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Characteristics of Pancreaticoduodenal Resection on Periampullary Tumor Cases by Jakarta Tertiary Hospital Team: Three Decade Report Lalisang, Toar JM; Mazni, Yarman; Moenadjad, Yefta; Matondang, Sahat
The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy Vol 20, No 2 (2019): VOLUME 20, NUMBER 2, AUGUST 2019
Publisher : The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy

Background: There were only few publications related to pancreaticoduodenal resection (PDR) /Whipple procedure in Indonesia in the past decade.Method: Retrospectively report of the characteristics and outcomes of PDR performed by Cipto Mangunkusumo Hospital surgical team from 1993 to 2017 were collected.Results: PDR were performed in 213 patients, with a mean age of 50.6 years and 54.4% patients were females. Predominant preoperative clinical findings were jaundice (68.9%) and mild hypoalbuminemia (69.9%). Biliary decompression was performed in 112 (52.6%) subjects. Average surgical waiting time was 3.5 months. While PDR were performed in 84 (39.5%) subjects, pyloric preserving pancreaticoduodenal technique was predominated in 128 (59.8) and predominated, especially during the latter years. Fifteen (9.0%) cases were benign. Thirty-one (14.6%) subjects underwent relaparotomy, 16 (51.6%) of whom died post-operatively. Overall operative mortality decreased from 16.9% to 5.5% in 2016, while resection rate generally increased over time, ranging from 2 - 21/year. Less than 10% of subjects survived for > 5 years, while < 20% survived for < 24 months. Overall morbidity was 65.1% in 177 survivors, with surgical site infection in 52.5%, pancreatic fistula in 24.2%, and post-pancreatectomy haemorrhage (PPH) as a fatal postoperative complication in 19 (8.9%) cases. Patients who died within 30 days postoperatively had significantly more relaparotomies and PPH (p < 0.001).Conclusion: Prolonged jaundice and mild hypoalbuminemia are dominant characteristics in our Indonesian PDR subjects. Cipto Mangunkusumo Hospital is a high-volume PDR centre and world class hospital. Mortality rates decreased with the increasing resection rates. Relaparotomy and PPH are predictors of poor outcome.

Clinical Presentation of Abdominal Tuberculosis Putranto, Agi S.; Bakti, Purnama S.; Mazni, Yarman; Jeo, Wifanto S.; Lalisang, Toar JM.
The New Ropanasuri Journal of Surgery
Publisher : UI Scholars Hub

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Introduction. Nowadays, tuberculosis remains an issue of global. It may have affected all gastrointestinal organs, including peritoneum. Thus, diagnostic approach of this abdominal tuberculosis remains challenging as it may present non–specific features and mimics other abdominal pathologies. A study focused on clinical and laboratory findings, imaging and evaluation of management of those diagnosed as abdominal tuberculosis was required. Method. A cross–sectional study proceeded retrospectively aimed for an evaluation. All abdominal tuberculosis managed in dr Cipto Mangunkusumo General Hospital, Jakarta and Fatmawati General Hospital, Jakarta during January 2011 to December 2013 were enrolled. Data collected from data registration, subject’s characteristic, clinical findings, laboratory findings, and imaging were variables subjected to analysis. Results. There were forty–eight subjects recorded. The most symptoms found were abdominal pain (81.25%), abdominal distention (72.9%), fever (68.75%) and weight loss (68.75%). While as most laboratory findings were leukocytosis (52%) and elevated erythrocyte sedimentation rate, ESR (72.9%). And up to 50% subject showed normal chest x–ray while as other showed non–specific features for pulmonary tuberculosis. Conclusion. Clinical presentations showed to be diverse. Laboratory finding, and imaging maybe valuable to diagnose abdominal tuberculosis, although chest x–ray represents non–specific features for pulmonary tuberculosis. Evaluation of these clinical findings and lead to accurate diagnostic approach; which was determine the characteristics associated with abdominal tuberculosis diagnostics value..

