Simulated surgical wound infection in mice: effect of stimulation on nonspecific host defense mechanisms

Experiments were conducted to ascertain whether nonspecific host defenses could be enhanced in a reliable animal model simulating the local bacterial infection that frequently complicates surgical wounds. The test lesion was studied in detail and exemplifies the concept that the ultimate expression of the host-pathogen interaction is the capacity of that pathogen to persist or grow in a given host. Mice were challenged by intramuscular insertion of cotton suture impregnated with 10(7) to 10(8) Escherichia coli K-12. The mice were subsequently killed at intervals, and the suture and muscle mass were retrieved, homogenized, and quantitatively cultured. Numbers of viable organisms in tissue from control animals were compared with those from experimental animals that received BCG (Bacillus Calmette-Guérin) vaccine, a nonspecific immunostimulant, prior to bacterial challenge. Improved tissue antibacterial activity appeared in animals that had received BCG vaccine 13 days prior to bacterial challenge. Differing doses and intervals were not protective. Enhancement of nonspecific host defense mechanisms may be helpful in combination with current measures for improved control of surgical wound infection.

Arterial injuries in children

Twenty-nine children sustained major arterial injuries secondary to gunshot wounds (nine), blunt injuries (11), penetrating injuries by sharp objects (five), and arteriographic injury (four). The femoral artery was most commonly injured, followed by the brachial, the carotid, subclavian, popliteal, aorta, innominate, and vertebral arteries. We repaired the majority of the arterial injuries by resecting the damaged vessel, with primary anastomosis or interposition grafting when necessary to avoid tension. Postoperative complications included clotted grafts in two patients, which were rendered patent by reoperation. Two children died postoperatively, although both had successful vascular repairs. All vascular repairs were patent at one year, and limb length disparity has occurred in one patient following a nerve injury. Our data indicate that early exploration and repair of all suspected vascular injuries can be accomplished with excellent results, even in young children.

The injured colon: relationships of management to complications

One hundred thirty-seven patients who sustained intraperitoneal colon wounds were admitted to the University of Louisville Hospital during the three-year period ending December 31, 1979. One hundred twenty penetrating wounds and 17 blunt injuries were treated. An intraoperative classification system was employed, in which Grade 1 injuries were characterized by minimal contamination, the absence of associated organ injuries, minimal shock, and no significant delay between injury and definitive operation. All of these were managed by single-layer closure. More severe wounds were treated by colostomy or exteriorization. The overwhelming majority of the patients (116) sustained Grade 2 injuries. Twenty-two patients (16%) died. Nine deaths (6% of the patients) were directly attributable to the colon wounds. Twenty-five Grade 1 injuries were treated by primary suture closure with a single complication (3% of the patients). Nine wounds were exteriorized for later reinsertion into the peritoneal cavity, but only two patients were spared colostomy by this method. Right colon injuries were, clearly, more severe than left or sigmoid colon wounds. Intraoperative classification allowed selection of a group of patients in whom suture repair was safe. Colostomy was associated with the lowest complication rate for Grade 2 and 3 wounds.

Colonoscopic diagnosis of angiodysplasias of the gastrointestinal tract

We have reviewed our experience with colonoscopy in the diagnosis of angiodysplastic lesions of the colon. In 14 of the patients in our series, the lesions in the colon were diagnosed colonoscopically, confirming arteriographic findings in many but being the only diagnostic modality facilitating the diagnosis in three of the patients. Results of our experience indicate that colonoscopy is an effective means of diagnosing or confirming the diagnosis of angiodysplastic lesions of the right colon. It should be part of the evaluation along with superior and inferior mesenteric angiography of every patient with occult gastrointestinal tract bleeding or iron deficiency anemia, or both, for whom no diagnosis can be made with standard barium contrast techniques.

