Search PubMed⌕ Search

Biomedical subjects

L W Baker

Publications and source records attributed to L W Baker.

At least 19 recordsLinked to original sources
PubMed1996

Prospective audit of multiple penetrating injuries to the colon: further support for primary closure.

Solitary colon injuries are being increasingly managed by intraperitoneal primary closure. The optimal management of the colon wound in multiple injuries of the colon, which have a high mortality, has not been determined. From 1983-1989, 668 patients sustained colonic injuries. In 71 of these patients the colon was injured at more than one site. Of the 597 single injuries to the colon, 472 (79%) were due to stabs and 102 (17%) to gunshot wounds. Sixty-eight men and three women sustained injuries at more than one site in the large intestine. The median age of patients was 26 years (range 13-66). In 61 patients the colon was injured at two sites and in seven patients at three sites. Three patients had more than three sites injured. The injuries were inflicted by: gunshots 35 (49%); stabs, 30 (42%); shotguns, three; and blunt trauma, three. Forty-one patients were treated by intraperitoneal primary closure (IPC) and 30 by a colostomy procedure or exteriorization of the primarily sutured colon (EPSC). Penetrating Abdominal Trauma Index (PATI) scores were high at 32 +/- 6, and were similar for all methods of colon wound management. Twenty-four patients were suffering from shock on admission, 13 of those patients were treated by primary repair and 11 were treated by an exteriorization procedure. Individuals treated by an exteriorization procedure stayed in hospital significantly longer, 45 days versus 21 days (P < 0.004) and had a higher mortality rate, five deaths versus one death (P < 0.04) than those patients who were primarily repaired. Intraperitoneal primary closure of all wounds is the method of choice for the majority of multiple injuries. Colostomy procedures or EPSC contribute to morbidity and mortality.

Adult↗
PubMed1995

Morphological aspects of microarterial anastomoses: a comparison of nylon with polydioxanone.

The morphological appearance of longitudinally sectioned rat femoral arteries was determined in intact arteries and from 3 to 435 days after vessel division and anastomosis with either 9/0 gauge nylon or polydioxanone (PDS) in 26 animals. The purpose of the study was to establish the mechanisms and compare the quality of healing after microarterial anastomosis and to determine whether PDS was degraded before sufficient anastomotic healing had taken place. The results revealed that there was no difference in the process of healing or quality of anastomosis with either suture material. From 3 to 21 days post anastomosis, there was a progressive separation of the ends of vessels within the developing scar. Anastomotic patency was established and maintained at first by an adventitial overgrowth of fibroblasts and undifferentiated adventitial cells and later by the growth of a smooth myocyte scar that stretched between the cut ends of the vessel and over the intima in the form of elongated circumferential plaques. The vessel was morphologically healed by the 21st day. The sutures served little or no purpose in maintaining anastomotic integrity after the 5th day, being situated in the scar forming between the separating vessel ends. PDS was present within the vessel wall up to 120 days post anastomosis and was certainly intact at the time of morphological healing, suggesting that this material is safe as a microvascular suture.

Anastomosis, Surgical↗
PubMed1995

Antibiotic monotherapy with meropenem in the surgical management of intra-abdominal infections.

In an open, multicentre, randomised study, the efficacy and safety of meropenem monotherapy as adjuvant antibiotic therapy in the surgical management of intra-abdominal infection was compared with that of the combination of cefotaxime and metronidazole. A total of 160 hospitalised adult patients with intra-abdominal infection requiring surgery were treated intravenously with either meropenem 1 g every 8 h (by bolus injection or infusion; n = 77) or cefotaxime 2 g and metronidazole 500 mg every 8 h (n = 83). Clinical and bacteriological responses to antibiotic therapy were assessed at the end of treatment and at 2-4 weeks' follow-up after treatment. The clinical response rates at the end of treatment and follow-up were 91% and 96%, respectively, for meropenem and 100% and 97%, respectively, for cefotaxime plus metronidazole. The bacteriological response rates were 90% and 93%, respectively, for meropenem and 92% at both time points for cefotaxime plus metronidazole. Both treatments were well tolerated. In this study, meropenem monotherapy was effective and as well tolerated as cefotaxime plus metronidazole. Meropenem monotherapy should, therefore, prove a useful alternative to standard combination therapy for the empirical treatment of intra-abdominal infections.

