. 8. Carotid artery plaque composition—relationship to clinical Circulation 1995;91:2844-50. presentation and ultrasound B-mode imaging. European 17. Boyle JJ, Bowyer DE, Weissberg PL, Bennett MR. Human Carotid Plaque Study Group. Eur J Vasc Endovasc Surg blood-derived macrophages induce apoptosis in human 1995;10:23-30. plaque-derived vascular smooth muscle cells by Fas-ligand/ 9. Wahlgren CM, Zheng W, Shaalan W, Tang J, Bassiouny HS. Fas interactions. Arterioscler Thromb Vasc Biol 2001;21:1402- Human carotid plaque calcification and vulnerability. 7. Relationship between degree of plaque calcification, fibrous 18. Wilcox JN, Smith KM, Schwartz SM, Gordon D. Localization cap inflammatory gene expression and symptomatology. of tissue factor in the normal vessel wall and in the Cerebrovasc Dis 2009;27:193-200. atherosclerotic plaque. Proc Natl Acad Sci USA 1989;86:2839- 10. Shaalan WE, Cheng H, Gewertz B, et al. Degree of carotid 43. plaque calcification in relation to symptomatic outcome 19. Kadoglou NP, Gerasimidis T, Golemati S, Kapelouzou A, and plaque inflammation. J Vasc Surg 2004;40:262-9. Karayannacos PE, Liapis CD. The relationship between 11. Nandalur KR, Hardie AD, Raghavan P, Schipper MJ, Baskurt serum levels of vascular calcification inhibitors and carotid E, Kramer CM. Composition of the stable carotid plaque: plaque vulnerability. J Vasc Surg 2008;47:55-62. insights from a multidetector computed tomography study 20. Zhao XQ, Yuan C, Hatsukami TS, et al. Effects of prolonged of plaque volume. Stroke 2007;38:935-40. intensive lipid-lowering therapy on the characteristics of 12. Li ZY, Howarth S, Tang T, Graves M, King-Im J, Gillard JH. Does carotid atherosclerotic plaques in vivo by MRI: a case- calcium deposition play a role in the stability of atheroma? control study. Arterioscler Thromb Vasc Biol 2001;21:1623-9. Location may be the key. Cerebrovasc Dis 2007;24:452-9. The THAI Journal of SURGERY 2011;32:137-140. Original Article Official Publication of the Royal College of Surgeons of Thailand
Effectiveness of Prophylaxis Antibiotic Used for Tension-free Hernioplasty: A Randomized Double- blinded Placebo-controlled Trial
Wibun Phanthabordeekorn, MD Department of Surgery, Paholpolpayuhasaena General Hospital, Kanchanaburi, Thailand
Abstract Objective: To evaluate the effectiveness of prophylaxis antibiotic used for tension-free hernioplasty on prevention of surgical wound infection. Materials and Methods: After having permission from the Ethical Review Board of the hospital, this randomized double-blinded placebo-controlled trial was performed from September 2010 to June 2011. One hundred and six patients with inguinal hernias, American Society of Anesthesiologists (ASA) Class 1-2, who never had allergy to cephalosporin and aged over 18 years-old were included. Fifty and 56 patients were allocated to the intervention and control groups, respectively. Results: At one-week follow-up, there was no difference of infection rate among the control and intervention groups. In other words, there was no sign of wound infection found in all of 106 patients. All patients did well without sign of wound infection at one-month follow-up. Conclusion: There is no clear benefit of preoperative prophylactic antibiotic for prevention of post inguinal hernioplasty wound infection. For deep surgical site infection, a longer follow-up at one year is needed for completion of CDC criteria.
Key words: inguinal hernioplasty, mesh graft, prophylactic antibiotic, surgical wound infection
INTRODUCTION Incidence of surgical wound infection after Inguinal hernioplasty is a common general inguinal hernioplasty ranged from 0.4-1.3%3. In surgical procedure. In the past, conventional hernia Thailand, this incidence especially in cases using mesh repair, without mesh graft, needed no prophylactic graft is still unknown and there has been no clinical antibiotic. However, contemporary surgeons practice guideline recommending prophylactic increasingly prefer tension-free hernioplasty due to its antibiotic for this procedure. Therefore, empirical low recurrent rate and clean wound in nature. Different antibiotic prophylaxis is routinely used in most institutes from conventional hernia repair by using mesh graft, without any medical evidences. Till now, there have which is a synthetic material, its risk of surgical wound been controversies in this issue whether prophylactic infection might be increased1,2. antibiotics are useful for inguinal hernioplasty4-7.
Correspondence address : Wibun Phanthabordeekorn, MD, Department of Surgery, Paholpolpayuhasaena General Hospital, Kanchanaburi 71000,Thailand; Telephone: +66 3462 2999; Fax: +66 ; E-mail: [email protected]
137 138 Phantthabordeekorn W Thai J Surg Oct. - Dec. 2011
At present, European hernia society guideline8, infections. which is an evidence-based guideline, recommends that there is no need for preoperative prophylactic RESULTS antibiotic in low-risk patients. However, their data came from European studies which have different From September 2010 to June 2011, there were population from our South-East Asia, in races, public- 106 patients included. Placebo group consisted of 56 health systems, climates, and environments, which can patients (aged 25-84 years old), 53 males and 3 females. affect patients’ surgical wound infections. Twelve patients in this group had more than one co- This study aimed to evaluate the effectiveness of morbidity. One patient had recurrent and one had prophylactic antibiotic used for tension-free bilateral hernias. The cefazolin group consisted of 50 hernioplasty on prevention of surgical wound infection patients (aged 20-82 years old), all were male. Ten of after surgery. this group had more than one co-morbidity. Two patients had recurrent and one had bilateral hernias (Table 1). MATERIALS AND METHODS No patients needed to be observed in the recovery After having permission from the Ethical Review room. Every patient was able to return to their Board of the hospital, this randomized double-blinded residences immediately after surgery. There was no placebo-controlled trial was performed from acute urinary retention or wound hematoma found. September 2010 to June 2011. All patients with inguinal No one needed re-admission from either surgical hernias, American Society of Anesthesiologists (ASA) complications or post-operative pain. At one-week class 1-2, never had an allergy to cephalosporin, and aged over 18 years-old were included after informed consents obtained. Table 1 Demographic data of all patients Patients were divided into two groups according Control Intervention to a computer-generated random sequence developed Characteristics group group by a hospital pharmacist. These allocations were (N = 56) (N = 50) accomplished without knowing by author or the nurse Age (mean and range in years) 57.3 (25-84) 52.5 (20-82) injecting drugs because either cefazolin (1 gram) or placebo looked the same by naked eyes. These drugs Gender Male 53 50 were given by intravenous injection 30 minutes before Female 3 0 surgical incision. The reason for using cefazolin was its Types efficacy over Staphylococcus aureus and Staphylococcus Direct 37 37 epidermidis which commonly caused mesh graft related Indirect 19 14 surgical wound infections1,2,4, and it had enough half- Incarcerated 4 4 life for inguinal hernioplasty. The placebo was normal Recurrent 1 2 saline solution. Laterality Aside from cefazolin or placebo as mentioned Unilateral 55 49 above, all patients had the same Lichtenstein inguinal Bilateral 1 1 hernioplasty under local anesthesia using 40 ml of 1% Comorbidity xylocain and 20 ml of 0.5% bupivacain. Preoperative Hypertension 14 14 local preparations were done by cleansing with 2% Cardiovascular diseases 8 6 Diabetes mellitus 5 4 chlorhexidine-70% alcohol solution and shaving in Respiratory diseases 3 4 the operating theatre. Every patient had mesh graft, Dyslipidemia 6 3 lightweight polypropylene mesh [Ultrapro-Ethicon] Gouty arthritis 1 2 sized 8 × 15 cm, placed by a day-case surgery. Follow- Chronic kidney diseases 2 2 ups were done at one week and one month after Cerebrovascular diseases 0 2 surgery to evaluate superficial surgical site infection Hyperthyroidism 1 0 Cirrhosis 1 0 according to CDC criteria and other surgical-related Vol. 32 No. 4 Prophylaxis Antibiotic Used for Tension-free Hernioplasty 139
follow-up, every patient had total stitches off and there infection rate of 4/49 in control group. This was in was no difference of wound infection rate among the contrast to the studies by Othman12 and Shankar et al13 control and the intervention groups (0%, 95% CI 0- which reported no difference in surgical wound 6.4% vs 0%, 95%CI 0-7.1%, respectively, p >0.999). In infection rate found after inguinal hernioplasty among other words, there was no sign of wound infection control and intervention groups. They also recom- found in all of 106 patients (0%, 95% CI 0-3.4%). All mended that prophylactic antibiotic should not be patients did well without any sign of wound infection routinely used in every case undergoing inguinal at one-month follow-up. hernioplasty but might be used in some selected cases with high-risk of surgical wound infection. At present, there is still no definite benefit from DISCUSSION preoperative prophylactic antibiotic for prevention of Lichtenstein inguinal hernioplasty is a surgical post inguinal hernioplasty wound infection. This procedure using mesh graft placed into the surgical surgical procedure still has many measures for infection wound. If there is surgical wound infection, it will be prevention such as proper surgical site skin preparation, very complex in treating it. Preoperative prophylactic aseptic technique, patient selection, surgical technique, antibiotic is an intervention that may decrease the risk type of mesh graft, and finally, duration of surgery8. of this infection, but there are some studies not From this study, the author could only explain supporting this intervention for every case of inguinal about superficial surgical site infection, which is only a hernia4,9,10. The reason is this intervention cannot surrogate end point. For deep surgical site infection, definitely decrease post operative infection rate while which is a primary end point, one-year follow-up is still increasing expenses and unnecessary use of antibiotics needed to be done, for completion of CDC criteria. that might also increase bacterial resistance rate in communities6. In addition, patients who receive this CONCLUSION intervention are at certain risk of hypersensitivity/ allergic reaction. Preoperative prophylactic antibiotic does not In this study, the patients did not need prior prevent superficial surgical site infection after a tension- admission to the hospital and after surgery, they could free inguinal hernioplasty. There is still no definite return to their residences almost always immediately. benefit from preoperative prophylactic antibiotic for There was no difference of wound infection rate among prevention of post inguinal hernioplasty wound the two groups, in other words, there was no wound infection. Therefore, there is no need for prophylactic infection found in this study. However, one-year antibiotic in every case undergoing this procedure. follow-up is still needed according to CDC criteria of Some patients who may need it may include some high- deep surgical site infection. risk patients such as immuno-compromised or poor- Previous study by Sanchez-Manuel et al 11 reported controlled diabetes mellitus ones. no definite benefit from prophylactic antibiotic used for decreasing wound infection rate after inguinal 7 hernioplasty. Aufenacker et al also found that REFERENCES preoperative prophylactic antibiotic did not decrease 1. Falagas ME, Kasiakou SK. Mesh- related infection after wound infection rate after inguinal hernioplasty. These hernia repair surgery. Clin Microbiol Infect 2005;11:3-8. 9 results were in contrast with a study by Sanabria et al 2. Delikoukos S, Tzovaras G, Liakou P, Mantzos F, Hatzitheofilou reporting that preoperative prophylactic antibiotic C. Late-onset deep mesh infection after inguinal hernia could decrease wound infection rate after inguinal repair. Hernia 2007;11:15-7. hernioplasty by 50%. 3. Bueno Lledó J, Sosa Quesada Y, Gomez I Gavara I, Vaqué In a Spanish study of preoperative prophylactic Urbaneja J. Prosthetic infection after hernioplasty: Five years experience. Cir Esp 2009;85:158-64. antibiotic conducted in patients undergoing inguinal 4. Perez AR, Roxas MF, Hilvano SS. A randomized, double- hernioplasty under local anesthesia, similar to this blind, placebo-controlled trial to determine effectiveness study, Celdrán et al10 reported that cefazolin could of antibiotic prophylaxis for tension-free mesh herniorrhaphy. decrease surgical wound infection. They found J Am Coll Surg 2004;200:393-7. 140 Phantthabordeekorn W Thai J Surg Oct. - Dec. 2011
5. Jain SK, Jayant M, Norbu C. The role of antibiotic prophylaxis 9. Sanabria A, Domingues LC, Valdivieso E. Prophylactic anti- in mesh repair of primary inguinal hernias using prolene biotics for mesh inguinal hernioplasty: a meta-analysis. Ann hernia system: a randomized prospective double-blind Surg 2007;245:392-6. control trial. Trop Doct 2008;38:80-2. 10. Celdrán A, Granizo JJ. Antibiotic prophylaxis for hernia 6. Terzi C. Antimicrobial prophylaxis in clean surgery with repair. J Am Coll Surg 2006;203:138-9. special focus on inguinal hernia repair with mesh. J Hosp 11. Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL. Antibiotic Infect 2006;62:427-36. prophylaxis for hernia repair. Cochrane Database Syst Rev 7. Aufenacker TJ, van Geldere D, van Mesdag T, et al. The role 2007;3:CD003769. of antibiotic prophylaxis in prevention of wound infection 12. Othman I. Prospective randomized evaluation of after Lichtenstein open mesh repair of primary inguinal prophylactic antibiotic usage in patients undergoing tension hernia: a multicenter double-blind randomized controlled free inguinal hernioplasty. Hernia 2011;15:309-13. trial. Ann Surg 2004;240:955-61. 13. Shankar VG, Srinivasan K, Sistla SC, Jagdis S. Prophylactic 8. Simons MP, Aufenacker T, Bay-Nielsen M, et al. European antibiotics in open mesh repair of inguinal hernia - a Hernia Society guidelines on the treatment of inguinal hernia randomized controlled trial. Int J Sur 2010;8:444-7. in adult patients. Hernia 2009;13:343-403. The THAI Journal of SURGERY 2011;32:141-144. Case Report Official Publication of the Royal College of Surgeons of Thailand
Laparoscopic Excision of an Infected Urachal Cyst in an Adult
Supoj Laiwattanapaisal MD Department of General Surgery, Rayong Hospital
Abstract Background and Objective: The infected urachal cyst is rare. We reported here our experience in minimally invasive laparoscopic excision in an adult patient. Material and Method: A 45-year-old fisherman was referred to the General Surgery Department at Rayong Hospital. He complained of peri-umbilical pain for two months with brownish yellowish foul-smell discharge from the umbilicus. We performed laparoscopic surgery using three 5-mm ports at the lateral border of rectus muscle. The cystic mass was excised together with medial umbilical ligament and removed via the umbilicus . Results: The total operative time was 150 minutes and the blood loss was minimal with no operative complications. Length of hospital stay was seven days. The pain score was 2-5. Pathology result showed a urachal cyst with chronic inflammation. Conclusion: Laparoscopic excision of infected urachal cyst can be performed with good outcome with minimal post operative complication.
Key words: Laparoscopic surgery, minimal invasive surgery, umbilicus, urachal cyst
INTRODUCTION very rare. We reported our experience of laparoscopic The urachus is a rare congenital abnormality of excision of infected urachal cyst. Patient data, intra- abdominal wall defect. It is a fibromuscular, tubular operative findings, pathologic data, and clinical extension of the allantois that develops with the descent outcomes were analyzed. of the bladder to its pelvic position. Persistence of urachal remnant may result in cyst without or with CASE REPORT infection, cyst with stone formation, fistula to urinary bladder, or carcinoma1. Recently, laparoscopic surgery A 45-year-old fisherman presented to the General has been reported to be effective and safe procedure Surgery Department at Rayong Hospital with a two- for a patient with urachal cyst2. Most patients were month history of periumbilical pain with brownish, found in the younger age group but an adult case is yellowish foul-smell discharge from the umbilicus. He
Correspondence address : Supoj Laiwattanapaisal MD, Department of General Surgery, Rayong Hospital, Rayong, Thailand; Telehone: +66 3861 1104 Ext. 2244; Fax: +66 3861 7460; E-mail: supoj–[email protected]
141 142 Laiwattanapaisal S Thai J Surg Oct. - Dec. 2011
had no fever, urinary symptoms and abdominal pain. supine position. The surgeon stands on the left side of The pain was located only around periumbilical area. the patient. We used three port sites which a 5-mm The cystic content looked like tooth paste as in Figure camera port and the other two 5 -mm ports were 1. inserted at lateral border of rectus muscle (Figure 2). We did not send preoperative investigation for The 30-degree laparoscope was used. The abdomen confirm diagnosis because of clear sign and symptom. was insufflated with carbon dioxide to pressure of 12 We had a prior experience with laparoscopic repair of mmHg. We excised the medial umbilical ligament umbilical hernia and we planned to use laparoscope until reaching the dome of bladder (Figure 3). No for diagnosis and treatment at the same time. bladder involvement was found. The infected cystic mass was excised then removed through the umbilicus Surgical Technique site due to a sinus tract from the cystic mass through We performed laparoscopic excision under umbilicus. general anesthesia. The patient was placed in the The total operative time was 150 minutes. The
AB Figure 1
AB Figure 2
AB
Figure 3 A A part of omentum was adhered to urachal cyst B The cyst was excised Vol. 32 No. 4 Laparoscopic Excision of an Infected Urachal Cyst in an Adult 143
blood loss was estimated at 10 mL. The patient stayed effective and safe as open technique with additional in hospital for five days. The pain score was 2-5. There advantages of decreased hospital stay, less post operative were no peri-operative complications. The pathological pain , and more rapid recovery6. In addition, we found results showed an inclusion cyst with chronic that laparoscopic technique provides an excellent view inflammation. At three-month follow-up there was no of the whole operative field. evidence of recurrence. All study case in Table 1 showed no complication7. Risk of cancer is small (0.5%) and usually occurs at the age of 40-70 years with no symptoms. The overall five- DISCUSSION year survival rate is only 10%10. In Thailand 2010 There are two treatment options for patients with Sompol Permpongkosol, et al8 reported three cases of infected urachal cyst presenting with peri-umbilical laparoscopic excision of urachal cyst with a good pain and discharge. The conservative or non-operative outcome and no complication. Most cases were treatment includes antibiotic therapy and drainage reported from the specialties of urology and pediatric (percutaneous or laparoscopic)3,4, however there is a surgery. The first report from general surgeon was by 30% chance of recurrence if it is a complicated urachal Linos D et al in 19972 but in Thailand we have never cyst. Another option is the operative treatment in seen the report before. There are many laparoscopic which minimally invasive surgery is the treatment of approaches for cyst excision depending on the site of choice. Traditionally, an open procedure using a urachal cyst7. In this present case we performed lower midline incision has been used with safe and laparoscopic removal using three ports at lateral border effective results5. However, minimally invasive tech- of rectus muscle. The advantage of this approach is niques have recently gained increasing acceptance. good view and the minimal risk of incomplete excision Laparoscopic removal has been proposed to be as of the urachal remnant proposed by Cutting et al9.
