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.

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.

Management and outcome of severe acute pancreatitis.

BACKGROUND: The treatment of severe acute pancreatitis (SAP) varies among several institutes. It has been evolving from routine surgical management to conservative management in the early stages. The surgical management has a role in the later stages of the disease. OBJECTIVE: The purpose of the present study was to review the management and outcome of the patients with SAP at King Chulalongkorn Memorial Hospital, Bangkok, Thailand. MATERIAL AND METHOD: Two hundred and ten patients with a diagnosis of acute pancreatitis at King Chulalongkorn Memorial Hospital, Bangkok, Thailand from December 2001 to April 2005 were studied by retrospective chart review. RESULTS: Forty patients were diagnosed with SAP, 27 men and 13 women. SAP was most commonly caused by alcohol abuse (47.5%) and biliary tract disease (37.5%). Eighteen patients (45%) had pancreatic necrosis. Among them, seven patients (38.9%) had infected necrosis, and the rest had sterile necrosis. All patients with infected pancreatic necrosis underwent open pancreatic necrosectomy, and three of 7 died. Four of 11 patients with sterile necrosis died. The overall mortality was 25%. CONCLUSION: Patients with SAP have high morbidity and mortality rates. The patients with infected pancreatic necrosis may require surgical management, whereas those with sterile necrosis or SAP without local complications can be managed with conservative treatment and/or intervention. Post-operative complications might occur, thus require long term follow-up.

Management of blunt duodenal injuries.

BACKGROUND/AIMS: Blunt duodenal injuries are relatively rare. Diagnosis is usually delayed resulting in significant morbidity and mortality. Treatment of the injured duodenum varies according to severity of injury and duration before diagnosis. Duodenal fistulas are serious complications with potential mortality. The purpose of this study was to examine results of treatment of patients with blunt duodenal injuries at our institution. PATIENTS AND METHOD: This is a retrospective study of patients who sustained blunt duodenal injuries and were admitted to King Chulalongkorn Memorial Hospital, Bangkok, Thailand from January 1990 to December 2003. During the study period, management of duodenal injuries at our institution depended largely on severity of injuries, timing of diagnosis and the presence of retroperitoneal infections. Intramural hematoma of the duodenum was treated conservatively. Uncomplicated wounds of the duodenum (grade II and grade III injury) with no obvious retroperitoneal infections were treated by simple duodenal repair. Pyloric exclusion was performed in cases of difficult duodenal repair and/or delayed diagnosis (> 24 hours after injury) with obvious evidence of retroperitoneal infections. RESULTS: Twenty six patients were entered into the study. Five patients (19.2%) had intramural hematoma of the duodenum, all were successfully treated by conservative treatment. Twenty one patients (80.8%) had transmural tear of the duodenal wall. Ten of them (47.6%) underwent simple repair, 10 (47.6%) underwent simple repair of the duodenal wounds combined with pyloric exclusion (2 of them underwent the operations elsewhere), and 1 (4.8%) underwent pancreaticoduodenectomy. Seven patients who had transmural tear of the duodenum developed complications (33.3%). Two patients had duodenal fistulas (9.5%); 1 in the simple repair group and 1 in the pyloric exclusion group. One patient who underwent pyloric exclusion had leakage of the gastrojejunostomy anastomosis with intact duodenal repair resulting in a complicated and prolonged hospital course. There was no mortality in this study. CONCLUSIONS: The outcome in management of blunt duodenal injuries at our institution was acceptable with low morbidity and no mortality. Intramural hematomas were safely treated conservatively. Uncomplicated duodenal wounds were treated by simple suture repair. Pyloric exclusion was a useful additional procedure in patients with complicated duodenal injuries. Retroperitoneal infections was a strong indication to perform this procedure in addition to simple repair of the duodenal wounds. Pancreaticoduodenectomy should be reserved for only severed combined duodenal and pancreatic head injuries.

Small-diameter H-graft portacaval shunt for variceal hemorrhage: experience at King Chulalongkorn Memorial Hospital.

