Simultaneous placement of long-term central venous catheters and surgical debridement for treatment of osteomyelitis.

Nonhealing wounds with underlying osteomyelitis require surgical debridement and a course of intravenous antibiotics usually via long-term venous catheter. Fear of catheter infection resulting from bacteremia or direct cross-contamination has traditionally led to staged procedures. A protocol for simultaneous placement of a long-term central venous catheter (Hickman) for antibiotic therapy and surgical debridement of chronic wounds with osteomyelitis does not result in elevated catheter-related infections. We conducted a prospective consecutive trial at a community-based tertiary-care training hospital. From October 1995 through June 1997 100 consecutive patients received 105 central venous catheters and surgical debridement for treatment of chronic wounds with underlying osteomyelitis at the same operative setting. Four catheters required removal because of infectious complications. There was no correlation between the bacteria cultured from the central venous line or blood cultures and the wound cultures. Combining placement of long-term central venous catheters and surgical debridement of chronic wounds with osteomyelitis at one operative setting results in an acceptably low catheter infection rate.

Multiple penetrating injuries to the heart diagnosed with ultrasonography.

Penetrating heart injury poses significant diagnostic and therapeutic challenges. Patients may initially appear in extremis or in stable condition. Surgeon-performed ultrasonography is effective in determining the presence or absence of tamponade. Definitive repair requires cardiorrhaphy, using a median sternotomy or thoracotomy incision, depending on the suspected injury site(s). Frequent postoperative complications can usually be managed without reoperation. Echocardiography, electrocardiography, and cardiac catheterization may be used postoperatively in reassessment. A patient with stab wounds to both ventricles of the heart is described.

Open scapulothoracic dissociation.

Scapulothoracic dissociation refers to the traumatic separation of the shoulder from the chest wall. This most commonly occurs as a closed injury. We present a case of open scapulothoracic dissociation and emphasize clinical features unique to this injury. In both closed and open scapulothoracic dissociation, the force necessary to shear the scapula from its thoracic attachments results in vascular disruption and neurologic injury to the upper extremity. As a consequence, patients have a pulseless, flail upper extremity with a significant chest wall hematoma (closed) or active bleeding (open). The first priority is to resuscitate and address life-threatening injuries. If the patient has active bleeding, immediate vascular control to prevent exsanguination is essential. Patients with ischemia and an incomplete injury or unreliable neurologic examination need revascularization. Outcome is based on the extent of brachial plexus or cervical nerve root avulsion. Patients with loss of neurologic function ultimately benefit from amputation at the appropriate level.

Combined blunt thoracic aortic and abdominal trauma: diagnostic and treatment priorities.

Combined blunt trauma to the thoracic aorta and abdomen challenges the surgeon from a diagnostic and therapeutic standpoint. Appropriately prioritizing diagnostic workup and treatment is critical to assuring patient survival. A management approach that considers the patient's injuries and clinical condition as well as the availability of aortography and cardiac surgery are essential. Patients with blunt aortic injury who are hemodynamically unstable with signs of intra-abdominal injury should have immediate abdominal exploration. Further assessment of the aortic injury and surgical repair can be delayed until after the critical intra-abdominal bleeding has been addressed. The stable patient who has both blunt abdominal trauma and blunt thoracic aortic injury but has no signs of ongoing abdominal hemorrhage should initially have arch aortography. Additional abdominal diagnostic studies may be done but should not delay indicated surgical repair of the aortic injury.

Acute pancreatitis: management of complicating infection.

Acute pancreatitis develops precipitously, changing the patient's condition from apparent good health to a critically ill status. Of patients who succumb, 80 per cent die from secondary infection in the pancreas-peripancreatic area. Infection supervenes in the second week or later after onset. Prophylactic antibiotic(s) appear to be helpful in avoiding, delaying, and/or lessening secondary sepsis. Once infection develops, treatment requires open debridement of necrotic material, drainage, and appropriate antibiotic therapy; or mortality will approach 100 per cent. Infecting organisms are commonly Escherichia coli, Klebsiella, Staphylococcus, Enterococcus, Bacteroides, and/or fungi. Antibiotics felt to be preferable for prophylactic therapy include 1) imipenem-cilastatin, 2) a quinolone + metronidazole, and 3) possibly an extended-spectrum penicillin. Treatment should be continued for 2 weeks or until recovery. Because fungus infections are occurring more often, prophylaxis with fluconazole may be warranted.

