小切口修剪联合多功能电离子清除顶泌汗腺治疗腋臭

目的：探讨小切口修剪联合多功能电离子清除顶泌汗腺治疗腋臭的疗效。方法：2009年1月至20015年3月笔者应用小切口修剪联合多功能电离子清除顶泌汗腺治疗腋臭258例（女性158例,男性100例）,术后术区碎纱布团缝线压迫固定外用弹力绷带包扎固定。所有患者均获随访,最短时间为3个月。结果：258例中,235例（91.1%）患者获满意疗效,无臭味残留;10例（3.9%）出现切口边缘5mm以内皮肤坏死;8例（3.1%）发生单侧血肿;5例（1.9%）单侧气味残留。结论：小切口修剪联合多功能电离子清除顶泌汗腺治疗腋臭获得满意疗效,术区局部形态良好。     

小切口联合内镜微创手术治疗感染性胰腺坏死疗效分析：附9例报告

背景与目的 近年来多学科协作的综合治疗在重症急性胰腺炎（SAP）治疗方面取得了一定进展,但感染性胰腺坏死（IPN）仍是SAP治疗公认的难点,也是影响SAP疗效的关键。本研究分析总结小切口联合内镜微创手术治疗IPN的临床疗效。方法 回顾性分析2019年6月—2021年6月湖南省常德市第一人民医院肝胆外科收治的9例行小切口联合内镜微创手术治疗的IPN患者临床资料。结果 9例患者中,男性7例,女性2例;平均年龄（46.7±11.6）岁;5例为高脂血症性胰腺炎、2例胆源性胰腺炎、2例酒精性胰腺炎;脓液细菌真菌培养阳性率为77.8%（7/9）。9例患者均顺利完成小切口联合内镜微创手术,4例经左侧腹膜后入路、3例经腹腔小网膜囊入路及2例联合入路。胰腺炎起病到首次手术时间（47.2±10.1）d,术后住院时间（20.4±9.6）d,总住院时间（36.1±18.1）d,手术时间（151.7±55.2）min;清除坏死组织量（240.0±119.6）g;术中出血量（55.4±44.2）mL;放置引流管数量中位数4（3~6）根。8例患者一次手术治愈,1例患者术后再次行经皮胰周脓肿穿刺置管引流术和胆道镜手术治疗;术后2例患者出现主要并发症,包括1例腹腔出血、1例结肠瘘。9例患者均顺利出院,无死亡病例。结论 小切口联合内镜微创手术结合了多种微创技术优点,良好地平衡了清创效率和手术创伤之间的矛盾,在高效彻底清除坏死组织的同时,也保障患者的手术安全性,值得进一步推广。     

小切口胆总管末端结石的治疗(附110例报告)

目的 探讨小切口胆总管末端结石的治疗。方法 对110例胆总管末端结石患者采用小切口术中胆道镜、气囊导管等治疗的临床资料进行回顾性总结。结果 术中采用胆道镜、气囊导管等清除末端结石86例（78．2％）。术后用胆道镜取出结石10例（9．1％），胆道镜联合内镜乳头括约肌切开技术清除结石14例（12．7％）。术中18例（16．4％）并发胆总管末端医源性损伤，其中1例术后并发消化道大出血死亡，其余病例经2～20年随访无远期并发症。结论 胆总管末端结石采用小切口术中胆道镜、气囊导管等相结合能清除多数结石，难以取出的末端结石于术后经内镜处理为妥。     

急性出血坏死性胰腺炎手术方式的再探讨

回顾性总结分析1991年以来手术治疗急性出血坏死性胰腺炎（AHNP）60例的经验。其中发病7日内手术39例（早期手术），7日后手术11例（中转手术），另外10例为胰腺炎急性期度过后择期行胆道手术。早期手术病人按手术方法不同分为两组：A组20例，B组19例，统计两组术后情况，说明早期手术时尽量减少手术创伤可降低术后早期死亡；术后短时间内拔除引流管，可减少坏死组织继发感染的机会，降低后期感染死亡率。中转手术11例，行坏死组织清除和胆道、胃肠道造瘘。其中有1例因术后残留的坏死组织继发感染拒绝再次手术而死亡，其余无严重并发症；3例胰腺脓肿采用小切口行坏死组织清除及脓肿引流，术后恢复顺利。     

