The management of patients with an open abdomen is challenging. Control of intra-abdominal fluid secretion, facilitation of abdominal exploration and preservation of fascia for abdominal wall closure can test even the most experienced surgeon. Over the years various techniques have been tried to minimise complications and expedite closure with VAC® therapy (KCI Medical, Witney, Oxford UK) being the newest. This article provides an overview of the techniques available for the management of the open abdomen from towel clips to VAC®.
Revisions in terminology of fluid collections in acute pancreatitis have necessitated reanalysis of their evolution and outcome. The course of fluid collections in patients with acute pancreatitis was evaluated prospectively.Consecutive adults with acute pancreatitis, who had contrast-enhanced CT (CECT) within 5-7 days of symptom onset, were enrolled in a prospective cohort study in a tertiary-care centre. Patients were treated according to standard guidelines. Follow-up transabdominal ultrasonography was done at 4-week intervals for at least 6 months. CECT was repeated at 6-10 weeks, or at any time if there were new or persistent symptoms. Asymptomatic collections were followed until spontaneous resolution. Risk factors for pancreatic pseudocysts or walled-off necrosis (WON) were assessed in multivariable analyses.Of 122 patients with acute pancreatitis, 109 were analysed. Some 91 patients (83·5 per cent) had fluid collections at baseline. Eleven of 29 with interstitial oedematous pancreatitis had acute peripancreatic fluid collections, none of which evolved into pseudocysts. All 80 patients with acute necrotizing pancreatitis had at least one acute necrotizing collection (ANC); of these, five patients died (2 after drainage), three underwent successful drainage within 5 weeks, and collections resolved spontaneously in 33 and evolved into WON in 39. By 6 months' follow-up, WON had required drainage in eight patients, resolved spontaneously in 23 and was persistent but asymptomatic in seven. Factors associated with increased risk of WON were blood urea nitrogen 20 mg/dl or more (odds ratio (OR) 10·96, 95 per cent c.i. 2·57 to 46·73; P = 0·001) and baseline ANC diameter greater than 6 cm (OR 14·57, 1·60 to 132·35; P = 0·017). Baseline ANC diameter over 6 cm was the only independent predictor of either the need for drainage or persistence of such collections beyond 6 months (hazard ratio 6·61, 1·77 to 24·59; P = 0·005).Pancreatic pseudocysts develop infrequently in oedematous acute pancreatitis. Only one-quarter of ANCs either require intervention or persist beyond 6 months, whereas more than one-half of WONs resolve without any intervention within 6 months of onset. Baseline diameter of ANC(s) is an important predictor of outcome.
Introduction The way pancreatoduodenectomy (PD) is performed can vary a lot around the world, and there is no agreed-upon standard approach. To learn more about how PD is practised in India, a survey was conducted among Indian surgeons to gather information about their current practices. Methods A survey was created and shared with surgeons in India who practice pancreatic surgery. It had 33 questions that aimed to capture information about different aspects of PD practice. These questions covered topics such as the surgeons' education and experience, how they evaluated patients before surgery, what they considered during the operation, and how they managed patients after surgery. Results A total of 129 surgeons were sent the survey, and 110 of them completed it. The results showed that 40.9% of the surgeons had less than five years of experience, and 36.4% of them performed more than 15 PDs in a year. When deciding whether to perform preoperative biliary drainage, 60% of surgeons based their decision on the level of bilirubin in the patient's blood, while the rest considered other specific indications. The majority of surgeons (72.7%) looked at the trend of albumin levels to assess the patient's nutritional status before surgery. Venous infiltration was seen as a reason for neoadjuvant therapy by 76.4% of the participants, whereas 95.5% considered upfront surgery in cases of venous abutment. When it came to the type of PD, 40% preferred classical PD, 40.9% preferred pylorus-resecting PD (PRPD), and the rest chose pylorus-preserving PD (PPPD). Pancreatojejunostomy (PJ) was the preferred method for 77.3% of surgeons, while 6.3% preferred pancreatogastrostomy (PG). About 65.5% of surgeons used octreotide selectively during the operation when the duct diameter was small. Nearly all surgeons (94.5%) preferred to secure feeding access during PD, and all of them placed intraperitoneal drains. As for postoperative care, 37.3% of surgeons attempted early oral feeding within 48 hours, while 28.2% preferred to wait at least 48 hours before initiating oral feeds. Conclusions The survey revealed significant differences in how PD is practised among surgeons in India, highlighting the heterogeneity in their approaches and preferences.
Abstract Chronic pancreatitis requires surgery for intractable pain, suspicion of malignancy and complications. Hybrid procedure comprising pancreatic head coring and main pancreatic ductal decompression is nowadays standard of care where surgery is indicated for pain. This becomes difficult if main pancreatic duct is not dilated or the disease is of small duct origin. We encountered a case of small duct chronic pancreatitis with intractable pain. We cored out deseased pancreatic tissue without searching the undilated duct. We are presenting this case with suitable figures. Keywords: Chronic pancreatitis, Surgery, small duct disease, Izbicki’s procedure Case Report A 44 years old male patient was referred to Surgical Gastroenterology Department for intractable abdominal pain due to chronic pancreatitis. The patient was a known alcoholic for last 15 years with nearly daily intake of 180-360 ml country liquor(alcoholic strength around 30-40% v/v). He started suffering from epigastric pain with radiation to back for last 4 years. He was diagnosed to have chronic pancreatitis. He continued to have alcohol in spite of recurrent pain for one more year. Initially pain was infrequent and of lesser intensity, coming once in 4-6 months and usually responding to oral non opioid analgesics. But for last 2 years prior to admission he was having more frequent pain of more intensity requiring hospitalization for 3-4 times per year. He was abstinent from alcohol for last 3 years. For last 1 month he had continuous type dull aching pain with back radiation and weekly 3-4 times severe pain. He was diabetic and on oral hypoglycaemic drugs for last 3 years with no recent change in glycaemic control. We investigated the patient. Blood reports revealed haemoglobin of 11.8%, total count of 6750/ cumm, platelet count of 227000/ cumm, serum albumin of 3.3 gm% and other liver functions and renal function tests being normal. Contrast enhanced computed tomography (CECT) scan revealed bulky head of pancreas with extensive calcifications (
'%3e%3ccircle r='20' fill='%23008'/%3e%3ccircle r='17.5' fill='%23fff'/%3e%3ccircle r='3.5' fill='%23008'/%3e%3cg id='d'%3e%3cg id='c'%3e%3cg id='b'%3e%3cg id='a' fill='%23008'%3e%3ccircle r='.875' transform='rotate(7.5 -8.75 133.5)'/%3e%3cpath d='M0 17.5.6 7 0 2l-.6 5L0 17.5z'/%3e%3c/g%3e%3cuse xlink:href='%23a' transform='rotate(15)'/%3e%3c/g%3e%3cuse xlink:href='%23b' transform='rotate(30)'/%3e%3c/g%3e%3cuse xlink:href='%23c' transform='rotate(60)'/%3e%3c/g%3e%3cuse xlink:href='%23d' transform='rotate(120)'/%3e%3cuse xlink:href='%23d' transform='rotate(-120)'/%3e%3c/g%3e%3c/svg%3e)
