Trauma Hybrid Operating Room (THOR) shortened procedure time in abdominopelvic trauma patients requiring surgery and interventional radiology procedures.

INTRODUCTION: Abdominopelvic injuries are common, and bleeding occurring in both cavities requires various bleeding control techniques i.e., laparotomy, angiographic embolization (AE), and orthopedic fixation. Hence, the use of Trauma Hybrid Operating Room (THOR) in abdominopelvic injuries has theoretical advantages including rapid bleeding control and minimizing patient transportation. The objective of the present study is to evaluate the impact of THOR in abdominopelvic injuries. METHOD: A pre-post intervention study of abdominopelvic injury patients requiring both surgery and interventional radiology (IR) procedures for bleeding control from January 2015 to May 2020 was conducted. The patients were divided into 2 groups, pre-THOR group (received surgery in OR and scheduled for IR procedures in a separate IR suite, before December 2017) and THOR group (received all procedures in THOR, after December 2017). The primary outcomes were procedure time (including transit time in the pre-THOR group) and mortality. RESULTS: Ninety-one abdominopelvic trauma patients were identified during the study period, 56 patients in pre-THOR group and 35 patients in THOR group. Distribution of injuries was similar in both groups (59 abdominal injuries, 25 pelvic fractures, and 7 combined injuries). The bleeding-control interventions in both groups were 79 laparotomies, 10 preperitoneal pelvic packings, 12 pelvic fixations, 45 liver AEs, and 21 pelvic AEs. THOR group underwent significantly less thoracotomy (1 vs. 11, p = 0.036), more resuscitative endovascular balloon occlusion of the aorta (REBOA, 0 vs. 5, p = 0.014), and more pelvic AE (13 vs. 9, p = 0.043). The procedure time was significantly shorter in THOR group (153 min vs. 238 min, p = 0.030). Excluding the transit time in the pre-THOR group, procedure time was not significantly different (153 vs. 154 min, p = 0.872). Both groups had similar mortality rates of 34%, but the mortality due to exsanguination was significantly lower in THOR group (11% vs. 34%, p = 0.026). CONCLUSIONS: THOR eliminated transit time, resulting in shorter procedure time in abdominopelvic trauma patients requiring bleeding-control intervention. Although overall mortality reduction could not be demonstrated, the mortality due to exsanguination was reduced in THOR group.

Open versus endovascular repair of primary infected thoracic and abdominal aortic aneurysms.

OBJECTIVE: Primary infected aortic aneurysms are life-threatening if not treated promptly, but still possess a high mortality rate following open repair. The goal of treatment is to prevent rupture and clear infection. An endovascular approach is accepted as a bridge to definitive open repair. Our study compares the outcomes of endovascular versus conventional open repair of infected aortic aneurysms. METHOD: A single-center retrospective review was conducted of data from January 2012 to December 2021. Patients were categorized into three cohorts according to aortic involvement: thoracic aortic aneurysm (TAA), thoracoabdominal aortic aneurysm (TAAA), and abdominal aortic aneurysm (AAA). The primary endpoint was survival rate and the assessment of any associated factors. RESULT: Ninety-nine patients presented with infected aortic aneurysms. Of the 56 patients who presented with infected TAA, 38 patients underwent thoracic endovascular aortic repair and 18 patients underwent open TAA repair. Forty patients presented with infected AAA, of which 21 patients underwent endovascular aortic repair and 19 patients underwent open repair. Three patients presented with infected TAAA and all underwent open repair. The mean age was 67 years (range 33-88); 74 patients (74.8%) were men and 71 patients (71.7%) had immune dysfunction. Mean follow-up time was 24 months in the endovascular repair group and 38 months in the open repair group. The probability survival rate in the endovascular repair group was 86%, 86%, 77% and 51% at 1 year, 2 years, 5 years and 10 years, respectively, and in the open repair group this was 81%, 81%, 76%, and 64% at 1 year, 2 years, 5 years and 10 years, respectively. CONCLUTIONS: Endovascular repair for primary infected aortic aneurysms plays an important role in current practice as an alternate to open surgery or used as bridging to definitive open surgical repair. No significant difference was observed in either short- or long-term survival in patients with infected aortic aneurysm undergoing open or endovascular repairs.

