Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy must be performed by a highly experienced endoscopist. The challenges are accessing the afferent limb in different types of reconstruction, cannulating a papilla with a reverse orientation, and performing therapeutic interventions with uncommon endoscopic accessories. The development of endoscopic techniques has led to higher success rates in this group of patients. Device-assisted ERCP is the endoscopic procedure of choice for high success rates in short-limb reconstruction; however, these success rate is lower in long-limb reconstruction. ERCP assisted by endoscopic ultrasonography is now popular because it can be performed independent of the limb length; however, it must be performed by a highly experienced and skilled endoscopist. Stent deployment and small stone removal can be performed immediately after ERCP assisted by endoscopic ultrasonography, but the second session is needed for other difficult procedures such as cholangioscopy-guided electrohydraulic lithotripsy. Laparoscopic-assisted ERCP has an almost 100% success rate in long-limb reconstruction because of the use of a conventional side-view duodenoscope, which is compatible with standard accessories. This requires cooperation between the surgeon and endoscopist and is suitable in urgent situations requiring concomitant cholecystectomy. This review focuses on the advantages, disadvantages, and outcomes of various procedures that are suitable in different situations and reconstruction types. Emerging new techniques and their outcomes are also discussed.

Background Coronavirus disease (COVID-19) has impacted both emergency and elective surgical management owing to its highly infectious nature and the shortage of personal protective equipment. This study aimed to review the outcomes of emergency surgical conditions and trauma during the pandemic lockdown. Material and Methods We retrospectively reviewed and collected data from patients who attended the Acute Care Surgery Service from 1 st April to 31 st May 2020 during Thailand’s COVID-19 pandemic lockdown. We separated staff and performed preoperative COVID-19 swab testing on all patients to assess the requirement for personal protective equipment. Compared with previous years of service, of 2018 and 2019. Preoperative COVID-19 testing was performed using multiplex and manual RT-PCR. Morbidity and mortality, consultation time, and waiting time to surgery were analyzed. Results A total of 61 patients were enrolled. The average age of patients was 53.8 years. The average consultation time, waiting time to surgery, and surgical duration were 10 minutes, 660 minutes, and 88.77 minutes, respectively. The average time taken to obtain the preoperative COVID-19 test result was 227.26 minutes. The morbidity and mortality rates were 9.84% and 1.64%, respectively. Compared with the same period in 2018 and 2019, consultation time was significantly faster (10 minutes; p = 0.033) and waiting time to surgery was significantly longer (660 minutes, respectively; p = 0.011). Morbidity and mortality between pandemic period and the previous year of service were not significantly different. No medical workers were infected with COVID-19. Conclusions During the COVID-19 pandemic, optimal triage of emergency patients is key. Waiting for preoperative COVID-19 swab testing in emergency case is safe and results in good outcomes. Although the waiting time to surgery was significantly longer owing to the time required to receive preoperative COVID-19 swab results, morbidity and mortality rates were unaffected.

AIMTo analyze the risk factors of postoperative pancreatic fistula following pancreaticoduodenectomy in a Thai tertiary care center.METHODSWe retrospectively analyzed 179 patients who underwent pancreaticoduodenectomy at our hospital from January 2001 to December 2016. Pancreatic fistula were classified into three categories according to a definition made by an International Study Group on Pancreatic Fistula. The risk factors for pancreatic fistula were analyzed by univariate analysis and multivariate logistic regression analysis.RESULTSPancreatic fistula were detected in 88/179 patients (49%) who underwent pancreaticoduodenectomy. Fifty-eight pancreatic fistula (65.9%) were grade A, 22 cases (25.0%) were grade B and eight cases (9.1%) were grade C. Clinically relevant pancreatic fistula were detected in 30/179 patients (16.7%). The 30-d mortality rate was 1.67% (3/179 patients). Multivariate logistic regression analysis revealed that soft pancreatic texture (odds ratio = 3.598, 95%CI: 1.77-7.32) was the most significant risk factor for pancreatic fistula. A preoperative serum bilirubin level of > 3 mg/dL was the most significant risk factor for clinically relevant pancreatic fistula according to univariate and multivariate analysis.CONCLUSIONSoft pancreatic tissue is the most significant risk factor for postoperative pancreatic fistula. A high preoperative serum bilirubin level (> 3 mg/dL) is the most significant risk factor for clinically relevant pancreatic fistula.

