Samuel E. Wilson

PYOGENIC LIVER ABSCESSES: SUCCESSFUL NON-SURGICAL THERAPY

Eleven consecutive patients with pyogenic liver abscesses were seen in a 20-month study period. Ten patients were treated with antibiotics alone. All ten had abscesses demonstrated by hepatic scintigraphy or sonography. In six patients purulent material was obtained by percutaneous aspiration of the liver. Blood-cultures were positive in each of the nine patients in whom they were obtained. Nine of the ten patients treated with antibiotics alone were cured; one died from complications of a liver biopsy. These results indicate that pyogenic liver abscesses can be effectively managed by medical therapy and that surgery is rarely required.

Chylous Ascites Following Abdominal Aortic Surgery

Three patients, two women, one man (mean age 74 years), who had abdominal aortic aneurysms (2) or aortobifemoral surgery (1), developed chylous ascites postoperatively. They were studied to determine their clinical course and develop a plan for management of this complication. In each patient, the ascites was not manifest until abdominal swelling developed two weeks after operation, and the problem was confirmed by the finding of milky fluid on paracentesis. A low serum albumin (mean 2.6 gm) was also characteristic. The ascites was not altered by parenteral nutrition or reduction of dietary fat and ingestion of medium chain triglycerides. In one patient (man, age 93) the ascites resolved spontaneously two months after abdominal aortic aneurysm surgery. Another (woman, age 70) was cured following operative ligation of a lymphatic fistula identified at operation five weeks after abdominal aortic aneurysm repair. In the third (woman, age 60), the ascites resolved immediately following placement of a peritoneal venous shunt six weeks after an aortobifemoral bypass. Chylous ascites is rare after aortic surgery and manifests itself about two weeks after operation, at times after discharge from hospital. It has an indolent course, but may resolve spontaneously up to two months after operation. Its course appears not to be foreshortened by diet, including omission of fat, but can be successfully treated surgically with a shunt or fistula ligation. If done early a protracted hospital course may be avoided.

Computed tomography-assisted management of splenic trauma

BACKGROUNDnIn patients who have suffered an injury to the spleen, preservation of the organ is of the utmost importance. To assist in management, contrast-enhanced computed tomography (CT) has been used. We reviewed our experience with a protocol for nonoperative management of splenic trauma based on CT grading of the injury.nnnMETHODSnDuring the initial period of the study, 50 CT examinations for blunt abdominal trauma in adults were reviewed by staff radiologists for evidence of splenic injury. The radiologists, blinded to clinical management decisions, graded the CT studies as A if there was a subcapsular hematoma or capsular disruption, B if there was a parenchymal injury not extending into the hilum, or C if there was deep laceration of fracture of the hilum. Following confirmation of the accuracy and reproducibility of the grading scale, the splenic trauma management protocol was instituted, in which nonhilar injuries were managed nonoperatively.nnnRESULTSnIn the initial assessment, patients managed nonoperatively had shorter hospital stays and received fewer blood transfusions than those undergoing operation. Among 30 patients subsequently enrolled in the protocol, those treated nonoperatively remained in the hospital for fewer days than those treated surgically. Again, fewer units of blood and platelets were used in the nonoperative group. Institution of the protocol decreased the incidence of celiotomy.nnnCONCLUSIONSnThe severity of splenic trauma evident on CT staging guides safe nonoperative management. Patients not suffering injury to the splenic hilum (A and B scores) can be managed without operation, resulting in shorter hospital stays and fewer blood products used.

Endoscopic intravascular surgery removes intraluminal flaps, dissections, and thrombus

Over the last 3 years angioscopic techniques have been used to guide intraluminal instrumentation in 73 patients undergoing thrombectomy, nine patients with vascular trauma, and 32 patients during laser angioplasty and balloon dilation. After balloon-catheter thromboembolectomy residual, occlusive thrombi tightly adherent to the arterial wall were removed with flexible biopsy forceps in 13 of 73 (18%) patients; underlying intimal flaps were removed in another four. In nine patients traumatic intimal defects caused by iatrogenic cannulation injuries (n = 5) or external trauma (n = 4) were managed by thrombectomy followed by complete or partial intravascular removal of the intimal flap (n = 6) or dissection plane (n = 3) with long flexible forceps and rotating brushes. Traumatic intimal defects observed in two additional patients were judged to be too severe for endoscopic manipulation and required immediate bypass grafting. Inspection after angioplasty in 32 patients revealed wall charring and obvious thermal damage after laser procedures in 28 (87%) and plaque cracking, intimal flaps, and fragmentation in 26 (81%). These defects were underestimated on intraoperative angiography. Large flaps and thrombus were removed endoscopically in three. We conclude that angioscopic study reveals the extent of intimal injury and gives insights into mechanisms of instrumentation. Adherent thrombus after embolectomy by balloon catheter and intimal flaps caused by trauma or angioplasty are common and, if severe, can be successfully treated by endoscopic intravascular manipulation in selected patients.

Current Status of Vascular Access Techniques

The authors describe in detail vascular access techniques that have proved to be most useful to them in a variety of situations, including total parenteral nutrition, dialysis, cancer chemotherapy and chronic intravenous medication, and plasmapheresis.

