Trauma Hybrid Operating Room (THOR) shortened procedure time in abdominopelvic trauma patients requiring surgery and interventional radiology procedures

INTRODUCTION

Abdominopelvic injuries are common, and bleeding occurring in both cavities requires various bleeding control techniques i.e., laparotomy, angiographic embolization (AE), and orthopedic fixation. Hence, the use of Trauma Hybrid Operating Room (THOR) in abdominopelvic injuries has theoretical advantages including rapid bleeding control and minimizing patient transportation. The objective of the present study is to evaluate the impact of THOR in abdominopelvic injuries.

METHOD

A pre-post intervention study of abdominopelvic injury patients requiring both surgery and interventional radiology (IR) procedures for bleeding control from January 2015 to May 2020 was conducted. The patients were divided into 2 groups, pre-THOR group (received surgery in OR and scheduled for IR procedures in a separate IR suite, before December 2017) and THOR group (received all procedures in THOR, after December 2017). The primary outcomes were procedure time (including transit time in the pre-THOR group) and mortality.

RESULTS

Ninety-one abdominopelvic trauma patients were identified during the study period, 56 patients in pre-THOR group and 35 patients in THOR group. Distribution of injuries was similar in both groups (59 abdominal injuries, 25 pelvic fractures, and 7 combined injuries). The bleeding-control interventions in both groups were 79 laparotomies, 10 preperitoneal pelvic packings, 12 pelvic fixations, 45 liver AEs, and 21 pelvic AEs. THOR group underwent significantly less thoracotomy (1 vs. 11, p = 0.036), more resuscitative endovascular balloon occlusion of the aorta (REBOA, 0 vs. 5, p = 0.014), and more pelvic AE (13 vs. 9, p = 0.043). The procedure time was significantly shorter in THOR group (153 min vs. 238 min, p = 0.030). Excluding the transit time in the pre-THOR group, procedure time was not significantly different (153 vs. 154 min, p = 0.872). Both groups had similar mortality rates of 34%, but the mortality due to exsanguination was significantly lower in THOR group (11% vs. 34%, p = 0.026).

CONCLUSIONS

THOR eliminated transit time, resulting in shorter procedure time in abdominopelvic trauma patients requiring bleeding-control intervention. Although overall mortality reduction could not be demonstrated, the mortality due to exsanguination was reduced in THOR group.

Outcomes of pancreaticoduodenectomy in patients with obstructive jaundice with and without preoperative biliary drainage: a retrospective observational study

Background

Preoperative biliary drainage (PBD) in patients with obstructive jaundice from periampullary neoplasms may reduce the untoward effects of biliary obstruction and subsequent postoperative complications. However, PBD is associated with bile contamination and increases infectious complications after pancreaticoduodenectomy (PD).

Objectives

To determine whether PBD is associated with more complications after PD.

Methods

Patients with obstructive jaundice from periampullary lesions who underwent PD from 2000 to 2015 at our institution were retrospectively enrolled. The cohort was divided into a group with PBD and a group without. PBD was performed using one of the following methods: endoprosthesis, percutaneous transhepatic biliary drainage, surgical biliary-enteric bypass, or T-tube choledochostomy. PDs were performed by the first author using uniform surgical techniques. Postoperative complications were recorded. Statistical analyses were conducted using an unpaired t, Fisher exact, or chi-squared tests as appropriate.

Results

There were 26 with PBD and 28 patients without. Patients in the 2 groups were similar in age, presenting serum bilirubin level, operative time, operative blood transfusion, and hospital stay. The group with PBD had longer duration of jaundice, more patients presenting with cholangitis, and more patients with carcinoma of the ampulla of Vater. The overall complications were higher in patients in the group with PBD than in the group without.

Conclusions

PBD was associated with more complications overall after PD. However, PBD was necessary and lifesaving in certain clinical situations and improved the condition of patients before they underwent PD. Routine PBD in patients with obstructive jaundice without definite indications is not recommended.

Abdominal vascular injuries: Blunt vs. penetrating

INTRODUCTION

Abdominal vascular injuries (AVIs) remain a great challenge since they are associated with significant mortality. Penetrating injury is the most common cause of AVIs; however, some AVI series had more blunt injuries. There is little information regarding differences between penetrating and blunt AVIs. The objective of the present study was to identify the differences between these two mechanisms in civilian AVI patients in terms of patient's characteristics, injury details, and outcomes.

