Colonoscopic perforation： A report from World Gastroenterology Organization endoscopy training center in Thailand

AIM： To determine the incidence of colonoscopic perforation （CP）, and evaluate clinical findings, management and outcomes of patients with CP from the World Gastroenterology Organization （WGO） Endoscopy Training Center in Thailand. METHODS： All colonoscopies and sigmoidoscopies performed between 1999 and 2007 in the Endoscopic unit, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok were reviewed. Incidence of CP, patients＇ characteristics, endoscopic information, intraoperative findings, management and outcomes were analyzed. RESULTS： A total of 17357 endoscopic procedures of the colon （13 699 colonoscopies and 3658 flexible sigmoidoscopies） were performed in Siriraj hospital over a 9-year period. Fifteen patients （0.09%） had CP： 14 from colonoscopy and 1 from sigmoidoscopy. The most common site of perforation was in the sigmoid colon （80%）, followed by the transverse colon （13%）. Perforations were caused by direct trauma from either the shaft or the tip of the endoscope （n = 12,80%） and endoscopic polypectomy （n = 3, 20%）. All patients with CP underwent surgical management： primary repair （27%） and bowel resection （73%）. The mortality rate was 13% and postoperative complication rate was 53%. CONCLUSION： CP is a rare but serious complication following colonoscopy and sigmoidoscopy, with high rates of morbidity and mortality. Incidence of CP was 0.09%. Surgery is still the mainstay of CP management.     

Roles of the MEK1/2 and AKT pathways in CXCL12/CXCR4 induced cholangiocarcinoma cell invasion

AIM:To evaluate the expression of C-X-C motif chemokine receptor 4(CXCR4)and its signaling cascades,which were previously identified as a key factor for cancer cell progression and metastasis,in cholangiocarcinoma cell lines.METHODS:The expression of CXCR4 and its signaling cascades were determined in the cholangiocarcinoma cell lines(RMCCA1 and KKU100)by Western blotting.The invasion assays and the detection of actin polymerization were tested in these cholangiocarcinoma cells treated with CXC chemokine ligand-12(CXCL12).RESULTS:Expression of CXCR4 was detected in both cholangiocarcinoma cell lines and activation of CXCR4 with CXCL12 triggered the signaling via the extracellular signal-regulated kinase-1/2(ERK1/2)and phosphoinositide 3-kinase(PI3K)and induction of cholangiocarcinoma cell invasion,and displayed high levels of actin polymerization.Addition of CXCR4 inhibitor(AMD3100)abrogated CXCL12-induced phosphorylation of MEK1/2 and Akt in these cells.Moreover,treatment with MEK1/2 inhibitor(U0126)or PI3K inhibitor(LY294 002)also attenuated the effect of CXCL12-induced cholangiocarcinoma cell invasion.CONCLUSION:These results indicated that the activation of CXCR4 and its signaling pathways(MEK1/2 and Akt)are essential for CXCL12-induced cholangiocarcinoma cell invasion.This rises Implications on a potential role for the inhibition of CXCR4 or its signal cascades in the treatment of cholangiocarcinoma.     

Surgical site infections in patients undergoing major operations in a university hospital: using standardized infection ratio as a benchmarking tool

BACKGROUND: Because patterns of infection acquired in patients undergoing operation are ever changing, it is an essential part of nosocomial infection surveillance programs to periodically document the epidemiologic features of infection in these patients. This study was conducted with the primary intention of describing the incidence and risk factors of the surgical site infection (SSI). METHODS: We performed a prospective study in patients undergoing certain major operations at a 750-bed university hospital in Thailand. The National Nosocomial Infection Surveillance (NNIS) system method and criteria were used for identifying and diagnosing infection. The infection rates were benchmarked with the NNIS report by means of indirect standardization and reported in terms of standardized infection ratio. Risk factors for SSI were evaluated using the multiple logistic regression model. RESULTS: From September 1998 to March 2000, the study included 4193 patients with 4437 major operations. The study identified 192 SSIs, 76 urinary catheter-related urinary tract infections, 26 central line-related bloodstream infections, and 39 instances of ventilator-associated pneumonia (VAP), yielding an infection rate of 4.3 SSIs/100 operations, 11.0 catheter-related urinary tract infections/1000 urinary catheter-days, 6.1 central line-related bloodstream infections/1000 central line-days, and 11.0 VAPs/1000 ventilator-days. When compared with data from NNIS, the standardized infection ratio of SSI, catheter-related urinary tract infection, central line-related bloodstream infection, and VAP were 2.3, 2.1, 1.1, and 0.8, respectively. The factors that significantly associated with SSI were duration of operation in minutes, American Society of Anesthesiologists (ASA) class, and degree of wound contamination. CONCLUSION: All of the infection rates identified, except VAP, were higher than the average NNIS rates. The risk factors for SSI were prolonged duration of operation, poor physical status according to ASA classification, and higher degree of wound contamination.     

A subclavian artery injury,secondary to internal jugular vein cannulation,is a predictable right-sided phenomenon

IMPLICATIONS: Internal jugular vein cannulation is a frequently performed procedure. We present a case with a review of the literatures of subclavian artery injury secondary to this procedure, recognizing that this complication may be a right-sided phenomenon secondary to its unique anatomical layout.     

Seroepidemiological survey among schoolchildren during the 2000-2001 dengue outbreak of Ratchaburi Province, Thailand

From August 2000 to 2001, a dengue outbreak occurred in Mueang district, Ratchaburi Province, Thailand. About 800 cases of dengue infection were reported, and among them, 49.5% were clinically diagnosed as dengue hemorrhagic fever according to the WHO criteria. During the outbreak, the incidence rate of dengue infection in Hin Gong subdistrict was 2.9 per 1,000 population. A seroepidemiological survey was conducted among primary schoolchildren from July 2000 to June 2001, to monitor dengue transmission. In a baseline survey, 283 children were surveyed for dengue antibody and 71% were IgG seropositive. In June 2001, the rate of dengue infection showed an increase of 8.8% with 8.0% among immune children and 10.3% among naive schoolchildren. Among 283 schoolchildren, 90 were followed up 3 times, in September and December 2000, and June 2001. An increase in the rate of seroconversion was observed in the period September to December 2000, while the peak dengue outbreaks in the dry season occurred in February 2001. Serosurveys among schoolchildren appear to be early warning system, and can be advantageous in early dengue control actions, in order to break the chain of transmission before an impending epidemic.     

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

AIM： To determine the relationship between preoperative 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/m^2; 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.