CT Scan as A Diagnostic Modality of Gastrointestinal Stromal Tumor: A Systematic Review Mazni, Yarman; Robby, Rizky DK
The New Ropanasuri Journal of Surgery
Publisher : UI Scholars Hub

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Introduction. Preoperative diagnosis of GIST is an important factor in the management. However, due to the rarity of the case, there is a controversy about the accuracy of CT scan as an accurate diagnostic tool. Therefore, a systematic review is required to find out the answer. Method. A review was conducted to find out evidence of the highest level regarding the accuracy of CT scan as a diagnostic modality of GIST. The study addressed to find out the sensitivity, specificity, positive and negative predictive values. A literature search carried out in database sites i.e. PubMed, ClinicalKey, ScienceDirect, and Cochrane using keywords “gastrointestinal stromal tumor” OR “GIST” AND “ultrasound” OR “CT scan” OR “MRI” AND “diagnostic” OR “imaging”. Systematic reviews, RCTs, cohort study, case report or series, studies in adults, published within the last ten years, and availability in full text were included. Correspondence, editorial, or commentary, and no histopathology data were excluded. The articles were critically appraised. The review proceeded in accordance with PRISMA. Results. Twelve studies were analyzed in the study. The sensitivity of CT scan was in range of 77.26–94.9%, specificity 77.2–100%, PPV 74.38– 100%, and NPV 68.32–81.2%. CT scan was found to be the modality of choice in establishing the diagnosis of GIST. Central necrosis, heterogenous enhancement, cavitation without lymphadenopathy were the features represented by CT scan. Conclusion. CT scan is the modality of choice in establishing diagnosis of uncomplicated GIST, with sensitivity and specificity of 94.9% and 100%, respectively. Other modalities were considered in advanced or GIST with metastasis.

Laparoscopic Approach in Correction of Adult Diaphragmatic Morgagni Hernia Mazni, Yarman; Prabowo, Andrio W
The New Ropanasuri Journal of Surgery
Publisher : UI Scholars Hub

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Introduction. Adult diaphragmatic hernia of Morgagni is a very rare congenital anomaly. Therefore, to date there is no standard surgical techniques used in the management. Thus, a systematic review aimed to find the highest evidence in the management. Method. A systematic review conducted in accordance with PRISMA. Literature search proceeded on PubMed and ScienceDirect using keywords "diaphragmatic hernia of Morgagni in adult", and "treatment". These articles were reviewed and appraised for the study design used, enrolled samples, validation of results, etc. to find out the level of evidence. The analysis was focused on length of stay, the recurrence, and complications. Results. There were 15 articles reviewed. The transabdominal approach provides better exposure, short length of stays, and low complications. Laparoscopic has been used widely and replaces open surgery. The defect closure using mesh is indicated in large defect of ≥20 cm2 . The hernial sac is unnecessary to resect, with no complication such as seroma or recurrence. Conclusion. A laparoscopic approach referred to the method of choice in the management of adult diaphragmatic hernia of Morgagni. Unnecessary resection of hernial sac and tension free defect closure should be of one consideration.

Comparative Analysis of Post Rubber Band Ligation and Stapled Hemorrhoidopexy Complications of Grade 2 and 3 Internal Hemorrhoids Mazni, Yarman; Basir, Ibrahim; Sumanto, Sumanto; Budiningsih, Setyawati
The New Ropanasuri Journal of Surgery
Publisher : UI Scholars Hub

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Introduction. The management of second–and third–degree internal hemorrhoid consists of non–surgical and surgical treatments. If non–surgical treatment does not succeed, then the recommended therapy is minimal invasive or surgery, depends on the clinical condition. Along with the development of science and technology, a technique known as rubber band ligation (RBL) and stapled hemorrhoidopexy emerges. In Indonesia, there is no data that can describe the distribution of postoperative complication rate. Method. A comparative cross–sectional study was conducted by gathering short term outcomes data from the subjects' medical records that underwent RBL or SH between 2011 to 2014 in three different hospitals in Jakarta. A univariate analysis was conducted to assess postoperative complications of RBL and SH subjects of second–and third–degree internal hemorrhoids. We use chi square test to assess the factors that influence the complications of categorical variables, and Fisher test if the chi square condition is not met. Results. Among 183 subjects, 49.2% underwent RBL and 50.8% SH. Second degree internal hemorrhoids were 40% and third degree were 60%. Postoperative complications consist of pain (RBL 4.4%, SH 8.8%), hemorrhage (RBL 2.3%, SH 4.9%), urinary retention (RBL 0, SH 2.7%), infection (RBL 0.5%, SH 1.6%) and stenosis (RBL 0, SH 0.5%). Postoperative complications on second degree internal hemorrhoidal was 8.2% and third degree 13.1% (p = 0.71). Complication of subject with third degree internal hemorrhoids after RBL 2.8%, SH 19.4% (p = 0.03). Conclusion. Complications of second– and third–degree internal hemorrhoids post RBL are no different with SH while for third degree internal hemorrhoid, complications after RBL ware significantly lower than SH.

