Keith Wichterman - Academia.edu (original) (raw)

Papers by Keith Wichterman

Archives of Surgery, Jun 1, 1979

Glucose intolerance occurs in patients with sepsis, and resistance to insulin has been thought to... more Glucose intolerance occurs in patients with sepsis, and resistance to insulin has been thought to be part of this process. To study this phenomenon, peritonitis was produced in rats by cecal ligation and puncture. One group was killed ten hours later (early sepsis). A second group of rats was killed 16 to 24 hours after ligation, just prior to their expected death (late sepsis). Insulin stimulated glucose uptake to the same extent in muscles from rats in early sepsis, late sepsis, and from control rats. Even at an insulin concentration that produced submaximal stimulation of glucose uptake, no difference in glucose uptake between the three groups of muscles was observed. Thus, there was no resistance to the stimulatory action of insulin on glucose uptake by skeletal muscle during early and late sepsis. However, basal glucose uptake by isolated soleus muscle from animals in late sepsis was significantly increased compared with controls when these muscles were incubated in an aerobic environment. Under anaerobic conditions, glucose uptake in these two groups of muscles increased to the same level. This indicates that there is some stimulus that increases glucose uptake in late peritonitis and may explain the hypoglycemia of late experimental or untreated sepsis. This stimulus could be hypoxia or some other factor resulting from decreased blood flow and increased anaerobic metabolism.

PubMed, Feb 1, 1979

Tissue adenine nucleotides were measured in rats to determine if there is depletion of energy sto... more Tissue adenine nucleotides were measured in rats to determine if there is depletion of energy stores associated with sepsis. Peritonitis was produced by cecal ligation and cecal puncture. At 16 to 24 hours after ligation, rats which were lethargic but still normotensive (late sepsis) and showed clinical and laboratory confirmation of peritonitis-sepsis were stunned by a blow on the head, and small pieces of tissue were removed and frozen. Adenine nucleotides were measured enzymatically. In late sepsis adenosine triphosphate (ATP) levels in liver and kidney decreased significantly; however, no significant decreases were observed in the diaphragm or gastrocnemius muscle. Hydrogen polarograph measurements of hepatic blood flow indicated that flow was decreased markedly at this stage of peritonitis. A second group of rats was prepared in the same manner, except they were studied 10 hours after ligation (early sepsis). Most rats at this stage of sepsis appeared to be only mildly ill; however, blood cultures obtained from six rats so prepared all were positive. These rats did not show any decrease in either hepatic blood flow or tissue adenine nucleotides. Thus the changes in adenine nucleotides observed in late sepsis (lpw-flow septic rats) are similar to those seen during early hemorrhagic shock and suggest inadequate perfusion associated with peritonitis as the cause.

Surgery, 1979

Surgery

The results of surgical repair in 22 patients with large paraesophageal hernia were analyzed. In ... more The results of surgical repair in 22 patients with large paraesophageal hernia were analyzed. In 18 of the 22 patients, the entire stomach had herniated into the thorax, and a portion of the transverse colon was in the chest in 10 patients. Six patients presented with acute obstruction due to organoaxial volvulus and required emergency repair; the other 16 underwent elective or urgent repair after presenting with epigastric fullness (nine), intermittent vomiting (five), heartburn (one), or gastrointestinal bleeding (one). Nineteen patients each had an abdominal repair with an added Hill-type procedure or a Nissen fundoplication to assure that the esophagogastic junction would remain well below the diaphragm. All had a temporary gastrostomy to fix the body and antrum of the stomach in a normal position. None has demonstrated recurrent herniation on repeat gastrointestinal study. Three patients had the repair through a left thoracotomy, and two of them later developed intraabdominal g...

Journal of Surgical Research, 1980

Study of the pathophysiology of infection requires the use of animal models in order to separate ... more Study of the pathophysiology of infection requires the use of animal models in order to separate the many variables. Meaningful controlled studies of septic patients are difficult because of the diversity of diseases, different organisms, and multiplicity of variables encountered in the clinical setting. Endotoxin animal models, although reproducible, do not adequately simulate many of the circulatory and metabolic alterations produced by sepsis. Numerous sepsis models utilizing bacterial infection have been developed without any standardization of approach and there are often problems of reproducibility. When we began to study sepsis, we found that many of the proposed and reported small animal models of sepsis could not be reproduced in our laboratory. This led us through a long period of trial and error in order to develop a reproducible and satisfactory small animal sepsis model. Because of this, and the need for review and standardization, previously used models of sepsis such as the administration of endotoxin, intravenous infusion of live organisms, the administration of fecal material into the peritoneal cavity, the placement of infected foreign material into the soft tissues of the extremity, and surgical operations that partially destroy the normal barriers of the gastrointestinal tract are reviewed. Modifications of an existing sepsis model in the rat are also presented, and criteria for future models for the study of sepsis such as reproducibility of the model, clinical signs of sepsis, positive blood cultures, and alterations ofvital signs are proposed.

