Siriraj Medical Journal

277-283

Authors: Thitima Chinachoti, M.D., Kullamas Jongthansesthakul, M.D., Panop Limratana, M.D., Patiparn Toomtong, M.D.

Objective: To identify the risk factors associated with prolonged intensive care unit admission (≥4 days) and mortality in postoperative surgical patients. Methods: A retrospective, case-control study was conducted in 527 patients admitted to postoperative intensive care units during a 1-year period. Fifteen factors were included in univariate and only significant factors were included in multivariate analyses. Results: Twenty one percent of all admissions had prolonged length-of-stay. From multivariate analysis, predicted risk factors were emergency surgery (OR 2.9, p=0.001, CI 1.6-5.2); remained intubation (OR 2.6, p=0.007, CI 1.3-5.4), unplanned ICU admission (OR 2.1, p=0.03, CI 1.1-4.2); SAPS II score >52 (OR 4.8, p<0.001, CI 2.5-9.2), SAPS II score >64 (OR 6.1, p<0.001, CI 2.7-13.8) and inotrope infusion in ICU (OR 4.5, p<0.001, CI 2.5-8) which were associated with prolonged ICU admission. Factors associated with ICU mortality (10.06%) were; ASA physical status >3 (OR 8.2, p=0.003, CI 2-32.9), ICU readmission (OR 3.9, p=0.007, CI 1.5-10.8), inotrope infusion in ICU (OR 3, p=0.006, CI 1.4-6.7), renal replacement therapy (OR 3.2, p=0.007, CI 1.3-8.2), SAPS II score 52-63 (OR 3.6, p=0.018, CI 1.2-6.8), SAPSII score >64 (OR 3.9, p=0.006, CI 1.4-9) and cirrhosis (OR 4.9, p=0.04, CI 1.1-21). Conclusion: ASA physical status >3 and SAPS II score >52 were independent predictive factors of both prolonged intensive care unit admission and mortality.

291-298

Authors: Ajalaya Teyateeti, M.D., Achiraya Teyateeti, M.D., Pawana Pusuwan, M.D.

Objective: To evaluate outcome of radioactive iodine (RAI) ablation/treatment in pathologically defined low risk of recurrence well-differentiated thyroid carcinoma (WDTC) patients. Methods: A 7-year retrospective review of medical records was done in 155 pathologically defined low risk of recurrence (LRR) WDTC patients. Total thyroidectomy or equal surgery and pre-ablative evaluation were done in all patients. The 1st dose of RAI ablation was either 30 or 80/100 mCi. The following doses of RAI ablation/ treatment were adjusted by patients’ risk of recurrence and treatment response. Criteria of successful ablation/ treatment were 1) no evidence of clinical disease 2) no demonstrable abnormal uptake on the follow-up 6-12 months diagnostic whole body scan (Dx-WBS) and 3) stimulated thyroglobulin (Tg) lower than 2 ng/mL and thyro- globulin antibodies (TgAb) lower than 40 IU/mL. Patients received RAI ablation/treatment until they achieved disease remission or there was evidence of treatment failure. Results: Cumulative success rate after the 1st, 2nd and 3rd RAI ablation/treatments were 61.3%, 75.5% and 82.6%, respectively. The risk of recurrence among 155 patients were 83.2% low risk (n=129), 11.6% intermediate risk (n=18), and 5.2% high risk (n=8). Of 129 true LRR patients, the success rates of 1st, 2nd and 3rd RAI ablation were 73.6% (n=95), 10.1% (n=13) and 6.2% (n=8), respectively. After RAI treatment for 3 sessions, disease remission was observed in 10 of 18 intermediate risk of recurrence (IRR) patients and only 1 of 8 high-risk of recurrence (HRR) patients. Between success and failure group, there was statistically significant difference in risk of recurrence (p-value = 0.000), baseline Tg (2.61 vs 7.17 ng/mL, p-value = 0.015) and TgAb (16.8 vs 33.7 IU/mL, p-value = 0.004). Conclusion: Disease remission in pathologically defined LRR patients after the 1st, 2nd and 3rd sessions of RAI ablation/treatment were 61.3%, 75.5% and 82.6%, respectively. IRR and HRR were found in 16.8% of patho- logically defined LRR patients. Risk of recurrence, baseline Tg and TgAb strongly correlated with RAI ablation/ treatment outcome. Highest success rate was observed in true LRR (89.9%). None of the IRR and HRR patients had disease remission following the 1st RAI ablation and remission rate was only 43.2% following 3 sessions of RAI treatment.

305-309

Authors: Witchuree Wejjakul, M.D., Anuwat Pongkunakorn, M.D.

Ochronosis is a musculoskeletal manifestation found in alkaptonuria which is a rare autosomal reces- sive disorder caused by the deficiency of homogentistic acid oxidase enzyme. This leads to accumulation and deposition of homogentistic acid (HGA) pigments in skin, sclera, tendon, ligament and cartilage. Ochronosis is asymptomatic until ochronotic arthropathy occurs. We reported a case of 64-year female presented with advanced degenerative changes in the knee, hip, shoulder and lumbo-sacral spine. The operative findings during total knee arthroplasty showed bluish-black discoloration of the entire articular surface. Her urine HGA level was extremely high. Histopathological exam confirmed ochronosis. The literature, differential diagnosis and management of this rare condition are reviewed.

313-316

Authors: Anuchit Lerstsirithong, M.D., Thawatchai Akaraviputh, M.D., Ananya Pongpaibul, M.D., Atthaporn Trakarnsgna, M.D., Chainarong Phalanusitthepha, M.D., Voraboot Taweeruthchana, M.D., Asada Methasate, M.D., Jirawat Swangsri, M.D., Thammawat Parakonthun, M.D., Vitoon Chinswangwattanakul, M.D.

Objective: Mesenteric and omental cyst are the rare intra-abdominal pathologies. We report laparoscopic excision of a large omental cyst in an adult patient. Methods: A 56 year-old female presented with a year history of upper abdominal pain with palpable mass at epigastrium. On physical examination, a non-tenderness mass, 8 cm in diameter, was noted in the right upper abdomen. Abdominal CT revealed large thin wall cyst without solid nodule or septation at right upper abdomen. Endoscopic ultrasonography revealed no demonstration of its origin without connection to duodenal wall, pancreatic and bile duct. The patient underwent a complete excision by laparoscopic approach. Intraoperative finding revealed an encapsulated thin wall smooth surface cystic mass in lesser sac. The patient made an uneventful postoperative recovery. Pathological examination showed simple mesothelial cyst. Discussion: Omental cysts often tends to be asymptomatic and is identified incidentally on imaging studies or at laparotomy. Ultrasonography, computed tomography and magnetic resonance imaging is a useful investigation to a correct diagnosis in patients with large cystic mass. Endoscopic ultrasonography is useful in distinguishing lesions arising in the wall of the GI tract from lesions. The complete excision is the treatment of choice. The advantages of laparoscopic approaches compared with open surgery are less postoperative pain, earlier recovery, shorter hospital stay, and better cosmetic. However, minimally invasive techniques should not compromise the basic surgical principles of complete excision. Conclusion: In our patient, we confirm the feasibility and safety of laparoscopic resection in large omental cyst.