An unnecessary femoral amputation?

Non-traumatic gas gangrene is extremely rare. It is commonly associated with perforation of an occult gastro-intestinal cancer. The patient's course is usually fulminant. We report a case of subcutaneous emphysema and myonecrosis of the lower extremity due to a perforated carcinoma of the large bowel. The diagnosis of colonic cancer was suspected but treatment was regrettably delayed leading to the perforation and subsequent lower extremity gas gangrene. The patient survived following a femoral amputation.

[Clostridium myonecrosis as a sequelae of intramuscular injections--description of 3 fatal outcomes]

In three fatal cases of clostridial myonecrosis, the following criteria were found: repeated intramuscular injections over several years with anti-inflammatory substances, delay in diagnosis in outpatient care, and following uncontrollable systemic septic complications, despite radical surgical treatment. Only early, aggressive surgical interventions can stop the rapid course of necrotizing soft-tissue infections.

[Apropos of a case of gas gangrene of the abdominal wall after cholecystectomy]

The authors report a new case of gas gangrene following cholecystectomy with a fatal outcome. Mode of infection and principles of diagnosis and therapy are discussed together with a review of the literature.

[Gas gangrene mediastinitis after Boerhaave syndrome]

Mediastinitis caused by infection with Clostridium perfringens and spontaneous rupture of the esophagus are both life threatening conditions. The combination of these two entities led to septic multiorgan failure in a 38-year-old woman. The patient was treated successfully by esophagectomy and postoperative lavage through a partially open abdomen. The lack of information regarding emesis, the leading symptom of Boerhaave's syndrome, caused delayed diagnosis: the triad of emesis, severe epigastric pain and emphysema of the skin was not established until 30 h after the onset of symptoms.

Nontraumatic gas gangrene

A 77-year-old man with a history significant only for coronary artery disease presented to the ED with left-arm pain, shortness of breath, nausea, and diaphoresis. Six hours after the patient's admission to the hospital for presumed unstable angina, fever and left arm swelling, associated with crepitus and violaceous bullae, developed. The patient was taken to the operating room, where he was found to have extensive myonecrosis requiring forequarter amputation of the left arm. Nontraumatic clostridial myonecrosis is a fulminant, often fatal infection. This rare condition is usually caused by Clostridium septicum and has a high association with underlying malignancy. The patient reported here was found to have a colonic lesion and acute leukemia, both previously undiagnosed. This case illustrates the insidious manner in which spontaneous myonecrosis may present.

Postoperative gangrenous peritonitis after laparoscopic cholecystectomy: a new complication for a new technique

We report a case of anaerobic peritonitis with bowel emphysema, but no hollow organ perforations, following gallbladder removal for acute acalculous cholecystitis using a laparoscopic procedure in a diabetic patient. Management consisted of profuse peritoneal irrigation and zipper laparostomy. After a long postoperative period, the patient recovered without sequelae. The patient suffered typical acute cholecystitis with empyema and a diabetic status; anaerobial flora is frequent in these cases. The patient was operated on by means of a closed technique without contact with either air or oxygen. Moreover, CO2 injection into the peritoneal cavity with this technique, along with gallbladder rupture, created an ideal medium for anaerobial growth. We suggest that acalculous cholecystitis in diabetic patients could represent a contraindication for laparoscopic cholecystectomy; alternatively, open cholecystectomy should at least be considered when gallbladder rupture occurs during laparoscopy.

Gas gangrene: potential for hyperbaric oxygen therapy

Clostridial myonecrosis (gas gangrene) is an uncommon sequela of traumatic injury. Infection with Clostridium perfringens in devitalized tissue is the most common cause. Wide surgical debridement and appropriate antibiotic therapy remain the standard of care. However, the addition of hyperbaric oxygen therapy to standard management has been shown to have a synergistic effect in reducing morbidity and mortality in both canine and murine models. Although no prospective human data are available, retrospective data indicate that concomitant hyperbaric oxygen therapy has resulted in a twofold reduction in mortality. Where feasible, hyperbaric oxygen therapy should routinely be incorporated into the treatment plan for gas gangrene. Primary care physicians are in a unique position not only to make an early diagnosis but also to have a central role in coordinating multidisciplinary care often needed for this potentially fatal infection.