Analysis of the morbidity, mortality, and cost of colostomy closure in traumatic compared with nontraumatic colorectal diseases

One hundred sixteen patients with acute colorectal diseases, operated upon emergently and needing an intestinal stoma, were reviewed to determine the cost and morbidity of treatment of patients with colorectal trauma compared to other surgical illnesses. The first group (57 patients) had perforating colonic or rectal trauma, the second (30 patients) perforated colonic disease, the third (24 patients) nonperforated colonic disease, and the fourth (five patients) a colonic injury, unrecognized initially but requiring subsequent treatment with a stoma. For the initial operation, hospital stay, complications, mortality, and costs were less for patients in group 1 (colonic injury) than in groups 2 and 3 (inflammatory or neoplastic diseases). Colostomy closure, whatever the antecedent disease or injury, required an average ten-day hospitalization, had no mortality, a complication rate of 0 to 6 percent, and an average hospital cost of

Does method of surgeon payment affect surgical care

6,500. The hospital stay and costs for the total treatment were slightly higher for nontraumatic illnesses, although the rate of colostomy closure was significantly less (68 and 77 percent versus 86 percent,P=.05).

Survival of patients with duodenal fistulas from necrotizing pancreatitis

Abstract The method of surgeon payment influences several important aspects of surgical care. The preoperative processes of laboratory tests and radiographic procedures were performed more frequently and less selectively by salaried surgeons without any corresponding improvement in outcome. Socioeconomic factors and difference in severity of disease accounted for most of the variations in outcome, but in appendicitis there was a trend for fee-for-service surgeons to undertake earlier operation resulting in fewer secondary complications. Although the patient-physician relationship was least developed by salaried surgeons, this was not reflected in any less knowledge of the procedure by the patient or dissatisfaction with surgical care. Operative workloads were highest for surgeons receiving salary plus percentage in fee-for-service group practice.

Comparative study of cefotetan and cefoxitin in the treatment of intra-abdominal infections

Acute necrotizing pancreatitis associated with occult duodenal necrosis and perforation developed in 3 patients 2 to 4 weeks after initially successful treatment of hemorrhagic pancreatitis. Exploration was required for fever, abdominal mass, or X-ray findings of an intra-abdominal abscess. At operation all pancreatic and retroperitoneal abscesses were drained with sump tubes, and the duodenal fistula was closed. An intraluminal tube, placed via a gastrostomy, was used for decompression of the duodenum. Postoperative management included total parenteral nutrition, antibiotics specific for aerobic and anaerobic flora, and frequent X-rays to locate new intra-abdominal abscesses. One to 4 reoperations were necessary because of continuing pancreatic necrosis and abscess formation in each patient. Necrotizing pancreatitis with unrelenting retroperitoneal sepsis and fistula formation results in serious morbidity, hospital stays of several months, and is now the major cause of death in patients with pancreatitis. Survival of all 3 patients resulted from drainage of evolving retroperitoneal abscesses and improvement in our technique for management of large duodenal fistulas.RésuméLarticle rapporte 3 cas de nécrose duodénale insoupÇonnée avec perforation, survenant de 2 à 4 semaines après traitement initialement efficace de pancréatite aigue hémorragique. Lexploration chirurgicale fut rendue nécessaire par lapparition de fièvre, masse abdominale et signes radiologiques dabcès dintra-abdominaux. Le traitement chirurgical consista en drainage des abcès pancréatiques et rétroduodénaux, et fermeture de la fistule duodénale. Leduodénum fut décomprimé à laide dun tube endoluminal introduit par gastrostomie. En période post-opératoire les patients furent traités par hyperalimentation parentérale totale, antibiothérapie spécifique et radiographie répétées pour localiser la formation de nouveaux abcès intra-abdominaux. Tous les patients durent Être réopérés de une à quatre reprises à cause de nécrose pancréatique persistante et abcédation. La pancréatite nécrosante avec infection rétropéritonéale persistante et fistulisation saccompagne dune morbidité grave, dune période dhospitalisation de plusieurs mois et est actuellement la principale cause de décès chez les patients porteurs de pancréatite. La survie de ces 3 patients est attribuable au drainage précoce des abcès péritonéaux, et aux progrès réalisés dans le traitement des fistules duodénales.

Microporous vascular grafts do not require neointima for resistance to bacteremic infection.

One hundred eighty-eight patients were enrolled in a multicenter, randomized clinical trial to compare the safety and effectiveness of 1 to 2 gm cefotetan every 12 hours with those of 1 to 2 gm cefoxitin every 6 hours in patients with intra-abdominal infections. Most of the infections were community acquired, were associated with gastrointestinal tract perforation, and were caused by both anaerobic and aerobic bacteria. The median duration of therapy was 6 days for each group. The clinical response rate for the 95 evaluable patients in the cefotetan group was 98%, and that for the 43 evaluable patients in the cefoxitin group was 95%. Bacteriologically, 97% of the 58 evaluable patients in the cefotetan group and 89% of the 27 evaluable patients in the cefoxitin group had a satisfactory or presumed satisfactory response; two patients in the cefotetan group and three in the cefoxitin group were considered bacteriologic failures. Cefotetan was as effective as cefoxitin in eradicating Bacteroides fragilis and other species of Bacteroides, Clostridium sp., and gram-negative bacilli. The incidence of treatment-related adverse reactions for cefotetan (27%) was not statistically different from that for cefoxitin (17%). No clinically significant differences were detected between the treatment groups in changes in the results of clinical laboratory tests performed before and after treatment; a decrease in hematocrit among the cefotetan group was statistically greater (p = 0.04) than that for the cefoxitin group, and a decrease in serum creatinine level for the cefoxitin group was greater than that for the cefotetan group (p = 0.02). Cefotetan may represent an effective, safe, and cost-saving alternative to cefoxitin for the prompt treatment of community-acquired intra-abdominal infections.