Popliteal arterial aneurysms. Their natural history and management

Eighty-seven popliteal aneurysms in 62 patients, of which 50 were treated surgically, were reviewed and their clinical characteristics summarized. The need for alertness in the clinical detection of these lesions was stressed. Because complications, namely thrombosis and embolization, were frequent (23% in the total group, 36% in the surgical group), we recommend surgical treatment not only in all symptomatic but also in asymptomatic aneurysms larger than 2 cm in diameter; nonsurgically treated cases must be followed up carefully. With this aggressive approach, no lives and only two limbs were lost (one in a case of irreversible gangrene of the foot). Of the two surgical techniques described, the bypass procedure with autogenous vein graft is, because of its simplicity, given preference over resection with graft.

Limb loss following Military Anti-Schock Trousers (MAST) application

External counterpressure is a safe and effective method to treat shock and restore central circulation. Experience with the short-term use of MAST has been favorable. If external counterpressure is maintained for extended periods, however, altered peripheral hemodynamics may result in permanent damage. The development of compartment syndrome requiring amputation is reported in two patients with associated leg fractures. This unfortunate experience suggests that the sustained use of MAST in patients with shock and comminuted lower extremity fractures may jeopardize limb survival.

Stroke and gangrene: complications of therapeutic plasma exchange therapy

Two patients underwent therapeutic plasma exchange therapy. One patient with advanced rheumatoid arthritis developed a stroke after his fifth exchange. The other patient, with progressive systemic sclerosis, required a below the knee amputation secondary to shunt problems. These cases are presented to caution physicians in selecting patients for pheresis procedures and suggest that major complications can occur with this technique.

Perinatal gangrene of the buttock: an iatrogenic or spontaneous condition?

Three cases of neonatal gangrene of the buttock are reported. They were characterized by: localization to the skin and muscles of one buttock; sudden onset, minutes after birth; sciatic palsy in two of three and absence of known causes, except for an umbilical injection at birth in two of three. This procedure seems responsible in the first two; the etiology of the apparently spontaneous third case is discussed.

Gangrene of the genitalia in children with pseudomonas sepsis

The incidence of Pseudomonas aeruginosa bacteremia is increasing. Successful management is based upon early and aggressive therapy of the bacteremia and the usually associated granulocytopenia. A small number of such patients present with ecthyma gangrenosum, a characteristic skin lesion. During the last 4 years 5 children with acute leukemia and granulocytopenia presented to our hospital with these lesions. Although they occur most frequently on the extremities, buttocks or perineal region 2 of our patients had only isolated lesions of the external genitalia, resulting in gangrene of the penis in 1 and gangrene of the labia majora in the other. The gross and histologic pathology is reviewed. Recognition of this characteristic skin lesion enables the prompt institution of appropriate therapy.

Quantitative aerobic and anaerobic bacteriology of infected diabetic feet

Quantitative aerobic and anaerobic cultures of deep tissue were performed on amputated infected lower limbs of 13 diabetic patients immediately after surgery. Dissection was made through intact skin distant from any preexisting ulcer. The results were compared with those obtained from: (i) ulcer swabs (pre- and postamputation), (iii) curettage of the ulcer base, and (iii) needle aspiration after normal saline injection. Anaerobic transport media were used for anaerobic cultures before prompt transfer to the anaerobic chamber. A mean of 4.7 bacterial species per specimen was seen (2.3 aerobes, 2.4 anaerobes). Mean log10 growth per gram of tissue was as follows: (i) aerobes plus anaerobes = 6.99, (ii) aerobes = 6.42, and (iii) anaerobes = 7.65. There was poor concordance between the deep tissue culture results and the results from other modalities of culture collection, though the results from other modalities of culture collection, though the results from curettage and saline aspiration were slightly better than those obtained from ulcer swabs. The most frequently isolated organisms were enterococci, anaerobic streptococci, and species of Proteus, Clostridium, and Bacteroides. When anti-microbial therapy is indicated for this patient population, the possibility of the concomitant presence of aerobes as well as anaerobes should be considered.

