Small bowel necrosis associated with early postoperative jejunal tube feeding in a trauma patient.

Several investigators have reported the association of small bowel ischemia and necrosis with needle catheter jejunostomy. We report a case of small bowel necrosis with continuous jejunal tube feeding and review the pathogenesis implicated in feeding-induced bowel necrosis.

Reengineering respiratory support following extubation: avoidance of critical care unit costs.

STUDY OBJECTIVE: We prospectively investigated alternative clinical practice strategies for critically ill trauma patients following extubation to evaluate the cost-effectiveness of these maneuvers. The primary change was elimination of the routine use of postextubation supplemental oxygen, with concurrent utilization of noninvasive positive pressure ventilatory support (NPPV) to manage occurrences of postextubation hypoxemia. DESIGN: Prospective, consecutive accrual of patients undergoing extubation. SETTING: Trauma ICU in a university hospital. INTERVENTIONS AND MEASUREMENTS: All patients received mechanical ventilation using pressure support ventilation (PSV) with continuous positive airway pressure (CPAP) as the primary mode. The patients were extubated to room air following a 20-min preextubation trial of 5 cm H(2)O CPAP at FIO(2) of 0.21, and demonstrating a spontaneous respiratory rate /= 7.30, PaCO(2) /= 50 mm Hg. The subgroup of patients who became hypoxemic (pulse oximetric saturation < 88%) within 24 h of extubation were treated with NPPV for up to 48 h duration. Patients who failed NPPV were reintubated. Four hundred fifty-one (84%) patients were successfully extubated to room air. Seventy-two patients (13%) became hypoxemic within 24 h, and NPPV was administered. Fifty-two patients (72% of those who were hypoxemic) responded to NPPV, while 20 patients failed to respond to therapy, were reintubated, and received mechanical ventilation for a mean of 4 days. Thirteen additional patients (2%) were reintubated for reasons other than hypoxemia. The overall reintubation rate for the group (n = 536) was 6.2%; for the postextubation hypoxemic group who failed NPPV, the reintubation rate was 3.7%. The elimination of routine supplemental oxygen via nasal cannula following extubation resulted in a potential direct cost avoidance of $50,006.88 for 451 patient days. Moreover, the 52 patients who were spared reintubation and mechanical ventilation provided an additional potential cost avoidance of $19,740.24 in unused ventilator days per patient. CONCLUSION: Eliminating the routine use of supplemental oxygen and employing NPPV as a method to prevent reintubation can facilitate a more aggressive, cost-effective strategy for the management of the trauma ICU patient who has been extubated.

Spontaneous rupture of the urinary bladder in the alcoholic patient.

A case of a young man with an acute abdominal condition and hematuria is presented. BUN and SCr levels were markedly elevated. Retrograde cystography revealed intraperitoneal extravasation of contrast material. At exploration, a large intraperitoneal bladder perforation was noted and repaired in two layers. Recovery was uneventful. The presentation, diagnosis, and treatment of spontaneous rupture of the urinary bladder are discussed.

Retroperitoneal abscess as a complication of retained gallstones following laparoscopic cholecystectomy.

Retroperitoneal abscess formation secondary to retained spilled gallstones after laparoscopic cholecystectomy is a rare complication. We describe the case of a patient with this complication as well as a novel method utilizing interventional radiologic localization with subsequent operative drainage and removal of the stones. A review of the literature is provided.

Ciliated foregut cyst of the pancreas.

Cystic lesions of the pancreas are relatively uncommon. We describe the case of a young man with a complex cystic mass located within the head of the pancreas. The patient underwent exploration with resection of the mass. Pathology revealed a ciliated epithelial cyst, a rare cystic lesion of the pancreas.

Diagnosis and management of acute aortic valvular disruption secondary to rapid-deceleration trauma.

Acute aortic valve rupture with resultant aortic insufficiency is a rare complication of blunt trauma. We describe a case in which a patient fell 70 feet, sustaining avulsion of two leaflets of the aortic valve along with multiple other injuries, primarily orthopedic. Our case demonstrates that patients with acute aortic regurgitation can be managed nonoperatively if necessary in the acute setting, enabling management of other significant trauma. Subsequent semielective valvular replacement may be undertaken if other injuries must take precedence.

Management of recurrent and perivascular femoral hernias by giant prosthetic reinforcement of the visceral sac.

