Long-term results of large diameter hepaticojejunostomy for treatment of Bile Duct Injuries following cholecystectomy.

OBJECTIVE: Bile Duct Injury (BDI) is one of the most serious complications of cholecystectomy. The authors analyzed the clinical presentation, surgical management and long-term outcome of 19 patients presenting with iatrogenic major BDIs (Straburg type E) following cholecystectomy who underwent Roux-en-Y hepaticojejunostomy. MATERIAL AND METHOD: Between 1992 and 2005, 19 patients with major BDIs (Strasberg type E) following cholecystectomy were included. Operative notes and charts of all patients were reviewed systematically. A follow-up examination of each patient was performed after a median of 22 months (range 1-120). RESULTS: Twelve patients presented with ascending cholangitis, two patients were referred to the hospital with biliary-cutaneous fistula and five patients (26.3%) were identified at the time of operations. All patients were treated with Roux-en-Y hepaticojejunostomy with at least 2 cm of the diameter of the biliary-enteric anastomosis. There was no postoperative mortality. Postoperative complication was found in 5 patients (26.3%). Until now, during the follow-up, neither clinical nor biochemical evidence of recurrent cholangitis has been found. CONCLUSION: Major BDIs are associated with high morbidity rate and prolonged hospitalization. Early detection and referral to an experienced center is crucial in the management of these patients. Roux-en-Y hepaticojejunostomy with large diameter of the biliary-enteric anastomosis is the surgical procedure of choice with good long-term outcome.

Early nutritional support in severe traumatic patients.

Multiple trauma is associated with altered metabolism, wasting of the lean body mass and compromised wound healing. Nutritional support is one way to improve the condition of these critically ill patients. We performed a prospective randomized study on the effect of early nutritional support in severely injured patients admitted to the Division of Traumatic Surgery, Siriraj Hospital between June 1992 and January 1994. Thirty-eight severe traumatic patients with ISS between 20-40 were randomly divided into control and study group. The 17 patients in the control group were treated in the conventional method with administration of hypo caloric intravenous regimen and supplement with oral diet as soon as the bowel function was returned. The 21 patients of the study group were fed either by enteral or parenteral feeding or both with an appropriate caloric and protein requirement as soon as hemodynamic status was stabilized. We found the study group had a lower mortality rate, a lower complication rate, a shorter period of ICU stay, and an earlier weaning from the ventilator than the control group. The study group also lost less weight than the control group. Nitrogen balance in the study group was significantly lower than the control group.