Outcomes of Local Excision for Early Rectal Cancer: a 6-year Experience from the Largest University Hospital in Thailand

Lohsiriwat, Varut,Anubhonganant, Worabhong,Prapasrivorakul, Siriluck,Iramaneerat, Cherdsak,Riansuwan, Woramin,Boonnuch, Wiroon,Lohsiriwat, Darin Asian Pacific Journal of Cancer Prevention 2013 Asian Pacific journal of cancer prevention Vol.14 No.9

Background: This study aimed to determine clinical outcomes of local excision for early rectal cancer from a University Hospital in Thailand. Materials and Methods: We performed a retrospective review of 22 consecutive patients undergoing local excision for early rectal cancer (clinical and radiological T1/T2) from 2005-2010 at the Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok. Data were collected from patients' medical records, including demographic and clinical characteristics, pathological report and surgical outcomes. Results: This study included 10 males and 12 females, with average age of 68 years. Nineteen patients (86%) underwent transanal excision and the others had trans-sacral excision. Median operative time was 45 minutes. Postoperative complications occurred in 2 patients (9%); 1 fecal fistula and 1 wound infection following trans-sacral excision. There was no 30-day postoperative mortality. Median hospital stay was 5 days. Pathological reports revealed T1 lesion in 12 cases (55%), T2 lesion in 8 cases (36%) and T3 lesion in 2 cases (9%). Eight patients received additional treatment; one re-do transanal excision, two proctectomies, and five adjuvant chemoradiation. During the median follow-up period of 25 months, local recurrence was detected in 4 patients (18%); two cases of T2 lesions with close or positive margins, and two cases of T3 lesions. Three patients with local recurrence underwent salvage abdominoperineal resection. No local recurrence was found in T1/T2 lesions with free surgical margins. Conclusions: Local excision is a feasible and acceptable alternative to radical resection only in early rectal cancer with free resection margins and favorable histopathology.

Colorectal Cancer Screening by Double Contrast Barium Enema in Thai People

Lohsiriwat, Varut,Prapasrivorakul, Siriluck,Suthikeeree, Wanwarang Asian Pacific Journal of Cancer Prevention 2012 Asian Pacific journal of cancer prevention Vol.13 No.4

Purpose: The incidence of colorectal cancer (CRC) has been increasing in Asian countries including Thailand. Double contrast barium enema (DCBE) is one of the investigation tools used in CRC screening. This study aimed to determine the incidence of colorectal neoplasm detected at screening by DCBE in Thai people. Methods: The computerized radiology database of screening DCBE in Thai adults between June 2009 and October 2011 at the Faculty of Medicine, Siriraj Hospital, was reviewed. DCBE examination performed in a surveillance program after curative CRC resection or the removal of colorectal polyps was also considered as a screening DCBE. Results: A total of 819 screening DCBEs performed during this 28-month period were analyzed. The mean age of patients was $59.8{\pm}13.6$ years. Of the total, 467 (57%) were male. A family history of CRC and a previous history of curative CRC resection or polyp removal were noted in 34 patients (4%) and 124 patients (15%), respectively. A total of 31 patients (3.8%; 95%CI = 2.7%-5.3%) were reported to have colorectal polyp or mass demonstrated on DCBE. Of these, follow-up endoscopy was performed in 20 cases (65%). According to pathological results, the incidence of advanced adenoma and CRC detected at screening DCBE was 0.7% (95%CI = 0.3%-1.6%; n=6) and 0.4% (95%CI = 0.1%-1.1%; n=3), respectively. Conclusions: The screening DCBE performed in Thai adults had a diagnostic yield of 0.7% for advanced adenoma and 0.4% for CRC.

