Ronald C. Jones

Management of pancreatic trauma.

Since 1950, 300 patients sustaining pancreatic injuries have been managed. Three-fourths of the injuries were due to penetrating trauma with a 20% mortality and one-fourth due to blunt trauma resulting in an 18% mortality. The pancreatic injury was responsible for death in only 3% of patients. Early onset of shock resulted in a 38% mortality whereas only 4% of normotensive patients died. No patient died of an isolated pancreatic injury. Sepsis was the second most common cause of death following hemorrhage. Preoperative serum amylase was elevated more frequently following blunt trauma than penetrating trauma, but did not correlate with injury.There has been a tendency toward more frequent use of distal pancreatectomy for simple penetrating injuries without obvious ductal violation which increases operative time, blood loss and possible intra-abdominal abscess since resection usually requires splenectomy. Patients considered for an 80% distal resection are better managed with a Roux-en-Y limb to the distal pancreas since three patients developed diabetes following an 80% or greater resection. A conservative approach consisting of Penrose and sump drainage is adequate for most injuries.

Management of pancreatic trauma

Since 1950, 300 patients sustaining pancreatic injuries have been managed. Three-fourths of the injuries were due to penetrating trauma with a 20% mortality and one-fourth due to blunt trauma resulting in an 18% mortality. The pancreatic injury was responsible for death in only 3% of patients. Early onset of shock resulted in 38% mortality whereas only 4% of normotensive patients died. No patient died of an isolated pancreatic injury. Sepsis was the second most common cause of death following hemorrhage. Preoperative serum amylase was elevated more frequently following blunt trauma than penetrating trauma, but did not correlate with injury. There has been a tendency toward more frequent use of distal pancreatectomy for simple penetrating injuries without obvious ductal violation which increases operative time, blood loss and possible intra-abdominal abscess since resection usually requires splenectomy. Patients considered for an 80% distal resection are better managed with a Roux-en-Y limb to the distal pancreas since three patients developed diabetes following an 80% or greater resection. A conservative approach consisting of Penrose and sump drainage is adequate for most injuries.

Evaluation of antibiotic therapy following penetrating abdominal trauma.

Postoperative infection accounts for significant morbidity and mortality following penetrating abdominal trauma. During a 2 1/2-year period, December 1980 through June 1983, 257 patients sustaining penetrating abdominal injury were initially treated at Parkland Memorial Hospital in Dallas. Following the patients written consent, they were prospectively randomized to receive, prior to surgery, intravenous clindamycin 600 mg every 6 hours and tobramycin 1.2 mg/kg every 6 hours (CT), or cefamandole 1 gm every 4 hours (M), or cefoxitin 1 gm every 4 hours (C). The antibiotics were continued for 48 hours. Major organ injuries in the three groups were comparable. The overall infection rate was significantly less in the cefoxitin group (13%), compared to cefamandole at 29%, and was comparable to the combination of clindamycin/tobramycin at 20%. The most significant difference followed colon injury. There were 96 patients who sustained colon injuries and the infection rate was CT 33%, M 62%, and C 19% (p = 0.002). If nonoperative wound infections were excluded from the colon group and only severe infections were evaluated, the infection rate was CT 18%, M 38%, and C 13% (p = 0.021). The infection rate was higher in the shock patients and tended to increase as age increased. Enterococcus, Escherichia coli, and Klebsiella pneumoniae were the most frequent aerobes isolated along with anaerobes. Five of six Bacteroides isolates from major infections occurred in the cefamandole group; two of which were in bacteremic patients. The hospital stay corresponded with infection rates, being 11.4 days (CT), 13.1 days (M), and 9.4 days (C). The results of this study indicate that cefoxitin is comparable to the combination of clindamycin/tobramycin and superior to cefamandole when used before surgery in patients sustaining penetrating abdominal trauma. The study suggests that antibiotic coverage should be against aerobes and anaerobes. Routine administration of an aminoglycoside is unnecessary.

Management of injuries to the inferior vena cava

Abstract 1. 1. Forty-two instances of injury to the inferior vena cava were found at laparotomy during the past ten years at Parkland Memorial Hospital. Of this group twenty-five survived, yielding a mortality of 40.5 per cent. 2. 2. Three principal factors determining survival were associated major vessel injury, the level of inferior vena cava injury and whether or not the vessel was actively bleeding at laparotomy. The latter seems to be the most important factor. 3. 3. All retroperitoneal hematomas should be explored. In 75 per cent of these cases, there was an additional reason to explore the retroperitoneal area. 4. 4. Suture repair by the technics outlined was the preferred method of treatment. Ligation was occasionally necessary if the injury was below the renal veins and primary repair could not be accomplished. 5. 5. It is essential to have a set of major vascular instruments immediately available when treating intra-abdominal trauma.

New horizons in the diagnosis and treatment of breast cancer using magnetic resonance imaging.

A new nuclear magnetic resonance imaging (MRI) technique, Rotating Delivery of Excitation Off-resonance (RODEO), has been developed to assist surgeons in the diagnosis and treatment of breast cancer. A nonrandomized, prospective study of 100 patients with a high suspicion of breast cancer was conducted; these patients were examined by RODEO and conventional breast imaging, including mammography. Forty-one breasts were removed by mastectomy; each pathologic specimen was examined by sectional analysis. This study was undertaken to determine the extent that RODEO can aid in detecting breast tumors (including multicentric disease) and in evaluating candidates for conservative breast surgery. RODEO detected 85 pathologically confirmed lesions, 64 of which proved to be malignant. RODEO had a sensitivity of 95%, compared with a sensitivity of 58% for conventional imaging. More study is needed to determine distinguishing MRI characteristics that are suspicious for malignancy. RODEO may be used clinically to assess multicentricity and response to chemotherapy.

Clostridial myonecrosis of the abdominal wall: Management after extensive resection

Abstract A method of temporary and permanent containment of abdominal viscera after extensive clostridial myonecrosis is described. Debridement is carried out through parallel incisions with maximal preservation of skin and subcutaneous tissue. Marlex mesh is used temporarily until the infection is completely controlled. The skin and subcutaneous tissue are then reapproximated, giving excellent wound coverage and markedly shortening the hospital stay.

Ronald Coy Jones, MD: A Conversation with the Editor

Ron Jones (Figure ​(Figure11) was bom in Harrison, Arkansas, on August 24, 1932, and spent most of his early years there. He attended the University of Arkansas for 3 years and then entered the University of Arkansas School of Medicine, where he spent 2 years before transferring to the University of Tennessee School of Medicine. He completed a rotating internship at the Los Angeles County General Hospital. In July 1958, he began a general practice residency at the University of Oklahoma Medical Center in Oklahoma City. During that training, he became interested in surgery and did his general surgery residency at Parkland Memorial Hospital in Dallas from 1960 to 1964. Thereafter, he remained on the surgical faculty of The University of Texas Southwestern Medical School and rapidly rose in rank to full professor within 10 years (1974). From 1974 to 1976 he was acting chairman of the Department of Surgery at Southwestern. In July 1987, he moved to Baylor University Medical Center (BUMC) as chairman of the Department of Surgery and has remained in that position since.