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Biomedical subjects

L M Flint

Publications and source records attributed to L M Flint.

At least 109 records · Page 6Linked to original sources
PubMed1981

Arterial injuries in children.

Twenty-nine children sustained major arterial injuries secondary to gunshot wounds (nine), blunt injuries (11), penetrating injuries by sharp objects (five), and arteriographic injury (four). The femoral artery was most commonly injured, followed by the brachial, the carotid, subclavian, popliteal, aorta, innominate, and vertebral arteries. We repaired the majority of the arterial injuries by resecting the damaged vessel, with primary anastomosis or interposition grafting when necessary to avoid tension. Postoperative complications included clotted grafts in two patients, which were rendered patent by reoperation. Two children died postoperatively, although both had successful vascular repairs. All vascular repairs were patent at one year, and limb length disparity has occurred in one patient following a nerve injury. Our data indicate that early exploration and repair of all suspected vascular injuries can be accomplished with excellent results, even in young children.

Adolescent↗
PubMed1981

Simulated surgical wound infection in mice: effect of stimulation on nonspecific host defense mechanisms.

Experiments were conducted to ascertain whether nonspecific host defenses could be enhanced in a reliable animal model simulating the local bacterial infection that frequently complicates surgical wounds. The test lesion was studied in detail and exemplifies the concept that the ultimate expression of the host-pathogen interaction is the capacity of that pathogen to persist or grow in a given host. Mice were challenged by intramuscular insertion of cotton suture impregnated with 10(7) to 10(8) Escherichia coli K-12. The mice were subsequently killed at intervals, and the suture and muscle mass were retrieved, homogenized, and quantitatively cultured. Numbers of viable organisms in tissue from control animals were compared with those from experimental animals that received BCG (Bacillus Calmette-Guérin) vaccine, a nonspecific immunostimulant, prior to bacterial challenge. Improved tissue antibacterial activity appeared in animals that had received BCG vaccine 13 days prior to bacterial challenge. Differing doses and intervals were not protective. Enhancement of nonspecific host defense mechanisms may be helpful in combination with current measures for improved control of surgical wound infection.

Animals↗
PubMed1981

Traumatic injury of the proximal superior mesenteric artery.

Injuries of the proximal superior mesenteric artery (SMA) are relatively uncommon, but extremely perplexing lesions. Fifteen consecutive patients with this injury, 13 injuries from gunshot wounds and two injuries from blunt trauma, have been treated. Associated lesions and massive blood loss were common, averaging 3.6 injuries and 4800 ml per patient, respectively. Methods of SMA repair include lateral arteriorrhaphy (11 patients), primary reanastomosis (3 patients), and saphenous vein grafts (1 patient). Two of three patients whose injuries included segmental loss of the SMA that required a primary end-to-end anastomosis suffered subsequent thrombosis. Second-look operations were performed in five patients with two of these requiring a further reconstructive procedure. The only late death occurred in a patient with a severe head injury and a failure of his SMA repair, which potentially could have been prevented by a second-look procedure. There were five deaths (33%), with four occurring from acute hemorrhages and one late death occurring following intestinal necrosis and sepsis. Malabsorption or other late intestinal complications did not occur. Our experience 1) supports the concept that proximal SMA lesions must be repaired, 2) suggests that primary anastomosis to repair arterial defects is associated with a high failure rate, and 3) demonstrates that the second-look operation is a useful adjunct in improving survival in these patients.

Adult↗
PubMed1981

The injured colon: relationships of management to complications.

