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Biomedical subjects

H H Stone

Publications and source records attributed to H H Stone.

At least 37 records · Page 2Linked to original sources
PubMed1983

Third-generation cephalosporins for polymicrobial surgical sepsis.

During 31 months of study, 808 patients with polymicrobial surgical infection were randomized for antibiotic therapy between a third-generation cephalosporin (moxalactam disodium [149], cefotaxime sodium [125], and cefoperazone sodium [141]) and the combination of gentamicin sulfate plus clindamycin (393). Results based on antibiotic therapy included the following: cure in 83% given cephalosporin, 73% with antibiotic combination; control but recurrent sepsis in 7% and 15%; and failure in 4% and 8%, respectively. Such data support the tenet that third-generation cephalosporins are at least equal, if not superior, to the combination of gentamicin plus clindamycin for treatment of polymicrobial surgical sepsis.

Abscess↗
PubMed1983

Safety of incidental appendectomy.

Reports in the surgical literature are conflicting as to whether appendectomy "in passing" during laparotomy for trauma or for some other disease state does or does not significantly increase patient morbidity or mortality. A chart survey of all appendectomies (342 for acute appendicitis and 146 as incidental procedures) performed on the trauma service of Grady Memorial Hospital over a 40 month period appeared to indicate that the wound infection rate (6.8 percent) was the same as that for acute simple or suppurative appendicitis (6.7 percent), whereas the intraabdominal sepsis rate (17.5 percent) paralleled that for more advanced gangrenous or perforative appendicitis (18.6 percent). Since the validity of a retrospective review is always open to question, a prospective, randomized trial was carried out only on patients with a negative abdominal exploration for trauma over a 22 month interval at the same trauma service. An odd second from the last digit hospital number dictated appendectomy, provided the appendix was readily accessible; an even digit in the same locus dictated retention of the appendix. In no patient did intraperitoneal sepsis develop, regardless of the procedure chosen. Wound infection rates were 1.8 percent for appendectomy (1 of 56), if local anatomic considerations precluded an easy appendectomy (0 of 45), and 3.6 percent for the control subjects without appendectomy (3 of 83). There were no deaths. These data cast considerable doubt on the reliability of retrospective reviews and support the generally accepted dictum that incidental appendectomy, especially in the trauma patient, can be a relatively innocuous procedure.

Abdominal Injuries↗
PubMed1983

Experimental production of rectal stenosis and atresia in the rabbit.

Clinical reviews have suggested that there are different causes for the various types of anorectal atresia and stenosis. Such inferences have primarily been based upon the presence or absence of associated fistulas and other anogenital, urinary, and more remote congenital defects. Rectal stenosis and atresia of the middle and/or upper third of the rectum were produced in 27 of 38 rabbit feti subjected to partial to complete interruption of the blood supply to the rectosigmoid colon between the 24th and 26th day of gestation. Such experimental feti were located in the right tube, while a sham laparotomy was performed during the same maternal operation on 26 feti located in the left tube. An additional undisturbed 28 feti were available in both tubes to serve as controls. No other anomalies were produced in any group. These findings suggest that local ischemia, occurring late during fetal life, may well be the mechanism responsible for the creation of rectal stenosis and atresia of the middle and/or upper rectum.

Animals↗
PubMed1983

Management of the major coagulopathy with onset during laparotomy.

An experience with 31 patients who developed major bleeding diatheses during laparotomy was reviewed. Management of the initial 14 patients was by standard hematologic replacement, completion of all facets of operation, and then closure of the peritoneal cavity, usually with suction drainage; only one patient survived. The subsequent 17 patients had laparotomy terminated as rapidly as possible to avoid additional bleeding. Major vessel injuries were repaired; ends of resected bowel were ligated; and holes in other gastrointestinal segments and the bladder were closed by purse-string sutures. One patient had a ureter ligated. Laparotomy pads (4-17) were then packed within the abdomen to effect tamponade, and the abdomen was closed under tension without drains or stomata. Following correction of the coagulopathy, the abdomen was re-explored at 15 to 69 hours in the 12 survivors. Definitive surgery then was completed: bowel resection and reanastomosis; ureter reimplantation; drains for bile, pancreatic juice, and urine; and stomata for bowel or urine diversion or decompression. Eleven of 17 patients, deemed to have a lethal coagulopathy, survived. This technique of initial abortion of laparotomy, establishment of intra-abdominal pack tamponade, and then completion of the surgical procedure once coagulation has returned to an acceptable level has proven to be lifesaving in previously non-salvageable situations.

