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H L Pachter

Publications and source records attributed to H L Pachter.

52 records · Page 3Linked to original sources
PubMed1984

A prospective comparison of two regimens of prophylactic antibiotics in abdominal trauma: cefoxitin versus triple drug.

To determine the best antibiotic regimen to employ in patients undergoing laparotomy for trauma, a randomized prospective study was designed comparing cefoxitin alone with a triple-drug regime of an aminoglycoside, ampicillin, and clindamycin. One hundred nineteen consecutive patients sustaining abdominal trauma (97 penetrating; 22 blunt) were divided by date of admission to a 24-hour course of antibiotics. The overall infection rate was 16.0%, with 14.5% of the cefoxitin-treated patients, and 18.0% of the triple-drug-treated patients developing an infectious complication. Excluding remote site infections, the abdominal wound and intraperitoneal infection rates were 13.0% for cefoxitin-treated patients, and 12.0% for triple-drug-treated patients. There was one instance of oliguric renal failure questionably related to an aminoglycoside. It is concluded that a 24-hour course of cefoxitin is a safe and effective prophylactic antibiotic regime in patients undergoing laparotomy for trauma.

Abdominal Injuries↗
PubMed1984

Management of penetrating wounds of the back and flank.

The results of a retrospective and prospective study of patients with penetrating wounds of the back and flank showed that physical examination alone was accurate in 72 and 83 per cent, respectively. The inaccuracy was primarily due to false-negative examinations. The most commonly injured organs were the liver and kidney. The presence of gross hematuria and intravenous pyelography proved to have an accuracy rate of 95 per cent in patients studied prospectively. Peritoneal lavage, although similarly accurate (95 per cent), was associated with a 10 per cent false-negative result when the wound was located in the back. Guidelines for the management of these patients include hospital admission, careful physical examination, urinalysis by dipstick and cell count, intravenous pyelography and peritoneal lavage. Initial hypotension usually is associated with visceral injury and is an indication for exploratory laparotomy. Strict adherence to these guidelines was associated with a negative exploration rate of less than 10 per cent and a decrease in the number of patients observed with visceral injury from 50 to 6 per cent.

Abdominal Injuries↗
PubMed1983

Experience with the finger fracture technique to achieve intra-hepatic hemostasis in 75 patients with severe injuries of the liver.

The most important concept emerging from the management of complex hepatic trauma is that direct suture ligation of severed blood vessels and bile ducts is the most effective treatment. Three essential maneuvers are necessary: (1) the use of the finger fracture technique to expose the laceration widely, so that individual ligation of severed blood vessels and bile ducts can be accomplished under direct vision; (2) occluding the portal triad for 20 to 60 minutes; (3) closure of the hepatic incision over a viable omental pedicle. Two hundred consecutive patients with hepatic injuries were treated at the Trauma and Shock Unit of Bellevue Hospital between July 1976 and January 1982. One hundred and twenty-five injuries (63%) could be managed by superficial suture and drainage alone; 75 (37%) more extensive injuries required additional therapy; 47 of the 75 injuries required inflow occlusion for periods of up to 60 minutes, with the mean occlusion time of 30 minutes. All patients were pretreated with 30 to 40 mg/kg of Solu-Medrol prior to cross-clamping the portal triad. In addition, the liver was cooled to 27-32 degrees C topically by pouring 1 liter of iced Ringer's lactate directly on the liver surface, monitoring the temperature with an intra-hepatic probe. Ischemia time exceeded 20 minutes in 70%, 30 minutes in 40% and 60 minutes in 7% of patients. This approach, with complex hepatic trauma, has been dramatically effective. There were only four deaths (5.3%). One (1.3%) patient required reoperation for bleeding; three patients (4%) developed perihepatic abscesses; and two patients (3%) developed biliary fistulae that spontaneously closed. An extended right hepatectomy was necessary in the one patient who required reoperation for bleeding. This represents the only case of a formal hepatic resection in this series. Hepatic artery ligation was not employed in any case. These experiences strongly endorse the direct approach to the treatment of major hepatic lacerations by opening a lacerated liver sufficiently to ligate lacerated blood vessels and bile ducts, followed by closure over an omental pedicle. The wide-spread adoption of this technique will probably lower the mortality from massive liver injuries to 5-10%.

Bile Ducts↗
PubMed1982

Iatrogenic intussusception: a complication of long intestinal tubes.

Intussusception secondary to long intestinal tubes is a relatively uncommon but potentially fatal occurrence. From 1976 to 1979 we have studied five patients with this complication. The mercury-filled bag stimulates peristalsis, the tube is drawn forward, and there is resultant telescoping and "pleating" of the proximal small bowel. If these pleats become fixed by adhesions, they may act as a lead point for intussusception, even after tube withdrawal. Early diagnosis is essential for effective therapy.

Adult↗
PubMed1981

Open and percutaneous paracentesis and lavage for abdominal trauma: a randomized prospective study.

