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Biomedical subjects

G L Jordan

Publications and source records attributed to G L Jordan.

At least 37 records · Page 2Linked to original sources
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↗
PubMed1986

Management of injuries to the superior mesenteric artery.

From 1978 through 1984, 22 patients with 20 penetrating and two blunt injuries to the proximal superior mesenteric artery were treated. Patients presented with exsanguinating hemorrhage (19), midline hematomas (two), or 'black bowel' (one). Two other patients developed 'black bowel' during operation. Direct cutdown through the mesentery was the approach in 11 patients, and three survived; a Mattox maneuver was used in ten patients, and five survived. Complex bypass or grafting procedures were performed in nine patients, and two survived. Ten of 15 deaths were secondary to hemorrhagic shock; two of five late deaths were related to problems with the vascular repair in patients with multiple injuries. Interposition grafting near a major pancreatic injury may lead to catastrophic postoperative problems. Bypass grafts from the distal aorta should have retroperitoneal tissue coverage of the suture line.

Abdominal Injuries↗
PubMed1986

Packing for control of hepatic hemorrhage.

From July 1978 to July 1985, 1,348 patients with hepatic injuries were treated. During this period, 66 patients (5.3% or 9.4 patients/year) required perihepatic packing. Penetrating wounds accounted for 77.2% of injuries requiring packing. Seventeen patients died in the operating room from massive hepatic and other intra-abdominal injuries and were excluded from further analysis. Perihepatic packing was inserted in 41 patients at a first operation and at a second or third operation in eight others. The major indications for packing were post-repair coagulopathies (85.5%) and extensive subcapsular hematomas or capsular avulsion (12.2%). Packing was removed from 28 surviving patients (28/49 = 57.1%) at an average of 3.7 days following insertion. Pack removal was accomplished by laparotomy in 24 patients (85.7%) and extraction through a hole in the body wall in four others. Ten postoperative intra-abdominal fluid collections, hematomas, or abscesses occurred in nine patients (9/49 = 18.4%) surviving the first operation. Perihepatic packing continues to be a life-saving adjunct in a highly selected group of patients with the most severe hepatic injuries and nonmechanical bleeding at the completion of repairs or extensive subcapsular hematomas.

Bandages↗
PubMed1986

Correlation of immunologic and nutritional status with infectious complications after major abdominal trauma.

Examination of the response of injured patients' lymphocytes to the mitogen phytohemagglutin in a defined medium provides a mechanism to define the relationship between alteration in immune function and septic complications. Lymphocytes from 30 victims of gunshot wounds to the abdomen were examined. Response to mitogen was measured by incorporation of [3H]-thymidine as a function of lymphocyte concentration, with a constant amount of mitogen phytohemagglutinin and a standard incubation period. A saturation curve was obtained, and lymphocyte response was expressed as the concentration necessary for half-maximal incorporation of radioactive label, L1/2. Lymphocyte transformation was compared with that found in a group of 50 healthy volunteers. On arrival in the emergency center, the in vitro lymphocyte response of patients was markedly diminished. There were seven patients for whom a lymphocyte curve could not be generated, i.e., L1/2 greater than 1 X 10(6). For the other 23 patients, L1/2 = 4.75 X 10(5) (SEM - 7.5 X 10(4)) compared with L1/2 = 1.5 X 10(5) (SEM - 5 X 10(4)) for normal volunteers (p less than 0.01). Measurement of skin test response, white blood cell count, anthropometric measurements, and albumin level were not predictive of patient course. In contrast the in vitro lymphocyte viability corresponded to the degree of injury, and recovery of lymphocyte function was associated with improvement in the patient's clinical course.

Abdominal Injuries↗
PubMed1985

Management of traumatic injuries to the extrahepatic biliary ducts.

From 1978 through 1984, 13 patients with traumatic injuries to the extrahepatic biliary ducts were treated. Twelve of the 13 patients had penetrating wounds, and associated intraabdominal injuries were uniformly present. Multiple types of operative repair were successfully utilized, with the choice dictated by the patient's condition and the location and extent of the ductal injury. In stable patients with partial tears or small through-and-through injuries, lateral repair with or without T-tube stenting was used successfully. With ductal transections, an end-to-end anastomosis or a bilioenteric anastomosis was used. The Whipple procedure was reserved for complex periampullary injuries. Morbidity was related to the complexity of the ductal repair, whereas mortality (4 of 13 patients, 31 percent) was related to associated injuries.

Adolescent↗
PubMed1985

Combined tracheoesophageal injuries.

