Healing of incisional wounds in stomach and duodenum: Functional interaction between normal and wounded tissue

The development of mechanical strength in healing wounds in rat stomach and duodenum was correlated with changes in the morphologic characteristics of the wounds and adjacent tissue. Wounds were made in the nonglandular (rumen) and the glandular oxyntic (corpus) parts of the stomach and in duodenum. The wounds were tested 5 to 40 days after operation. Biomechanical analysis showed that in intact tissues the nonglandular part of the stomach was more extensible and required more energy to rupture than the glandular part of the stomach and duodenum. The wounds tested together with adjacent tissue had less mechanical strength, but a pattern of strength development similar to that found in earlier studies where isolated wound tissue was investigated. Morphologic analysis showed that with healing time the point of maximal weakness moved laterally from the incision line, and that the rupture pattern was the same in all types of tissues postoperatively. These findings indicate that suture materials and technique are important throughout the early period of wound healing in stomach and duodenum, while the influence of sutures becomes negligible later on, when the weakest point of the healing wound is outside the tissue enclosed by the sutures.     

Healing of incisional wounds in stomach and duodenum: Collagen distribution and relation to mechanical strength

The present study was performed to determine the changes in and distribution of collagen concentration around a healing incision in rat stomach and duodenum. These concentrations were related to the mechanical properties presented previously. Wounds were made in the nonglandular (rumen) and the glandular oxyntic parts (corpus) of the stomach and in duodenum. Specimens were cut parallel to the incision line and hydroxyproline contents and dry defatted weight were measured. Wounds were investigated 5 to 40 days after operation.Of the intact tissues the nonglandular part of the stomach had twice the collagen concentration of the glandular oxyntic part and duodenum, which did not differ from each other. The healing wounds in the glandular oxyntic part of the stomach and duodenum showed the most rapid increase in collagen concentration in the incision line and 40 days postoperatively both had collagen concentrations significantly greater than those of intact tissues. Wounds in the nonglandular part of the stomach only reached the level of intact tissue after 40 days. The dimensions of the biochemically active zones around incisions in stomach and duodenum remain essentially unchanged for 40 days after operation. A relation between the development of collagen concentration and mechanical strength was shown.These findings indicate that wound healing in stomach and duodenum is rapid, that collagen is the primary factor in the mechanical properties and that the highest activity is limited to a zone close to the incision line. The width of the biochemical zone remains constant.     

Healing of incisional wounds in stomach and duodenum: A biomechanical study

The healing pattern of incisional wounds in the rat stomach and duodenum was determined. A model allowing the biomechanical determinations of complete load-deformation curves is described. Wounds were made in the nonglandular (rumen) and glandular oxyntic (corpus) parts of the stomach and in duodenum. The wounds were tested 5 to 40 days after operation.Of the intact tissues the nonglandular part of the stomach was found to be more extensible and required more energy to be ruptured than the glandular part of the stomach and duodenum. The healing wounds in the glandular part of the stomach and duodenum showed the most rapid increase in mechanical strength, and after 40 days both required more energy to be ruptured than intact tissue. Wounds in the nonglandular part of the stomach reached only 75 percent of intact strength value after 40 days. The process of wound healing resulted in an increase in tissue stiffness.These findings indicate that wound healing in stomach and duodenum is more rapid than that in most other tissues and that the load-strain data give a detailed picture of the healing process. The energy required to rupture a wound represents the most informative assessment of wound healing.     

Continuous direct tissue oxygen tension measurement by a new method using an implantable silastic tonometer and oxygen polarography

A new method of tissue oxygen tension measurement that is suitable for human use has been described. An implanted Silastic tube tonometer is combined with polarographic oxygen electrodes. The techniques of preparation, insertion, and measurement have been described. The advantages and disadvantages of this method have been considered in relation to established methods of tissue oxygen tension measurement. The method is suitable for clinical use and can be used to aid clinical decision-making.     

