Gene F. Coppa

Improved results from a standardized approach in treating patients with necrotizing fasciitis.

Necrotizing fasciitis has been associated with significant morbidity and mortality. Thirty-three patients were studied over a 3-year period. Predisposing factors included intravenous drug abuse (30%), diabetes (21%), and obesity (18%). Severe pain (94%) and abnormal temperature (88%) were present, whereas laboratory data and x-ray were nonspecific. Gram-positive organisms were most frequently recovered (B-hemolytic streptococcus 45%). Treatment consisted of antibiotics, surgical debridement, re-exploration 24 hours before surgery, nutritional support, and early soft tissue coverage as needed. Mean duration from admission to operation was 43 hours. The average number of operative debridements was three and the average length of hospitalization was 47 days. Patients operated on less than 12 hours from admission or greater than 48 hours had shorter hospital stays (36 and 38 days). The critical time period was 12-48 hours after admission; all deaths and amputations were in this group and the average hospital stay was 62 days (p less than 0.05). The number of operations did not correlate to hospital stay. Despite antibiotics and aggressive debridement, significant morbidity exists if operation is delayed more than 12 hours. Methods of early detection such as local bedside diagnostic incision and fascial inspection may be needed in high risk patients to further reduce the morbidity and mortality.

Significant trends in the treatment of hepatic trauma. Experience with 411 injuries.

Several significant advances in the treatment of hepatic injuries have evolved over the past decade. These trends have been incorporated into the overall treatment strategy of hepatic injuries and are reflected in experiences with 411 consecutive patients. Two hundred fifty-eight patients (63%) with minor injuries (grades I to II) were treated by simple suture or hemostatic agents with a mortality rate of 6%. One hundred twenty-eight patients (31%) sustained complex hepatic injuries (grades III to V). One hundred seven patients (83.5%) with grades III or IV injury underwent portal triad occlusion and finger fracture of hepatic parenchyma alone. Seventy-three surviving patients (73%) required portal triad occlusion, with ischemia times varying from 10 to 75 minutes (mean, 30 minutes). The mortality rate in this group was 6.5% (seven patients) and was accompanied by a morbidity rate of 15%. Fourteen patients (11%) with grade V injury (retrohepatic cava or hepatic veins) were managed by prolonged protal triad occlusion (mean cross-clamp time, 46 minutes) and extensive finger fracture to the site of injury. In four of these patients an atrial caval shunt was additionally used. Two of these patients survived, whereas six of the 10 patients managed without a shunt survived, for an overall mortality rate of 43%. Over the past 4 years, six patients (4.7%) with ongoing coagulopathies were managed by packing and planned re-exploration, with four patients (67%) surviving and one (25%) developing an intra-abdominal abscess. One additional patient (0.8%) was managed by resectional debridement alone and survived. During the past 5 years, 25 hemodynamically stable and alert adult patients (6%) sustaining blunt trauma were evaluated by computed tomography scan and found to have grade I to III injuries. All were managed nonoperatively with uniform success. The combination of portal triad occlusion (up to 75 minutes), finger fracture technique, and the use of a viable omental pack is a safe, reliable, and effective method of managing complex hepatic injuries (grade III to IV). Juxtahepatic venous injuries continue to carry a prohibitive mortality rate, but nonshunting approaches seem to result in the lowest cumulative mortality rate. Packing and planned reexploration has a definitive life-saving role when used adjunctively in the presence of a coagulopathy. Nonoperative management of select hemodynamically stable adult patients, identified by serial computed tomography scans after sustaining blunt trauma is highly successful (95-97%).

Experience with the finger fracture technique to achieve intra-hepatic hemostasis in 75 patients with severe injuries of the liver.

The most important concept emerging from the management of complex hepatic trauma is that direct suture ligation of severed blood vessels and bile ducts is the most effective treatment. Three essential maneuvers are necessary: (1) the use of the finger fracture technique to expose the laceration widely, so that individual ligation of severed blood vessels and bile ducts can be accomplished under direct vision; (2) occluding the portal triad for 20 to 60 minutes; (3) closure of the hepatic incision over a viable omental pedicle. Two hundred consecutive patients with hepatic injuries were treated at the Trauma and Shock Unit of Bellevue Hospital between July 1976 and January 1982. One hundred and twenty-five injuries (63%) could be managed by superficial suture and drainage alone; 75 (37%) more extensive injuries required additional therapy; 47 of the 75 injuries required inflow occlusion for periods of up to 60 minutes, with the mean occlusion time of 30 minutes. All patients were pretreated with 30 to 40 mg/kg of Solu-Medrol™ prior to cross-clamping the portal triad. In addition, the liver was cooled to 27–32 C° topically by pouring 1 liter of iced Ringers lactate directly on the liver surface, monitoring the temperature with an intra-hepatic probe. Ischemia time exceeded 20 minutes in 70%, 30 minutes in 40% and 60 minutes in 7% of patients. This approach, with complex hepatic trauma, has been dramatically effective. There were only four deaths (5.3%). One (1.3%) patient required reoperation for bleeding; three patients (4%) developed perihepatic abscesses; and two patients (3%) developed biliary fistulne that spontaneously closed. An extended right hepatectomy was necessary in the one patient who required reoperation for bleeding. This represents the only case of a formal hepatic resection in this series. Hepatic artery ligation was not employed in any case. These experiences strongly endorse the direct approach to the treatment of major hepatic lacerations by opening a lacerated liver sufficiently to ligate lacerated blood vessels and bile ducts, followed by closure over an omental pedicle. The wide-spread adoption of this technique will probably lower the mortality from massive liver injuries to 5–10%.