Coverage of the Left Subclavian Artery in Blunt Thoracic Aortic Injury Repair Is Rarely Indicated.

BACKGROUND: Thoracic endovascular repair has become the standard treatment for blunt thoracic aortic injury (BTAI). Occlusion of the left subclavian artery (LSA) is generally required for an adequate landing zone (ALZ). We propose that coverage of the LSA is not necessary for BTAI even with a short landing zone (SLZ). METHODS: Retrospective review of BTAI patients, who were treated from January 2008 to December 2020, was analyzed. BTAI was categorized into 2 cohorts, SLZ <20 mm and ALZ >20 mm. Demographic data, trauma scores, grade of BTAI, procedure-related data, and clinical outcomes were analyzed. t-Test and chi-squared tests were used for statistical analysis. RESULTS: Thoracic endovascular repair was performed in 59 BTAI patients (mean age of 38.9 ± 14 years, mean Injury Severity Score of 40.4 ± 9.3). Two cohorts were identified: 49 patients had an SLZ, and 10 patients had an ALZ (14 ± 3.1 mm vs. 25 ± 4.1 mm, P = 0.03). The procedures were performed successfully with 59 patients (86.4%) deploying in zone 3. In-hospital mortality (SLZ group: 4.1% vs. ALZ group: 0, P = 0.318), endoleak (SLZ group: 4.1% vs. ALZ group: 20%, P = 0.45), stroke (SLZ group: 0 vs. ALZ group: 0, P = 1), spinal cord ischemia (SLZ group: 2% vs. ALZ group: 0, P = 1), left arm ischemia (SLZ group: 0 vs. ALZ group: 0, P =1), and reintervention rate (SLZ group: 0 vs. ALZ group: 0, P = 1) were not statistically different between cohorts. CONCLUSIONS: BTAI repair with an SLZ can be treated successfully without covering the LSA, analyzing technical success and in-hospital complications. Mid- and long-term data are necessary to confirm the durability of this technique.

Abdominal vascular injuries: Blunt vs. penetrating.

INTRODUCTION: Abdominal vascular injuries (AVIs) remain a great challenge since they are associated with significant mortality. Penetrating injury is the most common cause of AVIs; however, some AVI series had more blunt injuries. There is little information regarding differences between penetrating and blunt AVIs. The objective of the present study was to identify the differences between these two mechanisms in civilian AVI patients in terms of patient's characteristics, injury details, and outcomes. METHOD: From January 2007 to January 2016, we retrospectively collected the data of AVI patients at King Chulalongkorn Memorial hospital, including demographic data, details of injury, the operative managements, and outcomes in terms of morbidity and mortality. The comparison of the data between blunt and penetrating AVI patients was performed. RESULTS: There were 55 AVI patients (28 blunt and 27 penetrating). Majority (78%) of the patients in both groups were in shock on arrival. Blunt AVI patients had significantly higher injury severity score (mean(SD) ISS, 36(20) vs. 25(9), p = 0.019) and more internal iliac artery injuries (8 vs. 1, p = 0.028). On the other hand, penetrating AVI patients had more aortic injuries (5 vs. 0, p = 0.046), and inferior vena cava injuries (7 vs. 0, p = 0.009). Damage control surgery (DCS) was performed in 45 patients (82%), 25 in blunt and 20 in penetrating. The overall mortality rate was 40% (50% in blunt vs. 30% in penetrating, p = 0.205). CONCLUSIONS: Blunt AVI patients had higher ISS and more internal iliac artery injuries, while penetrating AVI patients had more aortic injuries and vena cava injuries. Majority of AVI patients in both groups presented with shock and required DCS.

Experience with surgical treatment of retroperitoneal soft tissue sarcomas at a university hospital in Thailand.

