Primary esophageal repair for Boerhaave's syndrome whatever the free interval between perforation and treatment.

OBJECTIVES: Boerhaave's syndrome is the most sinister cause of esophageal perforation responsible with mortality rate ranging from 20 to 30%. Combination of mediastinal contamination with microorganisms, gastric acid and digestives enzymes, long free interval between injury and initiation of treatment causes severe mediastinitis which is fatal in most untreated cases. The aim of this paper is to emphasize primary esophageal repair and resuscitation whatever the free interval from rupture and repair. METHODS: A retrospective review of patients treated for Boerhaave's syndrome in our department from January 1980 to February 2003 was performed. The principle of treatment was surgical treatment and avoidance of esophageal exclusion or esophagectomy whichever was possible. RESULTS: There were 25 patients (17 males and 8 females). All patients were operated on by primary esophageal repair, except for three who underwent immediate exclusion of the esophagus and one patient who deceased on arrival before being operated. Patients were classified according to free interval between perforation and treatment: group 1 (n=9; 36%) within the 24 h (range from 12 to 24 h) and group 2 (n=16; 64%) more than 24 h (range from 2 to 17 days). Altogether 6 patients deceased (24%). In hospital mortality rate for groups 1 and 2 was, respectively, 44% (four patients) and 13% (two patients), not significantly different. Mean hospital stay was 63 days. Two patients developed anastomotic leakage needing esophagectomy and retrosternal coloplasty in one or more steps. One patient developed pleural abscess treated by percutaneous drainage. Three patients presented temporary symptomatic esophageal stenosis, of whom one underwent dilation. CONCLUSIONS: Long free interval before treatment does not preclude primary esophageal repair in Boerhaave's syndrome. Esophageal exclusion may be more often than not avoided in most cases.     

Primary esophageal repair for Boerhaave's syndrome

BACKGROUND: Boerhaave's syndrome is the most sinister cause of esophageal perforation. The mediastinal contamination with microorganisms, gastric acid, and digestive enzymes results in a mediastinitis that is often fatal if untreated. METHODS: We present a series of 21 patients seen in our unit in the 10 years 1987 to 1996. Esophageal repair was performed in 17 (81%) of them. After the resuscitation of the patient in the intensive care unit, our strategy is primary esophageal repair with a single layer of interrupted absorbable sutures combined with mediastinal toilet, mediastinal drainage, and drainage gastrostomy. The majority of patients (12/21) were referred more than 24 hours after perforation. RESULTS: The mean age of the patients was 60+/-17 years. The mean stay in the intensive care unit was 1.6+/-1.8 days and the median hospital stay, 14 days. There were three deaths, an overall mortality rate of 14.3%. CONCLUSIONS: When combined with mediastinal toilet, mediastinal drainage, and drainage gastrostomy, primary esophageal repair for Boerhaave's syndrome gives an acceptable mortality and should not be reserved for patients seen within 24 hours after spontaneous rupture.     

Experience with the Grillo pleural wrap procedure in 18 patients with perforation of the thoracic esophagus.

Perforation of the thoracic esophagus may be fatal unless diagnosed promptly and treated with an effective operation. The wide mortality range in different reports reflects the importance of these two factors. This range spans from as low as 11%, if operation is within 24 hours, to greater than 50% after two to three days. The high mortality with delayed treatment is principally due to inability to surgically close the perforation. Eighteen patients (aged from 31 to 78 years) were treated four hours to 14 days after thoracic esophageal perforation (less than 24 hours: 7 patients; 24 to 72 hours: 7 patients; greater than 72 hours: 4 patients). In 14 patients the perforation was sutured, after which the suture line was buttressed with a circumferential wrap of parietal pleura, originally described by Grillo. Underlying esophageal pathology was corrected and wide mediastinal drainage was instituted. All 14 patients recovered and were discharged from the hospital after a median stay of 20 days. Two patients had minor leaks at the suture line that soon closed. Four patients had perforations too extensive to close. Of these, one was resected, the Urschel procedure was used in two, and the Abbott T-tube drainage was used in one. Three of the four patients died. It was quite significant that the pleural wrap was equally effective with both early (6 patients) and delayed perforations (8 patients). These data indicate that the pleural wrap should be used routinely. Extensive perforations that cannot be closed should probably be treated by resection and drainage, followed by esophageal reconstruction at a later time.     

