Pyogenic liver abscess after gunshot injury: 10 years' experience at a single level 1 trauma center.

OBJECTIVES: Liver abscesses are approximately 50 % of all visceral abscesses, and trauma presents as a rare cause of the liver abscess. Otherwise, hepatic abscess is an uncommon complication of gunshot wound (GSW) to the liver among all trauma cases. Here we reviewed their experience in detail. METHOD: From January 1, 2004 to September 30, 2013, there were 2143 patients admitted to Ryder Trauma Center at Jackson Memorial Hospital/University of Miami with severe abdominal trauma: 1227 penetrating and 866 blunt. Among the patients who had penetrating trauma, 637 had GSWs and 551 had stab wounds. Thirty-nine patients had other kinds of penetrating traumas. Eleven patients were identified as having liver abscess, with 8 of them belonging to the GSW group, and 3 to the blunt injury group. The diagnosis and management of the 8 patients with a hepatic abscess after GSW to the liver were demonstrated. RESULT: There were seven males and one female with a mean age of 29 ± 10 years. There were one grade 2, four grade 3, two grade 4 and one grade 5 injuries. The mean abscess size was 10 ± 2 cm. The abscesses were usually caused by infection from mixed organisms. These abscesses were treated with antibiotics and drainage. No mortality and long-term morbidity were seen. CONCLUSION: Hepatic abscess after GSW to the liver is a rare condition, with an incidence of 1.2 %. It is usually seen in severe liver injury (grade 3 and above), but our patients were all treated successfully, with no mortality.

Secondary abdominal compartment syndrome after complicated traumatic lower extremity vascular injuries.

INTRODUCTION: Secondary abdominal compartment syndrome (ACS) can occur in trauma patients without abdominal injuries. Surgical management of patients presenting with secondary ACS after isolated traumatic lower extremity vascular injury (LEVI) continues to evolve, and associated outcomes remain unknown. METHODS: From January 2006 to September 2011, 191 adult trauma patients presented to the Ryder Trauma Center, an urban level I trauma center in Miami, Florida with traumatic LEVIs. Among them 10 (5.2 %) patients were diagnosed with secondary ACS. Variables collected included age, gender, mechanism of injury, and clinical status at presentation. Surgical data included vessel injury, technical aspects of repair, associated complications, and outcomes. RESULTS: Mean age was 37.4 ± 18.0 years (range 16-66 years), and the majority of patients were males (8 patients, 80 %). There were 7 (70 %) penetrating injuries (5 gunshot wounds and 2 stab wounds), and 3 blunt injuries with mean Injury Severity Score (ISS) 21.9 ± 14.3 (range 9-50). Surgical management of LEVIs included ligation (4 patients, 40 %), primary repair (1 patient, 10 %), reverse saphenous vein graft (2 patients, 20 %), and PTFE interposition grafting (3 patients, 30 %). The overall mortality rate in this series was 60 %. CONCLUSIONS: The association between secondary ACS and lower extremity vascular injuries carries high morbidity and mortality rates. Further research efforts should focus at identifying parameters to accurately determine resuscitation goals, and therefore, prevent such a devastating condition.

Enteroscopia doble balón y videocápsula endoscópica en el diagnóstico de patologías del intestino delgado: hospital universitario de maracaibo. 2007-2010 / Double-balloon enteroscopy and endoscopic video capsule in the diagnosis of diseases of the small intestine: maracaibo university hospital. 2007-2010