BACKGROUND: Portosystemic shunts remain to be a good means for preventing recurrent variceal hemorrhage in a certain number of patients who fail to respond to other therapeutic modalities. Total portal decompression is no longer recommended owing to the high incidence of postoperative encephalopathy and liver failure. Distal splenorenal shunt is too technically demanding. A small-diameter H-graft portacaval shunt (SDHGPCS) which partially decompresses the portal system and was popularized by Sarfeh et al and associates in 1983 seems to be a good alternative for its simplicity to construct and impressive results. PATIENTS AND METHOD: SDHGPCS with an 8 mm. PTFE graft has been performed to prevent recurrent variceal hemorrhage in cirrhotic patients who failed to respond to long term pharmacotherapy and endoscopic therapy during the last 3 years at our institution. Data analysis included: causes of cirrhosis, patients' Child-Pugh classification, operative time, operative blood transfusion, and results of treatment. RESULTS: Nine cirrhotic patients were entered into the present study. Three patients (33.3%) were in Child-Pugh class A and 6 (66.7%) were in Child-Pugh class B. Three patients had ringed PTFE grafts and 6 had non-ringed PTFE grafts. The operative time ranged from 225 to 420 minutes (mean 303, median 285 minutes). There was no perioperative (30 days) death. One postoperative intraabdominal hemorrhage was successfully treated by relaparotomy. Two patients were lost to follow up at 3 and 10 months after the operations. Four patients are alive and well at 12, 24, 30 and 35 months after the operations. One patient developed hepatic encephalopathy at 35 months postoperation which was thought to be secondary from progression of the hepatic parenchymal disease. One patient developed recurrent variceal hemorrhage at 30 months postoperation from portal vein thrombosis and was successfully treated by endoscopic variceal sclerotherapy (EVS). One patient died from carcinoma of the larynx 3 months after SDHGPCS and 2 died from end stage liver disease at 30 and 45 months after SDHGPCS. CONCLUSION: SDHGPCS is an effective mean to prevent recurrent variceal hemorrhage. The procedure is simple and practical to perform in hospitals with low volume of portosystemic shunt operations. The authors recommended SDHGPCS as an alternative in prevention of recurrent variceal hemorrhage in cirrhotic patients who fail to respond to other therapeutic modalities.

The results of focused assessment with sonography for trauma performed by third year surgical residents: a prospective study.

Focused assessment with sonography for trauma (FAST) is used as a screening tool to detect hemoperitoneum in patients with blunt abdominal injuries. The aim of this study was to evaluate the sensitivity and specificity of FAST performed by third year surgical residents. PATIENTS AND METHOD: Data were collected prospectively in one hundred and twenty-nine blunt abdominal trauma patients admitted to King Chulalongkorn Memorial Hospital from November 2000-November 2002. FAST was used by third year surgical residents to detect intraperitoneal fluid and considered positive if such fluid was identified. Data were analyzed using the chi-square test. RESULTS: Of the 129 patients, there were 31 female (24%) and 98 male (76%) patients, with the mean age of 34 years. The mean Injury Severity Score was 13.2. 53 patients had proven intraabdominal injuries and 76 had no injuries. FAST was positive in 28 patients and negative in 101 patients. There were 3 false positive FAST. The sensitivity and specificity of FAST were 47.17 per cent and 96.05 per cent, respectively. The positive predictive value was 89.29 per cent, the negative predictive value was 72.28 per cent and the accuracy was 81.59 per cent. CONCLUSION: FAST performed by third year surgical residents for blunt abdominal trauma had high specificity to detect hemoperitoneum. A positive FAST is a strong predictor of significant intraabdominal injury. The need for more practices to improve sensitivity is recommended.

Pelvic fractures: experience in management of 170 cases at a university hospital in Thailand.

BACKGROUND, OBJECTIVE AND METHOD: Management of patients with pelvic fractures requires a multidisciplinary team approach. Currently, survival has been dramatically improved but some controversies still remain. The purpose of this study was to examine management and results of treatment of patients with pelvic fractures who were admitted to the Trauma Unit, King Chulalongkorn Memorial Hospital, Bangkok, Thailand from January 1991 to December 2000. RESULTS: There were 170 patients in the study. The age ranged from 15 to 91 years (mean 33.89 +/- 16.14). The most common cause of injuries was motorcycle accidents (50.0%). There were 27 (15.9%), 47 (27.6%), 80 (47.1%) and 16 (9.4%) patients with Type I, II, III and IV pelvic fractures, respectively. Forty per cent of patients were in shock when they first arrived at the emergency room. Seventy two patients (42.4%) had 274 associated injuries. Sixteen patients (9.4%) had open pelvic fractures. The Injury Severity Score (ISS) ranged from 4 to 75 (mean 17.55 +/- 12.86). Eighty two patients (48.2%) received blood transfusion from 1 to 40 units (mean 10.04 +/- 8.47). Sixteen patients (9.4%) underwent pelvic angiography, 10 bleeding points were demonstrated and successfully treated by transcatheter embolization. One hundred and thirty two patients (77.6%) received no specific treatment for the pelvic fractures. The remainder (22.4%) were treated with pelvic sling in 6 patients (3.5%), skeletal traction in 21 patients (12.4%), external fixation in 6 patients (3.5%), internal fixation in 4 patients (2.4%), and right hemipelvectomy in 1 patient (0.6%). Fifteen patients (8.8%) died. Causes of death were exsanguination in 6 patients (40% of death), severe head injuries in 6 patients (40% of death) and sepsis with multisystem organ failure in 3 patients (20% of death). Nonsurvivors had a significantly higher ISS and units of blood transfusion than survivors (P < 0.001). The hospital stay ranged from 1 to 300 days (mean 24.7 +/- 34.19). CONCLUSION: Approximately 75 per cent of patients in our study had major pelvic fractures (Type II and Type III pelvic fractures). The majority of bleeding from pelvic fractures could be treated conservatively. Angiography with transcatheter embolization was extremely helpful when conservative treatment failed to stop pelvic bleeding. External fixation for early control of bleeding pelvic fractures was infrequently employed.