John R. Kirkpatrick

The injured colon: therapeutic considerations.

A prospective randomized study was carried out at the Detroit General Hospital over a two year period to evaluate methods of management in 165 patients with colonic injuries. Results of the study show that primary closure is a safe and reiable method of management when rigid criteria are incorporated in an ongoing protocol. Moreover, the technic of exteriorization is a safe adjunct to management and is recommended in any patient with a colonic injury above 18 cm in which one suture line is required and in which the additional operating time of twenty minutes will not compromise the management of secondary injuries. Patients not fulfilling these criteria should have primary colostomy. These principles make it possible to reduce the need for primary colostomy to approximately 50 per cent in a large ongoing group of patients with colonic injury.

Altered Immunologic Function and Nitrogen Metabolism associated with Depression of Plasma Growth Hormone

The specific role of endogenous growth hormone in regulating nitrogen metabolism during surgical stress and infection remains unclear. We have studied splanchnic amino acid uptake and plasma concentrations in patient groups exhibiting growth hormone hypersecretion or relative growth hormone depression in response to stress. Splanchnic amino acid uptake was similar in both groups although plasma levels were significantly higher in the presence of depressed growth hormone production suggesting increased net peripheral proteolysis. In association with this latter observation. T lymphocyte subset analysis revealed a greater incidence of depressed helper to suppressor cell ratios in the presence of depressed growth hormone suggesting a greater impairment of cellular immunity.

Selective versus standard hyperalimentation: A randomized prospective study☆☆☆

Fifty consecutive surgical patients were included in a randomized prospective study to determine the relative advantages and disadvantages of two types of nutritional support systems: one, selective hyperalimentation, relies on a balanced substrate formula, while the other, standard hyperalimentation, depends on carbohydrate and protein to satisfy the energy requirements of the patient. The patients who received the balanced substrate formula had significantly fewer complications than those receiving standard hyperalimentation, even though both groups achieved positive energy and nitrogen balance. The enhanced safety of selective hyperalimentation suggests its therapeutic superiority as a basic nutritional support system for a busy surgical service.

Injuries of the Colon

Prior to World War II, this type of injury was associated with a significant mortality and morbidity. Today, these wounds should be viewed as a serious event, but one that can be easily and safely managed provided sound surgical principles are adhered to and the surgeon is aware of the preferred therapy for the specific injury pattern present.

Alterations in the Metabolism of Exogenous Lipid Associated with Sepsis

The responses to an exogenous lipid challenge of nonhypermetabolic surgical patients requiring parenteral nutrition and seriously ill septic patients were compared. All patients received a 500-ml intravenous infusion of a 10% lipid emulsion over a 4-hr period. An early elevation of glycerol and triglyceride was noted during the infusion suggesting chylomicron fractionation. Peak triglyceride levels were higher in the septic group but the rate of lipid clearance appeared essentially identical in both septic and nonseptic patients. Lipoprotein lipase levels remained constant and were equal for both groups. Significant late ketone body production was statistically identical in both groups despite depressed albumin levels in the septic group suggesting adequate hepatic ketogenic capacity in septic as well as nonseptic patients.

Management of colonic injuries

PENETRATINO INJURIES Of the colon have always been a dilemma for the surgeon. Currently, we are investigating this problem with a prospective randomized study of patients with colonic injuries. From February 1972 to May 1973, 113 patients with injuries of the colon were treated in our institution. Twenty-three patients had injuries suitable for primary closure and 37 had low-lying injuries not suitable for randomization. The injuries of the remaining 53 patients have been managed by colostomy or primary closure with exteriorization of the suture line. This report concerns 27 patients treated by exteriorization of the colonic suture line. The operative technique used and results obtained are described.

Management of a high-risk intestinal anastomosis☆

Abstract An experimental model was utilized to evaluate and compare the function of an exteriorized intestinal anastomosis and an intraperitoneal anastomosis in sixteen animals. No anastomotic leakage occurred and no difference was noted in the microscopic appearance, function, and strength of the anastomoses at seven days. Return of the exteriorized anastomosis to the peritoneal cavity did not result in significant late complications. This technic was then utilized in managing thirty animals with obstructed colons. Sixty-seven per cent of these animals had healing of exteriorized anastomosis; those anastomoses which leaked (33 per cent) were converted to colostomies. No intraperitoneal contamination resulted from leakage of an exteriorized anastomosis.

Anabolic Steroid Administration During Nutritional Support: A Therapeutic Controversy

Nitrogen balance was determined in 48 patients who were entered into a randomized prospective double-blind study, comparing anabolic steroids versus placebo in our parenteral nutritional support system. The group included both young and old patients suffering from catabolic illnesses, in whom intravenous feeding ranged from 14-21 days. All participants received the active agent or placebo biweekly throughout the study. During the period of intravenous nutrition, there was statistically significant difference in nitrogen balance and protein conservation in the patients receiving the active agent.

Creation of a thoracic duct fistula: An improved technique

Abstract A simple, effective technique has been developed for creating a chronic thoracic duct fistula in dogs. The ease of construction and high lymph flow associated with the fistula make it the preferred technique when total body lymph collection is desired.

The high cost of gunshot and stab wounds

A 22CALIBER BULLET costs about 10 cents; a knife less than five dollars; and a rifle slightly more than fifty dollars. The low cost and easy accessibility of firearms has created a dangerous situation within our society. Medical educators, particularly surgeons, are well advised to critically evaluate the consequences of this problem in terms of manpower requirements, educational sequelae, and economic hardships. This problem also highlights the need for a continuing review of the social environment in which we as surgeons conduct our work. Inherent in this evaluation lies a commitment to express our views to the public in an effort to curb trends that are disruptive to all facets of society.