Abdomen↗
PubMed1994

Iatrogenic and accidental colon injuries--what to do?

PURPOSE: This study was designed to formulate management guidelines for a variety of rare iatrogenic and accidental injuries to the colon and rectum. METHODS: This review collates the available evidence in the literature. RESULTS: Both investigative and therapeutic maneuvers involving the colon, particularly endoscopy and radiographic contrast studies, are the most common cause of significant injury although the incidence is low. Even less common are injuries produced, at open surgery and minimally invasive surgery, by foreign bodies, enemas, or compressed air. The mechanisms and management of these injuries are discussed in detail. CONCLUSIONS: Evidence exists to support that a nonoperative approach is safe for the majority of injuries, particularly when the colon is "clean" at the time of injury. Adequate resuscitation, observation, and repeated reassessment are mainstays of a conservative policy. Operation is essential for progression of abdominal signs. Patients with established peritonitis at the time of presentation or with an unprepared bowel are best served by prompt operation.

Barium Sulfate↗
PubMed1993

The influence of splenectomy on infective morbidity after colonic and splenic injuries.

OBJECTIVE: To establish the incidence of early postoperative infections after civilian injuries to the spleen, colon, or both and assess the effect of splenectomy on outcome. DESIGN: Retrospective study of case notes. SETTING: University hospital. SUBJECTS: 403 Patients of whom 353 had splenic injuries, 91 with associated colonic injuries, together with 50 randomly selected patients with colonic injuries alone. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: 45 Patients had splenectomy and colonic injury (group 1), 46 had a colonic injury and the spleen conserved (group 2) 50 had colonic injury alone (group 3), 143 had splenectomy for injured spleen without colonic injury (group 4), and 119 had the spleen injured and conserved without colonic injury (group 5). Their mean age was 28 years. Overall mean Injury Severity Score (ISS) was 30.1, and Abdominal Trauma Index (ATI) 22.4. 68/403 died (17%), more than half within 48 hours. Early mortality was higher in both groups in which the spleen was removed but after stratification by ISS and ATI the differences were not significant. Late mortality (after 48 hours) associated with sepsis did not differ significantly among the groups, nor did the rate of infective complications. Mechanism and severity of injury had the most influence on morbidity and mortality. CONCLUSION: Removal of an injured spleen does not have an adverse influence on the incidence of serious infective complications in the early postoperative period in patients with injuries to the spleen, the colon, or both.

Adult↗
PubMed1992

Treatment of persistent and complicated pancreatic pseudocysts.

In a review of 1895 patients admitted with pancreatitis during a 4-year period, 241 (12.7%) were identified as having pseudocysts. The majority of these were treated without operation, but 59 patients (24.5%) needed surgical intervention because of persistence (17 cases) or development of complications (biliary obstruction in 16, infection in 12, duodenal obstruction in ten and haemorrhage in four). Most cysts (68%) resulted from alcohol-related chronic pancreatitis. Blunt abdominal trauma was the cause in three. Operations included internal drainage in 35 (cystogastrostomy in 23, cystojejunostomy with Roux-en-Y in ten and cystoduodenostomy in two), external drainage in 20, pancreatic resection in two, and gastroenteric or bilioenteric bypass in ten. There were six postoperative deaths (10.2%), one after internal drainage (3%) and 5 (25%) after external drainage (P < 0.01, Fisher's exact test). Pseudocyst decompression failed to relieve biliary obstruction in half of the patients and biliary-enteric anastomosis was necessary because of a stricture in the distal bile duct. Massive bleeding from pseudocyst-related false aneurysms was successfully controlled by transcatheter angiographic embolization in four patients. During 1-5 years' follow-up, 24 of the 53 surviving patients (45%) were readmitted with pancreatitis and three of these died. Pseudocysts recurred in three patients, with spontaneous resolution in two and need for operation in one. It is concluded that operative treatment of complicated pseudocysts carries a substantial mortality rate. The need for additional biliary-enteric bypass after cyst decompression should be carefully assessed during operation. Angiographic embolization of pseudocyst haemorrhage is a valuable therapeutic manoeuvre.

