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Biomedical subjects

G L Jordan

Publications and source records attributed to G L Jordan.

At least 19 recordsLinked to original sources
PubMed1992

Abbreviated laparotomy and planned reoperation for critically injured patients.

The triad of hypothermia, acidosis, and coagulopathy in critically injured patients is a vicious cycle that, if uninterrupted, is rapidly fatal. During the past 7.5 years, 200 patients were treated with unorthodox techniques to abruptly terminate the laparotomy and break the cycle. One hundred seventy patients (85%) suffered penetrating injuries and 30 (15%) were victims of blunt trauma. The mean Revised Trauma Score, Injury Severity Score, and Trauma Index Severity Score age combination index predicted survival were 5.06%, 33.2%, and 57%, respectively. Resuscitative thoracotomies were performed in 60 (30%) patients. After major sources of hemorrhage were controlled, the following clinical and laboratory mean values were observed: red cell transfusions--22 units, core temperature--32.1 C, and pH--7.09. Techniques to abbreviate the operation included the ligation of enteric injuries in 34 patients, retained vascular clamps in 13, temporary intravascular shunts in four, packing of diffusely bleeding surfaces in 171, and the use of multiple towel clips to close only the skin of the abdominal wall in 178. Patients then were transported to the surgical intensive care unit for vigorous correction of metabolic derangements and coagulopathies. Ninety-eight patients (49%) survived to undergo planned reoperation (mean delay 48.1 hours), and 66 of 98 (67%) survived to leave the hospital. With the exception of intravascular shunts, there were survivors who were treated by each of the unorthodox techniques. Of 102 patients who died before reoperation 68 (67%) did so within 2 hours of the initial procedure. Logistic regression showed that red cell transfusion rate and pH may be helpful in determining when to consider abbreviated laparotomy. The authors conclude that patients with hypothermia, acidosis, and coagulopathy are at high risk for imminent death, and that prompt termination of laparotomy with the use of the above techniques is a rational approach to an apparently hopeless situation.

Acidosis↗
PubMed1991

Evolution of the treatment of the injured colon in the 1980s.

During the past 10 years, 1006 patients with colon injuries were treated in an urban trauma center. Primary repair, including suture repair and resection with anastomosis, was performed in 614 patients (61%), colostomy in 284 patients (28%), and exteriorized repairs in 83 patients (8.3%). In the remaining 25 patients (2.5%) who were exsanguinating, the colon injuries were ligated. Independent risk factors for adverse outcomes (defined as a fecal fistula, abdominal abscess, stomal complication, or death from multisystem failure) were identified using multiple logistic regression analysis. These factors were used to match patients at similar risk within different treatment groups, and odds ratios for each treatment were calculated. The odds ratios for primary repair, colostomy, and exteriorized repair were 1.0, 1.9, and 2.0, respectively. Therefore, the chance of an adverse outcome was twice as great for both exteriorized repair or colostomy as for primary repair. It is concluded that further increases in the use of primary repair are warranted.

Abscess↗
PubMed1991

The future of general surgery.

The origin of the term "general surgery" is uncertain, but it is known that it has been in the lexicon of surgical parlance for more than a century. Although specialization began at least 150 years ago, it became a major trend at the end of World War I. The potential fragmentation of the specialty is the most significant problem currently faced by general surgeons. Other areas affecting the future of general surgery are discussed, including residency requirements, manpower analyses, and physician reimbursement. Because of rapid technologic changes and the aging of the population, surgeons need to incorporate those features that will improve patient care into their practices to meet the needs of the future.

Fees, Medical↗
PubMed1990

Gallstone pancreatitis. The question of time.

Two hundred consecutive patients with gallstone pancreatitis were treated during a 6-year period; 92 patients were operated on after the acute attack subsided but during the same admission (group 1), 102 patients were discharged after recovery and scheduled for elective surgery (group 2), and the conditions of 6 patients deteriorated and they underwent emergency operation (group 3). All patients in group 3 had hemorrhagic pancreatitis. Mortalities for groups 1, 2, and 3 were 0%, 0%, and 50%, respectively. Although the outcome of patients in groups 1 and 2 was similar, only 60 of 102 patients in group 2 had their treatment completed. Furthermore, 29 (44%) of 65 patients who were followed up in group 2 suffered recurrent pancreatitis or biliary tract disease before elective surgery. The timing of surgery in patients whose conditions improve is not critical; however, patients whose conditions deteriorate after admission have severe disease with high morbidity and mortality.