坏死性胰腺炎外科治疗

感染坏死性胰腺炎（INP）是目前国际公认的手术治疗急性胰腺炎的惟一适应症，但在手术方法的选择上尚未有一致的意见。为研究不同外科手术方法治疗感染坏死性胰腺炎的效果，作者收集了2000～2003荷兰8所医学中心和3家教学医院共计106例接受手术治疗的病例进行回顾性分析。106例病例根据手术治疗方法不同分为4组进行了比较，具体方法及分组情况为首次清除坏死组织后敞开切口准备进行再次或多次手术组（OAS组，23例），首次清除坏死组织后关腹进行坏死区域或局部不间断大剂量液体灌洗组（CPL组，53例），CPL后再次开腹或通过腰部切口进行腹膜后坏死组织清除组（MIP组，18例）以及首次开腹清除坏死组织后即关腹不再进行腹腔灌洗和再次手术（PAC组，12例）。     

小切口顶泌汗腺清除手术治疗腋臭症的并发症分析

目的：探讨应用小切口清除顶泌汗腺治疗腋臭术后发生的并发症的原因,以期改进手术方法,总结围手术期经验,减少并发症。方法：回顾2004年4月～2008年3月于我科门诊治疗的315名小切口顶泌汗腺清除术病例,统计其术后并发症发生情况,并对各类并发症进行分析。结果：315名患者,手术后效果满意306例（97％）,异味残留9例（3％）,出现皮下血肿31例（10％）,伤口延迟愈合12例（4％）。无皮肤坏死和上肢功能障碍,术区瘢痕轻微。结论：小切口顶泌汗腺清除手术成功率高,并发症少,经过总结经验,值得进一步推广。     

负压抽吸搔刮术联合小切口皮下修剪法治疗腋臭

目的:探讨负压抽吸搔刮术联合小切口皮下修剪法治疗腋臭的临床效果及安全性。方法:选择2015年1月-2017年1月在笔者医院医疗美容科就诊的425例腋臭患者为研究对象,采用负压抽吸搔刮术联合小切口皮下修剪法对腋臭患者进行治疗,术后随访1年,评价临床效果,观察复发率、残留率、术后并发症及患者满意度情况。结果:所有患者切口均一级愈合,切口瘢痕不明显;412例患者对手术效果满意,满意度为96.94%;10例患者发生术后并发症(单侧血肿),并发症发生率为2.35%,经负压引流清除后伤口愈合,无感染及皮肤坏死发生;13例患者发生残留(9例单侧残留,4例双侧残留),残留率为3.06%;9例患者出现复发,复发率为2.12%;残留及复发者均经二次手术,效果满意。结论:负压抽吸搔刮术联合小切口皮下修剪法对于腋臭是一种微创、安全、有效的治疗技术。     

开放手术联合腹腔镜技术治疗腹壁嵌顿性或绞窄性切口疝11例疗效分析

目的 分析开放手术联合腹腔镜技术（杂交手术）修补嵌顿性或绞窄性切口疝的临床疗效。方法 回顾性分析2011年1月至2015年1月华中科技大学同济医学院附属武汉市中心医院疝与腹壁外科采用杂交手术治疗的11例嵌顿性或绞窄性切口疝病人的临床资料,并对病人术后进行随访。结果 所有病人均顺利完成手术,术后未见肠管损伤、心肺衰竭等严重并发症发生。手术时间为80～244（151.9±65.2）min,疝环缺损最大径为3～8（4.5±1.2）cm。10例病人为小肠嵌顿伴肠梗阻,1例病人为肠系膜嵌顿;4例病人术中证实为绞窄性切口疝,术中探查为小肠缺血坏死,体外行坏死小肠切除吻合;术中4例病人发现有隐匿性缺损存在。病人术后排便时间为3～9（4.1±2.2）d,4例病人术后早期出现明显腹胀症状,对症处理2～7 d后缓解。病人术后住院时间为7～18（11.7±3.6）d。术后随访12～36个月,中位随访时间为21个月,均未出现肠梗阻、迟发性补片感染、补片膨出及疝复发等并发症。结论 杂交手术修补嵌顿性或绞窄性切口疝具有一定的优势,值得临床推广应用。     

