The Thai Journal of Surgery

Editorial

2026-09-21T10:19:50+07:00

Sentinel Lymph Node Identification for Breast Cancer Patients Using Fluorescence Navigation with Indocyanine Green: Early Experience at Lampang Hospital

2025-12-16T16:34:18+07:00

Background: Breast cancer is the most common malignancy among women. Axillary lymph node status is a key determinant of prognosis and treatment decisions. Although axillary lymph node dissection (ALND) provides accurate staging and regional control, it is associated with higher morbidity. Sentinel lymph node biopsy (SLNB) has therefore become the standard approach for axillary staging and avoiding unnecessary dissection. Indocyanine green (ICG) has recently been used as an alternative technique for sentinel lymph node localization via fluorescence imaging. This study presents a case series using ICG fluorescence navigation in breast cancer surgery.

Materials and Methods: From June 2022 to June 2024, 18 breast cancer patients underwent SLNB with ICG fluorescence navigation at Lampang Hospital. All patients had been diagnosed with breast cancer. These 18 patients included clinically node-negative cases and node-negative-to-positive patients (N1 to N0) who received neoadjuvant systemic treatment and underwent SLNB (dual mapping: standard isosulfan blue dye with ICG).

Results: Eighteen cases underwent sentinel lymph node biopsy (SLNB) using dual mapping with standard isosulfan blue dye and ICG for localization. No adverse events occurred from intraoperative use of ICG or blue dye. All lymph nodes visualized with either fluorescence or dye were excised. In total, we removed 75 lymph nodes across 18 procedures. ICG identified seventy nodes, while only 29 were detected with blue dye. On average, the ICG method detected 3.88 sentinel lymph nodes (SLNs) (range: 2-8), resulting in a detection rate of 100%. In comparison, only 1.61 SLNs (range: 0-4) were identified, with an identification rate of 88.88%.

Conclusion: Fluorescence-guided SLNB with ICG is safe and highly effective, improving detection rates compared to dye alone. This method enhances lymphatic mapping and supports surgical training for both surgeons and residents.

Prelaminated Forehead Flap Nasal Reconstruction of Pediatric Nasal Defect Secondary to Necrotizing Soft Tissue Infection: A Case Report

2026-03-17T11:10:05+07:00

Background: Necrotizing soft tissue infection (NSTI) in children that involves the nose is a rare presentation and requires serial surgical debridement followed by nasal reconstruction. Nasal reconstruction is often delayed until post-pubertal age due to ongoing facial growth, limited local tissue/donor sites, and poor adherence to post-surgical care. However, the facial defect has a greater psychosocial impact as the child grows.

Case: This case report describes an 8-month-old boy who developed necrotizing fasciitis of the right heminose/cheek following an iatrogenic laceration from a nasal oxygen cannula, which required urgent surgical debridement and antibiotic therapy. We performed a multi-stage reconstruction using a prelaminated forehead flap with a composite concha cartilage and skin graft.

Conclusion: This case highlights the importance of early diagnosis, aggressive treatment, and innovative reconstructive techniques in managing pediatric necrotizing soft tissue infection of the face, particularly in anatomically challenging areas like the nasal region.

Primary Epiploic Appendagitis Mimicking Acute Appendicitis: A Case Report and Diagnostic Insight

2026-08-10T13:54:04+07:00

Background and Objective: Epiploic appendagitis is an infrequent and often misdiagnosed cause of acute abdominal pain, commonly mistaken for conditions like appendicitis or diverticulitis due to its nonspecific and localized symptoms. Its underrecognition largely stems from limited clinical awareness and the lack of definitive diagnostic markers, with diagnosis typically made via computed tomography or incidentally during surgical exploration.

Case Description: This report presents a rare case of primary epiploic appendagitis in a 35-year-old male initially suspected to have acute appendicitis. Diagnostic laparoscopy revealed a normal appendix and a necrotic epiploic appendage originating from the mid-ascending colon. Laparoscopic excision of the appendage and prophylactic appendectomy were performed. The patient recovered well postoperatively and was discharged on day three, with follow-up confirming full recovery. Histopathology confirmed necrotic epiploic appendagitis.