Boerhaave's syndrome: a review of management and outcome

Spontaneous oesophageal rupture (Boerhaave's syndrome) is an uncommon but serious condition. A retrospective review was undertaken of the management of 34 patients (age range 17-85 years) presenting between 1991 and 2006. Contrast swallow was possible in 22 patients, confirming the diagnosis in 17. Five patients showed pleural effusion on chest X-rays, with subsequent aspiration or chest drain insertion, confirming the diagnosis. Eleven needed CT scan, four of which showed evidence of a leak. Whilst some patients were referred immediately with the diagnosis, some waited up to 12 days (median delay four days). Whilst most patients were treated by operation on the day of diagnosis, diagnostic delay >24 h and delay in referral resulted in treatment delays of up to 24 days. Fifteen (44%) patients were suitable for primary surgical repair, ten were treated by aggressive conservative management with thoracotomy performed to visualise the perforation and assess suitability for primary repair, and hemithorax being debrided and drainage tubes and nasogastric tubes being accurately positioned under direct vision. One patient required an emergency oesophagectomy and eight patients were suitable only for surgical debridement, their initial diagnosis being delayed (median 2 days, range 2-18 days). The major factor determining treatment was the condition of the patient following initial resuscitation, there being a tendency for delayed referrals to be unsuitable for primary repair (P=0.03). Combined 30-day and in-hospital mortality was 17.6% (n=6). Median ICU stay was 1.5 (range 1-50) days with those with delayed diagnosis needing an average of 6.5 days (range 1-45). Median hospital stay was 21 (range 4-210) days.     

Boerhaave's syndrome: The importance of early diagnosis and treatment.

Boerhaave's syndrome, spontaneous esophageal rupture, is associated with a 70% survival with surgical intervention. Mortality and morbidity are increased in direct proportion to the time between diagnosis and appropriate surgical intervention. Sepsis, hypovolemia and shock are the predominant causes of morbidity and mortality in Boerhaave's syndrome. Two cases of Boerhaave's syndrome are presented which were diagnosed rapidly, and were managed surgically, resulting in survival of the patients. A review of the literature is also presented with emphasis on the clinical and roentgenologic methods of diagnosis of spontaneous esophageal rupture. Particular attention is given to the fact that early diagnosis and treatment will unquestionably reduce the morbidity of this syndrome.     

Transabdominal approach for management of Boerhaave's syndrome

Several transthoracic approaches have been described for the surgical management of Boerhaave's syndrome that carry their own morbidity in patients who can be systemically unwell at presentation, and best practice is not established. We introduce a novel transabdominal approach to manage the perforation and spare these patients the trauma of a thoracotomy. Four patients with spontaneous esophageal rupture were managed using a transabdominal approach. Postoperative complications, length of intensive care unit stay, postoperative hospital stay, time to oral intake, and morbidity and mortality were used as outcome measures. After operation, the median intensive care unit stay was 4 days (range, 0-5) in patients who required a median of 10.5 days (range, 6-17) to establish oral intake. One patient required a transthoracic drainage of an empyema and one patient required percutaneous drainage of a mediastinal collection. The median length of stay was 38 days and there was zero mortality. The transabdominal approach is safe and effective for the management of Boerhaave's syndrome and should be considered in the treatment paradigm for this condition. Intrathoracic complications account for postoperative morbidity.     