腹腔镜经腹腹膜前疝修补术联合腹股沟区小切口在腹股沟疝治疗中的应用

目的探讨腹腔镜经腹腹膜前疝修补术（TAPP）联合腹股沟区小切口治疗难复性及嵌顿性腹股沟疝患者的临床疗效。 方法回顾性分析2016年1月至2019年4月，常熟市第二人民医院62例一期行疝修补手术的单侧难复性或嵌顿性腹股沟疝患者的临床资料，其中行腹股沟区小切口联合TAPP修补术患者16例，行TAPP修补术患者21例，行开放无张力修补术患者25例。 结果TAPP联合腹股沟区小切口组与TAPP组住院时间、手术时间、切口并发症、排尿困难及睾丸坏死发生率等方面比较，差异无统计学意义（P>0.05）；而在住院费用及术后阴囊/会阴肿胀发生率方面比较，差异有统计学意义（P<0.05）。TAPP联合腹股沟区小切口组与开放组比较，在住院时间、术后切口并发症发生率及排尿困难发生率比较，差异有统计学意义（P<0.05）；而在住院费用、手术时间、其他术后并发症发生率比较，差异无统计学意义（P>0.05）。 结论TAPP联合腹股沟区小切口治疗难复性或嵌顿性腹股沟疝行可缩短住院时间或减少术后并发症的发生，值得在临床中应用推行。     

空心加压螺钉联合钢板内固定治疗距骨颈骨折

目的:探讨采用空心加压螺钉联合钢板内固定技术治疗距骨颈骨折的临床疗效。方法:2007年3月～2010年8月,应用空心加压螺钉联合钢板内固定技术治疗24例闭合距骨颈骨折患者,男15例,女9例;年龄19～52岁,平均35.3岁。所有患者均采取双入路。观察术后骨折复位情况、术后并发症情况以及术后功能情况。结果:24例患者术后均获随访,随访时间2～4年,平均2.7年。术后切口均Ⅰ期愈合,23例患者距骨骨折获得愈合,1例患者出现骨折不愈合。未出现切口感染、皮肤坏死、以及骨折不愈合等术后并发症。发生创伤性踝关节炎2例,距骨下关节创伤性关节炎3例,按Hawkins疗效评价标准:优11例,良8例,可3例,差2例,优良率为79.2%。结论:空心加压螺钉联合钢板内固定治疗距骨颈骨折可使骨折固定更加坚固,骨折可获得解剖复位,术后并发症少,临床治疗效果满意,是治疗距骨颈骨折的有效方法。     

胆总管下端术后十二指肠瘘19例治疗分析

目的：了解胆总管下端手术后十二指肠瘘发生的原因及处理。方法：回顾性分析1975－2002年收治的19例胆总管下端手术后十二指肠瘘发生的原因，诊断和治疗。十二指肠瘘经确诊后均经手术治疗。治疗方式：脓肿引流13例，十二指肠修补5例，胃大部切除幽门旷置胃空肠吻合，空肠造口1例。结果：十二指肠瘘治愈15例，死亡4例，死亡原因：消化道大出血2例，腹膜后严重感染1例，并发重症胰腺炎1例。结论：行胆总管下端探查操作时应谨慎，避免发生医源性损伤。十二指肠后早期诊断尤为重要，十二指肠瘘手术以引流为主，并予以充分的肠内营养支持。     

