Surgery
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Splenectomy is known to increase the risk of overwhelming bacterial infection. Characteristically, there is a decrease in immunoglobulin IgM, properdin, and T-lymphocytes; impaired primary antibody response to antigen challenge; an altered opsonic function; and a tuftsin deficiency. Because the spleen is important in host defense, preservation of traumatized splenic tissue has been advocated. ⋯ Initially low IgM and C3 complement levels increased to normal. Scans at 8 weeks confirmed the presence of functioning splenic tissue. Autotransplantation of the spleen is a safe method for preserving splenic function when total splenectomy is mandatory for hemostasis.
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Fourteen patients with lateral duodenal fistulas were treated over an 8-year period. Fistulas occurred after abdominal trauma (7) or as complications of operations for peptic ulcer (4) and biliary tract disease (3). Six patients with posttraumatic fistulas had had a delay of longer than 24 hours in recognition of the initial duodenal injury. ⋯ Definitive operations performed in the presence of uncontrolled infection and with inadequate duodenal decompression were followed by fistula recurrence (3 patients). There was one fistula-related death (a 7% mortality rate). These results suggest that (1) lateral duodenal fistulas have a low rate of spontaneous closure; (2) when maximal nonoperative management fails, operative diversion and decompression of the duodenum can simplify management and reduce the mortality rate; and (3) definitive therapy is best reserved for situations in which infection is controlled.