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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.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.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).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.

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.

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 64-years-old, history of chronic lung disease, Glasgow Coma Scale 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.

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.

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.

Management of liver injuries: Predictors for the need of operation and damage control surgery,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.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.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%; p0.001, 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.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.

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.

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.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.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.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.

Background The Mangled Extremity Severity Score (MESS) is an objective criterion for amputation prediction after lower extremity injury as well as for amputation prediction after upper extremity injury. A MESS of C7 has been utilized as a cutoff point for amputation prediction. In this study, we examined the result of upper extremity vascular injurty (UEVI) management in terms of the amputation rate as related to the MESS. Methods During January 2002 to July 2007, we reviewed patients with UEVIs at our institution. Data collections included demographic data, mechanism of injuries, injury severity score (ISS), ischemic time, MESS, pathology of UEVI, operative management, and amputation rate. Decisions to amputate the injured limbs at our institution were made individually by clinically assessing limb viability (i.e., color and capillary refill of skin; color, consistency, and contractility of muscles) regardless of the MESS. The outcome was analyzed in terms of the amputation rate related to the MESS. Results There were 52 patients with UEVIs in this study: 25 (48%) suffered blunt injuries and 27 (52%) suffered penetrating injuries. The age ranged from 15 to 59 years (mean 28.7 years). The mean ischemia time was 10.07 h. The mean ISS was 17.52. There were 12 patients (23%) with subclavian artery injuries, 3 patients (5.76%) with axillary artery injuries, 18 patients (34.61%) with brachial artery injuries, and 19 patients (36.54%) with radial artery and/or ulnar artery injuries. Primary repairs were performed in 45 patients (86.54%), with ligations in 3 patients (5.77%). An endovascular stent-graft was used in one patient (1.92%). Primary amputations were performed in three patients (5.77%). Secondary amputations (amputation after primary operation) were done in 4 of 49 patients (secondary amputation rate 8.16%). All amputation patients suffered blunt injuries and had a MESS of C7 (range 7–11). The overall amputation rate in this study was 13.46% (7/52 patients). Multivariate analysis revealed that the only factor significantly associated with amputation was the MESS. There were no amputations in 33 patients who had a MESS of\7. We could avoid amputation in 12 of 19 patients who had a MESS C7. There were no mortalities among 52 UEVI patients. Conclusions MESS, an outcome score used to grade the severity of extremity injuries, correlates well with the risk of amputation. Nevertheless, a MESS of C7 does not always mandate amputation. On the other hand, the MESS is a better predictor for patients who do not require amputation when the score is \7. The decisions to amputate in patients should be made individually based on clinical signs and an intraoperative finding of irreversible limb ischemia.

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.

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.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.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 (p0.001, OR 34.3, 95% CI 14.6-80.5), orthopedics group (p0.001, OR 27.2, 95% CI 5.2-142.1), and female (p = 0.034, OR 14.3, 95% CI 1.7-102.5).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.

s 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.

Background Gastrointestinal fistulae associated with open abdomen are serious complications following trauma or other major abdominal surgery. Management is extremely difficult and the mortality is still high in spite of modern medical advances. Patients who survive initial physiological and metabolic derangements require operative closure of the fistula, which is technically demanding and poorly described in the literature. Methods A retrospective study of patients with small bowel fistulae associated with open abdomen was performed. Only patients who were stabilized sufficiently to undergo surgical closure of the fistula were enrolled in the study. The operative techniques comprised three important steps: exploratory laparotomy and resection of small bowel fistulae with end-to-end anastomosis; bridging the abdominal wall defect with a sheet of polyglycolic acid mesh; and covering the mesh with bilateral bipedicle anterior abdominal skin flaps. Results Eight patients were included in the study. The number of operations before surgical closure of the fistula ranged from one to six (mean, 3.6). The time from first operation to surgery for fistula closure ranged from 2.5 to 7.5 months (mean, 4.4 months). Three patients had recurrent fistula, and one died (mortality, 12.5%). Hospital stay ranged from 101 to 311 days (mean, 187 days). Conclusion We present a method of closure of small bowel fistulae associated with open abdomen and hope that this will provide surgeons encountering such complications with a good alternative for surgical management.

