The use of local and systemic antibiotics in rat fecal peritonitis.

Treatment of fecal peritonitis includes administration of antibiotics, physical removal of contaminants, and restoration of gastrointestinal integrity. The temporal relationship of parenteral antibiotics and peritoneal irrigation with varied antibiotic solutions was studied in a peritonitis model. Antibiotics in high concentrations may actually inhibit host immune cells; therefore, dilute solutions used were MIC (minimum inhibitory concentration) (micrograms per millimeter) equivalent to usually achieved standard therapeutic blood levels. Sprague-Dawley rats were given a quantitative intraperitoneal challenge of 2 x 10(10) CFU/kg Escherichia coli and 10 mg autoclaved rat feces. Rats were randomized to receive 30 mg/kg intramuscular ceftriaxone (CTRX) either at the time of challenge (T = 0) or 2 hr later (T = 2). Two hours after peritonitis, rats received peritoneal irrigation with 30 cc of (1) normal saline, (2) dilute (10 mg/liter) CTRX solution, or (3) concentrated (1000 mg/liter) CTRX solution or (4) no irrigation. Survival and intraperitoneal pathology were then assessed. Parenteral CTRX given concurrently with peritoneal contamination improved survival (67%) compared with parenteral administration given 2 hr later (33%) (P < 0.05). Intraperitoneal CTRX irrigation improved survival (100%) in animals that received parenteral CTRX concurrently with contamination; this beneficial effect was present with both dilute and concentrated solutions and was significantly better than saline irrigation alone. Parenteral antibiotics given early after contamination of the peritoneum associated later with peritoneal lavage with antibiotic solutions improved survival.

Porcine peritoneal sepsis: modeling for clinical relevance.

The characteristics of two types of intraperitoneal (i.p.) soilage sepsis models, autologous fecal inoculum (FEC) and a pure culture of Escherichia coli (EC), were studied in 26 male Yucatan minipigs (20-30 kg). Early (1-4 h) and late (24-72 h) changes were different between the two groups. The EC group was characterized early by hypotension, low cardiac output, and increased systemic and pulmonary vascular resistances, along with leukopenia, hypoglycemia, lactacidemia, and elevated blood urea nitrogen. Of the pigs in the EC group that survived the early effects, there were few significant differences in physiological parameters, compared to control pigs, that would indicate ongoing pathological processes. In contrast, the FEC group pigs demonstrated early hypotension, but with increased cardiac output and reduced systemic vascular resistance. Other parameter changes were similar to those seen in the EC pigs, but to a lesser degree, with the exception of elevations in serum lactate dehydrogenase. Also in contrast to the EC group, most of the changes in the FEC group persisted in later days, and FEC pigs demonstrated leukocytosis. There were also greater elevations in circulating lipopolysaccharide (LPS) concentrations in the EC group that returned later to baseline levels. In the FEC group, there were persistently elevated LPS concentrations over 72 h. These observations suggest that pigs challenged with intraperitoneal E. coli demonstrated an initial acute peritonitis and damaging physiologic effects of high levels of circulating LPS. Survivors in this group improved and were physiologically stable after 24 h. Pigs that received i.p. autologous feces developed an early acute peritonitis phase with lower levels of circulating LPS, and later developed pronounced peritoneal reaction as demonstrated by multiple abdominal abscesses, pyogenic granuloma formation, and adhesions with physiological evidence of developing sepsis over 72 h. These observations indicate that i.p. EC models evoke a systemic response not unlike intravenous administration of LPS or EC, however, the FEC model produced a systemic response akin to a slower developing septic process.

The surgical significance of Persian Gulf sand.

Foreign bodies, in particular sand and soil particles, can cause considerable reaction in wounds and remain in tissues indefinitely. The introduction of foreign material as a contaminant in wounds and intracavitary injuries to military personnel deployed in the Persian Gulf region can be a complicating factor in treatment. Samples of desert sand from the military operational areas of the Persian Gulf were analyzed and the acute local and systemic responses of intraperitoneal contamination determined in an experimental rat model.

Radionuclide cholescintigraphy in patients with suspected biliary tract obstruction.

