Asian Journal of Surgery

Optimal Technique for Abdominal Fascial Closure in Liver Transplant Patients

Unal Aydin, Yazici Pinar, Kilic Murat — 2010-01-01

Background: The ideal technique for abdominal closure of a Mercedes-type incision, which is still a serious issue among surgeons, has yet to be demonstrated clearly. The purpose of this study was to explain our novel technique for abdominal fascial closure in liver transplant patients. Methods: We analyzed retrospectively 180 consecutive adult-to-adult right lobe living donor liver transplants. The patients were divided into two groups based on two abdominal closure types used. Group A consisted of 78 patients who were submitted to abdominal closure with our new technique using three synthetic absorbable loop suture materials, and group B consisted of 102 patients whose abdominal closure was performed with another type of closure technique. Results: There were no significant differences between the demographic characteristics of the two groups. The mean closure time was significantly lower in group A than in group B (p <0.05). The incidence rates of ascites leakage and hernias were also significantly lower in group A (p <0.05). Conclusion: Our results indicate that the novel technique used in this study contributed to overcoming early and late postoperative complications associated with closure of the abdominal fascia in liver transplant patients. In addition, this new technique has proven to be easily applicable, faster, safer and efficient in these patients; it is also potentially useful for conventional surgery.

Impact of Short Hepatic Vein Reconstruction in Living Donor Adult Liver Transplantation Using a Left Liver Plus Caudate Lobe Graft

2010-01-01

Objective: To investigate the impact of short hepatic vein reconstruction in the transplanted left liver plus caudate lobe graft. Methods: Six left liver plus caudate lobe grafts used for living donor adult liver transplantation were included in this study. The liver grafts were divided into two groups: those with (V1 group; n = 4) or without (control group; n = 2) short hepatic vein reconstruction. The changes in the transplanted left lobe (segments II-IV) and caudate lobe were compared between the two groups at 1 month after transplantation. Results: The addition of the caudate lobe increased the graft volume by 15 mL, which corresponded to a 4.3% gain of graft volume at the time of transplantation. Although the graft volume/standard liver volume ratio of the whole grafts after transplantation showed no difference between the two groups, the regeneration rate of the caudate lobe in the V1 group was significantly greater than that in the control group (p= 0.04). Conclusion: Although no definite advantage from the V1 reconstruction was demonstrated, hepatic vein reconstruction with a significantly-sized short hepatic vein might provide an additional margin of safety for marginally-sized liver grafts during the early phase of graft regeneration.

Reconstruction of Hypopharynx and Cervical Oesophagus for Treatment of Advanced Hypopharyngeal Carcinoma and Recurrent Laryngeal Carcinoma

Qing Xiao, Guo-Hua Hu, Shi-Xun Zhong, Yi Qian, Quan Zeng, Su-Ling Hong — 2010-01-01

Objective: To review our treatment strategy and outcomes in reconstructing the hypopharynx and cervical oesophagus with five techniques for advanced hypopharyngeal carcinoma and recurrent laryngeal carcinoma. Methods: Thirty-one patients treated between 1996 and 2007 were analysed retrospectively. Defects of the hypopharynx and cervical oesophagus were reconstructed using the remaining laryngeal mucosa flap, pectoralis major myocutaneous flap, forearm free flap, jejunal free flap or latissimus dorsi myocutaneous flap. Results: All patients were treated successfully. Postoperative pharyngocutaneous fistulas occurred in four patients, one of whom died from haemorrhage of carotid artery 1 month after surgery, and the other three resolved spontaneously. Dysphagia occurred in three patients, which was caused by food mass occlusion, or oesophageal stricture and stoma stricture. The 3- and 5-year survival rates were 59.3% and 43.5%, respectively. Conclusion: A consensus treatment strategy for reconstructing the defect following hypopharyngectomy and cervical oesophagectomy has not been established. Every technique has its advantages and disadvantages. The treatment of choice depends upon the location and size of the carcinoma as well as the patient's characteristics and the doctor's experience.