Acute Disease↗
PubMed1992

Management options in malignant obstruction of the left colon.

Three of every 20 patients with carcinoma of the colon present with obstruction. The prognosis in the patient with malignant left colon obstruction is worse than for those with nonobstructing lesions, without adding the burden of a colostomy. Whenever feasible, acute obstruction should be treated by definitive resection with primary anastomosis and staged procedures reserved for only a few. How the former is achieved is open to debate. Whether or not the removal of all fecal matter from the colon is necessary before anastomosis is questionable and needs further appraisal. The risk of a metachronous lesion developing is highest in young patients with polyps or a previously resected carcinoma. The high risk patients would be best served by a subtotal colectomy. The choice of procedure must be tailored to each patient and the final decision made at the time of operation. An experienced colonic surgeon is needed to judge which option is most appropriate.

Carcinoma↗
PubMed1990

Colon wound management and prograde colonic lavage in large bowel trauma.

Between 1983 and 1987 prograde colonic lavage was prospectively evaluated in 389 patients with colon trauma. Predefined high risk patients had exteriorization of the primarily sutured colon. Intraperitoneal primary closure was otherwise used. Patients received prograde colonic lavage by random allocation. The healing exteriorized colon was interiorized 5-10 days after the initial surgery. The median age was 29 years and only 28 patients were women. Injuries were due to stab (316), gunshot (54), shotgun (10) or blunt trauma (9). Exteriorization of the primarily sutured colon was carried out in 217 patients of whom 101 had prograde colonic lavage. Twenty (9 per cent) died. Of the survivors, 150 (76 per cent) had their colon successfully interiorized and this rate was unaffected by prograde colonic lavage. Intraperitoneal primary closure was performed in 172 patients of whom 91 had prograde colonic lavage. Seven (4 per cent) died. Mortality was directly related to the number of associated injuries. Prograde colonic lavage, irrespective of the type of colonic wound management used, did not reduce the mortality rate, which was 7.2 per cent for those who had such lavage and 6.6 per cent for the rest. Prograde colonic lavage cannot therefore be recommended in colon trauma.

Adolescent↗
PubMed1988

Management of severe intra-abdominal sepsis: single agent antibiotic therapy with cefotetan versus combination therapy with ampicillin, gentamicin and metronidazole.

In a prospective, randomized trial involving 100 patients with severe intra-abdominal sepsis, the value of single agent antibiotic therapy with cefotetan was compared with that of combination therapy of ampicillin, gentamicin and metronidazole (AGM). All patients underwent exploratory laparotomy. The mortality rate was 3 per cent, all deaths occurring within 48 h of operation. Two-thirds of patients were considered severely ill on admission, and one-third were moderately ill. Six patients had positive blood cultures on entry into the study. The mean age was 31 years and concurrent disease was present in 14 per cent of the patients. A satisfactory response was achieved in 82 per cent of patients receiving cefotetan and in 65 per cent of those receiving AGM, whereas the response was unsatisfactory in 18 per cent of cefotetan patients and 35 per cent of those receiving AGM (P = 0.075 n.s.). Significant changes in laboratory values during the study occurred in 51 per cent of patients, and 7 per cent required vitamin K administration for hypoprothrombinaemia. The results of this study suggest that antibiotic therapy with single agent cefotetan is as safe and effective as a combination of ampicillin, gentamicin and metronidazole in patients with severe intra-abdominal sepsis requiring operative management.

Abdomen↗
PubMed1987

Selective management of abdominal and thoracic stab wounds with established peritoneal penetration: the eviscerated omentum.

In a prospective study involving 276 patients, stab wounds to the abdomen and lower chest with certain penetration into the peritoneal cavity were managed selectively. On the basis of physical findings, patients underwent either immediate laparotomy or close observation with frequent reexaminations and operation only if signs changed. The reliability of physical examination and the safety of nonoperative treatment in the absence of peritoneal signs were assessed. The overall incidence of major damage, including damage to the diaphragm, was 59.1 percent. Significant intraperitoneal visceral injury was found in 45.7 percent of patients with transabdominal stab wounds and in 25 percent of those with transthoracic stab wounds. Physical examination correctly predicted the findings in 90 to 96 percent of patients at initial assessment, with a sensitivity of 88.4 percent and a specificity of 93.9 percent. As delayed laparotomy after a change in signs during observation did not increase morbidity or hospital stay, and the unnecessary laparotomy rate in this study was 5.9 percent, we recommend a policy of selective management of abdominal and thoracic stab wounds with omental evisceration or other evidence of peritoneal penetration. Local wound care with amputation of the protruded omentum followed by close observation and monitoring of vital signs is safe surgical practice when no peritoneal signs or other indication for urgent exploration are present on admission.