Archives of Surgery, 1989

Ileocecal mass is occasionally encountered unexpectedly by surgeons operating for presumed append... more Ileocecal mass is occasionally encountered unexpectedly by surgeons operating for presumed appendicitis. A five-year retrospective study was performed to review the management of this problem. Thirteen patients were identified who had had right hemicolectomy performed for unexpected mass in which neoplasm, diverticular disease, or inflammatory bowel disease could not be differentiated from severe appendicitis at laparotomy. Seven patients (group 1) had a final pathologic diagnosis of appendiceal phlegmon. The other patients (group 2) had Crohn's disease, typhlitis, or neoplasm. Right hemicolectomy was performed with a morbidity of 7% and mortality of 7% in all patients. This procedure is acceptable for unexpected cecal mass.

American Journal of Infection Control, 1982

Archives of Surgery, 1979

Journal of Surgical Research, Sep 1, 2010

Journal of Surgical Research, Feb 1, 2008

Introduction: Previous studies have shown an increase in surgical morbidity, mortality, length of... more Introduction: Previous studies have shown an increase in surgical morbidity, mortality, length of stay (LOS), and cost in teaching hospitals (TH). These studies are confounded by many factors including large cross-sectional populations, disparate referral and practice patterns, analysis of all procedures grouped together, and disparate hospitals. Controlling for these confounding variables, we studied the effect of surgical residents on complications, mortality, length of stay (LOS), cost, and hospital margin in an academic based surgery residency program during rotations with non-academic based teaching faculty at a TH. Materials and Methods: Patients (nϭ2,293) received their care at a single TH from a group of eight surgeons associated with a large multispecialty clinic. Four surgeons [group1(Grp 1)] did not have resident coverage and the other four, Grp 2, had resident coverage. Continuous severity adjusted complications, mortality, LOS in days, cost, and hospital margin data was collected over a forty-two month period from 1/1/03-7/31/06. Data was entered into a relational database. Data was also compared to 22 peer hospitals. Differences were compared using the unpaired Student's t-test for continuous variables and Chi-Square for nominal variables, and were considered significant (*) for P Ͻ 0.05. Results: Analyzing all procedures together, there was no difference in complications, 3.78% vs. 5.07% (PϭNS) although a lower mortality, 1.00% vs. 2.87% (Pϭ0.004), Grp 1 vs. Grp 2 respectively. The cost for all patients was 46% higher in Grp 2 vs. Grp 1, PϽ0.0001, (1.09 vs. 0.85 compared to peer hospitals). Data is shown for the five most common procedures individually: major small/large bowel (bowel), laparoscopic cholecystectomy (chole), hernia excluding inguinal/ femoral (hernia), mastectomy, and appendectomy. Analyzing these 5 procedures together, there was no significant difference in complications, 2.48% vs. 3.70%, Grp 1 vs. Grp 2 respectively. Although there were no complications or mortalities listed for either group of patients with an appendectomy and no difference in LOS or margin, the cost was significantly greater 5,700ϩ/Ϫ2123vs.5,700ϩ/ Ϫ2123 vs. 5,700ϩ/Ϫ2123vs.4,964ϩ/Ϫ2072, (Pϭ0.007), Grp 2 (nϭ151) vs. Grp 1 (nϭ101) respectively. Data for the other common procedures is shown in the table.

Journal of Laparoendoscopic & Advanced Surgical Techniques, Apr 1, 2002

Toxic shock syndrome has been described in three clinical situations: pediatric abscesses; menses... more Toxic shock syndrome has been described in three clinical situations: pediatric abscesses; menses, especially among women using highly absorbent tampons; and after surgery. The syndrome is marked by the sudden onset of fever, a sunburn-like rash, and hypotension, and is associated with recovery of toxin-producing Staphylococcus aureus, usually from small amounts of serous or seropurulent fluid. The syndrome usually begins 1 to 2 days after the procedure. To date, no cases have been reported after laparoscopic surgery. We describe a case of postoperative toxic shock syndrome in a 41-year-old woman who underwent laparoscopic cholecystectomy. She required a second operation, antimicrobial therapy, and blood pressure support and eventually recovered fully. Culture of the operative bed yielded S. aureus that produced enteroxin B. Surgeons should investigate vigorously any fever and hypotension developing in the first 24 to 48 hours after laparoscopy. Toxic shock syndrome should be considered in the differential diagnosis.