A comparative study of skin blood flow in musculocutaneous and random pattern flaps

The present study in dogs was performed to evaluate the development of blood flow in cranial-based, rectus abdominis musculocutaneous (MCF) and random pattern (RPF) flaps and in adjacent intact skin before and after operation. Prior to raising of the flaps the intact skin area had the same blood flow in all the test injections. Following flap elevation blood flow in the MCF increased and on the second postoperative day (POD) it was 2.6 times the preoperative value. From POD 2 through POD 15 only minor changes were found for blood flow in MCF. Blood flow in the RPF immediately after surgery was only 31% of the preoperative value and 24% of the MCF value. After POD 2-3 blood flow in RPF, however, increased and reached the preoperative level and continued to increase through POD 15. Intact adjacent skin showed changes similar to those of MCF through POD 6, however, by POD 15 blood flow had decreased and was lower than that in MCF and RPF. Blood flow rates at remote sites in the groin and shoulder were identical and showed only a slight increase during the first two postoperative days. It is concluded that MCF have an early and continuous increase in blood flow after raising, while RPF have an early decrease. RPF, however, develop a subsequent increase in flow lasting through POD 15. Intact adjacent skin also showed increased blood flow which could not be attributed to a generalized increase in skin blood flow.     

Thromboembolic prophylaxis with dihydroergotamine-heparin in abdominal surgery: A controlled,randomized study

The prophylactic affect of dihydroergotamine-heparin (0.5 mg dihydroergotamine plus 5,000 units of heparin administered twice daily) against postoperative thromboembolic complications after gastrointestinal surgery was compared with the affect of 5,000 units of heparin administered three times daily in a controlled, randomized study. Fifty patients received the dihydroergotamine and heparin combination twice daily and 50 patients received 5,000 units of heparin three times daily. The two groups were comparable with respect to age, sex, body weight, and type of operation. The presence or absence of deep venous thrombosis in the legs was determined postoperatively by the radiofibrinogen uptake test. The frequency of deep venous thrombosis in the dihydroergotamine and heparin group was 12 percent compared with 18 percent in the heparin group (0.1 > p > 0.05). Wound hematoma developed in two patients in the heparin group and in one patient in the dihydroergotamine and heparin group (4 and 2 percent, respectively). No other hemorrhagic complications occurred.By combining heparin with dihydroergotamine it is possible to reduce the daily heparin dose by one third and still obtain the same level of prophylaxis against thromboembolism. The frequency of bleeding complications was very low in both groups, since only one wound hematoma occurred in the dihydroergotamine and heparin group and two in the heparin group.     

Dislocation of the superior tibiofibular joint

Derangements of the superior tibiofibular joint are divided into anterolateral, posteromedial and superior dislocations and chronic instability. Two cases of anterolateral dislocation, both needing open reduction, are presented together with a case of posteromedial dislocation.     

Short-term systemic prophylaxis with cefoxitin and doxycycline in colorectal surgery: A prospective,randomized study

The efficacy of cefoxitin or doxycycline as antibiotic prophylaxis in colorectal surgery was compared in 102 elective operations. Both drugs were used perioperatively only. Cefoxitin was used in 55 cases and doxycycline in 47. Ten patients in the cefoxitin group and 4 in the doxycycline group had wound infections. Three intraabdominal abscesses were seen, one after cefoxitin and two after doxycycline prophylaxis. All three were due to anastomotic leakage. Bacteriologic studies revealed no negative ecologic effects of prophylaxis. The short-term prophylaxis used did protect against serious infectious complications. The extended spectrum of cefoxitin provided no added benefit in prophylaxis. Patients with inflammatory bowel disease treated preoperatively with salicylazosulfapyridine run a greater risk of postoperative infection in spite of the prophylaxis.     

Parenteral and oral antibiotics in elective colon and rectal surgery. A prospective, randomized trial

Our evaluation consisted of a prospective, randomized clinical trial in a homogenous group of 241 patients undergoing elective colon and rectal resections. A significant decrease in wound infection was found in the patients who received intravenous cefoxitin in conjunction with standard bowel preparation. The infection rate correlated with the type of resection; rectal resections had the highest rate in each study group, but parenteral prophylaxis produced a significantly lower wound infection rate. E. coli and Staph. aureus were the most common bacterial isolates in both groups. B. fragilis was recovered in only two Group A patients, which most likely reflects the exceedingly low recovery rate of anaerobic bacteria in our laboratory. Urinary cultures were positive in a large number of patients and reflect the standard use of Foley catheterization in all patients who undergo resection of the colon or rectum. These data indicate that perioperative prophylactic administration of cefoxitin reduces the wound sepsis rate when combined with oral antibiotics and mechanical bowel preparation in patients undergoing resection of the colon or rectum.     