METHOD

From January 2007 to January 2016, we retrospectively collected the data of AVI patients at King Chulalongkorn Memorial hospital, including demographic data, details of injury, the operative managements, and outcomes in terms of morbidity and mortality. The comparison of the data between blunt and penetrating AVI patients was performed.

RESULTS

There were 55 AVI patients (28 blunt and 27 penetrating). Majority (78%) of the patients in both groups were in shock on arrival. Blunt AVI patients had significantly higher injury severity score (mean(SD) ISS, 36(20) vs. 25(9), p = 0.019) and more internal iliac artery injuries (8 vs. 1, p = 0.028). On the other hand, penetrating AVI patients had more aortic injuries (5 vs. 0, p = 0.046), and inferior vena cava injuries (7 vs. 0, p = 0.009). Damage control surgery (DCS) was performed in 45 patients (82%), 25 in blunt and 20 in penetrating. The overall mortality rate was 40% (50% in blunt vs. 30% in penetrating, p = 0.205).

CONCLUSIONS

Blunt AVI patients had higher ISS and more internal iliac artery injuries, while penetrating AVI patients had more aortic injuries and vena cava injuries. Majority of AVI patients in both groups presented with shock and required DCS.

Randomized controlled trial of chest tube removal aided by a party balloon

Background Recurrent pneumothorax is one of the most common complications after thoracostomy tube removal. The purpose of this study was to assess the optimal method of thoracostomy tube removal by comparing party balloon-assisted Valsalva and classic Valsalva techniques. Methods Trauma patients with indications for tube thoracostomy from 2014 to 2015 were recruited. Exclusion criteria were age < 15- or > 64-years-old, history of chronic lung disease, Glasgow Coma Scale < 13, latex allergy, or tracheostomy. Participants were randomly allocated by randomized block design into 4 groups using different Valsalva maneuvers: group A: classic inspired, group B: classic expired, group C: balloon-inspired; and group D: balloon-expired. The primary and secondary outcomes were recurrent pneumothorax and respiratory complications. Results Forty-eight tube thoracostomies were randomized for analysis; 4 patients had bilateral tube thoracostomies. The mean patient age was 38.1 ± 19.9 years. The incidence of recurrent pneumothorax confirmed by chest radiography was 15.4% in group A, 16.8% in group B, and none in groups C and D ( p = 0.31). When group A combined with group B was compared with groups C and D, the incidence was 16% vs. 0%, respectively ( p = 0.11). The thoracostomy tube reinsertion rate in all 4 groups was 0%, 8.33%, 0%, and 0%, respectively, which was not significant ( p = 0.38). Conclusions Performing the Valsalva maneuver correctly during full inspiration may be the method of choice for removing thoracostomy tubes. Using a party balloon forces the patient perform the Valsalva maneuver adequately and is simpler to explain.

Hepatic resection using ultrasonic surgical aspirator

Background

Hepatic resections conducted for malignant tumors can be difficult because of the need to create cancer-free margins.

Objectives

To examine the outcome of hepatic resections after the introduction of a Cavitron Ultrasonic Surgical Aspirator (CUSA).

Methods

A retrospective study of patients who underwent hepatic resection by a single surgeon between April 1999 to March 2013.

Results

We included 101 patients with 104 hepatectomies. Most hepatic parenchymal transections were performed using a CUSA under intermittent hepatic inflow occlusion (Pringle maneuver). Thirty-five patients underwent a right hepatectomy, 11 a left hepatectomy, 6 a right hepatectomy and segment I resection, 6 a right lobectomy, and 46 underwent segmentectomies, wedge resections, or other types of hepatic resections. Biliary-enteric reconstruction with a Roux-en-Y limb of the jejunum to a hepatic duct of the hepatic remnant was performed in 28 patients. Operative time was 90–720 min (median 300 min, mean 327 ± 149 min). Operative blood transfusion was 0–17 units (median 3 units, mean 3.9 ± 3.6 units). Twenty-one hepatectomies were conducted without blood transfusion. Thirty-four postoperative complications occurred in 30 patients with a 9% reoperation rate. Perioperative mortality was 6%. Age, operative time, operative blood transfusion, reoperation, and complications were significantly associated with mortality.