A 74-year-old female, who was diagnosed with superficial esophageal cancer, underwent endoscopic submucosal dissection (ESD) at another hospital, but a perforation occurred during the procedure. The perforation was closed with endoscopic clips, and the ESD was halted. The patient was referred to our hospital, and ESD was retried. There was severe fibrosis around the lesion, and injections into the submucosal layer were difficult. In addition, it was not possible to identify the submucosal layer, and making an oral-side incision caused a large perforation along the incision line. As continuing the submucosal dissection with an endoknife was considered difficult, the lesion was finally resected with hybrid ESD using a snare. The perforation was closed using polyglycolic acid (PGA) sheets and fibrin glue. Endoscopy performed 6 days later showed that the defect had been closed, and no contrast leakage was detected. Follow-up endoscopy conducted 3 months after the ESD showed ulcer healing at the dissection site and scar formation, but no residual tumor or esophageal stricture was noted. Our experience suggests that the use of PGA sheets with fibrin glue is a feasible, safe, and effective way of treating large esophageal perforations during ESD.

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Background and study aims Patients who have undergone colorectal surgery for resection of cancer and benign lesions are at risk for recurrent, residual, or metachronous lesions at the anastomosis site. Surgical resection of such lesions is difficult because of adhesions, and a stoma may be required as there are risks for leakage after resection. The feasibility and safety of endoscopic submucosal dissection (ESD) for these lesions remain unknown. Therefore, this case series aimed to examine the feasibility and safety of ESD by evaluating the clinical outcomes. Patients and methods We retrospectively investigated five patients who underwent ESD by a single expert for superficial neoplastic lesions at the anastomosis site after previous colorectal surgery. Results R0 resections were achieved for all lesions. Mean procedure time was 160.6 minutes. Mean dimensions of the resected specimen and tumor were 52.4 mm and 31.8mm, respectively. None of the patients had complications or recurrence after surveillance colonoscopy 1-year post-resection. Conclusions In an expert’s hands, ESD at the anastomosis site might be feasible minimally invasive treatment for superficial neoplastic lesions.

Introduction: Measures taken to prevent the spread of coronavirus disease 2019 (COVID-19) slow surgical processes, and patients are avoiding presenting at emergency departments during the outbreak because of fears of contracting the contagious disease. To analyze the rate of complicated appendicitis before and during the COVID-19 pandemic. Methods: We systematically reviewed the PubMed and SCOPUS databases for articles published from 2000 to 2021. Including the retrospective review data collected from our hospital of patients aged ≥18 years old who were diagnosed with acute appendicitis. The primary outcome of complicated appendicitis incidence was compared between before and during the COVID-19 pandemic period. We performed a meta-analysis using a random-effects model analysis. Results: A total 3559 patients were included for meta-analysis. The overall rate of complicated appendicitis was significantly higher during the pandemic (relative risk, 1.55; 95% confidence interval [CI], 1.26–1.89). The time from onset of symptoms to hospitalisation was 0.41 h longer during the pandemic, which was not significantly different (standardized mean difference, 0.41, 95% CI, −0.03 to 1.11). The operating time during the pandemic was significantly shorter than that before the pandemic (83.45 min and 71.65 min, p = 0.01). Conclusion: There are correlation between the pandemic and severity of acute appendicitis. The higher rate of complicated appendicitis in the pandemic indicates that patients require timely medical attention and appropriate treatment despite fears of contracting disease. Highlights

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