Enterocutaneous fistulas following laparotomy for trauma.

Enterocutaneous fistulas (ECF) are recognized complications of various bowel diseases. Trauma is reported as a rare cause of ECF. ECF following laparotomy for abdominal injury was studied in 15 patients to determine whether traditional principles of management for ECF are applicable in posttraumatic ECF. Thirty-three per cent of patients with posttraumatic ECF spontaneously healed fistulas with appropriate nutritional support without operative intervention. Sixty-six per cent of patients required operative intervention, either because of associated sepsis or failure to spontaneously heal. Five patients had fistulas originate from areas of bowel not injured in the initial injury. This study suggests traditional principles of management for ECF are applicable in ECF following laparotomy for abdominal injury and result in a spontaneous closure of fistulas in one-third of patients. In addition, sepsis is the main indication for early aggressive operative treatment of these fistulas.

High vacuum as a method of reducing porosity of polymethylmethacrylate.

In total hip arthroplasty, fracture and subsequent premature loosening are directly related to the strength of the cement mantle serving as an interface between bone and prosthesis. The cement has been shown to be weakened by its porosity, which enhances the formation of microfractures that contribute to crack propagation. By means of a vacuum mixing method for preparing the cement, nearly all the porosity can be removed and cement strength enhanced by about 17%.

Gallstones and risk of gallbladder cancer.

The relationship between gallstones and gallbladder cancer was investigated in a case-control study in 131 subjects with gallbladder cancer and 2,399 subjects without gallbladder cancer. Included in the study were male and female subjects from 3 racial groups: white, black, and Southwestern American Indian. For the non-Indian group there was a significant relationship between gallstones and gallbladder cancer, with an overall estimated relative risk (RR) of 4.4 (95% confidence interval, 2.6-7.3). For the Indian population the overall estimated RR was much higher: RR = 20.9; 95% confidence interval = 8.1-54. By the combination of the RR, the prevalence of gallstones, and the overall incidence of gallbladder cancer, the risk of gallbladder cancer was calculated in each population for subjects with untreated gallstones. In older subjects with gallstones the estimated 20-year cumulative risk for gallbladder cancer ranged from 0.13% in black males to 1.5% in Indian females. It was concluded that the risk of gallbladder cancer in untreated subjects with gallstones is heterogeneous, depending on race and sex as well as the period of exposure to gallstones.

Complications of colostomy closure.

The records of 83 patients with 85 colostomy closures at Charity Hospital, New Orleans from January 1976 through June 1981 were reviewed. There were 47 complications in 30 patients (36 percent) with no deaths. The material used for anastomosis and fascial closure, the precipitating or underlying disease, the site of colostomy, and the length of operation did not influence the complication rate. The major factor affecting the complication rate was the interval of time from creation of the colostomy to its closure. Those patients who underwent closure after a 90 day interval had a lower overall complication rate than comparison groups with less than a 30 day interval and 30 to 90 day intervals (p less than 0.05). Other factors that appeared to influence the complication rate were as follows: loop colostomies had a lower suture line complication rate than divided colostomies, patients who underwent relaparotomy and closure had a higher complication rate than those whose closures were confined to the colostomy site, and wounds left open or that underwent delayed primary closure had a lower infection rate than wounds closed primarily. Thus, loop colostomies appear to have fewer complications at the time of closure than divided stomas. This is most likely related to the necessity for relaparotomy in some of the patients with divided stomas and the need for minimal mesenteric dissection required for most loop colostomy patients. Divided stomas should still be created if indicated, but when a choice exists, loop colostomies are preferable. Contaminated wounds are best managed with secondary closure or delayed primary closure. Because of the significant difference in complication rates between intervals from formation to closure of a colostomy, all patients should have their colostomies closed only after a minimum of 90 days has elapsed.

Insulin receptor autoantibodies in sepsis.

