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.

Endoscopic transaxillary thyroid lobectomy: flexible vs rigid laparoscope.

BACKGROUND: The use of the endoscopic procedure for thyroid lobectomy in benign solitary thyroid nodule has been developed rapidly and increasingly refined in recent years. The early results are technically feasible, safe and mainly provide promising cosmetic results, some show a quicker recovery. The authors wanted to know if this procedure can be performed via rigid laparoscope which is simple, less expensive and widely available in many surgical centers. OBJECTIVES: The aims of this study were to evaluate operative time, blood loss, complication of flexible compared to 30 degrees rigid laparoscope in endoscopic transaxillary thyroid lobectomy for solitary thyroid nodule. METHOD: From February 2004 to June 2004, 13 cases of benign solitary thyroid nodule underwent the endoscopic transaxillary thyroid lobectomy. Flexible laparoscope techniques were performed in 9 cases and 30 degrees rigid laparoscope in the other 4 cases. Port site, number of ports and dissected method were the same in both procedures by the same surgeon. Operative time, blood loss, post-operative results were measured for evaluation. RESULTS: From 13 cases, 9 in the flexible laparoscope group and 4 in the rigid laparoscope group. All but one in the flexible group with torn internal jugular vein were successful. The mean operation time was 165.42 +/- 35.06 minutes, which was 175.63 +/- 35.70 minutes for flexible laparoscope group and 145 +/- 26.45 minutes for rigid laparoscope group. There was no recurrent laryngeal nerve injury and no subcutaneous emphysema. The patients were satisfied with the cosmetic results. CONCLUSION: On the basis of early experience with these 13 patients, the authors believe that endoscopic thyroidectomy using the rigid laparoscope has proved to be no different in the intra-operative results, so the authors do aimed to show that with the rigid laparoscope which is available in many surgical centers, less expensive and easy in maintenance will provide another surgical option for treatment of thyroid nodule, with maximized cosmetic effect.

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.