Table 1. Laparoscopic excision of complicated urachal cyst in an adults
Presenting Author Sex Age Surgery Pathology Complication symptom Neufang T 1992 F 28Training sinus at the Laparoscopic excision of Urachal cyst None umbilicus urachal remnant Siegel JF 1994 F 18Infection Laparoscopic excision of Urachal cyst None urachal remnant Jorion JL 1994 F 57Infection Laparoscopic excision of Urachal cyst None urachal remnant Stone N 1995 M 21Infection Laparoscopic excision of Urachal cyst None sinus and cyst, bladder closure with stapler Cadeddu J 2000 3 F 43.3Acute supropubic Laparoscopic radical Urachal cyst None 1 M (mean) pain and fever excision of urachal remnant in all cases Yamada T 2001 F 48Abdominal tumor Laparoscopic removal Urachal cyst None anterior abdominal wall mass Yohannes P 2003 F 16Umbilical discharge Laparoscopic radical Urachal sinus None excision of urachal sinus Castillo O 2005 M 25Abdominal pain and Laparoscopic excision of Infected uracha cyst None fever urachal remnant in both M 38Incidental cases Urachal cyst 144 Laiwattanapaisal S Thai J Surg Oct. - Dec. 2011
CONCLUSION 4. Marmol Navarro S, Guadalajara Jurado J, Cancelo Suarez The laparoscopic approach for infected umbilical P, Gil de la Puente J, Rajab R, Parra Mountaner LE. [Pyo- urachal cyst]. Arch Esp Urol 1992;45:1034-6. patients appears to be safe and effective with better 5. Mesrobian HG, Zacharias A, Balcom AH, Cohen RD. Ten cosmetic result. years of experience with isolated urachal anomalies in children. J Urol 1997;158(3 Pt 2):1316-8. 6. Kojima Y, Hayashi Y, Yasui T, Itoh Y, Maruyama T, Kohri K. Laparoscopic management for urachal cyst in a 9-year-old boy. Int Urol Nephrol 2007;39: 771-4. 7. Castillo OA, Vitagliano G, Olivares R, Sanchez-Salas R. Complete excision of urachal cyst by laparoscopic means: a new approach to an uncommon disorder. Arch Esp Urol REFERENCES 2007;60:607-11. 1. Seymour NE, Bell RL. Abdominal wall, omentum, mesentery, 8. Permpongkosol S, Bella AJ, Suntisevee S, Leenanupunth C, and retroperitoneum. In: Brunicardi FC, editor. Schwartz’S Stoller ML. Laparoscopic excision of urachal cysts in elderly principles of surgery. 9th ed. Houston, Texas: McGraw-Hill; men and woman following pregnancy. J Med Assoc Thai 2010. p. 1271. 2010;93:132-6. 2. Linos D, Mitropoulos F, Patoulis J, Psomas M, Parasyris V. 9. Cutting CW, Hindley RG, Poulsen J. Laparoscopic Laparoscopic removal of urachal sinus. J Laparoendosc management of complicated urachal remnants. BJU Int Adv Surg Tech A 1997;7:135-8. 2005;96:1417-21. 3. Berman SM, Tolia BM, Laor E, Reid RE, Schweizerhof SP, Freed 10. Michael S. Martin, Lembo RM. A-17-year-old Boy with SZ. Urachal remnants in adults. Urology 1988;31:17-21. Umbilical Discharge. Hospital Physician 2004:19-25. The THAI Journal of SURGERY 2011; 32:145-170. Official Publication of the Royal College of Surgeons of Thailand
Abstracts of the 36th Annual Scientific Meeting of the Royal College of Surgeons of Thailand, 14-16 July 2011, Ambassader City Jomtien Hotel, Jomtien, Pattaya, Cholburi, Thailand (Part 2)
PEDIATRIC SURGERY
MEDIUM-TERM FUNCTIONAL OUTCOME FOL- in one patient whereas significant constipation was observed LOWING ENDORECTAL PULLTHROUGH FOR in 3 patients. HIRSCHSPRUNG’S DISEASE Conclusions: Endorectal pull-through is an effective procedure for HD. However, it is not without problems. In Pathu Boonmahittisut, Paisarn Vejchapipat, medium term, the majority of the patients had good Prapapan Rajatapiti, Dusit Viravaidya, therapeutic results. Although HD is, at present, treated Soomboon Reukviboonsri, Soottiporn Chittmittrapap early in life, medium to long-term follow-up is needed to Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine, assess their function outcome. Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
Objectives: Endorectal pull-through is one of the PEDIATRIC LAPAROSCOPIC SURGERY: THE FIRST three most popular procedures for Hirschsprung’s disease STEP IN A TERTIARY CENTER (HD). The objective of this study was to evaluate medium- Nutnicha Suksamanapun, Akkrapol Mungnirandr, term functional outcome in patients with HD after Monawat Ngerncham, Thawatchai Akaraviputh, endorectal pull-through. Mongkol Laohapensang. Methods: Patients with HD, who were operated by Division of Surgery, Faculty of Medicine, Siriraj Hospital, Bangkok, endorectal pull-through during infancy (1-12 months old) Thailand between 2002 and 2005, were retrospectively reviewed. Parents of these children were interviewed regarding Background: Benefit of laparoscopy has been well functional outcome when their children were over 3 years accepted in many operations. Some of them even become old, based on Krickenbeck criteria, i.e. voluntary bowel standard approach, such as laparoscopic cholecystectomy movement, soiling and constipation. (LC), laparoscopic appendectomy. Recently, our institution Results: There were 28 patients who met the inclusion has adopted these techniques as approach of choice for criteria. However, twenty patients (18 boys and 2 girls) several operations. were followed up and their parents could be interviewed. Objective: To the result of our early experiences in The average age at the time of procedure was 3.95 months the laparoscopic surgery in pediatric patients. (range, 1-12 months). Fourteen patients (14/20) were Method: All of laparoscopic operations in pediatric operated via transanal approach. Primary endorectal pull- patient conducted in Division of Pediatric Surgery, the throughs were performed in 15 patients (75%). Department of Surgery, Faculty of Medicine Siriraj Hospital The mean age of the patients at the time of the were retrospectively reviewed from the first case in April interview was 5.62 years old (range, 3.0-8.2 years). According 2007 to May 2011 including both total laparoscopic to the interview, ninety percent (18/20) had normal approach and laparoscopic-assisted surgery. voluntary bowel movement. Constant soiling was noticed Result: There were 50 patients included in this study.
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The age ranges from 19 days to 15 year old (mean 9.0 year 11.9 days were 58.1% of male and 41.9% of female. The old). Average body weight was about 37.7 kg (range: 3-88). prevalence of the various forms of the superior labial The operations were LC (n = 20), laparoscopic appendec- frenum attachment was as follows: mucosal 0%, gingival tomy (n = 9), laparoscopic fundoplication (n = 5), laparo- 29%, papillary 59.7%, and papillary penetrating 11.3%. scopic genitourinary surgery (n = 11), laparoscopic-assisted 303 children (3 to 12 years of age), mean age 8.7 years were surgery for anorectal malformation and Hirschsprung’s 54.1% of male and 45.9% of female. The prevalence of the disease(n = 4). Operative time slowly decreased over time various forms of the superior labial frenum attachment was in more prevalent procedures such as LC and laparoscopic as follows: mucosal 18.8%, gingival 70%, papillary 7.3%, appendectomy without increasing of the complications. and papillary penetrating 4%. The maxillary midline Conversion rate was about 2% (n = 1). Oral diet could be diastema was presented 7.3% in this group and the type of started immediately after the operation in 11 patients the superior labial frenum that was as follows: gingival 4%, (mean: 1.32 days, range: 0-14 days). There were two cases papillary 41%, and papillary penetrating 55%. which post-operative complications occurred (internal Conclusion: The maxillary midline diastema was hernia (1 case), and another one had incisional hernia. found in the children period 7.3% and the papillary and Both of them occurred after laparoscopic fundoplication. the papillary penetrating type of the superior labial frenum Conclusion: The coming of new era of minimally is the risk factor that associates with a persisting midline invasive surgery is inevitable. Many types of the operation diastema. This study may be the pilot study for the further become standard approach in pediatric patients. Starting prospective and comparative studies which are needed to laparoscopic surgery with a standard simple procedure is conclude the proper management and determine the quite safe and effective. Additionally, this strategy also optimal timing for the resection of the superior labial facilitates laparoscopic surgical skill for beginner. frenum.
THE ASSOCIATION BETWEEN THE MIDLINE COLONIC ATRESIA: A 14-YEAR REVIEW DIASTEMAS AND THE SUPERIOR LABIAL FRENUM Prenakhun Chimshang, Achariya Tongsin, Rangsan Niramis, IN THAILAND Maitree Anuntkosol Chulathip Nakarerngrita, Bongkoch Petsongkramb, Department of Surgery, Queen Sirikit National Institute of Child Health, Monawat Ngernchama, Mongkol Laohapensanga Bangkok, Thailand Division of Pediatric surgery, Department of Surgery, Faculty of Medicine Background: Colonic atresia is a rare intestinal Siriraj Hospital, Mahidol University, Bangkok, Thailand anomaly compared with other intestinal atresias. The study Background: The superior labial frenum attachment of this anomaly is also rarely published in literature. may develop or relate to the maxillary midline diastema. Objective: The aim of this study is to review patients The studies on the distribution of the superior labial with colonic atresia in a 14-year period at Queen Sirikit frenum attachment in children are limit, especially in the National Institute of Child Health (QSNICH). infantile period. Materials and Methods: Medical records of the Objective: The purpose of this study was to examine patients treated at QSNICH between January 1997 and the prevalence of various types of the superior labial frenums December 2010 were reviewed. The study emphasized that related to the occurrence of a persisting midline demographic data, clinical presentations and the results of diastema in the infant (0 to 6 month of age) and the the treatment. children (3 to 12 years of age). Results: Only 18 neonates, 4 males and 14 females, Material and Methods: A cross-sectional study was were included for this review. Almost all of the patients conducted. The study population consisted of 124 infants were term neonates, except for 2 were preterm with the (0 to 6 month of age) from the tongue tie clinic of Siriraj birth weight less than 2,000 grams. Bilious vomiting, hospital and 303 children (3 to 12 years of age) from the abdominal distension and absence of meconium passage dental clinic of Sikhiu Hospital. The patients were clinically were the common presenting symptoms and signs. examined for the superior labial frenum attachment Regarding the operative findings, 10 patients (55.5%) had location and the association with a persisting midline atresia at the ascending colon, whereas atresias at the diastema. Descriptive statistics and SPSS program were transverse, descending and sigmoid colons were noted in 2, used for analysis in this study. 3 and 3 cases, respectively. Of the 18 patients, 13 cases were Results: 124 infants (0 to 6 month of age), mean age classified in the intestinal atresia type IIIa, 4 cases in type I Vol. 32 No. 4 Abstracts 147
and one case in type IV. Initial colostomy were performed laparoscopic mobilization of the testes, spermatic vessels in 17 patients and interval colonic anastomosis ranged and orchiopexy done in 1 setting. from 3 to 6 months. Afterwards one patient had a colonic Otherwise, 8 intra-abdominal testes were managed as atresia caused by a colonic web and was treated by web 2-stage procedures with laparoscopic clipping and excision and colonoplasty. Only one case (5.6%) died due transection of the testicular vessels, followed by laparoscopic to segmental small bowel volvulus at the age of one month orchiopexy approximately 6 months later. In all cases the after initial colostomy. vessels were clipped and the testes remained undisturbed Conclusions: Information from the present study during stage 1. At stage 2 testicular mobilization via revealed the rare incidence of colonic atresia treated at our laparoscopic dissection was required to complete stage 2. institute, approximately 1-2 cases per year. Almost all of the Bilateral laparoscopic Fowler-Stephens orchiopexy was patients with this entity should be treated by initial colostomy performed in 2 cases. and secondary colonic anastomosis after 3 months later. At the follow-up to the laparoscopy procedures all Treatment by this method obtained a good result with the testes were in a scrotal or high scrotal position; none had survival rate over 90%. atrophied thus far. Conclusions: Laparoscopic orchidopexy has begun to surpass open surgical exploration as the primary LAPAROSCOPIC MANAGEMENT OF NONPALPABLE treatment in boys with nonpalpable testes. The transition UNDESCENDED TESTIS in surgical procedures from inguinal exploration to laparoscopy has been adopted generally (not only in our Somboon Roekwibunsi institute) because it gives a better surgical outcome and less Department of Surgery, King Chulalongkorn Memorial Hospital, Bangkok, morbidity. Additionally laparoscopy can obviate the need Thailand for such costly investigations as MRI and computer Background: The mainstay of therapy for the palpable tomography. It can also render unnecessary laparotomy undescended testis is surgical orchiopexy with creation of and inguinal exploration. Laparoscopy has proved a a subdartos pouch. For the nonpalpable undescended valuable diagnostic and therapeutic tool in orchidopexy testis, however, laparoscopy has now become the treatment for the nonpalpable undescended testis at King of choice as it is the single most accurate modality for Chulalongkorn Memorial Hospital. diagnosis, localization and surgical management of nonpalpable testis. Objective: To study the laparoscopic management EVALUATION OF RECTAL POUCH LEVEL IN of undescended testes on children in recent years at King ANORECTAL MALFORMATIONS: COMPARISON Chulalongkorn Memorial Hospital. BETWEEN INVERTOGRAM AND PRONE LATERAL Materials & Methods: We retrospectively reviewed CROSS-TABLE RADIOGRAPH the records of all boys who underwent orchiopexy for Jitlada Konjanat, Rangsan Niramis, Achariya Tongsin, undescended testes at King Chulalongkorn Memorial Maitree Anuntkosol Hospital. These cases were identified from our com- Department of Surgery, Queen Sirikit National Institute of Child Health, puterized database, which dates from January, 2008 to Bangkok, Thailand April, 2011. Patients who underwent laparoscopic orchiopexy and testicular vessel transection and orchiopexy Background: Invertogram was used to evaluate the laparoscopically in 1 or 2 stages were reviewed in detail. level of blind rectal pouch in neonates with anorectal Results: We identified 98 undescended testes in 77 malformation (ARM) over 80 years ago. In recent years, patients. There were 30 nonpalpable testes in 21 patients, prone lateral crosstable radiograph (PLCTR) was 13 of which were identified laparoscopically as intra- recommended to demonstrate these anomalies instead of abdominal with 1 atretic. Single stage laparoscopic the invertogram with obtaining of equal information as the orchiopexy was performed on 7 testes, compared to 8 testes traditional procedure. in which the Fowler-Stephens procedure was performed Materials and Methods: During January 2009 to laparoscopically (there was 1 laparoscopic orchiectomy ). December 2010, all of the neonates with ARM who had no Thus, 2, 3 and 5 boys with left, right and bilateral nonpalpable evidence of cutaneous, urinary and genital fistula underwent testes, respectively, were treated with either laparoscopic both invertogran and PLCTR for demonstration of the orchiopexy or staged Fowler-Stephens orchiopexy. blind rectal pouchs. Demographic data and radiographic A 1-stage procedure done on 7 testes involved findings of the patients were collected and analyzed. 148 Abstracts Thai J Surg Oct. - Dec. 2011
Results: Twenty six neonates with ARM (23 males ABDOMINAL LAPAROTOMY USING PERI-UMBILICAL and 3 females) were available for the study. Twenty patients INCISION IN NEWBORNS: A PRELIMINARY REPORT (77%) were full term babies, whereas six patients (23%) Katawaetee Decharun, Paisarn Vejchapipat, were prematurity. Invertogram and PLCTR were done at Soottiporn Chittmittrapap the same time during 13 to 36 hours. Radiographic findings Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine, of the two methods in 20 patients were not different, In the Chulalongkorn University and King Chulalongkorn Memorial Hospital, remaining 6 cases, the findings of PLCTR were accurate Bangkok 10330, Thailand with confirmation by colostomy study (loopogram) or operative findings, while the evidence of invertogram We reported the use of peri-umbilical incision as an revealed higher than the actual levels abdominal laparotomy approach in 7 newborns. The Conclusion: Experience from the present study details of the patients are as follows: Infantile hypertrophic revealed that PLCTR was more accurate than invertogram pyloric stenosis (pyloromyotomy) 3 cases, Ileal atresia (bowel regarding interpretation of the level of rectal pouch in resection & anastomosis) 2 cases, duodenal atresia ARM. PLCTR should be routinely used for evaluation in (duodeno-duodenostomy) 1 case, and anorectal malfor- ARM instead of invertogram mation (descending colostomy at umbilicus) 1 case. Firstly, semi-circular incision around the umbilicus was performed. Secondly, subcutaneous space around the SIMPLE TREATMENT OF GIANT GASTROSCHISIS incision was created. Thirdly, the abdomen was entered via USING A PLASTIC SPRING LOAD SILO AND A extended incision of the abdominal sheath. Finally, the SILICONE SPRING LOAD SILO WITH REINFORCE targeted organs were eviscerated as necessary. The WING procedures of all patients were carried out without significant difficulties. There were no wound complications Cholasak Thirapatarapan in all patients. Division of Pediatric Surgery and Division of Vascular and Transplantation, In conclusions, abdominal laparotomy via peri- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital umbilical incision is feasible and safe in newborns. Cosmetic Mahidol University , Bangkok, Thailand results are satisfactory. Background: Retrospective studies have suggested that use of a preformed silo can effectively help abdominal wall closure in infants with gastroschisis. We simply invented LIVING RELATED DONOR LIVER TRANSPLAN- a plastic silo containing a spring load silicone ring to treat TATION FOR BILIARY ATRESIA CHILDREN: A 1O- gastroschisis infants whose abdominal wall could not be YEARS REVIEW FROM RAMATHIBODI HOSPITAL, primarily closed. Finally we modified the plastic silo to be MAHIDOL UNIVERSITY, BANGKOK, THAILAND a silicone silo with a reinforced wing. Kritsada Bunprasart Objective: To evaluate outcomes of treatment of Division of Pediatric Surgery and Division of Vascular and Transplantation, giant gastroschisis infants using a plastic silo and a spring- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital loaded silicone silo with reinforce wing Mahidol University , Bangkok, Thailand Methods: A preformed spring-loaded silo was placed at bedside or in the operating room to the gastroschisis Background: Biliary atresia is not an uncommon infants who had large amount of intestine eviscerate out of disease. In Thailand, there are 60-80 infants born with the abdomen. Gradual reduction and elective abdominal biliary atresia disease every year. Although the hepatico- wall closure was done later. The plastic silo were place in porto-enterostomy (Kasai’s operation) could create bile 4 patients at the early phase. The silicone silo was used in drainage for the patients, but their livers already had one patient. cirrhosis. The only chance to cure the deadly disease is liver Results: Abdominal wall defect could be successfully transplantation. Because of lacking of cadaveric liver closed in all infants. Systemic infection occurred in one donors, so we established the first living liver transplant infant with plastic silo and skin infection occurred in an program in Thailand infant with silicone silo Objectives: To review the outcomes of left lateral Conclusions: The use of a spring load silo placed at segment liver transplants from living donors in biliary the bedside or in the operating room could avoid urgent atresia children at Ramathibodi hospital during 2001-2011. surgical intervention. It especially help the infant who had Material and Method: Thirty three left lateral segment large amount of intestine eviscerated out of the abdomen. LRLT procedures for biliary atresia patients were performed Vol. 32 No. 4 Abstracts 149