Conclusion: Primary epiploic appendagitis should be considered in stable patients with focal abdominal pain and minimal systemic inflammatory features. In diagnostically uncertain patients, computed tomography can establish the diagnosis and help avoid unnecessary antibiotics, hospitalization, and surgery; reserve operative treatment for selected patients with persistent or worsening symptoms, recurrence, complications, or unresolved diagnostic uncertainty.

Serendipitous Dramatic Resolution of a Large Infected Pancreatic Pseudocyst through a Pancreaticopleural Fistula after Acute Pancreatitis: Case Report and Review of Literature

2026-08-10T13:21:11+07:00

Acute pancreatitis is a common clinical condition with a wide spectrum of local and systemic complications. Pancreaticopleural fistula (PPF) is a rare thoracic complication, more frequently associated with chronic pancreatitis and only infrequently reported following acute pancreatitis. We report a unique case of a 21-year-old female with alcohol-induced acute pancreatitis who developed infected walled-off necrosis (WON), complicated by a pancreaticopleural fistula just prior to planned surgical necrosectomy. We managed the condition with intercostal drainage and conservative therapy, resulting in complete clinical and radiological resolution without surgery. This case highlights an unusual mechanism of spontaneous internal drainage of infected necrosis into the pleural cavity, leading to clinical improvement and avoidance of major surgery. We also present a brief literature review.

Feasibility of Using Carbon Tattoo for Targeted Axillary Dissection in Node-Positive Breast Cancer Patients Treated with Neoadjuvant Systemic Therapy: Preliminary Results of a Prospective Study

2026-08-10T13:22:59+07:00

Background: Neoadjuvant systemic therapy (NST) frequently achieves axillary downstaging in node-positive breast cancer. Targeted axillary dissection (TAD)—combining sentinel lymph node biopsy (SLNB) with removal of pre-NST marked metastatic nodes—provides accurate post-NST axillary restaging. While advanced wireless markers are standard in high-resource settings, carbon tattooing offers an economical, radiation-free visual alternative. This prospective study evaluates the feasibility, accuracy, and volume-optimized safety of carbon tattooing for TAD within Thailand's public health infrastructure.

Materials and Methods: Patients with biopsy-proven axillary metastasis underwent dual marking (metallic clip + cortical carbon tattoo injection) prior to NST. We evaluated a refined injection volume (0.1 mL post-pilot) to minimize background spillage. After NST, we visually identified carbon-tattooed nodes intraoperatively and confirmed clip retrieval via specimen radiography. We performed SLNB using dual mapping with indocyanine green (ICG) fluorescence and blue dye to assess optical clarity between tracers. Primary endpoints were identification rate, accuracy (tattooed matching clipped node), and concordance (tattooed matching SLN).

Results: Twelve patients completed TAD post-NST (mean tattoo-to-surgery interval: 156 days). We visually identified carbon-tattooed nodes in 11 of 12 patients (identification rate: 91.7%). Mean targeted node retrieval was 5.58 nodes. Clipped and tattooed nodes were identical in 11 cases (accuracy: 91.7%), whereas tattooed nodes matched SLNs in 6 cases (concordance: 50.0%). SLN detection was 100% with ICG fluorescence without carbon interference, and 83.3% with blue dye. Cutaneous staining occurred in one patient (8.3%) with no procedural complications.

Conclusions: Carbon tattooing for TAD is a highly accurate, safe, and economical strategy post-NST. By optimizing injection volume and using real-time visual localization, this technique eliminates the need for expensive secondary radiologic localization procedures, providing a scalable TAD solution tailored to resource-constrained surgical oncology settings.

Feasibility of Low-Cost In-House 3D Printing in Mandibular Reconstruction with Fibula Free Flap: Initial Regional Experience from Northern Thailand

2026-08-10T13:59:02+07:00

Background: Computer-assisted mandibular reconstruction with fibula free flap (FFF) improves accuracy but is often limited by high cost and dependency on external engineering support. This study evaluated the feasibility, workflow, and outcomes of a low-cost, in-house 3D printing protocol for mandibular reconstruction in a regional hospital.