BACKGROUND: Retroperitoneal soft tissue sarcomas (RSTS) are rare malignant tumors with a distinguishing feature of slow growth in the silent retroperitoneal space. The patients usually present late with a large retroperitoneal mass surrounded by the major vascular structures and visceral organs rendering curative resection an extremely difficult and risky operation. The purpose of the present study was to demonstrate surgical experience and results of treatment of RSTS at King Chulalongkorn Memorial Hospital. Operative techniques of these complex surgical procedures were also described. MATERIAL AND METHOD: A retrospective study was performed in patients who had RSTS and underwent surgical resection between June 2003 and November 2011 at King Chulalongkorn Memorial Hospital, Bangkok, Thailand. All patients were followed after the operations until death or last follow-up at the out-patient clinic in October 2012. Data collection included demographic data, details of operations, operative complications, neoadjuvant and adjuvant chemoradiation therapy, local recurrence, treatment of local recurrence, and 5-year overall survival rate. Factors associated with local recurrence were also examined. RESULTS: During the 9.4-year period, 18 patients entered into the present study. Fourteen (77.8%) were female and four (22.2%) were male. The age ranged from 44 to 80 years (median 53.5 years). Duration of symptoms ranged from one week to 24 months (median 3.5 months). The tumor size ranged from 10 to 48 cm (median 27 cm) in greatest dimension. All patients underwent preoperative CT scan. Preoperative core needle biopsy was performed in one patient. One patient had preoperative radiation therapy. Sixteen patients (88.9%) underwent complete gross resection (CGR) (R0 or R1 resection) and two (11.1%) had palliative resection (R2 resection). All patients who had CGR (n = 16) had one or more contiguous organ resection (kidney 87.5%, colon 50%, or adrenal gland 43.7%). The operative time ranged from 120 to 360 minutes (median 330 minutes). The operative blood transfusion ranged from 0 to 12 units (median 2.5 units). Postoperative bleeding complication requiring reoperation occurred in three patients (16.7%). One patient had postoperative uncomplicated pancreatic fistula. There was no perioperative mortality. The final pathological reports were liposarcoma in 15 patients (83.3%). Other histology were atypical lipomatous tumor malignant fibrous histiocytoma, and unspecified spindle cell tumor in one patient each. Two patients who had palliative resection died at six and 16 months after the operations. Local recurrence occurred in five patients who had CGR (31.3%). One of them died at 60 months after the operation. The median follow-up time in patients who underwent CGR was 39.5 months (range 12-114 months). The 5-year overall survival of the entire cohort was 73.5% (95% CI: 44.3-88.4%). The 5-year overall survival of patients who had CGR was 83.3% (95% CI: 53.5-98.5%). Univariate analysis of the tumor size, tumor grading, status of the surgical margins, and primary operation or re-resection revealed no statistical significance in patients who had CGR with and without local recurrence. CONCLUSION: Acceptable outcomes after complete surgical resection of the RSTS were achieved from this small but important case-series. The authors have demonstrated that CGR with concomitant resection of the contiguous organs can be safely performed in patients with large RSTS. Preoperative CT scan was invaluable for diagnosis and treatment plan. Preoperative core needle biopsy was not necessary when preoperative CT scan was diagnostic. Intention for curative resection should be attempted whenever possible to minimize chance of local recurrence and improve survival. Experience of the surgical team is an important factor for successful results when conducting these technically demanding operations.

Management of liver injuries: predictors for the need of operation and damage control surgery.

UNLABELLED: Management of liver injuries: Predictors for the need of operation and damage control surgery, INTRODUCTION: The advancement in the management of liver injuries, including the use of non-operative management (NOM), damage control surgery (DCS) and angiographic embolisation (AE); has resulted, in improvement of outcomes. The aim of this study is to analyse the outcome of liver injury patients in our institution and to identify predictors for the need of operative management (OM) and DCS. PATIENTS AND METHODS: We retrospectively reviewed 218 patients with liver injury admitted to King, Chulalongkorn Memorial Hospital from May 2002 to May 2011. Data collection included demographic, data, emergency department parameters, detail of liver injuries, and outcome in terms of mortality rate (MR). Stepwise logistic regression was performed to identify mutually independent predictors for the need of OM and DCS. RESULTS: Two hundred and eighteen patients with liver injury were identified (156 blunt and 62 penetrating). One hundred fifty-four patients (70.6%) underwent OM due to hemodynamic instability, (96), peritonitis (24), and other indications (34). DCS (perihepatic packing and temporary abdominal, closure) was utilised in 45 patients. NOM was attempted in 64 patients (29.4%), 6 of these, subsequently required laparotomy (success rate 90.6%). Angiography was performed in 47 patients, (14 in NOM, 33 in OM) and 40 patients received AE (10 in NOM, 30 in OM). Overall MR was 17.4%, the, MR was significantly higher in OM than in NOM (24 vs. 1.6%; p<0.001, OR 19.92). The mutually independent predictors for the need of operation were low Glasgow Coma Score (GCS), penetrating mechanism, tachycardia, and hypotension; while the independent predictors for DCS were high grade (>4) liver injury, tachycardia, and blunt mechanism. CONCLUSIONS: Overall MR of liver injury patients was 17.4%. NOM carried a low MR and should be, attempted in the absence of hemodynamic instability and peritonitis. Patients with low GCS, penetrating injury, tachycardia, and hypotension were more likely to require operation. DCS should be considered while operating on patients with high grade liver injury, tachycardia, and blunt mechanism.