Conclusion

Careful preoperative diagnosis and evaluation of patients, faultless surgical techniques, and excellent postoperative care are important to avoid potentially serious postoperative complications and mortality. The CUSA is an effective assisting device during hepatic parenchymal transection with a concomitant Pringle maneuver, apparently reducing operative blood loss.

Surgical treatments of cystic neoplasms of the pancreas: an Asian university hospital experience

Background

Premalignant and malignant cystic neoplasms of the pancreas are relatively rare, but absolute indications for surgical resection. Modern imaging modalities have increased recognition of asymptomatic cysts resulting in therapeutic dilemmas of whether surgery or observation is appropriate.

Objectives

To examine our surgical experience with cystic neoplasms of the pancreas.

Methods

A retrospective study of patients who had cystic neoplasms of the pancreas and underwent surgical resections from June 2000 to April 2013. Presenting symptoms, surgical procedures, pathological diagnoses, and postoperative complications were analyzed.

Results

Data from 16 patients were examined. Two patients had asymptomatic cystic neoplasms. Fourteen had symptoms ranging from 2 days to 6 years before diagnosis and surgery. Six patients underwent pylorus preserving pancreaticoduodenectomy, 4 underwent distal pancreatectomy with splenectomy, 2 underwent splenic preserving distal pancreatectomy, and 1 each underwent a classical Whipple operation, total pancreatectomy, distal pancreatectomy with splenectomy with partial resection of the posterior gastric wall, and distal pancreatectomy with splenectomy with left colectomy. The operative time ranged from 150 to 450 minutes. Operative blood transfusion ranged from 0 to 5 units. Four patients had mucinous cystadenoma, 4 had intraductal papillary mucinous neoplasia with varying degree of dysplasia and carcinomatous changes, 6 had other malignancies, and 2 had other benign cysts. Postoperative complications occurred in 3 patients. There was no perioperative mortality.

Conclusion

Any suspicion of malignant changes in asymptomatic cysts should have them considered for surgical resection. Meticulous surgical techniques are important for pancreatic resection to minimize the occurrence of postoperative complications.

Selective management of penetrating neck injuries using "no zone" approach

INTRODUCTION

Selective management has been the standard management protocol in penetrating neck injuries (PNIs) since this approach has significantly reduced unnecessary neck exploration. The purpose of this study is to evaluate outcomes of selective management in PNIs using the "no zone" approach, in which the management is guided mainly by clinical signs and symptoms, not the location of the neck wounds.

MATERIALS AND METHODS

A retrospective study was performed in patients treated for PNIs at King Chulalongkorn Memorial Hospital (KCMH) from January 2003 to December 2013. The patients with hard signs of neck injury (i.e., active bleeding, significant haematoma, massive subcutaneous emphysema, and air bubbling through the neck wound) underwent emergency neck exploration. The asymptomatic patients and the patients with soft signs (other symptoms) were considered to be candidates for selective management. Data collection included demographic data, emergency department parameters, details of neck injury, and outcomes in terms of mortality, negative exploration rate, and missed injury rate.

RESULTS

Eighty-six PNI patients were treated at KCMH from 2003 to 2013, 64 of which sustained stab wounds, 12 gunshot wounds, 4 shotgun wounds, and 6 other causes. Thirty-six patients presenting with hard signs underwent immediate neck exploration and there were 2 negative explorations. Twenty-six patients with soft signs underwent selective investigations (including computed tomographic angiography in 21 patients), 5 patients required neck explorations due to positive results of the investigations with one negative exploration. All of the twenty-four asymptomatic patients were managed with close observation, none required subsequent neck exploration. There was no missed injury found in the present study. Successful non-operative management was carried out in 45 patients (52%). The overall negative exploration rate was 7% (3 in 41 patients undergoing neck exploration). Two patients with hard signs died from associated chest injuries (mortality rate 2%).

CONCLUSION

Selective management of penetrating neck injuries based on physical examination and selective use of investigations (no zone approach) is safe and simple with low negative exploration rate and no missed injury.

Induced Hypothermia in a Penetrating Trauma Patient with Cardiac Arrest from Exsanguination: The First Case Report

The authors report the use of induced hypothermia in a stab wound patient with left common femoral artery injury who had cardiac arrest from exsanguination immediately after arriving at a private hospital. The patient was transferred to the authors' institution (a university hospital) after successful cardiopulmonary resuscitation, for vascular repair. The patient remained comatose five hours after the vascular repair. The induced hypothermia (target body temperature of 33°C) was initiated 10 hours post arrest after the bleeding control and physiologic derangement restoration had been achieved. The patient recovered uneventfully with good neurological outcome.