Traumatic injury of the proximal superior mesenteric artery

Injuries of the proximal superior mesenteric artery (SMA) are relatively uncommon, but extremely perplexing lesions. Fifteen consecutive patients with this injury, 13 injuries from gunshot wounds and two injuries from blunt trauma, have been treated. Associated lesions and massive blood loss were common, averaging 3.6 injuries and 4800 ml per patient, respectively. Methods of SMA repair include lateral arteriorrhaphy (11 patients), primary reanastomosis (3 patients), and saphenous vein grafts (1 patient). Two of three patients whose injuries included segmental loss of the SMA that required a primary end-to-end anastomosis suffered subsequent thrombosis. Second-look operations were performed in five patients with two of these requiring a further reconstructive procedure. The only late death occurred in a patient with a severe head injury and a failure of his SMA repair, which potentially could have been prevented by a second-look procedure. There were five deaths (33%), with four occurring from acute hemorrhages and one late death occurring following intestinal necrosis and sepsis. Malabsorption or other late intestinal complications did not occur. Our experience 1) supports the concept that proximal SMA lesions must be repaired, 2) suggests that primary anastomosis to repair arterial defects is associated with a high failure rate, and 3) demonstrates that the second-look operation is a useful adjunct in improving survival in these patients.

Duodenal injury. Analysis of common misconceptions in diagnosis and treatment

Seventy-five consecutive patients who sustained injuries to the duodenum were admitted to our hospital over a nine-year period. Nineteen blunt injuries and 56 penetrating injuries were encountered. Blunt injuries were usually the result of motor vehicle accidents and steering wheel impact was frequently implicated. Penetrating injuries most commonly followed gunshot wounds, particularly those where the bullet tract travelled transversely across the peritoneal cavity. Seventy-nine per cent of the patients had two or more associated intra-abdominal organ injuries with other intestinal injuries, biliary tract injuries, and pancreatic injuries predominating. Forty-seven per cent of the patients were admitted in shock. Following blunt injury, diagnostic delay was encountered in two patients. Adjuncts to diagnosis such as abdominal roentgenograms, serum amylase levels, and contrast gastroduodenography, were not helpful. Peritoneal lavage, however, was valuable in patients with equivocal physical findings. Intraoperative diagnosis was also challenging. Complete mobilization of the structures surrounding the duodenum to provide exposure of the entire duodenum was necessary. Six injuries that initially appeared trivial would have been missed had this procedure not been followed. Suture closure was the most common reparative technique used. Tube decompression of the duodenum was a valuable addition. No suture line dehiscences were encountered in ten patients so treated. Overall mortality in patients surviving more than 24 hours was 12%.

Intimal disruption of major cerebral vasculature following blunt trauma

A child with blunt traumatic intimal disruption involving the major vessels responsible for cerebral circulation was treated by operation. The injured vessels included both common carotid arteries, both vertebral arteries, and the left subclavian artery. The carotid injuries were treated by saphenous vein interposition grafts, whereas the left subclavian and vertebral arteries were ligated. The patient sustained no neurological deficit and is now completely well 2 years after treatment. The case reported herein is unique in that total intimal disruption of the four major vessels responsible for cerebral flow was treated by operation, resulting in complete recovery. The successful outcome underscores the importance of complete angiographic evaluation and adequate operative exposure in such cases.

Posttraumatic acalculous cholecystitis

Acalculous cholecystitis occurred in six patients after trauma and burns. The majority developed signs and symptoms similar to acute calculous cholecystitis. All were treated by cholecystectomy after traditional conservative treatment failed. All had either gangrenous changes or focal necrosis of the gallbladder. Postoperative recovery was uniform. Acalculous cholecystitis occurs in 0.5% of large series of injured or burned patients. Delayed recognition led to a high mortality, reported as 24% overall with 10% related to gallbladder disease. Although cholecystostomy has been advocated, it appears that cholecystectomy, when feasible, affords the best overall results.

Effects of cooling and intraluminally administered antiseptics on surgically induced ischemia of the intestine in dogs

The efficacy of surface cooling and intraluminal antiseptic solutions for short term preservation of intestinal segments in preparation for free tissue transfer were investigated. Five segments of the small intestine and five segments of the colon were allocated to each group as follows: group 1, ischemia at 37 degrees C.; group 2, ischemia at 6 to 12 degrees C., and group 3, ischemia at 6 to 12 degrees C. plus povidone-iodine intraluminally. Histologic grading of segments allowed assessment of the efficacy of short term protection against ischemic changes. Surface cooling effectively prevented histologic evidence of ischemia. No additional benefit was observed using povidone-iodine intraluminally. Significant changes in tissue water content and evidence of bacterial invasion were not observed.

