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BACKGROUND Antimicrobial guidance for common bile duct (CBD) stones is limited. We sought to examine the effect of antibiotic duration on infectious complications in patients with choledocholithiasis and/or gallstone pancreatitis. METHODS We performed a post hoc analysis of a prospective, observational, multicenter study of patients undergoing same admission cholecystectomy for choledocholithiasis and gallstone pancreatitis between 2016 and 2019. We excluded patients with cholangitis and/or cholecystitis. Patients were divided into groups based on duration of antibiotics: prophylactic (

Background The incidence of underlying malignancy in appendicitis ranges between 0.5% and 1.7%. We sought to identify the subset of patients with appendicitis who are at increased risk of appendiceal malignancy. Methods Using the Eastern Association for the Surgery of Trauma Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous database, we included all patients from 28 centers undergoing immediate, delayed, or interval appendectomy between 2017 and 2018. Univariate then multivariable analyses were performed to compare patients with and without malignancy and to identify independent demographic, clinical, laboratory, and/or radiological predictors of malignancy. Akaike information criteria for regression models were used to evaluate goodness of fit. Results A total of 3,293 patients were included. The median age was 38 (27–53) years, and 46.5% were female patients. On pathology, 48 (1.5%) had an underlying malignancy (adenocarcinoma [60.4%], neuroendocrine [37.5%], and lymphoma [2.1%]). Patients with malignancy were older (56 [34.5–67] vs 37 [27–52] years, P 40 years with an appendiceal diameter >10 mm on computed tomography was 2.95% compared with 0.97% in patients ≤40 years old with appendiceal diameter ≤10 mm. The corresponding risk ratio for that population was 3.03 (95% confidence interval: 1.24–7.42; P = .02). Conclusion The combination of age >40 and an appendiceal diameter >10 mm is associated with a greater than 3-fold increased risk of malignancy in patients presenting with appendicitis.

Lower levels of physical activity in the first month after mild TBI predicts decreased conditioned pain modulation and greater pain catastrophizing in patients with mild TBI., Objective: The purpose of this study was to determine whether self-reported physical activity (PA) in the first month after mild traumatic brain injury (mTBI) predicts endogenous pain modulatory function and pain catastrophizing at 1 to 2 weeks and 1 month after injury in patients with mTBI. Methods: Patients with mild traumatic brain injury completed study sessions at 1 to 2 weeks and 1 month after injury. Assessments included a headache survey, Pain Catastrophizing Scale, International Physical Activity Questionnaire-Short Form, and several quantitative sensory tests to measure endogenous pain modulatory function including conditioned pain modulation (CPM), temporal summation, and pressure pain thresholds of the head. Hierarchical linear regressions determined the relationship between the PA variables (predictors) and pain catastrophizing and pain modulation variables (dependent variables) cross-sectionally and longitudinally, while controlling for potential covariates. Results: In separate hierarchical regression models, moderate PA, walking, and total PA at 1 to 2 weeks after injury predicted pain inhibition on the CPM test at 1 month, after controlling for significant covariates. In addition, a separate regression revealed that minutes sitting at 1 month predicted CPM at 1 month. Regarding predicting pain catastrophizing, the regression results showed that sitting at 1 to 2 weeks after injury significantly predicted pain catastrophizing at 1 month after injury. Conclusion: Greater self-reported PA, especially moderate PA, 1 to 2 weeks after injury longitudinally predicted greater pain inhibitory capacity on the CPM test at 1 month after injury in patients with mTBI. In addition, greater sedentary behavior was associated with worse pain inhibition on the CPM test and greater pain catastrophizing at 1 month after injury.