Incidence and associated factors of deep vein thrombosis in Thai surgical ICU patients without chemoprophylaxis: one year study

BACKGROUND

Deep vein thrombosis (DVT) is a major problem in the intensive care unit (ICU) patients, especially in Western countries. However; because the incidence of DVT in Asia ICU is lower, chemoprophylaxis (i.e., anticoagulant) is not routinely utilized. The aim of the present study was to identify the incidence and associated factors of DVT in Thai surgical ICU (SICU) patients without chemoprophylaxis.

MATERIAL AND METHOD

SICU patients admitted between June 2011 and July 2012 were screenedfor lower extremity DVT using doppler ultrasonography. Stepwise logistic regression was performed to identify associated factors for the development of DVT.

RESULTS

Three hundred andfive patients were included in the study, 174 were male (57%) and 131 were female (43%), with ages ranged from 15 to 99 years (mean 62.8 years). Eleven patients had DVT identified (DVT rate 3.6%), two of these had symptomatic pulmonary embolisms. The associated factors for the development of D VT were prior history of venous thromboembolism (p < 0.001, OR 34.3, 95% CI 14.6-80.5), orthopedics group (p < 0.001, OR 27.2, 95% CI 5.2-142.1), and female (p = 0.034, OR 14.3, 95% CI 1.7-102.5).

CONCLUSION

The incidence of D VT in Thai SICU patients was 3.6%. Further study is required to identify method and effectiveness of DVT prophylaxis in Asian ICU patients.

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

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.

Experience with surgical treatment of retroperitoneal soft tissue sarcomas at a university hospital in Thailand

BACKGROUND

Retroperitoneal soft tissue sarcomas (RSTS) are rare malignant tumors with a distinguishing feature of slow growth in the silent retroperitoneal space. The patients usually present late with a large retroperitoneal mass surrounded by the major vascular structures and visceral organs rendering curative resection an extremely difficult and risky operation. The purpose of the present study was to demonstrate surgical experience and results of treatment of RSTS at King Chulalongkorn Memorial Hospital. Operative techniques of these complex surgical procedures were also described.

MATERIAL AND METHOD

A retrospective study was performed in patients who had RSTS and underwent surgical resection between June 2003 and November 2011 at King Chulalongkorn Memorial Hospital, Bangkok, Thailand. All patients were followed after the operations until death or last follow-up at the out-patient clinic in October 2012. Data collection included demographic data, details of operations, operative complications, neoadjuvant and adjuvant chemoradiation therapy, local recurrence, treatment of local recurrence, and 5-year overall survival rate. Factors associated with local recurrence were also examined.

RESULTS

During the 9.4-year period, 18 patients entered into the present study. Fourteen (77.8%) were female and four (22.2%) were male. The age ranged from 44 to 80 years (median 53.5 years). Duration of symptoms ranged from one week to 24 months (median 3.5 months). The tumor size ranged from 10 to 48 cm (median 27 cm) in greatest dimension. All patients underwent preoperative CT scan. Preoperative core needle biopsy was performed in one patient. One patient had preoperative radiation therapy. Sixteen patients (88.9%) underwent complete gross resection (CGR) (R0 or R1 resection) and two (11.1%) had palliative resection (R2 resection). All patients who had CGR (n = 16) had one or more contiguous organ resection (kidney 87.5%, colon 50%, or adrenal gland 43.7%). The operative time ranged from 120 to 360 minutes (median 330 minutes). The operative blood transfusion ranged from 0 to 12 units (median 2.5 units). Postoperative bleeding complication requiring reoperation occurred in three patients (16.7%). One patient had postoperative uncomplicated pancreatic fistula. There was no perioperative mortality. The final pathological reports were liposarcoma in 15 patients (83.3%). Other histology were atypical lipomatous tumor malignant fibrous histiocytoma, and unspecified spindle cell tumor in one patient each. Two patients who had palliative resection died at six and 16 months after the operations. Local recurrence occurred in five patients who had CGR (31.3%). One of them died at 60 months after the operation. The median follow-up time in patients who underwent CGR was 39.5 months (range 12-114 months). The 5-year overall survival of the entire cohort was 73.5% (95% CI: 44.3-88.4%). The 5-year overall survival of patients who had CGR was 83.3% (95% CI: 53.5-98.5%). Univariate analysis of the tumor size, tumor grading, status of the surgical margins, and primary operation or re-resection revealed no statistical significance in patients who had CGR with and without local recurrence.