Abdominal Injuries↗
PubMed1985

Vascular occlusion in the pathogenesis of complicated amoebic colitis: evidence for an hypothesis.

Amoebic perforation of bowel, the final and most serious manifestation of transmural amoebic colitis, is due to thrombotic occlusion of vessels supplying the segment of bowel with subsequent infarction and ischaemic necrosis. The ischaemic nature of the necrosis is confirmed by its shape and the demonstration of vascular thrombosis in the resected specimens of perforated amoebic colitis. Specimen angiography confirms the avascular area confined to the macroscopic lesions. Thrombotic occlusion and amoebic invasion of blood vessels have been demonstrated histologically. This new information suggests that amoebic perforation of the bowel is due to vascular compromise.

Angiography↗
PubMed1985

Management of splenic trauma: the Durban experience.

In a retrospective survey of splenic trauma managed at a teaching hospital, the data of 127 patients during a 2 year period have been analysed. Splenic conservation was achieved in 47 laparotomies (38.8 per cent). Six patients with blunt abdominal trauma (4.7 per cent of all patients) were managed non-operatively. Splenic conservation by suture with or without packing with omentum or oxidized cellulose was successful in 27 out of 37 attempts. Failure of this technique was easily recognized during laparotomy and no patient required re-operation for continued splenic bleeding after splenorrhaphy. There was no significant difference between successful conservation of the spleen at laparotomy of patients below the median age (28 years) and older patients. Wound sepsis was increased after splenectomy (P less than 0.05). Splenic conservation is not appropriate for all types of splenic injury. Where conservation is not possible splenectomy and re-implantation is recommended.

Adolescent↗
PubMed1985

Esophageal transection versus injection sclerotherapy in the management of bleeding esophageal varices in patients at high risk.

In a prospective randomized trial of 76 patients at high risk with bleeding esophageal varices, transection of the esophagus with the EEA stapling apparatus was compared with injection sclerotherapy in the management of patients with Child's class B and C liver status. Thirty-nine patients underwent transection and 37 patients, sclerotherapy with a total of 92 injection procedures (2.4 per patient). The perioperative mortality (less than 30 days) was 28.9 per cent overall; 33.3 per cent for esophageal transection and 24.3 per cent for injection sclerotherapy (chi 2 = 0.375, p greater than 0.05). Gross ascites, severe encephalopathy and emergency operations were associated with a high mortality in the transection group, but other risk factors such as age and hypersplenism did not influence the outcome in either group. Only patients in Child's class C died after transection, but patients who died in the sclerotherapy group (mainly from recurrent bleeding) included patients from both Child's class B and C. Early recurrence of nonfatal bleeding affected one of 39 patients (2.5 per cent) after transection but was evident in 18 of 37 patients (48.6 per cent) after sclerotherapy (chi 2 = 19.12, p greater than 0.0005) and six patients died. Hemorrhage did not recur after transection during a follow-up period of two years, but a further 22 episodes of bleeding were recorded in 13 patients receiving sclerotherapy with five deaths. Postoperative complications and long term morbidity were similar in the two groups. Including readmissions for bleeding and repeat procedures, the mean hospital stay per patient was shorter for transection (14.5 versus 19.1 days) and the requirements for blood were less (1.9 units per patient versus 3.6 units per patient) than for sclerotherapy. It is concluded that esophageal transection effectively protects against short term recurrence of bleeding. Preoperative control of gross ascites will further reduce the mortality and comatose patients should be excluded from operation. Sclerotherapy provides little if any protection against recurrent bleeding and its use in the management of variceal hemorrhage in patients with advanced liver disease remains questionable. It is recommended as a temporary measure in patients at high risk until such time that more effective surgical treatment can be performed.

Adolescent↗