Accuracy of Self-Checked Fecal Occult Blood Testing for Colorectal Cancer in Thai Patients

Lohsiriwat, Varut Asian Pacific Journal of Cancer Prevention 2014 Asian Pacific journal of cancer prevention Vol.15 No.18

Purpose: Colorectal cancer (CRC) screening with fecal occult blood testing (FOBT) has been associated with a reduction in CRC incidence and CRC-related mortality. However, a conventional FOBT requires stool collection and handling, which may be inconvenient for participants. The EZ-Detect$^{TM}$ (Siam Pharmaceutical Thailand) is a FDA-approved chromogen-substrate based FOBT which is basically a self-checked FOBT (no stool handling required). This study aimed to evaluate the accuracy of EZ-Detect for CRC detection. Methods: This prospective study was conducted in the Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand between November 2013 and May 2014. Some 96 patients with histologically-proven CRC and 101 patients with normal colonoscopic findings were invited to perform self-checked FOBT according to the manufacturer's instructions. Results were compared with endoscopic and pathologic findings. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for CRC detection were calculated. Results: The present study revealed the sensitivity, specificity, PPV and NPV of this self-checked FOBT for CRC detection to be 41% (95% CI: 31-51), 97% (95% CI: 92-99), 93% (95% CI: 81-98) and 63% (95% CI: 55-70), respectively. The overall accuracy of the self-checked FOBT for identifying CRC was 70%. The sensitivity for CRC detection based on 7th AJCC staging was 29% for stage I, 32% for stage II and 50% for stage III/IV (P=0.19). The sensitivity was 33% for proximal colon and 42% for distal colon and rectal cancer (P=0.76). Notably, none of nine infiltrative lesions gave a positive FOBT. Conclusions: The self-checked FOBT had an acceptable accuracy of CRC detection except for infiltrative tumors. This home-administrated or 'DIY' do-it-yourself FOBT could be considered as one non-invasive and convenient tool for CRC screening.

Impact of Enhanced Recovery Program on Colorectal Cancer Surgery

Lohsiriwat, Varut Asian Pacific Journal of Cancer Prevention 2014 Asian Pacific journal of cancer prevention Vol.15 No.8

Surgical outcomes of colorectal cancer treatment depend not only on good surgery and tumor biology but also on an optimal perioperative care. The enhanced recovery program (ERP) - a multidisciplinary and multimodal approach, or so called 'fast-track surgery' - has been designed to minimize perioperative and intraoperative stress responses, and to support the recovery of organ function aiming to help patients getting better sooner after surgery. Compared with conventional postoperative care, the enhanced recovery program results in quicker patient recovery, shorter length of hospital stay, faster recovery of gastrointestinal function, and a lower incidence of postoperative complications. Although not firmly established as yet, the enhanced recovery program after surgery could be of oncological benefit in colorectal cancer patients because it can enhance recovery, maintain integrity of the postoperative immune system, increase feasibility of postoperative chemotherapy, and shorten the time interval from surgery to chemotherapy. This commentary summarizes short-term outcomes and potential long-term benefits of enhanced recovery programs in the treatment of colorectal cancer.

Current Colorectal Cancer in Thailand

Varut Lohsiriwat,Nopdanai Chaisomboon,Jirawat Pattana-Arun,Society of Colorectal Surgeons of Thailand 대한대장항문학회 2020 Annals of Coloproctolgy Vol.36 No.2

This article aimed to summarize the current status of colorectal cancer (CRC) in Thailand. In brief, CRC is the third most common cancer and accounts for 11% of the cancer burden in Thailand. It is the only malignancy with an increased incidence in both sexes in Thailand. Over 10,000 new CRC cases occur annually, and about 40% are rectal cancer. Due to the lack of CRC screening and public awareness, nonmetastatic cancer accounts only for 60%–70% of overall cases. The demand for general or colorectal surgeons outmatches the supply at a ratio of 1 general surgeon to 35,000 individuals. There are about 70 board-certified colorectal surgeons serving Thailand’s population of nearly 70 million. As a result, >25% of cancer patients wait more than 1 month before surgery. Regarding training for colorectal surgery, there are 3 major institutes in Bangkok providing a 2-year fellowship program. Cadaveric workshops are an important part of training – especially in laparoscopy for CRC. Recently, a population-based CRC screening program was launched using a fecal immunochemical test. The Ministry of Public Health of Thailand has established additional platforms for laparoscopy to support the potential detection of early CRC following implementation of this nationwide screening program.