Introducción: La Enteroscopia Doble Balón (EDB) y la Videocápsula Endoscópica (VCE) se introdujeron en el Hospital Universitario de Maracaibo desde 2007 y 2008, respectivamente. Se analizó y comparó el desempeño de estas pruebas para diagnosticar enfermedades del intestino delgado. Pacientes y Métodos: Se revisaron retrospectivamente los casos sometidos a EDB superior (EDBS), EDB inferior (EDBI) y/o VCE, desde su implementación hasta enero de 2010. Resultados: En 94 casos (55 ♂ y 39 ♀; 10-89 años) se realizaron 155 procedimientos: 52 EDBS, 8 EDBI, 16 VCE y 79 procedimientos combinados. Indicaciones predominantes: Hemorragia de origen oscuro, hemorragia digestiva superior o inferior, anemia, diarrea crónica y sospecha de tumoración intestinal. Visualización completa del tracto entérico: 86,7% (EDBS), 57,7% (EDBI) y 100% (VCE). Biopsias, terapias y/o cromomarcaje: 58,2% (EDBS) y 23,1% (EDBI). Diagnósticos endoscópicos predominantes: Malformaciones vasculares, enteropatías de aspecto parasitario, neoplasias malignas, enteropatías ulcerosas y erosivas. Concordancia indicación/diagnóstico: 74,3% (EDBS), 57,7% (EDBI) y 70% (VCE). Conclusiones: La EDB y la VCE constituyen herramientas eficientes con ventajas particulares para diagnosticar patologías del intestino delgado: La EDB permite realizar procedimientos adicionales; la VCE ofrece mayor probabilidad de visualizar todo el tracto entérico. En casos concretos, combinar estar pruebas podría aumentar su eficiencia diagnóstica y terapéutica.

Introduction: Double Balloon Enteroscopy (DBE) and Endoscopic Viocapsule (EVC) were introduced in the University Hospital of Maracaibo since 2007 and 2008, respectively. Their performance in diagnosing small bowel diseases were analyzed and compared. Patients and Methods: Cases undergoing upper DBE (UDBE), lower DBE (LDBE) and/or CE, were retrospectively reviewed since the introduction of these techniques, until January 2010. Results: In 94 cases (♂: 55; ♀:39; Ages: 10 to 89), 155 diagnostic procedures were performed: 52 UDBE, 8 LDBE, 16 EVC and 79 combined procedures. Predominating indications: obscure gastrointestinal bleeding, upper and/or lower gastrointestinal bleeding, anemia, chronic diarrhea, and suspicion of an intestinal tumor. Full visualization of small bowel: 86.7% (UDBE), 57.7% (DBUE) and 100% (EVC). Biopsies, therapies and/or India ink tattooing: 58.2% (UDBE) and 23.1% (DBLE). Predominant endoscopic diagnoses: vascular malformations, parasitic enteropathies, malign tumor, ulcerative enteropathies and erosive enteropathies. Agreement indication/diagnosis: 74.3% (UDBE), 57.7% (LDBE) and 70% (EVC). Conclusions: DBE and EVC constitute efficient methods with particular advantages for diagnosing small bowel pathologies: DBE allows additional procedures; EVC provides a greater chance of full visualization of small intestine. In specific cases, combination of these tests could improve their diagnostic and therapeutic efficiency.

Open surgical wounds: how does Aquacel compare with wet-to-dry gauze?

OBJECTIVE: To compare the healing rates of a hydrofibre dressing (Aquacel) and normal wet-to-dry gauze in the treatment of open surgical wounds. METHOD: Fifty patients with open surgical wounds were randomized to receive either saline-moistened gauze or Aquacel. The rate of wound healing was measured as ml/day (deep wounds) or cm2/day (superficial wounds) at each dressing change until an investigator blinded to the patient group diagnosed the wounds as having healed or the patient was withdrawn from the study. RESULTS: Of the 50 patients, seven were withdrawn from the study after the first evaluation. Of the remaining 43 patients, 21 had been randomly allocated to the gauze group and 22 to the Aquacel group. For deep wounds, a mean change in the wound healing rate of 1.9 +/- 1.3 cm3/day was reported for the gauze group and 2.9 +/- 2.3 cm3/day for the Aquacel group. These results approach statistical significance (p = 0.082). For superficial wounds, the mean change in the healing rate was 1.6 +/- 1.5 cm2/day for the gauze group and 1.9 +/- 2.2 cm2/day for the Aquacel group, but this was not statistically significant. CONCLUSION: Aquacel appears to be at least as effective as wet-to-dry gauze in the healing of open surgical wounds.