Background: Early revascularization of ischemic limbs is an important step in the management of complex extremity vascular injuries (CEVIs). We present our experience of using a temporary intravascular shunt (TIVS) in the management of patients with limb-threatening vascular injuries. Methods: Patients who had CEVIs at our institution from January 1996 to December 2000 were treated with early insertion of a TIVS at the initial phase of operations. The TIVSs were assembled from simple intravenous and extension tubes available in the operating room. Rigid stabilization of the injured bones and/or joints, debridement of the devitalized soft tissues, saphenous vein harvest for interposition grafts, and repair of any associated venous injuries were performed while the shunts were in place. Then, the shunts were removed and the injured arteries were repaired. Results: There were five men and two women in this series. The preoperative time ranged from 120 to 450 minutes (median, 390 minutes). All TIVSs were inserted within the initial 30 minutes of operation. The injured arteries were popliteal (five patients), common femoral (one patient), and brachial arteries (one patient). Three patients also had associated venous injuries (i.e., two popliteal veins and one common femoral vein). Six injured arteries were repaired with reversed saphenous vein grafts and one (popliteal artery) was repaired by end-to-end anastomosis. The shunt time ranged from 60 to 180 minutes (median, 120 minutes). One patient had a TIVS inserted into both injured popliteal artery and vein. The operative time ranged from 225 to 360 minutes (median, 285 minutes). No complications related to shunt insertion were observed and all limbs could be salvaged. Concluslon: A self-constructed shunt is inexpensive, safe, and convenient to insert. Early revascularization of the injured limb with a TIVS can eliminate the adverse effects of prolonged ischemia and enables the surgeons to manage other associated injuries in an unhurried manner. We recommend early insertion of TIVSs in CEVIs.

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.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.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.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.

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.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.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%).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.

Intramural duodenal haematoma (IDH) associated with blunt abdominal trauma is a rare condition. Patients usually present with gradual onset of vomiting and abdominal pain approximately 48 h after the injury. The haematoma usually resolves in 1—3 weeks with conservative therapy. Traditionally operations are reserved for patients with suspected duodenal perforation, bile or pancreatic duct compression and inadequate resolution of the haematoma after 7—14 days of conservative treatment. However, with advances in parenteral nutrition and critical care, we believe that prolonged conservative treatment should be acceptable in patients without perforation. In this report, we describe a patient with large IDH associated with blunt abdominal trauma causing gastric outlet obstruction and obstructive jaundice who had successful outcome after a long period (more than 3 weeks) of conservative treatment.

Simple cysts are common benign lesions of the liver. Treatment is reserved for symptomatic patients. Current management includes percutaneous aspiration with instillation of sclerosing agents, wide excision or unroofing, or fenestration of the cyst wall (50%) either by open or laparoscopic surgery. Total excision of the cyst wall is infrequently mentioned. The authors report a case of a large, recurrent simple cyst of the liver that was successfully treated by total excision.

Relaparotomy for abdominal sepsis is occasionally associated with wound edges necrosis and visceral edema prohibiting primary fascial closure. Planned ventral hernia with absorbable mesh is a life-saving method for abdominal wound management in such critically ill surgical patients.Examine results of treatment of patients who underwent relaparotomy for septic abdomen and closure of abdominal wound with absorbable mesh.A retrospective study of patients who underwent relaparotomy for abdominal sepsis and planned ventral hernia with absorbable mesh between 2004 and 2009 was performed Data analysis included indication for relaparotomy, type of absorbable mesh used, results of treatment, and status of patients during the follow-up period.Twelve patients participated to the present study Polyglycolic acid (Dexon) or polyglactin (Vicryl) mesh were used in six patients each. Final wound coverage was skin grafting in five patients (41.7%), skin flaps in one (8.3%), healing by secondary intention in five (41.7%), and human acellular dermal matrix and skin grafting in one (8.3%). One patient (8.3%) developed enterocutaneous fistula. There was no mortality. The hospital stay ranged from 17 to 201 days (mean 118 days).Planned ventral hernia with absorbable mesh is a good alternative in the management of patients who undergo relaparotomy for abdominal sepsis. The procedure is life-saving for these patients.

The authors report a case of extra-adrenal pheochromocytoma of the organ of Zuckerkandl presenting with hypertension and an abdominal mass in a young adult. Preoperative diagnosis was made by biochemical and imaging studies. The operation to remove the tumor was successfully performed. The patient remains normotensive and symptom free at 15-month follow-up. The authors also discuss the diagnostic modalities and surgical technique used in the presented patient.