BACKGROUND: Classical hernioplasties have been used to manage primary femoral hernias for over a century. In women, infrainguinal repair of the parietal defect is simple and successful. In men, femoral hernias are frequently associated with inguinal hernias and, therefore, a Cooper's ligament repair is indicated. For recurrent femoral hernias, however, the classical hernioplasties are often inadequate just as they are for the repair of recurrent inguinal hernias and a prosthetic repair is indicated. Giant prosthetic reinforcement of the visceral sac (GPRVS) is the descriptive name of a properitoneal groin hernioplasty with a large piece of Mersilene. The repair focuses on retaining the peritoneum rather than repairing the parietal defect and is efficient, anatomic, sutureless, and tension-free. It is the only repair that reliably eliminates all hernias of the groin, including perivascular femoral hernias. STUDY DESIGN: In this study, GPRVS by way of an abdominal incision was used to treat recurrent and perivascular femoral hernias. Also included are a description of and experiences with a new technique of unilateral GPRVS performed through an infrainguinal approach. RESULTS: The data reveal no recurrences in 69 problem femoral hernias of which 15 were primary (two perivascular) and 54 recurrent (four perivascular). CONCLUSIONS: Giant prosthetic reinforcement of the visceral sac performed transabdominally or by way of the newly described infrainguinal method is a useful and reliable method to treat primary, recurrent and perivascular femoral hernias.

[Treatment of recurrent and prevascularized femoral hernias by reinforcement of the visceral sac using a giant prosthesis]. / Traitement des hernies fémorales récidivées et prévasculaires par renforcement du sac viscéral à l'aide d'une prothèse géante (GPRVS).

Giant prosthetic reinforcement of the visceral sac (GPRVS) is the descriptive name of a preperitoneal groin hernioplasty with a large piece of Mersilene. The repair focuses on retaining the peritoneum rather than repairing the parietal defect and is efficient, anatomic, sutureless, and tension-free. Herein, is a discussion of its use to manage recurrent and perivascular femoral hernias and a description of a new technique of unilateral GPRVS done through an infrainguinal approach. The data presented reveal no recurrences in 69 problem femoral hernias of which 13 were primary, 50 recurrent and 6 perivascular.

Resolution of refractory pancreatic ascites after continuous infusion of octreotide acetate.

The treatment of pancreatic ascites remains a clinical challenge. Both medical and surgical management have high rates of mortality and recurrence. New methods in the treatment of pancreatic ascites are actively sought. We describe the successful use of a continuous infusion of octreotide acetate in the treatment of refractory alcoholic pancreatic ascites.

The defensin-related murine CRS1C gene: expression in Paneth cells and linkage to Defcr, the cryptdin locus.

The site of defensin-related CRS1C gene expression in mouse small bowel and the chromosomal location of the CRS1C locus, Defcr-rs1, have been determined. CRS1C (cryptdin-related sequence 1C) mRNA is an abundant small intestinal sequence that exhibits extensive similarity to the prepro-coding regions of defensin mRNAs yet does not encode a defensin (A. J. Ouellette and J. C. Lualdi, 1990, J. Biol. Chem. 265: 9831-9837). Using sequence-specific probes, CRS1C mRNA was detected in Paneth cells at the base of intestinal crypts by in situ hybridization. Southern blot analysis of genomic DNAs from inbred and recombinant inbred (RI) mouse strains, also conducted with probes specific for CRS1C, showed that the CRS1C locus maps to the proximal region of Chromosome 8. In 62 RI strains, no discordancies were found between Defcr-rs1 and Defcr, the cryptdin gene. Thus, both the Defcr-rs1 and the Defcr genes are expressed in Paneth cells and both are genetically inseparable within 1.58 cM on Chromosome 8. These studies identify a second defensin-related Paneth cell gene in mice.

Effects of cyclosporine on glucose metabolism.

Cyclosporine may have deleterious effects on glucose metabolism. This study was designed to characterize more precisely cyclosporine-induced alterations in glucose homeostasis in a large animal model with hyperglycemic and euglycemic clamp studies in addition to simple bolus glucose (IVGTT) and insulin (IVITT) tolerance tests. In experiment 1, IVGTTs and hyperglycemic clamp studies were performed in eight ewes before and after 4 weeks of cyclosporine treatment. Studies were repeated 4 weeks after cessation of therapy. In experiment 2, IVITTs and euglycemic clamp studies were performed in seven ewes before and after 4 weeks of cyclosporine treatment. Fasting glucose and insulin levels were not affected by cyclosporine treatment. In experiment 1 cyclosporine did not alter IVGTTs; however, during sustained hyperglycemia, cyclosporine caused a 37% decrease in net glucose disposal (p less than 0.001) and a 39% decrease in plateau plasma insulin levels (p less than 0.05). In experiment 2 cyclosporine had no effect on IVITTs. Plateau insulin values in euglycemic clamp studies were lowered by 27% (p less than 0.05) after cyclosporine treatment. In addition, the metabolic clearance rate of insulin was increased by 25% (p less than 0.05), and the steady-state insulin clearance rate was increased by 16% (p less than 0.003). Measurements of insulin sensitivity were unchanged by cyclosporine. These experiments suggest that cyclosporine treatment results in impairment of sustained synthesis and secretion of insulin, increased insulin clearance, and unaltered insulin sensitivity.