Comparison of antral tap with endoscopically directed nasal culture.

OBJECTIVES/HYPOTHESIS: The diagnosis of acute bacterial rhinosinusitis continues to generate controversy in critically ill patients. The efficacy of endoscopically directed cultures in these patients is unknown. We compared antral tap (AT) with endoscopic tissue culture (ETC) of the osteomeatal complex in an intensive care unit (ICU) setting. METHODS: Twenty patients admitted to a surgical/trauma ICU were evaluated by AT and ENB for the presence of rhinosinusitis. All patients had 1) a fever of unknown origin without resolution on empiric antibiotic therapy for > or =48 hrs; 2) other sources of fever ruled out; 3) computed tomography scan evidence of mucoperiosteal thickening +/- sinus air/fluid levels; and 4) attempt at conservative treatment with topical decongestants and removal of all nasal intubation. Microbiologic data were collected and analyzed for any statistical difference between groups. RESULTS: A total of 29 sides underwent simultaneous tap and endoscopically directed tissue culture. The mean age was 40 years (range, 23-77 y) with 85% being males. Fifteen of 20 (75%) patients in the AT group were culture-positive. Of the 49 isolates from the AT, 55% yielded Gram-negative bacilli (Acinetobacter sp. 37%) and 45% yielded Gram-positive cocci. The ETC group was culture-positive in 18 of 20 (90%) patients. Of the 52 isolates from the ETC, Gram-negative bacilli were found in 58% (Acinetobacter sp. 33%) and 42% yielded Gram-positive cocci. The ETCs were culture-positive in all but 1 patient with positive taps. There appeared to be a concordance between AT and ETC in 60% of the patients. In five instances (25%), results of the AT or ETC changed ICU management. Two patients ultimately required sinus surgery. CONCLUSIONS: Sinus taps and/or endoscopically directed tissue cultures led to a change in ICU care in 25% of ICU patients studied. In patients with fever of unknown origin and computed tomography evidence of sinusitis, an antral tap continues to provide important information concerning maxillary sinusitis. However, ETC may give as good a representation of the microbiology and secondary inflammatory changes responsible for bacterial ICU rhinosinusitis causing fever of unknown origin. Further study on a larger group of patients is needed.

Penetrating colon injuries requiring resection: diversion or primary anastomosis? An AAST prospective multicenter study.

BACKGROUND: The management of colon injuries that require resection is an unresolved issue because the existing practices are derived mainly from class III evidence. Because of the inability of any single trauma center to accumulate enough cases for meaningful statistical analysis, a multicenter prospective study was performed to compare primary anastomosis with diversion and identify the risk factors for colon-related abdominal complications. METHODS: This was a prospective study from 19 trauma centers and included patients with colon resection because of penetrating trauma, who survived at least 72 hours. Multivariate logistic regression analysis was used to compare outcomes in patients with primary anastomosis or diversion and identify independent risk factors for the development of abdominal complications. RESULTS: Two hundred ninety-seven patients fulfilled the criteria for inclusion and analysis. Overall, 197 patients (66.3%) were managed by primary anastomosis and 100 (33.7%) by diversion. The overall colon-related mortality was 1.3% (four deaths in the diversion group, no deaths in the primary anastomosis group, p = 0.012). Colon-related abdominal complications occurred in 24% of all patients (primary repair, 22%; diversion, 27%; p = 0.373). Multivariate analysis including all potential risk factors with p values < 0.2 identified three independent risk factors for abdominal complications: severe fecal contamination, transfusion of > or = 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxis. The type of colon management was not found to be a risk factor. Comparison of primary anastomosis with diversion using multivariate analysis adjusting for the above three identified risk factors or the risk factors previously described in the literature (shock at admission, delay > 6 hours to operating room, penetrating abdominal trauma index > 25, severe fecal contamination, and transfusion of > 6 units blood) showed no statistically significant difference in outcome. Similarly, multivariate analysis and comparison of the two methods of colon management in high-risk patients showed no difference in outcome. CONCLUSION: The surgical method of colon management after resection for penetrating trauma does not affect the incidence of abdominal complications, irrespective of associated risk factors. Severe fecal contamination, transfusion of > or = 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxis are independent risk factors for abdominal complications. In view of these findings, the reduced quality of life, and the need for a subsequent operation in colostomy patients, primary anastomosis should be considered in all such patients.