CONCLUSION

Acceptable outcomes after complete surgical resection of the RSTS were achieved from this small but important case-series. The authors have demonstrated that CGR with concomitant resection of the contiguous organs can be safely performed in patients with large RSTS. Preoperative CT scan was invaluable for diagnosis and treatment plan. Preoperative core needle biopsy was not necessary when preoperative CT scan was diagnostic. Intention for curative resection should be attempted whenever possible to minimize chance of local recurrence and improve survival. Experience of the surgical team is an important factor for successful results when conducting these technically demanding operations.

Damage control surgery in blunt cardiac injury

Background: Blunt cardiac injury (BCI) is a rare, but life threatening injury. The treatment of BCI is surgical repair. However, in a BCI patient with hypothermia, acidosis, and coagulopathy, an attempt to control the bleeding completely by surgery alone may not be successful. Damage control principles should be used in this situation.

Objective: To study a BCI patient who underwent a successful operation using damage control principles.

Methods: We reviewed and analyzed the patient’s chart, operative notes and follow up visit records. Review of the literature regarding the issue was also conducted.

Results: We report the case of a patient with BCI who developed hypothermia and coagulopathy during surgery. Abbreviated surgical repair was performed with a right pleuropericardial window created to avoid blood accumulation in the pericardial sac. Subsequent aggressive resuscitation was performed in the intensive care unit. We accepted ongoing bleeding through the right chest tubes while correction of hypothermia and coagulopathy was undertaken. The bleeding was gradually stopped once the patient’s physiology was restored. Although the patient developed a retained right hemothorax requiring subsequent video-assisted thoracoscopic surgery on the third postoperative week, he recovered uneventfully and was discharged on postoperative day 36.

Conclusion: In patients with BCI who develop coagulopathy during surgery, terminating the operation quickly and creating a pleuropericardial window is a possible bailout solution because this can prevent postoperative cardiac tamponade without leaving the chest open. Continue bleeding from the chest tubes is acceptable provided that adequate resuscitation to correct coagulopathy is underway.

Management of difficult abdominal wall problems by components separation methods: a preliminary study in Thailand

BACKGROUND

Acute (open abdomen) and late (ventral hernia) abdominal wall defects are difficult surgical problems requiring appropriate management for acceptable results. Several methods of abdominal wall reconstruction in these patients have been introduced with varying outcomes. Components separation method (CSM) is an autologous tissue repair that has been employed for such situations with satisfaction by many investigators. The authors have adopted this method of abdominal wall repair or reconstruction and used it in our patients with difficult abdominal wall problems since May 2005. The aim of the present study was to examine results of treatment of patients with large abdominal wall defects by CSM at our institution. A brief demonstration of surgical techniques and discussion of the related issues were also made.

MATERIAL AND METHOD

All patients with difficult abdominal wallproblems treated by CSM at King Chulalongkorn Memorial Hospital, Bangkok, Thailand between May 2005 and June 2012 were examined and analyzed The patients were divided into two groups, i.e. acute (open abdomen) and late (ventral hernia). Different methods of repair or reconstruction by CSM were described. No prosthetic mesh was used in the present study. Postoperative follow-up was done until August 2012. Operative morbidity and late sequelae were studied.

RESULTS

Twenty-six patients entered into the study. Eight (30.8%) underwent closure of acute abdominal wall defects and 18 (69.20%) underwent late ventral hernia repair. Four patients (50%) who underwent closure of acute abdominal wall defects also had closure of associated entero-atmospheric or small bowel fistulae. Four patients (22.2%) who underwent late ventral hernia repair also had closure of associated ileostomy or colostomy. Three types of CSM were used in the present study; i.e. original or standard components separation (SCS), modified components separation (MCS), and SCS plus bilateral anterior rectus abdominis sheath turnover flap (RSTF). Complications included seroma under the skin flap in one patient in the early closure group, two wound infections, two seroma under the skin flap, and one skin flap dehiscence in the late ventral hernia repair group. One small, asymptomatic recurrent ventral hernia was found during the follow-up period of the late ventral hernia repair patients (5.6%).

