Abdominoperineal resection in the treatment of devascularizing rectal injuries.

Local debridement, drainage, and diverting colostomy, with or without primary repair of the rectum, have been considered to be the standard treatment for most rectal injuries, but they are not sufficient for those patients sustaining uncontrollable bleeding or extensive rectal devascularization. This report assessed the indications and results of abdominoperineal resection of the rectum in these patients. Ten patients who were victims of explosive trauma presented with massive perineal injuries and extensive rectal devascularization. Six of these were treated with local debridement of necrotic tissue, pararectal drainage, antibiotics, and colostomy. Five of the six patients initially treated by colostomy died after operation from hemorrhage or sepsis. The sixth patients, who survived, had an abdominal resection of the rectum performed 5 days after the colostomy for removal of a gangrenous rectum. All five of those who underwent abdominoperineal resection survived (p less than 0.01). Increasing violence in the life patterns of modern society enhances the possibility of occurrence of this type of lesion, previously limited to military practice. The need for careful investigation of rectal viability is emphasized. Primary abdominoperineal resection of the rectum is advised when extensive devascularization has occurred.

Reversed ileal segment for treatment of ileostomy dysfunction. Clinical application.

Persistent, profuse ileostomy diarrhea developed gradually in a patient over a 12-hour period after proctocolectomy for ulcerative colitis. There was no evidence of ileostomy stenosis or dilation of the ileum proximal to the stoma. He was successfully treated with a reverse ileal segment of 10 cm, and gained 14 to 18 kg. ileostomy output became semisolid and decreased from 1,000 to 2,000 ml/day to 600 ml/day. The transit time changed from 12 minutes to 2 1/2 hours. Antiperistaltic segments of intestine prolong transit time and allow for greater absorption. While most patients with ileostomies are not troubled by severe diarrhea, the small proportion who are may be candidates for a reversed ileal segment.

Inferior vena cava interruption: a new indication?

Propagating illofemoral venous thrombosis that occurs despite adequate anticoagulation can be detected by the serial fibrinogen uptake test. Twenty-three patients who were receiving heparin sodium for confirmed iliofemoral thrombophlebitis underwent the serial fibrinogen uptake test. There was an increasing percentage of isotope uptake at the groin and the upper part of the thigh in eight of these patients, three of whom subsequently developed clinical signs, perfusion, and ventiliation lung scan findings compatible with the occurrence of pulmonary embolism. The remaining 15 patients had decreasing serial fibrinogen uptake during heparin therapy and no sequelas indicative of pulmonary embolism. Progressive thrombosis in adequately heparinized patients indicates failure of anticoagulation therapy and, when this occurs, we believe that interior vena cava interruption should be considered before a first, but potentially lethal, pulmonary embolus develops.

Radioisotope detection of venous thrombosis. Venous scan vs fibrinogen uptake test.

Experience with the fibrinogen uptake test and the technetium Tc 99m albumin aggregated venous scan in 89 patients showed the latter to be adequate for simultaneous screening for plumonary embolism and venous thrombosis of the lower extremities and pelvis. Because the fibrinogen uptake test differentiated active from inactive venous thrombosis, it is indicated when anticoagulation is considered for patients with a history of thrombophlebitis and equivocal clinical findings of acute activity. It can also be used to monitor high-risk patients and to detect proximal propagation of thrombi. The results of the technetium venous scan were abnormal in 97% of patients with venous thrombosis and the fibrinogen uptake test detected 100% of patients with acute activity. Both tests react to different aspects of the thrombotic disease, thus complementing each other. Because of their reliability, indications for phlebography are now less frequent.

Experimental evaluation of primary repair of colonic injuries.

To evaluate the management of colonic injuries, experimental models simulating acute injuries of the colon were studied utilizing New Zealand white rabbits. Seventy-nine rabbits underwent primary repair of colonic injuries in the presence of massive contamination and none showed any evidence of anastomotic leakage or breakdown. The fact that primary colonic repairs do heal even in the presence of infection suggests that breakdown of colonic anastomosis results from factors other than infection. Despite the absence of anastomotic leaks in this series, morbidity and mortality were high in those animals not given antibiotics. The high morbidity and mortality were due to peritonitis, intra-abdominal abscess, and wound infection, and were directly proportional to the length of time from colonic injury to repair. On the basis of this study, it is concluded that most isolated injuries of the colon can be closed primarily, if antibiotic therapy is begun immediately after injury and continued throughout the operative and postoperative periods.

