Management of pseudomembranous colitis.

Controversy exists as to the appropriate management of fulminant C. difficile-associated pseudomembranous colitis (PMC). We reviewed our most recent 5-year experience with 191 patients with PMC. Nine patients had an initial presentation of a surgical abdomen with clinical signs of peritonitis, elevated white blood cell count, and eight had received antibiotics prior to presentation. Two patients were placed on no cardiopulmonary resuscitation status at admission to the surgical intensive care unit; both died within 24 hours. The remaining seven patients had exploratory laparotomies. The four who had total abdominal colectomies with ileostomies recovered promptly. Two of the other three had no resection because there was edema of the colon, but no other gross pathological changes. The third had only a segmental colon resection. All three deteriorated postoperatively, and two were dead within 48 hours. The remaining patient was returned to the operating room 48 hours after the first procedure, and an abdominal colectomy and ileostomy was performed. She never recovered, however, and died 12 days later. We conclude that although most patients with PMC can be treated effectively medically, total abdominal colectomy with ileostomy is indicated when signs of peritonitis occur, even if the only finding at laparotomy is edema of the colon.

Nonoperative management of the adult ruptured spleen.

The risk of postsplenectomy sepsis has led to increased enthusiasm for preservation of the spleen. From January 1984 to December 1988, 51 consecutive adult patients with ruptured spleen sustained from blunt trauma were examined. Thirty-four patients (67%) had their conditions hemodynamically stabilized at the time of hospital admission and were placed on a regimen of strict bed rest with intensive monitoring. The average hemoglobin value at hospital admission in this group was 126 +/- 18 g/L, with an average drop of 17 +/- 14 g/L during their hospitalization; 14 patients required transfusions averaging 3 U each. Nonoperative treatment was successful in 33 (97%) of 34 patients; one patient whose condition deteriorated clinically underwent splenectomy on the fifth hospital day. These patients have been followed up for an average of 28 months with no sequelae from their splenic injury. We conclude that a nonoperative approach is a viable alternative in stable adult patients with splenic injuries due to blunt trauma when intensive monitoring is available.

A reappraisal of surgical management in necrotizing perineal infections.

The proper treatment of necrotizing perineal infections (Fournier's gangrene) remains unclear in the surgical literature. This study reports a technique that emphasizes anatomic considerations in the diagnosis and treatment of these infections together with mandatory use of colostomy in selected cases. Eight cases treated at William Beaumont Hospital from 1977 to 1985 were reviewed. There were five men and three women. All had predisposing local pathology. Recognizing the site of local pathology is the key factor in making correct surgical judgments in these cases. The perineum may be divided into the urogenital triangle and anal triangle by a line passing between the ischial tuberosities. Cases originating in the urogenital triangle were treated with antibiotics and wide surgical debridement. Two cases were successfully managed in this fashion. Cases originating in the anal triangle were treated with mandatory colostomy and mucus fistula with irrigation of the rectal segment together with antibiotics and wide debridement. Six cases were found to have originated in the anal triangle. Four were successfully treated. This anatomic approach and proper use of colostomy represents the correct treatment of these infections.

Cefamandole-erythromycin-heparin peritoneal irrigation: an adjunct to the surgical treatment of diffuse bacterial peritonitis.

The enthusiasm for the use of peritoneal irrigation has waxed and waned since its introduction by Dr. Pierce in 1905. The purpose of this study was to devise a relatively low-cost irrigant that could be used for continuous intraperitoneal lavage, with the intent of decreasing abscess formation following surgical treatment for generalized bacterial peritonitis. A solution of 1 L of normal saline containing 50 mg erythromycin, 50 mg cefamandole, 500 U heparin, and 5 mEq KCl was proven in in vitro studies to be bactericidal to Peptococcus anaerobius and Clostridium perfringens, and bacteriostatic to Klebsiella pneumoniae, Escherichia coli, Enterobacter aerogenes, Streptococcus faecalis, and Bacteroides fragilis. In a prospective study 50 patients underwent peritoneal lavage with 36 L over 2 days. No lavage patients developed intraabdominal abscesses. In a control group of 44 patients seven patients (15.9%) developed postoperative abscesses.

Inframesocolic transduodenal approach to the distal biliary-pancreatic ductal system.

The usefulness of the inframesocolic transduodenal approach to the distal biliary system in patients in whom numerous previous procedures had been performed was evaluated. First, the feasibility of the technique was ascertained by anatomic study. Ten anatomic dissections were performed during routine postmortem examinations. This proved that the duodenum, ampulla of Vater, distal common duct, and head of the pancreas could be adequately exposed via the inframesocolic approach and that it was reasonable to use the procedure clinically. This approach has been used successfully in five cases. It was found that (1) the inframesocolic approach to the duodenum and distal biliary system is useful, particularly in those patients requiring second operations in the right upper quadrant; and (2) the approach allows ready access to the area through virgin territory and has distinct advantages in exposure, operative time, and information available.