Enterovaginal fistula as a complication of intraoperative small bowel endoscopy.

Intraoperative endoscopy has been accepted as a method of small bowel evaluation for occult gastrointestinal bleeding. Although methodology of the procedure has been evolving, reported complications have been few, consisting of prolonged ileus, adhesions, submucosal hemorrhage, and serosal injuries. This case report describes an enterovaginal fistula as a complication of intraoperative small bowel endoscopy performed during a total colectomy procedure in a patient with chronic gastrointestinal bleeding, possibly caused by ischemia resulting from pleating of small bowel over the endoscope. This complication may be prevented by use of longer commercially available enteroscopes or by use of an enterotomy to insert the endoscope.

Villous tumors of the ampulla Vater.

Patients with villous tumors of the ampulla Vater usually present with jaundice, intermittent or constant, but may seek care for abdominal pain, intestinal hemorrhage, or pancreatitis. Because villous tumors may harbor carcinoma in 30 to 50 per cent of cases, appropriate management may require radical resection. We have managed four patients with villous lesions of the ampulla Vater occurring in 1981, 1992, 1993, and 1995. Three were villous (two with malignant change) and one was a villoglandular adenoma. Treatment consisted of local excision with reimplantation of the ducts in one patient, Whipple resection in two patients, and biliopancreatic bypass in one who had distant nodal metastases not resectable for cure. This patient died 18 months after operation of an unrelated disease, but the others were well at last follow-up. The presentation as well as the diagnostic and therapeutic considerations in the management of villous tumors of the ampulla Vater are discussed.

Preoperative needle-localized parathyroidectomy for persistent secondary hyperparathyroidism.

Several preoperative localization techniques have been developed to assist the surgeon, with varying degrees of accuracy, in identifying the offending gland during reoperative parathyroid surgery. This is a case report of persistent secondary hyperparathyroidism that was treated with preoperative, computed tomography-guided needle localization followed by surgery. The patient underwent successful resection of a hyperplastic fifth parathyroid gland, and her calcium level decreased appropriately postoperatively. This case demonstrates a perioperative localization scheme that reduces operative time, reduces the risk of injury to surrounding structures, and helps to assure cure.

Clostridium perfringens sepsis with intravascular hemolysis following laparoscopic cholecystectomy: a newly reported complication.

Clostridium perfringens sepsis with hemolysis following cholecystectomy is a rare complication that has a very high mortality. The best chance for survival is ensured by early diagnosis, prompt initiation of antibiotics, and hyperbaric oxygen therapy if readily available. To our knowledge, this is the first reported case following laparoscopic cholecystectomy.

Spilled gallstones--complications of abdominal-wall abscesses. Case report and review of the literature.

Laparoscopic cholecystectomy has become the preferred method for removal of the diseased gallbladder. While its morbidity and mortality rates are lower than those of the open technique, it does have associated complications which may cause significant morbidity. The morbidity associated with spilled gallstones is not well studied and little can be found in the literature on this subject. We encountered a patient who developed abscesses within the abdominal wall following laparoscopic cholecystectomy. We recommend that spilled gallstones be removed when possible and that surgeons be aware of this possible complication.

Systemic calciphylaxis.

Systemic calciphylaxis is a rare, poorly understood syndrome of progressive ischemic necrosis, usually associated with hyperparathyroidism. The combination of hyperparathyroidism, usually secondary or tertiary, and chronic renal failure seems to produce a particular biochemical environment conducive to the development of an unusual progressive form of ischemia. Early recognition and diagnosis, appropriate therapy including wound care, and expeditious parathyroidectomy often will halt the progression of the disease, minimize limb loss, and prevent subsequent sepsis and death.