慢性钙化性胰腺炎的分型与手术治疗

目的探讨慢性钙化性胰腺炎的分型与手术治疗。方法采用回顾性描述性研究方法。收集2015年1月至2019年12月湖南省人民医院收治的121例慢性钙化性胰腺炎患者的临床资料;男99例,女22例;中位年龄为43岁,年龄范围为10~78岁。Ⅰ型慢性钙化性胰腺炎选择行胰十二指肠切除术、保留十二指肠胰头全切除术、保留十二指肠胰头勺式切除术,合并胰周假性囊肿行假性囊肿外引流术。Ⅱ型慢性钙化性胰腺炎选择行胰体尾+脾切除术、胰管切开取石+胰管空肠Roux-en-Y吻合术。Ⅲ型慢性钙化性胰腺炎选择行胰十二指肠切除术、保留十二指肠胰头勺式切除术,合并胰周假性囊肿行假性囊肿外引流术。Ⅳ型慢性钙化性胰腺炎行胰管盆式内引流术。观察指标:(1)手术情况。(2)术后情况。(3)随访情况。采用门诊和电话方式进行随访,了解患者术后疼痛复发或再发胰腺炎、血糖情况、新发糖尿病及腹泻。随访时间截至2020年1月。正态分布的计量资料以±s表示;偏态分布的计量资料以M(范围)表示。计数资料以绝对数表示。结果(1)手术情况:48例Ⅰ型慢性钙化性胰腺炎患者中,15例行胰十二指肠切除术,手术时间为(6.8±1.9)h,术中出血量为(398±110)mL;8例因胰管不扩张行保留十二指肠胰头全切除术,手术时间为(3.7±0.8)h,术中出血量为(137±62)mL;25例胰管扩张均行保留十二指肠胰头勺式切除术,手术时间为(3.9±1.5)h,术中出血量为(123±58)mL。8例Ⅱ型慢性钙化性胰腺炎患者中,2例行胰体尾+脾切除术,平均手术时间为5.1 h,平均术中出血量为200 mL;6例行胰管切开取石+胰管空肠Roux-en-Y吻合术,手术时间为(2.7±0.8)h,术中出血量为(145±39)mL。49例Ⅲ型慢性钙化性胰腺炎患者,4例行胰十二指肠切除术,手术时间为(7.2±1.4)h,术中出血量为(415±98)mL;45例因胰管扩张行保留十二指肠胰头勺式切除术,手术时间为(4.3±1.1)h,术中出血量为(135±47)mL。16例Ⅳ型慢性钙化性胰腺炎患者均行胰管盆式内引流术,手术时间为(3.3±1.3)h,术中出血量为(150±27)mL。(2)术后情况:48例Ⅰ型慢性钙化性胰腺炎患者中,15例行胰十二指肠切除术患者术后首次肛门排气时间、进食流质食物时间、住院时间分别为(2.9±1.1)d、(3.5±1.1)d、(14.8±2.7)d;术后3例发生并发症,其中2例发生消化道出血(1例胃镜下止血后痊愈,1例经介入治疗后痊愈),1例发生A级胰瘘,延迟拔管后愈合,无胆瘘发生。8例行保留十二指肠胰头全切除术患者上述指标分别为(2.0±0.5)d、(2.5±0.4)d、(9.5±2.5)d;术后1例发生A级胰瘘,延迟拔管后胰瘘愈合。25例行保留十二指肠胰头勺式切除术患者上述指标分别为(2.4±0.8)d、(2.5±1.3)d、(9.8±3.1)d;1例发生消化道出血,经介入治疗后痊愈,1例发生A级胰瘘,延迟拔管后愈合。8例Ⅱ型慢性钙化性胰腺炎患者中,2例行胰体尾+脾切除术患者术后平均首次肛门排气时间、平均进食流质食物时间、平均住院时间分别为3.0 d、3.5 d、14.0 d;围术期未出现任何并发症。6例行胰管切开取石+胰管空肠Roux-en-Y吻合术患者术后首次肛门排气时间、进食流质食物时间、住院时间分别为(2.5±0.5)d、(2.5±0.7)d、(8.5±1.5)d;术后2例发生A级胰瘘,延迟拔管后胰瘘愈合。49例Ⅲ型慢性钙化性胰腺炎患者中,4例行胰十二指肠切除术患者术后首次肛门排气时间、进食流质食物时间、住院时间分别为(3.2±0.8)d、(4.1±1.2)d、(15.3±2.4)d;术后1例发生A级胰瘘,延迟拔管后愈合,无出血、胆瘘发生。45例行保留十二指肠胰头勺式切除术患者上述指标分别为(2.5±1.6)d、(2.8±0.9)d、(10.1±2.8)d;术后1例发生胰肠吻合口出血,再次手术后愈合,1例发生A级胰瘘,延迟拔管后愈合,1例发生B级胰瘘,予以穿刺置管、反复冲洗后愈合。16例Ⅳ型慢性钙化性胰腺炎行胰管盆式内引流术患者术后首次肛门排气时间、进食流质食物时间、住院时间分别为(2.6±0.7)d、(3.3±0.5)d、(10.4±3.0)d;术后1例发生腹腔内少量出血,表现为桥襻引流管引流少量暗红色液体,予以去甲肾上腺素氯化钠溶液冲洗后愈合。(3)随访情况:121例患者中,113例(Ⅰ型44例、Ⅱ型7例、Ⅲ型46例、Ⅳ型16例)获得随访,随访时间为3~58个月,平均随访时间为34个月。随访期间13例(Ⅰ型5例、Ⅱ型1例、Ⅲ型6例、Ⅳ型1例)术后疼痛复发或再发胰腺炎,55例(Ⅰ型15例、Ⅲ型40例)腹痛明显改善,45例(Ⅰ型24例、Ⅱ型6例、Ⅳ型15例)未诉腹痛。37例(Ⅰ型13例、Ⅱ型2例、Ⅲ型17例、Ⅳ型5例)合并糖尿病患者中,20例(Ⅰ型6例、Ⅱ型2例、Ⅲ型12例)血糖恢复正常,17例(Ⅰ型7例、Ⅲ型5例、Ⅳ型5例)血糖需要药物控制;术后新增5例(Ⅰ型4例、Ⅲ型1例)糖尿病患者。3例(Ⅱ型1例、Ⅲ型2例)患者术后发生腹泻。2例Ⅲ型患者死亡,其中1例行胰十二指肠切除术后18个月因胰腺癌死亡,1例行保留胰十二指肠勺式切除术后5个月因再发重症急性胰腺炎死亡。结论慢性钙化性胰腺炎为良性病变,治疗应尽量保留胰腺功能组织;不同类型的慢性钙化性胰腺炎应选择不同的手术方式。     