during 2001-2011. There were 25 girls and 8 boys. The perforation and 1 colono - biliary - fistula). There was an median age was 1.5 years with a median weight of 9 kg. intractable choledochojejunostomy leak because of Donors included 25 mothers and 8 fathers. Methyl infection. All of the complications were successful treated prednisolone and FK506 were primary immunosuppressive by surgical correction. Late choledocho-jejunostomy drugs. Details of the operation, complications and outcomes stricture occurred in 2 patient, one treated with trans- were studied. hepatic dilatation, the other one treated with re-anastomosis. Results: There was no donor mortality and low There were mild to moderate degree of rejection morbidity. Patient and graft survival rates were 90.9%. 2 salvaged by mini-pulse and pulse therapy. 30 patients who patients died from preserving failure and 1 patients died received LRLT are living with good quality of life. from hepatic vein obstruction superimposed with infection. Conclusion: Living related liver transplantation has Of the 30 survivals, there were 4 vascular complications (1 good long-term results in biliary children. It helps arterial occlusion, 2 arterial bleeding and 1 portal vein expanding liver grafts and reduces waiting time for the stricture). Three intestinal complications occurred in the small patients. post Kasai’s recipients (1 small bowel perforation, 1 colonic
NEUROSURGERY
THE OUTCOME FOLLOWING DECOMPRESSIVE there was significant difference in mortality of patients with CRANIECTOMY OR CONSERVATIVE TREATMENT malignant middle cerebral artery (MCA) infarction in FOR MALIGNANT MIDDLE CEREBRAL ARTERY conservative group and surgery group [(17/50 (34%) INFARCTION versus 20/32 (62.5%)), p = 0 .011]. Also at 3 months after infarction, there was significant difference in mortality in Nunthasiri Wittayanakorn conservative group and surgery group [19/50 (38.0%) Bhumibol Adulyadej Hospital, Bangkok, Thailand versus 21/32(65.6%)], p = 0.015]. There was significant Background: At present,malignant middle cerebral high mortality rate in surgery group which age _ 60. artery (MCA) infarction has high morbidity and mortality Dyslipidemia and ischemic heart disease were risk factors rate worldwide. The aim of this study was to identify the of malignant middle cerebral artery (MCA) infarction mortality rate, to determine the value of decompressive related death with odd ratio 1.419 (95%CI 0.504-4.00) and craniectomy in patients who presented with malignant 2.00 (95%CI 0.345-11.578) respectively. middle cerebral artery (MCA) infarction, to compare Conclusion: The mortality rate of patients with functional outcome in elderly patients with younger patients malignant middle cerebral artery (MCA) infarction treated and identify significant risk factors related to the mortality. in our hospital was nearly 50% and the rest of patients were Method: Medical records of patients with malignant dependent. There was significant high mortality rate in middle cerebral artery (MCA) infarction treated in surgery group with age _ 60 years which could be explained Bhumibol Adulyadej hospital between January 2008 and by the severity of disease. In addition, the more underlying April 2011 were reviewed. A total of 82 patients with diseases, an tribute to higher the more mortality. complete medical record and radiographic imagings were included in this study. The area of infarction was determined by the ABC/2 method and the degree of herniation was SELECTIVE LUMBAR NERVE ROOT BLOCK UNDER determined with Ambient cistern effacement and shift of FLUOROSCOPE VS ULTRASOUND the midline. The Glasgow Coma Scale score was assessed Narongdet Wetchagama, Verapan Kounsongtham, for neurologic status at admission, at operative time (in Sorayouth Chumnanvej surgery group), and at one-week time after infarction. All Neurosurgery Division, Surgery Department, Faculty of Medicine, patients were assessed with the modified Rankin Scale (RS) Ramathibodi Hospital, Mahidol University, Bangkok, Thailand at discharge and at 3 months after infarction. Results: The mortality rate of patients with malignant Background and Objectives: Particularly in lumbar middle cerebral artery (MCA) infarction at discharge was radicular back pain, selective nerve root block (SNRB) is 45% and 3 months after infarction was 48.8%. At discharge, the accepted procedure both for diagnostic and therapeutic 150 Abstracts Thai J Surg Oct. - Dec. 2011
pain management. This study was performed to determine OPERATIVE INTERVENTION FOR TRAUMATIC the accuracy of needle-tip under ultrasound guidance BRAIN INJURIES IN THE ELDERLY subsequently confirmed with fluoroscopy in patients who Li LF, Leung GKK, Wong HHT, Yuen WK underwent SNRB. To date, no studies have been performed in comparing these 2 techniques. Department of Surgery, Li Ka Shing Faculty of Medicine, The University Methods: After the IRB approval, a prospective trial of Hong Kong, Queen Mary Hospital, Hong Kong. was conducted to determine the accuracy of ultrasound Introduction: The management of traumatic brain guidance SNRB in 40 consecutive patients with lumbar injuries (TBI) in the elderly (age ≥ 65 years) is a constant radicular pain undergoing fluoroscopic guidance SNRB dilemma in neurosurgery. Advanced age is associated with from January 2010 to January 2011. Firstly, needle tip was poor clinical outcome as well as poor rehabilitation poten- located at the desired optimal landmark under ultrasound tial. The benefit of operative intervention in this group of guidance and then subsequently fluoroscopic confirmation patients is controversial. The aim of this study is to investigate of needle-tip position was undergone. Finally, the injection for factors which may predict outcome of operative was performed as usual. The primary outcome was the treatment in elderly patients with severe head injuries. accuracy of needle-tip placement comparing between under Method: A retrospective analysis was conducted on ultrasound and subsequently fluoroscopic confirmation. 68 elderly patients who had been operated on for TBI in a The secondary outcome was the associated factors of the designated trauma center from 2006 to 2010. The impact accuracy of needle-tip under ultrasound guidance. All of patients’ age, pre-operative GCS, papillary responses, patients who had been undergone these procedure did not imaging findings, pre-existing medical conditions, and the receive analgesic medication. use of anticoagulant/antiplatelet agents on patient Results: In addition, 78 lumbar nerve roots were outcomes were studied. Clinical outcome measures were injected in the patients who underwent SNRB under hospital mortalities, GCS, and Glasgow Outcome Score fluoroscopic guidance. The accuracy of needle-tip on each (GOS) upon hospital discharge. lumbar nerve roots under ultrasound guidance comparing Results: The overall mortality rate was 55.9%. Old with subsequently fluoroscopic confirmation ranged from age, abnormal papillary response, low pre-operative GCS, 7.14%-80.95%. Mean of the accuracy of needle-tip under the presence of midline shift and obliteration of cistern on ultrasound guidance comparing with subsequently CT were associated with poor survival. Upon further fluoroscopic confirmation was 62.82% while 95%CI ranged subgroup analysis, age was a prognostic factor but should from 51.13-73.50. The age older than 65 years old was not be a limiting factor for operation-patient aged 70 - 79 significantly associated with the poor accuracy under with normal bilateral papillary response still had a overall ultrasound guidance (P value = 0.0095). There was no survival rate of 86.6% and good outcomes (GOS 4 or 5) in significant difference of the accuracy of needle-tip with sex, 53.3% of patients. Abnormal papillary response in at least BMI and spinal appearance. There is no serious adverse one eye and pre-operative GCS < 13 were associated with event in all patients periprocedurely and at follow-up. very poor prognosis. Pre-operative GCS was positively Conclusions: To position the needle-tip under correlated with GCS upon discharge. ultrasound guidance is feasible and has good safety profile. Conclusion: Elderly TBI patients with normal bilateral However; the accuracy could be achieved individually. papillary responses and GCS ≥ 13 were found to have a Because of the accuracy of ultrasound guidance technique good chance of achieving good functional survival after depends on the operator, steep learning curve and larger aggressive operative intervention. The latter should not be prospective clinical study is needed. withheld based on patients’ age alone.
ORTHOPEDIC SURGERY
UNIVERSAL EXTERNAL FIXATORS DEVICE medial side together with medial joint space narrowing is an indication if it fails after complete program of conservative Prakit Tienboon, Nara Jaruwangsanti treatment. There are many selective ways of surgery depend Department of Orthopaedics, Faculty of Medicine, Chulalongkorn on severity of the degeneration, aging and activity of the University, Bangkok, Thailand patients. Osteotomy at the proximal tibia concomitance Background: Surgical treatment of the varus knee with vulgus realignment to change loading from medial to deformity with degenerative change of the cartilage on the lateral joint space is one of the treatments of choice. In the Vol. 32 No. 4 Abstracts 151
past, many surgical techniques had been developed. The osteotomy bone was strong union. The entire instrument high tibial dome osteotomy was a one developed by Doctor is removed out. Apart from this invention, the MIS technique Coventry and Doctor Maquet. This was quite a big operation was also developed. Surgical wound length was reduced and the old design external fixator had high worse impacted from 7.5 cm. to 1.5 cm. Patients were allowed to walk in a to many patients during the healing bone process. day after surgery and only 3-4 days in hospital. Nevertheless the long term out come after surgery had high Results: The new invention implant was size smaller percentage of success rate. and friendly user to doctors and patients. The MIS surgical Objective: To present a brand new invention of the technique and operative timing still the same about only 20 first Thai universal fixators and the new development of minutes. Average healing time of the osteotomy bone was minimal invasive surgical technique for high tibial same about 6 weeks. The clinical result was reported in the osteotomy. year 2008. [Tienboon P, Atiprayoon S. Comparing dome Materials and Methods: The new external fixators high tibial osteotomy for patients more than sixty years old were invented and name universal fixators. It was a compact with patients less than sixty years old. Asian Biomedicine design to cope untoward of the old design and make more 2008; 2(5): 381-8. patient comfortable. After osteotomy at the proximal tibia, Conclusion: The new invention and development of this instrument is used to external fix the bone by first Thai universal external fixators instrument for high compressive force technique for about 6 weeks. When the tibial osteotomy and the MIS technique were reported.
PLASTIC & RECONSTRUCTIVE SURGERY
A RANDOMIZED CONTROLLED TRIAL COMPARING 6/0 sutures was 9.22 (SD 2.53) and 9.06 (SD 1.66), TOPICAL SKIN ADHESIVE WITH SKIN SUTURES IN respectively (P = 0.817). THE PRIMARY REPAIR OF THE CLEFT LIP Conclusions: The results of the primary cleft lip repair using Dermabond topical skin adhesive are equivalent to Tapanutt Likhitmaskul, Tanasit Kangkorn, Suriya Fongkerd the cosmetic results of the primary cleft lip repair using Department of Surgery, Chonburi hospital, Chonburi, Thailand Dermalon 6/0 sutures. Background: Dermabond (2-Octyl Cyanoacrylate) Keywords: cleft lip repair, topical skin adhesive, skin topical skin adhesive represent an alternative adjunctive sutures, scar outcome technique for skin closure. With the purported advantages over traditional skin sutures on cosmetic results, cost benefits and operative times, using of Dermabond in the primary UNSATURATED FATTY ACIDS AFFECT MESEN-º cleft lip repair may improve post-operative wound cosmesis. CHYMAL STEM CELL SECRETION OF ANGIOGENIC Objective: To compare the scar outcome of AND INFLAMMATORY MEDIATORS Dermabond topical skin adhesive and interrupted Andria Smith2, Surawej Numhom1, Lara Muffley2, Austin Bell2, Dermalon 6/0 sutures among patients undergoing primary Anne Hocking2 cleft lip repair. 1Division of Plastic Surgery, Ramathibodi Hospital, Mahidol University, Materials and Methods: The study prospectively Bangkok, Thailand, 2Department of Surgery, University of Washington, enrolled and randomized 36 patients who underwent Seattle, WA, USA primary cleft lip repair to receive skin closure with Dermabond or Dermalon 6/0 sutures (n = 18 each). Background: The promise of mesenchymal stem cell Outcome parameter was the scar outcome. The scar (MSC) therapy to treat diabetes mellitus and diabetic outcome was assessed by a blinded plastic surgeon using a complications has generated significant scientific and clinical scar assessment score by visual analogue scale clinical interest. Ongoing clinical trials in progress are (VAS). The independent T-test was used to test for primarily focused on the ability of MSC to ameliorate tissue significance for the VAS assessment tool. damage by secreting cytokines and growth factors that Results: There were no significant differences in the promote angiogenesis while reducing inflammation and scar outcome between the two groups. The overall mean fibrosis. However, critical to the development of MSC- VAS score for the patients using Dermabond and Dermalon based therapies for patients with type 2 diabetes is an 152 Abstracts Thai J Surg Oct. - Dec. 2011
understanding of how their metabolic environment, which substitute developed in Thailand. It is a permanent dermal consists of high levels of glucose and fatty acids, impacts substitute aiming to reduce contracture. Donated human MSC biology. skin tissue is aseptically processed using technique to remove Purpose: To determine whether unsaturated fatty the epidermis and cells that can lead to tissue rejection and acids alter MSC secretion of angiogenic and inflammatory graft failure. The result is an acellular dermal template of mediators natural biological components that acts as a dermal scaffold. Methods: Primary human MSC were exposed to The objective of this study is to assess the safety and ability elevated levels of either omega-6 polyunsaturated fatty in achieving durable and cosmetic definitive coverage of acids (linoleic acid and arachidonic acid) or PoreSkin. monounsaturated fatty acids (oleic acid) for seven days in Method: Eleven hypertrophic burn scars were the presence of either normal or high glucose. Outcomes enrolled in prospective study. Scar excision and grafting measured included MSC proliferation, gene expression with Pore Skin were performed 11 times in six patients. and protein secretion. MSC proliferation was measured by After scar excision, human dermal substitute (PoreSkin) both counting viable cells and quantifying BrdU combined with nanocrystalline silver dressing (Acticoat®) incorporation during DNA synthesis. MSC gene expression and negative pressure wound therapy (NPWT) followed by was assessed using relative quantitative real time PCR and delayed splitthickness skin grafting were performed. protein secretion was assessed using ELISAs. The primary outcome assesss by the success of PoreSkin Results: Exposure to unsaturated fatty acids inhibited grafting or percentage of its take and the success of skin human MSC proliferation. MSC expression and secretion grafting or percentage of autograft take, complications, of growth factors and cytokines was also altered after reaction and pain. The secondary outcome assesses by exposure to unsaturated fatty acids. Linoleic acid up- their durable and cosmetic properties. regulated MSC expression and secretion of VEGF, IL-11, IL- Results: Engraftment rates of PoreSkin and autograft 6 and IL-8; arachidonic acid elicited similar effects. In are 99.1 % and 91.8 % at day 5 follow by 97.7% and 87.3% contrast, oleic acid had no significant effect on VEGF and at day 14. One wound required partial PoreSkin debride- IL-8 mRNA and secreted protein levels. ment due to infection. Two wounds required repeat Conclusion: Collectively, these data suggest that autograft. All patients’ pain scores are less than 5. Vancouver perturbations in the metabolic environment may influence scar scales are all improved although without statistically MSC regulation of cellular responses to injury. Furthermore, significant (p <0.05). No major complications or rejection these data support the need for in vitro and in vivo studies are observed. to define the functional consequences of an altered MSC Conclusion: The major finding in this phase I clinical secretome. This work is directly relevant for the develop- study is that the performance of PoreSkin as a dermal ment of MSC therapy targeting the pancreas and diabetic substitute is comparable to other commercial dermal complications including cardiovascular disease, nephro- substitutes in term of engraftment rate, complications and pathy and chronic non-healing wounds. rejection. Infection is a major problem using PoreSkin as same as other dermal substitutes.
