Hepatic trauma: evaluation of routine drainage.

Routine drainage of liver wounds created by trauma has recently been challenged, prompting a prospective, randomized trial of drainage via a Penrose dam versus no drain in patients having emergency laparotomy for abdominal trauma. We excluded cases in which definite bile leak was noted at operation. Of 167 patients studied, six had obligatory drainage because of obvious bile leak. Among the remaining 161 patients, there was no significant difference as to demographics, mode of injury, volume of blood lost or used for resuscitation, incidence and severity of shock, number and types of associated injuries, or magnitude of liver wound between the 78 allocated to drainage and the 83 left without a drain. Resultant mortality, duration of hospitalization, incidence of wound and/or intra-abdominal infection, and likelihood of subsequent bile fistula were not different. Such data support the routine use of a drain only if bile leakage from the liver wound is found at laparotomy. Without obvious bile leak, drainage of a specific liver injury does not appear to be necessary.

Extraperitoneal versus transperitoneal drainage of the intra-abdominal abscess.

Controversy as to whether the intra-abdominal abscess should be drained extraperitoneally or through formal laparotomy still rages. Arguments for a transperitoneal approach include no need to identify specific locus preoperatively and uniform drainage of all abscesses, especially any otherwise unrecognized pus collection. Proponents for the extraperitoneal route stress failure to contaminate previously uninvolved peritoneal spaces and more reliable avoidance of injury to intestine, predisposing to subsequent intestinal fistula. To resolve this impasse, a prospective study of each method was based upon a schedule of previously randomized treatment options. After 32 months of study, 60 patients had been enrolled without obvious differences between treatment groups with respect to demographic features, preoperative definition and locus of infection, precipitating cause of sepsis, associated diseases, responsible bacteria and antibiotic therapy. With the transperitoneal approach, five patients had hollow viscus injury, while seven eventually had an intestinal fistula develop, causing major problems in four. Despite no obvious intestinal injury with the extraperitoneal route, two transient intestinal fistulas did occur. Seven patients drained transperitoneally had additional abscesses discovered, yet another operation was required to drain at least one complicating abscess in seven of this same group. With the extraperitoneal route, only two patients needed reoperation to drain another abscess. Although there were more deaths and complications in the group drained transperitoneally, morbidity (47 per cent) and mortality (7 per cent) were not significantly different statistically. Such data refute the professed superiority of a transperitoneal approach to intra-abdominal abscess drainage, both from need to reoperative for second abscess as well as incidence of latter intestinal fistula. Best results were noted with abscess identification through computerized tomography followed by extraperitoneal drainage.

Ceftriaxone versus combined gentamicin and clindamycin for polymicrobial surgical sepsis.

During a 7 month trial for therapy of polymicrobial surgical sepsis, intravenous antibiotic treatment was randomized between gentamicin (1 mg/kg every 8 hours) plus clindamycin (8 mg/kg every 6 hours), and the cephalosporin, ceftriaxone (1 g every 12 hours) in 197 patients, of whom 99 were being treated for peritonitis, 93 for soft tissue sepsis, and 5 for other forms of infection. No significant differences were noted in patient demographics, type of sepsis, associated disease states, surgical procedure, or causative aerobic or anaerobic pathogens. Results demonstrated approximately equivalent efficacy, although cure rates obtained with ceftriaxone in patients with soft tissue sepsis or intraabdominal abscess were superior to those achieved with combination gentamicin and clindamycin. There were no significant side effects with ceftriaxone therapy, such as the renal failure noted in six of the patients treated with gentamicin and clindamycin. We conclude that single agent treatment with ceftriaxone is preferable because of the greater safety and the longer dosing intervals.

Abdominal incisions: transverse vs vertical placement and continuous vs interrupted closure.

A previous retrospective review of 2,006 emergency laparotomies had suggested that anesthesia and operative times could be reduced by using a continuous stitch closure for all layers of the incision. A prospective, randomized study was then implemented through use of odd/even digits in the last and next-to-last digits in the hospital number. Of 551 patients subjected to laparotomy because of abdominal trauma, no intraperitoneal injury was found in 212. There was no statistically significant difference in time expended or complications (wound or other, including pulmonary) on contrasting transverse (101) with vertical (111) incisions, or on comparing continuous (104) and interrupted (108) closure, with the exception of an average 26 minutes in time saved by a continuous suture (P = .02). Analysis of these same factors in 339 patients with trauma found at laparotomy could document no statistically significant difference. Such data support the use of a running suture for closure of the abdominal wall as a practical method to save anesthesia and operating time without increased risk of developing a wound or other postoperative complication.

