Breakdown of intestinal repair after laparotomy for trauma: incidence, risk factors, and strategies for prevention

BACKGROUND: Breakdown of intestinal repair and enteric leakage after trauma laparotomy can have dire consequences. Factors contributing to these failures when stratified according to location of intestinal injury and method of repair were examined. METHODS: We retrospectively reviewed all intestinal injuries occurring in a recent 2-year time span in adult patients surviving for more than 48 hours at a Level I trauma center. Data included Injury Severity Score, Abdominal Trauma Index score, site (stomach, duodenum, small and large intestine), and type of repair (enterorrhaphy vs. resection and anastomosis). Physiologic parameters within 48 hours of repair were assessed. Nonparametric analysis was used with significance assessed at the 95% confidence interval. RESULTS: Two hundred twenty-two intestinal repairs in 171 patients were evaluated. All repairs but one were performed at the initial surgery. Eleven (5%) of these failed in 11 patients (6.4%)--four duodenum, four small bowel, and three colon--and were not recognized for an average of 15 days. Breakdown of repair occurred in patients with higher Injury Severity Scores and Abdominal Trauma Index scores (30 vs. 21 and 29 vs. 14, respectively; p < 0.001) and higher intraoperative blood and fluid administration (8.8 vs. 2.2 U and 11.5 vs. 5.1 L, respectively; p < 0.05). This was associated with longer intensive care unit and hospital stays (15.1 vs. 1.9 and 68.4 vs. 10.4 days, respectively; p < 0.001). All small bowel leaks occurred after resection and anastomosis versus enterorrhaphy (p < 0.05). All anastomotic breakdowns (four small bowel, one colon) occurred in the setting of massive blood and fluid administration versus those that did not leak (12.5 vs. 1.7 U and 12.7 vs. 5.8 L, respectively; p < 0.05). Four of 12 duodenal enterorrhaphies failed. All were associated with pancreatic injury versus none without (p < 0.05). The abdominal compartment syndrome occurred in three patients. In each case, breakdown of a small bowel anastomosis occurred. CONCLUSIONS: (1) Stomach repair and small bowel and large-bowel enterorrhaphy may be safely accomplished in any setting. (2) Associated pancreatic injury is a risk factor for disruption of duodenorrhaphy. (3) In patients with massive blood and fluid administration, delay of bowel anastomoses should be considered. (4) Disruption of small bowel anastomoses is associated with abdominal compartment syndrome.     

Is total abdominal hysterectomy with bilateral salpingo-oophorectomy adequate for new FIGO stage I endometrial carcinoma?

OBJECTIVE: The new FIGO staging for endometrial cancer cases complies with other forms of surgical staging and correlates better with clinical outcomes because it includes prognostic factors. This study was done to investigate whether total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH+BSO) is adequate for new FIGO Stage I endometrial carcinoma. SUBJECTS: Sixty-five cases of endometrial carcinoma defined according to the new FIGO Stage Ia (n = 26), Ib (n = 24) and Ic (n = 15) were analysed. They all received TAH+BSO only and were followed up for at least two years. METHODS: The histologic type, grade, depth of myometrial invasion, lympho-vascular tumour emboli and tumour size were analysed by t-test to correlate the risk factors for treatment failure. RESULTS: There were no recurrences after TAH+BSO in Ia and Ib cases. However, recurrences occurred in five cases (33%) of Stage Ic with deep myometrial invasion, high histologic grade, large tumour size and tumour emboli. CONCLUSIONS: TAH+BSO is inadequate in some Ic cases with a high histologic grade, deep myometrial invasion and tumour emboli. Thus, thorough pre-operative and intra-operative staging, adequate operation method and prompt post-operative adjuvant therapy are indispensable for successful treatment.     

Effects of a permanent magnetic field on 45Ca2+ ion influx in excitable and inexcitable cells and proliferative activity of rat spleen cells

When experimental animals were exposed to Permanent Magnetic Fields with magnetic induction (B = 0.2 T), the influx of 45Ca2+ ions into brain cells was activated, but the influx of 45Ca2+ ions into spleen cells was depressed. Similar effect was observed upon incubation of brain and spleen tissues in magnetized physiological solution. Incorporation of 3H-thymidine into spleen cells increased upon direct exposition to magnetic field and upon exposition of the spleen in magnetized physiological solution as well.     