Lessons learned from 100 personal consecutive cases of pancreaticoduodenectomy at a university hospital in Thailand.

BACKGROUND: Pancreaticoduodenectomy (PD) is a major operation with potential disastrous complications. Experience of the surgical team with high surgical volume is an important factor contributing to better outcome. The purpose of this study was to examine results of 100 consecutive cases of PD operated by the first author. Various aspects of this technically demanding operation related to our experience were discussed and reviewed. MATERIAL AND METHOD: A retrospective study of 100 patients who had undergone PD during a period of 20.5 years was presented. The indications for PD were periampullary neoplasms or other symptomatic lesions at the pancreatic head. All patients had preoperative CT scan to evaluate extent of the disease and resectability. Preoperative biliary drainage was performed in selected cases. The operations were conducted in the same manner in most cases. Before 2000, no external drainage of the pancreatic remnant was used. Since 2000, external drainage of the pancreatic remnant was routinely used, except in one patient who had total pancreatectomy. Postoperative complications and mortality were studied. RESULTS: Carcinoma of the ampulla of Vater and carcinoma of the head of the pancreas were the leading indications for PD (34% and 30%, respectively). No preoperative tissue diagnosis was made in patients who had carcinoma of the head of the pancreas. Two patients had emergency PD because of massive gastrointestinal bleeding. Sixty seven per cent underwent pylorus preserving PD (PPPD) and 33% underwent classical PD. Twenty eight patients had no external pancreatic drainage, 71 had external pancreatic drainage, and one had total pancreatectomy. The postoperative morbidity and mortality were 44% and 2%, respectively. The postoperative pancreatic fistula rate was higher in patients without external pancreatic stent but no statistical significance was detected (21.4% vs. 12.7%, NS). There was no mortality in patients aged > 70 years (n = 29) while two patients aged < 70 died (n = 71). The difference was not statistically significant. CONCLUSION: PD could be safely performed with low pancreatic fistula and low mortality rate by experienced surgeons. Preoperative CT scan is extremely helpful in evaluation the extent of the disease and resectability. In patients with suspected carcinoma of the pancreatic head, PD should be performed without preoperative tissue diagnosis by experienced pancreatic surgeons. Elderly (aged > 70 years) is not a contraindication for PD. We strongly recommend the use of external pancreatic stent to prevent pancreatic fistula.

Management of difficult abdominal wall problems by components separation methods: a preliminary study in Thailand.