Robotically assisted laparoscopic transhiatal esophagectomy

Background Esophagectomy is a technically demanding operation with high procedure-related morbidity and mortality rates. Minimally invasive techniques were introduced in the late 1980s in an effort to decrease the invasiveness of the procedure. Data concerning the use of robotic systems for esophageal cancer are scarce in the literature. The goal of this report is to describe the authors’ early experience using robotically assisted technology to perform transhiatal esophagectomy (RATE). Methods Between September 2001 and May 2004, 18 patients underwent RATE at the authors’ institution. A retrospective review of prospectively collected data was performed. Gender, age, postoperative diagnosis, operative time, conversion rate, blood loss, hospital stay, length of the follow-up period, and complications were assessed. Results At the authors’ institution, 18 patients underwent RATE, including 16 men (89%), with a mean age of 54 years (range, 41–73 years). The RATE procedure was completed for all 18 patients (100%). The mean operative time was 267 ± 71 min, and estimated blood loss was 54 ml (range, 10–150 ml). The mean intensive care unit stay was 1.8 days (range, 1–5 days), and the mean hospital stay was 10 days (range, 4–38 days). A total of 12 perioperative complications occurred for 9 patients, including 6 anastomotic leaks, 1 thoracic duct injury, 1 vocal cord paralysis, 1 pleural effusion, and 2 atrial fibrillations. Anastomotic stricture was observed in six patients. There were no perioperative deaths. Pathologic examination of the surgical specimen yielded an average of 14 lymph nodes per patient (range, 7–27). During the mean follow-up period of 22 ± 8 months, 2 patients died, 2 were lost to follow-up evaluation, 3 had recurrence, and 11 were disease free. Conclusion The current study shows that RATE, with its decreased blood loss, minimal cardiopulmonary complications, and no hospital mortality, represents a safe and effective alternative for the treatment of esophageal adenocarcinoma.     

Primary spontaneous pneumothorax: one-stage treatment by bilateral videothoracoscopy

BACKGROUND: The goal of the study was to report our 7-year experience with single-stage bilateral videothoracoscopy for bleb excision and pleural abrasion in patients suffering primary spontaneous pneumothorax. METHODS: From November 1992 through June 1999, 12 men were operated on in our department. Preoperative chest computed tomographic scans were obtained for all patients. Operative indications included simultaneous bilateral pneumothorax (n = 2), contralateral recurrence (n = 1), ipsilateral recurrence with contralateral blebs or bullae, and job restrictions (n = 9). RESULTS: Mean age at operation was 26+/-6 years. All patients had multiple blebs or bullae located in upper lobes, and 4 patients (33%) had pleural adhesions. All blebs or bullae were resected at operation. The mean number of staple cartridges was 5 per patient (range, 3 to 8). All patients had bilateral pleurabrasion. There were no perioperative complications and no conversion to thoracotomy. The mean operative time was 168+/-17 minutes (range, 140 to 190 minutes). The mean drainage time was 5 days (range, 4 to 26 days) and the mean hospital stay was 7.7+/-1.4 days for 11 of 12 patients. Postoperative complications included prolonged air leak (16.5%), incomplete lung reexpansion (25%), and pleural effusion (8.5%). One patient required reoperation on the right side through transaxillary thoracotomy within 1 month of videothoracoscopy for pleurodesis failure. Follow-up was 100% complete. Mean follow-up is 50+/-34 months (range, 9 to 88 months) and no patient has had recurrence of pneumothorax. All patients except one returned to full occupational activity within 5 weeks of surgery. CONCLUSIONS: Single-stage bilateral videothoracoscopy for bilateral bleb excision and pleurabrasion is a safe procedure that does not result in major complications and provides excellent long-term results. This approach could be considered in young patients with bilateral primary spontaneous pneumothorax, or in those requiring radical therapy for the prevention of ipsilateral and contralateral recurrences.     

Boerhaave's syndrome - rapidly evolving pleural effusion; a radiographic clue

Boerhaave's syndrome is the rare and often fatal condition of spontaneous esophageal rupture. Meckler's triad of vomiting, pain and subcutaneous emphysema are characteristic features of Boerhaave's syndrome. When these symptoms are absent, diagnosis is frequently late and often occurs as the result of incidental investigation. This contributes to the observed high morbidity and mortality. Unless specifically considered in the differential diagnosis, this rare disease is frequently overlooked. The authors described the case of a patient in whom the diagnosis was made several days following presentation by observing that a large pleural effusion had evolved rapidly on chest radiographs. This uncommon radiological sign has relatively few causes and prompted a review of the history and diagnosis, followed by the initiation of additional investigations that confirmed Boerhaave's syndrome.     

