We prospectively studied peritonitis secondary to small bowel leakage in 30 critically ill patients, each of whom had complete diversion of intestinal continuity by stoma, fistula, or both. All patients received total parenteral nutrition during implementation of the protocol. The proximal intestinal effluent was collected and recycled into the distal small bowel. During reinfusion of succus entericus, a significant reduction in the output of the proximal stoma was observed (mean 30.2%, p less than 0.001). The reinfusion also significantly reduced the volume from isolated small bowel loops in six patients (32.6%, p less than 0.001). When isotonic dialysate solution was infused into the distal intestine, a lesser though significant reduction in stoma output occurred (mean 20.3%, p less than 0.001). These findings demonstrate a consistent inhibitory effect upon upper gastrointestinal secretions by reinfusion of succus entericus. Clinical benefits of this technique include simplified control of fluid and electrolyte balance in patients with high output stomas and optimal utilization of remaining absorptive capacity for enteral nutrition.
Wound management following laparotomy for postoperative peritonitis and varying degrees of parietal necrosis remains a challenging and controversial problem. Because maintained peritoneal integrity and primary wound closure offer the best opportunity for survival, an original technique involving bilateral incisions to relax skin and rectus fascia is proposed. This technique permits medial myocutaneous advancement and primary tension-free skin closure of midline laparotomy incisions. Sixty-nine patients with severe postoperative peritonitis were treated according from 1980 through 1985. Nine of these patients died of advanced multiple organ failure soon after referral, and eight more died after prolonged treatment. Fourteen patients had one or more reoperations for complications. Only nine wound failures resulted, including five eviscerations and four wound infections followed by progressive dehiscence. The bilateral relaxing incisions healed secondarily without complication. Survivors developed midline wound hernia; ten of the 52 surviving patients have had these repaired. This method of primary closure is safe when performed in conjunction with rigorous surgical care of intraperitoneal infection and may enhance survival. We recommend the technique to surgeons who treat severe postoperative peritonitis and septic necrosis of midline laparotomy wounds.
During a 9-year period, six women with ulcerative colitis (UC) and rectovaginal fistulas were surgically treated. Three underwent ileoanal pull-through procedures with simultaneous repair of the rectovaginal fistulas. Two patients had Kock pouches, and one had a Brooke ileostomy because extensive destruction of the rectal sphincter prohibited ileoanal procedures. The three patients who had ileoanal procedures all had excellent functional results. There has been no evidence of Crohn's disease or fistula recurrence. We believe that rectovaginal fistulas occur more frequently in UC than is generally accepted, and they can be safely managed with current reconstructive techniques.
Throughout the evolution of polymer support based combinatorial synthesis, many issues have been raised
concerning chemistry at the interior of the support bead. Long standing questions regarding size exclusion,
reagent diffusion, and reaction kinetics remain unresolved, largely due to limited analytical capabilities
which address chemical activity at the core of the solid phase support bead. A variety of novel infrared
spectroscopic techniques for the direct evaluation of intrabead reagent dynamics are presented in this work.
Specifically, these spectroscopic tools facilitate analysis and understanding of reagent penetration and intra-bead reagent mobility parameters. Data from these studies downplay size exclusion as a consequential factor
in the delivery of small molecule reagents throughout synthesis on polystyrene-based resins. Experiments
presented here, however, illustrate the first direct spectroscopic evidence of thermodynamic reagent partitioning
between the support bead and surrounding solvent as an essential factor in efficient delivery of reagent to
the solid phase support interior.
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