The Thai Journal of Surgery

Editorial

Kaweesak Chittawatanarat — 2026-07-08

Re-Evaluating the Role of Delayed Cholecystectomy: Safety and Timing in the Management of Acute Cholecystitis

Nan-Ak Wiboonkhwan — 2026-07-08

Background: Early laparoscopic cholecystectomy (LC) is the standard treatment for acute cholecystitis (AC) to reduce hospital stay and costs, but optimal timing remains debated due to severe complications like bile duct injury (BDI). Delayed LC (DLC) after conservative management or drainage provides a safer alternative with lower postoperative complications and BDI rates

Materials and Methods: This narrative review analyzed literature from PubMed and Embase (1990–October 2025). Surgical timing was categorized by inflammation phases: Early (<7 days), Intermediate (7 days to 6 weeks), and Delayed (>6 weeks). Evidence from RCTs, meta-analyses, and registries was evaluated, with a focus on BDI risks, surgeon experience, and hospital readiness. Limitations include potential selection bias and lack of formal quality assessment.

Results: Under optimal conditions, early LC reduced hospital stay and costs but was associated with higher postoperative complication rates (up to 26.7%). BDI rates peaked at 2.8% when operating between days 4–7, and open conversion rates reached 21%–28.6% in Grade I/II cases. Conversely, delayed LC after drainage mitigated these risks; one study reported zero conversions in the delayed group, and a meta-analysis showed a significantly higher BDI risk (HR 6.07) with early intervention.

Conclusion: Choosing between early and delayed LC must be individualized, prioritizing patient safety over economic benefits. While early LC is preferred under optimal conditions, it requires high expertise. In resource-variable settings, delayed LC serves as an essential, safer alternative that aligns with international guidelines.

Acute Cholecystitis During the COVID-19 Pandemic: A Result of Delayed Surgical Intervention

Alejandro Daniel Navarro Alcala — 2026-07-08

Background: Biliary pathology represents 3–10% of acute abdominal pain cases in emergency departments, with a lithiasic origin in 90–95%. The SARS-CoV-2 pandemic placed immense strain on healthcare systems worldwide, leading to major reductions in surgical procedures. The Mexican Institute of Social Security (IMSS) reported a 38.38% decrease in interventions between 2019 and 2020 (546,654 fewer surgeries), while the Security and Social Services of the State Employees Institute (ISSSTE) noted an 80.53% reduction in laparoscopic cholecystectomies, from 9,896 in 2019 to 2,926 in 2020. This trend aligns with a global cancellation rate of 81.5%, which affected nearly all surgical specialties. These reductions likely influenced patient outcomes. This study assessed the impact of the pandemic on patients undergoing elective cholecystectomy.

Materials and Methods: We analyzed data from 513 patients who underwent elective laparoscopic cholecystectomy in 2019 and compared it with data from 52 patients in 2021, during the pandemic. Our findings were assessed against nationwide trends to evaluate the pandemic’s impact on these procedures.

Results: During the study period, a variety of results (210) were observed, including hepatic abscess (0.47%) and acute cholecystitis (70%), classified as mild (63.8%) and moderate (6.19%) according to the Tokyo 2018 Guidelines. Other outcomes included hydrocholecyst (12.85%), pyocholecyst (15.71%), emphysematous cholecystitis (0.47%), and gangrenous cholecystitis (0.47%). No significant difference in overall complication incidence was observed between the two years, except for moderate acute cholecystitis, which showed a statistically significant increase (p = 0.024).

Conclusion: The pandemic's effect on overall outcomes in patients who underwent delayed elective procedures during the established period was associated with a significant increase in cholecystitis severity, with a notable rise in moderate acute cholecystitis (p = 0.024). This study is the first to examine the effects of the pandemic on surgical patients whose care was delayed.

Comparative Oncologic Outcomes between Emergency and Elective Surgery in Colon Cancer Patients in Suratthani Hospital: A Retrospective Cohort Study

Thanakorm Orapan — 2026-07-08

Background: Colon cancer remains a major cause of morbidity and mortality worldwide. Emergency surgical presentations, such as obstruction or perforation, are associated with poorer outcomes compared to elective surgery. This study aimed to compare the clinical and oncologic outcomes between elective and emergency surgeries in colon cancer patients.

Materials and Methods: A retrospective cohort study was conducted at Suratthani Hospital, Thailand, including patients who underwent colon cancer surgery between January 2016 and December 2020. Patients were categorized into elective and emergency surgery groups (obstruction or perforation). Exclusion criteria included rectal cancer, stage IV disease, iatrogenic perforation, and incomplete follow-up. Demographics, tumor characteristics, treatments, and outcomes were analyzed. Survival was assessed using Kaplan-Meier and Cox regression analyses. Hazard ratios (HR) with 95% confidence intervals (CI) were calculated using multivariable Cox regression to adjust for unbalanced baseline characteristics.