Life expectancy of patients with malignant pleural effusion treated with video-assisted thoracoscopic talc pleurodesis

The aim of the current study was to analyse postoperative complications and survival after video-assisted thoracoscopic (VATS) talc pleurodesis for malignant pleural effusion. All patients with morphologically proven malignant pleural effusion who underwent VATS talc pleurodesis from November 1995 to November 2002 were included in retrospective analysis. VATS was performed in general anaesthesia and 5 g of asbestos-free talc was insufflated into the pleural cavity. Postoperative pleural drainage was used until fluid output was less than 100 ml/24 h. Ninety-eight patients (28 male and 70 female) with mean age 59.6 (range 18-82) years were included. Thirteen patients had a bilateral pleural effusion. The most common primary cancer sites were lung (30 cases), breast (25) and ovarium (11). Average duration of the operation was 46 (range 10-120) min. Median duration of postoperative drainage was 3 (range 1-20) days and postoperative hospitalisation 7 (range 3-70) days. Twenty-eight patients had postoperative complications (fever in 17 cases). In seven cases pleurodesis was ineffective. Median survival was 8.4 months. Six-, 12- and 24-month survival was 58% (95% CI [0.47-0.67]), 39% [0.29-0.49] and 20% [0.12-0.29], respectively. Survival data after VATS talc pleurodesis advocate use of this invasive treatment method despite the advanced stage of cancer.     

Thoracoscopic versus open repair of tracheoesophageal fistula and esophageal atresia

BACKGROUND/OBJECTIVE: Recent studies show the minimally invasive approach to the repair of esophageal atresia (EA) and tracheoesophageal fistula (TEF) is feasible. This study aimed to evaluate the efficacy and safety of the thoracoscopic versus open techniques. METHODS: We performed a retrospective review of EA/TEF cases from June 2000 to July 2006. Patient characteristics, operative time, blood loss, duration of narcotic usage, time to extubation, time to first oral feeding, length of stay, complications, and follow-up were analyzed. RESULTS: Thirty-five type-C EA/TEF patients were evaluated. Two patients with excessively long gaps who required esophageal "bougienage" stretching were excluded. Twenty-five patients underwent traditional repair through thoracotomy. There were 8 thoracoscopic attempts, 7 of which were successfully completed without a conversion. The mean operative time was 130 minutes (range, 75-240) for the thoracoscopic approach, compared to 123 (range, 82-205) for the thoracotomy; mean duration of narcotic use was 5 days (range, 1-12), as compared to 23 (range, 2-190); the mean time to extubation was 4.6 days (range, 1-12), compared to 19 (range, 3-150); the mean days to per os feeding were 9.8 days (range, 7-17) versus 37 (range, 7-360); and the mean length of stay was 21.8 days (range, 11-38), compared to 66 (range, 8-280). There were no intraoperative complications or deaths in either group. The anastomotic leak rate was 14 versus 20%, whereas the stricture rate was 14 versus 50% for the closed and open techniques, respectively. Of the thoracoscopic group, 87.5% had at least one major associated anomaly, compared with 70% of patients undergoing thoracotomy. Follow-up for the thoracoscopic and open groups were 18 and 28 months, respectively. CONCLUSION: Our results suggest that the outcomes of the thoracoscopic technique are comparable to that of the open technique. However, the number is small, and more data are needed to further evaluate the procedure.     

九例腹腔镜解剖性肝Ⅷ段切除的可行性与策略分析

目的:探讨完全腹腔镜解剖性肝Ⅷ段切除的策略、安全性及近期疗效。方法:回顾分析湖南省人民医院2015年1月至2019年12月行腹腔镜解剖性肝Ⅷ段切除9例患者资料,其中男性6例,女性3例,年龄范围29～67岁,平均年龄53.6岁。观察手术时间、术中失血量、术后住院时间、术后并发症等指标。出院后随访生存和复发情况。结果:9例...     