Retroperitoneal ruptures of the duodenum. Our experience

The authors describe a case of retroperitoneal rupture of the duodenum following blunt abdominal trauma. The aetiology, symptomatology of these lesions are discussed and treatment is stressed. Duodenal fistula continues to be a serious postoperative complication. Primary repair with drainage is the preferred treatment. Gastrostomy, internal decompression and feeding jejunostomy are usefully added in the most severe duodenal injuries.     

Postoperative bezoar ileus after early enteral feeding

Postoperative enteral nutrition is a widely accepted route of application for nutrition formulas due to a low complication rate, a good acceptance by patients. and a favorable cost-effectiveness. We report three cases of bezoar ileus after early postoperative enteral nutrition, using a fine needle jejunostomy (FNJ) in two cases and a nasoduodenal tube in one case. A male patient who underwent gastric resection for a gastrointestinal stroma tumor and was nourished through an fine needle jejunostomy developed an acute abdomen on the seventh postoperative day. Surgical exploration revealed a mechanical ileus caused by denaturated nutrition formula distal to the catheter tip. The second case, a female patient, underwent gastric resection for a gastric cancer and on the fourth postoperative day developed acute onset of abdominal pain. Intraoperative findings were the same as described in the first case. The third case, a male patient with necrotizing cholecystitis, underwent open cholecystectomy. Postoperative enteral feeding was performed using a nasoduodenal tube. He developed a small bowel obstruction on the 17th postoperative day that was caused by an intraluminal bezoar. In conclusion, bezoar formation represents an underestimated complication of postoperative enteral feeding. Acute onset of abdominal pain and the development of small bowel obstruction are the main clinical symptoms of this severe complication. The pathogenesis of bezoar formation remains unclear.     

