Single-dose cefuroxime versus multiple-dose cefazolin as prophylactic therapy for high-risk cholecystectomy.

The ideal regimen for the prevention of postoperative infections occurring after elective cholecystectomy has been widely debated. This double-blind, randomized study was conducted to compare the effectiveness and safety of cefuroxime with that of cefazolin in 295 patients undergoing elective cholecystectomy who were considered to be at high risk for postoperative infection. Patients were randomly assigned to receive either a single 1.5 gram dose of cefuroxime plus three doses of placebo, or four 1 gram doses of cefazolin. Each regimen was begun 30 to 60 minutes preoperatively and repeated every six hours for three doses postoperatively. Patients were evaluated during the hospitalization period and again at 30 days. All postoperative infections, including remote infections, were included in the definition of failure. Bacteriologic success rates were 95.5 percent in the cefuroxime group and 98.2 percent in the cefazolin group (p > 0.05). Corresponding clinical success rates were 91.4 and 94.9 percent (p > 0.05), respectively. There was no association between intraoperative bile cultures and the risk of failure or the type of microorganism isolated from postoperative infections. Both regimens were well-tolerated. In view of the additional costs and time associated with preparation and administration of multiple doses, a single preoperative 1.5 gram dose of cefuroxime may be a cost-effective alternative to four 1 gram doses of cefazolin in patients undergoing elective cholecystectomy who are at high risk for postoperative infection.

Is exploratory celiotomy necessary for all patients with truncal stab wounds?

Mandatory exploratory celiotomy was carried out in 1241 consecutive patients with truncal stab wounds. Four hundred seventy-one (38%) patients who had no intra-abdominal injury identified at operation developed 16 complications (3%), with one patient (0.2%) dying postoperatively. The average length of hospitalization (5 days) was increased if the patient: (1) required a simultaneous operation for associated site injuries (9 days), (2) developed postoperative complications (16 days), or (3) required reoperation (27 days). The 1990 projected cost per patient for routine celiotomy has increased 92% over that seen 10 years ago. Selective management protocols using observation, repeated physical examination, and special diagnostic procedures could be instituted for asymptomatic hemodynamically stable patients with truncal stab wounds if appropriate facilities and personnel are available. Successful implementation should preserve medical resources for those patients with trauma requiring a life-saving operation.

Percutaneous transhepatic cholangiography and biliary decompression. Invasive, diagnostic, and therapeutic procedures with too high a price?

To investigate and/or treat the causes of jaundice, 221 patients underwent the following procedures over 7 years: percutaneous transhepatic cholangiography (PTC) alone (104 patients), PTC with external biliary drainage (69 patients), or PTC with external/internal biliary drainage (48 patients). Forty-nine procedure-related complications occurred in 39 patients (18%). Three patients (1.5%) required an emergency operation for hepatic hemorrhage (2 patients) and a perforated gallbladder (1 patient). Two patients (1%) died as a direct result of the procedure secondary to hemorrhage (1 patient) and sepsis (1 patient). Preoperative biliary decompression, although technically (95%) and physiologically (82%) successful in the majority of patients, had no therapeutic benefit when compared (nonrandomized) with those patients without alleviation of jaundice prior to surgical intervention.

Traumatic splenic injury: its management in a patient population with a high incidence of associated injury.

Nonoperative management of splenic trauma is receiving increasing support following delineation of the spleen's role in infection. Controversy regarding the proper management of this injury led us to study retrospectively 236 consecutive patients with splenic trauma. Blunt trauma occurred in the majority (161); the remainder suffered penetrating abdominal injury secondary to gunshot or stab wounds. Diagnostic peritoneal lavage was accurate in establishing splenic injury in blunt trauma (no false-positive, but three false-negative findings). Associated intra-abdominal injury occurred in 48% and 92% of patients with blunt and penetrating trauma, respectively. Diagnostic peritoneal lavage is an accurate method for establishing an intra-abdominal injury and the need for abdominal exploration in patients with blunt abdominal trauma. Because of the high rate of associated intra-abdominal injury in splenic trauma, nonoperative management can be expected to result in a disturbing incidence of missed intra-abdominal injury in patients with abnormal peritoneal lavage findings.