Acute emphysematous cholecystitis associated with pneumobilia: a case report

This report describes a rare case of acute emphysematous cholecystitis with pneumobilia in the common bile duct. The patient was a 66-year-old woman with a part history of diabetes mellitus, and operations for gastric and breast carcinoma. The chief complaint was pain in the right hypochondrium with severe right hypochondrial tenderness and distention of the gallbladder detected on examination. Laboratory tests showed leukocytosis, marked elevation of CRP, jaundice, liver dysfunction, and hyperglycemia. Gas was detected in the gallbladder on plain abdominal X-rays and CT scans of the abdomen, and a small amount of gas was also observed in the common bile duct. On the day of admission, percutaneous transhepatic gallbladder drainage (PTGBD) was carried out under ultrasound guidance, and Clostridium perfingens and E. coli were detected in the bile. Imaging after PTGBD showed no cystic duct obstruction. On the 12th day after PTGBD, cholecystectomy and choledochotomy with primary closure were performed. The postoperative course was good and the patient was discharged on the 15th day after surgery.

CT of pancreatic gas gangrene

A case of gas gangrene complicating acute pancreatitis is presented. The presence of gas within the pancreatic bed is very suggestive of infection with gas forming organisms in the right clinical setting.

[Anaerobic gas gangrene after the amputation of an extremity]

During 30 years of practical work the authors observed 6 patients with anaerobic mephitic gangrene after amputation of the extremity for atherosclerotic (in 3 patients), diabetic (in 2 patients) and vast wounds of the foot. Among the most substantial noninfective causes of the development of anaerobic mephitic gangrene in the postoperative period there were continuous preoperative ischemia of the extremity against the background of a decreased level of haemoglobin, total protein, lymphocytes. An early operation and intensive complex specific and nonspecific therapy resulted in recovery of 3 patients.

Malignancy, mortality, and medicosurgical management of Clostridium septicum infection

BACKGROUND

Necrotizing Clostridium septicum infections (CSI) have a strong association with malignancy or immunosuppression. To clarify this relationship and determine how it impacted mortality, the experience with CSI at a single institution was reviewed.

METHODS

Records of all patients admitted to our hospital with culture proven clostridial infection from 1966 through 1993 were reviewed.

RESULTS

Among patients presenting with clinical gas gangrene, 281 had culture proven clostridial infection and 32 (11.4%) had CSI. The mortality among CSI patients was 56%, whereas 26% of all patients with clostridial infections died (p = 0.001). An associated malignancy was found in 50% of patients with CSI, whereas this was seen in only 11% of patients with other clostridial infections (p = 0.0001 for CSI versus clostridial infection overall). The remaining patients with spontaneous CSI all had evidence of immunosuppression.

CONCLUSIONS

The high mortality and likelihood of associated malignancy or hematologic disease underscore the importance of a high index of suspicion and the need to search for and treat associated conditions in all patients with CSI.

Free gracilis muscle transplantation for hand reconstruction

Free muscle transplantation with motor innervation is the only way to add contractile elements to upper extremities with extensive loss of musculature due to direct trauma or untreated compartment syndrome (Volkmann's contracture). The functional cross-sectional area and the mean resting fiber length determine the maximum power and the contracting amplitude of the donor muscle, respectively. Although considerably weaker than the finger flexors to be replaced, the gracilis muscle was the preferred donor muscle because of the consistent anatomy of its neurovascular pedicle and the minimal donor site morbidity. In a series of 15 gracilis transplantations, all 13 muscles that survived regained function. Finger motion was dependent on the preoperative condition of tendons and joints. Even after complete loss of the flexor and extensor compartment after direct trauma or infection, a useful upper extremity could be restored, which was preferable to the only alternative--amputation.

[Gas gangrene after cholecystectomy]

We report on a case of an infection by clostridium perfringens (gas gangrene) following cholecystectomy and ERCP. Reviewing the literature, mode and risk of infection and principles of therapy are discussed.

Clostridial gas gangrene associated with congenital generalized lipodystrophy: report of a case

Congenital generalized lipodystrophy (CGL) is a rare disease, the main symptoms of which are a reduction of systemic subcutaneous fat, characteristic facial features, hypertrichosis, and insulin-resistant diabetes. We report herein the unusual case of a 25-year-old man with CGL in whom gas gangrene developed, an association which has never before been encountered.

Gas gangrene from subcutaneous insulin administration

A case of gas gangrene that caused intractable shoulder pain refractory to narcotics in an immunocompromised host is presented. Gas gangrene has been associated with severe trauma involving penetrating wounds, compound fractures, extensive soft-tissue injury, intramuscular injection of epinephrine, and interruption of arterial blood supply. This case describes an elderly insulin-dependent diabetic woman who developed gas gangrene in her arm and leg at the site of her subcutaneous insulin injections. The responsible organism was Clostridium septicum. Emergency medicine physicians must consider gas gangrene Clostridium infection in immunocompromised individuals without evidence of trauma who present with localized and intractable pain.