Adolescent↗
PubMed1983

Abdominal incisions: transverse vs vertical placement and continuous vs interrupted closure.

A previous retrospective review of 2,006 emergency laparotomies had suggested that anesthesia and operative times could be reduced by using a continuous stitch closure for all layers of the incision. A prospective, randomized study was then implemented through use of odd/even digits in the last and next-to-last digits in the hospital number. Of 551 patients subjected to laparotomy because of abdominal trauma, no intraperitoneal injury was found in 212. There was no statistically significant difference in time expended or complications (wound or other, including pulmonary) on contrasting transverse (101) with vertical (111) incisions, or on comparing continuous (104) and interrupted (108) closure, with the exception of an average 26 minutes in time saved by a continuous suture (P = .02). Analysis of these same factors in 339 patients with trauma found at laparotomy could document no statistically significant difference. Such data support the use of a running suture for closure of the abdominal wall as a practical method to save anesthesia and operating time without increased risk of developing a wound or other postoperative complication.

Abdomen↗
PubMed1982

Injury to the popliteal artery.

During a 32 year period, 164 patients with 165 popliteal artery injuries were treated. One hundred twenty-five injuries were due to penetrating trauma, and 40 to blunt force. During the first decade reviewed, with ligation the main method of management, the amputation rate was 74 percent. Almost routine attempts at vascular repair over the ensuing 10 years reduced the amputation rate to 28 percent. During the final 12 years, six amputations were required for 81 injuries, thereby producing an amputation rate of only 6 percent. From this experience, the following principles of management have evolved: (1) early diagnosis is best accomplished by a careful history and detailed physical examination, not by arteriography; (2) thrombectomy followed by distal heparinization before repair is the best method for guaranteeing an adequate arterial outflow tract and thus successful revascularization; (3) resection of all injured vessels with reconstitution of continuity by the use of an interposed saphenous vein graft is often warranted to avoid tension; (4) popliteal vein repair should be performed when practical; and (5) subperiosteal fibulectomy-fasciotomy should be done routinely immediately after vascular repair.

Adolescent↗
PubMed1982

Colonic atony in association with sigmoid volvulus: its role in recurrence of obstructive symptoms.

We reviewed a 30-year experience in management of 129 patients with 163 acute obstructions due to sigmoid volvulus. Recurrent obstruction of the colon was observed in 47 (or 45%) of 104 patients who survived their initial obstructive episode: 61% after rectal tube insertion, 45% after detorsion, 33% after sigmoid plication, and 21% despite sigmoid colectomy. Subsequent barium enema or surgical exploration showed true sigmoid volvulus to be the cause of recurrent obstruction in 36 of 47 patients, while atonic bowel, involving the sigmoid alone or more proximal colon as well, was responsible for the other 11 recurrent obstructions. Sigmoid excision was corrective only if bowel atony was limited to that portion of the colon. Only more extensive colectomy, so as to include all flaccid colon, consistently obviated recurrence. Failure to recognize functional obstruction accounted for five of the 25 total deaths.

Adolescent↗
PubMed1982

Clinical evaluation of cefotaxime versus gentamicin plus clindamycin in the treatment of polymicrobial peritonitis.

One hundred fifty-one patients with presumed aerobic-anaerobic mixed peritoneal infections were treated in a prospective, randomized trial with either cefotaxime alone (76) or the combination of gentamicin-clindamycin (75). Primary and complicating foci of sepsis were cultured for both aerobic and anaerobic pathogen identification and antibiotic susceptibility. In vitro aerobic disk sensitivities (114 isolates) to cefotaxime were 82% and to gentamicin, 88%; anaerobic agar-diffusion sensitivities (227 isolates) to cefotaxime were 87% and to clindamycin, 98%. Only enterococci and Pseudomonas sp were consistently resistant to cefotaxime. Infection was eliminated in 82% of those treated with cefotaxime and in 87% of those treated with the gentamicin-clindamycin combination, yet sepsis recurred in 11% of those treated with cefotaxime and in 13% for those given gentamicin-clindamycin. Five patients (7%) demonstrated nephrotoxicity for gentamicin. (Serum creatinine increased greater than 1.5 mg/100 ml over pretreatment levels.) Otherwise, incidence and severity of adverse reactions were identical for the two groups and consisted primarily of phlebitis and diarrhea. One patient in each treatment group died of uncontrolled sepsis. Although results suggested a laboratory superiority of gentamicin-clindamycin, there was a clinical equality in therapeutic benefit and a greater safety following the use of cefotaxime alone.