腹腔镜阑尾切除术后再手术原因分析

目的 分析腹腔镜阑尾炎手术后再手术的原因,探讨腹腔镜阑尾炎手术中应注意的事项.方法 2003年5月~2013年3月,发生11例腹腔镜阑尾切除术后再手术.急性阑尾炎10例,慢性阑尾炎1例.再手术原因：腹腔脓肿4例,回盲部肿瘤1例,腹腔大出血并休克1例,腹膜后血肿1例,小肠漏1例,肠粘连1例,盆腔炎1例,胰腺炎1例.经保守治疗无效,8例行腹腔镜探查,3例开腹探查.结果 二次手术均成功.腹腔脓肿4例行腹腔镜脓肿清洗引流,腹腔大出血并休克1例行腹腔镜探查腹壁下动脉结扎,肠粘连1例行腹腔镜探查粘连带松解,盆腔炎1例行腹腔镜盆腔冲洗引流＋抗感染治疗,胰腺炎1例行腹腔镜胰腺被膜打开胰腺周围置管引流;小肠漏1例行腹腔镜探查＋开腹小肠肠管部分切除吻合术,腹膜后血肿1例行开腹探查阑尾动脉结扎,回盲部肿瘤1例行开腹右半结肠切除术（病理高分化腺癌）.术后7~21天痊愈出院.结论 腹腔镜下阑尾切除术后再手术的原因为：术前术中漏诊、误诊;术中脓液清洗不彻底,术后引流不通畅致腹腔脓肿形成;术中操作不规范,致腹壁下血管、阑尾动脉出血.腹腔镜阑尾切除术应注意规范操作,术中应探查仔细,防止漏诊、误诊.     

Whipple术中应用改良式胃造瘘术的临床研究

目的探讨Whipple术中应用改良式胃造瘘术的临床意义。方法总结2004年11月至2006年12月收治的36例Whipple术中行改良式胃造瘘术加空肠造瘘术（治疗组）患者的临床资料,并与24例同期Whipple术中行传统胃造瘘术加空肠造瘘术（对照1组）及22例同期行Whipple术加空肠造瘘术（对照2组）的患者进行对照研究。对3组患者的手术时间,术后开始行肠内营养时间,术后留置鼻胃引流管时间以及术后胃瘫、胰瘘、胆瘘、腹腔感染等并发症的发生率进行统计学分析。结果治疗组及对照2组术后胃瘫发生率明显低于对照1组（P〈0．05）;治疗组术后留置鼻胃引流管时间明显短于对照2组（P〈0．01）;3组的手术时间、术后开始行肠内营养时间、胰瘘、胆瘘及腹腔感染发生率的差异无统计学意义（P〉0．05）。结论Whipple术中行改良式胃造瘘术安全、可靠,可以明显缩短术后鼻胃引流管留置时间;与传统胃造瘘方法相比,可明显降低术后胃瘫的发生率。     

Predictors and outcomes of jejunostomy tube placement at the time of pancreatoduodenectomy

BackgroundClinically relevant postoperative pancreatic fistula and delayed gastric emptying cause substantial morbidity after pancreatoduodenectomy. Per international guidelines, the placement of jejunostomy tubes may be considered for patients at risk for malnutrition, such as those with a high risk for clinically relevant postoperative pancreatic fistula and related complications. This study determined predictors and postoperative outcomes of jejunostomy tube placement.MethodsPatients undergoing pancreatoduodenectomy in 2014 to 2015 were identified using the American College of Surgeons National Surgical Quality Improvement Program and Procedure-Targeted Pancreatectomy Participant Use Files. Multivariable logistic regressions were used to identify factors associated with concurrent jejunostomy tube placement and postoperative outcomes.ResultsOf 3,600 patients, 8.9% underwent jejunostomy tube placement. Patients given a jejunostomy tube were more likely white (odds ratio 1.46, P = .016), to have low preoperative serum albumin levels (odds ratio 2.13, P < .001), to have received neoadjuvant radiotherapy (odds ratio 2.14, P < .001), and to have received an intraoperative transfusion (odds ratio 1.50, P = .004). We observed no association between jejunostomy tube placement and an increasing number of risk factors for clinically relevant postoperative pancreatic fistula (P = .96) or delayed gastric emptying (P = .54). Overall, jejunostomy tube placement was associated with increased morbidity (odds ratio 1.34, P = .020) and duration of stay (P < .001), but not mortality (P = .12). Among patients with low serum albumin or those who developed clinically relevant postoperative pancreatic fistula or delayed gastric emptying, jejunostomy tube utilization was not associated with morbidity or mortality.ConclusionJejunostomy tube placement during pancreatoduodenectomy was not driven by risk factors for clinically relevant postoperative pancreatic fistula or delayed gastric emptying, suggesting that practice patterns play a role. Among patients with at-risk preoperative albumin or who developed these complications, jejunostomy tube placement was not associated with worse outcomes, supporting selective utilization per guideline recommendations.     

