Operative Management of Small Bowel Fistulae Associated with Open Abdomen

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

Pancreaticoduodenectomy with External Drainage of the Pancreatic Remnant

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

Colorectal adenocarcinoma in cirrhotic patients

Colorectal carcinoma in cirrhotic patients is different from that in patients without the liver disease. The aims of this study were to evaluate the incidence of liver metastasis, postoperative mortality, and the predictors of longterm survival