Adolescent↗
PubMed1982

Clinical comparison of cefotaxime versus the combination of gentamicin plus clindamycin in the treatment of polymicrobial soft-tissue surgical sepsis.

The safety and efficacy of cefotaxime versus a combination of gentamicin and clindamycin were compared in a prospective, randomized study of 98 surgical patients with polymicrobial soft-tissue infection or septicemia. Forty-nine patients received cefotaxime (20 mg/kg every six hours), and 49 received gentamicin (1 mg/kg every eight hours) plus clindamycin (5 mg/kg every six hours); all drugs were given intravenously. Overall, there was no statistical difference in clinical response to the two regimens, infection being eliminated in 73% of the patients treated with cefotaxime and 71% of those given gentamicin plus clindamycin. Adverse effects were mild and self-limited in both treatment groups, although three patients treated with gentamicin plus clindamycin experienced some loss of renal function. Most aerobic gram-negative rods were sensitive to both cefotaxime and gentamicin, but anaerobes were slightly more sensitive to clindamycin than to cefotaxime. Cefotaxime appeared to be at least as effective as gentamicin plus clindamycin in the treatment of polymicrobial soft-tissue infections and septicemia, and, in light of the loss of renal function associated with the gentamicin-clindamycin regimen, somewhat safer. The high failure rate among patients on both regimens with septicemia of unknown origin (five of the nine treated with cefotaxime and two of the four treated with gentamicin and clindamycin), however, indicates the critical role of surgical management in the treatment of polymicrobial soft-tissue sepsis.

Adolescent↗
PubMed1982

Use of antibiotic prophylaxis in penetrating abdominal trauma.

Information concerning the efficacy of prophylactic antibiotics in patients sustaining penetrating abdominal trauma is limited. Duration of such therapy is also uncertain. Thus a prospective, randomized, double-blind study was performed at Grady Memorial and City of Memphis Hospitals. A total of 360 patients sustaining penetrating abdominal trauma were randomized to one of three groups: group 1, cefotaxime perioperatively only; group 2, cefotaxime perioperatively plus postoperative doses every six hours for 24 hours; and group 3, cefazolin perioperatively plus postoperative doses every six hours for 24 hours. Postoperative infection of the incision or peritoneal cavity occurred in 20 (17%) of the patients in group 1, 13 (10%) in group 2, and 11 (9%) in group 3. Differences were not statistically significant. The occurrence of higher infection rates in group 1 may be explained by the greater number of patients sustaining shotgun wounds and rectal injuries. This study lends support to the practice of discontinuing antibiotic therapy on termination of the operative procedure. Cefotaxime has been found to be a reliable, effective agent for prophylaxis against infection in patients who have sustained penetrating abdominal trauma.

Abdominal Injuries↗
PubMed1982

A technique for transduodenal sphincteroplasty.

A technique for transduodenal sphincteroplasty is presented. T-tube decompression of the common bile duct and subphrenic space drainage are routinely avoided. To date, results in 123 consecutive patients have been excellent. The single most troublesome wound complication, duodenal fistula, had been avoided in the most recent 68 patients by colonic or omental onlay of serosa.

Ampulla of Vater↗
PubMed1981

Management of acute full-thickness losses of the abdominal wall.

Over a 20-year interval, 167 patients sustained acute full-thickness abdominal wall loss due to necrotizing infection (124 patients), destructive trauma (32 patients), or en bloc tumor excision (11 patients). Polymicrobial infection or contamination was present in all but five of the patients. Of 13 patients managed by debridement and primary closure under tension, abdominal wall dehiscence occurred in each. Only two patients survived, the 11 deaths being caused by wound sepsis, evisceration, and/or bowel fistula. Debridement and gauze packing of a small defect was used in 15 patients; the single death resulted from recurrence of infectious gangrene. Pedicled flap closure, with or without a fascial prosthesis beneath, led to survival in nine of the 12 patients so-treated; yet flap necrosis from infection was a significant complication in seven patients who survived. The majority of patients (124) were managed by debridements, insertions of a fascial prostheses (prolene in 101 patients, marlex in 23 patients), and alternate day dressing changes, until the wound could be closed by skin grafts placed directly on granulations over the mesh or the bowel itself after the mesh had been removed. Sepsis and/or intestinal fistulas accounted for 25 of the 27 deaths. Major principles to evolve from this experience were: 1) insertion of a synthetic prosthesis to bridge any sizeable defect in abdominal wall rather than closure under tension or via a primarily mobilized flap; 2) use of end bowel stomas rather than exteriorized loops or primary anastomoses in the face of active infection, significant contamination, and/or massive contusion; and 3) delay in final reconstruction until all intestinal vents and fistulas have been closed by prior operation.