One hundred thirty-seven patients who sustained intraperitoneal colon wounds were admitted to the University of Louisville Hospital during the three-year period ending December 31, 1979. One hundred twenty penetrating wounds and 17 blunt injuries were treated. An intraoperative classification system was employed, in which Grade 1 injuries were characterized by minimal contamination, the absence of associated organ injuries, minimal shock, and no significant delay between injury and definitive operation. All of these were managed by single-layer closure. More severe wounds were treated by colostomy or exteriorization. The overwhelming majority of the patients (116) sustained Grade 2 injuries. Twenty-two patients (16%) died. Nine deaths (6% of the patients) were directly attributable to the colon wounds. Twenty-five Grade 1 injuries were treated by primary suture closure with a single complication (3% of the patients). Nine wounds were exteriorized for later reinsertion into the peritoneal cavity, but only two patients were spared colostomy by this method. Right colon injuries were, clearly, more severe than left or sigmoid colon wounds. Intraoperative classification allowed selection of a group of patients in whom suture repair was safe. Colostomy was associated with the lowest complication rate for Grade 2 and 3 wounds.

Adult↗
PubMed1981

Emergency abdominal wall reconstruction with polypropylene mesh: short-term benefits versus long-term complications.

The acute replacement of full-thickness abdominal wall has been facilitated by polypropylene mesh (Marlex) (PPM), allowing debridement of nonviable tissue and restoration of abdominal wall integrity without tension. However, no substantial long-term follow-up has been reported on the definitive wound coverage after the use of PPM in open wounds. Since 1976, we have placed PPM in 31 patients; 25 for infectious complication, three for massive bowel distension preventing abdominal closure, and three for shotgun wounds with extensive tissue loss. In 29 of 31 patients, the mesh was placed in heavily contaminated wounds; extensive fasciitis was present in 23 patients and 21 had intra-abdominal abscesses. Following mesh placement, 23 reoperations were required for continuing complications. No patients eviscerated, despite these multiple procedures. Polypropylene mesh was highly effective in restoring abdominal wall continuity. Despite advantages when PPM was used, significant long-term problems developed. Seven patients died from their primary illness in the postoperative period. Nine wounds were closed by granulation and subsequent split-thickness skin grafts. All nine developed mesh extrusion and/or enteric fistulae. Nine wounds healed by secondary intention, six developed enteric fistulae or continuing mesh extrusion. Full-thickness flap coverage after granulation provided the best means of wound closure. Polypropylene mesh had significant early advantages for providing abdominal wall integrity even in the presence of severe infection. However, long-term problems were common when wounds were closed to skin grafts or secondary intention. If the mesh cannot be completely removed, strong consideration should be given to myocutaneous flaps for coverage after the primary illness has resolved.

Abdominal Injuries↗
PubMed1981

Indomethacin pretreatment in continuous positive-pressure ventilation.

The purpose of the study was to investigate the possible involvement of prostaglandins (PG) and thromboxanes (TX) in the cardiovascular and pulmonary changes associated with the use of continuous positive-pressure ventilation (CPPV). Indomethacin (IND), an inhibitor of PG cyclo-oxygenase, was used to block the synthesis and release of PG and TX in the lung after alveolar stretch with CPPV. Groups of dogs received CPPV (buffer group) or CPPV + IND 5 mg/kh iv (CPPV + IND). Pulmonary edema or alveolar hemorrhage was evident in 5 of 6 buffer animals. This damage was also manifested by a 50% decrease in lung compliance. However, IND appeared to block development of lung tissue damage in 5 of 6 CPPV + IND dogs and compliance remained normal. A 52% lowering of cardiac index (CI) in the buffer group paralleled a 71% reduction of left ventricular dP/dt max (first derivative of left ventricular pressure). Peak transmural right heart filling pressure decreased only 15%. in contrast, the 38% decrement of CI in the CPPV + IND animals was coupled with a 98% reduction in filling pressure, but only a 25% decrease in dP/dt max. CPPV-induced changes may have been related, in part, to the release of cytotoxic negative inotrope(s) from damaged alveolar membranes because IND pretreatment blocked this damage.

Analysis of Variance↗
PubMed1981

Colonoscopic diagnosis of angiodysplasias of the gastrointestinal tract.