High compliance with surgical site infection (SSI) prevention bundle reduces incisional SSI after colorectal surgery

Varut Lohsiriwat 대한대장항문학회 2021 Annals of Coloproctolgy Vol.37 No.3

Purpose: This study aimed to evaluate association between compliance with surgical site infection (SSI) prevention bun- dle and the development of superficial or deep incisional SSI following colorectal surgery and to evaluate the impact of incisional SSI on surgical outcomes. Methods: A prospectively collected database of consecutive patients undergoing elective colectomy and/or proctectomy from 2011 to 2019 in a university hospital was reviewed. The association between compliance with Thailand’s SSI Preven- tion Bundle (10 level-1A interventions) and the incidence of incisional SSI was determined. Surgical outcomes were com- pared between those with incisional SSI and those without. Results: This study included 600 patients with a median age of 64 years (range, 18–102 years). Some 126 patients (21.0%) had stoma formation and 52 (8.7%) underwent laparoscopy. The incidence of incisional SSI was 5.5% (n = 33; 32 superfi- cial incisional SSI and 1 deep incisional SSI). Higher compliance with care bundle tended to decrease incisional SSI (P = 0.20). In multivariate analysis, compliance of 70% or more was the only dependent factor for reducing incisional SSI (odds ratio, 0.39; 95% confidence interval, 0.15 to 0.99; P = 0.047). None of individual interventions were significantly as- sociated with a lower probability of incisional SSI. Compared with counterparts, patients with incisional SSI had a 2-day longer length of postoperative stay (6 day vs. 4 day, P < 0.001) but comparable time for gastrointestinal recovery and simi- lar rate of 30-day mortality or readmission. Conclusion: High compliance with SSI prevention bundle (especially ≥ 70%) reduced incisional SSI after colorectal surgery.

Reconstruction in patients who may undergo radiation therapy

Visnu Lohsiriwat 대한외과학회 2014 대한외과학회 학술대회 초록집 Vol.2014 No.11

Screening Colonoscopy from a Large Single Center of Thailand - Something Needs to be Changed?

Aswakul, Pitulak,Prachayakul, Varayu,Lohsiriwat, Varut,Bunyaarunnate, Thirapol,Kachintorn, Udom Asian Pacific Journal of Cancer Prevention 2012 Asian Pacific journal of cancer prevention Vol.13 No.4

Background: Results of screening colonoscopy from Western countries reported adenoma detection rates (ADRs) of 30-40% while those from Asia had ADR as low as 10%. There have been limited data regarding screening colonoscopy in Thailand. The objectives of this study were therefore to determine polyp and adenoma detection rates in Thai people, to evaluate the incidence of colorectal cancer detected during screening colonoscopy and to determine the endoscopic findings of the polyps which might have some impact on endoscopists to perform polypectomy. Materials & Methods: This study was a retrospective electronic chart review of asymptomatic Thai adults who underwent screening colonoscopy in our endoscopic center from June 2007 to October 2010.Results: A total of 1,594 cases were reviewed. The patients had an average age of $58.3{\pm}10.5$ years (range 27-82) and 55.5% were female. Most of the cases (83.8%) were handled by staff who were endoscopists. A total of 488 patients (30.6%) were reported to have colonic polyps. Left-sided colon was the most common site (45.1%), followed by right-sided colon (36.5%) and the rectum (18%). Those polyps were removed in 97.5% of cases and 88.5 % of the polyps were sent for histopathology (data lost 11.5%). Two hundred and sixty three cases had adenomatous polyps, accounting for 16.5 % ADR. Advanced adenomas were detected in 43 cases (2.6%). Hyperplastic polyps were mainly located distal to the splenic flexure of the colon whereas adenomas were found throughout the large intestine. Ten cases (0.6%) were found to have colorectal cancer. Four advanced adenomas and two malignant polyps were reported in lesions ${\leq}$ 5 mm. Conclusion: The polyp detection rate, adenoma detection rate, advanced adenoma detection rate and colorectal cancer detection rate in the screening colonoscopy of Thai adults were 30.9%, 16.5%, 2.6% and 0.6% respectively. Malignant transformation was detected regardless of the size and location of the polyps. Therefore, new technology would play an important role indistinguishing polyps.