Antiperistaltic ileal segment in the prevention of ileostomy diarrhea.

Diarrhea, often profuse, accompanied by skin excoriation and nutritional and electrolyte depletion is a major complication of ileostomy. In an attempt to improve the course of these patients, an experimental study using dogs was undertaken to investigate an antiperistaltic ileal segment for the prevention of ileostomy diarrhea. Ileostomies were created in dogs. All the dogs with ileostomies died within nine days of weight loss and massive electrolyte and water depletion. A second group of animals underwent creation of an ileostomy simultaneously, with an antiperistaltic ileal segment placed 30.5 cm proximal to the ileostomy. These dogs maintained their weight and electrolyte and water balance. The stools in the group with the reversed ileal segment became semisolid to solid, compared to the watery diarrhea of dogs with ileostomies only.

Meckel's diverticulum: should it be excised incidentally at operation?

Meckel's diverticulum is the most common congenital abnormality of the small intestine, occurring in about 2 per cent of the population. Complications of a Meckel's diverticulum, including hemorrhage, inflammation, bowel obstruction, and neoplasms, occur in 15 to 33 per cent of cases and invariably demand operative treatment. When signs or symptoms arise from a Meckel's diverticulum, morbidity and mortality are high. Incidental Meckel's diverticulectomy should be performed at any age when the morbidity and mortality of the primary procedure will not be increased substantially.

Intestinal necrosis and perforation in patients receiving immunosuppressive drugs.

Immunosuppressive agents are frequently used in transplant recipients for prevention of homograft rejection and in patients with leukemia for treatment of their primary disease. From 1973 to 1975, fifty-nine patients undergoing renal transplantation and forty-one patients with leukemia were treated at the University of California (Davis) Medical Center. Intestinal necrosis and perforation developed in four (7 per cent) of those receiving transplants and in four (10 per cent) of the patients with leukemia. One transplant receipient and all four patients with leukemia had extensive necrosis of both the small and large intestines. Two transplant recipients had isolated sigmoid perforations, and one had splenic flexure colonic perforation. All died from septicemia with septic shock. The etiology of these intestinal complication appears related to immunosuppressive agents, particularly high dosages of steroids. Despite the grave prognosis, early surgical intervention is the only method of dealing with these complications. Early diagnosis as well as properly timed and selected operations are necessary for the successful management of these patients.

Clinical evaluation of 99mTc-pyridoxylideneglutamate for hepatobiliary scanning.

Clinical evaluation of hepatobiliary scanning using 99mTc-PG was done in twenty normal volunteers and eighty-three patients with liver and biliary tract disease. Satisfactory images of the biliary tract were obtained using small dosages of this agent. In normal humans, the agent reached the liver in 5 minutes, and the common bile duct, gallbladder, and duodenum in 10 to 20 minutes. The gallbladder was not visualized when the cystic duct was obstructed in patients with acute and chronic cholecystitis. In patients with partial common bile duct obstruction, a distended duct was visualized and there was delay in transit of radioactivity into the duodenum. With complete common bile duct obstruction, no radioactivity was seen in the biliary or gastrointestinal tracts up to 24 hours after injection. Hepatocellular disease was characterized by delayed liver clearance and delayed visualization of the biliary and gastrointestinal tracts. There were no toxic or other untoward effects in any patients.

Hepatobiliary scanning using 99mTc-pyridoxylideneglutamate.

Technetium 99m-pyridoxylideneglutamate (99mTc-PG) administered intravenously is excreted by hepatocytes into the bile canaliculi and enters the gallbladder through the cystic duct and consequently, can be used for scanning the hepatobiliary ductal system. A total of 166 patients representing 27 normal subjects, 84 patients referred for investigation for pain in the upper right quadrant of the abdomen and 55 jaundiced patients were evaluated with 99mTc-PG. In normal human volunteers, the agent reached the liver in five minutes, and the common bile duct, gallbladder, and duodenum within 15 minutes. Satisfactory images of the hepatobiliary tract were obtained using small dosages of 99mTc-PG. The gallbladder was not visualized when the cystic duct was occluded. In the presence of acute cholecystitis, cystic duct obstruction, or in chronic cholecystitis where other roentgenographic studies showd a nonfunctioning gallbladder, there was no concentration of 99mTc-PG in the gallbladder. In partial common bile duct obstruction is distended common bile duct was visualized along with delay in transit of radioactivity into the duodenum. Complete common bile duct obstruction was associatedwith no radioactivity in either the biliary or the gastrointestinal tracts up to 24 hours after injection. Hepatocellular disease was characterized by delayed liver clearance and delayed visualization of biliary and gastrointestinal tracts. 99mTc-PG scanning proved capable of differentiating between hepatocellular disease and extrahepatic biliary tract obstruction.