Background Residents are often viewed as contributors to Emergency Department (ED) prolongation of length of stay (LOS). To understand this proposition, we performed a study to identify ED patient care intervals and how each contributed to LOS. Methods We performed a retrospective review of prospectively gathered data on 145 ED surgery consults. Residents prospectively documented patient names, page times, and time of plan. Key ED patient care intervals were then retrospectively extracted from the patient's chart. A time analysis was then performed. Results Average arrival to disposition time was 305 min, and residents averaged 47 min to see and staff consults. The longest intervals were arrival to imaging (75 min) and imaging time (73 min). Average disposition to discharge time was 170 min (36% of LOS). Conclusions Surgery residents see and staff consults within the norms for care established by the hospital. Imaging time is a bottleneck hindering disposition. Access block also significantly increases ED LOS.

Background Post-traumatic headache (PTH) is one of the most common and long-lasting symptoms following mild traumatic brain injury (TBI). However, the pathological mechanisms underlying the development of persistent PTH remain poorly understood. The primary purpose of this prospective pilot study was to evaluate whether early pain modulatory profiles (sensitization and endogenous pain inhibitory capacity) and psychological factors after mild TBI predict the development of persistent PTH in mild TBI patients. Methods Adult mild TBI patients recruited from Level I Emergency Department Trauma Centers completed study sessions at 1–2 weeks, 1-month, and 4-months post mild TBI. Participants completed the following outcome measures during each session: conditioned pain modulation to measure endogenous pain inhibitory capacity, temporal summation of pain and pressure pain thresholds of the head to measure sensitization of the head, Pain Catastrophizing Scale, Center for Epidemiological Studies – Depression Scale, and a standardized headache survey. Participants were classified into persistent PTH (PPTH) and no-PPTH groups based on the 4-month data. Results The results revealed that mild TBI patients developing persistent PTH exhibited significantly diminished pain inhibitory capacity, and greater depression and pain catastrophizing following injury compared to those who do not develop persistent PTH. Furthermore, logistic regression indicated that headache pain intensity at 1–2 weeks and pain inhibitory capacity on the conditioned pain modulation test at 1–2 weeks predicted persistent PTH classification at 4 months post injury. Conclusions Overall, the results suggested that persistent PTH is characterized by dysfunctional alterations in endogenous pain modulatory function and psychological processes in the early stages following mild TBI, which likely exacerbate risk for the maintenance of PTH.

Background The Trauma Quality Improvement Program was designed by the American College of Surgeons to measure quality benchmarks across American College of Surgeons–certified trauma centers. The Hospital Consumer Assessment of Healthcare Providers and Systems survey was developed to report patient satisfaction with inpatient care and has been used as a surrogate for quality of care by the Affordable Care Act. The purpose of this study was to determine the correlation of hospitals’ Hospital Consumer Assessment of Healthcare Providers and Systems data to the Trauma Quality Improvement Program quality analysis. Methods A retrospective review of available Trauma Quality Improvement Program and Hospital Consumer Assessment of Healthcare Providers and Systems results from an American College of Surgeons level 1 trauma center 2016–2017 was performed. Trauma Quality Improvement Program and Hospital Consumer Assessment of Healthcare Providers and Systems data were represented as either above, at, or below the mean of national data and were analyzed using the Fisher exact test. Results Hospital Consumer Assessment of Healthcare Providers and Systems scores from wards participating in care of trauma patients were summarized by perceived level of quality. Trauma Quality Improvement Program data for risk-adjusted mortality were included in analysis for all trauma admissions. The Fisher exact test was used to analyze contingency tables of data and was found to support the null hypothesis ( P = .1109). Conclusion Overall Hospital Consumer Assessment of Healthcare Providers and Systems rating is most significant for hospitals because it is a global view of patient satisfaction and is used to determine a portion of hospital reimbursement. It is believed that higher patient satisfaction is correlated with lower readmission rates and improved outcomes, thus resulting in cost savings for hospitals. However, it appears that overall Hospital Consumer Assessment of Healthcare Providers and Systems rating does not correlate with measured outcomes in terms of risk-adjusted mortality for trauma admissions. It is suggested from these data that trauma patients be considered independently from other hospitalizations and that Hospital Consumer Assessment of Healthcare Providers and Systems may not be an appropriate tool to determine reimbursement for trauma admission.

