Endobronchial drainage of undiagnosed lung abscess during chest physical therapy. A case report.

Bronchial drainage, positive-pressure lung inflation, chest-wall percussion, and suctioning were performed in a patient with postoperative atelectasis, lung infection, and respiratory failure. A previously undiagnosed posterior lung abscess subsequently drained into the bronchial tree, causing dissemination of the infection and a severe deterioration of pulmonary function. Dissemination of pulmonary infection from a lung abscess is a possible complication that should be considered when prescribing and administering chest physical therapy.

Mechanical intestinal obstruction in patients with gynecologic disease: a review of 368 patients.

To review the management of intestinal obstruction associated with gynecologic disease, the authors studied the records of 368 patients with acute intestinal obstruction. Most patients (83%) had gynecologic malignancies. Obstruction of the small intestines was more common than obstruction of the large intestines (77% versus 23%). Major causes of mechanical small bowel obstruction included extrinsic neoplasms (62%, mostly ovarian carcinomas), radiation therapy-associated strictures and adhesions (17%), postoperative adhesions (14%), and inflammatory strictures and adhesions (3%). Obstruction of the colon was caused mainly by extrinsic neoplasms (45%), strictures and adhesions associated with radiation therapy (26%), fecal impaction (9%), and intrinsic neoplasms (8%). Gastrointestinal intubation successfully relieved 81% of small bowel obstructions caused by postoperative adhesions. Tube suction alone was rarely successful when the obstruction was caused by malignant neoplasms. The prognosis was dependent on the cause of the underlying disease. The cases studied in this report were compared with a large number of cases of bowel obstruction in general surgery. It is concluded that bowel obstruction associated with gynecologic disease has unique features deserving wider recognition.

Conservative management of small bowel obstruction.

Intestinal Cantor tubes were used in the management of 69 gynecologic patients with pelvic malignancies who presented with small bowel obstruction. Small bowel obstruction was secondary to radiation injury, persistent or recurrent carcinoma, or postoperative adhesions. Thirty-one patients (45%) in this series had successful resolution of their small bowel obstruction with a Cantor tube, including 12 of 14 patients (86%) with postoperative adhesions. Complete obstruction of the small bowel was the only prognostic factor definitely associated with tube failure. Seventy percent of all patients had successful passage of the tube on one attempt, and no major complications were encountered. The Cantor tube has proved to be safe, effective, and easy to use, and guidelines for the management of it are included. Cantor tube decompression should be considered in the initial management of small bowel obstruction, since a significant percentage of the patients with this condition will not require surgical intervention.

Altered capillary permeability in neurogenic pulmonary oedema.

Two cases of fatal neurogenic pulmonary oedema are depicted. The hemodynamic study failed to document any hypertensive crisis or pulmonary hypertension. By contrast, the low values of pulmonary capillary wedge pressures and the high protein concentration in tracheal fluid suggest a pulmonary capillary wall lesion.

Abscess-fistula association: radiologic recognition and percutaneous management.

Thirty-five patients with postoperative enteric and/or biliary fistulae were diagnosed and treated by percutaneous catheter drainage. All were initially considered to have postoperative abdominal abscesses, and the enteric or biliary communications were unrecognized before radiologic intervention. In addition, at the time of initial catheter insertion, only six of the 35 abscesses were recognized as being associated with an underlying fistula. In the other 29 patients the fistulae were found either by clinical follow-up or contrast sinogram after 24-72 hr of catheter drainage. Percutaneous catheter drainage was the definitive treatment in 28 (80%) of the 35 patients. The seven failures were either from inadequate catheter positioning or inability to treat the primary cause of the fistula (e.g., radiation enteritis, perforated cancer). These data suggest that even abscesses with underlying fistulae, traditionally an indication for surgical intervention, may be successfully managed by percutaneous methods.

Acute renal failure associated with increased intra-abdominal pressure.

Anuric renal failure developed in four patients in association with increased intra-abdominal pressure from postoperative hemorrhage. Polyuria and resolution of the renal failure occurred in each patient in response to operative decompression of the abdomen. Renal failure secondary to increased intra-abdominal pressure has been previously produced experimentally in dogs by the intraperitoneal installation of graded amounts of saline. This is the first report of this type of renal failure in clinical practice.

Preoperative parenteral feeding in patients with gastrointestinal carcinoma.

In a comparative clinical trial to examine the influence of 10 days of preoperative parenteral nutrition (PPN) on the postoperative complication rate for gastrointestinal carcinoma 59 patients (controls) received the regular hospital diet and 66 received PPN. The two groups were similar in nutritional status and in distribution of site and stage of tumour and type of operation. The rates of postoperative wound infection, pneumonia, major complications, and mortality were generally lower in the PPN group, but the differences were significant only for major complications and mortality. The clinical results can be explained by the improvement in various indices of humoral and cellular immunocompetence and the protein status in the PPN group and their deterioration in the control group during the preoperative course.

Marital changes after intestinal bypass surgery.

A retrospective interview study was undertaken of 14 spousal pairs in which one member had undergone the intestinal bypass procedure for massive obesity. Much unanticipated marital discord occurred. Sexual problems were particularly troublesome and affected both members in the spousal pairs. The results point to the role of massive obesity as a selective and stabilizing factor in the marriages of this subset of overweight persons.

Repair of left ventricular-aortic discontinuity complicating endocarditis from an aortic valve prosthesis.

A case of bacterial endocarditis from an aortic valve prosthesis is described in which subannular pseudoaneurysm caused discontinuity of the aorta and left ventricle. Successful repair was accomplished using compound sponge-felt to bolster the left ventricular outflow tract and to obliterate the aneurysm.