International Journal of Pediatric Otorhinolaryngology, Oct 1, 1984

A case of laryngotracheoesophageal cleft in a newborn is presented. A newborn presenting with res... more A case of laryngotracheoesophageal cleft in a newborn is presented. A newborn presenting with respiratory distress underwent contrast radiographic studies, direct laryngoscopy, bronchoscopy, and esophagoscopy, demonstrating a complete laryngotracheoesophageal cleft, esophageal diverticulum and microgastria. Attempts to maintain an adequate airway by ligation of the salivary ducts and ligation of the distal esophagus were unsuccessful. Continued biliary drainage per endotracheal tube postoperatively afforded a presumptive diagnosis of bronchobiliary fistula. The child expired on its fourth day of life. A review of the literature and modalities of therapy for these rare and unusual combinations of foregut anomalies is discussed. This is the first reported case of a newborn with the combination of laryngotracheoesophageal cleft, bronchobiliary fistula, microgastria and esophageal diverticulum.

Surgery, Aug 1, 2008

Background. Previous studies have demonstrated an increase in surgical morbidity, mortality, dura... more Background. Previous studies have demonstrated an increase in surgical morbidity, mortality, duration of stay, and costs in teaching hospitals. These studies are confounded by many variables. Controlling for these variables, we studied the effect of surgical residents on these outcomes during rotations with non-academic-based teaching faculty at a teaching hospital. Methods. Patients received care at a single teaching hospital from a group of 8 surgeons. Four surgeons did not have resident coverage (group 1) and the other 4 had coverage (group 2). Continuous severity adjusted complications, mortality, length of stay, cost, and hospital margin data were collected and compared. Results. Five common procedures were examined: bowel resection, laparoscopic cholecystectomy, hernia, mastectomy, and appendectomy. Comparing all procedures together, there were no differences in complications between the groups, although there was greater mortality, a greater duration of stay, and higher costs in group 2. When comparing the 5 most common procedures individually, there was no difference in complications or mortality, although a greater length of stay and higher costs in group 2. Conclusions. Comparing the most common procedures performed individually, patients cared for by surgeons with surgical residents at a teaching hospital have an increase in duration of stay and cost, although no difference in complications or mortality compared to surgeons without residents.

International Journal of Pediatric Otorhinolaryngology, 1984

The Breast Journal, 2004

The goal of this study was to evaluate the periareolar injection of technetium 99m sulfur colloid... more The goal of this study was to evaluate the periareolar injection of technetium 99m sulfur colloid to identify axillary sentinel nodes and compare the number of sentinel lymph nodes identified with preoperative lymphoscintigraphy to intraoperative biopsy using a handheld gamma probe. A total of 104 consecutive patients diagnosed with invasive breast cancer participated in this prospective study, with 81 patients receiving an intradermal periareolar injection and 23 patients receiving an intradermal peritumoral injection of filtered technetium 99m sulfur colloid. Preoperative lymphoscintigraphy was performed for sentinel node mapping and localization. In addition to selective sentinel node biopsy, axillary dissection was performed on all patients to determine false-negative rates. Routine histologic staining was performed on all identified nodes, along with immunohistochemical staining of sentinel nodes negative on initial routine staining. With an intradermal periareolar injection, the sentinel node identification rate was 91.4% (74/81), axillary metastatic rate 35.1% (26/74), sentinel node positive only 61.5% (16/26), and false negative 3.8% (1/26). With an intradermal peritumoral injection, the sentinel node identification rate was 91.3% (21/23), axillary metastatic rate 42.9% (9/21), sentinel node positive only 88.9% (8/9), and false negative 0% (0/9). A total of 241 sentinel nodes were identified with biplanar lymphoscintigraphy and 173 sentinel nodes were harvested during surgery, yielding a 28.2% increase in sentinel nodes identified with lymphoscintigraphy. This study demonstrates that intradermal periareolar injection of filtered technetium 99m sulfur colloid is successful in identifying axillary sentinel nodes with a low false-negative rate. Preoperative lymphoscintigraphy aids in the identification and surgical planning of sentinel node biopsy and provides an objective measure of surgical performance.

Surgery, 2008

Journal of Surgical Research, 2010