Primary Lymphoma of the Thyroid: Diagnostic and Therapeutic Considerations

Basro Sarinah, Abdullah-Noor Hisham — 2010-01-01

Background: Primary thyroid lymphoma is uncommon and accounts for less than 2–5% of all thyroid malignancies. The aim of the present study was to review our experience and management of primary thyroid lymphoma and to discuss the diagnostic and therapeutic considerations. Methods: Eleven women and six men with primary thyroid lymphoma were diagnosed and managed in our department between October 1998 and March 2006. The clinical course and pathological spectrum of this disorder affecting the thyroid gland were reviewed. Results: Twelve patients had a prior history of thyroid disease. Clinical symptoms included a rapidly enlarging neck mass (88%), dyspnoea (65%), dysphagia (53%) and hoarseness of voice (35%). Five patients were hypothyroid at the time of diagnosis. Fifteen patients underwent fine-needle aspiration cytology (FNAC). Six patients had an initial diagnosis of lymphocytic thyroiditis. FNAC results were highly suggestive of thyroid lymphoma in only five patients. In the remaining patients, FNAC results showed a follicular lesion in two patients and were inconclusive in the other two patients. A further incisional biopsy was performed in five patients, and a diagnosis of non-Hodgkin's lymphoma (NHL) was confirmed in four patients and inconclusive in one. Five patients had a core biopsy. Four revealed NHL and one had lymphocytic thyroiditis. Nine patients underwent surgery; three of whom had emergency debulking of the tumour for acute airway obstruction. A final diagnosis of thyroid lymphoma was confirmed in all these patients. Sixteen patients had B-cell and one had T-cell NHL. Fifteen patients received combination chemotherapy with or without irradiation. All tumours dramatically decreased in size soon after initiation of treatment. Overall survival was 82%, with a mean follow-up of 19 months. Conclusion: The diagnosis of primary thyroid lymphoma should be considered when dealing with rapidly growing goitres. The role of FNAC in diagnosing thyroid lymphoma is limited but it is still useful in the initial work-up. Nevertheless, surgical intervention is often required to establish the diagnosis and relieve critical airway compression. A combination of chemotherapy and irradiation is the mainstay of management.

Anti-adhesive Effect and Safety of Sodium Hyaluronate and Sodium Carboxymethyl Cellulose Solution in Thyroid Surgery

2010-01-01

Objective: A number of researchers have suggested the use of sodium hyaluronate carboxymethyl cellulose (HA-CMC) membrane for preventing postoperative adhesion. This study evaluated the anti-adhesive effect and safety of a newly developed HA-CMC solution in thyroidectomy. Methods: Seventy-four patients who underwent thyroidectomy were prospectively randomized. In the study group of 38 patients, 5 mL HA-CMC solution was applied to the operative field after thyroidectomy. The subjects were asked about adhesive symptoms using a four-item questionnaire at 2 weeks, 2 months and 6 months after surgery. In addition, three items on the appearance of neck wrinkles and scars were evaluated by a physician. Each item was scored from 0 to 10. Results: The mean (± standard deviation) total adhesion score at each visit was 15.22 ± 8.99, 10.42 ± 8.41, and 7.24 ± 5.83 for the control group and 19.29 ± 9.71, 9.46 ± 5.71, and 6.03 ± 4.32 for the study group. Total adhesion scores for both groups decreased with time (p < 0.001), but no significant differences were noted between the two groups (p > 0.066). There were no complications related to the HA-CMC solution. Conclusion: The HA-CMC solution did not decrease subjective or objective postoperative adhesion in patients undergoing thyroid surgery, although it was biologically safe.

Is Transurethral Catheterisation the Ideal Method of Bladder Drainage? A Survey of Patient Satisfaction With Indwelling Transurethral Urinary Catheters

Siew Pang Chan, Glenn Wei Leong Tan, Choon Kiat Ho — 2010-01-01

Objective: Bladder catheterisation is a routine part of major abdominal surgery. Transurethral catheterisation is the most common method of bladder drainage but is also notorious for its discomfort and increased risk of urinary tract infection. The present study aimed to establish patient satisfaction with transurethral catheterisation and to assess the incidence of clinically significant urinary tract infections after transurethral catheterisation through survey. Methods: All patients who underwent major open abdominal surgery between October 2006 and December 2008 and required standard transurethral bladder catheterisation, were asked to participate in the study. Fifty patients were recruited. Results: Male patients were more dissatisfied than their female counterparts with transurethral catheterisation (satisfaction score: 4.18/10 vs. 2.75/10; p = 0.05). Male patients had more than double the score for pain at the urinary meatus with the catheter in situ (p =0.012) and during urine catheter removal (p = 0.013). Half the patients in the study also had symptoms of urinary tract infection after catheter removal. Conclusion: Our study emphasised the discomfort of transurethral urinary catheters, especially in male patients, and the high incidence of urinary tract infections in both sexes. Consideration should be given to the utilisation of alternative methods of bladder drainage, such as suprapubic catheterisation, which can be performed with ease during laparotomy.