The main indications for laparoscopic cholecystectomy are stone-related diseases in adults. With a normal abdominal ultrasound (US), a hepatobiliary iminodiacetic acid (HIDA) scan with ejection fraction (EF) is recommended to evaluate gallbladder function. Biliary dyskinesia or low gallbladder EF (EF 35%) is a recognized indication for cholecystectomy. Recent articles report long-term resolution of symptoms in children with high EFs on the HIDA scan. The purpose of this study is to evaluate the response of patients with biliary colic and hyperkinetic gallbladder to cholecystectomy. We suggest that laparoscopic cholecystectomy might be a considerable surgical option in a subset of the adult population whose workup for food-related biliary abdominal pain is negative except for the high-value EF on HIDA scan.Data were consecutively collected from all patients who underwent laparoscopic cholecystectomy between June 2012 and June 2019 at a single institution. Cases were identified using Current Procedural Terminology codes. Patients older than 17 years of age with the negative US (no stone, no sludge, no gallbladder wall thickening) and EF greater than 80% on cholecystokinin (CCK)-HIDA scan were included in this study. All patients were seen at 2 weeks and 10-16 months after surgeries.Over 7 years from June 2012 until June 2019, of 2116 patients who underwent laparoscopic cholecystectomy, 59 patients (2.78%) met study criteria. Postprandial abdominal pain was the most common symptom (43, 72.90%) followed by nausea/vomiting. Forty-seven patients (74.6%) had a reproduction of symptoms with CCK infusion. The average EF was 88.51%. Final pathology showed chronic cholecystitis in 41 (69.5%) patients, cholesterolosis in 13 (22%), polyp in 2 (3.4%). Thirty-six (61%) patients had complete resolution of symptoms, 9 (15%) patients had partial resolution, and 14 (24%) patients had no change. There was a complete resolution rate of 61% and an improvement rate of 76%.In patients with biliary symptoms, negative ultrasound, and elevated EF on HIDA scan (EF 80%), laparoscopic cholecystectomy led to a significant rate of symptomatic relief. Interestingly, 94% also had unexpected pathologic findings. This disease process requires further analysis, but this could represent a new indication for laparoscopic cholecystectomy in the adult population.

Pancreatic microadenomas are benign tumors of neuroendocrine origin less than 5 mm in size. Whereas most microadenomas are non-functional; a few rare functional pancreatic microadenomas have been described in the setting of multiple endocrine neoplasia type one (MEN-1). In this report, we describe a unique case of multiple functional microadenomas of the pancreatic head in a patient who presented with persistent secretory diarrhea, refractory hypokalemia, metabolic acidosis and elevated plasma vasoactive intestinal peptide (VIP) levels. Following extensive serologic, radiographic and endoscopic work up, our patient underwent open pancreaticoduodenectomy with subsequent resolution of diarrheal symptoms and electrolyte abnormalities on postoperative follow up.

Objective To evaluate whether elevated intracranial pressure (ICP) or depressed cerebral perfusion pressure (CPP) is a better predictor of intracranial compartment syndrome and long-term functional outcomes in blunt traumatic brain injury. Methods This was a retrospective evaluation of data collected on 203 patients with blunt traumatic brain injury who were admitted to Miami Valley Hospital, a Level I trauma center, over a 2 years period, whose initial hospital management required an intracranial pressure monitor. Serial measurements of ICP and CPP were recorded during the patients hospital stay. These patients were then evaluated at 3,6,12 and 24 months post-injury to assess their outcome based on functional status, as defined by death vegetative state, severe disability, moderate disability and good recovery. Results Utilizing an ICP cut-off value of 25 or greater and a CPP value of less than 60 at any point during the patients hospital course, ICP elevation consistently correlated with a higher percentage of deaths and persistent vegetative state than a depression in CPP value. Outcomes as measured by severe or moderate disability where similar in both groups. However, neither measure approached statistical significance. Conclusion ICP appears to be a better predictor of intracranial compartment syndrome and extent of brain injury, predicting better than CPP values, the outcome of death or persistent vegetative state. This may help to predict prognosis, change management strategies and guide discussions with family, especially in the early phase of injury. How to cite this Article Markert RJ, Saxe JM, Chadwick CL. Intracranial Pressure is a Better Predictor of Mortality than Cerebral Perfusion Pressure. Panam J Trauma Critical Care Emerg Surg 2012;1(1):15-19.