Adolescent↗
PubMed1990

Splenorrhaphy. The alternative.

From 1980 to 1989, 240 adult patients underwent splenorrhaphy at one urban trauma center. This represents 43.4% of all splenic injuries seen during this time interval. Splenic injuries were graded I to V, and splenorrhaphy was attempted except when the spleen was shattered or when multiple injuries with associated hypotension were present. Penetrating wounds, blunt trauma, or iatrogenic/unknown etiologies were present in 54.2%, 41.6%, and 4.2% of patients, respectively. Grade I or II injuries were present in 51.7% of patients, grade III in 34.6%, grade IV or V in 9.6%, and unknown grade in 4.1%. The technique of splenorrhaphy was simple suture (usually chromic) with or without the addition of topical hemostatic agents in 200 patients (83.3%), topical agents alone in 12 (5%), unknown type of repair in 12 (5%), compression, cautery, or nonbleeding injury in 9 (3.8%), and partial or hemisplenectomy in 7 (2.9%). Postoperative rebleeding occurred in three patients (1.3%) with grade II, III, and IV injuries, respectively, and led to splenectomy at reoperation. In another patient who had a hemisplenectomy performed for a grade IV injury, subphrenic abscesses and septic shock led to the death of the patient. Splenorrhaphy can be safely performed in properly selected adult patients after a variety of injuries. The risk of rebleeding is practically nil when the spleen is fully mobilized and visualized during repair.

Adult↗
PubMed1989

Pancreatic resection for pancreatic cancer.

In the majority of patients, pancreatic resection is performed for a proved carcinoma or for a mass in the pancreas with clinical features of carcinoma. Preoperative preparation is similar to that for other cancer operations, and good nutritional status and normal clotting factors are important. In many patients with resectable lesions, preoperative histologic diagnosis is not possible.

Duodenum↗
PubMed1989

Five thousand seven hundred sixty cardiovascular injuries in 4459 patients. Epidemiologic evolution 1958 to 1987.

Large epidemiologic analyses of cardiovascular injuries have been limited to studies of military campaigns compiled from many surgeons working in many hospitals with variable protocols. A detailed civilian vascular trauma registry provides a unique opportunity for an epidemiologic evolutionary profile. During the last 30 years in a single civilian trauma center directed by a consistent evaluation and treatment philosophy, 4459 patients were treated for 5760 cardiovascular injuries. Eighty-six per cent of the patients were male, and the average age was 30.0 years. Penetrating trauma was the etiology in more than 90% (GSW,51.5%; SW,31.1%; SGW,6.8%). All other injuries were iatrogenic or secondary to blunt trauma. Truncal injuries (including the neck) accounted for 66% of all injuries treated, while lower extremity injuries (including the groin) accounted for only 19%. Injuries to the abdominal vasculature accounted for 33.7% of the injuries. One thousand fifty-seven patients had 2 or more concurrent vascular injuries, and 32 patients had 4 or more separate vascular injuries. The 27 patients-per-year average of the early 1960s has risen to a current average of 213 patients per year. Economic and population factors influenced wounding agents and injury patterns during the evaluation period. This extensive civilian series presents epidemiologic profiles that are distinctly different from military reports and serves as a guide for current trauma center and health planners.

Adolescent↗
PubMed1988

Comparison of multiple-parameter prognostic systems in acute pancreatitis.

A database of laboratory and clinical values was collected from 200 patients with acute pancreatitis. This database was analyzed using several multiple-parameter indicator systems. All systems tested demonstrated a similar ability to predict accurately both mortality and severity in these patients. The predictive power was maintained whether the scores were grouped or presented individually. The superiority of one system over another could not be demonstrated. It is probable that systems could be devised that would be just as effective as those analyzed; on the other hand, a trend toward unification is very desirable.

Acute Disease↗
PubMed1988

Abdominal gunshot wounds. An urban trauma center's experience with 300 consecutive patients.