BACKGROUND: Acute (open abdomen) and late (ventral hernia) abdominal wall defects are difficult surgical problems requiring appropriate management for acceptable results. Several methods of abdominal wall reconstruction in these patients have been introduced with varying outcomes. Components separation method (CSM) is an autologous tissue repair that has been employed for such situations with satisfaction by many investigators. The authors have adopted this method of abdominal wall repair or reconstruction and used it in our patients with difficult abdominal wall problems since May 2005. The aim of the present study was to examine results of treatment of patients with large abdominal wall defects by CSM at our institution. A brief demonstration of surgical techniques and discussion of the related issues were also made. MATERIAL AND METHOD: All patients with difficult abdominal wallproblems treated by CSM at King Chulalongkorn Memorial Hospital, Bangkok, Thailand between May 2005 and June 2012 were examined and analyzed The patients were divided into two groups, i.e. acute (open abdomen) and late (ventral hernia). Different methods of repair or reconstruction by CSM were described. No prosthetic mesh was used in the present study. Postoperative follow-up was done until August 2012. Operative morbidity and late sequelae were studied. RESULTS: Twenty-six patients entered into the study. Eight (30.8%) underwent closure of acute abdominal wall defects and 18 (69.20%) underwent late ventral hernia repair. Four patients (50%) who underwent closure of acute abdominal wall defects also had closure of associated entero-atmospheric or small bowel fistulae. Four patients (22.2%) who underwent late ventral hernia repair also had closure of associated ileostomy or colostomy. Three types of CSM were used in the present study; i.e. original or standard components separation (SCS), modified components separation (MCS), and SCS plus bilateral anterior rectus abdominis sheath turnover flap (RSTF). Complications included seroma under the skin flap in one patient in the early closure group, two wound infections, two seroma under the skin flap, and one skin flap dehiscence in the late ventral hernia repair group. One small, asymptomatic recurrent ventral hernia was found during the follow-up period of the late ventral hernia repair patients (5.6%). CONCLUSION: CSM is a good alternative for management of difficult abdominal wall problems, especially in situations that employment of prosthetic mesh may be inappropriate. Its advantages are avoidance of prosthetic mesh and low risk of infection in potentially infected environment. It is versatile in various abdominal wall problems even in large abdominal wall defects. CSM is recommended when associated enteric fistula, ileostomy, colostomy closure, or other potentially infected procedures are simultaneously performed.

Management of open abdomen with an absorbable mesh closure.

PURPOSE: To examine the methods and results of treatment in patients with an open abdomen (OA) at a single institution where an absorbable mesh closure (AMC) is most commonly used. METHODS: A retrospective study was performed in OA patients from January 2001 to June 2007. Outcomes were analyzed in terms of enteroatmospheric fistula (EAF) formation and survival. RESULTS: There were 73 OA patients receiving definitive closures (40 trauma and 33 nontrauma). Twenty-four patients were able to undergo a delayed primary fascial closure (DPFC) after initial vacuum pack closure (DPFC rate 33%). The DPFC rate was significantly lower in patients with an associated infection or contamination (9% vs 44%, P = 0.002). The EAF and mortality rates of the DPFC group were 0% and 13%, respectively. Absorbable mesh closure was used in 41 of 49 patients who failed DPFC (84%). There were 9 patients who had EAF (overall EAF rate 12%), 6 of whom were in the AMC group (EAF rate 15%). The overall and AMC group mortality rates were 29% and 37%, respectively. CONCLUSION: Absorbable mesh closure carries high EAF and mortality rates. Therefore, DPFC should be considered as the primary closure method. Absorbable mesh closure should be reserved for patients who fail DPFC, especially those with peritonitis or contamination.

Outcomes and complications of open abdomen technique for managing non-trauma patients.

BACKGROUND: Damage control surgery and the open abdomen technique have been widely used in trauma. These techniques are now being utilized more often in non-trauma patients but the outcomes are not clear. We hypothesized that the use of the open abdomen technique in non-trauma patients 1) is more often due to peritonitis, 2) has a lower incidence of definitive fascial closure during the index hospitalization, and 3) has a higher fistula rate. METHODS: Retrospective case series of patients treated with the open abdomen technique over a 5-year period at a level-I trauma center. Data was collected from the trauma registry, operating room (OR) case log, and by chart review. The main outcome measures were number of operations, definitive fascial closure, fistula rate, complications, and length of stay. RESULTS: One hundred and three patients were managed with an open abdomen over the 5-year period and we categorized them into three groups: elective (n = 31), urgent (n = 35), and trauma (n = 37). The majority of the patients were male (69%). Trauma patients were younger (39 vs 53 years; P < 0.05). The most common indications for the open abdomen technique were intraabdominal hypertension in the elective group (n = 18), severe intraabdominal infection in the urgent group (n = 19), and damage control surgery in the trauma group (n = 28). The number of abdominal operations was similar (3.1-3.7) in the three groups, as was the duration of intensive care unit (ICU) stay (average: 25-31 days). The definitive fascial closure rates during initial hospitalization were as follows: 63% in the elective group, 60% in the urgent group, and 54% in the trauma group. Intestinal fistula formation occurred in 16%, 17%, and 11%, respectively, in the three groups, with overall mortality rates of 35%, 31%, and 11%. CONCLUSION: Intra-abdominal infection was a common reason for use of the open abdomen technique in non-trauma patients. However, the definitive fascial closure and fistula rates were similar in the three groups. Despite differences in indications, damage control surgery and the open abdomen technique have been successfully transitioned to elective and urgent non-trauma patients.