Current indications and results of pulmonary decortication for nontuberculous chronic empyema

Pulmonary decortication for nontuberculous chronic empyema has become a rare operation, whose indications and results are now rarely analysed and discussed. The authors report a series of 40 consecutive decortications performed over a period of 15 years. PATIENTS: 40 patients treated by pulmonary decortication over 15 years for nontuberculous chronic empyema secondary to pneumonia (27 cases; 2/3 of cases), post-traumatic haemothorax (5 cases), iatrogenic infection after pleural tap (5 cases) and septicaemia (3 cases). Chronic empyema had been present for an average of 6 months (1 to 60 months). Decortication was performed for drainage of persistent pleural suppuration in 22 cases and to release the encysted lung in 18 cases. Decortication, always comprising parietal pleural stripping and visceral decortication, lasted an average of 3 hours (2 to 8 hours), and was accompanied by mean bleeding of 1 litre (of 200 ml to 3.41). RESULTS: 27 patients (67%) had an uneventful postoperative course, with drainage for 6 days and a mean hospital stay of 13 days. 13 patients (33%) developed various complications, mainly re-expansion defects (10 cases), responsible for pyothorax in 4 cases, 3 of which required secondary drainage. One patient died from intestinal obstruction in a context of peritoneal carcinomatosis (operative mortality: 2.5%). 25 patients were reviewed with a mean follow-up of 54 months, with complete pulmonary re-expansion in 23 cases (92%) and a residual pouch in 2 cases. Vital capacity (VC) was evaluated in 8 patients, with a mean improvement of 40% (15 to 66%) in 6 patients, stable VC in one patient, and a 25% reduction in the last patient, a smoker and with chronic bronchitis. CONCLUSION: Pulmonary decortication is an effective, but relatively major operation to treat chronic encysted empyema. Encystment must be prevented by effective drainage of empyema, now facilitated by the possibility of early videothoracoscopic pleural debridement.     

Laparoscopic surgery for benign lesions of the pancreas

Background: Minimally invasive pancreatic surgery, although known to be feasible and safe, is still not considered a standard procedure. We report our experience with laparoscopic pancreatic surgery in a retrospective case series. Materials and Methods: Fifteen consecutive patients (3 male, 12 female) underwent primarily laparoscopic pancreatic surgery from February 2000 to June 2005. Histologically confirmed diagnoses were: neuroendocrine pancreatic tumors (n = 11), adult nesidioblastosis (n = 1), serous cystadenoma (n = 1), and pseudocysts due to chronic pancreatitis (n = 2). Results: Enucleation (n = 3) or left pancreatic resection with spleen preservation (n = 6) was performed laparoscopically in 9 patients. The mean (+/-standard deviation) operative time was 173 +/- 48 minutes (range, 120-250 minutes) and the mean postoperative hospital stay was 5.5 +/- 1.2 days (range, 5-8 days) for the laparoscopic cases. Conversion to open surgery was necessary in 6 patients because of: closeness of the lesion to the portal/mesenteric vein (n = 3), inadequate intraoperative tumor localization (n = 2), or stapler device dysfunction (n = 1). In these patients, open enucleation (n = 1), middle segment pancreatectomy (n = 2), left pancreatic resection (n = 2), and pylorus-preserving Whipple resection (n = 1) were performed. The mean operative time was 268 +/- 74 minutes (range, 150-360 minutes) with a mean postoperative hospital stay of 8 +/- 2 days (range, 6-10 days). Both operative time and hospital stay were significantly longer in patients with secondary open surgery compared to patients with successful laparoscopic operations. Conclusion: Laparoscopic enucleation or distal pancreatectomy with spleen preservation for benign lesions located in the body or tail of the pancreas can be performed safely, with all the potential benefits of minimally invasive surgery. Preoperative tumor localization is of utmost importance to limit pancreatic mobilization and to avoid blind pancreatic resection and conversion to open surgery.     

