Chadin Tharavej

A multidisciplinary approach in the management of hepatic injuries

We reviewed 87 patients with hepatic injuries who were admitted to King Chulalongkorn Memorial Hospital, Bangkok, Thailand, from January 1995 to December 1999; 76% of them had sustained blunt trauma and 24% penetrating trauma. Their injury severity scores (ISS) ranged from 4 to 57 (mean 20.94+/-12.8); 50% of them were in shock on arrival; 8.1, 28.7, 25.3, 19.5, and 18.4% suffered from hepatic injuries graded I, II, III, IV, and V, respectively. Seventeen patients (19.5%) were successfully managed non-operatively; three of them underwent hepatic angiography, which in two revealed leakage of contrast medium from the right hepatic artery; both were successfully treated by embolization. One patient had bile leakage and collection, which was successfully treated by ultrasound-guided percutaneous drainage. Seventy patients (80.5%) underwent exploratory laparotomy; nine of them died in the operating room. Of the remaining 61 who left the operating room alive, 21 had perihepatic packing, which was frequently used in those with injuries to segments V, VI, VII, and VIII (Couinauds nomenclature). Eight patients who had packing and one who had not died in the postoperative period. Two patients who had packing underwent subsequent hepatic angiography with embolization before successful pack removal. The overall mortality was 20.7%. The mortality in complex hepatic injuries (grades IV and V) was 13 out of 33 (39.4%). We believe that non-operative management should be considered in haemodynamically stable patients. Angiography with embolization is invaluable in improving outcome in both non-operative and operative patients. Perihepatic packing is life-saving in complex hepatic injuries that cannot be effectively treated by simple surgical procedures. Finally, ultrasound- or CT-guided percutaneous drainage of bile leakage or collections spared a number of patients from open and complicated surgery.

High dose radiation with chemotherapy followed by salvage esophagectomy among patients with locally advanced esophageal squamous cell carcinoma

Locoregional failure is a major problem associated with chemoradiation treatment for squamous cell esophageal carcinoma. The aim of this study was to assess the feasibility, efficacy, and toxicity of preoperative radiation (dose > 50 Gy) with platinum‐based chemotherapy followed by esophagectomy in locally advanced squamous cell carcinoma.

Outcome of endoscopic small-bore naso-jejunal tube stenting in early postoperative jejunal limb obstruction after gastrectomy

BackgroundEarly postoperative jejunal limb obstruction is a rare complication following gastric surgery with jejunal reconstruction. The condition is mainly attributed to kinking of the jejunal limbs, gastrojejunal or jejunojejunal anastomosis. There has been currently limited information regarding the safety and efficacy of endoscopic treatment in patients with early postoperative jejunal obstruction. We aimed to investigate outcome of endoscopic small-bore naso-jejunal (N-J) tube stenting across the obstructed segment in patients with uncomplicated early postoperative partial jejunal limb obstruction.MethodsAll patients diagnosed of jejunal limb obstruction within 8 weeks after gastric-related surgery were reviewed. Patients with malignant obstruction, complete closed loop obstruction, sepsis, instability, intestinal strangulation, or perforation were excluded. All patients underwent endoscopic dekinking and stenting for 2 weeks with an N-J tube using 16-French single lumen plastic nasogastric tube across the obstruction segment after failed conservative therapy. Successful N-J tube placement across the obstruction point was confirmed by contrast study. Complications, technical, and clinical success were evaluated.ResultsTwenty-one patients met the criteria. The primary operations were 7 partial gastrectomies with Billroth-II reconstruction, 7 total or partial gastrectomies with Roux-en-Y reconstruction and 4 Whipple’s operations, 2 bypass procedures, and 1 proximal gastrectomy. Most common site of obstruction was jejunojejunal anastomosis and gastrojejunal anastomosis following Roux-en-Y and Billroth-II reconstruction, respectively. Endoscopic N-J tube placement was technically successful in 20 out of 21 patients (95%). One patient had aspirated pneumonia. There was no procedure-related mortality. After N-J tube removal, clinical success was demonstrated in 19 out of 20 patients (95%) at the median duration of 6 months. One patient underwent reoperation due to repeated tube dislodgement.ConclusionsEndoscopic stenting with a 16-F naso-jejunal tube across the angulated segment is safe and effective for treatment of patients with uncomplicated early postoperative partial jejunal limb obstruction following gastric surgery with jejunal reconstruction.