We have reviewed our experience with colonoscopy in the diagnosis of angiodysplastic lesions of the colon. In 14 of the patients in our series, the lesions in the colon were diagnosed colonoscopically, confirming arteriographic findings in many but being the only diagnostic modality facilitating the diagnosis in three of the patients. Results of our experience indicate that colonoscopy is an effective means of diagnosing or confirming the diagnosis of angiodysplastic lesions of the right colon. It should be part of the evaluation along with superior and inferior mesenteric angiography of every patient with occult gastrointestinal tract bleeding or iron deficiency anemia, or both, for whom no diagnosis can be made with standard barium contrast techniques.

Adolescent↗
PubMed1981

Total parathyroidectomy and parathyroid autotransplantation in patients with chronic renal failure.

Sixteen patients with chronic renal failure underwent total parathyroidectomy and parathyroid autotransplantation into the muscle of the forearm. Pertinent preoperative medical history of these patients included renal osteodystrophy, metastatic vascular calcifications, intractable itching and uncontrollable hyperphosphatemia. Efforts to control preoperative serum calcium and elevated serum parathormone levels were unsuccessful. The mass of parathyroid tissue implanted, in most instances, was approximately half that used in other series. Postoperatively, all patients received vitamin D and calcium orally, which were gradually decreased. Fourteen of the 16 patients had relief of symptoms, and all had restoration of parathormone levels to normal or slightly above normal, although in two patients, partial excision of hyperfunctioning tissue from the forearm was subsequently required because of recurring symptoms of secondary hyperparathyroidism. All patients had evidence of functioning grafts six to 40 months postoperatively or until death, attributable to intercurrent causes. The success of total parathyroidectomy and parathyroid autotransplantation in patients with chronic renal failure and symptomatic secondary hyperparathyroidism makes this a viable approach to the disease in such patients.

Female↗
PubMed1981

Management of necrotizing tracheostomy infections.

Management of three patients with necrotizing tracheostomy infections resulting in tracheal dissolution was reviewed with respect to presentation, cause, and management. Loss of tracheal substance led to difficulty in ventilation because of a large air leak. The stomal area cavitated in two patients, denuding the right common carotid artery in one. Purulent peristomal drainage was present in all three patients. Common factors of possible etiologic significance included necrotizing polymicrobial gram-negative tracheobronchial infections caused by Pseudomonas, Enterobacter, and Klebsiella species. Also of possible importance were suture fixation of the appliance, history of neurologic injury, and closure of the incision. Immediate therapy consisted of oral intubation for ventilatory purposes and a regimen of hourly application of 1% neomycin dressings. Seven to 21 days were necessary to allow formation of sufficient granulation tissue to support replacement of the tracheostomy appliance for continued mechanical ventilation. Once spontaneous ventilation was possible, a Montgomery T-tube was inserted for long-term tracheal stenting prior to reconstruction. The two patients treated by tracheal stenting are long-term survivors. Avoidance of suture fixation of the appliance, aggressive treatment of bronchopulmonary infection, and adequate stomal toilet may help to avoid this devastating complication.

Adolescent↗
PubMed1981

Management of transmediastinal gunshot wounds.

Gunshot wounds that transverse the mediastinum are major management problems for two primary reasons: (1) multiple injuries to vital structures are common and (2) the operative approach to control hemorrhage may not afford the optimum exposure to repair the various injuries encountered. We devised a management plan whereby patients in hemodynamically unstable condition underwent immediate operation and patients in stable condition underwent a rapid work-up to evaluate the organs at risk for injury including angiography, esophagoscopy, esophagography, bronchoscopy, and pericardial exploratory surgery while under local anesthesia. A total of 76 patients were treated. Thirty-three patients in unstable condition underwent immediate thoracotomy for hemorrhage or shock or median sternotomy for cardiac tamponade. Multiple organs were injured (average 2.7) and the mortality rate was high (12 of 33) because of the severity of the injuries. Twenty-seven of 43 patients in stable condition required operation after the systematic evaluation disclosed injuries to the great vessels (11), esophagus (9), trachea and bronchi (6), and heart (6). Three patients died of delayed complications (6.9%). The 16 patients who were in stable conditions and had no demonstrable injury were closely followed without operation with one complication and one death from an associated abdominal injury. A management plan for this difficult subset of patients with penetrating thoracic trauma is detailed.