Pancreatic pseudocyst: management in fifty-four patients.

The management of pancreatic pseudocyst was reassessed in fifty-four patients: only sixteen (30 per cent) regressed with nonoperative management; six (11 per cent) died of septic complications; and thirty-two (64 per cent) eventually required operation. Most pseudocysts did not regress with nonoperative therapy, thus emphasizing the need of serial clinical and ultrasonic examination at frequent intervals to detect nonresolution or complications requiring earlier operation than previously advocated.

Detection of anticoagulation therapy failures in patients with venous thrombosis.

Results of ultrasonic monitoring of venous patency and fibrinogen uptake testing were evaluated in ten patients with venous thrombosis receiving heparin therapy. Two propagating venous thromboses were detected 24 to 48 hours before massive pulmonary embolism developed, thus emphasizing the usefulness of these methods for detection of anticoagulation therapy failures.

Penetrating torso injuries: the role of paracentesis and lavage.

Controversy still exists regarding the proper approach to patients with penetrating torso injuries. Mandatory immediate celiotomy and selective observation both have associated risks. Paracentesis with lavage is a rapid, easily performed and readily available technique which can, with a high degree of accuracy, differentiate on initial evaluation those patients with penetrating visceral injuries from those without such injuries. Complications are minimal. The use of these two procedures in evaluating penetrating torso injuries has led to improved patient care and produced major lowering of medical and socioeconomic costs.

Effects of antibiotics on prevention of infection in contaminated abdominal operations.

A prospective study was undertaken on 102 patients with massice intraperitoneal contamination from traumatic or spontaneous perforation of intestinal or pancreaticobiliary tract to determine the effects of combined systemic and intraperitoneal antibiotic administration on the prevention of the postoperative sepsis, intra-abdominal abscess formation and wound infection. Large doses of gentamicin and clindamycin were given parenterally before, during, and after the operation for five days. In addition, the peritoneal cavity and the abdominal incision were irrigated intraoperatively with antibiotic solution containing the same antibiotics. The drugs were given so as to provide a potent level of antibiotics during the operation and in the immediate postoperative period. The postoperative wound infection rate was 4 per cent, intra-abdominal abscess 2.9 per cent, sepsis 1 per cent, resulting in a total infectious complication rate of 7.9 per cent. This is a marked reduction in the incidence of infectious complications and compares favorably with the results from either parenteral or intraperitoneal therapy alone. Furthermore, no complications were encountered due to this method of therapy. These results do not indicate that antimicrobial drugs be given prophylactically to all surgical patients, but they strongly suggest the advantages of combined systemic and intraperitoneal antibiotics in the management of patients with massive intraperitoneal contamination.

Arterial scan versus radiographic angiography in detection of shallow arterial ulcers.

A comparison of 99m-technetium albumin aggregated arterial scan and radiographic angiography for detection of shallow intimal carotid artery ulcerations was made in a series of 12 anesthetized dogs, having a total of 16 acute arterial ulcerations. Radiographic angiography showed positive findings related to presence of stenosis or mural thrombosis in 12 instances. Direct visualization of ulceration was only exceptionally encountered. Arterial scan detected 14 of 16 intimal ulcers. The radionuclide method was reliable even in absence of stenosis or when only minimal mural thrombosis was present. Moreover, autopsy scan of the isolated arterial segments detected all 16 intimal lesions. These results indicate that the arterial scan was a more reliable method for detection of shallow arterial ulcers in this experimental model than radiographic angiography, especially when arterial lumen stenosis or mural thrombosis were minimal or absent.

Traumatic duodenal injuries: an analysis of 32 cases.

Thirty-two patients were treated for duodenal and associated injuries during the past five years. Fifty-nine per cent resulted from penetrating trauma, while 41 per cent were secondary to blunt injury. The incidence of blunt trauma represents a fourfold increase from previously published series. The morbidity rate still remains high at 47 per cent, with fistulas and infections being the most common complications. The mortality rate was 9.3 per cent, with death resulting from major intra-abdominal vascular injuries. Awareness of the potential injury to the duodenum, aggressive resuscitative measures, early operative management and improved postoperative care can lead to further reduction of these figures.