Hemoperitoneum score helps determine need for therapeutic laparotomy.

PURPOSE: Sonography provides a fast, portable, and noninvasive method for patient assessment. However, the benefit of providing real-time ultrasound (US) imaging and fluid quantification shortly after patient arrival has not been explored. The objective of this study was to prospectively validate a US hemoperitoneum scoring system developed at our institution and determine whether sonography can predict a therapeutic operation. METHODS: For 12 months, prospective data on all patients undergoing a trauma sonogram were recorded. All sonograms positive for free fluid were given a hemoperitoneum score. The US score was compared with initial systolic blood pressure and base deficit to assess the ability of sonography to predict a therapeutic laparotomy. RESULTS: Forty of 46 patients (87%) with a US score > or = 3 required a therapeutic laparotomy. Forty-six of 54 patients with a US score < 3 (85%) did not need operative intervention. The sensitivity of sonography was 83% compared with 28% and 49% for systolic blood pressure and base deficit, respectively, in determining the need for therapeutic operation. CONCLUSION: We conclude that the majority of patients with a score > or = 3 will need surgery. The US hemoperitoneum scoring system was a better predictor of a therapeutic laparotomy than initial blood pressure and/or base deficit.

Prospective randomized trial of two wound management strategies for dirty abdominal wounds.

OBJECTIVE: To determine the optimal method of wound closure for dirty abdominal wounds. SUMMARY BACKGROUND DATA: The rate of wound infection for dirty abdominal wounds is approximately 40%, but the optimal method of wound closure remains controversial. Three randomized studies comparing delayed primary closure (DPC) with primary closure (PC) have not conclusively shown any advantage of one method over the other in terms of wound infection. METHODS: Fifty-one patients with dirty abdominal wounds related to perforated appendicitis, other perforated viscus, traumatic injuries more than 4 hours old, or intraabdominal abscesses were enrolled. Patients were stratified by cause (appendicitis vs. all other causes) and prospectively randomized to one of two wound management strategies: E/DPC (wound packed with saline-soaked gauze, evaluated 3 days after surgery for closure the next day if appropriate) or PC. In the E/DPC group, wounds that were not pristine when examined on postoperative day 3 were not closed and daily dressing changes were instituted. Wounds were considered infected if purulence discharged from the wound, or possibly infected if signs of inflammation or a serous discharge developed. RESULTS: Two patients were withdrawn because they died less than 72 hours after surgery. The wound infection rate was greater in the PC group than in the E/DPC group. Lengths of hospital stay and hospital charges were similar between the two groups. CONCLUSION: A strategy of DPC for appropriate dirty abdominal wounds 4 days after surgery produced a decreased wound infection rate compared with PC without increasing the length of stay or cost.

Combined carotid artery injury and laryngeal fracture secondary to dog bite: case report.

Approximately 914 new dog bite injuries requiring emergency department visits occur daily in the United States. Attacks by dogs with training and strength to attack should be triaged cautiously because of the possibility of serious internal injury. A high index of suspicion is needed when treating patients with neck injuries secondary to dog bites. We report a case of successfully treated combined carotid artery and laryngeal injury produced by a dog bite.