From July 1983 through December 1987, 300 consecutive patients with penetrating gunshot wounds of the abdomen causing visceral or vascular injuries were treated. Resuscitative thoracotomy was required in 20 patients (6.6%), and only two survived. The most commonly injured organs were the small bowel (60%), colon (41.6%), liver (29.3%), vascular structures (24.6%), stomach (17.3%), and kidney (17.0%). The overall survival rate for the series was 88.3%; however, if only the 226 patients without vascular injuries are considered, the survival rate was 97.3%. In the 35 patients who died, the blood pressure on admission was 51 mmHg, 18 required a resuscitative thoracotomy, four visceral or vascular injuries were present, and the median blood replacement was 18 units. The cause of death was perioperative shock in 30 patients (85.7%), whereas five patients (14.3%) died of sepsis and multiple organ failure. The most common postoperative complication in survivors and patients who died later in the study was an intra-abdominal abscess (3.0%). Rapid conservative operative techniques for civilian gunshot wounds leads to few postoperative complications and an excellent survival rate, especially if vascular injuries are not present.

Abdominal Injuries↗
PubMed1988

The treatment of crotalid envenomation without antivenin.

Eighty-one patients were treated for crotalid envenomation over the past 12 years at the Ben Taub General Hospital, Houston. Bites were inflicted by copperheads (56%), water moccasins (15%), and rattlesnakes (12%). In 17% of patients the species of snake was not identified. Using a grading scale of one to four from minimal to severe envenomation, 54% were grade I, 29% grade II, 7% grade III, 6% grade IV, and 4% were not graded because the patients were seen more than 12 hours after envenomation and not evaluated by other physicians. Five patients received one dose (10 cc) of crotalid antivenin each before transfer to our Emergency Center. All patients were treated with intravenous fluids, antibiotics, tetanus prophylaxis, immobilization of the injured part, and elevation of the extremity to the level of the heart. No patients received antivenin or excisional therapy at this institution and one minor digital fasciotomy was performed. There were no deaths or amputations in this series. Eight patients developed superficial necrosis of the skin but only one required a skin graft. Three patients developed hematologic abnormalities and were treated with either platelet transfusions or fresh-frozen plasma. One patient required dopamine for hypotension refractory to fluid resuscitation. This experience supports a conservative approach to venomous snakebites and raises the question about the need to utilize traditional therapy for snakebites caused by species seen in our locality.

Adolescent↗
PubMed1987

Management of injuries to the suprarenal aorta.

During a 12 year period, 79 patients with a diagnosis of a penetrating wound to the suprarenal aorta were treated. An analysis of the records of these patients has led to the following conclusions: With a midline penetrating wound and presence of a supramesocolic hematoma or hemorrhage, injury to the suprarenal aorta should be suspected. If a midline supramesocolic hematoma is present or if hemorrhage can be controlled by direct pressure, a lateral approach with medial mobilization of the intraabdominal viscera on the left side allows rapid vascular control. Although lateral aortorrhaphy is preferred, patch grafting, and end-to-end anastomosis, or insertion of a prosthetic graft was required in 46 percent of the patients who underwent repair. As in all previous series, the insertion of synthetic patches or prostheses was not complicated by infection. The average survival rate for injuries to the suprarenal aorta in series reported since 1974 is 33 percent. Finally, the continuing problem of irreversible shock suggests the need for rapid transport from the field to the hospital for victims of penetrating wounds to the abdomen.

Aorta, Abdominal↗
PubMed1987

Management of combined pancreatoduodenal injuries.

From 1969 to 1985, 129 patients with combined pancreatoduodenal injuries were treated at one urban trauma center. A total of 104 patients (80.6%) had penetrating wounds, and multiple visceral and vascular injuries were usually associated with the pancreatoduodenal injury. Primary repair or resection of one or both organs coupled with pyloric exclusion and gastrojejunostomy (68 patients) and drainage was used in 79 patients (61.2%) in the entire study and in 59% (36 of 61) of all patients treated since 1976. Simple primary repair of one or both organs and drainage was performed in 31 patients (24%), whereas the remaining 19 patients (14.8%) had pancreatoduodenectomies (13 patients) or no repair before exsanguination (six patients). Major pancreatoduodenal complications occurring in the 108 patients surviving more than 48 hours included pancreatic fistulas (25.9%), intra-abdominal abscess formation (16.6%), and duodenal fistulas (6.5%). The overall mortality rate for the study was 29.5% (38 of 129). The acute mortality rate with these injuries will remain high secondary to injuries to associated organs and vascular structures. The morbidity and late mortality rates related to the moderate to severe pancreatoduodenal injury itself can be decreased by the addition of pyloric exclusion and gastrojejunostomy to the primary repairs.