Cholecystectomy with and without drainage: A randomized,prospective study of 300 patients

A randomized, prospective study of 300 cholecystectomies was undertaken to evaluate the merits of drainage through a standard Penrose or Chaffin-Pratt sump tube matched against no drainage at all. There was no difference in mortality or length of hospital stay. There was, however, a significantly higher incidence of postoperative pyrexia due to atelectasis and wound infection in the drainage groups. Neither drain fulfilled its objective of providing outflow for a subhepatic collection, thus avoiding bile peritonitis. This study suggests that surgical drainage after every uncomplicated cholecystectomy is unnecessary and unwise.     

Femoral neck fracture: sliding screw plate versus sliding nail plate--a randomized trial

In a randomized trial 49 patients with fracture of the neck of the femur and an age of less than 70 years or a high level of physical activity were allocated to treatment with a sliding screw plate or a sliding nail plate fixation. The patients were followed for 2-5 years. At follow-up the union rate was found to be 86.2 per cent of the fractures in the screw plate group and 73.7 per cent in the nail plate group (P less than 0.3). Necrosis of the femoral head was encountered in respectively 10 and 21 per cent. Hip replacement was necessary in respectively 23.3 and 31.6 per cent. The nail slid out of the femoral head, resulting in recurrence of the fracture's displacement in three fractures with a sliding nail plate, and in none with a sliding screw plate (P = 0.053). Secondary loss of the femoral neck's angle was more frequently seen in the sliding nail plate group (P less than 0.01). In conclusion, the sliding screw plate gives better fixation of fractures of the neck of the femur and was followed by a lower frequency of reoperation than after an unthreaded device.     

Sliding screw in the treatment of trochanteric and subtrochanteric fractures

From spring 1979 all patients with trochanteric and subtrochanteric fractures treated at Aarhus County Hospital have been operated on with the sliding nail, and the patients' progress has been followed for 1 year. In this article the results from the 92 first operations are compared with the results from a controlled trial comparing Ender's nailing and McLaughlin's nail-plate fixation. The latter series originated from the same department but from 1976 until 1978.It was found that the time of anaesthesia in the Ender, the McLaughlin and in the sliding-nail group was 125, 131 and 145 minutes respectively. There was no significant difference in the occurrence of post-operative complications between the 3 groups. In the Ender group 56 per cent of the patients had technical complications compared with 23 per cent in the McLaughlin group. In the Ender group 14 per cent had second operations compared with only 3 per cent in the two other groups. The results at the 1-year follow-up examination were the best in the sliding-nail group. It was concluded that the use of the sliding nail carried great advantages compared with Ender nailing and McLaughlin nail plating.     

Bovine carotid artery heterografts versus polytetrafluoroethylene grafts. A prospective, randomized study

A prospective, randomized comparison of BCAH and PTFE vascular access grafts resulted in no statistically significant difference when analyzed for survival rates of complications, types of complications, reasons for failure, and clot salvageability. The results in diabetic patients were similar to those in nondiabetic patients. The majority of retrospective studies and subjective experiences favor PTFE grafts over BCAHs. The explanation may be part that BCAH preceded PTFE grafts into clinical use, and inexperience in the operating room and in the dialysis unit had an effect on BCAH results. A review of impressions of the graft materials indicated a decided preference for PTFE grafts.     

Selective versus standard hyperalimentation: A randomized prospective study

Fifty consecutive surgical patients were included in a randomized prospective study to determine the relative advantages and disadvantages of two types of nutritional support systems: one, selective hyperalimentation, relies on a balanced substrate formula, while the other, standard hyperalimentation, depends on carbohydrate and protein to satisfy the energy requirements of the patient. The patients who received the balanced substrate formula had significantly fewer complications than those receiving standard hyperalimentation, even though both groups achieved positive energy and nitrogen balance. The enhanced safety of selective hyperalimentation suggests its therapeutic superiority as a basic nutritional support system for a busy surgical service.     

Preoperative antibiotics for abdominal gunshot wounds. A prospective, randomized study

In an effort to define the optimal preventive antibiotics for gunshot wounds to the abdomen, 100 consecutive patients were randomized while in the emergency department to receive either combination ampicillin, amikacin, and clindamycin, combination doxycycline and penicillin, or carbenicillin (Groups I, II, and III, respectively). Antibiotics were continued for 5 days in the presence of distal ileal or colonic injury. The study groups were comparable in age, sex, incidence of shock, degree of peritoneal contamination, and abdominal trauma index. The incidence of infection was not statistically different among the groups. Enterobacteriacea were the predominant offenders, although anaerobes were identified in all groups. The critical risk factor was distal ileal or colon injury. This study indicates that a regimen employing a single agent whose spectrum includes both aerobes and anaerobes is as effective as more expensive and potentially toxic multiagent regimens.     

