William A. Altemeier

Intra-abdominal abscesses.

Abstract A study of 501 patients with 540 intra-abdominal abscesses seen on the surgical services of the University of Cincinnati Medical Center during the past twelve years was undertaken to define the incidence by type and anatomic location, the sources, the effectiveness of diagnosis and treatment, the extended periods of required hospitalization, and the causes of mortality. The results have emphasized the continuing incidence, clinical importance, complexity of bacterial etiology, and the obscure nature of the various types of intra-abdominal abscesses. The high mortality of patients with unrecognized and undrained pancreatic and retroperitoneal abscesses has been striking when compared to the marked reduction in mortality possible by earlier diagnosis and adequate surgical drainage. Although significant advances have been made in the diagnosis and localization of hepatic abscesses, improved methods of earlier recognition and localization will be necessary to achieve earlier diagnosis, more effective surgical treatment, and lower mortality in patients with other types of intra-abdominal abscesses, particularly those in the retroperitoneal and recessed intraperitoneal areas.

Role of Suture Materials in the Development of Wound Infection

THE SEARCH for an ideal suture material suitable for all purposes has been pursued by surgeons since the time of Pare. None has been found, however, and despite numerous investigations concerning tissue reaction, handling qualities, holding strength, etc., surprisingly little has been written concerning the ability of various types of suture material commonly in use to resist bacterial infection after their introduction into contaminated wounds. Several investigators have compared the incidence of infection in wounds closed with various suture materials both experimentally and clinically. Halsted,5 in 1913, expressed a strong preference for the use of silk in clean surgical wounds, but stated that it should be avoided in contaminated or infected ones. Whipple,8 in 1933, strongly advocated the use of silk in repair of clean wounds, indicating that the incidence of infection was actually less than when chromicized catgut was used. In 1937, Shambaugh and Dunphy7 studied the comparative incidence of infection in contaminated wounds closed with silk or with chromicized catgut in dogs. The wounds were contaminated either with feces or an uncounted staphylococcal culture. They found that infection actually occurred less frequently with silk than with catgut, and there was little problem with extrusion of the silk. In 1940, Elkin4 published a clinical study which compared the incidence of infection between silk and catgut in both clean and potentially infected cases. Infection occurred considerably more frequently in the catgut group than in the silk group in both categories. It was not stated whether chromic catgut or plain catgut was used in that particular study. Nonetheless, the methods of preparation and sterilization of catgut materials have changed considerably since that time, leaving some doubt about the present-day application of these studies. James and MacLeod6 performed a more complete study in 1961, implanting small pieces of contaminated suture material subcutaneously into mice. Although their problems included extrusion of suture material and only fair quantitation of the numbers of viable organisms introduced, much significant information was obtained. Their experiments indicated that silicone-treated silk was similar to untreated silk in the ability to withstand contamination and that cotton and merseline sutures resembled silk. Nylon, however, withstood contamination somewhat better than the other materials tested. Catgut and steel wire could not be evaluated because of the problem of extrusion. They concluded that the degree of enhancement of infection by the suture material roughly paralleled the inflammatory reaction caused by the suture material itself. Elek and Conen,3 in their studies with normal human subjects observed that approximately 1,000,000 staphylococci were

Changes in humoral components of host defense following burn trauma.

Serum opsonic activity for E. coli 075, conversion of C3 by inulin, total hemolytic complement (CH(50)), levels of native C3, factor B, C3b inactivator (KAF), properdin (P), and immunoglobulins (Ig) were determined in 14 patients with burns involving 13% to 91% body surface during 6 to 8 weeks postburn. In the 12 uninfected patients, levels of IgG and IgA were reduced during the first 10 days postburn, and decreased concentrations of P and IgM were demonstrated from three to 6 weeks postburn. C3 conversion was reduced from 10 days to 6 weeks postburn. Levels of C3, factor B, and KAF were normal or elevated for the entire study period. No difference in the occurrence of humoral abnormalities was noted in patients with burns caused by flame, immersion scald, or acid contact. Reduction in C3 conversion and P concentration were the only abnormalities which correlated with increasing burn size. Bacteremia and/or fungemia was documented in the other two patients. In one of these patients, reduction in CH(50) occurred during septicemia due to S. aureus, and in the other, reduction in all measurements of complement was associated with candidemia and Pseudomonas septicemia and occurred prior to the development of shock. Serum opsonic activity was only reduced significantly during sepsis, suggesting that this abnormality occurred as a result rather than a cause of infection. These results indicate that consumption of components of the classical and/or alternative pathways of complement activation may be an important mechanism by which infection is perpetuated in the burn patient. They also emphasize the importance of the clinical management of the burn patient in preventing the development of septic complications.

Staphylococcus aureus Associated with Toxic Shock Syndrome: Phage Typing and Toxin Capability Testing

Phage type 29 Staphylococcus aureus was identified singly or with type 52 in 64.1% of 248 coded isolates from patients with toxic shock syndrome. These phage types also have a high capability of producing pyrogenic exotoxin C and enterotoxin F. The origin and development of these toxigenic strains were explored by studying 25,220 isolates of S. aureus stored in a staphylococcal bank between 1960 and 1979. A small percentage of phage types 29, 52 were found in 1960, but their prevalence increased between 1961 and 1970, and continued at elevated levels through 1979. The toxigenic capabilities of these phage types were apparently acquired about 1971 and increased up to 1975. High levels of prevalence persisted during the following 4 years, and receded in 1980 and 1981. Other evidence during 1980 and 1981 indicates that these strains of S. aureus have become an important pathogen in surgical wounds, burns, and other infections.