PHASE I CLINICAL EVALUATION OF PORE SKIN: A HUMAN DERMAL SUBSTITUTE THE EFFICACY OF SMART PORTABLE NEGATIVE PRESSURE DEVICE: A PRELIMINARY STUDY Tanapron Termwattanaphakdee, Tanom Bunaprasert, Apichai Angspatt Apirag Chuangsuwanich, Thana Chueabundit, Plastic and Reconstructive Unit, Department of Surgery, Faculty of Somkuan Wancheang Medicine, Chulalongkorn University, Bangkok, Thailand Division of Plastic Surgery, Siriraj Hospital, Mahidol University, Bangkok, Thailand Introduction: Extensive full-thickness wound is a major challenge. It needs to be grafted and often faces with Background: The benefits of negative pressure limit donor site problem. Dermal substitutes are among therapy (NPT) in wound bed preparation and skin graft the tissueengineered products applied to clinical use. There fixation are well accepted in many wound care centers. But are a lot of commercial dermal substitute products now the cost of the treatment and the immobility of the patients available. Besides their effectiveness, all of them are very are the disadvantages of the system. The authors have tried expensive. PoreSkin, manufactured by faculty of medicine to find a small, portable, not expensive suction device for Chulalongkorn university, is the first human dermal the NPT and innovate the Smart Portable Negative Pressure Vol. 32 No. 4 Abstracts 153
Device(SPNPD) for the NPT. cadaver hands using an innovative instrument. The Objective: To evaluate the efficacy of the SPNPD in instrument was made from a Steimann pin, 3 mm. in skin graft fixation. diameters. The 2 tip ends were blunt and a sharp knife was Method: The SPNPD was innovated by selection of made between them. A tiny incision was made about 0.5 the pump, battery and pressure regulator. All the part were cm. proximal to the A1 pulley. The instrument was assembled together. The device was tested for the safety inserted so that the longer tip end was just under the A1 and accuracy before clinical usage by Biomedical instrument pulley before the A1 pulley was completely cut while the department, Faculty of Medicine Siriraj Hospital. The instrument was moving horizontally forward. There were device was used on skin graft fixation in 4 patients. The 12 men and 6 women. Ages ranged from 35-81years with grafted areas were inspected at 5 and 7 days for graft mean age of 53.2 years. The exclusion criterior are previous survival. history of hand surgery or trauma and age under 20. The Result: The device worked flawlessly. Average result, including completeness of the A1 pulley release, percentage of graft survival was 96.25%. All of the patients injury to the A2 pulley, flexor tendon damage, laceration of were satisfied with the device because they could mobilize the neurovascular structures, age, and operating time are out of the beds. reported. Conclusion: SPNPD was effective for skin graft fixation Results: A l pulley was completely released in 93 and could be used as conventional negative pressure therapy. digits and incompletely released in 7 digits. Injuries to neither the flexor tendons nor digital nerves were not identified. The success rate was 97 %.The mean operating AN INNOVATIVE INSTRUMENT FOR SEMI-OPEN time on each digit was 2.5 minutes in thumb, 1.8 minutes RELEASE OF A1 PULLEY: A CADAVERIC STUDY in index finger, 2.1 minutes in middle finger, 1.9 minutes in ring finger and 2.4 minutes in little finger. Sittiwat Intarakhao, Arthi Kruavit Conclusion: A new innovative instrument is more Division of Plastic and Maxillofacial Surgery, Department of Surgery, effectively releasing of A1 pulley. There are no injuries to Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok flexor tendon and neurovascular nearby structure in this 10400, Thailand study. It can be quickly, effectively and safely performed. Background: Stenosing tenosynovitis or tenovaginitis The incomplete release are more likely due to quality of of the thumb or fingers is one of the most common causes cadaver and the learning curve. It is concluded that semi- of hand pain and disability. It is commonly called trigger open release with this instrument can be successfully applied thumb or trigger finger (TF). It is caused by a çmismatché in the clinical practice. between the size of the flexor tendon and the first annular pulley (A1 pulley), most often when the tendon develops a nodule (knot) or swelling in its lining. The tendon swells, SMART NEUROSURGICAL PROBE, ROBOTIC SYSTEM it must squeeze through the opening of the sheath, which AND SENSORS INTEGRATION FOR COMPUTER causes pain, popping, or a catching feeling in the finger or ASSISTED NEUROSURGERY thumb. Now conservative treatments do not provide relief Tassanai Parittotokkaporn1,2, Siraruj Sakoolnamarka1, of the symptom.The goal standard for treatment of TF is Luca Frasson2, Seong Young Ko2, Ferdinando Rodriguezy Baena2, surgical release of the A1 pulley. Open. Although the Giancarlo Ferrigno3 success rate of open surgical release is almost 100% but 1Division of Neurosurgery, Department of Surgery, Phramongkutklao complications have been described such as digital nerve Hospital and College of Medicine, Thailand, 2Mechatronics in Medicine injury, infection, joint stiffness, weakness, scar tenderness Lab, Department of Mechanical Engineering, Imperial College London, and bowstringing of the flexor tendon. Recent clinical UK, 3Bioengineering Department, Politecnico di Milano, Milan, Italy results indicate that percutaneous A1 pulley release is safe and effective. Several methods using various instruments Background: The flexible and steerable probe for percutaneous release have been reported with presented in this study has been developed at Imperial satisfactory results, but few complications such as incomplete College London. The integration of the flexible probe release and flexor tendon damage have been described. prototype into a robotic system is part of the development To prevent such complications, an innovative instrument for robotic assisted minimally invasive neurosurgery in the was designed for semi-open release of the A1 pulley. context of the European FP7 ROBOCAST (ROBOt and Materials & Methods: Semi-open release of the A1 sensors integration for Computer Assisted Surgery and pulley was performed in 100 digits from 18 fresh-frozen Therapy). 154 Abstracts Thai J Surg Oct. - Dec. 2011
Objectives: The goal of the project is to provide a graft hyperpigmentation. robotic system for assistance in keyhole neurosurgery for in Materials and Methods: 18 patients with Skin graft vitro experimentation in the operating room (OR) by hyperpigmentation were treated by IPL. There were 10 employing the steerable neurosurgical probe, an intelligent females and 8 males. Their age ranged from 21 to 70 years autonomous trajectory planner, a high level controller, with a mean age of 49.6 years. The cutoff filters of 590 nm advance robotic system and a set of field sensors. were used for 3 treatments at intervals of 3-4 weeks. Patients Materials & Methods: An attached picture shows a were treated with an energy fluence of 20-28 J/cm2, pulse view of the integrated components of the ROBOCAST width of 2-4 milliseconds, double pulsemode, and a delay of system. A 6-axis serial gross positioning robot (1) is used to 15-40 milliseconds. The degree of pigmentation (melanin support a miniature parallel robot (2) holding the steerable index) was objectively recorded with a Derma Spectrometer. probe (3) to be introduced through a keyhole opening in Subjective assessment was made by two blinded, nontreating a skull model (4). An electromagnetic tracking system (5) physicians. is used to control the position and orientation of the Results: 11% of patients showed marked clinical steerable probe tip, while an optical tracking system (6) improvement, 50% did moderate improvement, and 28% monitors the robot and skull position. A flexible two-part did slight improvement. The melanin index (37.56 ± 2.99) probe (length = 200mm, outer diameter = 12 mm) was decreased after the treatment comparing before the pushed from the base by a cable-link actuator into a brain- treatment (40.67 ± 2.70), which shows a significant like phantom made from gelatine to reach a target. difference (P < 0.001). 6 patients developed blisters and 3 Results: Preoperative diagnostic images showing the patient had erythema that all resolved within 1 week without location of the deep brain target are processed by the high leaving permanent marks. level controller, which supplies the path of minimum risk Conclusions: IPL is effective and safe in treating skin trajectory based on digital brain segmentation. The graft hyperpigmentation. Adverse reactions were minimal controller generates the motion signals required to actuate and self-limited. the flexible probe. An electromagnetic position sensor, embedded at the tip of the flexible probe, provides the position feedback to control probe motion. The novel EVALUATION OF WOUND HEALING ACTIVITY OF steerable probe has been demonstrated to achieve LAWSONIA INERMIS LINN GPO PREPARATION IN curvilinear trajectories to reach a target. The prototype has RAT MODEL been found to produce a targeting accuracy of approxi- Vitusinee U-deea, Sriprasit Boonvisuta, mately 0.68 mm ± 1.45 mm. Sitthichoke Taweepraditpola, Kanapon Pradniwatb, Conclusions: This project is addressed by integrating Chada Phisalaphongc, Yada Akkhawattanangkuld existing and novel medical technology in the fields of aDivision of Plastic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol medical robotics, surgical planning and real time monitor- University, Bangkok, Thailand, bDepartment of Pathology, Faculty of ing into a next-generation steerable neurosurgical probe. Madicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, cResearch and Development Institue , Government Pharmaceutical Organization, Bangkok, Thailand, dDepartment of Clinical Science and PROSPECTIVE STUDY ON THE TREATMENT OF Public Health Medicine, Faculty of Veterinary Science, Mahidol University, HYPERPIGMENTED SKIN GRAFT BY INTENSE Bangkok, Thailand. PULSED LIGHT Extraction leaves of Lawsonia inermis Linn can promote Narupon Rojanapithayakorn, Tara Vongviriyangkoon, MD wound healing activity, enhance wound contraction, Division of Plastic Surgery, Department of Surgery, Faculty of Medicine, enhance tensile strength and increase hydroxyproline Siriraj Hospital, Mahidol University, Bangkok ,Thailand content. It can be used as a wound healing agent. Lawsonia Background and Objectives: Skin graft hyperpigmen- inermis Linn Extract and Lawsonia inermis Linn GPO tation is a common phenomenon among Asian. This preparation was evaluated for wound healing potential in condition is difficult to treat and can cause severe psycho- rat model. logical distress. Intense pulsed light (IPL) has been used to Fresh henna leaves (Lawsonia inermis Linn) were treat pigmented lesions with promising result. The role of collected and blended with 16% ethanol after that extract IPL in treating skin graft hyperpigmentation has not been of Lawsonia inermis Linn was filtered. The filtrate was used explored. The purpose of this study was to assess the for the experiment. The preparation was the extract of efficacy and complication of IPL in the treatment of skin Lawsonia inermis Linn add with GPO formulation in ratio Vol. 32 No. 4 Abstracts 155
1:9. The wound healing activity was assessed by measuring Extract) and group V (Lawsonia inermis Linn GPO the wound area and recording the day of complete Preparation) has showed faster rate of epithelialization epithelialization. The wound was also subjected to (Mean ± SD, days: 12.2 ± 0.44, 12.0 ± 0.70 respectively) than histopathological studies to examine the microscopic group III (hydrogel) and a control group. It has showed changes. equivalent rate of epithelialization compared to group II The result reveals that the animal in group V; treated (Mean ± SD, days: 12.20 ± 0.44). Histopathological studies with Lawsonia inermis Linn preparation has showed a also supported the wound healing in group IV and group significant relation reduction in wound area (88%, 96%) V, tissue obtained from the 20th day which has showed more when compared to a control group (77%, 87%) and a fibroblast and collagen and few inflammatory cells when standard group; treated with silver sulfadiazine (82%, 92%), compared to a control and a standard group. Thus this and treated with hydrogel (72%, 89%). The rate of epithe- study can conclude the use of Lawsonia inermis Linn GPO lialization is the animal in group IV (Lawsonia inermis Linn. preparation as a wound healing agent.
SURGICAL EDUCATION
SURGICAL EDUCATION AND TRAINING IN THE aspects of their curriculum where simulation can assist in UNITED KINGDOM the acquisition of various competencies. Research requirements during training vary between the specialties. John P Collins Formative assessment and feedback is based on the United Kingdom trainee’s learning portfolio which includes their learning Major changes have taken place in postgraduate agreement at the commence of each rotation, a record of surgical education and training in the United Kingdom their training and the outcome of workplace-based over the past ten years. This reform has been driven by assessments and although the latter remain a challenge to multiple societal, political, regulatory, professional and implement. Progress each year depends on the outcome of educational factors. an external annual review of competence progression The four surgical colleges in the UK and Ireland (ARCP). Summative assessment includes formal responded to these factors by initiating the UK Surgical Membership and Fellowship examinations and completion Curriculum Project. Working with the nine surgical of training is recognised by a Certificate of Completion of specialties, a new curriculum framework has been developed Training (CCT). The majority of trainees undertake further including standards, national regulatory systems, web-based training before applying for a consultant post. educational resources and clear processes for teaching and Concerns about the number of medical graduates learning. Each specialty has developed a new curriculum commencing surgical training but with little hope of around generic and specialty based knowledge, technical becoming surgeons, the impact of reduced working hours skills and judgement and have agreed on the professional and the challenges relating to implementing workplace- skills generic to all specialties. This has resulted in the based assessments remain the focus of ongoing discussions. Intercollegiate Surgical Curriculum Programme (ISCP) which now forms the basis for surgical training across the nine surgical specialties. IMPROVING SURGICAL EDUCATION AND TRAINING Surgical education and training is divided into core John P Collins and specialty training with separate selection required for United Kingdom each component. Selection is nationally organised and locally administered with all eligible applicants being The hallmarks of a successful surgical education and interviewed. The level of previous experience required for training program include clearly defined outcomes, the selection and the failure of large numbers of satisfactory development and delivery of high quality programs, access core trainees to progress to specialty training remains to an accredited learning environment, the availability of controversial. Several courses are provided some of which an equipped motivated and sustainable faculty, exposure are mandatory. Simulation to enhance learning is slowly of the trainee to high quality care and the recruitment and gaining traction with each specialty working to identify selection of trainees with the right attributes to be successful 156 Abstracts Thai J Surg Oct. - Dec. 2011
surgeons as well as meeting societal workforce needs. The educational roles involved and the provision of appropriate broad roles of a surgeon must be identified and a program recognition and support. developed to prepare trainees for these roles. Attempts In order to attract and select high quality medical have been made to identify competencies which underpin graduates for surgical training, greater efforts must be each of these roles and some programs base their selection, made to sow and foster the seeds of a possible surgical education and assessment around these competencies - the career during medical school followed by a commitment to so called competency-based training. However the surgeon’s merit-based selection. The processes and methods used for overall role is complex and medical education can only be selection must be transparent and defensible. partially conceptualised on obtaining competencies. The concept of competent professional practice where observed performance is more than the sum of the set of competencies DELIVERING SURGICAL EDUCATION IN THE used remains important. Improvements of a program must DIGITAL AGE - A NEW PARADIGM? focus on the development and circulation of clear David Tolley curriculum content, on methods to improve its delivery to President, Royal College of Surgeons of Edinburgh help learning and on ensuring assessment is aligned to the curriculum. Simulation, e-learning and other forms of The birth of the net generation (generation Z) at the technology-enhanced learning must be explored and those dawn of the worldwide web in the early 1990s, has spawned selected should be appropriate for the local environment. a highly connected group of individuals who are dependent Trainees work in a broad range of clinical environ- on communication and media technologies. These ùdigital ments and geographical locations each of which must be nativesû demand instant access to social networking, the undergo regular accreditation to ensure they provide an internet and instant messaging through smart phone adequate volume and suitable case-mix of patients, a positive technology. Their approach to knowledge acquisition training culture and a suitable environment for learning. differs significantly from previous generations and their Appropriate processes and criteria must be developed to reliance on digital technology offers new opportunities for undertake such accreditation. Exposure of trainees to high surgical training and assessment. These approaches are quality patient care with appropriate supervision and explored during the presentation which also looks at the graduated responsibility will ensure that safety and quality potential for global interaction through, for example, the considerations become an integral focus of their award winning Edinburgh Surgical Sciences Qualification professional lives. which has developed as a result of a partnership between Without an equipped and motivated faculty no training the University of Edinburgh and the Royal College of will take place. Sustaining this vital resource involves Surgeons of Edinburgh. ongoing recruitment, equipping them for the different
SKIN AND SOFT TISSUE
GENE EXPRESSION PROFILES AND FUNCTIONAL and the role of fibroblast derived from dermal cone/fat GENOMICS IN DERMAL FIBROBLASTS FROM DEEP dome has not been studied. CONE/FAT DOME OF THE DUROC PORCINE MODEL Materials and Methods: We analyzed the genome- OF FIBROPROLIFERATIVE SCARRING wide patterns of gene expression in fibroblasts isolated from deep cone/fat dome, in shallow and deep partial- Surawej Numhom1, Anne M. Hocking2, Kathy Q. Zhu2, thickness wounds using Duroc porcine model. GoMiner Gretchen J. Carrougher2, Loren H. Engrav2 and Ingenuity Pathway Analysis were used to determine the 1Department of Surgery, Ramathibodi Hospital, Mahidol University, transcriptome and functional genomic. Bangkok, Thailand, 2Department of Surgery, University of Washington, Results: Our Analyses identified BMP4 (Bone Seattle, WA, USA Morphogenetic Protein 4), IGF1R (Insulin-like Growth Background: Hypertrophic scarring is a major Factor 1 Receptor), IGFBP5 (Insulin-like Growth Factor devastating problem after burn injury and the molecular Binding Protein 5), THBS1 (Thronbospondin1) and etiology of this process remains unknown. Fibroblasts AGT(Angiotensinogen) as the candidate genes that need thought to play a key role in the fibroproliferative scarring to be explored further. Through literature mining using Vol. 32 No. 4 Abstracts 157
Gene Ontology and Ingenuity Knowledge Base, these helpful in identifying the interactions between endogenous candidate genes showed mainly associated with extracellular fibroblasts and the surrounding cellular players and a matrix, cell proliferation, cell migration, angiogenesis, potential remodeling pathway for hypertrophic scarring. tumorigenesis and rheumatoid arthritis. Understanding this complex interplay is important to Conclusions and Significance: While the pathogenesis provide a basis for systems biology of cutaneous of fibroproliferative scarring remains poorly understood, fibroproliferation and formulating an effective therapeutic the use of comparative gene expression arrays may prove strategy of hypertrophic scarring.