Safety of incidental appendectomy.

Reports in the surgical literature are conflicting as to whether appendectomy "in passing" during laparotomy for trauma or for some other disease state does or does not significantly increase patient morbidity or mortality. A chart survey of all appendectomies (342 for acute appendicitis and 146 as incidental procedures) performed on the trauma service of Grady Memorial Hospital over a 40 month period appeared to indicate that the wound infection rate (6.8 percent) was the same as that for acute simple or suppurative appendicitis (6.7 percent), whereas the intraabdominal sepsis rate (17.5 percent) paralleled that for more advanced gangrenous or perforative appendicitis (18.6 percent). Since the validity of a retrospective review is always open to question, a prospective, randomized trial was carried out only on patients with a negative abdominal exploration for trauma over a 22 month interval at the same trauma service. An odd second from the last digit hospital number dictated appendectomy, provided the appendix was readily accessible; an even digit in the same locus dictated retention of the appendix. In no patient did intraperitoneal sepsis develop, regardless of the procedure chosen. Wound infection rates were 1.8 percent for appendectomy (1 of 56), if local anatomic considerations precluded an easy appendectomy (0 of 45), and 3.6 percent for the control subjects without appendectomy (3 of 83). There were no deaths. These data cast considerable doubt on the reliability of retrospective reviews and support the generally accepted dictum that incidental appendectomy, especially in the trauma patient, can be a relatively innocuous procedure.

Management of the major coagulopathy with onset during laparotomy.

An experience with 31 patients who developed major bleeding diatheses during laparotomy was reviewed. Management of the initial 14 patients was by standard hematologic replacement, completion of all facets of operation, and then closure of the peritoneal cavity, usually with suction drainage; only one patient survived. The subsequent 17 patients had laparotomy terminated as rapidly as possible to avoid additional bleeding. Major vessel injuries were repaired; ends of resected bowel were ligated; and holes in other gastrointestinal segments and the bladder were closed by purse-string sutures. One patient had a ureter ligated. Laparotomy pads (4-17) were then packed within the abdomen to effect tamponade, and the abdomen was closed under tension without drains or stomata. Following correction of the coagulopathy, the abdomen was re-explored at 15 to 69 hours in the 12 survivors. Definitive surgery then was completed: bowel resection and reanastomosis; ureter reimplantation; drains for bile, pancreatic juice, and urine; and stomata for bowel or urine diversion or decompression. Eleven of 17 patients, deemed to have a lethal coagulopathy, survived. This technique of initial abortion of laparotomy, establishment of intra-abdominal pack tamponade, and then completion of the surgical procedure once coagulation has returned to an acceptable level has proven to be lifesaving in previously non-salvageable situations.

Third-generation cephalosporins for polymicrobial surgical sepsis.

During 31 months of study, 808 patients with polymicrobial surgical infection were randomized for antibiotic therapy between a third-generation cephalosporin (moxalactam disodium [149], cefotaxime sodium [125], and cefoperazone sodium [141]) and the combination of gentamicin sulfate plus clindamycin (393). Results based on antibiotic therapy included the following: cure in 83% given cephalosporin, 73% with antibiotic combination; control but recurrent sepsis in 7% and 15%; and failure in 4% and 8%, respectively. Such data support the tenet that third-generation cephalosporins are at least equal, if not superior, to the combination of gentamicin plus clindamycin for treatment of polymicrobial surgical sepsis.

A technique for transduodenal sphincteroplasty.

A technique for transduodenal sphincteroplasty is presented. T-tube decompression of the common bile duct and subphrenic space drainage are routinely avoided. To date, results in 123 consecutive patients have been excellent. The single most troublesome wound complication, duodenal fistula, had been avoided in the most recent 68 patients by colonic or omental onlay of serosa.

Colonic atony in association with sigmoid volvulus: its role in recurrence of obstructive symptoms.

We reviewed a 30-year experience in management of 129 patients with 163 acute obstructions due to sigmoid volvulus. Recurrent obstruction of the colon was observed in 47 (or 45%) of 104 patients who survived their initial obstructive episode: 61% after rectal tube insertion, 45% after detorsion, 33% after sigmoid plication, and 21% despite sigmoid colectomy. Subsequent barium enema or surgical exploration showed true sigmoid volvulus to be the cause of recurrent obstruction in 36 of 47 patients, while atonic bowel, involving the sigmoid alone or more proximal colon as well, was responsible for the other 11 recurrent obstructions. Sigmoid excision was corrective only if bowel atony was limited to that portion of the colon. Only more extensive colectomy, so as to include all flaccid colon, consistently obviated recurrence. Failure to recognize functional obstruction accounted for five of the 25 total deaths.