Primary closure and healing of the perineal wound in abdominoperineal resection of the rectum for carcinoma

Abstract Since delay in perineal wound healing in patients undergoing abdominoperineal resection has continued to be a problem, a method for improving the results in both male and female patients has been developed. Instead of the traditional open technic of dealing with perineal and deep pelvic wounds, primary closure of the perineal wound has been used in association with continuous catheter suction drainage. With this technic in conjunction with intravenous antibiotic therapy started one or two hours preoperatively, the incidence of perineal wound infection has been only 7.1 per cent, and primary wound healing has occurred in 92.9 per cent of 127 patients.

Neutrophil function in selected surgical disorders.

MICROBIAL infections continue to cause disability and death in a wide variety of surgical disorders, and analysis of the related etiological factors often fails to provide an adequate explanation for the development of infection. Infections occur infrequently in normal persons postoperatively even though variable degrees of bacterial contamination regularly accompany operations.6 8 Conversely, a similar amount of bacterial contamination may pose a serious threat to a patient with an impairment of his host resistance.4 Although the diseases which produce these abnormalities of host resistance are both diverse and complex, diminished resistance to infection can be related to abnormalities of inflammatory lesions, opsonic substances, or phagocytic cells.2 In this trinity of host defense (inflammatory lesion-opsonin-phagocyte), each is important, but the first two provide only ancillary mechanisms to aid the phagocyte. This investigation was performed to study the importance of the antibacterial function of polymorphonuclear leukocytes as a factor of host defense in patients with selected surgical disorders.

Serum-mediated inhibition of polymorphonuclear leukocyte function following burn injury.

Serial scrum samples from 12 bacteremic burned patients were tested at a physiologic concentration for their ability to facilitate phagocytosis and intracellular killing of the homologous infecting Staphylococcus aureus strains by normal human polymorphonuclear leukocytes in comparison to pooled normal human serum. Serum-mediated inhibition of leukocyte bactericidal activity was demonstrated in three of the patients during 13 to 56 days after burn. Decreased bactericidal activity was related to an inhibitory effect of the burn sera on the phagocytic process, which reduced the number of internalized bacteria available for intracellular killing. The serum-mediated inhibition of phagocytosis was not found to be dependent on bacterial surface properties unique to S. aureus. The inhibitory effect was shown to involve a direct interaction of the burn sera with the leukocytes, which was not associated with cell death and was not reversed by washing of the leukocytes

Laser surgery in exsanguinating liver injury.

Thirty-two conditioned 15-18 kg dogs underwent laparotomy, heparinization, left lateral hepatic lobe injury and subsequent partial left lateral hepatic lobectomy. The hemostatic capabilities of the surgical scalpel combined with suture ligatures and stay sutures, the Bovie, and the CO2 laser were compared. The CO2 laser proved significantly more effective in achieving hemostasis both in comparison to the Bovine and the surgical scalpel combined with classical methods. The postoperative mortality utilizing the Bovie was 11%, the scalpel 30% and the laser 23%. Two of the three laser deaths were related to a bulky laser delivery system which can be redesigned. Postoperative laboratory evaluation revealed that SGOT, LDH, alkaline phosphatase, total protein, albumin and hemoglobin levels were altered in the postoperative period but returned to normal levels in uniform fashion in all groups. There was no statistical difference between various surgical modalities with regard to these parameters. The white blood count was significantly lower in laser dogs when compared to the other two groups. Other laboratory parameters were unchanged. Damage to liver tissue may be less extensive when the laser is utilized as opposed to the Bovie or stay suture methods of hemostasis and healing is equally good. The CO-2 laser is considered a valuable ancillary tool in hepatic resection and clinical evaluation is warranted.

Relative roles of burn injury, wound colonization, and wound infection in induction of alterations of complement function in a guinea pig model of burn injury.

Stimuli involved in induction of alterations of the complement system and production of circulating inhibitor(s) of phagocytic function of polymorphonuclear neutrophils following burn injury were investigated using a guinea pig model of scald burn injury. The activity of C1-C9, assessed by measurement of total hemolytic complement, was found to increase primarily in response to burn injury per se, whereas reduction in the activity of the alternative complement pathway was shown to develop in association with natural colonization and local burn wound infection with bacterial pathogens. Invasive burn wound infection induced experimentally with Staphylococcus aureus, Pseudomonas aeruginosa, or Candida albicans exacerbated this latter abnormality, caused consumption of C1-C9 activity, and was associated with appearance of serum factors that depressed phagocytosis of Escherichia coli 075 by peritoneal polymorphonuclear neutrophils. Thus injury and coexistent infection both play important roles in induction of humoral alterations of host defense associated with burn injury.

Hyperparathyroidism: Therapy and Response, with a Test for Assessment of Response

Abstract Postoperative observation for 44 patients with primary hyperparathyroidism (parathyroidal), reported in 1966, further supports the contention that partial parathyroidectomy is effective tr...