CONCLUSION

CSM is a good alternative for management of difficult abdominal wall problems, especially in situations that employment of prosthetic mesh may be inappropriate. Its advantages are avoidance of prosthetic mesh and low risk of infection in potentially infected environment. It is versatile in various abdominal wall problems even in large abdominal wall defects. CSM is recommended when associated enteric fistula, ileostomy, colostomy closure, or other potentially infected procedures are simultaneously performed.

Lessons learned from 100 personal consecutive cases of pancreaticoduodenectomy at a university hospital in Thailand

BACKGROUND

Pancreaticoduodenectomy (PD) is a major operation with potential disastrous complications. Experience of the surgical team with high surgical volume is an important factor contributing to better outcome. The purpose of this study was to examine results of 100 consecutive cases of PD operated by the first author. Various aspects of this technically demanding operation related to our experience were discussed and reviewed.

MATERIAL AND METHOD

A retrospective study of 100 patients who had undergone PD during a period of 20.5 years was presented. The indications for PD were periampullary neoplasms or other symptomatic lesions at the pancreatic head. All patients had preoperative CT scan to evaluate extent of the disease and resectability. Preoperative biliary drainage was performed in selected cases. The operations were conducted in the same manner in most cases. Before 2000, no external drainage of the pancreatic remnant was used. Since 2000, external drainage of the pancreatic remnant was routinely used, except in one patient who had total pancreatectomy. Postoperative complications and mortality were studied.

RESULTS

Carcinoma of the ampulla of Vater and carcinoma of the head of the pancreas were the leading indications for PD (34% and 30%, respectively). No preoperative tissue diagnosis was made in patients who had carcinoma of the head of the pancreas. Two patients had emergency PD because of massive gastrointestinal bleeding. Sixty seven per cent underwent pylorus preserving PD (PPPD) and 33% underwent classical PD. Twenty eight patients had no external pancreatic drainage, 71 had external pancreatic drainage, and one had total pancreatectomy. The postoperative morbidity and mortality were 44% and 2%, respectively. The postoperative pancreatic fistula rate was higher in patients without external pancreatic stent but no statistical significance was detected (21.4% vs. 12.7%, NS). There was no mortality in patients aged > 70 years (n = 29) while two patients aged < 70 died (n = 71). The difference was not statistically significant.

CONCLUSION

PD could be safely performed with low pancreatic fistula and low mortality rate by experienced surgeons. Preoperative CT scan is extremely helpful in evaluation the extent of the disease and resectability. In patients with suspected carcinoma of the pancreatic head, PD should be performed without preoperative tissue diagnosis by experienced pancreatic surgeons. Elderly (aged > 70 years) is not a contraindication for PD. We strongly recommend the use of external pancreatic stent to prevent pancreatic fistula.

Cardiac trauma: has survival improved? A university hospital experience in Bangkok, Thailand

BACKGROUND

Cardiac trauma, if not recognized and properly treated, will lead to a fatal outcome. For the past 16 years, the authors' policy for diagnosing and treating cardiac trauma has not changed but the survival rate in our institute has improved when compared between the two cohorts.

OBJECTIVE

Study the factors for survival in patients with cardiac trauma.

MATERIAL AND METHOD

Data was collected from chart review between September 1994 and April 2010. Patients presenting in extremis with suspected cardiac trauma will receive emergency room thoracotomy. Patients with equivocal Focused Assessment with Sonography for Trauma will receive formal transthoracic echocardiography. If still in doubt, the authors' policy will proceed with intra operative subxiphoid window and a set up for median sternotomy.

RESULTS

Throughout the study period, 44 patients had cardiac trauma and the overall mortality rate was 13.6%. Four patients had blunt injury resulting in one ventricular septal defect and three ruptured right atrium. Right ventricle was injured the most 44%, right atrium 23%, left ventricle 20%, left atrium 2%, one patient had superior vena cava injury, and another patient had inferior vena cava injury. In this cohort, 30% underwent emergency room thoracotomy. Associated injuries were presented in 38% of cases.

CONCLUSION

High index of suspicion and prompt management for cardiac trauma should be considered in patients presenting with injuries to the chest, which has been the authors' policy for the past 16 years. The mortality rate had dropped from 26% to 4% but is not statistically significant.

Management of open abdomen with an absorbable mesh closure

PURPOSE

To 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.

METHODS

A 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.

RESULTS

There 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.

CONCLUSION

Absorbable 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.