An extra-adrenal pheochromocytoma of the organ of Zuckerkandl: report of a case.

The authors report a case of extra-adrenal pheochromocytoma of the organ of Zuckerkandl presenting with hypertension and an abdominal mass in a young adult. Preoperative diagnosis was made by biochemical and imaging studies. The operation to remove the tumor was successfully performed. The patient remains normotensive and symptom free at 15-month follow-up. The authors also discuss the diagnostic modalities and surgical technique used in the presented patient.

Management of upper extremity vascular injury: outcome related to the Mangled Extremity Severity Score.

BACKGROUND: The Mangled Extremity Severity Score (MESS) is an objective criterion for amputation prediction after lower extremity injury as well as for amputation prediction after upper extremity injury. A MESS of >or=7 has been utilized as a cutoff point for amputation prediction. In this study, we examined the result of upper extremity vascular injurty (UEVI) management in terms of the amputation rate as related to the MESS. METHODS: During January 2002 to July 2007, we reviewed patients with UEVIs at our institution. Data collections included demographic data, mechanism of injuries, injury severity score (ISS), ischemic time, MESS, pathology of UEVI, operative management, and amputation rate. Decisions to amputate the injured limbs at our institution were made individually by clinically assessing limb viability (i.e., color and capillary refill of skin; color, consistency, and contractility of muscles) regardless of the MESS. The outcome was analyzed in terms of the amputation rate related to the MESS. RESULTS: There were 52 patients with UEVIs in this study: 25 (48%) suffered blunt injuries and 27 (52%) suffered penetrating injuries. The age ranged from 15 to 59 years (mean 28.7 years). The mean ischemia time was 10.07 h. The mean ISS was 17.52. There were 12 patients (23%) with subclavian artery injuries, 3 patients (5.76%) with axillary artery injuries, 18 patients (34.61%) with brachial artery injuries, and 19 patients (36.54%) with radial artery and/or ulnar artery injuries. Primary repairs were performed in 45 patients (86.54%), with ligations in 3 patients (5.77%). An endovascular stent-graft was used in one patient (1.92%). Primary amputations were performed in three patients (5.77%). Secondary amputations (amputation after primary operation) were done in 4 of 49 patients (secondary amputation rate 8.16%). All amputation patients suffered blunt injuries and had a MESS of >or=7 (range 7-11). The overall amputation rate in this study was 13.46% (7/52 patients). Multivariate analysis revealed that the only factor significantly associated with amputation was the MESS. There were no amputations in 33 patients who had a MESS of <7. We could avoid amputation in 12 of 19 patients who had a MESS>or=7. There were no mortalities among 52 UEVI patients. CONCLUSIONS: MESS, an outcome score used to grade the severity of extremity injuries, correlates well with the risk of amputation. Nevertheless, a MESS of >or=7 does not always mandate amputation. On the other hand, the MESS is a better predictor for patients who do not require amputation when the score is <7. The decisions to amputate in patients should be made individually based on clinical signs and an intraoperative finding of irreversible limb ischemia.

Pancreaticoduodenectomy with external drainage of the pancreatic remnant.