[Necrotizing soft tissue infections]

Necrotizing soft tissue infections are a group of life- and limb-threatening infections. They are caused by aerobic and anaerobic bacteria occasionally in a synergistic polymicrobial combination. The literature describing necrotizing soft tissue infections is controversial and often contradictory. Depending on their clinical appearance, tissue level and microbiological findings, necrotizing soft tissue infections are classified into two major groups, infections within the subcutaneous/fascia niveau and within the muscle level. Necrotizing infections of the subcutaneous level are further differentiated in hemolytic streptococcal gangrene, necrotizing fasciitis, clostridium fasciitis, and anaerobic nonclostridium fasciitis. In particular, necrotizing fasciitis is a rapidly progressing process, which is characterized by suppurative fasciitis, following by vascular thrombosis and cutaneous gangrene and is often accompanied by severe systemic toxicity, seen as septic-toxic shock and progressive (multi-) organ failure. Nineteen cases of necrotizing soft tissue infections were treated at the Department of Surgery, University Hospital of Zurich, between 1989 and 1992. These infections originated from "neglected trauma" in 9 (9/19), drug injections in 4 (4/19), acute infections in 3 (3/19), operative wounds in 2 (2/19) and perforation of the intestine in 1 case (1/19). Most of the patients (13/19) suffered from chronic debilitating diseases and were compromised by a suppressed immune system. We treated two groups of patients, one with septic-toxic clinical course and the other without. Eleven patients (11/19) belonged to group one and four of them, showing necrotizing fasciitis of the trunk, died as a result of multiorgan failure (MOF). Furthermore, three patients in this group had a limb amputated. In the other group without septic-toxic signs, no one died or lost a limb. The two groups differed also in length of hospital stay, an average of 60 days in group one (23 days intensive care) and 25 days in group two. Our results suggest that prompt recognition and treatment of necrotizing soft tissue infections are essential for the patient's survival. Often the full extent of the infections is underestimated initially, resulting in delayed surgical therapy. To control the rapidly spreading necrosis, early diagnosis and radical debridement of the affected tissue are essential and should be done without compromise, even if the affected limb must be amputated.

Effect of hyperbaric oxygen and surgery on experimental multimicrobial gas gangrene

An experimental multimicrobial gas gangrene rat model was developed and the therapeutic effect of surgery was compared to the combined effect of surgery and hyperbaric oxygen (HBO). The infection was caused by an intramuscular injection of a mixture of bacteria including Clostridium perfringens, Bacteroides fragilis, Escherichia coli and Streptococcus faecalis. The mortality, morbidity and wound healing were assessed during a follow-up of 2 weeks. The mortality of the control rats was 60%, with rats treated with surgery alone 35% and the combined treatment group 20% (NS). In the combined treatment group, 84.4% of the survivors healed completely; the corresponding figure in the surgery group was 15.4% (p < 0.001). In experimental multimicrobial gas gangrene the addition of HBO to surgery reduces morbidity and improves wound healing but does not reduce mortality statistically significantly.

[Treatment of gas gangrene. Results of a retro- and prospective analysis of a traumatologic patient sample over 20 years]

From 1970 to 1977 and from 1978 to 1990, the treatment and outcome in 136 patients with gas gangrene were investigated. The prognosis was better in patients with gas gangrene after trauma than in patients with gas gangrene resulting from vascular insufficiency or malignant tumours. In the first group the lethality of gas gangrene was 28.6%, in the second group, 7.1%. This difference is significant (P < 0.05). In 40.5% the infected extremities were saved. Patients with injuries without fractures did not lose limbs because of gas gangrene or die of it. When an operation was performed before or after the first session of oxygenation at high pressure (OHP) lethality was lower (20%) and the rate of saved limbs higher (80%) than with later operation (lethality, 50%; saved limbs, 45.5%). All patients who could not be treated by OHP, or only once or twice, died. From 1970 to 1977 patients who were treated surgically and received OHP for 5 days survived, and since 1978 this has applied to patients treated for 4 days. In general, the lives of patients with gas gangrene are no longer in danger by the 5th day of therapy. The use of checklists for diagnosis and therapy has been practised since 1978, and this is assumed to be one factor in the better outcome.

Effect of hyperbaric oxygen and surgery on experimental gas gangrene

An experimental model of clostridial gas gangrene was developed in rats and the therapeutic value of surgical debridement alone versus a combination of surgery and hyperbaric oxygen (HBO) was assessed. The infection was produced by an intramuscular injection of Clostridium perfringens microorganisms. The mortality of untreated rats was 100%. The mortality of the rats treated only with surgery was 37.5% compared to 12.5% when HBO was added to the treatment protocol (p < 0.01). In the group treated with HBO and surgery 82.5% of the animals healed completely and were able to walk normally, whereas the corresponding figure in the rats treated with surgery alone was 12.5% (p < 0.001). In the present experimental setting HBO treatment was an important therapeutic adjunct to surgery reducing both mortality and morbidity.