Acute mediastinitis: clinical features and review of a case load

The term acute mediastinitis describes a number of clinical conditions, usually secondary to diseases of other aetiology with which they tend to share the severity of the clinical picture. In these situations even a timely diagnosis and adequate therapeutic management are not always enough to ensure healing. Over the period 1987-2002 15 patients with acute mediastinitis were observed (8 male, 7 female), aged from 22 to 90 years (mean age: 57.9), distributed as follows: descending necrotising mediastinitis, 4 cases; iatrogenic oesophageal rupture, 2 cases; iatrogenic tracheal rupture, 3 cases; oesophageal perforation (foreign body), 4 cases; Boerhaave's syndrome, 1 case; oesophageal perforation (lye ingestion), 1 case. All patients except one--managed medically--were submitted to mediastinal drainage (surgical or by mediastinoscopy), combined with cervical debridement and drainage in cases of descending necrotising mediastinitis, alimentary tract diversion (cervical oesophagostomy + feeding jejunostomy + gastric decompression) in cases of large oesophageal lesions or if the lesion occurred more than 24 hours before observation, and uni- or bilateral tube thoracostomy. Furthermore, antibiotic therapy was always administered, initially choosing broad-spectrum medications, and subsequently adjusting according to bacterial cultures. Four patients died. In 4 cases (2 descending necrotising mediastinitis, 2 acute mediastinitis secondary to oesophageal perforation) repeated interventions were necessary in order to drain pleural or mediastinal effusions. Acute mediastinitis remains a serious clinical entity, the outlook of which is often poor. Factors influencing outcome are the patient's age and general condition (adequate immune response), a timely diagnosis, preoperative localisation of effusions, an aggressive therapeutic approach including drainage of infection sites in the mediastinum, neck and/or pleural cavities, alimentary tract diversion in cases of oesophageal lesions observed late, adequate antibiotic therapy, and nutritional support (total parenteral/enteral nutrition).     

Early Decortication for Postpneumonic Empyema in Children: Effect on Pulmonary Perfusion

Early pulmonary decortication was performed on 66 of 137 children with postpneumonic empyema, while 71 received conventional treatment. The mean age of the 66 patients with decortication was 5.5 years (range 6 months-14 years). The empyema was left-sided in 34 and right-sided in 32. Decortication was performed when lung expansion was not obtained after 10-12 days of intercostal tube drainage, antibiotic therapy (guided by sensitivity tests of pleural fluid) and pleural irrigation. Scintigraphy showed loss of pulmonary perfusion on the side of empyema to be 65% ± SD 20 (25–98)% before decortication in the 23 tested patients. In ten of them the test was repeated after surgery and showed significant (p < 0.001) diminution of the perfusion defect, from 57 ± 6.8 (25–84)% to 4 ± 2.6 (0-8)%. The hospital stay was significantly (p < 0.001) shorter for the surgically treated than for the classically managed patients, viz. 19.5 ± 4 (13–36) days vs 73.6 ± 14 (34–110) days. Early decortication thus had beneficial effects on pulmonary perfusion and hospital stay.     

An initial experience and evolution of laparoscopic hepatic resectional surgery

BACKGROUND: The use of minimally invasive procedures has revolutionized modern surgery. Only recently has laparoscopy been introduced for use in hepatic surgery. METHODS: Patient demographics, tumor characteristics, and outcomes were evaluated for all initial cases of laparoscopic hepatic resection. RESULTS: Twenty-one resections were performed in 17 patients; 5 were performed for malignancy, of which 3 had underlying cirrhosis, and the remaining 12 for benign symptomatic disease. Mean patient age was 55.4 (range, 24-82 years). The mean number of lesions was 1.4 (range, 1-5), having an average size of 7.6 cm (range, 2-30 cm). Mean operative time was 2.8 hours (range, 2-5 hours) hours. Most resections involved 1 or more Couinaud segments. Mean blood loss was 288 cc (range, 50-150 cc). Complications included re-operation for hemorrhage (n=2), biliary leakage (n=1), and death from hepatic failure (n=1). Mean length of stay was 2.9 days (range, 1-14). When compared with our series of 100 patients who underwent open hepatic resection for benign tumors, significantly greater means ( P <.05) were noted for blood loss (485 cc), operative time (4.5 hours), and length of stay (6.5 days). CONCLUSIONS: Laparoscopic hepatic surgery, though complex, can be performed safely and efficaciously. Minimally invasive surgery appears to provide several distinct advantages over traditional open hepatic surgery. However, techniques for the laparoscopic control of bleeding and bile leak remain in their infancy.     