From 1974 through 1984, 23 patients with combined tracheoesophageal injuries from penetrating wounds were treated. Physical examination, endoscopy, a barium swallow, or a combination of these techniques confirmed the diagnosis preoperatively in 19 patients. A variety of operative techniques were used, with 20 of 23 repairs involving some type of primary repair of the trachea and esophagus, such as side repair or end-to-end anastomosis, with or without a tracheostomy. Major complications occurred in 74 percent of the patients and included eight cases of pneumonia, eight esophageal leaks, six tracheoesophageal fistulas, five mediastinal abscesses, four wound infections, and two carotid artery blowouts. To decrease the number of complications, several refinements in operative technique have been suggested.

Adolescent↗
PubMed1985

A four-year experience with splenectomy versus splenorrhaphy.

From 1980 to 1984, 326 patients requiring splenectomy or splenorrhaphy were treated at one urban trauma center. Splenic injuries were graded in severity from one to five at the time of celiotomy. Splenorrhaphy was attempted in all patients, except when the spleen was shattered or avulsed or when multiple injuries were present. The mechanisms of injury were: penetrating wounds in 51.2%, blunt trauma in 46%, and iatrogenic mishaps in 2.8% of patients. Grade 1 or 2 injuries were present in 23.9%, Grade 3, 4, or 5 injuries were present in 59.8%. Spleens removed or repaired with unknown grading or removed as part of distal pancreatectomies accounted for 16.3% of patients. Excluding uninjured spleens removed with pancreatectomies, 55.4% (169) of injured spleens required splenectomy and 44.6% (136) had a splenorrhaphy performed. Splenorrhaphy was most commonly performed with chronic suture with or without the addition of topical agents. Grade 1 and 2 injuries were repaired in 88.5%; Grade 3 injuries were repaired in 61.5%; and Grade 4 and 5 injuries were repaired in 7.7% of patients. Splenectomy is generally performed in patients with multiple associated intraabdominal injuries and the more severe grades of splenic injury, and has a mortality rate 13.5 times as great as that for patients undergoing splenorrhaphy. Splenorrhaphy can be performed in approximately 50% of patients with injured spleens and has practically no risk of rebleeding.

Abscess↗
PubMed1984

Emergency center arteriography in the evaluation of suspected peripheral vascular injuries.

From January 1982 through June 1983, 488 patients with suspected peripheral vascular injuries were examined with the use of 515 emergency center arteriograms performed by surgical residents via hand injection of contrast material using a single roentgenographic film. A total of 130 (25%) abnormal arteriograms resulted, including vascular spasm in nine instances and occlusion of noncritical arteries in 19 instances. One hundred two (20%) operations resulted from these abnormal emergency center arteriograms. A diminished pulse rate was the indication for performing 76 arteriograms, 52 (68%) of which were abnormal; however, only 43 patients from this group required surgery. Anatomic proximity to a major vessel was the sole indication for performing 352 arteriograms, 59 (17%) of which were abnormal. There was one false-normal arteriogram, one delayed development of an arteriovenous fistula, and four false-abnormal arteriograms. No complications of arteriography occurred during examination or at the time of clinic follow-up. Single-injection arteriography in the emergency center is a simple, sensitive, accurate, and cost-effective technique for the examination of patients with potential peripheral vascular injuries.

Angiography↗
PubMed1984

Emergency management of perforated peptic ulcers in the elderly patient.

The results of selective operative treatment for perforated peptic ulcers in 93 elderly patients 60 years of age or older have been found to be similar to those in a large group of patients of all ages with selective operative treatment for perforated peptic ulcers (1,127 patients). Elderly patients with previous symptoms of acid-peptic disease who do not have serious associated diseases that increase the risk of operation or generalized peritonitis or localized abscesses in the peritoneal cavity can undergo definitive ulcer procedures for perforated peptic ulcers with satisfactory morbidity and low mortality rates. Simple closure or omental patch closure is performed when such contraindications to a definitive operation are present and can be expected to have a greater mortality for this reason. Gastrectomy for a perforated gastric ulcer and truncal vagotomy and hemigastrectomy for a perforated duodenal ulcer offer the best long-term results for elderly patients who are fit to undergo definitive operation.

Aged↗
PubMed1984

Five hundred open taps or lavages in patients with abdominal stab wounds.

From 1980 to 1984, 500 asymptomatic patients with anterior abdominal stab wounds found to have penetrated the anterior peritoneal cavity on local wound exploration in the emergency center were evaluated by the technique of open peritoneal tap, quantitative diagnostic peritoneal lavage, or both. The technique was found to have several advantages, including earlier diagnosis of intraperitoneal visceral injuries in asymptomatic patients and a significant lowering of the incidence of unnecessary celiotomies in a busy county hospital. Also, it was extremely cost-effective. The major disadvantages were the number of false-positive results of taps and lavages based on red blood cell counts of more than 100,000/mm3, all of which resulted from bleeding from abdominal wall stab wound sites. An accuracy rate of approximately 91 percent was maintained throughout the period of the study, whereas there were only 1.8 false-negative results of lavage per year. Local wound exploration coupled with open peritoneal tap and diagnostic peritoneal lavage is recommended as a rapid, safe, and cost-effective technique for the evaluation of large numbers of asymptomatic patients who present with anterior abdominal stab wounds.