Effect of α1-Adrenergic Antagonists on Lower Ureteral Stones With Extracorporeal Shock Wave Lithotripsy

Huijun Wang, Ke Liu, Zhigang Ji, Hanzhong Li — 2010-01-01

Objective: To evaluate the efficiency of α1-adrenergic antagonists on stone clearance after extracorporeal shock wave lithotripsy (ESWL) in patients with lower ureteral stones. Methods: A total of 107 patients with solitary lower ureteral stones and who underwent single ESWL sessions were divided into two groups. Group 1 received our standard medical therapy, and group 2 was treated with 0.4 mg/day tamsulosin for a maximum of 2 weeks. All patients were re-evaluated with plain film radiography and ultrasound each week during treatment. Results: Twenty-four of the 52 patients in group 1 (46.2%) and 41 of 55 patients in group 2 (74.5%) (p =0.002) were found to be stone-free. Among patients with stones 10-15 mm in diameter, the stone-free rate was 36.4% in group 1 and 73.0% in group 2 (p = 0.003). Average stone expulsion time was 11.6 days and 8.1 days in groups 1 and 2, respectively (p = 0.000). Ureteral colic occurred in 10 patients (19.2%) in group 1 but only 3 patients (5.5%) in group 2 (p = 0.043). The only side effect of tamsulosin was slight dizziness in 2 of the 55 (3.6%) patients in group 2. Conclusion: Adjunctive therapy with α1-adrenergic antagonists after ESWL is more effective than, and equally as safe as lithotripsy alone in the treatment of patients with lower ureteral stones. The use of α1-adrenergic antagonists is more useful for stones with a large dimension, and can also reduce stone expulsion time and episodes of ureteral colic.

Role of High Augmentation Index in Spontaneous Intracerebral Haemorrhage

2010-01-01

Background: Intracerebral haemorrhage (ICH) is the most disabling and least treatable form of stroke. Its risk factors include old age, hypertension, diabetes mellitus, hypercholesterolaemia, smoking and high alcohol intake, which are also associated with arterial stiffness. The aim of the present study was to determine the prognostic value of high augmentation index (AI), which is a surrogate marker of arterial stiffness, in patients with spontaneous ICH. Methods: A prospective study of 60 patients with spontaneous supratentorial ICH was conducted. Outcome was assessed using the Modified Rankin Scale at 3 months follow-up. Data were collected on age and sex, risk factors for ICH, clinical parameters, laboratory parameters, radiological findings and hospital management. Logistic regression analysis was carried out to identify independent predictors of 3-month outcome and mortality. Results: Admission Glasgow Coma Scale score (OR, 0.7; 95% CI, 0.450–0.971; p = 0.035), total leukocyte count (OR,1.2; 95% CI, 1.028–1.453; p = 0.023) and haematoma volume (OR, 1.1; 95% CI, 1.024–1.204; p = 0.011) were found to be statistically significant in multivariate analysis of 3-month poor outcome. Factors independently associated with mortality were high AI (OR, 8.6; 95%CI, 1.748–40.940; p = 0.007) and midline shift (OR, 7.5; 95%CI, 1.809–31.004; p = 0.005). Conclusion: Admission Glasgow Coma Scale score, total leukocyte count and haematoma volume were significant predictors for 3-month poor outcome; high AI and midline shift were significant predictors for 3-month mortality.

Clinical and Microbiological Spectrum of Necrotizing Fasciitis in Surgical Patients at a Philippine University Medical Centre

2010-01-01

Objective: The study describes the clinical characteristics, bacteriology and risk factors for mortality of patients with necrotizing fasciitis (NF), seen in a university medical centre. Methods: The medical charts of NF patients admitted to the institution from January 2004 to July 2007 were retrieved and reviewed retrospectively. Results: The majority of the 67 patients included in the study presented with localized nonspecific inflammatory manifestations: tenderness (94%), warmth (86%), oedema (76%), skin necrosis (75%), and ulceration (68%). Diabetes mellitus (22%) was the most common predisposing medical condition. The most frequent isolates were Escherichia coli (44%), Acinetobacter baumannii (19%), Staphylococcus aureus (15%) and Enterococcus faecium (15%). Overall mortality rate was 36%. Risk factors significantly associated with mortality were truncal involvement (p = 0.034), leukocytosis (p = 0.038), acidosis (p = 0.001), hypoalbuminaemia (p = 0.004), hypocalcaemia (p = 0.000) and hyponatraemia (p = 0.023). Logistic regression analysis revealed acidosis [p < 0.05, odds ratio (OR) = 9] and hypoalbuminaemia (p < 0.05, OR = 14) as significant independent risk factors for mortality. Conclusion: The identified risk factors can inform clinicians of increased mortality risks for certain patients with NF. They should serve as a trigger for more aggressive surgical and critical care, and antimicrobial therapy for these patients.

Isolated Dextrogastria Simulating Congenital Diaphragmatic Hernia: A Diagnostic Dilemma

Inna Kedle Indrajit, Monal Kansra, Man Mohan Harjai — 2010-01-01

We report eventration of the right hemidiaphragm with isolated asymptomatic dextrogastria in a newborn. The diagnosis of this rare association could not be made clinically or by various imaging techniques. The final diagnosis could only be ascertained at laparotomy. The pathology was corrected by plication of the right hemidiaphragm, anterior fixation of the stomach, and Ladd's procedure.