Control of hemorrhage from a trocar site.

Bleeding from a trocar site may occur while performing laparoscopic procedures. A technique of controlling hemorrhage from a trocar site is described.

M13 bacteriophage displaying disulfide-constrained microproteins.

A display-phage library (TN2), displaying an 18-residue peptide fused to coat protein III, represents a collection of up to 8.55 x 10(6) peptides encoded by only 1.68 x 10(7) DNA sequences. Each displayed peptide has two fixed cysteine residues (allowing disulfide formation) and six variegated residues, four between the cysteines and one either side of the cysteines. Screening this library against streptavidin (Sv) and the anti-beta-endorphin monoclonal antibody, 3-E7, yielded phage displaying disulfide-constrained microproteins with sequences similar to those published for the linear-peptide display phage. Analysis of selected clones indicated that a disulfide bond is required for high-affinity binding to each of the target proteins. The microproteins selected for binding to Sv and 3-E7 show more stringent sequence specificity than do linear peptides selected for binding to the same targets.

Thoracoscopic ligation of the thoracic duct.

Traditional operative management for chylous drainage refractory to conservative therapy is thoracic duct ligation via right open thoracotomy. This case report details successful thoracoscopic ligation of the thoracic duct for a chylous leak following a left neck dissection. Since the thoracoscopic approach is less morbid than open thoracotomy, early operative management is recommended for thoracic duct injuries.

Laparoscopic cholecystectomy technique for removal of the gallbladder from the peritoneal cavity.

A new laparoscopic cholecystectomy technique for removing the gallbladder from the peritoneal cavity through the umbilical incision is presented. This method is faster than the traditional technique and eliminates the necessity of transferring the camera from the umbilical port to a second port.

Laparoscopic retrieval of spilled stones.

Spillage of gallstones during laparoscopic cholecystectomy is occasionally a problem. The use of a finger cut off of a size 9 sterile glove as an intraperitoneal sack facilitates the removal of these stones.

One-day hospitalization following modified radical mastectomy.

Postoperative management of patients following modified radical mastectomy has changed dramatically in recent years. Historically, patients usually remained in the hospital with closed suction drainage until the amount of drainage had decreased sufficiently for them to be removed. The feasibility of early discharge on the day following surgery was studied in a prospective manner in 29 consecutive breast cancer patients; 27 underwent unilateral modified radical mastectomy and 2 bilateral mastectomies by a single surgeon. All patients were instructed before surgery about planned early discharge and drain care. Twenty-seven of 29 patients (93.3%) were discharged the day following surgery. However, 2 patients refused discharge and were discharged on postoperative Day Two, and one patient was readmitted for confusion. Drains were removed in the office an average of 5.07 days after surgery. Forty-five per cent of patients developed a seroma that required aspiration at least once. No significant long-term sequela were experienced as a result of early discharge. The average hospital cost was reduced by $2,474.00 or 36 per cent (P less than 0.001) as compared to other surgeons in the same medical center who held to traditional postoperative care. The authors conclude that discharge on the day following surgery for patients undergoing a modified radical mastectomy is safe and cost effective.

Directed evolution of a protein: selection of potent neutrophil elastase inhibitors displayed on M13 fusion phage.

Inhibitors of human neutrophil elastase were engineered by designing and producing a library of phage-displayed protease inhibitory domains derived from wild-type bovine pancreatic trypsin inhibitor and fractionating the library for binding to the target protease. The affinity of one of the engineered variants for human neutrophil elastase (Kd = 1.0 pM) is 3.6 x 10(6)-fold higher than that of the parental protein and exceeds the highest affinity reported for any reversible human neutrophil elastase inhibitor by 50-fold. Thus the display phage method has allowed us to obtain protein derivatives that exhibit greatly increased affinity for a predetermined target. The technology can be applied to design high-affinity proteins for a wide variety of target molecules.