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M Schein

Publications and source records attributed to M Schein.

At least 73 records · Page 4Linked to original sources
PubMed1996

Let us shorten antibiotic prophylaxis and therapy in surgery.

Excessive duration of antibiotics for prophylaxis and treatment of surgical infection appears to be the principal reason for "inappropriate" administration in current surgical practice. The main factors to blame are the inability of the clinician to distinguish between contamination, infection, and inflammation. Failure to distinguish between contamination and infection is the reason that prophylaxis is unnecessarily carried through into the postoperative phase for prolonged periods. Failure to distinguish between infection and inflammation misguides surgeons to continue antibiotics for unnecessarily long treatment periods. The concept for shortening courses of antibiotic administration is supported by a forum of experts. The majority of experts also favored a trend away from the use of therapeutic courses of fixed duration, by tailoring the duration of administration to the intraoperative findings to shorten treatment courses. Specific recommendations are (1) contamination: single dose prophylaxis (gastroduodenal peptic perforations operated within 12 hours, traumatic enteric perforations operated within 12 hours, peritoneal contamination with bowel contents during elective or emergency procedures, early or phlegmonous appendicitis, or phlegmonous cholecystitis); (2) resectable infection: 24-hour postoperative antibiotics (appendectomy for gangrenous appendicitis, cholecystectomy for gangrenous cholecystitis, bowel resection for ischemic or strangulated "dead" bowel without frank perforation); (3) advanced infection: 48 hours to 5 days, based on operative findings and patient's condition (intra-abdominal infection from diverse sources); (4) severe infection with the source not easily controllable: longer administration periods may be necessary (e.g., infected pancreatic necrosis).

Anti-Bacterial Agents↗
PubMed1996

Hypothesis: compartmentalization of cytokines in intraabdominal infection.

BACKGROUND: Although the proximal role of systemic cytokines in the infectious-inflammatory cascades is well recognized, the magnitude and meaning of its intraperitoneal levels in peritonitis have received little attention. We hypothesized that in peritonitis a significant and clinically relevant cytokine-mediated inflammatory response is compartmentalized in the peritoneal cavity. METHODS: MEDLINE was used to search the literature for all articles dealing with experimental, primary, and secondary bacterial peritonitis and cytokines. RESULTS: Bacterial peritonitis is associated with an immense intraperitoneally compartmentalized cytokine response, with plasma levels of cytokines representing only the tip of the iceberg. Although certain amount of cytokines may be beneficial to the peritoneal defense mechanisms, higher levels correlate with adverse outcome. Thus it is plausible to look at acute peritonitis as initially a combined infective (microorganism) and inflammatory (cytokines) process. The clinical significance of the distinction between peritoneal inflammation and infection and the relevance of our findings to the stratification and treatment of peritonitis are discussed. CONCLUSIONS: Current surgical and antibiotic therapy for peritonitis is able to clear the peritoneal cavity of infective concentration of bacteria, but many patients continue to die of an uncontrolled activation of the inflammatory cascade. We suggest that one potential venue for therapeutic progress is the modulation of the compartmentalized peritoneal inflammatory response.

Animals↗
PubMed1996

Management of secondary peritonitis.

OBJECTIVE: The authors review current definition, classification, scoring, microbiology, inflammatory response, and goals of management of secondary peritonitis. SUMMARY BACKGROUND DATA: Despite improved diagnostic modalities, potent antibiotics, modern intensive care, and aggressive surgical treatment, up to one third of patients still die of severe secondary peritonitis. Against the background of current understanding of the local and systemic inflammatory response associated with peritonitis, there is growing controversy concerning the optimal antibiotic and operative therapy, intensified by lack of properly conducted randomized studies. In this overview the authors attempt to outline controversies, suggest a practical clinical approach, and highlight issues necessitating further research. METHODS: The authors review the literature and report their experience. RESULTS: The emerging concepts concerning antibiotic treatment suggest that less-in terms of the number of drugs and the duration of treatment-is better. The classical single operation for peritonitis, which obliterates the source of infection and purges the peritoneal cavity, may be inadequate for severe forms of peritonitis; for the latter, more aggressive surgical techniques are necessary to decompress increased intra-abdominal pressure and prevent or treat persistent and recurrent infection. The widespread acceptance of the more aggressive and demanding surgical methods has been hampered by the lack of randomized trials and reportedly high associated morbidity rates. CONCLUSIONS: Sepsis represents the host's systemic inflammatory response to bacterial peritonitis. To improve results, both the initiator and the biologic consequences of the peritoneal infective-inflammatory process should be addressed. The initiator may be better controlled in severe forms of peritonitis by aggressive surgical methods, whereas the search for methods to abort its systemic consequences is continuing.

