Complete abdominal wound dehiscence: evaluation of the non-operative management

Complete abdominal wound dehiscence "burst abdomen" is a challenging surgical complication and continue to be a major source of morbidity and mortality after laparotomies. The costs for managing burst abdomen are considerable, frequently requiring medical treatment, surgical intervention and prolonged hospital stay. Twenty six patients, who had burst abdomen, were seen between December; 2000 and April 2004 at Ain Shams University Hospitals. Fifteen patients were selected for conservative treatment [group A] and eleven patients were treated by classical abdominal mass closure with tension sutures [group B]. Patients selected for conservative treatment included those whose disruption occurred from the second postoperative week onwards, disruption occurred secondary to major wound sepsis or any intra-abdominal septic focus draining through the wound [without any evidence of intra-abdominal collections] or those with stable dehisced fascial defect that occurred at any time and under any circumstances, revealing amalgamated loops of bowel, which were adherent to wound edges [frozen abdomen]. Patients not falling into these categories were treated by mass closure. The mean hospital stay was 25 days in group A and 22 days in group B. Mortality was 20% [3 cases] among group A, all of them died in the early postoperative period from complications unrelated to the conservative protocol. Mortality was 36.4% [4 cases] among patients of group B, 50% of them died from intra-operative mishaps occurred at the time of closure [small intestinal injury]. Follow-up for 8 months or more was complete in 10 patients in group [A] and in 7 patients in group [B]. Four incisional [ventral] hernias were noted among 10 patients treated conservatively and followed up for more than 8 months. Repair was required in two patients [20%]. The other two patients had only diffuse protrusion during coughing or straining because of stretched weak scar without localized defects and required no further treatment. Two ventral hernias [28.6%] with multiple defects were seen in the survived 7 patients of group B, both of them has been repaired using polyprolene mesh. The results of this study strongly document the safety and efficacy of conservative treatment as an alternative method in treating abdominal wall dehiscence in certain situations. We believe this to be the method of choice in cases where the bowel loops are adherent to the wound edges, where the wound is infected and oedematous, when closure can only be done under tension and in high risk patients unfit for operation

first postoperative year results of transthoracic Ivor-Lewis esophagectomy with stapled intrathoracic esophagogastric anastomosis for treatment of lower esophageal cancer

Esophageal cancer represents one of the most lethal malignancies affecting mankind. This is compounded by the fact that adenocarcinoma of the esophagus is increasing in incidence at a rate exceeding that of any other neoplasm. At most centers, esophageal resection remains the therapeutic alternative of choice for patients who are considered to be surgical candidates. The surgeons' opinions about Ivor Lewis operation has long been sceptic because of the consequences if leakage of the intra thoracic anastomosis occurred. However, with the advent of stapling devices and with the advances in operative techniques, a well vascularized oesophageal substitute can be prepared and a safe anastomosis can be constructed. In the present work, we managed 17 patients with carcinoma of the lower oesophagus by Ivor-Lewis subtotal esophagectomy with 2 field lymphadenectomy from May 2000 to July 2004. We used the stomach as an oesophageal substitute and a stapled oesophagogastric anastomosis was done at the apex of thorax. The median ICU stay was 2 days [1-38 days] and the median postoperative stay for those patients without complication was 14 days. The proximal longitudinal resection margin was infiltrated in 1 case while 3 cases showed involvement of the circumferential margin. Primary pulmonary complication occurred in 6 patients with 1 related mortality. Leakage occurred in 4 patients, 3 among them were managed conservatively. Three patients died postoperatively [17.6% with only one case died from surgical rather than medical complication], one from acute respiratory distress syndrome, second from profound sepsis following extensive mediastinal leakage and third one from massive myocardial infarction. At the end of the 1[st] postoperative year, 10 patients were alive. It has been concluded that Ivor Lewis operation is a good option for patients with carcinoma of the lower oesophagus and a better outcome depends on early recognition and aggressive management of complications that can minimize subsequent mortality