Abdominal Injuries↗
PubMed1984

Civilian trauma in the 1980s. A 1-year experience with 456 vascular and cardiac injuries.

During 1982, 312 patients with 408 vascular injuries and 48 cardiac injuries were seen. Two or more vascular or cardiac injuries were present in 34% of patients. Over 87% of injuries were secondary to gunshot wounds, stab wounds, or shotgun wounds. Vascular injuries were most commonly seen in the extremities (39.9%) or abdomen (31.9%). The most common arterial injuries occurred in the brachial artery (39 patients), while the most common venous injuries occurred in the internal jugular vein (26 patients). Arterial injuries were treated by the insertion of substitute vascular conduits (33.9%), ligation (22.6%), lateral arteriorrhaphy (18.6%), or end-to-end anastomosis (15.4%). Venous injuries were treated by lateral venorrhaphy (63.7%) or ligation (25.1%). In the 272 patients admitted with only vascular injuries, survival was 84.2%. Cardiac injuries in 38 patients most commonly occurred in the right ventricle (50%) and right atrium (25%). In the 34 patients who had only cardiac injuries and less than 4 minutes of prehospital cardiopulmonary arrest prior to arrival in the emergency center, survival was 64.7%.

Adult↗
PubMed1984

Perioperative antibiotic therapy for penetrating injuries of the abdomen.

From 1979 through 1981, 152 patients with penetrating injuries of the intra-abdominal gastrointestinal tract were placed on one of three different perioperative antibiotic regimens in a prospective randomized fashion. The three regimens were A) cefamandole 2 grams every 4 hours, B) cefoxitin 2 grams every 6 hours, and C) ticarcillin 3 grams every 4 hours and tobramycin 1.5 mg/kg every 8 hours. Antibiotics were administered intravenously before and for 48 hours following surgical exploration and repair. The three treatment groups were similar with respect to age, average number of organ injuries, and distribution of organ injuries. Cefoxitin-treated patients experienced uneventful recoveries more often than cefamandole-treated patients (94% vs. 80.3%, p less than 0.05) when the incidence of gram-negative wound infection and intra-abdominal abscess formation was considered, while the number of patients who experienced uneventful recoveries in the ticarcillin-tobramycin group was not statistically different from the other two groups of patients. Bacteroides fragilis was isolated from three of the six abscesses occurring in the cefamandole-treated group, while no anaerobes were isolated from abscesses in patients treated with either of the other two regimens. The results of this study suggest that the most effective perioperative antibiotic regimen for patients with penetrating gastrointestinal wounds should possess activity against both aerobic and anaerobic flora of the bowel.

Abdomen↗
PubMed1983

Severe duodenal injuries. Treatment with pyloric exclusion and gastrojejunostomy.

During a 12-year period, 313 patients with duodenal injuries were treated. Primary repair, pyloric exclusion, and gastrojejunostomy were used in 128 patients (41%) with severe duodenal and pancreaticoduodenal injuries, to reduce "duodenal" morbidity and mortality. The duodenal fistula rate was 2.2% overall, and 5.5% in the patients undergoing exclusion. Only two deaths were due to fistulas. Forty-two patients underwent upper gastrointestinal tract examinations after operation. In patients examined 21 days or more after operation, 94% had a patent pylorus. Marginal ulceration was infrequent (four patients), as were complications associated with the procedure (3%). Pyloric exclusion with gastrojejunostomy is a quick and simple procedure that allows return of pyloric patency and is associated with a low incidence of duodenal fistulas. When fistulas do develop, they are usually easily controlled and are associated with a low mortality. We believe pyloric exclusion with gastrojejunostomy to be the procedure of choice in patients with severe duodenal and pancreaticoduodenal trauma.

Adolescent↗
PubMed1981

Intraabdominal abscess after penetrating abdominal trauma.

In 57 (2.4 percent) of 2,416 patients undergoing laparotomy for penetrating abdominal trauma from 1977 to 1980, an intraabdominal abscess developed in the postoperative period. Preoperative antibiotic administration, careful closure of gastrointestinal tract perforation with diversion as necessary, and copious irrigation of the peritoneal cavity at the completion of surgery were common factors in all operations. Over 80 percent of penetrating wounds leading to abscesses occurred in the upper quadrants, and common risk factors included multiple intraabdominal solid organ injuries requiring open drainage, coupled with gastrointestinal tract perforation. Physician delay in the recognition of patients with intraabdominal abscess and in reoperation was a common problem.

Abdominal Injuries↗