SURGICAL ONCOLOGY
THE MOST PREVENTABLE & CURABLE CHRONIC yr. by 2030. DISEASE LaMar McGinnis, Jr. SURGEONS AND CANCER - THE NEXT GENERATION Lee Jong-wook, director general of the World Health LaMar McGinnis, Jr. Organization, has stated that noncommunicable diseases are now the # 1 cause of death globally and have the largest Surgery has historically been the most successful economic impact on their countries of all health problems. treatment for early stage solid tumors. Cancer has become Together, the NCD’s cause 35 million deaths/yr. and are the #1 cause of death globally as populations expand and expected to increase by 17% over the next 5 years. The age and lifestyles change. A global pandemic of cancer is NCD’s are diverse but mainly include heart disease, stroke, predicted. Our scientific understanding of the basic biology cancer, chronic respiratory disease and diabetes. Cancer of this most feared malady is exploding along with exciting has become the #1 cause of death and economic loss progress in pharmacogenetics and always advancing among the NCD’s. It is estimated that 70% of these cancers technology. What will/should be the role of surgeons/ could be prevented. This presentation will discuss the surgical oncologists/interventional biologists in the 21st surgeons role and responsibility in combatting this looming century? worldwide pandemic, predicted to cause 17 million deaths/
TRANSPLANTATION SURGERY
QUALITY OF LIFE IN LIVER TRANSPLANTATION IN (HRQoL) of patients and their spouse or caregivers after SIRIRAJ HOSPITAL liver transplantation. The aim of the study was to analyze patients and their spouse or caregivers HRQoL between Yongyut Sirivatanauksorn1, Wethit Dumronggittigule1, pre-transplant and post-transplant groups, using generic Somchai Limsrichamroen1, Teera Kolladarungkri2, and disease specific health questionnaire. Cherdsak Iramneerat1, Prawat Kositamongkol1, Methods: The study was conducted in Siriraj organ Prawej Mahawithitwong1, Supreecha Asavakarn1, transplant unit, Faculty of Medicine Siriraj Hospital, Mahidol Chutiwichai Tovikkai1 University between October 2010 and January 2011. The 1Department of Surgery, 2Department of Preventive and Social Medicine, Short Form-36 (SF-36) and Chronic Liver Disease Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand Questionnaire (CLDQ) were used to evaluate the HRQoL Background: Liver transplantation is a treatment of of pre-transplant and post-transplant patients. The HRQoL choice in end-stage liver disease. It gives a chance to get scores of the patients and caregivers were analyzed and back to an active and prolonged life. Recently, more compared between two groups. attention is being paid to health related quality of Life Results: The post-transplanted patients [N=50, mean 158 Abstracts Thai J Surg Oct. - Dec. 2011
age 53 (23-76) years, male 72%, female 28%] and their Conclusion: Hematocrit level has significant effect spouse and caregivers demonstrated significant better on reported tacrolimus level. We have studied and generic SF-36 HRQoL scores ie. physical and social developed a simple formula to convert reported tacrolimus functioning, role limitation because of physical or emotional level in anemic patient back to level as if it would be if problems, bodily pain, vitality, and general and mental patients’ hematocrit was 40%. With this formula, better health than pre-transplanted patients [N = 42, mean age 55 dose adjustment can be accomplished with less side effects. (22-69) years, male 71%, female 21%]. Similarly, the post- Further studies are required to validate this formula and its transplanted group showed significant improved CLDQ clinical significance. scores in the part of fatigue, activity, abdominal symptoms, systemic symptoms and worry. In term of emotional func- tion, there was insignificant different between two groups. MANAGEMENT OF BRAIN DEATH PATIENTS AT Conclusions: Liver transplantation improves HRQoL LERDSIN HOSPITAL: 33 CASES ANALYSIS of end-stage liver patients and their spouse or caregivers. A Ekarit Kunsriraksakul prospective longitudinal study to assess long term HRQoL Lerdsin Hospital, Bangkok, Thailand of the patients and their spouse or caregivers over time might be conducted to eliminate time-frame bias. Background: Diagnosis of brain death and appropriate treatment are involved with medicolegal issue that determine death for the heart beating patients. Nowadays, CORRECTED TACROLIMUS LEVEL IN ORTHOTRO- medical standard show us that brain dead patients are the PIC LIVER TRANSPLANT WITH ANEMIC PATIENT dead persons who are eligible for organ donation. As well as in Thailand, management of brain death which certified Rawin Vongstapanalert, Somchai Limsrichamrern, by Thai Medical Council related to ethical principle and is Yongyut Sirivatanauksorn, Prawat Kositamongkol, still not the discipline of law. Hence, most cases of brain Prawej Mahawithitwong, Supreecha Asavakarn, dead patients are neglected diagnosis and lose an Chutvichai Tovikkai opportunity for organs donation. However, the authors Department of Surgery Faculty of Medicine Siriraj Hospital, Bangkok, need to study this topic in order to inform the benefit of Thailand brain death diagnosis and organ donation. Background: Tacrolius is known to be much more Objectives: concentrated in red blood cell than in plasma. Current 1. To evaluate and study for appropriate technique practice still uses tacrolimus whole blood level for to confirm brain death by apnea test. monitoring. There has been no formulation to calculate 2. To study for attitude of patient relatives about the effect of hematocrit on reported whole blood level. organ donation. This study was conducted to establish a simple, easy to use 3. To study for appropriate management for brain formula to calculate the effect of hematocrit on reported dead patients. tacrolimus level. Materials and Methods: The study method is Material and Method: Twenty six stable liver retrospective review in potential brain dead patients that transplant recipients were recruited for the study. During may be eligible for organ donation at Lerdsin hospital routine follow up, blood sample was drawn for routine during 2006-2010. All patients were managed under tacrolimus whole blood trough level. The studied blood recommendation by organ donation center of Thai Red sample was centrifuged and half of red blood cell was Cross. Documentation of patients such as sex, age, diagnosis, removed. The rest of the specimen was recombined and blood pressure, temperature, presentation of diabetes rechecked for whole blood trough level and hematocrit. mellitus, innotropic drug administration, time to apnea Results are plotted and analyzed. A formula was developed. test, time to disconnection of ventilator during apnea test,
Result: Whole blood tacrolimus trough level of 26 level of PaCO2 and PaO2 were analyzed. After the brain patients varied, ranging from 1.40 to 12.70 with mean of death diagnosis was confirmed by apnea test. The patient’s 5.52. After removal of part of red blood cell, tacrolimus relatives were informed about the opportunity for organ level declined in every single specimen. The formula for donation and the organ donation process was done. correction of reported tacrolimus level in anemic patient Results: There were 33 patients (12 female and 21 to hematocrit of 40% derived from this study is as followed male). 15 cases were traumatic brain injury, 14 cases were Corrected tacrolimus level = (0.6 X tacrolimus level) + [0.6 spontaneous hemorrhage and 4 cases were brain tumor. Xtacrolimus level X (40/Hct)]. Polyurea was found 26 cases. There were all neurogenic Vol. 32 No. 4 Abstracts 159
shock. Average time from apnea to apnea test was 18 hours hypotension. Adequate fluid resuscitation and innotropic (6-72 hours). Average time of ventilation disconnection medication are the keys of success. After adequate was 16.5 minutes (8-30 minutes). All cases significantly resuscitation was done. Systolic blood pressure is more passed apnea test without hypoxia. 23 cases (69.69%) than 80 mmHg while no evidence of brain stem sign , brain accepted to donate organ and 21 cases success to organ death diagnosis will be performed immediately as guideline. harvest. Then organ coordinator informs the patient’s relatives and Conclusions: Common problem in the potential the success rate for organ donation was 69.69%. donor patients are polyuria, diabetic insipidous and
UPPER GASTROINTESTINAL SURGERY
LAPAROSCOPIC CRURAL REPAIR AND NISSEN HYPERTHERMIC INTRAPERITONEAL CHEMOPER- FUNDOPLICATION IN A CASE OF PARAESOPHAGEAL FUSION (HIPEC) FOR GASTRIC CANCER WITH TYPE III WITH REFLUX ESOPHAGITIS CARCINOMATOSIS: SIRIRAJ EARLY EXPERIENCES Thawatchai Tullavardhana, Prinya Akranurakkul, Asada Methasate, Thammawat Parakonthun, Witoon Ungkitphaiboon Thawatchai Akaraviputh, Vitoon Chinsawangwatanakul, Department of Surgery, Faculty of medicine, Srinakharinwirot University, Thanyadaj Nimmanwudipong Nakhonnayok, Thailand Miminally Invasive Surgery Unit, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand Background: Patients with paraesophageal hernia are usually symptomatic with gastroesophageal reflux Gastric cancer with carcinomatosis is fatal condition disease dysphagia, chronic epigastric pain. The authors with the patients’survival of only a few months. Surgery is present a laparoscopic crural repair without mesh for not possible and chemotherapy is usually not effective. repair of paraesophageal hernia. Combined with Total peritonectomy with hyperthermic intraperitoneal laparoscopic Nissen fundoplication is an antireflux chemoperfusion (HIPEC) is thought to be the only way to procedure for correction of reflux esophagitis. combat this condition but due to its high morbidity, its Method: A 67 years old female present with chronic application is still limited in a few specialized centers. epigastric discomfort and heartburn. The patient pre- We report two cases of gastric cancer with operative evaluation include barium esophagogram and carcinomatosis, treated with HIPEC. The patients were in esophagogastroscope that shown paraesophageal type III relative young age group (age 42 and 47 years), with with reflux esophagitis. Laparoscopic repair include mutiple nodules diagnosed seen during diagnostic reduction of hernia contents, removal of the hernia sac, laparoscopy. Both patients had no nodules in the area of closure of the hiatal defect, and an antireflux procedure. visceral peritoneum and no gross tumor was left after the Crural repair and Nissen fundoplication were done by operation. Total gastrectomy with splenectomy with distal laparoscpic simple suture technique with prolene 2-0. pancreatectomy with cholecystectomy and total perito- Result: Operative time was 3 hours and postoperative nectomy was done in both patients (in one patient period was uneventful. The patient was recovery from hysterectomy and bilateral salpingo-oophorectomy was symptom of dyspepsia and heartburn. A barium esopha- added due to Krukenberg tumor). After completion of the gogram was performing at 6 month and 1 year after organs and peritoneum, extensive lavage of the abdominal operation. No recurrent of paraesophageal was detect cavity was done with warm saline (10 liters) followed by from imaging study. hyperthermia of the abdomen with ciplastin 70mg/kg. Conclusion: Laparoscopic repair of paraesophageal body weight. Then anastomosis was done and the abdomen is associated with improved long-term symptom relief, low closed. morbidity. A crural repair without mesh is safe and no The operation time was 400 and 530 minutes recurrent of paraesophageal hernia after 1 year of follow respectively and bloss loss was 710 ml. Hospital stay was up period. prolonged (30days, mean hospital stay) but no serious 160 Abstracts Thai J Surg Oct. - Dec. 2011
complication occurred. The patients did well while receiving chemotherapy. One patient had positive malignant cell at post-operative chemotherapy with no ascites detected. proximal resection margin and one patient had positive HIPEC is effective in treating gastric cancer with distal resection margin. Mean length of hospital stay was 19 carcinomatosis with minimal postoperative days (range: 11-38), mean operative time was 319.5 minutes complication. It should be included in the option for the (range: 150-530), mean estimated blood loss was 750.4 mL treatment of gastric cancer. (range: 200-3100). Six patients had postoperative complication, 1 patients had pneumonia, 2 patient had pleural effusion, 1 patient had wound dehiscent, 1 patient RESULTS OF COMBINED ORGAN RESECTION FOR had minute leakage from esophagojejunostomy anasto- LOCALLY ADVANCED GASTRIC CANCER IN SIRIRAJ mosis, 1 patient had pancreatic fistula, all of them were HOSPITAL improved with conservative treatment. Ten of fifteen (66.67%) patients survived more than 1 year after surgery. Thammawat Parakonthun, Thawatchai Akaraviputh, Conclusions: Combined organ resection for locally Asada Methasate, Vitoon Chinswangwatanakul, advanced gastric cancer had equivalent early postoperative Thanyadej Nimmanwudipong outcomes compared with standard surgical resection. Minimally Invasive Surgery Unit, Division of General Surgery, Department Postoperative complication was minimal and 1-year survival of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, was acceptable. Bangkok 10700, Thailand
Background: Gastric cancer is one of the leading causes of cancer death worldwide. Most of the patient in Thailand HISTOPATHOLOGIC RESPONSE AFTER NEOADJU- presented with locally-advanced or advanced disease that VANT CHEMORADIATION FOR LOCALIZED needed extensive surgery. ESOPHAGEAL CANCER Objectives: Gastrectomy with systematic lympha- Chutima Soparat, Chadin Tharavej denectomy is the standard treatment for gastric cancer. En Department of Surgery, Faculty of Medicine, Chulalonkorn University, bloc tumor removal combined with adjacent organ resection Bangkok 10330, Thailand is said to be an extensive surgery for locally advanced gastric cancer which can cure the patient but it is associated with Background: Esophageal cancer who were treated high morbidity and mortality. Therefore, the results and with neoadjuvant chemoradiation, there are unclear about outcomes of this aggressive treatment were analysed. what is the predictor for outcome after neoadjuvant therapy Materials & Methods: The study was retrospectively and survival outcome. analysed from the medical records of patients who Objective: To assess responsiveness of the neoadju- underwent gastrectomy with D2 lymphadenectomy vant chemoradiation for localized esophageal cancer in combined with adjacent organ resection at the Department term of pathologic results, and survival of Surgery, Siriraj Hospital between October 2004 and Methods: Thirty-nine patients with localized March 2011. Combined organ resection was defined as the esophageal cancer who received neoadjuvant standard gastrectomy with lymphadenectomy combined chemoradiation therapy and followed by esophagectomy. with the removal of organ or part of organ that suspected Responsiveness were assessed for residual carcinoma. to be involved by gastric cancer. Clinicopathological features, residual carcinoma status and Results: There were 20 patients who underwent pretherapy stage and posttherapy were compared. combined organ resection. The mean age was 58.55 years Result: A histopathological response to neoadjuvant (range: 36-92) and there were 10 females and 10 males. was correlated significantly with complete tumor resection Three patients were stage II gastric cancer, 15 patients were status. Complete pathological response in 51.4% . Minor stage III, and 2 patients were stage IV. Three patients had pathologic response was present in14.4 % . The pathological positive peritoneal cytology. Three patients underwent response was significantly correlated to 2-year survival rate subtotal gastrectomy and 17 patients underwent total at level 10% (P = 0.8) .Level of dose of radiotherapy were gastrectomy. D2 lymphadenectomy was performed in all not significantly correlated with tumor response (p = 0.921) patients. Five patients underwent combined distal and survival at 2 year (p = 0.697) esophageal resection, 9 patients with distal pancreatectomy, Conclusion: Histopathological response were 6 patients with colectomy, 2 patients with liver resection, 2 significantly correlated to tumor rescetion and survival patients with pancreaticoduodenectomy, and 2 patients outcome . with peritonectomy with hyperthermic intraperitoneal Vol. 32 No. 4 Abstracts 161
TRAUMA, BURN, CRITICAL CARE
PROGNOSTIC VALUE OF BLOOD LACTATE 24 hr (T24). MONITORING IN CRITICALLY ILL TRAUMA Results: There were 128 patients (average age 34 + PATIENTS: HELP OR HYPE? 16 years, 81% male, 79% blunt trauma injury, ISS 26 + 11) who met the study criteria admitted during the 1-year study Nitipat Watanyuta1, Burapat Sangthong1, Komet Thongkhao1, period. Reduction of lactate within the first 24 hrs was Osaree Akaraborworn1, Prattana Chainiramol1, associated with an improved survival rate, as seventy-eight Khanitta Kaewsaengrueang1, Surasak Sangkhathat1, of 85 patients (92%) whose lactate level normalized in Rassamee Sangthong2, Prasit Wutthisuthimethawee3, 24 hrs survived, while only 22 of the 43 patients (51%) who Boonprasit Kritpracha1 did not clear their lactate level to normal by 24 hrs survived 1Department of Surgery, 2Epidemiology Unit, 3Department of Emergency (p < 0.001) (Figure 1). The blood lactate levels had a high Medicine, Songklanagarind Hospital, Prince of Songkla University, mortality predictive value and the prognostic value on the Songkhla, Thailand serial monitoring during the first 24 hrs was well preserved Background: The quest for the ideal endpoint of (T0AUC = 0.76, T8AUC = 0.83, T16AUC = 0.77, T24AUC = resuscitation after severe trauma is still unresolved. 0.81) (Figure 2) Elevations in blood lactate level and the failure to normalize Conclusion: Lactate clearance within the first 24 hrs such elevations have been shown to predict a poor outcome of ICU resuscitation was associated in our study with in critically ill patients. Although many guidelines and improved outcome in trauma patients thus confirming protocols, i.e. Advanced Trauma Life Support (ATLS)® prognostic importance of serial blood lactate monitoring strongly advocate the use of blood lactate level, others, during this critical period. including some textbooks such as the Sabiston Textbook of Surgery feel the evidence is as yet inconclusive. There is a sparsity of published data concerning the use in critically ill ANATOMICAL STUDY OF INTERNAL ILIAC VEIN IN trauma patients. SOFT CADAVERS Objectives: To examine the prognostic value of the first and repeated blood lactate level assays during shock resuscitation after intensive care unit (ICU) admission in trauma patients. Introduction: Anatomy of internal iliac vein is variable Materials and Methods: All trauma ICU patients which could be problematic while performing aggressive admitted to Songklanagarind Hospital during August 2009 pelvic dissection. Although several types of variation have to July 2010 who met the inclusion criteria of the been reported, classification of these variations has not standardized shock resuscitation protocol were reviewed. been well established. The aim of this study was to report The protocol was an early goal-directed process with the the classification of the internal iliac vein variation and to goal of attaining an oxygen delivery index (DO2I) >500 report new venous branches in the pelvic venous system mL/min/m2 and/or to reduce blood lactate to <2.5 mmol/ discovered during dissection. L within 24 hrs. The protocol inclusion criteria were one Material and Methods: Anatomical dissection of or more of: (i) massive transfusion (>10 units PRCs in 24 internal iliac vein was performed in 20 soft cadavers, 10 hrs); (ii) major abdominal trauma (abdominal AIS >3); male and 10 female. The anatomy of internal iliac vein was (iii) severe pelvic fracture requiring transfusion > 6 units; classified into normal anatomy and anatomical variation. (iv) vasopressor need after resuscitation in the operating Normal anatomy was defined when there was one main room; and (v) progressive lactic academia. Blood lactate trunk of internal iliac vein, which compose of anterior levels were measured at admission and every 8 hrs for the division (obturator vein, inferior gluteal vein, internal first 24 hrs of admission. Patient demographics, hemo- pudendal vein, middle rectal vein) and posterior division dynamic parameters, injury severity scores (ISS), transfusion (superior gluteal and lateral sacral vein). The internal iliac requirements, and survival outcomes were recorded. vein deviated from the normal pattern was classified into Receiver operating characteristic (ROC) curves for mortality anatomical variation. were constructed with corresponding areas under the ROC Results: Normal anatomy of internal iliac vein was values (AUC) to evaluate the prognostic values of blood found in 11 cadavers (55%). The internal iliac vein deviated lactate levels on admission (T0), at 8 hr (T8), 16 hr (T16), from the normal pattern discovered in this study including 162 Abstracts Thai J Surg Oct. - Dec. 2011
