Michael L. Schwartz

Surgical wound infections. A 5-year prospective study of 20,193 wounds at the Minneapolis VA Medical Center.

This report describes a 5-year prospective study of postoperative wound sepsis utilizing a careful program of wound surveillance. Surgical wounds following 20,193 operations on all surgical services were surveyed by a trained nurse epidemiologist. Daily examination of wounds, culture of all suspicious wounds, and 30-day outpatient clinic follow-up were performed. Results were disseminated at monthly intervals to all involved surgeons and operating room personnel. Prospective and ongoing analysis of results facilitated identification and rectification of specific problem areas. Wound infection rates demonstrated a steady decline over the course of the study, overall rates dropping from 4.2% to 1.9% (p <0.05). This reduction in incidence of postoperative wound sepsis of 55% is estimated to have saved 2740 inhospital days and nearly

Clinical and endoscopic findings in patients early in the course of clostridium difficile-associated pseudomembranous colitis

750,000.

Cholangitis due to malignant obstruction of biliary outflow.

Endoscopic and clinical features are reported for 39 patients detected early in the course of pseudomembranous colitis. Disease was detected early by virtue of careful surveillance in patients in whom diarrhea developed. Early proctosigmoidoscopic findings in pseudomembranous colitis are illustrated. Clinical presentation includes development of fever, leukocytosis, abdominal pain, and even an ileus picture on radiography in addition to diarrhea.

Peritoneovenous shunt therapy for leaking ascites in the cirrhotic patient.

This study reports the clinical presentation and hospital course of 21 patients with cholangitis and malignant diseases, obstructing the biliary tree. Eleven of 21 patients had cholangitis as the initial presentation of biliary disease, and the diagnosis of carcinoma was made at operation or autopsy examination. A total of 14 patients with cholangitis had no prior biliary surgery. Patients who underwent operations to relieve biliary obstructions during episodes of cholangitis had greater incidences of resolution of cholangitis (eight of 14 patients) than those patients treated non-operatively (none of eight patients). Only five patients survived long enough to leave the hospital, but each of these patients were palliated by some sort of drainage procedure. These data suggest that a small portion of this high risk group of patients may benefit significantly from early operative therapy of their cholangitis.

Giant duodenal ulcer

Review of clinical and operative records of 86 patients at the Minneapolis VA Medical Center and Mount Sinai Hospital undergoing peritoneovenous (PV) shunt for Intractable ascites revealed a subgroup of patients (n = 9) who developed leaking ascites prior to shunting. The etiology of leaking ascites was as follows: 1) ruptured umbilical hernia (UH) (four patients), 2) repeated paracentesis (three patients), and 3) postoperative incisional ascitic fluid leak (two patients). Initial therap) included local sterile compression dressing, intravenous antibiotics, and management of fluid and electrolytes. All nine patients underwent subsequent closure of the fascial defect and PV shunt to prevent reaccumulation of ascites (simultaneous procedures were performed in five patients). No patient developed postoperative septic complications, organ failure, gastrointestinal bleeding, or encephalopathy. There were no early deaths; however, three late deaths (18 months, 2, and 4 years) were due to variceal bleeding and/or liver failure. Ascites was well controlled in seven patients with PV shunt alone, the other two ultimately responding to medical therapy. We conclude that peritoneal fluid leaks can be treated successfully by repairing the fascial defect and placing a PV shunt. In the absence of infected ascites and clinical peritonitis, PV shunt may be performed simultaneously with closure of UH, thus preventing the reaccumulation of ascites during the immediate postoperative period.

The clinical and pathologic correlations in mechanical biliary obstruction and acute cholangitis.

Abstract Benign giant duodenal ulcer appears to be a unique type of generalized peptic ulcer disease. Massive hemorrhage, perforation, and obstruction are frequent complications. The disorder is best diagnosed endoscopically and treated with one of the standard acid-reducing procedures.

Local Anticoagulation of Prosthetic Heart Valves

Recently reported series of patients with cholangitis have shown no consistently recognizable differences in clinical presentation between patients with and patients without purulence in the biliary tree, in spite of a clearly higher mortality associated with suppurative cholangitis. To determine whether microscopic changes in the liver ductular system more accurately correspond to clinical status than does the gross finding of suppuration in the common bile duct, a retrospective study was made of 70 patients operated upon for mechanical biliary obstruction and in whom liver biopsy was obtained. Forty patients had benign obstruction, and 30 had malignant disease. The severity of morphologic cholangitis in liver biopsies was graded in a semiquantitative fashion based on inflammatory changes within the portal triads. No significant correlation (chi-square analysis) was found between liver histology and clinical presentation, laboratory data, or mechanism of biliary obstruction. In fact, three patients exhibiting clinical cholangitis had but mild histologic changes; conversely, four patients with minimal symptoms had multiple hepatic microabscesses. The clinical presentations of patients with mechanical biliary obstruction fail to correspond uniformly to either gross or microscopic pathologic findings in the biliary tree. Symptoms and signs of cholangitis may be attributed to some other as yet undefined factors.

Clostridium difficile-associated diarrhea and colitis in adults. A prospective case-controlled epidemiologic study

W ITH THE introduction of totally clothcovered prosthetic heart valves in the mid1960 s, it was hoped that thrombosis and subsequent emboli could be avoided, even without systemic anticoagulation. Unfortunately, this did not prove to be the case; at present, in the mitral position, anticoagulation is the rule rather than the exception. In addition, emboli and anticoagulationrelated hemorrhage are still leading causes of morbidity and mortality in the late postoperative period. A method of local valve anticoagulation without systemic anticoagulation would appear to be a means of accomplishing satisfactory valve function free of the hazards associated with current oral anticoagulant management.