Shell and core in monkey and human nucleus accumbens identified with antibodies to calbindin-D28k

The neurochemical division of the rodent nucleus accumbens into shell and core is now a widely accepted concept. However, such divisions in the primate nucleus accumbens have yet to be fully clarified and described. In the present study, the forebrains of three primates--marmoset, rhesus monkey, and human--and a Wistar rat, were immunoreacted with antibodies directed against calbindin-D28k. The patterns of immunoreactivity in the primates' ventral striatum were mapped and compared to that of rat. Calbindin staining was uneven in all species and there was no evidence of a bicompartmental organization, i.e., striosome/patch and matrix, in central parts of the nucleus. Nucleus accumbens in primates, as in rat, could be divided immunohistochemically into a crescent-shaped outer shell--medially, ventrally and laterally--and an inner core. In general, medial parts of the shell stained less intensely for calbindin than did lateral parts. However, interspecific variation in the intensity of the immunoreactive staining and the mediolateral extent of the shell was obvious. The core, which immunostained unevenly, was consistently more intensely immunoreactive than either medial or lateral shell in all species except the marmoset. These results suggest that the neurochemical subdivisions of shell and core established for nucleus accumbens of rodents are also present in primates. However, further work is needed to establish whether these territories are homologous and, if so, the full extent of that homology.     

Electrical transport in light rare-earth vanadates

This paper reports electrical transport studies of rare-earth vanadates (RVO₄ with R = Ce, Pr, Nd, Sm, Eu and Gd), prepared by solid state reaction and characterized by X-ray diffraction studies. TGA study (300 to 1200 K) shows no weight loss; possible phase transitions in the range 1075 to 1300 K have been indicated by DTA studies. All these vanadates are typical semiconducting compounds with room temperature electrical conductivity (σ) lying between 10⁻⁴ and 10⁻²Ω⁻¹m⁻¹. Measurements of σ and the Seebeck coefficient (S) are reported in the temperature interval 400 to 1200 K. Two linear regions 400 to T ₁K and T ₁ to T ₂K have been obtained from the log σ against T ⁻¹ as well as the S against T ⁻¹ plots followed by a peak around T ₃ and minima around T ₄K. T ₄>T ₃>T ₂>T ₁, are different for different vanadates. It has been concluded that in the interval 400 to T ₁K, conduction is of the extrinsic hopping type with Ce⁴⁺ in CeVO₄, Pr⁴⁺ in PrVO₄ and V⁴⁺ in Nd to Gd vanadates as dominant defect centres. In the temperature interval T ₁, to T ₂K, the conduction has been shown to be of the intrinsic band type in all vanadates with polarons of intermediate coupling strength as the dominant charge carriers. Above T ₂ all vanadates tend to become metallic, but before this is achieved the phase change makes the conductivity smaller. T ₄ is close enough to the temperature corresponding to the DTA peak to be termed the phase transition temperature.     

The characteristics of the spontaneous activity of single neurons in the human ventrolateral thalamus during changes in the functional state of the brain

In the thalamic ventro-lateral nucleus of parkinsonian patients, two main types of convergent cells were shown to exist: 1) units with irregular discharges (A-cells, 74%) and 2) units with bursts of unstable rhythmic discharges (B-cells, 26%). The functional brain changes were accompanied by modifications of A-cells activity into the transient rhythmic burst-like pattern, characterized by two different types of intrinsic structure burst discharges being in some cases similar to the structure of B-cells. A correlation between activities of these units and the type of parkinsonian pathology was revealed.     

Erythema nodosum in pregnant patients with coccidioidomycosis

Pregnant patients with coccidioidomycosis develop dissemination and serious disease more frequently than do the general population. To assist in prognosis and management, we analyzed the significance of erythema nodosum in pregnant patients with coccidioidomycosis. Sixty-one pregnant patients (mean age +/- SD, 26.4 +/- 6.3 years) were evaluated. Seventy percent of the patients were Hispanic; 15%, African American; 13%, Caucasian; and 2%, unknown race. Of the 30 patients (49%) who developed erythema nodosum, 0 had disseminated disease (P = .001), 1 (3%) with pulmonary involvement required therapy for > 1 year, and 29 (97%) recovered (P = .0008). Of the 31 patients (51%) without erythema nodosum, 11 (35%) had disseminated disease, 12 (39%) required therapy for > 1 year, 17 (55%) recovered, 1 (3%) died, and 1 (3%) had an outcome that was unknown. Erythema nodosum appears to be a salient marker of a positive outcome for pregnant patients, more so than for the general population.