Biomedical subjects
E C Mangiante
Publications and source records attributed to E C Mangiante.
Rectal gunshot wounds. Management of civilian injuries.
The diagnosis and operative management of 43 consecutive low velocity wounds of the rectum were evaluated with regard to postoperative morbidity and mortality. Rectal and proctoscopic examinations, although frequently positive (80% and 91%, respectively), were not uniformly reliable in making the preoperative diagnosis. Diversion of the fecal stream by colostomy occupies a key role in operative management. Loop colostomy appears not only as efficacious as end colostomy and mucus fistula, but also requires less time to perform and subsequently close. Distal rectal washout is an important adjunct which reduces the incidence of rectal and intra-abdominal infectious complications. Civilian and military wounds of the rectum appear to differ in terms of the postoperative complications, mortality rate, and management techniques.
Posttraumatic and postoperative acute cholecystitis.
The development of peritonitis in hospitalized patients, especially those with significant associated illness, can be a difficult and delayed diagnosis. To ascertain the clinical presentation of acute cholecystitis in this group, a retrospective analysis was performed. Over a 10-year period 18 patients were identified who developed either posttraumatic or postoperative acute cholecystitis. The condition occurred in 12 patients admitted for some form of trauma and in six patients after elective surgery. Fever and right upper quadrant pain and tenderness were present in most. These physical findings were generally accompanied by leukocytosis (average = 16,200), hyperbilirubinemia (average = 4.2), and elevated alkaline phosphatase (average = 214). At laparotomy gangrenous cholecystitis was found in the majority, reflecting delayed diagnosis. Eleven patients had acalculous disease, and seven patients calculous cholecystitis. Three patients died, yielding a 17 per cent mortality. The majority with acalculous disease had significant underlying illness. Shock, multiple transfusions, or infection preceded acute cholecystitis in this group. Those with calculous cholecystitis were usually not as ill prior to its development. The morbidity of acute cholecystitis in previously hospitalized patients can be reduced by an awareness of the predisposing factors in those with acalculous disease. Emphasis should be placed on signs and symptoms rather than laboratory values to ensure early diagnosis and treatment of acute cholecystitis in hospitalized patients regardless of the presence or absence of gallstones.
Blunt duodenal disruption.
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Diagnosis and management of blunt bronchial injury.
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Duodenal rupture due to blunt trauma: a problem in diagnosis.
In our review of ten cases of duodenal disruption due to blunt trauma, we found a 30% mortality. Since early diagnosis would have lowered morbidity and mortality, a high index of suspicion needs to be maintained, combined with an aggressive diagnostic approach. Successful operation demands thorough duodenal exploration and facility with different methods of management.
Popliteal aneurysms. A clinical appraisal.
From 1950 to 1980, 49 popliteal aneurysms in 34 patients have been treated at the University of Tennessee Center for the Health Sciences. A retrospective analysis of these patients' records revealed that 88 per cent of these aneurysms and 40 per cent of patients had synchronous or metachronous development of aneurysms in other locations. At the time of diagnosis, 22 per cent of patients were truly asymptomatic, and 36 per cent presented with claudication. Approximately one third of patients presented with an acute limb-threatening complication, e.g., thrombosis, embolization, or rupture. Limb salvage rates were worse in patients with thrombosis (45%) and embolization (75%). The diagnosis was made on physical examination in all patients, with arteriography and ultrasonography proving to be useful adjuncts. This analysis supports proximal and distal aneurysmal ligation with reversed saphenous vein bypass as the procedure of choice. Asymptomatic aneurysms should be repaired based on a significant incidence of limb-threatening complications when untreated and a superior patency rate following surgical management.
Neoplasia of the extraperitoneal rectum and anus. The perineal dilemma.
A retrospective analysis was undertaken of 113 patients with biopsy-proven neoplasia of the extraperitoneal rectum and anus occurring between 1970 and 1975. Common initial symptoms included bleeding, constipation, and diarrhea; colon obstruction was the initial symptom in only ten cases. Adenocarcinoma occurred in 90 per cent of cases while lesions such as epidermoid cancer, carcinoid, and melanoma were encountered rarely. Operative treatment consisted of abdominoperineal resection (APR) in 60 cases, colostomy alone in 26 cases, anterior resection 13 cases, and electrocoagulation in four cases. Ten patients refused operative therapy. Of patients undergoing APR, 7 per cent died in the perioperative period. Postoperative morbidity included infection, impotence, bladder dysfunction, and perineal complications. The single most important factor contributing to this high morbidity was perineal wound management: 34 patients managed by the open method sustained a 47 per cent complication rate while the 26 patients with closed and adequately drained wounds had only a 15 per cent complication rate.
Cervicothoracic arterial injuries: recommendations for diagnosis and management.
Management of arterial injuries at the thoracic outlet and neck presents a major challenge to the trauma surgeon: hemorrhagic shock, neurologic deficit, and limb loss are the serious sequelae. Over a 13-year period, 118 patients with injuries to the innominate, carotid, subclavian, and axillary arteries were evaluated. Most injuries were penetrating (78%). Half of the patients were diagnosed by physical examination and half by angiography. Patients were treated by either primary repair (35%), interposition graft (31%), ligation (8%), or anticoagulation (26%). Two patients required amputations (1 digit, 1 above elbow). Overall mortality was 14%, with 5% due to consequences of hemorrhagic shock, 7% due to cerebral ischemia, and 2% due to other causes. Claviculectomy, median sternotomy, and trap door incisions were routinely used for proximal vascular control and repair. We conclude that liberal use of angiography is indicated in stable patients for penetrating wounds near major arteries, and for blunt injuries associated with neurologic deficits unexplained by computed tomography. Patients with obvious arterial injury should have immediate exploration. Extensile exposure is mandatory for appropriate management. Blunt carotid dissections are generally best managed non-operatively with anticoagulation.
Prophylactic antibiotics for elective colorectal surgery or operation for obstruction of the small bowel: a comparison of cefonicid and cefoxitin.
Elective colorectal surgery carries a rate of septic complications of up to 35% in patients not receiving prophylaxis. This can be reduced to 5% in patients receiving appropriate prophylactic agents. The safety and efficacy of cefonicid, a new cephalosporin with a half-life of 4-5 hr, were compared with those of cefoxitin for prophylaxis in patients undergoing elective colorectal procedures or surgery for obstruction of the small bowel. Fifty-seven assessable patients were randomly assigned in a double-blind fashion to therapy with 1 g of cefonicid intravenously (iv) or intramuscularly (im) 1 hr before surgery only or 2 g of cefoxitin iv or im 1 hr before surgery and 2 g every 6 hr for 24 hr. Groups were comparable in terms of underlying diseases. Samples for blood culture were obtained immediately before and after surgery and at 8:00 A.M. on the first and second postoperative days. No blood cultures were positive. Two of 30 patients receiving cefonicid developed wound infections (6%). Two of 27 patients receiving cefoxitin developed wound infections, and one developed an intraabdominal abscess (11%). No significant adverse effects were noted. The results suggest cefonicid may be an effective prophylactic antibiotic for bowel surgery. Most importantly, cefonicid offers the advantages associated with the administration of a single daily dosage, among which are reduction of pharmacy costs and the freeing of nursing hours for patient care.