Results: Of the 191 included patients, 104 (54.5%) underwent elective surgery, and 87 (45.5%) underwent emergency surgery (75 obstruction, 12 perforation). The emergency group had significantly higher comorbidity rates (p = 0.032), colostomy rates (p < 0.001), and longer hospital stays (p = 0.006). Five-year overall survival was significantly lower in the emergency group (HR 1.58, 95% CI: 1.09–2.29) compared to the elective group (reference), particularly in perforation cases (HR 2.85, 95% CI: 1.62–5.02; p < 0.001). Multivariate analysis identified perforation, obstruction, comorbidity, stage III disease, poor/mucinous histology, and absence of adjuvant chemotherapy as independent predictors of worse survival.

Conclusion: Emergency surgery for colon cancer, especially for perforation, is associated with worse oncologic outcomes compared to elective procedures. Early detection, timely elective intervention, and adjuvant chemotherapy are crucial for improving survival in colon cancer patients.

Outcomes and Risk Factors Associated with Major Amputation in Patients with Acute Lower Limb Ischemia Undergoing Revascularization

Pak Hanaroonsomboon — 2026-07-08

Objective: To identify outcomes and risk factors associated with major amputation in patients with acute limb ischemia (ALI) who underwent revascularization.

Materials and Methods: Retrospective, cohort, risk factor study (PROGRESS II). Baseline and operative characteristics were collected from vascular surgery unit between 2017 and 2024 at Khon Kaen Hospital. Inclusion criteria were patient 18 years old and older whom diagnosed ALI underwent revascularization. Primary outcome was major amputation. Operative techniques included thromboembolectomy and surgical bypass. Risk factors for major amputation were analyzed using risk ratio regression. Statistical uncertainties were expressed as 95% two-sided confidence intervals (95% CI) in all analyses. A p-value less than 0.05 was considered statistically significant.

Results: A total of 152 patients underwent surgical revascularization for ALI. 63.5% were male. Major amputation rate was 17.1%. Mean age was 61.8 ± 16.0 years. Significant clinical characteristics associated with major amputation were onset, sepsis, and acute kidney injury (AKI). Multivariable analysis showed male sex, alcohol use, diabetic mellitus (DM), hypertension (HT), atrial fibrillation (AF), chronic kidney disease (CKD), fasciotomy, reperfusion injury, and chronic heart failure (CHF), were the significant prognostic factors for major amputation in patients with ALI who underwent revascularization.

Conclusion: In high-volume retrospective cohort study showed a significant major limb loss number with some modifiable prognostic factors. Fasciotomy may be performed to save limb, and the health literacy should be educated to get the patients suffering from ALI come to the hospital earlier.

Prospective Randomized Clinical Trial of Accelerated Re-Epithelialization of Split-Thickness Skin Graft Donor Sites Using Injectable Platelet-Rich Fibrin (I-PRF)

Premsak Sakarinpanichakul — 2026-07-08

Background: Autologous platelet-rich fibrin (PRF) is a fraction of blood with a high concentration of platelets and multiple growth factors. Its application has shown promising results in wound care. However, it remains controversial whether applying PRF to donor site wounds of split-thickness skin grafts (STSGs) improves the epithelialization rate. This study aimed to determine the effect of injectable platelet-rich fibrin (I-PRF) on the epithelialization of donor-site wounds in STSG.

Materials and Methods: This randomized controlled clinical trial included 30 patients who underwent STSG procedures at Buriram Hospital between November 2023 and February 2025. The donor site wounds were divided into two groups for the study. The intervention group received an I-PRF and paraffin gauze, while the control group received paraffin gauze alone. The evaluation assessed the time required to re-epithelialize donor-site wounds and measured epithelial thickness after full re-epithelialization.

Results: The mean age of the patients was 50.7 ± 18.7 years, and 63.3% were male. Time to complete epithelialization of donor wounds did not differ significantly between I-PRF and control groups (11.9 ± 2.6 days vs 11.9 ± 2.7 days; p = 0.851). The mean epithelial thickness of the I-PRF group was higher than that of the control group, but the difference was not statistically significant (208 ± 110 mm vs 197 ± 118 mm; p = 0.698).

Conclusion: Compared to traditional therapy, a single application of injectable platelet-rich fibrin did not significantly influence the re-epithelialization of an STSG donor wound.

Performance of APCS Risk Score and Fecal Immunochemical Test in Predicting Colorectal Cancer: A Retrospective Diagnostic Accuracy Study.

