A permanent tendon-to-bone suture technique in the distal phalanx

This technique is used to place a permanent tendon-to-bone suture in the distal phalanx without increasing the amount of dissection beyond that needed for a Bunnell button repair. This technique has the advantage of greater strength without the problems of a percutaneous device that must be removed before full wound healing strength has developed.     

Administration of beta-aminopropionitrile to human beings with urethral strictures: A prelimary report.

(1) No toxic signs or symptoms and no unusual laboratory determinations were observed in five patients with posterior urethral strictures treated by dilatation of the urethra and administration of 1 gm per day of beta-aminopropionitrile (BAPN) for twenty-one days. (2) Patients treated with 1 gm daily of BAPN for twenty-one days showed an increase in cold saline-extractable and acid-extractable collagen in proplast sponge-collected and dermal scar tissue comparable with that reported previously after doses of 3 to 5 gm of BAPN daily. (3) Significant reduction in the breaking strength of newly synthesized connective tissue was observed in patients treated with BAPN. (4) None of the patients in this study showed abnormalities in net collagen synthesis or in synthesis of noncollagenous protein. (5) The difference in the results of this study and two previous trials of BAPN in human beings which were discontinued because of toxic and or hypersensitivity signs and symptoms is hypothesized to be the result of development of highly purified BAPN fumarate.     

Management of airway trauma. I: Tracheobronchial injuries

One hundred six consecutive patients with injuries to the tracheobronchial tree who were admitted to the emergency room of the Tulane Medical Center Hospital or the Charity Hospital of Louisiana at New Orleans over a period of almost 20 years were analyzed retrospectively. Penetrating trauma of the neck or chest was reported in 100 of the patients, and only 6 had blunt trauma to the neck or thorax as the cause of injury. There were 18 deaths among the 106 patients (16.98%), including 11 (13.75%) of 80 with injuries of the cervical trachea. Seven (53.8%) of 13 with principal injuries of the thoracic trachea died; all 13 patients with major bronchial injuries survived. On admission to the emergency room, all patients had signs of airway compromise such as tachypnea, dyspnea, cyanosis, subcutaneous emphysema, or an abnormal respiratory pattern. Severe airway compromise was evident in 46 patients; 24 (23%) were treated with oral or nasal intubation, 19 (18%) with emergency tracheostomy, and 3 (2%) with intubation of a tracheal injury. Hemoptysis was an unreliable signal of serious injury, being present in only 28 of the patients. Patients who had major vascular injuries combined with trachea involvement were generally not salvageable. In regard to morbidity and mortality, the most common preventable errors were delay in diagnosis and treatment of tracheobronchial injuries, missed esophageal injuries, massive aspiration of blood, and abdominal vascular injuries.(ABSTRACT TRUNCATED AT 250 WORDS)     

Coronary bypass surgery in patients with circulating lupus anticoagulant

Clinical and laboratory experience with circulating lupus anticoagulant in 3 patients undergoing coronary artery bypass procedures is reported. This circulatory anticoagulant inhibits activation of prothrombin by the prothrombin activator complex (factor Xa, factor V, and phospholipid). The presence of lupus anticoagulant was initially detected because of a prolonged activated partial thromboplastin time and a normal or mildly prolonged prothrombin time. The 3 patients underwent uncomplicated coronary artery bypass grafting and experienced no abnormal bleeding postoperatively. The lupus anticoagulant is a rare cause of bleeding after open-heart surgery. It appears to be a problem only when an additional coagulation defect is present.     

Primary hyperparathyroidism in the seventies: A decade of change?

In an effort to identify new trends in the presentation and treatment of primary hyperparathyroidism, 66 patients treated since 1975 were compared with 100 patients diagnosed and treated from 1948 to 1970. Despite widespread use of multichannel analyzers, the late patients had an insignificant increase in diagnosis while asymptomatic (18 percent versus 9 percent in the early group). Hypertension was the most common presenting complaint in patients seen since 1975, compared with renal disease in patients seen before 1970. Findings of diffuse hyperplasia were more common in the late patients (17 percent versus 3 percent in the early patients). There were no differences in rates of operative complications or persistent postoperative hypercalcemia. In the late series of patients persistent hypercalcemia after surgery for hyperplasia was due to inadequate resection of parathyroid tissue. In the adenoma patients, failure to locate the abnormal parathyroid gland was the cause of operative failure.     