Incidence and susceptibility of pathogenic bacteria vary between intensive care units within a single hospital: implications for empiric antibiotic strategies.

BACKGROUND: The purpose of this study was to determine whether the incidence of recovery and patterns of antibiotic susceptibility of pathogenic bacteria vary between intensive care units (ICUs) in a single teaching hospital. METHODS: Culture and susceptibility results were collected prospectively for a 3-month period (April through June 1999) in each of the surgical, trauma, and medical ICUs. The number of unique isolates and susceptibility patterns were determined. Susceptibility of isolates among ICUs was compared with chi2. RESULTS: Statistically significant differences between ICUs in susceptibility to various antibiotics were found for Staphylococcus aureus, Enterococcus sp, Acinetobacter sp, Enterobacter sp, Klebsiella sp, and Pseudomonas sp. Notably, vancomycin-resistant Enterococcus was not seen in the medical ICU, whereas it was seen in both the surgical and trauma ICUs. Klebsiella spp resistant to ceftazidime were seen only in the trauma ICU. The aminoglycosides and quinolones had attenuated activity against Pseudomonas sp in the surgical ICU, whereas they remained highly effective in the trauma ICU. Cefazolin had no activity against the Enterobacter sp in either of the surgical ICUs, but was highly effective in the medical ICU. CONCLUSION: Although the microbiologic results of this study should not be extrapolated to other institutions, the principle is of value. There is variability between ICUs in a single large teaching hospital in susceptibility of bacterial pathogens to various antibiotics. This may have implications in the design of empiric antibiotic strategies and the planning of the hospital formulary. Hospital wide or composite ICU antibiograms are inadequate for planning empiric therapy in the ICU.

Biodebridement: a case report of maggot therapy for limb salvage after fourth-degree burns.

The wound healing and antimicrobial properties of maggots are well known. Maggot debridement therapy has been used for the treatment of various conditions. For maggot debridement therapy, the larvae of the blowfly are applied over necrotic or nonhealing wounds. We used maggot debridement therapy with the larvae of Phaenicia sericata for limb salvage after bilateral lower extremity fourth-degree burns.

Pharmacokinetics and burn eschar penetration of intravenous ciprofloxacin in patients with major thermal injuries.

Adequate penetration of antibiotics into burn tissue and maintenance of effective serum levels are essential for the treatment of patients sustaining major thermal injuries. The pharmacokinetics and burn eschar penetration of intravenous ciprofloxacin were determined in 12 critically ill patients with burn injuries. Mean age for the 12 patients was 45 +/- 17 (range 25-82 years), total body surface area burned (TBSAB) = 38 +/- 15% and Acute Physiology and Chronic Health Evaluation (APACHE) II score = 8 +/- 6. Patients received recommended doses of ciprofloxacin, 400 mg q12h iv, for three doses beginning 72 h post-burn. Serum concentrations were measured at t = 0, 0.25, 0.5, 0.75, 1.0, 1.25, 1.5, 2.0, 4.0 and 12.0 h after the first and third doses. Burn eschar biopsies were obtained after the third ciprofloxacin dose. Three of these 12 patients (25%) manifested later signs of clinical sepsis (TBSAB = 61 +/- 6% and APACHE II score = 11 +/- 3) and underwent a second infusion of three doses of intravenous ciprofloxacin, blood sampling and eschar biopsy. Serum and eschar concentrations were determined by high performance liquid chromatography. Serum ciprofloxacin concentrations were comparable to those of normal volunteers (C(max) = 4.0 +/- 1 mg/L and AUC = 11.4 +/- 2 mg.h/L) during the immediate post-burn period after dose 1 (C(max1) = 4.8 +/- 3 mg/L and AUC(0-12) = 12.5 +/- 7 mg. h/L) and dose 3 (C(max3) = 4.9 +/- 2 mg/L and AUC(24-36) = 17.5 +/- 11 mg.h/L). Mean burn eschar concentration during the 72 h post-burn was significantly lower than that found during clinical sepsis (18 +/- 17 compared with 41.3 +/- 54 microg/g; P < 0.05 by t test). Similar serum concentrations were achieved in patients with clinical sepsis (C(max1) = 4.2 +/- 0.2 mg/L and AUC(0-12) = 15.0 +/- 3 mg. h/L; C(max3) = 5.0 +/- 1 mg/L and AUC(24-36) = 22.8 +/- 9 mg.h/L). A positive correlation between burn eschar concentrations and C(max) (r = 0.71, r(2) = 0.51, P = 0.01) was found by linear regression analysis. A C(max)/MIC ratio > 10 (MIC = 0.5 mg/L) and an AUC/MIC ratio > 100 SIT(-1).h (serum inhibitory titre) (MIC = 0.125 mg/L) were achieved. High burn eschar concentrations and serum levels, similar to those found in normal volunteers, can be achieved after intravenous ciprofloxacin infusion in critically ill burns patients.