Background We conducted this study to compare short-term outcomes and charges between methods of hernia repair and anesthesia in the outpatient setting. Methods Using New York's state ambulatory surgery databases, we identified discharges for patients who underwent inguinal hernia repair. Patients were grouped by method of hernia repair. We compared hospital-based acute care encounters and total charges across groups. Results Locoregional anesthesia (5.2%) experienced a similar frequency of hospital-based acute care encounters within 30 days of discharge when compared with patients receiving general (6.0%) or having a laparoscopic procedure (6.0%). Risk-adjusted charges increased across groups (locoregional = $6,845 vs general = $7,839 vs laparoscopic = $11,340, P Conclusion Open inguinal hernia repair under local anesthesia reduces healthcare charges.

Vascular-enteric fistula is an uncommon complication following surgery on the aorta. Diagnosis requires a high index of suspicion. Iliac-enteric fistula formation is an uncommon complication following the creation of an aortoiliac bypass with prosthetic graft. Citation: Micallef CJ, Pasley J, Saxe JM, Williams PC, Wick C (2015) Prog Science 2(2):e07 | doi: 10.14721/pscience.2015.e07 Original Published: J Surg Radiol. 2010 Jul 1;1(1) | Republished: 02/16/2015 Copyright: © 2015 Micallef CJ. et al. Published by TranScience. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. Funding: none Competing Interests: The authors have declared that no competing interests exist. E-mail: Christopher.Micallef@wright.edu unstable and was resuscitated and taken to the OR. Operatively, an iliacenteric fistula was noted, consistent with the preoperative imaging. The patient underwent an axillofemoral bypass with excision of the fistula with primary anastomosis of the bowel. Unfortunately, the patient eventually expired from intractable bleeding and a coagulopathy.

In patients who have sustained blunt abdominal trauma, detection of free intraperitoneal air on computed tomography (CT) is thought to be a fairly specific finding of bowel rupture. We devised a method to determine the accuracy of a radiologist in identifying this important finding on CT scans in patients with blunt abdominal trauma. We retrospectively reviewed 50 CT scans and the radiologist’s report in patients who had undergone diagnostic peritoneal lavage (DPL) before the CT scan. We analyzed the report to see whether either free intraperitoneal air or the possibility of DPL was mentioned. Thirty scans retrospectively demonstrated free intraperitoneal air. The radiologist detected this finding in 25 patients (83%). In 5 patients (17%), the radiologist did not detect the free air or raise the possibility of a previous lavage. The amount of air introduced postlavage was variable, depending on the surgical technique and the time interval between the lavage and the CT scan. Air was most often demonstrated (in order of frequency) anterior to the liver, in the rectus recesses adjacent to the lavage defect, and in the fissures of the liver. In the five patients in whom free air was not identified, the amount or location of the air did not contribute to the error. The findings of this study were reviewed with all of the radiologists at a physician quality assurance meeting. A follow-up study of 25 patients was then obtained, and free air was detected in 25 (100%) of the cases. In summary, (a) free intraperitoneal air was missed in 17% of patients; (b) air preferentially collects beneath the diaphragm and in the rectus recesses; (c) there was no correlation between the amount or location of air and the error rate; (d) the most important variable is the examiner’s experience, and this can be improved markedly through education.