two main trunks of internal iliac vein pattern and middle abdomen. Damage control resuscitation refers to correction sacral trunk pattern. Two main trunks pattern was found of the coagulopathy of trauma often seen in the damage in 8 cadavers (40%) while the middle sacral trunk pattern control scenario. was found in one cadaver (5%). In addition, new pelvic Historically, resuscitation has involved incremental vein branches including pelvic side wall tributary and S1 restoration of whole blood with component therapy based tributary were found in all cadavers. on studies originally from Viet Nam. More recent studies Conclusion: The variation of internal iliac vein is from Iraq have demonstrated that early use of whole blood common. The classification of variation established in this or early reconstitution of whole blood, in principle (1:1 study may be helpful for surgeons while performing resuscitation), is associated with decreased mortality. Similar aggressive pelvic dissection. Further study is warranted. retrospective studies in civilian trauma have suggested the importance of this strategy. Concerns regarding crystalloid resuscitation have also contributed to support for damage FRONTIERS IN PREHOSPITAL CARE IN EARLY control resuscitation. A recent survey of trauma centers in RESUSCITATION the United States and Europe showed protocols regarding damage control resuscitation are inconsistent and still David B. Hoyt, MD, FACS often target restoration of fresh frozen plasma and platelets Executive Director, American College of Surgeons, Chicago, Illinois, USA inconsistently. A prospective randomized trial is under Prehospital care is rapidly evolving due to prospective consideration by the FDA to establish the optimal ratio of randomized trials now possible with funding from the resuscitation. The history of this discussion and current National Institutes of Health and the Department of Defense protocols and controversies will be reviewed. in the U.S. The greatest areas for consideration involve early airway management, fluid resuscitation, and early management of head injury. The effects of hypoxia and ATLS EVIDENCE AND EVALUATION hypoventilation on head injury have led to interest in early J B Kortbeek, MD FRCSC FACS airway management, including rapid sequence intubation. Recent data suggests despite the potential advantages, that early airway management, including intubation, can have The Advanced Trauma Life Support Course was unintended consequences if protocols do not correct for developed in Nebraska in 1978 and introduced by the excessive ventilation. The results of airway management American College of Surgeons Committee on Trauma in and recent trials will be reviewed. 1980. It has been widely adopted and currently is taught in The other major prehos-pital resuscitation strategies over 60 countries. More than one million doctors have involve fluid management. The status of hypotensive taken the course. Organized trauma care is associated with resuscitation, use of alternative crystalloid resuscitation decreases in mortality and morbidity. Standardized trauma with hypertonic saline, oxygen-carrying solutions (blood education of doctors and other health care providers is a substitutes), and other adjuvants for resuscitation are all required to meet trauma system verification standards. currently being considered. The results of recent work on Medical education has evolved from principles introduced each of these will be reviewed to help inform the best by Halsted. strategy for early resuscitation. Current and future trends in ATLS instruction are based on evidence supporting changes in medical education. Curricula and teaching methods will continue NEW RESUSCITATION STRATEGY: DAMAGE to evolve as advances in both technology and in CONTROL RESUSCITATION understanding the science of education accelerate. David B. Hoyt, MD, FACS Executive Director, American College of Surgeons, Chicago, Illinois, USA POST INJURY MULTIPLE ORGAN FAILURE IN A Repeated episodes of hypotension and organ UNIVERSITY HOSPITAL IN THAILAND hypoprofusion will lead to severe metabolic acidosis, Thitipat Wattanakul, Rattaplee Pak-art coagulopathy, and hypothermia. Recently a new approach has been proposed in these circumstances. Damage control, in general, includes an abbreviated surgical procedure, Background: Multiple organ failure (MOF) is one of temporary packing, and temporary closure of the chest or the common causes of late trauma death. There are only Vol. 32 No. 4 Abstracts 163
a few studies in Thailand about its incidence and risk months) in after RRTT]. Of these, 83 patients (8.8%) were factors. died after admission and analyzed for characters of mortality. Objective: To study the incidence, risk factors, types The average age of mortality patient was 38.7 ± 16.3 years. of post injury MOF in a University hospital. Male was predominant gender. The most common Methods: The patients who admitted to surgical mechanism of injury was motor cycle accident. Although intensive care unit (ICU) of King Chulalongkorn memorial there were no difference of character and mechanism of hospital between 2006 -2011 were retrospectively studied. injuries between two periods but patients associated with Demographic data included injury severity score (ISS), maxillofacial injury had significant lower mortality in after mechanisms of injury, blood transfusion, MOF type, ICU RRTT (28.5% vs. 10.5%; p = 0.04). However; after RRTT stay, hospital stay, mortality were collected. Denver MOF group had higher occurrence of urinary complication and score were applied for evaluation. acute renal failure significantly. Average adjusted monthly Results: Two hundred and one patients were enrolled mortality rate was lower in after RRTT (9.0 ± 6.1 vs. 6.9 ± in this study, 174 were male (86.57%). Mean age was 34.62 4.0%). Time series analysis between two periods demon- years, mean ISS was 26.00, the major cause of injury was strated decrease trend in monthly mortality in after RRTT blunt mechanism (64.68%).Massive transfusion was [coefficient (95% CI) = -0.61(-1.13 to -0.23); p<0.01)]. administered 21.39% and post injury MOF occurred 15.92% Conclusion: Rapid response trauma team (early MOF 40.63%, late MOF 59.37%). Mean ICU stay and establishment could be decrease mortality trend. Protective hospital stay was 8.11 and 36.29 days, respectively. Overall effect was predominant in patient associated with mortality was 12.44% but in the MOF group mortality was maxillofacial injury. 45.45%. Significant risk factors of post injury MOF were Keyword: Rapid response trauma team, trauma team age > 30 years (p = 0.022), blunt injury (p = 0.011) and ISS activation, mortality, time series analysis > 25 (p = 0.032). Post injury MOF increased ICU stay (p = 0.001), hospital stay (p = 0.04) and mortality (p < 0.001). Conclusions: Incidence of post injury MOF in a TRAUMA TEAM ACTIVATION: WHAT DO WE LEARN? University hospital in Thailand is high and related to Komet Thongkhao, Burapat Sangthong, Osaree Akaraborworn increasing of ICU stay, hospital stay, morbidity and mortality. Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
CHARACTERS OF MORTALITY AND TIME SERIES Background: The outcomes of treatment for severe ANALYSIS IN THORACIC INJURY BEFORE AND AFTER trauma victims may be improve by the early presence in the RAPID RESPONSE TRAUMA TEAM ESTABLISHMENT emergency room of trauma team under the leadership of an expert trauma surgeon. The criteria for activation aim Kaweesak Chittawatanarat1, Chagkrit Ditsatham1, to identify patient who are at risk or need higher level of Narain Chotirosniramit1, Kamtone Chandacham1, care. Tidarat Jirapongchareonlap1, Patrinee Traisathi2 Objective: To evaluate a trauma team activation 1Department of Surgery, Faculty of Medicine, 2Department of Statistic, criteria after implementation at Songklanagarind Hospital, Faculty of Science, Chiang Mai University, Chiang Mai, Thailand a level I trauma center. Background: Severe thoracic injury is a life Materials and Methods: Adult trauma patients (age _ threatening condition and need prompt as well as proper 15 years) who directly come to Songklanagarind Hospital treatment. Department of surgery, faculty of medicine, from January to December 2009 and met one or more of Chiang Mai University has established rapid trauma team the trauma team activation criteria were enrolled. The (RRTT) in July 2006. The aims of this study were to verify criteria consisted of (I) penetrating injury to the chest or mortality rate alteration after setting up RRTT. the abdomen (II) systolic blood pressure _ 90 mmHg. (III) Methods: We performed retrospective before and pulse rate > 120 beat per minute. (IV) respiratory rate <10 after designed study between January 2004 and September or > 30/min (V) severe head injury (GCS score _ 8) and 2009. The month before July 2006 was defined as “before (VI) trauma arrest. Data were retrieved from the trauma RRTT” and after was “after RRTT”. Monthly mortality rate, registry and descriptive reports. severity injury score (ISS) and demographic data were Results: One hundred and fifty-three patients met collected. inclusion criteria. The mean age was 33 ± 13 years. The Results: A total 951 patients were included [427 (30 most of patients were male (85%) and the average ISS was months) in before RRTT and 524 (39 18. The most common criteria for activation was pulse rate 164 Abstracts Thai J Surg Oct. - Dec. 2011
> 120 bpm (37%). The activation occurred about 52 major burn by radical debridement with knife, scissors and percent of patients who met the criteria and the surgeon hydrojet then dressing initially by silversulfadiazine cream. can present at resuscitation room about 75 percent of The dressings were change to various silver containing them. The procedures which commonly performed in the dressing such as hydrofiber with silver, alginate with silver ER were endotracheal intubation and central venous as silver-nanocystalline. Surgeon, intensivist,pulmonologist, catheterization (43%). Fifty-seven patients (37%) received nephrologist, infection specialist, nutritionist, pain specialist emergency operation and the most common operation was and psychiatrist work together to control infection hemo- exploratory laparotomy (23%). Rate of emergency stasis of the patient such as blood albumin, respiration, operation was high in patients present with hypotension creatinine and electrolyte. We retrospectively reviewed the (61%) followed by penetrating torso injury (48%). The record of all major been. There were 62 major burn mortality rate was high in severe head injury patients patients. (43%). All patients who present with cardiac arrest died. The average age was 33.17 ± 1 (range from 0.75 to 78). The average length of hospital stayed was 14 day. One The average %TBSA (percent of total body surface area) hundred and two patients (67%) survived until discharge. was 34.9 ± 1(range from 1 to 98). The average Baux score Conclusions: The majority of severely trauma patients (age+%TBSA) was 68.07 ± 1(range from10.75 to 142). The who met the trauma team activation criteria survived until average revised Baux scores (age+%TBSA+17 -if inhalation discharge. The activation occurred about half of them and injury exist) was 74.93 ± 1 (range from 10.75 to 159). Our the surgeon can present in the emergency department in overall motality was 14.52%. The patient who died had the majority of cases. Rate of emergency operation was larger %TBSA than survivors (%TBSA of died patients = high in patients present with hypotension or penetrating 70.89 ± 1, %TBSA of survivors = 24.61 ± 1) and had higher torso injury. Trauma arrest and severe head injury patients revised Baux scores (revised Baux scores of died patients = had high mortality rate. Good compliance with the criteria 112 ± 1, revised Baux scores of survivors = 58.67 ± 1). may translate to improve outcomes. The mortality was compatible with revised Buax scores, Key words: Trauma, Team activation criteria, Triage but some of our patients had very severe injury. There were 4 of our mortality had special situation from New Year 2009 accident. There was one of them died from brain anoxia MANAGEMENT OF BURN IN BANGKOK HOSPITAL and brain death. There were 2 patients had severe muscle MEDICAL CENTER: TEAM APPROACH burns which is more than 3˚ burn. There was another one died from lower airway obstruction. There was another Nitibhon A, Muangman P, Onnoi J, Siripakarn T, one from plane crashed in 2008 had 90%TBSA burn with Maneechay S severe associated injury such as inhalation injury and Surgery Clinic, The Bangkok Hospital, Bangkok Hospital Group multiple opened fractures. We think that if our patients did Major burn is a serious disease and need meticulous not have severe associated injury as above the mortality care. At Bangkok Hospital Medical Center, we take care should be lower.
UROLOGY
SWL 2011 IMPROVING OUTCOME HM3 with less analgesic requirements in an ambulatory care setting. David Tolley Scottish Lithotriptor Centre, Edinburgh, UK
This presentation reviews the progress made in LAPAROSCOPIC PYELOPLASTY, VARIETY OF shockwave lithotripsy (SWL technology) in the last 25 years TECHNIQUES AND WHAT’S NEW and the factors affecting outcome of treatment. It discusses Stanley Duke Herrell ways to improve outcome with existing technology and examines the value of audit in this process. Advances in shockwave technology are described: the Pyeloplasty remains the gold standard for congenital success rates obtained with third and fourth generation and acquired UPJ obstruction. Minimally invasive surgery lithotriptors match those obtained with the original Dornier (MIS) in the form of laparoscopy and robotic surgery are Vol. 32 No. 4 Abstracts 165
highly effective with reduced recovery and pain. The noted with multiple cystic lesions, ranging 0.3-8.3 cm in presenter has a large experience in primary and complex diameter. The cystic lesions showed no abnormal reconstructive cases using MIS and will present a variety of calcification or focal solid mass. The mass effect of both techniques and challenging cases. In addition, some new kidney results compressed second part duodenum and the techniques pioneered at Vanderbilt, including microlapa- adjacent IVC. The patient underwent simultaneous bilateral roscopic repairs will be discussed. LESS cysts decortications. Pain relief was measured by comparing preoperative and postoperative visual analog pain scales. A 2-cm umbilical incision was made, and the UPDATE ON IMAGE-GUIDED KIDNEY SURGERY tissues were bluntly dissected into the abdomen. XCONE port was inserted into the abdomen through the umbilicus. Stanley Duke Herrell A 30˚ long laparoscope was inserted to the 5 mm access site. Incorporation of imaging data into surgical Special curved instruments were used in addition to standard procedures may revolutionize treatment and surgery for laparoscopic instruments. the kidney. The presenter will show ongoing research work Results: Sixty eight major and minor cysts (20 Right into the incorporation of image guidance techniques into and 48 Left) were identified and decorticated. The operative robotic and ablative kidney surgery. was 4 hours 25 minutes. The intraoperative estimated blood loss was 100 mL. Approximated 1,500 mL of cyst fluid was drained during the procedure. There were no LAPAROSCOPIC AND ROBOTIC PARTIAL NEPHREC- major or minor complications or postoperative complic- TOMY: HOW FAR DO WE GO? ations. The patient began oral intake after 16 hours and Stanley Duke Herrell did not require parenteral analgesics postoperatively. The Nephron sparing surgery should be encouraged for hospital stay was 4 days after the procedure. The patient all amenable masses and is considered a standard of care. returned to his usual activities 1 week postoperatively after Laparoscopic and robotic techniques are rapidly gaining the procedure. The wall of the cysts and cyst fluid revealed popularity and will be discussed. New techniques, such as benign tissue. At follow-up, the laboratory test results were parenchymal clamping and complex reconstruction, will not significantly changed; the current serum creatinine be reviewed with cases and videos. was 1.0 mg/dL, the creatinine clearance was 97.6 mL/min and the creatinine clearance changed +5.5 % at 6 months. The follow-up CT show remaining cysts are largely intra- SIMULTANEOUS BILATERAL LAPAROENDOSCOPIC parenchymal. The patient’s blood pressure did not change SINGLE SITE CYSTS DECORTICATIONS IN THE over the course of treatment. TREATMENT OF SYMPTOMATIC AUTOSOMAL There was a significant reduction in the pain scale, DOMINANT POLYCYSTIC KIDNEY DISEASE from 7.4/10 preoperatively to 2.3/10 on follow-up. Conclusions: Simultaneous Bilateral LESS cysts Sompol Permpongkosol, Udomsak Wijitsettakul decortications in the treatment of symptomatic ADPKD Division of Urology, Department of Surgery, Faculty of Medicine, can be done and is a feasible procedure for symptomatic Ramathibodi hospital, Mahidol University, Bangkok 10400, Thailand relief. Introduction and Objective: Patients with Autosomal Dominant Polycystic Kidney Disease (ADPKD) have significant morbidity due to large kidney size and the LAPAROENDOSCOPIC SINGLE -SITE NEPHRO- resultant compression of adjacent organs. Our objective is URETERECTOMY WITH AN ENDOSCOPIC DISTAL to present our experience with transumbilical simultaneous URETERAL APPROACH FOR THE MANAGEMENT OF bilateral laparoendoscopic single site (LESS) cysts UPPER URINARY TRACT TRANSITIONAL-CELL decortications in the treatment of symptomatic ADPKD. CARCINOMA Methods: A 41-year-old normotensive man with a 4- Sompol Permpongkosol, MD, Poptape Chanpasoppon, year history of ADPKD presented with complaints of chronic Charoen Leeranupunth abdominal discomfort, marked fullness and bilateral flank Division of Urology, Department of Surgery, Faculty of Medicine, pain that was greater on the left side. Both kidneys were Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand palpable. The preoperative serum creatinine was 1.1 mg/ dL and the creatinine clearance was 92.5 mL/min. The CT Introduction: Endoscopic ureteral surgery has been scan showed severe enlargement of bilateral kidney was proposed as a complementary step in nephroureterectomy, 166 Abstracts Thai J Surg Oct. - Dec. 2011
either open or laparoscopic, to obviate the low abdominal LAPAROENDOSCOPIC SINGLE SITE EXTRAVESICAL incision. URETERAL REIMPLANTATION IN ADULT USING X- Objective: To describe our technical details of CONE SINGLE PORT AS A TREATMENT OF laparoendoscopic single-site (LESS) nephroureterectomy VESICORETERAL REFLUX with an endoscopic distal ureteral approach for the Sompol Permpongkosol, Poptape Chanpasoppon, management of upper urinary tract transitional-cell Charoen Leenanupunth carcinoma (TCC) based on oncologic principles. Division of Urology, Department of Surgery, Faculty of Medicine, Method: A 61-year-old man with a diagnosis of TCC Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand of the left renal pelvis underwent transperitoneal LESS nephroureterectomy with an endoscopic distal ureteral Introduction: Laparoscopic single site extravesical approach. He had a history of open abdominal exploration neoureterocystostomy is a technically demanding for ruptured appendicitis since 10 year ago. Computed procedure, especially when the intracorporeal freehand Tomography scan demonstrated left renal pelvic enhancing suturing technique is used. mass. The patient characteristic, preoperative presentation, Objective: We report our initial experience in the operative details, postoperative recovery, and perioperative treatment of vesicoureteral reflux or VUR by laparo- complications were reviewed. The patient was anesthetized endoscopic single site (LESS) intracorporeal and generally, and then placed in a left flank position. A 3-cm extravesical transperitoneal ureteroneocystostomy with X - umbilical skin incision was made and extended down to the CONE single port. peritoneum. X-CONE port was inserted through the Patient and Methods: A 42-year-old woman was umbilicus. Pneumoperitoneum was created. A 30_ long referred with recurrence urinary tract infection. Voiding laparoscope was inserted to the 5 mm access site. Using cystoureterography revealed right vesicoureteric reflux special curve or S-PORTAL and standard laparoscopic with dilated pelvocalyceal system and hydroureter, instruments, the LESS nephroureterectomy was performed suggestive right vesicoureteral reflux grade 3. No bladder in the same process as conventional laparoscopic overactivity was found during the urodynamic study. The nephrectomy. The renal artery was first ligated and then patient underwent LESS ureteral reimplantation by the the renal vein was transected using Hem-o-lok clips, refluxing technique. After the induction of general respectively. Then we changed the position of the patients anesthesia, endotracheal intubation, the patient was to a supine position with a 30-degree Trendelenburg. positioned in the Trendelenburg position. Cystourethros- “Pluck” transurethral detachment of intramural ureter by copy was performed and a double-J-stent was inserted in resection of ureteral meatus and surrounding tissue was right ureteric orifice. A 2-cm umbilical incision was made, performed with a resectoscope and subsequent cephalad and the tissues were bluntly dissected into the abdomen. extraction. The X-CONE port was inserted through the umbilicus. A Results: The procedure was completed successfully 30˚ long laparoscope was inserted to the 5 mm access site. without conversional laparoscopic or open surgery and Special curved instruments were used in addition to standard without additional extraumbilical trocars or incisions. LESS laparoscopic instruments. Intracorporeal suturing was nephreoureterectomy with an endoscopic approach was performed with an Endo-stitch device. performed in 380 minutes. The estimated blood loss of 350 Results: LESS ureteral reimplantation was mL and Pain scale was 0-1while no morphine requirements. successfully performed in the patient. The surgery lasted There was no intraoperative complication. The patient was for 180 min and the estimated blood loss of less than 50 mL. discharged on postoperative day 3 without perioperative No intra and postoperative complications were observed. complications. The urethral Foley catheter was removed A full diet was started 24 hours after surgery. The abdominal on postoperative day 7.The postoperative cosmetic result drain was removed after 48 hours. The patient was was excellent as the incision scar was hidden inside the belly discharged at day 4 with the indwelling Foley catheter and button. Pathological analysis revealed upper transitional was called for follow-up on an outpatient basis for removal cell carcinoma. of the Foley catheter on postoperative day 7. The stent was Conclusions: According to our experience, an removed 6 weeks after surgery. Follow up studies revealed endoscopic approach for upper urinary tract TCC is a complete resolution of reflux and urinary tract infection minimally invasive technique that is safe and effective as a was not developed complementary technique for one-step LESS Conclusion: LESS ureteral reimplantation with X- nephreoureterectomy and adheres to oncologic principles. CONE single port is an effective procedure with good Long terms of oncologic outcome are required. results. It is an advanced LESS technique that closely Vol. 32 No. 4 Abstracts 167
resembles open and standard laparoscopic surgical scans after 3weeks confirmed complete treatment of the techniques and provides a safe alternative to existing lesion methods. It is technically more challenging in terms of Conclusion: Our results showed that the LESS RFA intraoperative ergonomics and instruments clashing and on small renal mass was safe as an alternative treatment for requires advanced surgical skills. Prospective studies are exophytic RCCs and represents a promising treatment for needed for further conclusions. some patients with small RCCs. Further research and a longer follow-up period are needed to confirm our results.