Gram positive infection in trauma patients: new strategies to decrease emerging Gram-positive resistance and vancomycin toxicity.

Bacterial resistance to antibiotics has become a serious problem in medicine. Particularly worrisome is the increasing incidence of multi-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). Not surprisingly, in view of the high incidence of life-threatening infections and heavy antibiotic use, resistance has become very frequent and problematic in intensive care units. The standard approach for the treatment of MRSA is vancomycin or teicoplanin. Long-term therapeutic and unrestricted prophylactic use of vancomycin has given rise to VRE which in turn may lead to the emergence of vancomycin-resistant S. aureus (VRSA) through plasmid mediated transmission. In order to reduce the incidence of VRE and to avoid the emergence of VRSA, vancomycin use should be restricted and alternative antibiotic strategies should be developed. Using those antibiotics to which MRSA are still generally sensitive, perhaps in combination with new ones, such as, quinupristin/dalfopristin, should be entertained. We performed a retrospective review of the Gram-positive infections in our Level 1 Trauma Center Intensive Care Unit, and an analysis of the resistance patterns of the NMSA infections showed that additional resistance rarely develops within less than 5 days. We then designed a new strategy for the treatment of MRSA infections. This strategy consists of the sequential use of a range of antibiotics with activity against MRSA in short 5-7 day pulses until the full clinical course is completed. Studies validating the benefit of this approach are currently in preparation.

The epidemic of cocaine-related juxtapyloric perforations: with a comment on the importance of testing for Helicobacter pylori.

OBJECTIVE: This is a report of 50 consecutive patients with juxtapyloric perforations after smoking "crack" cocaine (cocaine base) at one urban public hospital. SUMMARY BACKGROUND DATA: Although the exact causal relation between smoking crack cocaine and a subsequent juxtapyloric perforation has not been defined, surgical services in urban public hospitals now treat significant numbers of male addicts with such perforations. This report describes the patient set, presentation, and surgical management and suggests a possible role for Helicobacter pylori in contributing to these perforations. METHODS: A retrospective chart review was performed, supplemented by data from the patient log in the department of surgery. RESULTS: From 1994 to 1998, 50 consecutive patients (48 men, 2 women) with a mean age of 37 had epigastric pain and signs of peritonitis a median of 2 to 4 hours (but up to 48 hours) after smoking crack cocaine. A history of chronic smoking of crack as well as chronic alcohol abuse was noted in all patients; four had a prior history of presumed ulcer disease in the upper gastrointestinal tract. Free air was present on an upright abdominal x-ray in 84% of patients, and all underwent operative management. A 3- to 5-mm juxtapyloric perforation, usually in the prepyloric area, was found in all patients. Omental patch closure was used in 49 patients and falciform ligament closure in 1. Two patients underwent parietal cell vagotomy as well. In the later period of the review, antral mucosal biopsies were performed through the juxtapyloric perforation in five patients. Urease testing was positive for infection with H. pyonri in four, and these patients were prescribed appropriate antimicrobial drugs. CONCLUSIONS: Juxtapyloric perforations after the smoking of crack cocaine occur in a largely male population of drug addicts who are 8 to 10 years younger than the patient group that historically has perforations in the pyloroduodenal area. These perforations are usually 3 to 5 mm in diameter, and an antral mucosal biopsy for subsequent urease testing should be performed if the location and size of the ulcer allow this to be done safely. Omental patch closure is appropriate therapy for patients without a history of prior ulcer disease; antimicrobial therapy and omeprazole are prescribed when H. pylori is present.