Definitive control of bleeding from severe pelvic fractures

Forty patients with severe pelvic fracture and extraperitoneal hemorrhage were reviewed. Eighteen patients seen prior to 1975 (group I) were clinically similar to 22 patients seen subsequently (group II). Major pelvic fracture hemorrhage was defined as bleeding in excess of 2,000 ml over and above initial resuscitation volumes. Ten of 22 group II patients met the criteria for continued extraperitioneal bleeding and were immobilized in an inflatable G-suit after surgically remediable lesions had been excluded. Ventilator support and hemodynamic monitoring were instituted and clinical response recorded. Prompt cessation of bleeding was observed in nine of ten patients. One patient required selective catheterization of a bleeding artery with subsequent embolic occlusion. Significant reductions in overall mortality and the frequency of shock related death were observed in group II patients. Sepsis was the leading cause of late death in survivors. Immobilization of pelvic fracture patients in the G-suit is recommended as a means of controlling continuing retroperitoneal hemorrhage when surgically correctable bleeding points have been dealt with. Failure of patients to respond promptly to the G-suit strongly suggests arterial bleeding amenable to selective catheterization and embolic occlusion.

Hepatic cellular hypoxia in murine peritonitis

Reduced oxygen consumption and lactic acidosis were observed frequently in patients with peritonitis. This study was designed to evaluate whether reduced oxygen consumption is secondary to deficient oxygen delivery or is a function of primary injury to mitochondria. Peritonitis was produced in rats by cecal ligation and perforation. Animals were killed at 2, 4, and 6 hours and agonally. Oxygen utilization was studied polarographically in isolated hepatic mitochondria with glutamate, pyruvate, and succinate substrates. State 3, state 4, respiratory control index (RCI), and ADP:O ratios were determined. Whole tissue and isolated mitochondrial ultrastructure were examined by electron microscopy. Systemic blood pressure and oxygenation were monitored. Hepatic tissue oxygenation was examined using a surface oxygen electrode. Peritonitis resulted in acceleration of state 3 respiratory rates and increased respiratory control indices at all time intervals. Maximal respiratory control was observed at 4 hours with all substrates. Whole tissue mitochondria demonstrated mild swelling and thinning of membranes and matrix. Experimental and control isolates showed similar orthodox-to-condensed conformational changes. Hepatic tissue oxygenation declined to less than 10% of control by 6 hours, while arterial Po2 was unchanged. The conclusions of this study are that lethal peritonitis results in (1) no primary injury to the hepatic mitochondria, (2) increased efficiency of hepatic mitochondrial oxygen utilization, and (3) reduced hepatic tissue oxygenation. The exact mechanisms of defective oxygen delivery require further study.

Selective hepatic artery ligation: limitations and failures

The hospital records of 540 consecutive patients with hepatic trauma were reviewed. Persistent arterial bleeding from hepatic wounds was encountered in approximately 10% of severe liver injuries. Compression of the porta hepatis will result in cessation of bleeding in such patients and subsequent ligature of the appropriate lobar artery will provide permanent, safe control of bleeding. Failures of selective hepatic artery ligation commonly result from incomplete diagnosis of the extent of injury to portal veins and hepatic veins.

Effects of concurrent sepsis with clinically significant pulmonary embolic disease

Forty-one patients with significant pulmonary emboli were reviewed. The presence of heart disease and obesity was found with relatively constant frequency throughout the groups presented. Postoperative infections (wounds or abscess) were frequently associated with fatal or significant pulmonary embolism, particularly after abdominal and pelvic operations. The infection rate (65 per cent) in patients in whom significant pulmonary embolism developed after abdominal and pelvic operations is particularly striking when compared to the overall infection rate of 7 per cent for major operations in our hospital. Recent studies of prophylactic minidose heparinization reveal an increased number of complications due to the heparin [24], and thus the proper selection of cases for prophylactic minidose heparin is mandatory. The data suggest that patients at high risk for the development of postoperative complications of infection are also at high risk for the development of significant pulmonary emboli and should be considered candidates for prophylactic minidose heparinization.