This study was undertaken to investigate possible factors contributing to altered glucose homeostasis in a patient with a history of total pancreatectomy and intermittent sepsis. Blood was drawn when the patient had received no exogenous insulin for the previous 24 hours, had a serum insulin level of 0.3 microU/mL, and gave an inappropriately low glucose response to large amounts of infused glucose. The IgG fraction prepared from this serum stimulated glucose oxidation in vitro and inhibited binding of insulin labeled with I 125 to isolated rat adipocytes, thus fulfilling some of the criteria for autoantibodies to the insulin receptor. The results are compatible with the hypothesis that insulin-receptor autoantibodies may have developed as a result of perturbation of this patient's immune status promoted by intermittent septic episodes and that, preterminally, as these antibodies converted in vivo to their in vitro-type behavior, they may have been partially responsible for the severe disturbances of glucose homeostasis.

The use of a selective beta-adrenergic receptor blocker for the preoperative preparation of thyrotoxic patients.

Metoprolol, a cardioselective beta-blocker, was used in two asthmatic, thyrotoxic patients in preparation for thyroidectomy. Adequate reduction in resting heart rate was achieved in both individuals without inducing clinically significant airway obstruction. Beta-1-blockade can be selectively employed in this clinical setting, but patients should be hospitalized and closely monitored for adverse effects on pulmonary function. Metoprolol therapy in patients with reversible airway obstruction is discussed with reference to recent studies on relative cardioselectivity.

Prospective evaluation of central venous pressure (CVP) catheters in a large city-county hospital.

Over a 12-month period, this survey was conducted prospectively to examine the complication rate associated with the insertion and use of central venous catheters on the Louisiana State University Service at Charity Hospital, New Orleans. No attempt was made to alter or influence the current techniques and methods for catheter insertion. Three-hundred and ninety-seven patients received 554 catheters. The overall complication rate was 13.7%. Major mechanical complications occurred with 4.0% of catheters, and infectious complications occurred with 5.2%. Of the 22 major mechanical complications, 13 were associated with morbidity. Twelve of the 13 complications with morbidity occurred with 286 subclavian catheterizations (4.2%), while only 1 of the 13 complications with morbidity occurred with 248 internal jugular catheterizations (0.4%). Based on these data, it is recommended that the internal jugular approach be used in the majority of patients, reserving the subclavian approach for patients on long-term parenteral nutrition or when the internal jugular approach is not feasible technically.

Primary carcinoma of the gallbladder.

The records of patients with primary carcinoma of the gallbladder treated at Charity Hospital, New Orleans, Louisiana, from 1965 through 1978 were reviewed. Eighty patients had histologically proven primary carcinoma of the gallbladder. Sixty-nine patients had sufficient data available for evaluation. Only one patient (1.4%) was clinically free of disease at five years. Surgical procedures were performed in 45 of the 69 patients. The remainder of the patients had their disease proved at autopsy. Thirty-five patients had widespread metastatic disease at the time of operation. None of these patients survived more than one year. Only 10 patients had potentially curable lesions. The diagnosis of carcinoma of the gallbladder was not made at operation in eight of these patients. The only five-year survivor was in this subgroup. This patient had papillary adenocarcinoma confined to the mucosa and muscularis, and had a cholecystectomy alone. This report reinforces the difficulty in diagnosis and the dismal prognosis for patients with primary carcinoma of the gallbladder. Intraoperative examination of the gallbladder, earlier operation for documented gallbladder disease, and more aggressive surgical therapy should improve survival figures.

Mallory-Weiss syndrome. Review of 69 cases.