Peerapong Inlao — 2026-07-08

Objective: To evaluate the diagnostic performance of APCS and FIT for predicting colorectal cancer (CRC), and to develop an enhanced predictive model incorporating clinical and laboratory parameters.

Methods: A retrospective study of 662 patients undergoing colonoscopy at Rattanaburi Hospital, Thailand (January 2022–April 2025). Clinical data, quantitative FIT, APCS scores, and histopathology were analyzed

Results: Mean age was 61.3 years; 42.45% were male. Adenomas comprised 93.96% of lesions, and adenocarcinomas (CA) 2.87%. The subgroup with APCS ≥4 and positive FIT had the highest CA detection rate (6.29%). For predicting CA, FIT alone had an AUROC of 0.56 (sensitivity 68.4%, specificity 45.3%), while APCS ≥4 alone had an AUROC of 0.59 (sensitivity 68.4%, specificity 50.7%). Combining FIT and APCS ≥4 increased specificity to 79.0% (sensitivity 47.4%, AUROC 0.64). Multivariable regression identified FIT positivity (OR=7.66), APCS ≥4 (OR=4.54), diabetes mellitus (OR=8.84), and hematocrit (OR=0.70) as independent CA predictors (p<0.01 for all except APCS p=0.01). An enhanced model combining these variables significantly improved performance (AUROC 0.86).

Conclusion: Standalone APCS or FIT scores offer limited predictive accuracy (AUROC <0.65). However, incorporating diabetes and hematocrit into an enhanced model significantly improves diagnostic performance (AUROC 0.86), showing high potential for risk-based screening.

The Effect of Time-to-Surgery on Enteral Feeding Outcomes in Neonates with Uncomplicated Gastroschisis

Pattarin Lertnuwat — 2026-07-08

Objectives: To evaluate the effect of time-to-surgery on enteral feeding outcomes in neonates with uncomplicated gastroschisis.

Materials and Methods: Retrospective review of NICU admissions for gastroschisis in Lampang Hospital, February 2014 – December 2024. The primary outcomes were the time to initiation of enteral feeding and the time to full enteral feeding (discontinuation of parenteral nutrition).

Results: Twenty-three patients with uncomplicated gastroschisis were analyzed in this study. Ten cases (43.5%) underwent surgery in less than 2 hours, 4 (17.4%) between 2–4 hours, 2 (8.7%) between 4–6 hours, 2 (8.7%) between 6–8 hours, and 5 (21.7%) between 8–10 hours. Primary fascial closure was performed in 5 cases (21.7%) and silo placement with staged closure in 18 cases (78.3%). The mean and median times to surgical intervention were 4.5 and 4 hours, respectively (range, 0.5–10 hours). The median time to start enteral feeding and achieve full enteral feeding was 15 days (IQR, 14.25–20.5) and 23.5 days (IQR, 21.0–28.0), respectively. One patient in the 8-10 hours group, managed with staged closure, died due to ventilator-associated pneumonia and sepsis. There were no statistically significant differences regarding the days to start enteral feeding, days to full enteral feeding, days to extubation, and length of stay. However, a clinical trend toward earlier enteral feeding and a shorter duration of total parenteral nutrition (TPN) was observed when surgery was performed earlier.

Conclusion: Although statistical significance was not reached, this study demonstrated that earlier surgical intervention may affect enteral feeding outcomes, specifically the time to start feeding and the duration of TPN in uncomplicated gastroschisis. Therefore, prenatal diagnosis and prompt in utero maternal transfer to a tertiary pediatric surgical center are advocated.

Ileal Perforation and Cervical Nodal Metastasis in Small Bowel Adenocarcinoma: A Case Report

Huynh Loc Tran — 2026-07-08

Small bowel adenocarcinoma (SBA) is a rare malignancy that typically presents late and is difficult to diagnose, particularly when arising in the ileum. We report an exceptional case of SBA presenting simultaneously with ileal perforation and cervical lymph node metastasis - two manifestations that are individually uncommon and exceedingly rare in combination. A 69-year-old woman presented with an acute abdomen and a newly enlarged cervical lymph node; laparoscopy revealed a 2-mm ileal perforation with peritoneal nodules, and subsequent cervical node excision confirmed metastatic carcinoma. Histopathology and immunohistochemistry demonstrated CK7 and EMA positivity with CK20 negativity, supporting the diagnosis of SBA and excluding colorectal, neuroendocrine, and stromal neoplasms. This unusual presentation highlights the diagnostic challenges posed by ileal tumors, underscores the critical role of timely surgical exploration, and emphasizes the importance of immunohistochemistry in establishing tumor origin when clinical and radiologic findings are ambiguous.