To compare the accuracy and safety of open abdominal paracentesis and lavage vs percutaneous paracentesis and lavage, 210 consecutive patients were prospectively randomized into two groups of 105 each. There were no false-negative diagnoses in either group. The accuracy rate for the open method was 98.1%, and 91.4% for the percutaneous method. Six major complications were encountered with the percutaneous method, for a complication rate of 5.7% compared with no major complications with the open method. The results suggest that the open technique is superior to the percutaneous method.

Abdominal Injuries↗
PubMed1981

Evolving concepts in splenic surgery: splenorrhaphy versus splenectomy and postsplenectomy drainage: experience in 105 patients.

A major advance in recent years has been the demonstration in children that most injuries of the spleen can safely be repaired. There is, however, a relative paucity of data regarding primary suture repair of the spleen in adults. This report describes experience with the treatment of 27 consecutive injuries of the spleen between 1978-1980. Splenorrhaphy was successful in 24 of 27 patients. Eighteen of the 24 patients were older than 15 years of age. Seven injuries resulted from penetrating trauma, 13 from blunt trauma, and four from injuries during operation. Repair included debridement, partial splenectomy, and primary suture repair, often in conjunction with Avitene((R)). There were no reoperations for bleeding or postoperative infection. Three splenectomies (11%) were necessary because of either complete destruction of the splenic pulp, or separation of the spleen from its blood supply at the hilum. A separate question for decades has been the influence of types of drainage on infection following splenectomy. To study this question, between 1976-1978, 78 patients undergoing splenectomy were randomized prospectively by sealed envelopes into three groups. Group I-no drainage (23 patients); Group II-closed drainage with Jackson-Pratt drains (30 patients); Group III-open drainage with Penrose drains (25 patients). All but three drains were removed within 48 hours. In these three patients, the drains were removed after 96 hours. In the 53 patients in Group I and II, there were no infections. In Group III (Penrose drains) there were two complications: evisceration of a loop of small bowel through the drain site, and one subphrenic abscess in a patient with a concomitant colonic injury. Present experience does not show any significant difference among the three groups. Concomitant enteric injuries and the duration of drainage maybe the most significant factors influencing infection. The presence or absence of drains per se does not seem significant.

Adolescent↗
PubMed1979

Recent concepts in the treatment of hepatic trauma: facts and fallacies.

Experience with 85 consecutive patients treated at Bellevue Hospital for hepatic trauma over the past two years has established the importance of several principles of management. Simple liver injuries can be treated by superficial suture and drainage. Using this approach in 57 patients there were no deaths and no postoperative abscesses. Among 28 other patients with complex liver injuries, the first six patients (Group 1) were treated by lobectomy alone (1 patient), lobectomy and intracaval shunt (3 patients), hepatic artery ligation (1 patient), and left lateral segmentectomy (1 patient). Only one of the six survived. In the next 22 consecutive patients managed by the Pringle maneuver combined with finger fracture technique of the hepatic parenchyma and a viable omental pack there was only one death (4.5%). An intracaval shunt was used successfully once in this group, in a patient with a lacerated middle hepatic vein. Only one patient developed a postoperative subphrenic abscess (4.5%), and no patients required reoperation for bleeding. Eighty-two per cent of these 22 patients safely tolerated inflow occlusion of greater than 20 minutes with steroid protection. Hepatic artery ligation is superfluous in the majority of liver injuries. In complex injuries involving lobar branches of the portal vein, the retrohepatic cava or hepatic veins hepatic artery ligation is probably ineffective. Hepatic resection is rarely required and carries a prohibitive mortality. The finger fracture technique provides a direct approach to the source of heniorrhage and is probably the procedure of choice.

Adult↗
PubMed1979

Simplified distal pancreatectomy with the Auto Suture stapler: preliminary clinical observations.

The most serious complication following distal pancreatectomy is the development of a pancreatic fistula or subphrenic abscess. These complications are particularly prone to occur following distal pancreatectomy for trauma. The injured pancreas is divided in a contaminated field, often in the presence of hemorrhage and partly devitalized tissues, in which identification and secure closure of the transected pancreatic duct may be difficult. A review of 12 surgical publications describing experience with 234 distal pancreatectomies performed for trauma found the average pancreatic fistula rate to be 13% an in some reports as high as 25% to 30%. In an attempt to decrease the high postoperative fistula rate after distal pancreatectomy, transection of the gland with the autosuture has been investigated. There are at least three theoretical advantages of this technique. The pancreas is transected through healthy tissue, the pancreatic duct is closed securely, and stainless steel sutures are used, which probably are more resistant to the development of infection than other suture material. This report describes a technique of distal pancreatectomy for both trauma surgery and elective surgery with the TA-55 Auto Suture stapler. TA-55 Auto Suture stapler, with 3.5 mm staples, is placed across the mobilized pancreas, and two rows of staggered stainless steel staples are laid down. The gland distal to the stapler then is amputated. At present this technique has been used in a total of 12 cases--four for trauma and eight during elective procedures. One fistula related to pancreatectomy performed with the Auto Suture stapler developed, for a complication rate of 8.3%. This preliminary experience indicates that a more widespread evaluation of this technique is indicated.