Long-term outcomes after anal fistula surgery: results from two university hospitals in Thailand

Weeraput Chadbunchachai,Varut Lohsiriwat,Krisada Paonariang 대한대장항문학회 2022 Annals of Coloproctolgy Vol.38 No.2

Purpose: This study aimed to evaluate long-term outcomes after anal fistula surgery from university hospitals in Thailand. Methods: A prospectively collected database of patients with cryptoglandular anal fistula undergoing surgery from 2011 to 2017 in 2 university hospitals was reviewed. Outcomes were treatment failure (persistent or recurrent fistula), fecal continence status, and chronic postsurgical pain. Results: This study included 247 patients; 178 (72.1%) with new anal fistula and 69 (27.9%) with recurrent fistula. One hundred twenty-one patients (49.0%) had complex fistula; 53 semi-horseshoe (21.5%), 41 high transsphincteric (16.6%), 24 horseshoe (9.7%), and 3 suprasphincteric (1.2%). Ligation of intersphincteric fistula tract (LIFT) was the most common operation performed (n=88, 35.6%) followed by fistulotomy (n=79, 32.0%). With a median follow-up of 23 months (interquartile range, 12–45 months), there were 18 persistent fistulas (7.3%) and 33 recurrent fistulae (13.4%)—accounting for 20.6% overall failure. All recurrence occurred within 24 months postoperatively. Complex fistula was the only significant predictor for recurrent fistula with a hazard ratio of 4.81 (95% confidence interval, 1.82–12.71). There was no significant difference in healing rates of complex fistulas among seton staged fistulotomy (85.0%), endorectal advancement flap (72.7%), and LIFT (65.9%) (P=0.239). Four patients (1.6%) experienced chronic postsurgical pain. Seventeen patients (6.9%) reported worse fecal continence. Conclusion: Overall failure for anal fistula surgery was 20.6%. Complex fistula was the only predictor for recurrent fistula. At least 2-year period of follow-up is suggested for detecting recurrent diseases and assessing patient-reported outcomes such as chronic pain and continence status.

Accuracy of Preoperative Urinary Symptoms, Urinalysis, Computed Tomography and Cystoscopic Findings for the Diagnosis of Urinary Bladder Invasion in Patients with Colorectal Cancer

Woranisarakul, Varat,Ramart, Patkawat,Phinthusophon, Kittipong,Chotikawanich, Ekkarin,Prapasrivorakul, Siriluck,Lohsiriwat, Varut Asian Pacific Journal of Cancer Prevention 2014 Asian Pacific journal of cancer prevention Vol.15 No.17

Background: To determine the accuracy of preoperative urinary symptoms, urinalysis, computed tomography (CT) and cystoscopic findings for the diagnosis of urinary bladder invasion in patients with colorectal cancer. Materials and Methods: Records of patients with colorectal cancer and a suspicion of bladder invasion, who underwent tumor resection with partial or total cystectomy between 2002 and 2013 at the Faculty of Medicine Siriraj Hospital, were reviewed. Correlations between preoperative urinary symptoms, urinalysis, cystoscopic finding, CT imaging and final pathological reports were analyzed. Results: This study included 90 eligible cases (71% male). The most common site of primary colorectal cancer was the sigmoid colon (44%), followed by the rectum (33%). Final pathological reports showed definite bladder invasion in 53 cases (59%). Significant features for predicting definite tumor invasion were gross hematuria (OR 13.6, sensitivity 39%, specificity 73%), and visible tumor during cystoscopy (OR 5.33, sensitivity 50%, specificity 84%). Predictive signs in CT imaging were gross tumor invasion (OR 7.07, sensitivity 89%, specificity 46%), abnormal enhancing mass at bladder wall (OR 4.09, sensitivity 68%, specificity 66%), irregular bladder mucosa (OR 3.53, sensitivity 70%, specificity 60% ), and loss of perivesical fat plane (OR 3.17, sensitivity 81%, specificity 43%). However, urinary analysis and other urinary tract symptoms were poor predictors of bladder involvement. Conclusions: The present study demonstrated that the most relevant preoperative predictors of definite bladder invasion in patients with colorectal cancer are gross hematuria, a visible tumor during cystoscopy, and abnormal CT findings.