Gallstone Ileus in Cipto Mangunkusumo General Hospital, Jakarta: A Case Series Lalisang, Toar JM; Hehuwat, Georgina P.; Lalisang, Arnetta NL; Pratama, Irfan K.; Mazni, Yarman
The New Ropanasuri Journal of Surgery
Publisher : UI Scholars Hub

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Introduction. Gallstone ileus is an uncommon mechanical bowel obstruction caused by a gallstone in the gastrointestinal tract which enters due to bile-enteric fistulae. This study aims to describe gallstone ileus and its management. Method. Data were retrospectively collected from medical records. Clinical manifestations, laboratory data, supporting radiographic examinations, treatment, postoperative care, and outcomes were collected. Results. We report two gallstone ileus cases at Cipto Mangunkusumo General Hospital, Jakarta which admitted in the last 20 years. The first case was a woman 33 years in 2002 and the second was man 45 years in 2017. Ileus was the main clinical symptoms. Gallstone ileus was diagnosed with preoperatively based on clinical and radiology findings. Laparotomy was performed and ileostomy for stones evacuation and cholecystectomy were performed without bile-enteric fistula repair. Large black stones were found at terminal ileum which made the obstruction. Conclusion. Gallstone ileus was an uncommon disease which can be treated and has a good prognosis. Plain abdominal x-ray has an important role in diagnosis and treatment approach.

Intraoperative Pancreatic Assessment in Pancreaticoduodenectomy The Correlation with Pancreatic Fistula Formation Mazni, Yarman; Syafiuddin, Ardani F; Putranto, Agi S
The New Ropanasuri Journal of Surgery
Publisher : UI Scholars Hub

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Background Pancreatic cancer affects 25,000 to 30,000 people in the United States each year and is the fourth or fifth leading cause of cancer-related death in this country. It is generally resected by pancreaticoduodenectomy, with or without preservation of the pylorus and proximal duodenum. Anastomotic leaks, intra-abdominal abscesses, and delayed gastric emptying account for most of the perioperative complications after pancreaticoduodenectomy. Anastomotic leaks of pancreas are resulted pancreatic fistula about 45%. A lot of study that have been done to find risk factors of postoperative pancreatic fistula (POPF) with contradictive results. Method This study was done for 70 patients of pancreaticoduodenectomy procedure. Data was collected from medical record in 2016-2019. The data are pancreatic texture, pancreatic duct diameter, pancreaticojejunal anastomotic technique, use of stent in pancreaticojejunal, and POPF. We analyzed the data bivariat with Spearman. Results There are 41,4% male and 58,6% female, Patient with underweight about 21,4%, normoweight 57,1%, overweight 15,7%, dan obese 5,7%. Patient with Diabetes Melitus (DM) about 11,4% and no DM 88,6%. The mean of blood glucose is 136,03 mg/dl. Patient with no POPF about 21,4% and with POPF 78,6%. The A type POPF about 69,1%, B type 14,5%, and C type 16,4%. Pancreatic duct diameter 78,6% and >3 mm about 21,4%. Soft texture pancreas about 22,9% and hard 77,1%. Use of stent about 21,4% and no stent 78,6%. Pancreaticojejunal anastomotic type of dunking or invaginating about 82,9% and duck to mucosa sebanyak 17,1%. The significant risk factor in univariate analysis is diameter of the pancreatic duct (p=0,007). Conclusion Diameter of the pancreatic duct can be used as a risk factor to predict POPF in pancreaticoduodenectomy procedure.

Evaluation of the Implementation of ERAS Protocol in Colorectal Surgery at dr. Cipto Mangunkusumo General Hospital, Jakarta Jeo, Wifanto S; Mazni, Yarman; Suryadi, Andre S
The New Ropanasuri Journal of Surgery
Publisher : UI Scholars Hub