Moore prosthesis in the treatment of fresh femoral neck fractures: A critical review with special attention to secondary acetabular degeneration

A consecutive series of 106 patients with displaced femoral neck fractures was treated initially with Moore prostheses. The patients' mean age was 82.5 years (range, 67–91). At follow-up after two years, 71 patients attended. Thirty-seven per cent of these were in need of a conversion of their one-piece device to a total hip replacement on account of hip pain. When only active patients living in their own homes were considered, 55 per cent were found to need total hip replacements. The main reason for the development of hip pain was acetabular derangement.

It was concluded that active patients, disregarding their age, should not be treated with one piece prostheses if their fractures could be satisfactorily reduced and pinned. If this cannot be accomplished, a primary total hip replacement may be considered.     

Postoperative enteral versus parenteral nutritional support in gastrointestinal surgery. A matched prospective study

The effects of an elemental-enteral diet administered by a needle catheter jejunostomy or central total parenteral nutrition were prospectively studied in 15 patients undergoing abdominal operations. Infusions were started 1 day after operation and continued for 7 to 10 days. The two nutrient modalities were matched to deliver equal amounts of nitrogen and calories. Both promoted positive nitrogen balance and preserved body weight and serum proteins (albumin, transferrin, thyroxine-binding prealbumin, and retinol-binding protein). Both enteral and parenteral nitrogen caused a similar increase in plasma insulin levels. Pancreatic glucagon, total glucagon, gastrin, and pancreatic polypeptide were also maintained at similar levels in both groups. Plasma vasoactive intestinal polypeptide levels declined in patients receiving total parenteral nutrition but remained stable in the patients who were fed enterally. Both routes caused modest, inconsequential elevations in liver enzymes, but were otherwise equally safe. Patients tolerated total parenteral nutrition far better in the early postoperative period. Patients whose needs are great are probably better treated by total parenteral nutrition. Needle catheter jejunostomy feeding, however, is much less expensive. These studies do not support the commonly held belief that enteral nutrition is a more efficient route for administration of calories and protein.     

The treatment of burn shock: results of a 5-year randomized,controlled clinical trial of Dextran 70 v. Ringer lactate solution

Whether colloid mixtures or exclusively electrolyte solutions should be preferred for treatment of burn shock has been a topic of discussion for many years. The burns unit in Copenhagen has run a randomized, controlled trial, during the 5-year period 1971-5, in which every even-numbered patient was treated with Dextran 70 and every odd-numbered patient with Ringer lactate. Each group comprised 86 patients. The manner in which the two patient groups respond to treatment is essentially different. The characteristic features of the Dextran group are the relatively small quantities of fluid and sodium administered, the moderate hourly diuresis, the lack of haemoconcentration and reduced sodium uresis during the days subsequent to institution of shock treatment. Patients treated with Ringer lactate, on the contrary, receive more fluid and sodium, the hourly diuresis will be larger, but in spite of this these patients tend to haemoconcentrate to a considerable degree. The sodium uresis is normal all the time. Thus, these two methods of treatment create entirely different pathophysiological conditions. The weight of the patients treated with Ringer lactate is significantly greater than that of those treated with Dextran 70, but there is no difference in the extent of the burn either in square metres or in the percentage of body surface burned. A comparison is therefore permissible. The 86 patients treated with Dextran 70 had a calculated mortality of 29·9 according to Bull and Fisher (1954) and an actual mortality of 18. The 86 patients treated with Ringer lactate had an expected mortality of 32·5 and an actual mortality of 16. No statistically significant difference in mortality is to be found between the two groups. The authors consequently conclude that Ringer lactate is to be preferred to Dextran 70 because it is simpler to dose; dosing instructions do not lead to misinterpretation, treatment rarely needs to be adjusted and it is practically impossible to give an overdose.     

Prophylactic oophorectomy in colorectal carcinoma

It is a well established fact that women with recurrent colorectal carcinoma have a high frequency of ovarian metastases. This study was undertaken to see if microscopic metastases could be found in serial sections of ovaries removed at the time of primary operation. Of 58 patients, 4 had microscopic metastases and an additional 2 patients had macroscopic metastases. This finding, plus the risk of the development of a primary ovarian carcinoma, favors prophylactic oophorectomy in women with colorectal carcinoma.