LAPAROENDOSCOPIC SINGLE SITE SURGERY (LESS) RADIOFREQUENCY ABLATION TREATMENT FOR ESTROGEN AND PROGESTERONE RECEPTOR IN RENAL CELL CARCINOMA PATIENTS WITH BLADDER PAIN SYNDROME Pokket Ungbhakorn, Sompol Permpongkosol Pokket Ungbhakorn, Panus Chalermsanyakorn, Division of Urology, Department of Surgery, Faculty of Medicine, Supannee Nilskulwat, Wachira Kochakarn Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand Department of Surgery, Ramathibodi Hospital, Bangkok, Thailand
Introduction: Nephron-sparing surgery is now Objective: The hypothesis of the present study is accepted as an alternative treatment option for small renal whether bladder mucosa of patients with bladder pain tumors. However, hemostasis during laparoscopic partial syndrome(BPS) have estrogen receptor(ER) and nephrectomy can be technically challenging, especially progesterone receptor (PR) more than normal population. without hilar vascular clamping.RFA has been increasingly Material and Method: From July 2009 to December applied in the management of small renal tumors. We 2010, 15 female patients with chronic bladder pain syndrome reported our experience of laparoendoscopic single site and 10 female patients without bladder pain were enrolled surgery (LESS) radiofrequency ablation (RFA) for the in this study. Three pieces of trigonal bladder mucosa were treatment of small renal tumors. Our objective was to assess biopsied and sent for estrogen receptor and progesterone the short-term oncologic efficacy of RFA. receptor immunohistochemistry staining by the Benchmark Material and Method: LESS of RFA with a automated machine. The results were reported as positive temperature-based radiofrequency generator was and negative and then compared between 2 groups. performed on a exophytic renal tumor size range 2.7cm (c Results: Estrogen receptor was found in 14 out of 15 T1N0M0) in a female patient age 61 years. Using the hand- patients in BPS group (93%) and in 7 out of 10 patients in assisted laparoscopic approach, the kidney is mobilized control group (70%). Progesterone receptor was found in transperitoneally, and the renal tumor with overlying 10 out of 15 patients in BPS group (66.7%) and 5 out of 10 perinephric fat is exposed. Initial contrast-enhanced patients in control group. Both were not significantly computed tomography (CT) examination was performed different with p = 0.267 and p = 0.678 , respectively. 21 days after the procedure, with subsequent CT assessment Conclusion: The authors concluded that ER and PR at three months, six months, and every six months thereafter. might not play a role in the etiopathogenesis of BPS/IC . Serum creatinine measurement was conducted along with However,other receptors should be further investigated each time CT examination.We evaluated the technical about their role in this type of pain. success, technical effectiveness, ablation zone, benign periablation enhancement, irregular peripheral enhancement, and complications. ULTRASTRUCTURAL STUDY OF THE DETRUSOR IN Results: The tumor was biopsied before RFA, of END STAGE RENAL DISEASE which was diagnosed as renal cell carcinoma (RCC) Premsant Sangkum*, Panas Charermsanyakorn** , Furhman nuclear grade II. Under laparoscopic Kittinut Kijvikai*, Wisoot Kongcharoensombat*, ultrasonography control of tine placement, a ??? -minute Wachira Kochakarn* thermoablation cycle at 100 degrees C mean temperature *From the Division of Urology, Department of Surgery, **Department of was performed. The operative time was 210minutes, with Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol Univesity, an estimated blood loss of 100 mL and no patient required Bangkok, Thailand. a blood transfusion and postoperative hospital stays of 3days. Technical success and effectiveness was achieved. Background: After successful renal transplantation, There was complete ablation. No death or renal failure almost 50% of the patients make complaint of lower urinary after the procedure has yet been found. Abdominal CT tract symptoms. There is no definite conclusion to explain 168 Abstracts Thai J Surg Oct. - Dec. 2011
these voiding symptoms, and ultrastructural study of mg/dl in ESRD group and control group, respectively. In detrusor muscle in end stage renal failure has never been ESRD group, all showed hypertrophy of muscle bundles, carried out before. fibrosis between muscle bundles, muscle bundle Objective: We therefore studied ultrastructural degeneration, and fragmentation of muscle cells. 93% in changes of detrusor muscle in the specific group of end ESRD group had fibrosis around nerve bundles and stage renal disease patients. enlarged muscle cell nuclei. 60% had enlarged nerve Materials and Methods: Detrusor biopsy of 20 patients, bundles, and 53% showed amorphous inclusion in muscle including 15 in end stage renal disease and 5 in normal cells. The ESRD group displayed many more ultrastructural creatinine patients, was obtained by open technique. Biopsy changes than in control group and some appearances were was done during the reimplantation of the ureter at the not present in control group. time of kidney transplantation. In normal renal function Conclusions: There were distinct ultrastructural group, detrusor biopsy was done at the time of open changes of detrusor muscles in ESRD patients. It is possible bladder surgery from other urologic diseases. The that these ultrastructural changes of detrusor muscles may specimens were processed for light microscope and be associated with voiding dysfunction after kidney transmission electron microscope using standard transplantation. techniques. Results: All specimens from open biopsy Key words: detrusor, ultrastructural, end stage ranal provided sufficient quality to be examined by electron disease microscope. The average creatinine level was 9.2 and 1.0
VASCULAR SURGERY
ANATOMICAL STUDY OF INTERNAL ILIAC VEIN IN sacral trunk pattern. Two main trunks pattern was found SOFT CADAVERS in 8 cadavers (40%) while the middle sacral trunk pattern was found in one cadaver (5%). In addition, new pelvic Introduction: Anatomy of internal iliac vein is variable vein branches including pelvic side wall tributary and S1 which could be problematic while performing aggressive tributary were found in all cadavers. pelvic dissection. Although several types of variation have Conclusion: The variation of internal iliac vein is been reported, classification of these variations has not common. The classification of variation established in this been well established. The aim of this study was to report study may be helpful for surgeons while performing the classification of the internal iliac vein variation and to aggressive pelvic dissection. Further study is warranted. report new venous branches in the pelvic venous system discovered during dissection. Material and Methods: Anatomical dissection of THORACIC VASCULAR SURGICAL EXPOSURE internal iliac vein was performed in 20 soft cadavers, 10 David B. Hoyt, MD, FACS male and 10 female. The anatomy of internal iliac vein was Executive Director, American College of Surgeons, Chicago, Illinois, USA classified into normal anatomy and anatomical variation. Normal anatomy was defined when there was one main Rapid decision making in exposure of vascular injuries trunk of internal iliac vein, which compose of anterior is critical to mortality following penetrating trauma. Access division (obturator vein, inferior gluteal vein, internal to the thoracic inlet, the mediastinum and lower neck are pudendal vein, middle rectal vein) and posterior division often challenging from the standpoint of exposure and (superior gluteal and lateral sacral vein). The internal iliac temporary tamponade. The principles of thoracic inlet vein deviated from the normal pattern was classified into vessel exposure, the use of median sternotomy, resuscitative anatomical variation. thoracotomy, and the principles of exposure of the aorta at Results: Normal anatomy of internal iliac vein was the level of the diaphragm will be reviewed and emphasis found in 11 cadavers (55%). The internal iliac vein deviated on proximal and distal control and adequate exposure for from the normal pattern discovered in this study including repair or ligation will be emphasized. two main trunks of internal iliac vein pattern and middle Vol. 32 No. 4 Abstracts 169
WOUND CARE
A CASE REPORT OF 0.1% BACTAINE AND 0.1% Materials & Methods: A retrospective review of POLYHEXANIDE (PRONTOSAN®) IN WOUND CARE medical records was carried out in 129 patients with DFU who received WF10 treatment during July 2009-June 2010. Nitibhon A The patient’s presentations in this study were classified as: Surgery Clinic,The Bangkok Hospital, Bangkok Hospital Group neuropathic ulcer (occur on high plantar pressure area), A wound with infection need meticulous wound care ischemic ulcer (ischemic necrosis/gangrene and some and debridement. Conventional daily wound debridement degree of infection), and severe infected ulcer (severe and wound dressing cause severe pain and high cost. A case inflammation (i.e. necrotizing fasciitis, severe cellulitis, report was using 0.1% Betaine and 0.1% Polyhexanide deep abscess, osteomyelitis)). Patient demographics (Protosan(r)) and modern advanced dressing can reduced included age, gender, wound type, co-morbidities, and pain and cost of wound care. concomitant treatments. Wound assessments were A female with infected epidermal cyst about 3 cm. in monitored using Wound Severity Scores (WSSs) (range 0- diameter at lateral side of her left knee, the surrounding 16). The reduction of WSSs to 0-1(full of granulation tissue tissue was infected also. The infection did not response to with re-epithelialization) indicates the good response. antibiotics so excisional biopsy was done. The wound was Increase or no change in WSSs reflects poor response. left opened. She was very sensitive to pain so conventional Safety evaluation was monitored in all patients. daily debridement could not be done. Irrigations and Results: The total of 129 patients presented with 21 packing the wound with Prontosan for 10 minutes then (16.3%) neuropathic ulcer, 49 (38.0%) ischemic ulcer and dressing with Silver alginate (AskinaCalgitral thin) was 59 (45.7%) severe infected DFU. There were 86 (66%) done every 3-4 days. Until there was minimal debris at patients had a good response in average 10.8 ± 9.0 (2-43) wound base, the dressing was changed to dry hydrogel with weeks, and a poor response was noted in 11 (8.5%) patients foam (AskinaTransorbent®), but still useProntosan. The after follow up for 11.4 ± 2.7 (6-16) weeks. Minor amputation wound was healed in 5 weeks without suturing. was necessary for 12 (9.3%) patients, but no major amputation. The outcome of treatment in different wound types showed the percentage of good and poor response in THE EFFICACY OF WF10 (IMMUNOKINE) ADJUNCT the patients with neuropathic ulcer (81 and 0%), ischemic TO STANDARD TREATMENT FOR DIABETIC FOOT ulcer (43 and 18%), and severe infected ulcer (76 and 3%), ULCERS respectively. The treatments were well tolerated. Six patients (4.73%) had developed anemia after WF10 Narongchai Yingsakmongkol treatment which could be managed by RBC replacement. The HRH Princess Maha Chakri Sirindhorn Medical Centre, Department Precaution should be taken in patient with severe underlying of Surgery, Faculty of Medicine, Srinakharinwirot University heart disease. Background: Diabetic foot ulcer (DFU) is the leading Conclusions: WF10 adjunct to standard treatment cause of hospitalization and limb amputation. Clinical for DFU is a safe and effective method. studies have reported that 25-50% of infected DFUs lead to a minor amputation, whereas 10-40% requires major amputations. Infection and ischemia are major risk factors CASES REPORT OF LARGE CHRONIC INFECTED of limb amputation. WF10 has been shown to have anti- PELVIC WOUNDS BY HYDROSURGERY DEBRIDE- inflammatory and anti-infectious effects which mediated MENT by increasing immune response, exerts a marked phagocytic Nitibhon A activity of macrophages and increase tissue oxygen tension. Surgery Clinic, The Bangkok Hospital, Bangkok Hospital Group We have previously reported on the efficacy of WF10 adjunct to standard DFU treatment significantly reduced Infected chronic wound needs meticulous infection/inflammation, necrotic tissue, and enhanced debridement and wound case. Debridement of large granulation tissue formation in the double-blind, wound needs general anesthesia which effect on patient’s randomized, placebo-controlled trial. homeostasis and high cost 3 chronic infected wounds at Objectives: To evaluate the safety and efficacy of pelvic area in 2 patients, each wound were about 5% body WF10 therapy in the treatment of DFU. surface area in size were reported by using hydrosurgery 170 Abstracts Thai J Surg Oct. - Dec. 2011
(Vergaget®) and Hydrofiber with silver (Aquacel Ag®) hallux interphalangeal joint (IPJ) with distal resection of dressing every 2-3 days. The wounds could be closed in 2, the hallux proximal phalanx (PP). Mean follow up in 13 3 and 4 weeks, respectively. The duration of treatment was patients was 1.9 years. The technique of operation, results, short, caused tolerable pain, resulting in appreciated of the complications and recurrent rate are discussed. Results: patients. The duration of the follow up ranged from 5 months to 3 years and 7 months (mean 1.9 years), 4 men, 9 women, their ages ranging from 47 to 69 years (mean 58.3) with DM DISTAL RESECTION OF THE HALLUX PROXIMAL type 2 for 3 to 30 years (mean 12.3). Local anesthetic PHALANX A PROMISING TECHNIQUE FOR operative time ranged from 45 to 90 min. Almost patients TREATING DM RECALCITRANT HALLUX CALLUS with hallux IPJ hyperdorsiflexion was observed for one ULCER night hospital staying except 7 days staying in one because hallux osteomyelitic ulcer on the other hallux. No need for Taweesak Srikummoon plaster immobilization, no K-wire fixing, limiting activities Department of Surgery, Theptarin hospital, Bangkok, Thailand (careful walking) for the first 1-2 weeks. All 13 chronic Introduction: Recalcitrant hallux callus ulcer in DM recalcitrant hallux callus ulcer have healed and healing patients are not uncommon even though undergone time ranged from 3 to 4 weeks (mean 3.5) with minimal conservative modalities. As well as the DM foot wounds will complication. The surgical wound healing time ranged be risky for minor or major amputation. Preventive or from 3-4 weeks (mean 3). treated operations have been developed for this problem. Discussion: The successful rate of hallux callus ulcer In case of related operations are osteotomy, interphalangeal healing is very promising with a hundred percent by this arthroplasty, arthrodeses or Keller’s operation for hallux technique even though 2 feet (hallux) with late recurrence. ulcer, hallux rigidus for example. Operative technique is easy to train with simple instruments. Methods: A retrospective review, the DM patients Surgical wound healing was normal in cases without with recalcitrant hallux callus ulcer between 2007 and 2010 significant arterial compromised. Minor or acceptable was performed to assess the results of treating DM complications were observed. recalcitrant hallux callus ulcer at medio-plantar area of Subjects Index & Authors Index Volume 32
January to December 2011 172 Index Thai J Surg Sept. - Dec. 2011
Subjects Index to Volume 32 (January to December 2011)
A Detection of circulating tumor cells in the peripheral blood A case of ampullary tumor successfully managed with endoscopic independently predict survival in patients with advance ampullectomy, 107* malignant biliary tract diseases: a new guide for selection of A case report of 0.1% bactaine and 0.1% polyhexanide stents, 105* (prontosan(r)) in wound care, 169* Distal resection of the hallux proximal phalanx a promising A randomized controlled trial comparing topical skin adhesive technique for treating DM recalcitrant hallux callus ulcer, with skin sutures in the primary repair of the cleft lip, 151* 170* A review of surgical education and training in Thailand - findings and recommendations, 65 E Abdomino-perineal resection (APR) with vertical rectus Early discharge after mastectomy: a safe alternative to the abdominis myocutaneous (VRAM) Flap, 89* standard duration of postoperative hospital confinement, Additonal source of pulmonary blood flow as definitive palliation 84* for cyanotic bidirection glenn shunt, 98* Eary outcome of laparoscopic radical gastrectomy for advanced Age of colorectal cancer patients: 10 years analysis, 94* gastric cancer in national cancer institute, 107* An innovative instrument for semi-open release of A1 pulley: a Effectiveness of prophylaxis antibiotic used for tension-free cadaveric study, 153* hernioplasty: a randomized doubleblinded placebo- Anatomical resection of segment 8 for liver tumor: a glissonian controlled trial, 137 approach, 103* Endoscopic findings of gastrointestinal metastases from Anatomical study of internal iliac vein in soft cadavers, 161* malignant melanoma, 77 Anatomical study of internal iliac vein in soft cadavers, 168* Endoscopic strapler esophagodiverticulotomy for zenker’s Atls evidence and evaluation, 162* diverticulum: a case report at Samjitivej Sukhumvit hospital, Audiovisual DVD combined with standard traditional informed 110* consent enhances surgical patient satisfaction and Endoscopic submucosal dissection of lateral spreading tumor, comprehension: a comparative trial in laparoscric 110* cholecystectomy, 110* Endoscopic ultrasonography-guided fine needle aspiration Axillary artery cannulation for surgery on the hostile aorta, 9 cytology for diagnosis of accessory spleen minicking neoplasm of pancreas, 62 C Epicardial implantation, innovative technique for placement of Cases report of large chronic infected pelvic wounds by cardioverter-defibrillator lead in infant and children, 99* hydrosurgery debridement, 169* Estrogen and progesterone receptor in patients with bladder Changing the fecal route after emergency left sided malignant pain syndrome, 167* colonic obstruction, can we made the different when colonic Evaluation of rectal pouch level in anorectal malformations: stent is one of the options, 94* comparison between invertogram and prone lateral cross- Characters of mortality and time series analysis in thoracic table radiography, 147* injury before and after rapid response trauma team Evaluation of wound healing activity of lawsonia inermis linn establishment, 163 GPO preparation in rat model, 154* Childhood appendicitis in regional hospital, 73 Colonic atresia: a 14-year review, 146* F Combined endoscopic and laparoscopic intragastric resection Factors determining circumferential resection margin of rectal in management option for submucosal tumor of stomach, cancer at Maharat Nakorn Ratchasima Hospital, 21 109* Factors impacting readiness to discharge time from recovery Congenital heart block at srinagarind hospital: a case report, 100* room after laparoscopic cholecystectomy, 53 Corrected tacrolimus level in orthotropic liver transplant with Fenestrated aortic stent graft in thoracoabdominal aortic anemic patient, 158 aneurysm: lesson one, 100* Cost reduction in colonoscopy by using olive oil as a lubricant, Field fine needle aspiration cytology (FNAC): a new experience, 86* 102* Five years results of off-pump versus on-pump coronary artery D bypass surgery: pospective nonrandomized comparison study, Delivering surgical education in the digital age-a new paradigm?, 95* 156* Five years retrospective study for recurrent and persistent differentiated thyroid cancer, 101* *Abstract Frontiers in prehospital care in early resuscitation, 162*