Approach to the management of complex hepatic injuries

BACKGROUND: Complex hepatic injuries American Association for the Surgery of Trauma Organ Injury Scale grades IV and V incur high mortality rate ranging from 40 to 80%, respectively. The objective of this study is to assess the clinical experience with an aggressive approach to the management of these, the most complex of hepatic injuries. METHODS: This is a retrospective 6-year study (1992-1997) at an American College of Surgeons urban Level I trauma center of patients sustaining complex hepatic injuries whose interventions included surgery, angiographic embolization, endoscopic retrograde cholangiopancreatography plus biliary stenting and percutaneous computed tomographic-guided drainage. The main outcome measure was survival. RESULTS: A total of 22 patients sustaining complex hepatic injuries; mean age of 26 years (range, 10-52 years), mean Revised Trauma Scale score of 9.9, mean Injury Severity Score of 32 (range, 16-75), American Association for the Surgery of Trauma - Organ Injury Scale grade IV (13 cases); grade V (9 cases). Mean estimated blood loss was 4,600 mL; mean number of units of blood transfused was 15. The patients underwent the following interventions: surgery (n = 22), re-operated (n = 13), mean number of operations 1.6 (range, 1-4), extensive hepatotomy and hepatorrhaphy (n = 17), nonanatomic resection (n = 7), formal hepatectomy (n = 4), packing (n = 10), direct approach to hepatic veins (n = 3); angiographic embolization (n = 15); endoscopic retrograde cholangiopancreatography and stenting (n = 5); computed tomographic guided drainage (n = 6). Mean length of stay in the intensive care unit was 21 days (range, 2-134 days), mean hospital length of stay was 40 days (range, 2-147 days). Overall mortality rate was 14% (3 of 22 cases), hepatic mortality rate was 9% (2 of 22 cases), mortality rate by injury grade was 8% grade IV (1 of 13 cases) and 22% grade V (2 of 9 cases). CONCLUSION: In this select patient population, improvements in mortality rates can be achieved with an aggressive approach to the management of complex hepatic injuries, including surgery, early packing, angiographic embolization, endoscopic retrograde cholangiopancreatography and stenting of biliary leaks, and drainage of hepatic abscesses.     

Surgical treatment strategy for multiple injury patients in ICU

Objective: To investigate the surgical treatment for patients with multiple injuries in ICU.Methods: Clinical data of 163 multiple injury patients admitted to ICU of our hospital from January 2006 to January 2009 were retrospectively studied, including 118 males and 45 females, with the mean age of 36.2 years (range, 5-67 years). The injury regions included head and neck (29 cases),face (32 cases), chest (89 cases), abdomen (77 cases), pelvis and limbs (91 cases) and body surface (83 cases). There were 57 cases combined with shock. ISS values varied from 10 to 54, 18.42 on average. Patients received surgical treatments in ICU within respectively 24 hours (10 cases), 24-48 hours (8 cases), 3-7 days (7 cases) and 8-14 days (23 cases).Results: Forthe 163 patients, the duration of ICU stay ranged from 2 to 29 days, with the average value of 7.56 days. Among them, 143 were cured (87.73%), 11 died in the hospital (6.75%) due to severe hemorrhagic shock (6 cases),craniocerebral injury (3 cases) and multiple organ failure (2 cases), and 9 died after voluntarily discharging from hospital (5.52%). The total mortality rate was 12.27%.Conclusions: The damage control principle should be followed when multiple injury patients are resuscitated in ICU. Surgical treatment strategies include actively controlling hemorrhage, treating the previously missed injuries and related wounds or surgical complications and performing planned staging operations.