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Background: The enhanced recovery after surgery (ERAS) protocol, an evidence-based perioperative strategy, has been proven in reduces the postoperative length of stay and perioperative complications rates in colorectal surgery. The implementation of ERAS defined by 15 components. However, the evaluation of ERAS component that have been applied to the outcomes in unclear. Methods: A retrospective study was performed on 63 patients who undergone elective colorectal surgery based on ERAS protocol from January 2015 to December 2017 at Cipto Mangunkusumo Hospital. Patient characteristics, demographic, clinical findings, and length of stay (LOS) colleted from medical records. The relationship between the number of ERAS that accomplish and LOS was analyzed. Result:All patients implemented up to 11 of 15 ERAS components. The mean age of the patients was 53 years old; 46% of patients were males, and 54% were females. There were no mortality rates. The morbidity rate was 7.9%, caused by surgical site infection 1.6%, pneumonia 1.6%, and urinary retention 4,8%. The most common location for colorectal tumour and procedure were sigmoid (47,6%) and colostomy closure (25,4%). There was a relationship between the total ERAS component protocols and the average length of stay (p Conclusion: The higher number of ERAS components applied to one patient, the shorter LOS for postoperative care needed.

External Validation Of 10 Points Intraoperative Gallbladder Scoring System (G10) In Laparoscopic Cholecystectomy at RSUPN dr. Cipto Mangunkusumo Mazni, Yarman; Jeo, Wifanto Saditya; -, Rony
The New Ropanasuri Journal of Surgery
Publisher : UI Scholars Hub

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Introduction. Laparoscopic cholecystectomy has become a standard treatment for symptomatic cholecystolithiasis in dr. Cipto Mangunkusumo Hospital (RSCM). This study aims as a preliminary study to externally validate the 10-point intraoperative gallbladder scoring system (G10), an assessment system of laparoscopic cholecystectomy's difficulty. Method. A cross-sectional study was carried out. Enrolling subjects who underwent laparoscopic cholecystectomy from January 2019 to December 2019. Data of the subjects were collected from medical records. We assessed each of the subjects' G10 scores and operation techniques based on the intraoperative images and surgical reports. The surgical technique divided into two groups, those are the Critical View of Safety (CVS) technique and bailout procedure group, consisting of fundus–first cholecystectomy, subtotal cholecystectomy, and conversion. The correlation of G10 score between CVS and bailout was analysed using the Mann-Whitney nonparametric test. A Kendall's tau was performed to measure the correlation between the G10 score and the bailout procedure. Statistical power was calculated by G-power application. A ROC test was performed to calculate the sensitivity and specificity of the G10 scoring system to predict bailout procedure, then the cut-off value was determined. Results. There was a significant and positive correlation between the G10 score with the bailout procedure (2 indicate subjects at high risk of bailout procedure (72.2% vs. 20.98%). Conclusion: This study showed that the G10 score has good accuracy in predicting a bailout procedure. The use of G10 scores intraoperatively is "essential" to provide valid and objective assessment in determining the difficulty of surgery. When the G10 score is 1 or 2, it's safe to perform the CVS technique. Whereas, if the G10 score is three or greater, surgeon should consider bailout procedure.

Analysis of Preoperative and Intraoperative Risk Factors Of Surgical Site Infection In Gastrointestinal Surgeries Syafitri, Annisa; Mazni, Yarman; Budiningsih, Setyawati
The New Ropanasuri Journal of Surgery
Publisher : UI Scholars Hub

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Introduction. Surgical site infection (SSI) after gastrointestinal surgery can affect the mortality and morbidity of the patients. Risk factors are needed to prevent and decrease the number of SSI. This study investigated the incidence of SSI, the preoperative and intraoperative risk factors of gastrointestinal surgeries.. Method. A retrospective audit analysis of age, nutritional status, preoperative length of stay, length of surgery, type of surgery, degree of contamination in adult gastrointestinal surgery patients at dr. Cipto Mangunkusumo General Hospital from 2012 to 2016. Outcomes consisted of incidence, and potential univariate risk factors were determined to investigate the independently associated factors using multivariate logistic regression. Results. In four years, the incidence of SSI is 3.4% among 4,357 gastrointestinal surgeries, with 86.4% of surgical site infections appears in contaminated wound operations. Our study included 116 subjects. From univariate analysis between SSI as dependent factors and the risk factors, age (p = 0.2), preoperative length of stay (p=0,06), length of surgery (p = 0.1), and degree of contamination (p = 0.003) have correlative association with SSI. The risk factor with surgical site infection is surgical wound contamination (OR = 1.233, p = 0.011) and independent from other risk factors.. Conclusion: Four factors correlate with SSI; there are age, preoperative length of stay, length of surgery, and degree of contamination. The degree of contamination is a significant risk factor for SSI.

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