The records of patients treated for upper gastrointestinal bleeding from 1974 through 1978 were reviewed. Five percent of this group (69 patients) had bleeding due to the Mallory-Weiss syndrome. Only 36 percent of patients had a correct admitting diagnosis. Esophagogastroscopy proved the most reliable diagnostic tool, with 94 percent of 63 patients studied having the diagnosis of Mallory-Weiss laceration confirmed. Initial management was medical in all patients. Twenty-one patients (30 percent) required operative intervention. There was a good correlation between the transfusion requirement and the need for operation. There were two deaths in this series; both were considered preventable. The Mallory-Weiss syndrome is common. Esophagogastroscopy performed early can result in a diagnostic accuracy rate of greater than 90 percent. Aggressive nonsurgical therapy after early diagnosis should continue to reduce the role of operation in the treatment of this condition. However, if bleeding continues after initial medical management, or if bleeding continues after 1,500 ml of blood is required, then surgical therapy should be instituted without delay.

Albumin synthesis and nitrogen balance in postoperative patients.

In a continuing prospective randomized study in a series of patients in the postoperative state, the rate of albumin synthesis was measured using the 14C carbonate technique. The majority of the patients studied were subjected to partial or total colectomy, and each patient was randomized to receive a hypocaloric intravenous regimen consisting of 3.5% amino acids (essential and nonessential) or 3.5% amino acids with 2.5% glucose. A mean (+/- SEM) of 75.7 +/- 2.7 gm/day of amino acids was given to the seven patients in the amino acid group. A mean of 74.0 +/- 5.9 gm/day of amino acids and 52.8 +/- 4.2 gm/day of glucose was infused in the group of five patients given amino acids with glucose. The albumin synthetic rate (mg/kg/day) measured on the fourth day after operation in the amino acid alone group was 233.9 +/- 27.9 as compared to 204.1 +/- 24.4 in the group given amino acids with glucose (P = NS). The urea synthesis rates (mg/kg/day) in the two groups were 334.2 +/- 47.8 and 250.3 +/- 27.5, respectively, and the net Kjeldahl nitrogen balances (grams per day) were -4.98 +/- 1.92 and -2.68 +/- 1.49, respectively. We conclude that infused amino acids promote the synthesis of albumin equally effectively in the presence or absence of a small amount of added glucose. Glucose may reduce slightly the pool of amino nitrogen available for albumin and urea synthesis by diverting some of the infused amino acids from protein synthesis by the liver to muscle.

Antacid titration in the prevention of acute gastrointestinal bleeding: a controlled, randomized trial in 100 critically ill patients.

We randomized 100 critically ill patients at risk of developing acute gastrointestinal ulceration and bleeding into two groups. One (51 patients) received antacid prophylaxis, and the other (49 patients) received no specific form of prophylaxis. Hourly antacid titration kept the pH of the gastric contents above 3.5. Two of the 51 patients who received antacid prophylaxis and gastrointestinal bleeding. Twelve of the 49 control patients bled (P less than 0.005). Of the 12 patients in the control group who bled, seven were placed on antacid medication, and all seven apparently stopped bleeding. Analysis of all the patients showed that an increasing prevalence of respiratory, failure, sepsis, peritonitis, jaundice, renal failure and hypotension was correlated with a greater frequency of bleeding. No patients required operative treatment to control bleeding. These data indicate that the occurrence of acute gastrointestinal bleeding in critically ill patients can be reduced by antacid titration.

Changing patterns in the management of pancreatic pseudocysts.

The records of patients treated from 1938 through June, 1974, for pancreatic cysts have been reviewed. There was 205 cysts including 168 pseudocysts, 21 neoplastic, 13 retention, and 3 congenital pseudocysts. An analysis of two eras has been made: cysts treated prior to 1962 (56 patients) and cysts treated after 1962 (98 patients). In the earlier era 66.4% of patients were treated by external drainage and 34% by excision or internal drainage. By marked contrast in the more recent era only 27% were treated by external drainage and 73% by excision or internal drainage. The recurrence rate fell from 27% in the earlier era to 6% in the modern era. Improved morbidity was evidenced by a reduction from 32.2% to 15.3% in additional procedures required. Individualization in the treatment of pseudocyts with adherence to establish criteria for procedure selection with increased reliance on excision or internal drainage, as well as early diagnosis and timely intervention have improved the results of surgical therapy in this disease.