Role of completion pancreatectomy as a damage control option for post-pancreatic surgical complications.

INTRODUCTION: Management of pancreatic leak and haemorrhage is complex with high mortality rates. In this study, the results of completion pancreatectomy which was performed as a last resort option were analysed. PATIENTS AND METHODS: 25 patients who had completion pancreatectomy from among 677 patients who had pancreatoduodenectomy or distal pancreatectomy over a period of 18 years were analysed in terms of the indications for completion pancreatectomy, outcome and survival data. RESULTS: Indications for completion pancreatectomy include pancreatic leak in 12 patients (48%), both bleeding and pancreatic leak in 8 (32%), and haemorrhage alone in 5 (20%) patients. 18 (72%) patients also had splenectomy. Median ITU stay was 4 and 8 days for those who survived and died post-completion pancreatectomy, respectively. 36% patients had septicaemia and 32% patients had multiple organ failure. 12 patients survived the operation with a median survival of 52 months. CONCLUSION: 25 (3.6%) patients required surgical intervention for pancreatic complications. The incidence of splenectomy was 84.6% in those who died after completion pancreatectomy compared to 58.3% of those who survived (Fisher's exact test two-sided 0.20). Despite significant morbidity and mortality, completion pancreatectomy has a role in the management of post-pancreatic surgical complications.

A tale of three spilled gall stones: one liver mass and two abscesses.

Spilled gall stone has been one of the most common complications of laparoscopic cholecystectomy. Spillage occurs in up to 40% of cases; complications related to spillage are rare and can present within weeks to years. We report 3 cases referred to a tertiary centre for management of such complications. The first patient presented with clinical and radiological findings of cyst 1 week after laparoscopic cholecystectomy. She was initially thought to have a hydatid cyst. At laparotomy it turned out to be a liver abscess with stones at the centre of the cavity. The second patient presented with recurrent episodes of fever and on investigation was found to have a sub-hepatic abscess. The third patient had similar clinical symptoms to the second patient but presented 7 years after surgery. We recommend that every attempt should be made to avoid gall-bladder perforation during dissection; if this happens every effort should be made to remove the spilled stones.

An alternative method of wound pain control following hepatic resection: a preliminary study.

BACKGROUND: Epidural analgesia is considered one of the optimal methods for provision of postoperative pain relief in patients recovering from major upper abdominal operations. Concerns regarding the potential risk of neurological complications prompted an evaluation of an alternative strategy using a continuous intermuscular bupivacaine (CIB) infusion combined with patient-controlled analgesia (PCA). METHODS: Two fine-bore catheters are inserted in the deep intermuscular intercostal neuronal plane during abdominal wound closure, and a continuous infusion of bupivacaine 0.25% is commenced for 72 h postoperatively. Simultaneously, patient-controlled analgesia provided intravenous morphine on demand. The study comprised 10 consecutive patients undergoing liver resection in whom CIB infusion and PCA were employed. The feasibility, safety and efficacy of the technique were investigated, analysing postoperative pain scores, morphine requirements, spirometry and oxygen saturation. RESULTS: There were no postoperative deaths. Postoperative morbidity included one urinary tract infection, one minor chest infection and acute confusional episodes in two patients. Median pain scores and morphine requirements at 12, 24, 48 and 72 h postoperatively were satisfactory. Spirometry and oxygen saturation values also remained within the normal range. DISCUSSION: Preliminary experience with CIB infusion/PCA in the aftermath of major liver resection has demonstrated its simplicity and safety as an alternative method of postoperative pain control. Further study is required to investigate the role of CIB infusion/PCA as a practical alternative to epidural analgesia or PCA alone.

Clinical aspects of adhesive intestinal obstruction.

BACKGROUND: Mechanical intestinal obstruction remains one of the commonest surgical emergencies. With hernias being electively repaired and obstructive hernias becoming less common, adhesive obstruction has emerged as the leading cause of intestinal obstruction in the west. This study was designed to analyse any such changes in the pattern of intestinal obstruction in the population of Pondicherry of Tamilnadu of South India. METHODS: Data were collected from the compiled case records at JIPMER, Pondicherry, both retrospectively and prospectively from 1984 to 1992 about the clinical aspects of intestinal obstruction and analysed. RESULTS: There were 572 patients admitted with a diagnosis of intestinal obstruction in this period. Obstructed external hernia occurred in 219 patients and adhesive obstruction in 176 patients. Fourteen percent of the patients with adhesive obstruction had appendicectomy as the index laparotomy in the past. Majority of the patients presented within 10 years of the index laparotomy. Adhesive obstruction was managed mainly by conservative treatment in 109 cases. There were 25 patients with recurrent obstruction; most of them were conservatively managed. CONCLUSIONS: Obstructed external hernias were the commonest cause of intestinal obstruction. Increasing the patient awareness will help to decrease the incidence of obstructed hernias significantly. Adhesive obstruction deserves a conservative approach with judicious application of surgical intervention. A careful approach is required to avoid the increased morbidity and mortality associated with delay in the diagnosis of gangrenous obstructions.

The Vale knot: an intracorporeal slipknot.

Mastering intracorporeal ligation and suturing is an essential skill for the performance of most advanced endoscopic surgical procedures. Although many disposable instruments have become available for various tasks necessitating the construction of sutures and knots; issues of performance, safety, and cost-efficiency remain to be settled. The authors believe that training should aim at the development of manual skills that could realize the clinical and cost-efficiency benefits of using conventional surgical tasks in the endoscopic setting.