172 Vol. 32 No. 4 SubjectsIndex Index 173
G application on liver: complication or proof of efficacy? A Gene expression profiles and funcitonal genomics in dermal lognterm clinical observational study, 102* fibroblasts from deep cone/fat dome of the duroc Low grade appendical mucinous neoplasm with rupture, 88* porcinemodel of fibroproliferative scarring, 156* M H Mailgnant choledochal cyst: a case report and review, 103* Health related quality of life in patients with hepatocellular Major vascular injury in laparoscopic cholecystectomy, 41 carcinoma, 103* Malignant choledochal cyst: a case report and reviews, 80 Histopathologic response after neoadjuvant chemoradiation Management of brain death patients at Lerdsin Hospital: 33 for localized esophageal cancer, 160* cases analysis, 158* Hybrid operating room for temporary occlusion of major aorto Management of burn in Bangkok Hospital medical center: pulmonary collateral artires (MAPCA) during open heart team approach, 164* surgery, 98 Medium-term functional outcome following endorectal Hyperthermic intraperitoneal chemoperfusion (HIPEC) for pullthrough for hirschsprung’s disease, 145* gastric cancer with carcinomatosis: Siriraj early experiences, Metachronous second primary colorectal cancer in patients 159* with gastric cancer: two cases report and literature review, 35 Midterm results of aortic valve sparing operation with david I procedure, 98* Implementing an ureban model of a community-based breast Mitral regurgitation associated with secundum atrial septal cancer control program, 85* defect, 97* Improving surgical education and training, 155* Mucosectomized sigmoid flap: a novel technique for Incidence and risk factors or early postoperative seizure in pelvicreconstruction after exenteration for advanced pelvic patients with intracranial tumor removal: prasat neurological malignancy, 92* institute experience, 124 Intraoperative colonoscopy: is it a better way for detection N anastomosis leakage after circular stapler anastomosis?, 94* New resuscitation strategy: damage control resuscitation, 162* Iodine status and the prevalence of autoimmune thyroiditis in Normative anorectal manometric parameters using customized Sri Lanka, 101* waterperfusion catheter, 87* Nutritional assessment for surgical patients by Bhumibol L Nutrition Triage (BNT) and subjective global assessment Laparoendoscopic single site extravesical ureteral reimplan- (SGA), 45 tation in adult using x-cone single port as a treatment of vesicoreteral reflux, 166* O Laparoendoscopic single -site nephroureterectomy with an One-site, one-stop outpatient breast service in a government endoscopic distal ureteral approach for the management of hospital, 85* upper urinary tract transitional-cell carcinoma, 165* Onestage total sacreactomy for large giant cell tumor of the Laparoendoscopic single site surgery (LESS) radiofrequency sacrum, 90* ablation treatment for renal cell carcinoma, 167* Operative intervention for traumatic brain injuries in the elderly, Laparoscopic and robotic partial nephrectomy: how far do we 150* go?, 165* Outcome of laparoscopic assisted pancreaticoduodenectomy Laparoscopic crural repair and nissen fundoplication in a case in Chulalongkorn Hospital, 104* of paraesophageal type III with reflux esophagitis, 159* Laparoscopic cylindrical abdominoperineal resection with en P bloc vaginectomy and sacrectomy with perineal and Pediatric laparoscopic surgery: the first step in a tertiary center, neovaginal reconstruction using the sigmoid flap, 91* 145* Laparoscopic enucleation of insulinoma: a report of two cases, Pelvic exenteration, total penectomy, bilateral orchiectomy 101* with subtotal sacrectomy, subtotal pelvectomy en bloc for Laparoscopic excision of an infected urachal cyst in an adult, aggressive pelvic liposarcoma, 92* 141 Phase I clinical evaluation of pore skin: a human dermal Laparoscopic management of esophagealleiomyoma, 108* substitute, 152* Laparoscopic management of nonpalpable undescended testis, Post injury multiple organ failure in a university hospital in 147* Thailand, 162* Laparoscopic pyeloplasty, variety of techniques and what’s new, Predictors of acuternal insufficiency and renal dialysis after 164* coronary artery bypass grafting, 97* Laparoscopic ventral hernia repair,108* Principles of statistics for surgeons II descriptive or summary Living related donor liver transplantation for biliary atresia statistics, 1 children: a 10-years review from Ramathibodi Hospital, Prognostic value of blood lactate monitoring in critically ill Mahidol University, Bangkok, Thailand, 148* trauma patients: help or hyper?, 161* Localized fluid collection after carrierbound fibrin sealant Prospective randomized controlled trial of patients undergoing cardiac surgery comparing modified mini-bypass circuit with *Abstract conventional cardiopulmonary bypass, 96* 174 SubjectsIndex Index Thai J Surg Sept. - Dec. 2011
Prospective study on the treatment of hyperpligmented skin Strong expression of CD24 is associated with increased graft by intense pulsed light, 154* cholangiocarcinoma progression, 105* Surgeons and cancer-the next generation, 157* Q Surgical education and training in the united Kingdom, 155* Quality of life in liver transplantation in Siriraj Hospital, 157* Surgical outcome of colorectal cancer: the lymph node number does matter, 93* R Surgical outcomes of hepatocellular carcinoma in King Recoartation after coarctation repair; sixteen years experience, Chulalongkorn memorial hospital, 105* 99* Surgical treatment for perihilar cholangiocarcinoma at King Redo lung volume reduction in a patient with severe emphysema: Chulalongkorn memorial Hospital, 106* a case report, 99* SWL 2011 improving outcome, 264* Related factors in necrotizing enterocolitis after gastroschisis repair, 113 T Reoperation rates after inguinal herniorrhaphy: a 10-year review The association between the midline diastemas and the superior at a tertiary care hospital, 13 labrial prenum in Thailand, 146* Report case of angiosarcoma of the descending thoracic aorta The efficacy of smart portable negative pressure device: a presenting with ruptured thoracic aneurysm, 97* preliminary study, 152* Results of combined organ resection for locally advanced gastric The efficacy of WF10 (immunokine) adjunct to standard cancer in Siriraj Hospital, 160* treatment for diabetic foot ulcers, 169* Role of central venous oxygen saturation (SCVO2) to predict The endoscopic vein dissector and its role in endoscopic thryroid weaning success cardiovascular disease patients in surgical surgery, 100* ICU, 96* The most preventable & curable chronic disease, 157* The outcome following decompressive craniectomy or S conservative treatment for malignant middle cerebral artery Sedative-free reduction of acute anterior shoulder dislocation infarction, 149* saves postreduction service time in the emergency room, 49 The relationship between carotid plaque calcification and Selective lumbar nerve root block under fluoroscope vs stability, 131 ultrasound, 149* Thoracic vascular surgical exposure, 168* Simple treatment of giant gastroschisis using a plastic spring Thoracoscopic radical esophagectomy for cancer, according to load silo and a silicone spring load silo with reinforce wing, microanatomy, 106* 148* Three years follow-up after ligation of intersphincteric fistula Simplified saline continence test for evaluation of anorectal tract (lift) for fistula-in-ano, 95* capacity: technique and normative data, 87* Total mesorectal excision: tips and techniques, 88* Simultaneous bilateral laparoendoscopic single site cysts Transsacral rectal resection for benign rectal stricture, 89* decortications in the treatment of symptomatic autosomal Trauma team activation: what do we learn?, 163* dominant polycystic kidney disease, 165* Tumor characteristics and adjuvant treatments of primary breast Single balloon enteroscopy assisted endoscopic retrograde cancers which deeloped recurrence: a review of 66 patients cholangiopancreatography and precut sphincterotomy for admitted at vicente sotto memorial medical center from treatment of retained common bile duct stone in billroth II January 2000 to December 2007, 84* gastrectomy patient, 60 Single-port laparoscopic anterior resection for rectal cancer, U 91* Ultrasound guided harmonic scalpel assisted removal of benign Si-wa hand port for hand-assisted laparosocpic surgery: an breast tumours a Siriraj experience, 86* innovative device, 120 Ultrastructural study of the detrusor in end stage renal disease, Smart neurosurgical probe, robotic system and sensors 167* integration for computer assisted neurosurgery, 153* Universal external fixators device, 150* Special anoscopy for stapled hemorrhoidopexy, 93* Unsaturated fatty acids affect mesenchymal stem cell secretion Stes (single-port access transanal endoscopic surgery), 90* of angiogenic and inflammatory mediators, 151* Update on image-guided kidney surgery, 165*
*Abstract Vol. 32 No. 4 Index 175
Authors Index to Volume 32 (January to December 2011)
A Chokvanitphong V, 107 Aegem U, 105 Choomchuay N, 88 Aimareerat O, 107 Chotirosniramit N, 163 Akaraborworn O, 161, 163 Chuangsuwanich A, 152 Akaraviputh T, 41, 53, 60, 62, 77, 120, 145, 159, 160 Chueabundit T, 152 Akkhawattanangkul Y, 154 Chumnanvej S, 149 Akranurakkul P, 88, 159 Chungsomprasong P, 98 Angthong W, 88 Chuthapisith S, 86 Anuntkosol M, 146, 147 Collin JP, 65, 155 Apiwanich C, 107 Asavakarn S, 157, 158 D Asavapiyanond S, 97 de Leon A, 84, 85 Asdornwised U, 53 Decharun K, 148 Atittharnsakul P, 87, 90, 91, 92, 94, 95 Di Carlo I, 102, 103 Ditsatham C, 163 B Dulayaprapa S, 120 Baena FR, 153 Dumronggittigule W, 157 Baking STA, 84, 85 Bell A, 151 E Benjacholamas V, 99 Engrav LH, 156 Boonmahittisut P, 145 Ernando R, 101 Boonpipattanapong T, 93 Euanorasetr C, 35 Boonsripitayanon M, 86 Boonvisut S, 154 F Boonyongsunchai P, 80, 103 Fernando R, 102 Bunaprasert T, 152 Ferrigno G, 153 Bunprasart K, 148 Fongkerd S, 151 Buranakitjaroen V, 113 Frasson L, 153
C G Calder PC, 131 Gallagher PJ, 131 Carrougher GJ, 156 Gough IR, 65 Castro D, 85 Grimble RF, 131 Chaichotre C, 94 Chainiramol P, 161 H Chaiprasit P, 73 Harnroongroj T, 49 Chaiyaroj S, 95, 96 Herrell SD, 164, 165 Chaiyasri A, 98 Hocking A, 151, 156 Chalermsanyakorn P, 167 Hoyt DB, 162, 168 Chandacham K, 163 Chanmayka T, 100 I Chanpasoppon P, 165, 166 Imchit C, 110 Chanwat R, 103, 107 Imruetaicharoenchoke W, 86 Charermsanyakorn P, 167 Intanoo W, 100 Cherntanomwong P, 95 Intarakhao S, 153 Chewatanakornkul S, 101 Iramneerat C, 157 Chimshang P, 146 Ittichaikulthol W, 110 Chinsawangwatanakul V, 159, 160 Chittawatanarat K, 96, 163 J Chittmittrapap S, 145, 148 Jaidee N, 110
175 176 AuthorsIndex Index Thai J Surg Sept. - Dec. 2011
Jantarawan T, 98 Manomaipiboon A, 45 Jaroensiriwat P, 110 McGinnis LM Jr, 157 Jaruwangsanti N, 150 Methasate A, 60, 159, 160 Jayatunge DNU, 101, 102 Muangman P, 164 Jerajakwatana S, 110 Muffey L, 151 Jirapongchareonlap T, 163 Mungnirandr A, 145 Jitisakulratana V, 97 Jungsomprasaong P, 99 N Nakarerngrita C, 146 K Namchaisiri J, 99 Kaewsaengrueang K, 161 Narong S, 105 Kanghae S, 99 Navicharern P, 89, 104, 108 P, 109 Kangkorn T, 141 Nawarawong W, 98 Kanjanasilp P, 90 Ngernchama M, 145, 146 Kasetsermwiriya W, 100 Nilskulwat S, 167 Keeratichamroen S, 105 Nimmanwudipong T, 159, 160 Keeratipongpaiboon K, 49 Niramis R, 113, 146, 147 Khomvilai S, 86, 93, 94, 95, 110 Nitibhon A, 164, 169 Khongphatthanayothin A, 99 Nivatvongs S, 105 Khuhaprema T, 103, 107 Nonthasoot B, 105, 106 Khunpugdee S, 103, 107 Numhom S, 151, 156 Kiatpadungkul W, 94 Kijvikai K, 167 O Ko SY, 153 Ohtsuka K, 60 Kochakarn W, 167 Onnoi J, 164 Kolladarungkri T, 157 Opasanon S, 41 Kongcharoensombat W, 167 Osugi H, 106 Kongphanich C, 80, 103 Konjanat J, 147 P Kortbeek JB, 162 Pak-art R, 162 Kositamongkol P, 157, 158 Pakdeniti P, 95 Kounsongtham V, 149 Pamornsingh P, 97 Kripracha B, 161 Panjapiyakul C, 110 Kritsanakul A, 93 Parakonthun T, 159, 160 Kruavit A, 153 Parittotokkaporn T, 153 Kunsriraksakul E, 158 Pasukdee P, 88 Kuptarnond 100 Pasuwachate S, 101 Pattana-arun J, 86 J, 87, 88, 89, 90, 91, 93, 94, 95 L Pausawasdi N, 60, 62 Laiwattanapaisal S, 141 Permpongkosol S, 165, 166, 167 Laksanabunsong P, 99, 100 Petsongkramb B, 146 Laohapensang M, 145, 146 Phanchaipetch T, 98 Laohathai P, 110 Phanthabordeekorn W, 137 Leelakusolvong S, 60 Phisalaphong C, 154 Leelawat K, 105 Phunya J, 110 Leeranupunth C, 165, 166 Pibul K, 45 Lertsapcharoen P, 99 Pimkow S, 21 Lertsirisopon S, 100 Pinto MDP, 101, 102 Lertsithichai P, 1, 13, 95, 96 Pitiguagool V, 97 Lertudomphonwanit T, 49 Pongpruttiparn T, 62 Leung GKK, 150 Pornchai S, 13 Li LF, 150 Pornpeera J, 101 Likhitmaskul T, 151 Praditphol N, 105 Limsrichamroen S, 157, 158 Pradniwat K, 154 Pranamrattana U, 100 M Prasarttong-osoth P, 86 Magno CJ, 84 Prathanee S, 100 Mahattanobon S, 101 Prechawittayakul P, 93 Mahawithitwong P, 157, 158 Pruekeprasert P, 101 Malakorn S, 88, 89, 91 Pumchandh S, 104 Maneechay S, 164 Punchai S, 104, 108, 109 Vol. 32 No. 4 AuthorsIndex Index 177
Pungpapong S, 89, 104, 108, 109 T Purintrapiban B, 96 Tadadontip P, 124 Pushatanamukayanunt P, 86 Taesombat V, 105 Tagab H, 85 R Tanatraworasin A, 98 Rajatapiti P, 145 Tansawet A, 100, 104 Ratanashu-ek T, 105 Tantiplachiva K, 87, 94, 95 Ratanawichitrasin A, 86 Tantiwongkosri K, 98, 99 Rattananon O, 9 Taweepraditpol S, 154 Rattaplee P, 101 Techapongsatorn S, 45, 100 Rerkasem K, 131 Termwattanaphakdee T, 152 Reukviboonsri S, 145 Thanapongsathorn W, 110 Roekwibunsi S, 147 Thanasrivanitchai S, 105 Rojanapithayakorn N, 154 Thanavachirasin K, 89 Rojanasakul A, 86, 87, 93, 94, 95 Thanomnak N, 107 Ruangsee C, 95, 96 Tharavej C, 89, 104, 108, 109, 160 Ruengsakulrach P, 97 Thiengthiantham R, 45 Rujanavej P, 103, 107 Thirapatarapn C, 148 Thongcharoen P, 99 S Thongkao K, 163 Sahakitrungruang C, , 90, 91, 92, 94, 95 Thongtawee T, 105 Sakoolnamarka S, 153 Thupvong K, 97 Samphao S, 101 Tienboon P, 150 Sangkhathat S, 93, 161 Tohtong R, 105 Sangkum P, 167 Tolley D, 156, 164 Sangthong B, 161, 163 Tongkhao K, 161 Sangthong R, 161 Tongsin A, 146, 147 Santichatngam P, 21 Toro A, 102, 103 Sermdamrongsak U, 110 Toskulkao T, 53 Shearman CP, 131 Tovikkai C, 157, 158 Siguan SS, 84, 85 Traisathi P, 163 Sirichindakul B, 1054 Trakulhoon V, 45 Sirimontaporn N, 110 Treepongkaruna S, 105 Siripakarn T, 164 Tujinda S, 105 Sirivatanauksorn Y, 157, 158 Tullavardhana T, 159 Siriwittayakorn P, 94 Tuvayanon W, 53, 120 Sithijirakorn N, 94 Slisatakorn W, 98 Slisatkorn W, 100 U Smith A, 151 U-dee V, 154 Soongswang J, 98 J, 99 Udomchaiprasertkul W, 105 Soparat C, 160 Udomsawaengsup S, 89, 104, 108, 109 Srikoch Y, 80, 103 Ungbhakorn P, 167 Srikummoon T, 170 Ungkitphaiboon W, 159 Srikureja W, 60, 62 Uthaipaisanwong A, 106 Sriprayoon T, 62, 77 Sriworarak R, 113 V Sriyoschati S, 98, 99, 100 Vatcharasiritham C, 97 Subtaweesin T, 99 Veerasarn K, 124 Subwongcharoen S, 105 Vejchapipat P, 145, 148 Suesat P, 108 Viengteerawat S, 95, 96 Sukanya S, 101 Viratanapanu I, 95 Suksamanpun N, 145 Viravaidya D, 145 Sumetchotimaytha W, 103, 107 Vongstapanalert R, 158 Sutharat P, 94 Vongviriyangkoon T, 154 Suthi T, 107 Suttiwongsing A, 113 W Suvikapakornkul R, 13 Waitittipong S, 97 Suwanakijboriharn C, 97 Wakhanrittee J, 96 Suwanthanma W, 35 Wangcheang S, 152 Wanitsuwan W, 89, 93 178 Index Thai J Surg Sept. - Dec. 2011
Wannaprasert J, 105 Wongwanit C, 100 Watanyuta N, 161 Wora-Urai N, 65 Wattanakul T, 162 Wuttisuthimethawee P, 161 Wetchagama N, 149 Wijitsettakul U, 165 Y Witchapan A, 110 Yingsakmongkol N, 169 Withurawanit W, 9 Yottansurodom C, 97 Wittayanakorn N, 149 Yuen WK, 150 Wong HHT, 150 Wongboonate S, 77 Z Wongidpoonpol S, 98 Zhu KQ, 156 Wongkornrat W, 98, 100