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. [Asian J Surg 2008;31(4):167–73]

We report a 67-year-old man who presented with sudden onset of pain in the left flank in association with anemia and hypotension. Imaging studies revealed hepatocellular carcinoma (HCC) at the right lobe of the liver with bilateral adrenal metastases and recent hemorrhage in the left adrenal gland. His serology for hepatitis C was positive. Abdominal exploration with left adrenalectomy was performed. The postoperative course of the patient was uneventful and three cycles of transarterial chemoembolization (TACE) were administered. His general condition gradually deteriorated, and he died 6 months after surgery. Spontaneous massive AH due to metastatic HCC is unusual. Considering the high incidence of HCC in Asia, clinicians should be aware of this atypical and fatal presentation.

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.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.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.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%.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.

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.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.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.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.

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.

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.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.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.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.

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.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.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.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.

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.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.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.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.

Management of the open abdomen in trauma and nontrauma patients is difficult, and some areas of controversy remain. Gastrointestinal fistulas are serious complications that are associated with significant mortality. We present our method for management of patients with open abdomen and also present a logical technique of subsequent repair of the late giant ventral hernias that uniformly occur in these patients.From January 1992 to December 2001, nine patients with open abdomen underwent successful immediate closure with bilateral bipedicle anterior abdominal skin flaps. The major points of this technique of abdominal closure are coverage of abdominal viscera with absorbable mesh and mobilization of the skin and subcutaneous tissue on both sides of the abdominal wound to cover the absorbable mesh. All patients had uneventful recovery and also had subsequent late giant ventral hernias. Repair of the late giant ventral hernias was performed several months later by inserting a large sheet of nonabsorbable mesh under the rectus abdominis muscles that form the neck of the ventral hernia bilaterally. This technique of ventral hernia repair is also called retrorectus prosthetic mesh repair.Five men and four women were entered into the study. The age ranged from 22 to 53 years (median, 35 years). Seven patients suffered from blunt and penetrating trauma and two patients suffered from nontrauma causes. All patients with immediate closure of the open abdomen had uneventful recovery. Late giant ventral hernias (diameter,10 cm) occurred in all patients. The time from closure of the open abdomen to subsequent repair of the giant ventral hernias ranged from 7 to 48 months (median, 14 months). Follow-up after hernia repair ranged from 1 to 72 months (median, 9 months), and we have seen no evidence of recurrence.Immediate closure of the open abdomen with bilateral bipedicle anterior abdominal skin flaps is an effective technique for dealing with such potentially complicated problems. Management of late giant ventral hernias with retrorectus prosthetic mesh repair is theoretically reasonable and, so far, no recurrence has been observed in our patients.

To evaluate patients with stab wounds of the anterior abdomen with diagnostic peritoneal lavage (DPL), by using initial aspiration of gross blood from the lavage catheter of more than 10 ml or red blood cell (RBC) count in the lavage fluid of more than 10,000/mm3 as criteria for exploratory laparotomy.Prospective study.University hospital, Thailand.40 patients who had stab wounds of the anterior abdomen penetrating through the peritoneum but had no obvious indications for immediate exploratory laparotomy.Diagnostic peritoneal lavage (DPL), exploratory laparotomy.Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of positive DPL as an indication for exploratory laparotomy.In 27 patients (68%) the DPL was positive and in 13 (33%) it was negative. In 18 patients (67%) the initial aspiration of gross blood was more than 10 ml and in 9 (33%) the RBC count in lavage fluid was more than 10,000/mm3. These 27 patients had exploratory laparotomies, 2 of which were negative. All 13 patients who had negative DPL were observed and discharged home uneventfully. The sensitivity of DPL for positive laparotomy was 100%, the specificity was 87%, the PPV was 93%, the NPV was 100% and the accuracy was 95%. When operative findings of bleeding from the stab wound into the peritoneal cavity were considered as a "negative" laparotomy (n = 7) the sensitivity, the specificity, the PPV, the NPV and the accuracy became 100%, 59%, 67%, 100%, and 78%, respectively.The use of DPL in patients with stab wounds of the anterior abdomen, using initial aspiration of gross blood from the lavage catheter of more than 10 ml or RBC count in the lavage fluid of more than 10,000/mm3 as positive criteria for exploratory laparotomy, is safe and practical.

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 (Couinaud’s 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.

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.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 (P0.001). The hospital stay ranged from 1 to 300 days (mean 24.7 +/- 34.19).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.