Materials and Methods: Eighteen patients who underwent in-house, open-source–based 3D–planned FFF reconstruction between 2020 and 2025 were retrospectively reviewed. We analyzed demographic, operative, and reconstructive parameters, including ischemia time, operative duration, flap survival, and postoperative outcomes.

Results: The mean age was 60.9 years, with an equal sex distribution. Squamous cell carcinoma was the most common diagnosis (61%), and lateral-type defects predominated (78%). All reconstructions used osteocutaneous FFF with a single skin paddle. The mean defect length was 83.8 mm, ischemia time was 101 ± 32 minutes, and total operative time was 613 ± 110 minutes. No patient required routine ICU admission. All 18 flaps survived (100%). Minor complications included two fistulae (11%) and one plate exposure (5.6%). The average 3D printing cost was approximately 100 THB (USD 2.7) per model.

Conclusion: An in-house, surgeon-driven 3D printing workflow using open-source software is feasible, accurate, and cost-effective for mandibular reconstruction. A regional hospital setting can achieve outcomes comparable to high-cost commercial systems, supporting broader access to digital reconstructive technology.

Long term Outcomes of Surgical Treatment and Anatomical Characteristics of Acute and Chronic Cryptoglandular Anal Fistula Following Surgery

2026-07-14T19:49:36+07:00

Background and Objective: Cryptoglandular anal fistula often recurs after surgery, especially with complex anatomy. This study evaluated healing, recurrence, anatomical patterns, and recurrence predictors in patients treated during acute abscess or chronic fistula stages.

Materials and Methods: This retrospective cohort study included 320 adults who underwent anatomy-tailored surgery for cryptoglandular anal fistula at Rayong Hospital (2012–2025). Patients were classified into acute abscess (n=142) or chronic fistula (n=178) groups. Anatomy was assessed via systematic mapping, supplemented by MRI in complex or recurrent cases.

Results: Median follow-up was 42 months. The acute group showed a significantly higher healing rate (97.2% vs. 92.1%, p<0.017) and a lower recurrence rate (2.8% vs. 7.9%, p<0.041) than the chronic group. Multivariable Cox regression identified high transsphincteric fistula as the sole independent predictor of recurrence (adjusted HR 23.13, p<0.001).

Conclusion: Anatomy-tailored surgery yielded high healing and low recurrence rates, with high transsphincteric anatomy strongly predicting recurrence.

Reduction Mammoplasty: The Factors that Influence Outcomes and Patients' Satisfaction in Calabar, Nigeria

2026-07-21T12:20:32+07:00

Background: Breast reduction surgery, also called reduction mammoplasty, is a common breast aesthetic surgery.

Objective: We aim to investigate factors that influence reduction mammoplasty outcomes and patient satisfaction at our institution.

Patients and Methods: This 10-year retrospective study included 39 patients who underwent reduction mammoplasty from January 2014 to December 2023. We reviewed patients’ records, including sociodemographic parameters, complication types, and patient satisfaction levels. Exclusion criteria included incomplete records and other breast surgeries performed for reasons unrelated to the study's purpose. We analyzed the results using the Statistical Package for the Social Sciences (SPSS) version 20.0, along with questionnaires (5-point Likert scale) and postoperative BREAST-Q outcomes to assess patient satisfaction.

Results: Table 1 shows the socio-demographic parameters, including age range, educational level, and surgeon cadre; all patients were female. The Table showed an age range of 25-50 years, with a mean value of 38 ± 5 years. The 41-50 age group had the most patients. All surgeons were plastic surgeons. Table 2 shows the various complications and their corresponding frequencies. Predictors such as obesity and surgical technique constituted major outcome parameters. Patient satisfaction with the decision, assessed using a 5-point Likert scale, was high (90-98%), and the BREAST-Q outcome was also high (p = 0.03).

Conclusion: Reduction mammoplasty is a common breast aesthetic surgery. The factors that influence outcomes were age, educational level, breast asymmetry, obesity, surgical technique, and impact on sexuality. We identified factors that influence patient outcomes. Overall patient outcomes showed a high level of patient satisfaction.