Feeding jejunostomy: is its routine use in major upper gastrointestinal surgery justified?

An audit of jejunostomy feeding following major oesophagogastric surgery was carried out. The aim was to measure caloric and nitrogen intake, weight change, and to record complications. Twenty consecutive patients undergoing elective upper gastrointestinal surgery resulting in either an oesophagogastric or oesophagojejunal anastomosis were studied prospectively. In the eighteen cases whose catheters functioned, average calorie and nitrogen intake per day over the first 10 postoperative days was 1360 Kcal and 7.2 g respectively and average weight loss at 10 days was 1.3 kg. There was one major complication due to catheter dislodgement, resulting in an extraperitoneal abscess and subsequent small bowel fistula. In one other case the catheter was blocked from the immediate postoperative period and this could not be remedied. In the eighteen patients who were fed via the jejunostomy for 10 days, mild diarrhoea occurred in eight cases, but was easily managed. As experience with the technique increased, there was a significant increase in the amount of calories and nitrogen administered. This audit has demonstrated that provided care is taken with the technique of insertion of the jejunostomy catheter, satisfactory nutritional support can be provided in patients following oesophageal anastomoses with a low morbidity rate.     

Successful Treatment of Gastric Fistula following Rhabdomyolysis after Vertical Banded Gastroplasty

Vertical banded gastroplasty is a gastric restrictive operation which has been performed with very satisfactory results in our department. We present a 46year-old male with BMI 48, who experienced rhabdomyolsis after a VBG operation, complicated by perforation of an upper pouch ulcer and subsequent gastric fistula. Cardiac and renal failure occurred, necessitating intensive therapy with catecholamines, diuretics and hemodialysis. The patient underwent multiple operations, drainage of a retroperitoneal abscess, suture of a perforated ulcer, and gastric decompression by a gastrostomy. Prolonged treatment including TPN, drainage, broad spectrum antibiotics, skin and would protection and jejunostomy feeding, were necessary to obtain an eventual successful outcome. This case demonstrates that unexpected surgical complications may occur in morbidly obese patients and how difficult and long the management of these may be. Rhabdomyolsis is a potentially life-threatening complication of bariatric surgery, and careful postoperative observation of the patient is mandatory.     

Preoperative evaluation of retroperitoneal venous system anomalies during abdominal aortic aneurysm rupture

The association of a retroaortic left renal vein and an abdominal aortic aneurysm (AAA) fistula is an infrequent event. We present two cases of AAA rupture into the retroaortic left renal vein. Preoperative computed tomography (CT) assessment showed retroperitoneal bleeding due to a large AAA rupture with an associated unusual retroaortic left renal vein. Patients underwent successful arteriovenous fistula sutures with abdominal aortoiliac replacement. The patients had uneventful recoveries, and they were discharged on the seventh to ninth postoperative day (POD) without renal complications. The clinical onset was characterized by the unique syndrome: continuous abdominal bruit, abdominal and left flank pain with an associated pulsatile mass (Mansour Triad). Moreover patients presented with haematuria, proteinuria and a large non-functional left kidney on the imaging scan. The CT-scan may suggest the presence of the venous anomaly. Unusual anatomical presentation recommends a careful surgical approach during AAA operations.