Traumatic hepatic duct injury: New approach to surgical management

Blunt traumatic injury to the biliary tract is rare, and its management is one of the most difficult and challenging problems confronting surgeons. If disruption occurs in the hepatic ducts, occult ductal injury may even go unnoticed. A high index of suspicion is the single most important factor leading to the identification and successful management of these injuries. A patient with massive upper abdominal injuries secondary to blunt trauma is reported on. Intraoperative cholangiography demonstrated bilateral hepatic duct transection. The injury was successfully managed by Roux-en-Y hepatoportal enterostomy, an approach that has not been previously reported. Primary repair or hepatic cholangiojejunostomy is the treatment of choice for hepatic duct injuries. Hepatoportal enterostomy, however, offers a satisfactory alternative in treatment when the patient is unstable or when primary repair is not possible. The literature is reviewed and the pathogenesis, diagnosis and treatment of nonpenetrating injuries to the biliary tract are discussed.     

Management of traumatic peripheral vein injuries: Primary repair or vein ligation

The management and outcome of 83 patients who had 86 venous injuries were retrospectively reviewed to identify optimal management techniques in patients with peripheral vein injuries. Venous injuries of the arms were associated with no long-term sequelae, and management with vein ligation appears safe. In patients with venous injuries of the legs, primary repair by lateral suture or primary end-to-end reanastomosis is recommended when technically easy. In patients who are unstable or in whom primary repair cannot be performed, vein ligation is recommended. Autogenous vein interposition grafting appears indicated only in the popliteal area when vein reconstitution should be aggressively sought. Vein ligation in peripheral vein injuries should be followed with aggressive postoperative management to prevent the development of distal edema. Limb elevation is effective in minimizing the development of adverse sequelae.     

Efficacy of antibiotic prophylaxis in high risk gastroduodenal operations

A double-blind, prospective and randomized clinical trial of the efficacy of antibiotic prophylaxis in gastroduodenal operations was studied in 39 patients over an 18 month period. All patients had clinical features that placed them at high risk for the development of postoperative wound or intraabdominal sepsis. In the placebo group of 20 patients seven gastric-related infections developed, while 1 of the 19 patients who received perioperative cefamandole had one gastric-related infection (p < 0.01). The responsible microorganisms were those that are normal components of the oral or intestinal microflora. Nongastric-related infections and deaths did not differ significantly in the two study groups. The results of this study confirm the efficacy of the use of short-term perioperative antibiotic prophylaxis in patients undergoing gastroduodenal surgery for bleeding duodenal or gastric ulcer, obstructing duodenal ulcer, gastric ulcer or malignancy.     

Adverse effect of splenectomy in experimental peritonitis

Patients undergoing splenectomy have increased operative morbidity and mortality, especially when associated with gastrointestinal surgery or injury. This present study was designed to assess the effect of splenectomy on mortality in a polymicrobial fecal peritonitis model and evaluate therapy with antibiotic (cefoxitin) or immunomodulation (glucan). Human stool-barium (0.15 cc) was placed in the peritoneum of Sprague-Dawley rats at the time of splenectomy or sham surgery. Splenectomy animals were then treated with 5% dextrose, cefoxitin (60 mg im q 6 hr), glucan (7.5 mg ip prior to surgery), or cefoxitin plus glucan. Splenectomy resulted in decreased survival (5% vs 30%, P less than 0.05). Treatment with cefoxitin (90%) or glucan (47%) significantly improved survival. Combined glucan-cefoxitin therapy had no improvement over cefoxitin alone. Peritoneal and blood cultures were performed 12 hr postoperatively. There were no significant differences in growth of bacteria between sham and splenectomy animals. Cefoxitin treatment resulted in lower growth of bacteria from both blood and peritoneum (P less than 0.05). Glucan treatment caused a significant decrease in the number of bloodborne bacteria (P less than 0.05). Intravascular colloidal carbon clearance and leucocyte counts were performed at 12 hr postoperatively. Presence of peritonitis significantly enhanced intravascular clearance, while splenectomy had no effect. Addition of glucan or cefoxitin therapy to splenectomy animals did not enhance intravascular clearance. Leucocyte counts were significantly lower (P less than 0.05) when splenectomy was added to peritonitis animals. Glucan and cefoxitin therapy did not increase leucocyte counts. Based on these studies we conclude that (1) splenectomy increases mortality in fecal peritonitis, (2) antibiotic and immunomodulator afford some protection, and (3) exact mechanism of protection remains unclear.     

Hemangioendothelioma of the pancreas obstructing the common bile duct and duodenum

A 6-mo-old male with a hemangioendothelioma of the pancreas obstructing the common bile duct and duodenum required temporary bypass of these structures while awaiting involution of the tumor treated primarily by corticosteroids and radiation therapy.