Adult↗
PubMed1979

The radiation-injured bowel.

Radiation disease of the intestine is usually iatrogenic and frequently unavoidable. The disease, its treatment, and the disability produced are formidable. There is hope that means may be found to increase the resistance of the intestine to radiation damage. Radiation enteropathy is an insidious, progressive disease that is seen with increasing frequency. Serious disabilities may develop after years of gestation. Those patients who require surgery are treated by control of sepsis, correction of metabolic abnormalities, and reversal of protein/calorie malnutrition prior to definitive surgery. The treatment of choice is resection with anastomosis, but recurrences may occur many years later in intestine grossly normal at the time of surgery.

Colitis↗
PubMed1979

Traumatic injuries of the portal vein. The role of acute ligation.

Injuries to the portal vein are rare but have a high risk with a mortality of 50--70% secondary to exsanguinating hemorrhage. When managing injuries to the portal vein, lateral venorrhaphy, end to end anastomosis, or an interposition graft should be attempted whenever possible. However, in a hemodynamically unstable patient or when confronted with a nonreconstructable injury, acute portal vein ligation may be the procedure of choice as it is safely tolerated in some 80% of patients. Of eleven reported patients in whom the portal vein was ligated acutely for traumatic injury, six survived. Four of the nonsurvivors died of massive associated injuries. Of the six surviving patients, five tolerated acute ligation of the portal vein without complication. Should portal vein ligation be performed a "second look" operation is essential in 24 hours to examine the bowel for viability. A portosystemic shunt with its inherent complications should not be done as a primary procedure when attempts at reconstruction of the portal vein have failed. Shunting should be reserved for those few patients who develop stigmata of portal hypertension or impending infarction of the bowel.

Abscess↗
PubMed1977

Low dose heparin: bleeding and wound complications in the surgical patient. A prospective randomized study.

A randomized prospective study of low dose heparin was performed in 175 surgical patients to determine the frequency of bleeding and wound complications. The patients were divided into three groups: (1) low dose heparin (5000 units two hours before operation and 5000 units every 12 hours following operation for five days); (2) low dose heparin postoperatively only; and (3) a control group. The frequency of bleeding and wound complications was 27% in group I, 7.5% in group II, and 1.4% in group III. The difference between the control patients and those heparinized pre- and postoperatively is statistically significant (p less than 0.005). None of the patients in any of the three groups had a pulmonary embolus, but the number of patients involved is too small to assess the significance of this finding. However, a bleeding and wound complication rate of 27% is significant. These findings indicate that perhaps the routine use of low dose heparin should be reserved for those patients with preoperative factors indicating an increased risk from thromboembolism.

Hematoma↗
PubMed1977

Heparin.

Explore the source record for details and available documents.

Heparin↗
PubMedDate not supplied

Laparoscopy for penetrating thoracoabdominal trauma: pitfalls and promises.

BACKGROUND: How should the stable patient with penetrating abdominal or lower chest trauma be evaluated? Evolving trends have recently included the use of diagnostic laparoscopy. In September 1995 we instituted a protocol of diagnostic laparoscopy to identify those patients who could safely avoid surgical intervention. DESIGN: Prospective case series. MATERIALS AND METHODS: Hemodynamically stable patients with penetrating injuries to the anterior abdomen and lower chest were prospectively evaluated by diagnostic laparoscopy, performed in the operating room under general anesthesia, and considered negative if no peritoneal violation or an isolated nonbleeding liver injury had occurred. If peritoneal violation, major organ injury or hematoma was noted, conversion to open celiotomy was undertaken. RESULTS: Seventy consecutive patients were evaluated over a two-year period. The average length of stay (LOS) following negative laparoscopy was 1.5 days, and for negative celiotomy 5.2 days. There were no missed intra-abdominal injuries following 30 negative laparoscopies, and 26 of 40 laparotomies were therapeutic. The technique also proved useful in evaluation of selected blunt and HIV+ trauma victims with unclear clinical presentations. However, while laparoscopy was accurate in assessing the abdomen following penetrating lower chest injuries, significant thoracic injuries were missed in 2 out of 11 patients who required subsequent return to OR for thoracotomy. CONCLUSIONS: Laparoscopy has become a useful and accurate diagnostic tool in the evaluation of abdominal trauma. Nevertheless, laparoscopy still carries a 20% nontherapeutic laparotomy rate. Additionally, significant intrathoracic injuries may be missed when laparoscopy is used as the primary technique to evaluate penetrating lower thoracic trauma.

Abdominal Injuries↗