Background Thoracic needle decompression is lifesaving in tension pneumothorax. However, performance of subsequent tube thoracostomy is questioned. The needle may not enter the chest, or the diagnosis may be wrong. The aim of this study was to test the hypothesis that routine tube thoracostomy is not required. Methods A prospective 2-year study of patients aged ≥18 years with thoracic trauma was conducted at a level 1 trauma center. Results Forty-one patients with chest trauma, 12 penetrating and 29 blunt, had 47 needled hemithoraces for evaluation; 85% of hemithoraces required tube thoracostomy after needle decompression of the chest (34 of 41 patients [83%]). Conclusions Patients undergoing needle decompression who do not require placement of thoracostomy for clinical indications may be assessed using chest radiography, but thoracic computed tomography is more accurate. Air or blood on chest radiography or computed tomography of the chest is an indication for tube thoracostomy.

The National Acute Spinal Cord Injury Study II concluded in 1990 that high-dose methylprednisolone (MP) improved neurologic recovery after acute spinal cord injury (ASCI). We tested this conclusion by analysis of 54 patients with ASCI; 25 patients were treated without MP before 1990 whereas 29 patients were treated with MP after 1990. Neurologic deficit was assessed regularly, in most cases daily. Motor and sensory scores on admission, and best results at one-half week (days 2 to 4), 1 week (days 6 to 10), 2 weeks (days 11 to 21), 1 month, and 2 months were noted for both groups. Motor assessment was recorded in 22 muscle segments on a scale of 0 (complete deficit) to 5 (normal); the range, thus, was 0 to 110. The 23 patients with closed injuries demonstrated no difference in improvement with or without MP. In contrast, MP was associated with impaired improvement in the patients with penetrating wounds; the 15 patients with no MP therapy had an admission motor score of 49, which increased by 6.9 at one-half week, whereas the 16 patients treated with MP had an admission motor score of 48, which decreased by 0.3 at one-half week (p = 0.03). The neural status seen by day 4 persisted throughout the next 2 months. Changes in sensation paralleled the changes in motor function. We conclude that MP therapy for penetrating ASCI may impair recovery of neurologic function.

Optimizing cerebral oxygenation is advocated to improve outcome in head-injured patients. The purpose of this study was to compare outcomes in brain-injured patients treated with 2 types of monitors.Patients with traumatic brain injury and a Glasgow Coma Scale score8 were identified on admission. A polarographic cerebral oxygen/pressure monitor (Licox) or fiberoptic intracranial pressure monitor (Camino) was inserted. An evidence-based algorithm for treatment was implemented. Elements from the prehospital and emergency department records and the first 10 days of intensive care unit (ICU) care were collected. Glasgow Outcome Scores (GOS) were determined every 3 months after discharge.Over a 3-year period, 145 patients were entered into the study; 81 patients in the Licox group and 64 patients in the Camino group. Mortality, hospital length of stay, and ICU length of stay were equivalent in the 2 groups. More patients in the Licox group achieved a moderate/recovered GOS at 3 months than in the Camino Group (79% vs 61%; P = .09).Three-month GOS revealed a clinically meaningful 18% benefit in patients undergoing cerebral oxygen monitoring and optimization. Six-month outcomes were also better. Unfortunately, these important differences did not reach significance. Continued study of the benefits of cerebral oxygen monitoring is warranted.