Adult↗
PubMed1980

Duodenal injury. Analysis of common misconceptions in diagnosis and treatment.

Seventy-five consecutive patients who sustained injuries to the duodenum were admitted to our hospital over a nine-year period. Nineteen blunt injuries and 56 penetrating injuries were encountered. Blunt injuries were usually the result of motor vehicle accidents and steering wheel impact was frequently implicated. Penetrating injuries most commonly followed gunshot wounds, particularly those where the bullet tract travelled transversely across the peritoneal cavity. Seventy-nine per cent of the patients had two or more associated intra-abdominal organ injuries with other intestinal injuries, biliary tract injuries, and pancreatic injuries predominating. Forty-seven per cent of the patients were admitted in shock. Following blunt injury, diagnostic delay was encountered in two patients. Adjuncts to diagnosis such as abdominal roentgenograms, serum amylase levels, and contrast gastroduodenography, were not helpful. Peritoneal lavage, however, was valuable in patients with equivocal physical findings. Intraoperative diagnosis was also challenging. Complete mobilization of the structures surrounding the duodenum to provide exposure of the entire duodenum was necessary. Six injuries that initially appeared trivial would have been missed had this procedure not been followed. Suture closure was the most common reparative technique used. Tube decompression of the duodenum was a valuable addition. No suture line dehiscences were encountered in ten patients so treated. Overall mortality in patients surviving more than 24 hours was 12%.

Abdominal Injuries↗
PubMed1980

Posttraumatic acalculous cholecystitis.

Acalculous cholecystitis occurred in six patients after trauma and burns. The majority developed signs and symptoms similar to acute calculous cholecystitis. All were treated by cholecystectomy after traditional conservative treatment failed. All had either gangrenous changes or focal necrosis of the gallbladder. Postoperative recovery was uniform. Acalculous cholecystitis occurs in 0.5% of large series of injured or burned patients. Delayed recognition led to a high mortality, reported as 24% overall with 10% related to gallbladder disease. Although cholecystostomy has been advocated, it appears that cholecystectomy, when feasible, affords the best overall results.

Adult↗
PubMed1980

Intimal disruption of major cerebral vasculature following blunt trauma.

A child with blunt traumatic intimal disruption involving the major vessels responsible for cerebral circulation was treated by operation. The injured vessels included both common carotid arteries, both vertebral arteries, and the left subclavian artery. The carotid injuries were treated by saphenous vein interposition grafts, whereas the left subclavian and vertebral arteries were ligated. The patient sustained no neurological deficit and is now completely well 2 years after treatment. The case reported herein is unique in that total intimal disruption of the four major vessels responsible for cerebral flow was treated by operation, resulting in complete recovery. The successful outcome underscores the importance of complete angiographic evaluation and adequate operative exposure in such cases.

Brain↗
PubMed1979

Effects of concurrent sepsis with clinically significant pulmonary embolic disease.

Forty-one patients with significant pulmonary emboli were reviewed. The presence of heart disease and obesity was found with relatively constant frequency throughout the groups presented. Postoperative infections (wounds or abscess) were frequently associated with fatal or significant pulmonary embolism, particularly after abdominal and pelvic operations. The infection rate (65 per cent) in patients in whom significant pulmonary embolism developed after abdominal and pelvic operations is particularly striking when compared to the overall infection rate of 7 per cent for major operations in our hospital. Recent studies of prophylactic minidose heparinization reveal an increased number of complications due to the heparin [24], and thus the proper selection of cases for prophylactic minidose heparin is mandatory. The data suggest that patients at high risk for the development of postoperative complications of infection are also at high risk for the development of significant pulmonary emboli and should be considered candidates for prophylactic minidose heparinization.

Adult↗