Effect of limiting post-shock pulmonary edema on mortality from bacterial pneumonia

Dogs were subjected to hemorrhagic shock and then resuscitated according to physiological parameters. Randomly selected dogs received a sublethal dose of intratracheal microorganisms. In comparing the results with those previously reported from our laboratory, in which animals received an 85% greater resuscitation of Ringer's lactate, it appears that pulmonary edema in the post-shock contaminated state can be limited. Furthermore, through minimization of pulmonary edema, pulmonary defenses appear to be improved and mortality from infection reduced.

Occult splenic abscess: an unrecognized complication of heroin abuse

Despite increased recognition of surgical problems related to narcotic addiction, splenic abscess has not been commonly recognized as such a complication. Seven male patients with splenic abscess secondary to heroin abuse have been treated. Six had bacterial endocarditis. Symptoms were nonspecific. Splenomegaly in two patients was the only useful physical finding. Five patients had left pleural effusion, of which three were proven to be empyemas. Staphylococcus aureus was the predominant pathogen of of bacterial endocarditis and splenic abscess. The splenic scan was diagnostic. All patients recovered following curative splenectomy.

Closure of an acute perforated peptic ulcer with the falciform ligament

When management of a perforated peptic ulcer necessitates simple closure, the omentum may not be of adequate quality to buttress such a closure. In this unusual circunstance, we have found the falciform ligament to serve as an effective alternative to satisfactorily peptic perforations.

Emergency operations for Crohn's disease

Seventeen patients with Crohn's disease requiring emergency operative procedures disclosed important factors leading to successful outcome. In seven of the ten patients not known to have Crohn's disease, the history strongly suggested this diagnosis. Two patients died; three others had major complications, including two anastomotic leaks and two postoperative intraperitoneal abscesses. Wide drainage of abscesses, preservation of intestinal absorptive surface, avoidance of anastomoses in the presence of acute infection, and vigorous supportive nutrition are important features of the management of patients requiring emergency operation for complications of regional enteritis.

Bleeding vascular malformations of the intestine

Thirty-nine patients with bleeding vascular malformations were evaluated. The age range was from 3 to 78 years, with a bimodal age distribution. The younger patients had no associated diseases, while those in the older category invariably had an associated cardiac lesion (aortic stenosis in 12 patients and severe atherosclerotic disease in 11 patients). With experience, colonoscopy has become a valuable adjunct to arteriography with the lesion visualized in 12 patients. Arteriography is the most useful study being diagnostic in 35 of 38 cases. Exploration alone was diagnostic in only one of 39 patients. The most common site of bleeding was the cecum (21 patients) followed by the proximal small intestine (eight patients), terminal ileum (seven patients), and ascending colon (five patients). The lesions in the proximal small bowel were much more common in the younger patients and were believed to be congenital. Resection controlled the bleeding in the majority of patients, although four recurrences have been noted. All have been documented angiographically to have been from a new lesion and two were controlled with reoperation. The key elements to control of these patient's bleeding include: (1) systematic work-up with a team approach emphasizing careful visceral angiography, and (2) the avoidance of a premature laparotomy prior to complete evaluation.

Missile tract infections after transcolonic gunshot wounds

Severe invasive infections around missiles or missile tracts may occur after transcolonic gunshot wounds. Observations in seven patients disclosed that infections of bone, soft tissue, retroperitoneum, and vascular structures resulted from the contamination of these tissues by missiles that had passed through the lumen of the colon. The infections were frequently obscure and difficult to diagnose unless the missile was considered to be a potential source of contamination. Two of seven patients died as a direct result of infection. Aggressive debridement of missile tracts, removal of accessible missiles, and adjunctive antibiotic therapy were useful.