OBJECTIVE: Leakage of the pancreaticojejunal anastomosis is a serious complication after pancreaticoduodenectomy. External drainage of the pancreatic remnant is one of several methods for reducing pancreaticojejunal anastomotic leakage or fistula. We investigated complications after pancreaticoduodenectomy with and without external drainage of the pancreatic remnant. METHODS: Patients who underwent pancreaticoduodenectomy at King Chulalongkorn Memorial Hospital, Bangkok, Thailand from November 1991 to October 2007 were enrolled. Before 2001, no external pancreatic drainage was employed during pancreaticojejunal anastomosis (non-stented group). Since 2001, external drainage of the pancreatic remnant has been routinely performed with a paediatric feeding tube (stented group). RESULTS: There were 28 patients in the non-stented group and 45 in the stented group. Stented patients had undergone significantly more previous abdominal operations, pylorus preserving pancreaticoduodenectomy, and end to end anastomosis of the pancreatic remnant and jejunal limb. Leakage of the pancreaticojejunal anastomosis or pancreatic fistula, overall complications, and re-laparotomy rate were significantly higher in the non-stented group (leakage or fistula 21.4% vs. 6.7%, overall complications 50% vs. 33.3%, and re-laparotomy 18% vs. 2.2%). The only death was in the non-stented group. CONCLUSION: External drainage of the pancreatic remnant after pancreaticoduodenectomy is an effective method for prevention of pancreaticojejunal anastomosis leakage and other related complications.

Pylorus preserving pancreaticoduodenectomy with low incidence of early delayed gastric emptying.

BACKGROUND AND OBJECTIVE: Early delayed gastric emptying (early DGE) is a common complication after pylorus-preserving pancreaticoduodenectomy (PPPD). The authors studied the occurrence of early DGE in the presented patients. The explanation of authors' results was discussed and a brief literature review was performed. MATERIAL AND METHOD: The occurrence of early DGE was studied in 37 patients with periampullary neoplasms or other benign conditions who underwent PPPD between from April 1992 and March 2006. The operations were performed by the first author with uniform surgical techniques. After the year 2000, an external pancreatic stent was routinely inserted into the pancreatic duct during pancreaticojejunostomy anastomosis. RESULTS: Early DGE occurred in two patients (5.4%), one in the non-stented and one in the stented group. Two patients had pancreatic fistula and two had wound infection. The overall morbidity rate was 16.2%. There was no re-operation or intra-abdominal abscess requiring drainage or mortality in the present study. CONCLUSIONS: The occurrence of early DGE after PPPD may be lessened by strict awareness and avoidance of complications associated with PPPD. Surgical experiences with faultless and meticulous surgical techniques are important for lowering such complications.

Operative management of small bowel fistulae associated with open abdomen.

BACKGROUND: Gastrointestinal fistulae associated with open abdomen are serious complications following trauma or other major abdominal surgery. Management is extremely difficult and the mortality is still high in spite of modern medical advances. Patients who survive initial physiological and metabolic derangements require operative closure of the fistula, which is technically demanding and poorly described in the literature. METHODS: A retrospective study of patients with small bowel fistulae associated with open abdomen was performed. Only patients who were stabilized sufficiently to undergo surgical closure of the fistula were enrolled in the study. The operative techniques comprised three important steps: exploratory laparotomy and resection of small bowel fistulae with end-to-end anastomosis; bridging the abdominal wall defect with a sheet of polyglycolic acid mesh; and covering the mesh with bilateral bipedicle anterior abdominal skin flaps. RESULTS: Eight patients were included in the study. The number of operations before surgical closure of the fistula ranged from one to six (mean, 3.6). The time from first operation to surgery for fistula closure ranged from 2.5 to 7.5 months (mean, 4.4 months). Three patients had recurrent fistula, and one died (mortality, 12.5%). Hospital stay ranged from 101 to 311 days (mean, 187 days). CONCLUSION: We present a method of closure of small bowel fistulae associated with open abdomen and hope that this will provide surgeons encountering such complications with a good alternative for surgical management.

Successful management of a superior mesenteric artery aneurysm by ligation: a case report.

Superior mesenteric artery aneurysm (SMAA) is a rare entity. Management varies from simple ligation with or without revascularization to endovascular placement of a covered stent graft. The authors report a case of SMAA who presented with retroperitoneal hemorrhage. Diagnosis was made from abdominal computed tomography and angiography. The cause of SMAA was not definitely identified but infective origin was highly suspicious. The patient underwent successful treatment with ligation of the superior mesenteric artery proximal and distal to the SMAA.