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.
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The objective of this study was to define the response of extravascular lung water (EVLW) to different levels of positive end-expiratory pressure (PEEP) following a standardized oleic acid injury to the lung. All animals responded to the injection of intravenous oleic acid by the rapid development of hypoxemia. There was a twofold increase in EVLW during the first 3 hours after oleic acid injection which remained stable during the remainder of the experiment, including periods on PEEP. ⋯ This was due to the decrease in cardiac output that more than offset the effects of a diminished Qs/Qt with PEEP. This study indicates that the mechanism by which PEEP improves oxygenation does not appear to be mediated by effect on lung water. The study also emphasizes the importance of determining oxygen transport when managing patients on PEEP.
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The reticuloendothelial system (RES) is thought to ensure organ integrity following trauma, burn, and sepsis by removing potentially embolic particulate matter and blood-borne bacteria from the circulation. Blockade of the RES with foreign colloids is known to result in a consumptive depletion of opsonic fibronectin, which modulates reticuloendothelial function, and an increase in lung localization of test particles. We investigated the role of neutrophils as a contributing factor in the increased localization of blood-borne bacteria in the lung after blockade. ⋯ Experimentally induced neutropenia abrogated the effect of colloid injection on lung localization of bacteria. It is concluded that a particulate load results in simultaneous RE blockade and neutrophil margination in the lung, both of which contribute to the increase in lung localization of bacteria. A mechanism for neutrophil-mediated pulmonary injury related to RE dysfunction following trauma is proposed.