Cost and morbidity associated with antibiotic prophylaxis in the ICU.

BACKGROUND: Although the high cost and inappropriate use of antibiotics have been documented before, we are not aware of any data on nonsurgical site infectious morbidity associated with prolonged courses of prophylactic antibiotics (PA). STUDY DESIGN: Data regarding antibiotic orders were collected using a custom designed microbiology database in the Surgical Intensive Care Unit of a teaching hospital from October 1, 1995 through April 30, 1997. The database was retrospectively reviewed. The cost of PA in excess of 1 day was calculated. Frequency of bacteremia and line infections were compared in patients receiving 1 day or less of PA versus more than 4 days of PA. RESULTS: Sixty-one percent of PA orders were continued for more than 1 day. Cost of PA beyond 1 day totaled $44,893. Bacteremia and line infection were more frequent in the patients receiving more than 4 days of PA. CONCLUSIONS: There was poor compliance with the protocol of stopping PA at 24 hours. The cost of noncompliance was $44,893. There were more bacteremias and line infections in patients with duration of PA of more than 4 days.

Empiric therapy of sepsis in the surgical intensive care unit with broad-spectrum antibiotics for 72 hours does not lead to the emergence of resistant bacteria.

BACKGROUND: It is our practice to treat suspected sepsis with imipenem/cilastatin and gentamicin (IMP/GENT) for 72 hours while awaiting culture results. We wanted to determine if this practice engenders antimicrobial resistance. METHODS: Review of prospectively collected data regarding use of IMP/GENT and microbial sensitivity to imipenem/cilastatin during the first and last 7 months of a 19-month study period (October 1, 1995, to April 30, 1997). RESULTS: The susceptibility of appropriate organisms to imipenem/cilastatin was 76% in the early period and 80% in the late period (p = 0.42). Pseudomonas aeruginosa was more susceptible in the late period (88 vs. 62%; p = 0.007). Resistance to gentamicin (30% early vs. 21% late; p = 0.02) and representative cephalosporins (cefoxitin, 52% early vs. 61% late; p = 0.35; ceftazidime, 26% early vs. 23% late; p = 0.76) did not develop during the study period. The incidence of fungemia was the same in both periods (4 of 467 admissions vs. 3 of 599 admissions; p = 0.48). CONCLUSION: This protocol did not lead to the emergence of resistant bacteria.

Laparoscopic cholecystectomy in cirrhotic patients.

BACKGROUND: Reported mortality for open cholecystectomy in patients with cirrhosis ranges from 10% to 80%. Laparoscopic cholecystectomy has gained acceptance in the general population and has become the procedure of choice for symptomatic cholelithiasis. We reviewed our experience with the use of laparoscopic cholecystectomy in this group. STUDY DESIGN: We did a retrospective review of the records of 25 consecutive laparoscopic choleoystectomy procedures performed on cirrhotic patients from May 1992 to July 1996. RESULTS: There were no mortalities in our group. All procedures were completed laparoscopically. Mean length of stay was 1.7 days (range, 1 to 8 days). Morbidity consisted of wound hematomas, pneumonia, and ascites for a rate of 32%. Only patients with Child's Class A and Class B cirrhosis were operated on. CONCLUSIONS: Laparoscopic cholecystectomy can be performed safely in cirrhotic patients with well compensated liver function.