Cervical near-hangings are not rare, but have received little attention in the trauma literature. Increasing numbers of patients received from our local jail and detention centers prompted this study.Seventeen-year review of a level I Trauma Center Registry identified 67 patients with cervical strangulation for study. Data were analyzed using the Mann-Whitney test to evaluate continuous predictors, and Fisher's exact test for categorical predictors.Ten of 67 patients died (14.9% mortality). Patients having a lower Glasgow Coma Score (GCS) at the scene (3.5 +/- 1.3 vs. 8.3 +/- 5.0; p = 0.001) and lower GCS in the emergency department (ED) (3.0 +/- 0.0 vs. 9.0 +/- 5.3; p0.001) were more likely to die. Injuries consisted predominantly of neck abrasions and anoxic brain injuries (83% mortality). Laryngeal fractures and carotid arterial injuries were detected. No cervical spine fractures were seen, but subluxations were identified. Forty-two percent of the patients were in detention centers when the near-hanging incident occurred.Cervical near-hangings are referred to the Trauma Service for evaluation. Scene or ED GCS of 3 does not preclude neurologically intact survival, although mortality is high. In our study, the most useful prognostic factors were the need for airway control by intubation or cricothyrotomy, cardiopulmonary resuscitation, lower scene and ED GCS, and cerebral edema on CT Scan. Optimal evaluation includes head and neck CT and CT angiography of the neck. We plan to share these results with local authorities and encourage improvement in risk identification, with earlier involvement of mental health personnel.

Toxic epidermal necrolysis and Stevens-Johnson syndrome are a spectrum of disease characterized by a delayed hypersensitivity reaction that involves the skin and mucous membranes and typically is associated with either recent upper respiratory infection or with certain medications. Ecthyma gangrenosum is a rare necrotizing vasculitis that most commonly affects immunocompromised and burn patients and is often a sequela of Pseudomonas aeruginosa bacteremia. The cutaneous lesions of ecthyma gangrenosum are characterized by an erythematous halo surrounding a dark gray or black nodule. P. aeruginosa preferentially invades the venules, resulting in secondary thrombosis of the arterioles, tissue edema, and separation of the epidermis. Management of ecthyma gangrenosum includes systemic treatment with antipseudomonal antibiotics and debridment of the lesions, as well as improving the patient's immune status if possible. We present a case of a patient admitted to the burn unit for toxic epidermal necrolysis who developed pseudomonal bacteremia with ecthyma gangrenosum.

Background: Primary closure after trauma celiotomies is not always accomplished. We reviewed our experience with delayed closure in trauma patients. Methods: Prospective data were collected on patients who had damage-control celiotomy and were discharged with open abdomens. The time to closure, repair methods, and complication data also were compiled. Results: In the 6-year period, 84 patients underwent damage-control celiotomy. Thirty-one patients died and 33 patients had early closure. Twenty patients had closure during a subsequent hospitalization (mean time to delayed closure, 193 days): 8 patients (40%) had component separation, 3 (15%) had component separation with mesh, 4 (20%) had mesh alone, and primary closure occurred in 5 (25%). Nine patients (45%) had complications such as wound and mesh infections, hernias, and fistulas. Repair before or after 6 months showed no statistically significant difference for the presence of complications or enterotomies (P .64 and .5743, respectively). Conclusions: Open-abdomen reconstruction presents significant challenges. Closure within 6 months is possible; the presence of complications is not affected by early repair. © 2006 Excerpta Medica Inc. All rights reserved.

Background Salmonella typhi infection continues to be a significant problem worldwide. Patients suffering from “typhoid” in endemic regions such as West Africa often present late in the course of the disease with symptoms of malnutrition and peritonitis. Clinical peritonitis in these patients is invariably associated with perforation of the terminal ileum and purulent peritonitis. Operative intervention and its success have not been well documented. The purpose of this article is to review the experience of 1 hospital in West Africa and the efficacy of operative management of perforated intestine from typhoid. Methods A retrospective review of all patients admitted between January and October of 2003 to the Carolyn Kempton Memorial Hospital in Togo, West Africa, with the diagnosis of typhoid. Demographic data including age, sex, number of perforations, and outcome were obtained. All patients were treated with ampicillin, gentamycin, and flagyl or chloramphenicol as the sole antibiotic therapy along with operative management. Results One hundred ninety-one patients with typhoid were admitted. One hundred twelve patients underwent laparotomy for perforation, 18 of whom died from persistent typhoid septicemia for a mortality rate of 16%. Reoperative management was used in some patients who did not respond immediately. Conclusions Primary repair of typhoid perforation is a safe and effective treatment. Patients with persistent septicemia after laparotomy most likely have resistant Salmonella typhi infection. Availability of second-line antibiotic therapy in these third world countries would likely improve outcomes. Prospective studies on appropriate antibiotic therapy along with operative management in endemic areas are necessary until resources are available for preventative measures.