Parenteral and oral antibiotics in elective colon and rectal surgery. A prospective, randomized trial.

Our evaluation consisted of a prospective, randomized clinical trial in a homogenous group of 241 patients undergoing elective colon and rectal resections. A significant decrease in wound infection was found in the patients who received intravenous cefoxitin in conjunction with standard bowel preparation. The infection rate correlated with the type of resection; rectal resections had the highest rate in each study group, but parenteral prophylaxis produced a significantly lower wound infection rate. E. coli and Staph. aureus were the most common bacterial isolates in both groups. B. fragilis was recovered in only two Group A patients, which most likely reflects the exceedingly low recovery rate of anaerobic bacteria in our laboratory. Urinary cultures were positive in a large number of patients and reflect the standard use of Foley catheterization in all patients who undergo resection of the colon or rectum. These data indicate that perioperative prophylactic administration of cefoxitin reduces the wound sepsis rate when combined with oral antibiotics and mechanical bowel preparation in patients undergoing resection of the colon or rectum.

Hepatic resection for metastatic colon and rectal cancer. An evaluation of preoperative and postoperative factors.

Hepatic resection for metastatic colorectal cancer has been reported in over 700 patients. However, approximately 5000 patients each year are candidates for surgical excision. Since 1972, 25 patients have undergone hepatic resection for colorectal metastases at New York University. Potentially curable synchronous lesions were detected by preoperative liver chemistries and operative palpation. Patients were screened for metachronous lesions by serial liver chemistries and carcinoembryonic antigen (CEA) determinations; when clinical findings or laboratory findings were either positive or equivocal, then scanning techniques were used. Most patients had solitary lesions (20). Thirteen of 25 lesions were synchronous; 12 were metachronous. Anatomic lobectomy was performed in 13 patients (6 extended resections); and wedge resection was performed in 12. The operative mortality rate was four per cent; the 2-year survival rate, 65%; the 5-year survival rate, 25%. Hypertonic dextrose solutions were administered during and after operation. Post-operative albumin requirements ranged from 200 to 300 grams/day. Coagulation factors II, V, VII, and fibrinogen decreased after surgery to 30 to 50% of their preoperative levels. Subsequent elevation of these factors correlated with increased bile production and improvement in liver chemistries 10 to 14 days after operation. At present, hepatic resection for colorectal metastases provides the only potential method of salvage, offering a 20 to 25% long-term survival rate.

Experience with selective operative and nonoperative treatment of splenic injuries in 193 patients.

During the past decade splenic salvage procedures rather than splenectomy have been considered the preferred treatment for traumatic splenic injuries. Splenic preservation has been most often accomplished by splenorrhaphy and more recently by a controversial nonoperative approach. This report delineates indications, contraindications, and results with splenectomy, splenorrhaphy, and nonoperative treatment based on an 11-year experience (1978 to 1989) in which 193 consecutive adult patients with splenic injuries were treated. One hundred sixty-seven patients (86.5%) underwent urgent operation. Of these, 111 (66%) were treated by splenorrhaphy or partial splenectomy and 56 (34%) were treated by splenectomy. During the last 4 years, 26 additional patients (13.5%) were managed without operation. Patients considered for nonoperative treatment were alert, hemodynamically stable with computed tomographic evidence of isolated grades I to III splenic injuries. Overall 24% of the injuries resulted from penetrating trauma, whereas 76% of the patients sustained blunt injuries. Complications were rare, with two patients in the splenorrhaphy group experiencing re-bleeding (1.8%) and one patient (4%) failing nonoperative treatment. The mortality rate for the entire group was 4%. This report documents that splenorrhaphy can safely be performed in 65% to 75% of splenic injuries. Splenectomy is indicated for more extensive injuries or when patients are hemodynamically unstable in the presence of life-threatening injuries. Nonoperative therapy can be accomplished safely in a small select group (15% to 20%), with a success rate of nearly 90% if strict criteria for selection are met.