Radionuclide cholescintigraphy is used to help establish the diagnosis of acute cholecystitis and is thought to provide additional information regarding the patency of the biliary duct system. Nonvisualization of the extrahepatic biliary duct system and lack of excretion into the duodenum despite uptake in the liver (a positive study) is considered indicative of common bile duct obstruction. The authors retrospectively reviewed 281 hepatobiliary cholescintigrams done at Stamford Hospital from July 1, 1987 to June 30, 1989. Previous authors have demonstrated a false-positive rate of eight to 15 per cent in those cases that have a documented normal extrahepatic biliary system at operation. Of those patients explored after a common bile duct obstruction pattern depicted by cholescintigram in the authors' series, 46 per cent of patients were found to have normal extrahepatic biliary systems. Factors possibly contributing to this high false-positive rate are discussed. The utility of radionuclide hepatobiliary scans may be limited for diagnosis of biliary duct obstruction.

Prediction of operative cholangiography in patients undergoing elective cholecystectomy with routine liver function chemistries.

A retrospective reviews of 195 consecutive patients who underwent elective cholecystectomy and operative cystic duct cholangiography (OCDC) were reviewed to establish criteria to correlate the preoperative laboratory data of liver chemistry tests and the actual biliary tract disease found in each patients. Patients who had a history of jaundice or other clinical indication for common bile duct exploration were excluded from this study. The patients were divided into four groups based on the results of the OCDC: I negative, II false positive, III false negative, and IV positive for choledocholithiasis. The results of the preoperative liver chemistry studies of the patients in each of the four groups were analyzed by the chi 2 method. The four liver chemistry tests were lactate dehydrogenase, SGOT, bilirubin, and alkaline phosphatase. When results of all preoperative liver chemistry tests were normal, there was no incidence of choledocholithiasis. As the number of chemistry test result elevations increased from one to four, the incidence of choledocholithiasis increased from 17% to 50% (p less than 0.001). Preoperative liver chemistry tests in selected patients undergoing elective cholecystectomy may provide a valuable indicator to the surgeon as to whether an OCDC should be performed at the time of surgery.

The use of mixed venous blood gas determinations in traumatic shock.

A series of 10 seriously injured patients requiring resuscitation and definitive operative control of hemorrhage was studied. Simultaneous arterial and mixed venous blood gases were measured sequentially throughout the resuscitative and operative periods. Improvement of the mixed venous oxygen saturation was associated with survival. In this study, mixed venous oxygen saturations were valuable predictors of survival and were a helpful parameter to monitor during the resuscitative, operative, and immediate postoperative periods.

Penetration of clindamycin into the human appendix.

Clindamycin penetrated extremely well into inflamed (19) and normal (one) appendices. Average levels in appendiceal tissue taken 26 to 300 minutes after a single intravenous dose were 154% of the simultaneous serum concentration.

A shunt equation for estimating the splenic component of portal hypertension.

A modification of the Berggren pulmonary shunt equation was derived for use in estimating the splenic component of portal hypertension. It was used in nine patients, six of whom had sufficient decreases in portal flow and pressure after splenic artery and coronary vein ligation. The average decrease in portal flow was 52%.

Metallic foreign bodies in the stomach.

We present a case of a patient who ingested 648 metallic objects that formed an intertwining mass within the stomach, requiring operative removal. Of interest was the absence of symptoms and complications after 11 years of continual ingestion. To our knowledge, this is the second heaviest accumulation of metallic foreign objects removed from the stomach of a living patient.

Gastrointestinal injuries.

Any wound that penetrates the abdomen may involve the gastrointestinal tract whether controlled for a specific operation of diagnostic procedure or uncontrolled when secondary to blunt or penetrating trauma. The first important consideration is the prevention of complications. The choice of incisions, the managment of the contaminated peritoneal cavity, intestinal fistulas and specific bowel injuries and the importan differences in the treatment of injuries to small intestine versus to large intestine and rectum be considered. Bowel viability must also be determined.

Traumatic pseudoaneurysms: a review of 32 cases.

The management of 23 patients with traumatic pseudoaneurysms is presented. A pulsatile mass associated with pain was the usual presentation. Hypertension and hypovolemic shock from rupture are uncommon presentations but potential hazards of this lesion. Twenty-one pseudoaaeurysms were treated surgically. Resection with end-to-end anastomosis (eight patients), with graft replacement (one patient), with lateral repair (seven patients) was done. Hypothermia with circulatory arrest and external Dacron shunt were used to prevent visceral ischemia during high aortic occlusion. There were no mortalities or significant postoperative complications.