Bivins Ba

With the obvious failure of nonoperative means of producing permanent weight reduction in patients with morbid obesity, operative approaches have become popular. In the late 1960's and early 1970's, jejunoileal bypass was shown to produce permanent weight reduction and became the most performed operation. However, as the patients were observed for a long term, many untoward complications became evident. The most serious complication of liver disease and even liver failure with fatalities was observed and has accounted for 91 reported deaths following jejunoileal bypass. Other complications include severe electrolyte imbalance, requiring frequent rehospitalization of the patient; renal calculi which is related to excess oxalate absorption; arthritis which is probably secondary to complement activation of high molecular weight immune complexes formed in response to the absorption of bacterial antigens; cholelithiasis which is related to reduced bile salts; a variety of intestinal difficulties, such as bypass enteritis, and pseudo-obstruction of the colon; osteomalacia and decreased bone mineral content; failure in absorption of some medications and fat-soluble vitamins, and most recently, the possibility of induced carcinoma of the colon. Because of these many complications, it is suggested that the jejunoileal bypass is not an appropriate operation for morbidly obese patients and should be abandoned.

Infusion phlebitis is the most common complication of intravenous therapy. Six methods of reducing the incidence of infusion phlebitis including inline final filtration, buffers, heparin, hydrocortisone, heparin-hydrocortisone combinations, and frequent set changes were tested in a two part randomized prospective double-blind study of 266 surgical patients. Patients who received filtered fluids had a significantly decreased incidence of infusion phlebitis as compared with that of controls (P = 0.0000001). Of the other methods tested, only the heparin-hydrocortisone combinations achieved any significant decrease in phlebitis (P less than 0.5). Therefore, inline filtration is a highly effective means of decreasing the incidence of infusion phlebitis and should be considered as a routine part of intravenous therapy.

Over-all, the results of this review suggest that mandatory exploration for penetrating wounds of the neck may be safely supplanted by selective management. The basis for this conclusion includes: 1, most neck wounds were not associated with significant injury; 2, routine exploration did not obviate the possibility of missed injuries; 3, negative findings at exploration were associated with a number of complications; 4, hospital stay for patients with negative neck exploration results was similar to those with positive exploration findings, and 5, it appears that selective management should not increase the need for special diagnostic studies. Patients with clearly positive clinical findings indicating visceral neck injury should undergo operative exploration. Those with a negative clinical examination should be closely observed. Contrast roentgenographic and other special studies should be reserved for those with equivocal clinical findings or who have a change in clinical status under observation.

During the review period, 41 trauma service patients were found to have penetrating pancreatic injuries. The cause of injury was a gunshot wound in 25 patients, stab wound in 13 patients, and shotgun wound in 3 patients. All patients had at least one other intra-abdominal organ injured, and 19 (46%) were admitted in shock. The pancreatic injury was managed by resection in 21 patients, drainage in 19 patients, and diverticulization in 1 patient. Complications related to the pancreatic injury developed in 11 (52%) treated by resection. By comparison pancreatic complications were seen in only three (16%) patients managed with drainage (P = 0.04). The mortality rate for resection was 19 per cent compared to 11 per cent for drainage (N.S.). Differences in morbidity observed could not be clearly accounted for by severity of injury. Based on these data, the authors recommend drainage for the majority of penetrating pancreatic injuries and suggest resection be reserved for injuries requiring debridement for hemostasis.