Abdominal Muscles↗
PubMed1981

Gallstone pancreatitis: biliary tract pathology in relation to time of operation.

During a 29-month trial, 65 patients with acute gallstone pancreatitis were randomly selected for biliary tract explorations either within 73 hours of admission (36 patients) or at three months following remission with nonoperative measures (29 patients, with five others awaiting elective operation). The details of surgery were identical, i.e., cholecystectomy, transduodenal sphincteroplasty, and pancreatic duct septotomy. Major bile ducts were cleared of stones by Fogarty catheter passage up the sphincteroplasty. At early operation, pancreatitis was in the acute edematous form in 29 patients, necrotizing in six, and hemorrhagic in one. Acute inflammatory changes were also noticed in three patients who underwent late operation. The locations of the gallstones in patients undergoing early versus delayed operations were, respectively: 97% and 100% in gallbladder, 75% and 28% within common or hepatic ducts (p < 0.02), and 31% and 0% free in duodenum (p < 0.01). The distal choledochus and ampulla were inflamed in 89% of the patients who underwent early operations, but in merely 17% operated upon electively (p < 0.01). Concomitant acute cholecystitis was present in 31% of the patients if surgery was performed during the initial admission, but in only 3% of the patients at delayed operation (p < 0.05). Most striking was the sudden "gush" of pancreatic juice when the ampullary sphincter was first stretched or cut during sphincteroplasty at early operation. Precipitous falls in serum amylase levels then followed over the next 24 hours. No significant differences were noticed in the mortality rate (one death after early operation, two after a delayed procedure), major morbidity rate (in four and three patients, respectively), or in duration of the initial hospitalization period (early operation: 13.5 days, delayed operation: 16.7 days). However, a second admission to the hospital for the delayed operation (12.1 days) was avoided by early operation. These data support the concept that biliary pancreatitis is probably initiated by gallstone passage through, or lodgement at, the ampulla of Vater. The resultant ampullary edema with or without gallstone impaction appears to be the anatomic cause for major pancreatic duct obstruction and the consequent pancreatitis. Early and appropriate surgical relief of the biliary tract pathology via a transduodenal sphincteroplasty can obviate the need for a second admission to the hospital without increasing, significantly, the attendant morbidity and mortality rates.

Acute Disease↗
PubMed1981

Experiences in the management of pancreatic trauma.

A 30-year experience in the management of 283 consecutive patients with acute pancreatic trauma was reviewed. Of these injuries 224 were penetrating; 59 were from blunt trauma. Diagnosis was made by laparotomy in all patients, although elevated serum amylase suggested this injury in 23 (56%) of 41 patients with nonpenetrating injuries. Operative measures were initially involved with correction of associated injury when present (961 organ injuries in 278 patients: 3.5 injuries per patient). During the earlier years, Penrose drains were placed to the site of injury. Significant pancreatic complications (fistula in 13, suppurative pancreatitis or abscess in six, pseudocyst in three) were noted in 19 (46%) of the 41 patients so managed. Routine sump drainage dramatically reduced the incidence of pancreatic complications to 2% in the 198 patients having external drainage alone. Distal resection was performed in 29 patients, without later pancreatic insufficiency. Most disappointing were the results from Roux-en-Y internal drainage: fistula developed in five and lethal bacterial pancreatitis in three of the seven patients so treated. Five patients died from exsanguination during exploration for major vascular trauma, and all three patients undergoing pancreaticoduodenectomy succumbed within 20 hours after operation. The overall mortality was 13.8%, with only seven deaths out of the last 100 patients treated. Profound hemorrhagic shock and its complications (19), suppurative pancreatitis (eight), and post-traumatic respiratory insufficiency (three) accounted for 30 of the 39 fatalities.

Acute Disease↗