Abdominal mycobacterial infections in immunocompromised patients.

A review of the discharge diagnoses and mycobacterial cultures of patients admitted to a major New York City hospital over an 18-month period revealed 21 patients with abdominal mycobacterial infections (17 male, 4 female) with an average age of 36 years. Acquired immunodeficiency syndrome (AIDS) or an identifiable AIDS risk was present in 14. The disease was manifest by peritoneal (eight patients), ileocecal (seven), and hepatic involvement (three), and psoas abscess (three). Diffuse abdominal pain was the most frequent presenting symptom. However, absence of pain (19 percent) and lack of abdominal findings (28 percent) were not uncommon. The erythrocyte sedimentation rate was significantly elevated (mean 72 mm/hour), whereas the white blood cell count was normal in 18 patients. Computed tomography findings were abnormal in all patients studied and suggested mycobacterial infection in 67 percent. Ten patients (48 percent) required surgery. Although there were no individual differences in clinical or laboratory presentation between the operative and nonoperative patient groups, more patients with pain and higher fever were operated upon. There was one postoperative death. The overall mortality rate was 24 percent, and the mean survival and follow-up 10.2 months and 12.2 months, respectively.

A Prospective Comparison of Two Regimens of Prophylactic Antibiotics in Abdominal Trauma: Cefoxitin versus Triple Drug

To determine the best antibiotic regimen to employ in patients undergoing laparotomy for trauma, a randomized prospective study was designed comparing cefoxitin alone with a triple-drug regime of an aminoglycoside, ampicillin, and clindamycin. One hundred nineteen consecutive patients sustaining abdominal trauma (97 penetrating; 22 blunt) were divided by date of admission to a 24-hour course of antibiotics. The overall infection rate was 16.0%, with 14.5% of the cefoxitin-treated patients, and 18.0% of the triple-drug-treated patients developing an infectious complication. Excluding remote site infections, the abdominal wound and intraperitoneal infection rates were 13.0% for cefoxitin-treated patients, and 12.0% for triple-drug-treated patients. There was one instance of oliguric renal failure questionably related to an aminoglycoside. It is concluded that a 24-hour course of cefoxitin is a safe and effective prophylactic antibiotic regime in patients undergoing laparotomy for trauma.

Management of diverticulitis of the ascending colon. 10 years' experience.

Diverticulitis of the ascending colon is an uncommon disease which mimics appendicitis. The correct diagnosis is rarely made, but can be suggested by the patterns of signs and symptoms and confirmed by barium contrast study. Diverticulitis of the ascending colon should be treated by the same plan as diverticulitis of the left colon. If the diagnosis is established, nonoperative management is indicated initially. Operation is indicated when the diagnosis is in doubt, when perforation has occurred, or when the patient does not respond to nonoperative treatment. At operation, ascending colon diverticulitis can be recognized as an inflammatory mass involving the wall and mesentery of the colon. The inflammatory mass is best treated by resection with primary anastomosis of the ileum to the ascending or transverse colon in an area removed from the site of infection.

The role of Chiba-needle cholangiography in the diagnosis of possible acute pancreatitis with cholelithiasis.

In patients with suspected severe acute pancreatitis and known or suspected cholelithiasis, it may be extremely difficult to exclude the diagnosis of gangrenous cholecystitis or obstructive choliingitis by nonopcrative means. Since early intra-abdominal surgery has, in our experience, led to markedly increased morbidity in patients with gallstone pancreatitis, non-operative visualization of the biliary tree by percutaneous transhepatic Chiba-needle cholangiography (PTCNC) has been evaluated in 14 patients with suspected acute pancreatitis in whom life-threatening acute biliary disease could not be excluded by other nonopcrative means. The final diagnosis was acute pancreatitis in nine patients (Group A) (mean scrum amylase 3242 SU%) and acute biliary disease with hyperamylasemia in five patients (Group B) (mean serum amylase 2084 SU%). PTCNC made visualization of the biliary system possible in all patients and excluded the diagnosis of cystic duct or common duct obstruction in each case. Following PTCNC, potentially hazardous early laparotomy was avoided in eight of nine Group A patients. Biliary surgery was undertaken on day 3 to 13 in four Group B patients. When early laparotomy may be needed to evaluate or treat possible life-threatening acute biliary disease but is considered undesirable because of possible acute pancreatitis, PTCNC appears to be a safe and effective nonoperative method of obtaining precise anatomical delineation of the biliary tree.