Abdomen↗
PubMed1996

Carcinoid tumor of the common bile duct.

A case of primary carcinoid tumor of the common bile duct is presented. Diagnostic and therapeutic uncertainties of this extremely rare cause of jaundice are discussed.

Adult↗
PubMed1996

Safety of laparoscopic cholecystectomy on a teaching service: a prospective trial.

In a prospective audit of our first 213 laparoscopic cholecystectomies (LC), we compared the results obtained by qualified surgeons to those obtained by residents. The first group started performing LC after undergoing formal laboratory laparoscopic courses. The second group was introduced to LC by standard attending-resident teaching in the operating room. In all, 137 LC wer performed by qualified surgeons and 76 by residents. Patients' clinical and laboratory characteristics were not significantly different in the two groups. The conversion rate to laparotomy (11.5% and 12.5%), mean duration of surgery (88 and 83 min), iatrogenic perforation of the gallbladder (16% and 18.5%), "lost stones" (7% and 4%), use of drains (12% and 13%), and extension of the umbilical port incision (about 30% in both groups) were similar in the two groups. The incidence of biliary (3% and 4%) and infectious (3.5% and 4%) complications was equivalent in both groups. We conclude that with the traditional attending-resident approach to surgical education, residents safely and quickly acquire the necessary skills to perform LC without jeopardizing the safety of patients.

Adult↗
PubMed1996

Duration of antibiotic treatment in surgical infections of the abdomen. Forum statement: a plea for selective and controlled postoperative antibiotic administration.

Excessive duration of antibiotics appears to be the principal reason for their inappropriate use in current surgical practice. The main factors to blame are the inability of the clinician to distinguish between contamination and infection, infection and inflammation, and failure to stratify the latter. Consequently, and unnecessarily, prophylactic drugs are carried through into the postoperative period and treatment is continued for long periods. Most experts who contributed to this Discussion Forum favour a trend away from the use of therapeutic courses of fixed duration, and towards attempts to stratify the infective processes, minimising administration by tailoring the duration to the clinical findings. As a consensus of this forum specific recommendations are: Contamination (gastroduodenal peptic perforations operated within 12 hours, traumatic enteric perforations operated with 12 hours, peritoneal contamination with bowel contents during elective or emergency procedures, early or phlegmonous appendicitis or phlegmonous cholecystitis): single dose prophylaxis. Resectable infection (appendicectomy for gangrenous appendicitis, cholecystectomy for gangrenous cholecystitis, bowel resection for ischaemic or strangulated dead bowel without frank perforation): 24 hours postoperative antibiotics. Advanced infection (intra-abdominal infection from diverse sources): 48 hours to 5 days, based on operative findings and patient's condition. Severe intra-abdominal infection with the source not easily controllable (infected pancreatic necrosis, postoperative intra-abdominal infection): longer courses may be necessary.

Anti-Bacterial Agents↗
PubMed1995

Inflammatory response in peritoneal exudate and plasma of patients undergoing planned relaparotomy for severe secondary peritonitis.

OBJECTIVE: To study the pattern of intraperitoneal cytokine release in secondary peritonitis and its correlation with plasma levels and prognosis. DESIGN: Noncomparative descriptive case series. SETTING: Department of surgery in a university hospital. PATIENTS: Seventeen consecutive patients undergoing planned relaparotomy for severe intra-abdominal infection (Acute Physiological and Chronic Health Evaluation [APACHE II] score > 10; mean score, 17.5). INTERVENTIONS: The following were measured at the first and last serial operations in the peritoneal exudate and plasma: endotoxin, tumor necrosis factor alpha (TNF-alpha), interleukin-1 (IL-1), interleukin-6 (IL-6), elastase, and neopterin. MAIN OUTCOME MEASURES: Survival and death. RESULTS: Six patients died. Peritoneal endotoxin levels were significantly higher than in the plasma and were significantly higher in the nonsurvivors. Plasma TNF-alpha, IL-6, elastase, and neopterin levels remained elevated in the nonsurvivors prior to death. Levels of TNF-alpha, IL-6, elastase, and endotoxin were 19, 993, 239, and 7 times higher, respectively, in the peritoneal exudate than in plasma, all significant differences. Elastase and TNF-alpha levels decreased in survivors during the operative treatment but remained elevated in the nonsurvivors. CONCLUSIONS: Secondary peritonitis is associated with a significant cytokine-mediated inflammatory response that is compartmentalized in the peritoneal cavity and indicates an adverse prognosis. Levels of cytokines in the exudate of peritonitis may be used to better stratify the severity of peritonitis and, in future, to guide local therapy.

Adult↗