Supparerk Prichayudh

Management of liver injuries: Predictors for the need of operation and damage control surgery

UNLABELLED Management of liver injuries: Predictors for the need of operation and damage control surgery, INTRODUCTION The advancement in the management of liver injuries, including the use of non-operative management (NOM), damage control surgery (DCS) and angiographic embolisation (AE); has resulted, in improvement of outcomes. The aim of this study is to analyse the outcome of liver injury patients in our institution and to identify predictors for the need of operative management (OM) and DCS. PATIENTS AND METHODS We retrospectively reviewed 218 patients with liver injury admitted to King, Chulalongkorn Memorial Hospital from May 2002 to May 2011. Data collection included demographic, data, emergency department parameters, detail of liver injuries, and outcome in terms of mortality rate (MR). Stepwise logistic regression was performed to identify mutually independent predictors for the need of OM and DCS. RESULTS Two hundred and eighteen patients with liver injury were identified (156 blunt and 62 penetrating). One hundred fifty-four patients (70.6%) underwent OM due to hemodynamic instability, (96), peritonitis (24), and other indications (34). DCS (perihepatic packing and temporary abdominal, closure) was utilised in 45 patients. NOM was attempted in 64 patients (29.4%), 6 of these, subsequently required laparotomy (success rate 90.6%). Angiography was performed in 47 patients, (14 in NOM, 33 in OM) and 40 patients received AE (10 in NOM, 30 in OM). Overall MR was 17.4%, the, MR was significantly higher in OM than in NOM (24 vs. 1.6%; p<0.001, OR 19.92). The mutually independent predictors for the need of operation were low Glasgow Coma Score (GCS), penetrating mechanism, tachycardia, and hypotension; while the independent predictors for DCS were high grade (>4) liver injury, tachycardia, and blunt mechanism. CONCLUSIONS Overall MR of liver injury patients was 17.4%. NOM carried a low MR and should be, attempted in the absence of hemodynamic instability and peritonitis. Patients with low GCS, penetrating injury, tachycardia, and hypotension were more likely to require operation. DCS should be considered while operating on patients with high grade liver injury, tachycardia, and blunt mechanism.

Pancreaticoduodenectomy with External Drainage of the Pancreatic Remnant

OBJECTIVE Leakage of the pancreaticojejunal anastomosis is a serious complication after pancreaticoduodenectomy. External drainage of the pancreatic remnant is one of several methods for reducing pancreaticojejunal anastomotic leakage or fistula. We investigated complications after pancreaticoduodenectomy with and without external drainage of the pancreatic remnant. METHODS Patients who underwent pancreaticoduodenectomy at King Chulalongkorn Memorial Hospital, Bangkok, Thailand from November 1991 to October 2007 were enrolled. Before 2001, no external pancreatic drainage was employed during pancreaticojejunal anastomosis (non-stented group). Since 2001, external drainage of the pancreatic remnant has been routinely performed with a paediatric feeding tube (stented group). RESULTS There were 28 patients in the non-stented group and 45 in the stented group. Stented patients had undergone significantly more previous abdominal operations, pylorus preserving pancreaticoduodenectomy, and end to end anastomosis of the pancreatic remnant and jejunal limb. Leakage of the pancreaticojejunal anastomosis or pancreatic fistula, overall complications, and re-laparotomy rate were significantly higher in the non-stented group (leakage or fistula 21.4% vs. 6.7%, overall complications 50% vs. 33.3%, and re-laparotomy 18% vs. 2.2%). The only death was in the non-stented group. CONCLUSION External drainage of the pancreatic remnant after pancreaticoduodenectomy is an effective method for prevention of pancreaticojejunal anastomosis leakage and other related complications.

Management of Open Abdomen with an Absorbable Mesh Closure

PurposeTo examine the methods and results of treatment in patients with an open abdomen (OA) at a single institution where an absorbable mesh closure (AMC) is most commonly used.MethodsA retrospective study was performed in OA patients from January 2001 to June 2007. Outcomes were analyzed in terms of enteroatmospheric fistula (EAF) formation and survival.ResultsThere were 73 OA patients receiving definitive closures (40 trauma and 33 nontrauma). Twenty-four patients were able to undergo a delayed primary fascial closure (DPFC) after initial vacuum pack closure (DPFC rate 33%). The DPFC rate was significantly lower in patients with an associated infection or contamination (9% vs 44%, P = 0.002). The EAF and mortality rates of the DPFC group were 0% and 13%, respectively. Absorbable mesh closure was used in 41 of 49 patients who failed DPFC (84%). There were 9 patients who had EAF (overall EAF rate 12%), 6 of whom were in the AMC group (EAF rate 15%). The overall and AMC group mortality rates were 29% and 37%, respectively.ConclusionAbsorbable mesh closure carries high EAF and mortality rates. Therefore, DPFC should be considered as the primary closure method. Absorbable mesh closure should be reserved for patients who fail DPFC, especially those with peritonitis or contamination.