Clinical evaluation of cefotaxime versus gentamicin plus clindamycin in the treatment of polymicrobial peritonitis.

One hundred fifty-one patients with presumed aerobic-anaerobic mixed peritoneal infections were treated in a prospective, randomized trial with either cefotaxime alone (76) or the combination of gentamicin-clindamycin (75). Primary and complicating foci of sepsis were cultured for both aerobic and anaerobic pathogen identification and antibiotic susceptibility. In vitro aerobic disk sensitivities (114 isolates) to cefotaxime were 82% and to gentamicin, 88%; anaerobic agar-diffusion sensitivities (227 isolates) to cefotaxime were 87% and to clindamycin, 98%. Only enterococci and Pseudomonas sp were consistently resistant to cefotaxime. Infection was eliminated in 82% of those treated with cefotaxime and in 87% of those treated with the gentamicin-clindamycin combination, yet sepsis recurred in 11% of those treated with cefotaxime and in 13% for those given gentamicin-clindamycin. Five patients (7%) demonstrated nephrotoxicity for gentamicin. (Serum creatinine increased greater than 1.5 mg/100 ml over pretreatment levels.) Otherwise, incidence and severity of adverse reactions were identical for the two groups and consisted primarily of phlebitis and diarrhea. One patient in each treatment group died of uncontrolled sepsis. Although results suggested a laboratory superiority of gentamicin-clindamycin, there was a clinical equality in therapeutic benefit and a greater safety following the use of cefotaxime alone.

Clinical comparison of cefotaxime versus the combination of gentamicin plus clindamycin in the treatment of polymicrobial soft-tissue surgical sepsis.

The safety and efficacy of cefotaxime versus a combination of gentamicin and clindamycin were compared in a prospective, randomized study of 98 surgical patients with polymicrobial soft-tissue infection or septicemia. Forty-nine patients received cefotaxime (20 mg/kg every six hours), and 49 received gentamicin (1 mg/kg every eight hours) plus clindamycin (5 mg/kg every six hours); all drugs were given intravenously. Overall, there was no statistical difference in clinical response to the two regimens, infection being eliminated in 73% of the patients treated with cefotaxime and 71% of those given gentamicin plus clindamycin. Adverse effects were mild and self-limited in both treatment groups, although three patients treated with gentamicin plus clindamycin experienced some loss of renal function. Most aerobic gram-negative rods were sensitive to both cefotaxime and gentamicin, but anaerobes were slightly more sensitive to clindamycin than to cefotaxime. Cefotaxime appeared to be at least as effective as gentamicin plus clindamycin in the treatment of polymicrobial soft-tissue infections and septicemia, and, in light of the loss of renal function associated with the gentamicin-clindamycin regimen, somewhat safer. The high failure rate among patients on both regimens with septicemia of unknown origin (five of the nine treated with cefotaxime and two of the four treated with gentamicin and clindamycin), however, indicates the critical role of surgical management in the treatment of polymicrobial soft-tissue sepsis.

Use of antibiotic prophylaxis in penetrating abdominal trauma.

Information concerning the efficacy of prophylactic antibiotics in patients sustaining penetrating abdominal trauma is limited. Duration of such therapy is also uncertain. Thus a prospective, randomized, double-blind study was performed at Grady Memorial and City of Memphis Hospitals. A total of 360 patients sustaining penetrating abdominal trauma were randomized to one of three groups: group 1, cefotaxime perioperatively only; group 2, cefotaxime perioperatively plus postoperative doses every six hours for 24 hours; and group 3, cefazolin perioperatively plus postoperative doses every six hours for 24 hours. Postoperative infection of the incision or peritoneal cavity occurred in 20 (17%) of the patients in group 1, 13 (10%) in group 2, and 11 (9%) in group 3. Differences were not statistically significant. The occurrence of higher infection rates in group 1 may be explained by the greater number of patients sustaining shotgun wounds and rectal injuries. This study lends support to the practice of discontinuing antibiotic therapy on termination of the operative procedure. Cefotaxime has been found to be a reliable, effective agent for prophylaxis against infection in patients who have sustained penetrating abdominal trauma.