Abdomen↗
PubMed1986

Liberal use of emergency center thoracotomy.

Emergency center thoracotomy is a heroic technique of resuscitation and treatment which was revived in the 1960s to improve the survival of patients presenting with cardiac wounds. With excellent survival rates attained in such patients, the technique was extended to victims of trauma with other mechanisms and locations of injury. At present, the technique has a survival rate ranging from 3 to 20 percent; however, most recent series of unselected patients show a survival rate of 8 to 10 percent. In this series, there were no survivors when emergency center thoracotomy was utilized after a period of prehospital cardiopulmonary resuscitation. Patients with isolated stab wounds to the thorax, especially those with cardiac injuries, had the best survival rate of any subgroup in the series. If emergency center thoracotomy was utilized for patients with some vital signs on admission and with neck or truncal gunshot wounds, blunt trauma, or abdominal trauma, the survival rate decreased to 2 to 4 percent; however, the small but constant survival rate in all of these groups justifies its continued use.

Adult↗
PubMed1986

Single agent cephalosporin prophylaxis for penetrating abdominal trauma. Results and comment on the emergence of the enterococcus.

Multiple studies have shown that the incidence of infectious complications after penetrating abdominal wounds are decreased by the perioperative administration of antibiotics. In this study of three separate single cephalosporin agents (cefotaxime, cefoxitin, and moxalactam) given for a 48 hour period in patients who sustained perforating gastrointestinal wounds, uncomplicated recoveries occurred in 93 percent of all patients. The rates of uncomplicated recovery were significantly different for the three groups; however, patients with major intraabdominal vascular injuries were more common in the cefoxitin-treated group. One disturbing feature was the presence of enterococci in 57 percent of isolates from wound infections and 60 percent of isolates from intraabdominal abscesses. Enterococci as sole isolates were found in one of two wound infections and three of four intraabdominal abscesses in the moxalactam-treated group.

Abdominal Injuries↗
PubMed1986

The injured colon.

Controversy continues regarding the initial management of civilian colon injuries. The main issues are the safety of colostomy versus the desirability of primary repair and the role of exteriorized repair. From 1979 through 1984, 727 patients with injuries to the colon were treated at a large urban trauma center. Ninety-seven per cent of injuries were caused by penetrating wounds. Ten patients died in the operating room prior to repair of the colon wound. For patients who survived long enough to have their injury treated, 52.4% were treated by primary repair, 32.9% were treated with colostomies, and 14.6% were treated with exteriorized repair. Of the factors that have been stated to influence decision making, the extent of the colon injury was the most important. Location, number, and type of associated injuries, fecal contamination, and shock were less important. However, none of these latter factors mandated performance of a colostomy. The overall mortality rate for the series was 9.9%. Forty-one out of 70 deaths occurred within the first 48 hours and were due to shock and hemorrhage. The mortality rate for primary repair was significantly lower than that for colostomies (p less than 0.01). The presence of shock and age greater than 40 were significant factors influencing mortality (p less than 0.01). Mortality also was directly related to the number and type of associated abdominal injuries. Abdominal abscess also occurred significantly less often in patients treated with primary repair than in those with colostomies (p less than 0.01). The use of exteriorized repair was successful in avoiding colostomy in 59% of patients. Primary repair can be performed with minimal morbidity and mortality and should be the mainstay of treatment for civilian colon injuries.

Adolescent↗
PubMed1986

Management of 1000 consecutive cases of hepatic trauma (1979-1984).

From 1979 to 1984, 1000 patients with hepatic injuries were treated at one urban trauma center. Penetrating wounds were present in 86.4% of patients. Simple hepatorrhaphy, use of topical hemostatic agents, or drainage alone were the only forms of therapy required in 881 patients, and 65 (7.3%) died. Extensive hepatorrhaphy or hepatotomy with selective vascular ligation, resectional debridement or resection, selective hepatic artery ligation, or perihepatic packing were required, often in combination, in 119 patients, and 40 (33.6%) died. Uncomplicated recoveries occurred in 798 of the 918 patients (86.9%) surviving greater than 48 hours. In the remaining 13.1% of patients, intra-abdominal abscess formation was the most common late complication (32/918 = 3.5%). Mortality for the entire series of 1000 patients was 10.5%, with 78.1% (82/105) of all deaths occurring in the perioperative period from shock or transfusion-related coagulopathies.

Constriction↗