Early nutrition is advocated for patients with head injury to counter the postinjury hypermetabolic state. The gastric route of feeding often leads to vomiting and aspiration pneumonitis. This study was designed to identify the role of lower esophageal sphincter (LES) function in this complication. The LES function was assessed within 72 hours of admission in 16 patients with a head injury and a Glasgow Coma Scale (GCS) score less than 12 (range, 3-11). Other admission assessments included an APACHE II score of 11.7, Injury Severity Score (ISS) of 30.5, and a Revised Trauma Score (RTS) of 6.4. These studies were repeated 1 week postinjury in five patients. Dysfunction of the LES was present in all 16 patients; the average gastric-to-esophageal pressure difference was -0.49 mm Hg (range, -0.59 to 2.5) compared with a normal value of greater than 20 mm Hg. The five patients restudied at 1 week had a gastric-to-esophageal pressure difference of 13.3 mm Hg (range, -3.4 to 36.6 mm Hg). The single patient with a GCS score below 12 at 1 week had a low LES tone. These data show that LES dysfunction accompanies acute head injury and contributes to aspiration pneumonitis after early gastric feeding. Nutrition in patients with low GCS scores should be parenteral or via the jejunum.

Primary closure of the abdominal wound following laparotomy in patients with hemorrhagic shock, massive transfusions, swollen abdominal viscera, and loss of compliance of the abdominal wall cannot be achieved without excessive tension. Persistence at primary closure in such patients leads to respiratory compromise, oliguria, enterocutaneous fistula, impaired abdominal wall nutrient blood flow, necrotizing fasciitis, evisceration, and sometimes death of the patient. A method of closure using an abdominal wall pack consisting of fluff gauze and rayon cloth is described. This method allows for fascia approximation and secondary wound healing without hernia in about 7 to 10 days as the patient enters the diuretic phase of resuscitation.

Fibrin gel (FG) has recently been shown to be bactericidal in the management of contaminated hepatic injury; antibiotic loading of fibrin gel (AFG) may augment this effect. We evaluated the antimicrobial properties of FG and AFG in a rat model of contaminated splenic injury. Fibrin gel was made from centrifuged plasma of separate donor rats and bovine thrombin. Antibiotic fibrin gel was similarly produced following intravenous injection of 70 mg/kg ticarcillin. Male Holtzman rats (250-300 g) were anesthetized and a laparotomy done. The abdomen was contaminated with 1 x 10(7) Bacteroides fragilis and the spleen transected in the midportion. Treatment consisted of splenorrhaphy (S) (n = 7), FG application (n = 7), or AFG (n = 7). The animals were autopsied at 1 week to evaluate abscess formation and abdominal adhesions (grade I = none, grade II = mild, grade III = severe). Antibiotic/fibrin gel significantly decreased abscess formation following splenic injury when compared with S (2 of 7 vs. 7 of 7; p less than 0.05 by ANOVA) without an increase in adhesions. Fibrin gel also decreased abscess formation but not significantly (4 of 7 vs. 7 of 7). Histologic analysis confirmed the beneficial effect of FG and AFG on wound healing. The bactericidal effect of FG is improved by antibiotic loading in contaminated intraabdominal injury.

• A patient with villous adenoma of the common bile duct presented with obstructive jaundice, weight loss, and icterus. Results of preoperative evaluation suggested cancer of the pancreas or common bile duct. Despite normal findings of intraoperative needle biopsies, a duodenopancreatectomy was performed. Three years after operation the patient is without significant problems. We present the surgical challenge of treating this unique entity. (Arch Surg1988;123:96)