Surgical strategies for challenging common bile duct stones in the endoscopic era: A comprehensive review of current evidence

While endoscopic retrograde cholangiopancreatography(ERCP)remains the primary treatment modality for common bile duct stones(CBDS)or choledocho-lithiasis due to advancements in instruments,surgical intervention,known as common bile duct exploration(CBDE),is still necessary in cases of difficult CBDS,failed endoscopic treatment,or altered anatomy.Recent evidence also supports CBDE in patients requesting single-step cholecystectomy and bile duct stone removal with comparable outcomes.This review elucidates relevant clinical anatomy,selection indications,and outcomes to enhance surgical understanding.The selection between trans-cystic(TC)vs trans-choledochal(TD)approaches is described,along with stone removal techniques and ductal closure.Detailed surgical techniques and strategies for both the TC and TD approaches,including instrument selection,is also provided.Additionally,this review comprehensively addresses operation-specific complications such as bile leakage,stricture,and entrapment,and focuses on preventive measures and treatment strategies.This review aims to optimize the management of CBDS through laparoscopic CBDE,with the goal of improving patient outcomes and minimizing risks.

Is fascial closure required for a 12-mm trocar?A comparative study on trocar site hernia with long-term follow up

BACKGROUND Despite the infrequency of trocar site hernias(TSHs),fascial closure continues to be recommended for their prevention when using a≥10-mm trocar.AIM To identify the necessity of fascial closure for a 12-mm nonbladed trocar incision in minimally invasive colorectal surgeries.METHODS Between July 2010 and December 2018,all patients who underwent minimally invasive colorectal surgery at the Minimally Invasive Surgery Unit of Siriraj Hospital were retrospectively reviewed.All patients underwent cross-sectional imaging for TSH assessment.Clinicopathological characteristics were recorded.Incidence rates of TSH and postoperative results were analyzed.RESULTS Of the 254 patients included,70(111 ports)were in the fascial closure(closed)group and 184(279 ports)were in the nonfascial closure(open)group.The median follow up duration was 43 mo.During follow up,three patients in the open group developed TSHs,whereas none in the closed group developed the condition(1.1%vs 0%,P=0.561).All TSHs occurred in the right lower abdomen.Patients whose drains were placed through the same incision had higher rates of TSHs compared with those without the drain.The open group had a significantly shorter operative time and lower blood loss than the closed group.CONCLUSION Routine performance of fascial closure when using a 12-mm nonbladed trocar may not be needed.However,further prospective studies with cross-sectional imaging follow-up and larger sample size are needed to confirm this finding.

Pre-operative hypoalbuminemia is a major risk factor for postoperative complications following rectal cancer surgery

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

Predictive significance of cancer related-inflammatory markers in locally advanced rectal cancer

BACKGROUND Locally advanced rectal cancer is treated using neoadjuvant chemoradiation(nCRT),followed by total mesorectal excision(TME).Tumor regression and pathological post-treatment stage are prognostic for oncological outcomes.There is a significant correlation between markers representing cancer-related inflammation,including high neutrophil-to-lymphocyte ratio(NLR),monocyteto-lymphocyte ratio(MLR),and platelet-to-lymphocyte(MLR)and unfavorable oncological outcomes.However,the predictive role of these markers on the effect of chemoradiation is unknown.AIM To evaluate the predictive roles of NLR,MLR,and PLR in patients with locally advanced rectal cancer receiving neoadjuvant chemoradiation.METHODS Patients(n=111)with locally advanced rectal cancer who underwent nCRT followed by TME at the Minimally Invasive Surgery Unit,Siriraj Hospital between 2012 and 2018 were retrospectively analyzed.The associations between post-treatment pathological stages,neoadjuvant rectal(NAR)score and the pretreatment ratios of markers of inflammation(NLR,MLR,and PLR)were analyzed.RESULTS Clinical stages determined using computed tomography,magnetic resonance imaging,or both were T4(n=16),T3(n=94),and T2(n=1).The NAR scores were categorized as high(score>16)in 23.4%,intermediate(score 8-16)in 41.4%,and low(score<8)in 35.2%.The mean values of the NLR,PLR,and MLR correlated with pathological tumor staging(ypT)and the NAR score.The values of NLR,PLR and MLR were higher in patients with advanced pathological stage and high NAR scores,but not statistically significant.CONCLUSION In patients with locally advanced rectal cancer,pretreatment NLR,MLR and PLR are higher in those with advanced pathological stage but the differences are not significantly different.