Frostbite in Saskatoon: a review of 10 winters

In a review of 101 patients suffering from frostbite who were admitted to hospitals in Saskatoon during 10 winters, it was found that alcohol consumption was a contributing factor in 39 patients and a motor vehicle accident or breakdown in 33 others. Sixty-six patients underwent primary treatment in Saskatoon, the other 35 were referred for management of demarcated gangrene. Two hospitalized patients died, both of causes unrelated to the frostbite. The preliminary results of bone scanning with radioactive technetium methylene diphosphonate in frostbitten patients suggest that this is not a good prognostic indicator of the ultimate extent of tissue loss until 5 days have elapsed from the time of exposure. The lesion appeared to decrease in extent and increase in depth over a 3-week period. The mainstays of treatment remain rapid rewarming and adequate delay before conservative débridement or amputation. The delay allows healing of partial-thickness injuries and demarcation of full-thickness injuries. One third of patients receiving primary care in Saskatoon required amputation.

Clinically recognized limb ischemia in the neonate after umbilical artery catheterization

During a 4 year period, 1,461 critically ill neonates were admitted to the newborn intensive care unit of the Newark Beth Israel Medical Center, and 507 (35 percent) had umbilical artery catheters inserted for physiologic monitoring. In five patients (1 percent) clinically significant limb ischemia developed as a result of catheter complications. Frank gangrene was observed in three patients; two died from the primary illness soon after the onset of gangrene and the third survived after leg amputation. The other two infants had advanced ischemia that responded favorably to catheter removal and heparinization. Irreversible limb ischemia in this setting is infrequent, and milder forms are usually unrecognized or undocumented. High placement of the catheter or the length of time it is in place were not related to complications. Limb ischemia occurred soon after catheter insertion rather than after its protracted use. Major complications may be reduced by placement of the catheter in the lower abdominal aorta or internal iliac artery, clinical awareness and observation and frequent noninvasive monitoring. Immediate catheter removal and intravenous anticoagulation are warranted if ischemia persists. From this study, we believe that the benefits derived from judicious umbilical artery catheterization outweigh any inherent risk.

[Peripheral gangrene in a congenital sucrase isomaltase deficiency (author's transl)]

A case of ischaemic necrosis of extremities due to haemodynamic shock with disseminated intravascular coagulation (DIC) is reported. The onset of haemodynamic shock and the appearance of vascular disorder were produced at once. Both processes, haemodynamic shock and DIC were originated by the administration of food containing sucrose and starch to an infant whose posterior study confirms to suffert a congenital sucrase isomaltase deficiency. Sucrase isomaltase deficiency was documented by oral sucrose loading tests and by enzymatic assay of small intestinal mucose biopsy.

Necrotising fasciitis due to streptococcus pyogenes

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Indications for operation in acute necrotizing enterocolitis of the neonate

A study to evaluate criteria for operation was carried out in 61 infants with acute necrotizing enterocolitis (NEC). A total of 10 clinical, roentgenographic, and laboratory criteria were considered. Each proposed operative criterion was correlated with the documented presence or absence of intestinal gangrene in these infants. Indications for operation verified by this study were (1) pneumoperitoneum, (2) paracentesis findings positive for gangrenous intestine, (3) erythema of the abdominal wall, (4) a fixed abdominal mass, and (5) a persistently dilated loop of intestine on serial abdominal radiographs. The first two signs occurred frequently; the latter three were rare. Operative indications which proved to be invalid in this study were (1) clinical deterioration, (2) persistent abdominal tenderness, (3) profuse lower gastrointestinal hemorrhage, (4) the roentgenographic finding of gasless abdomen with ascites, and (5) severe thrombocytopenia. Twenty-four of the infants were operated on. The mortality rate among the infants operated on after free intestinal perforation had occurred (64%) was double that of infants operated on for intestinal gangrene without perforation (30%). Paracentesis may identify infants with intestinal gangrene prior to the development of perforation and may permit advantagenous timing of operation. This analysis of the frequency and reliability of proposed operative criteria may aid the surgical decision.

[Spontaneous mesenteric venous thrombosis, a rare complication of oral contraceptives (author's transl)]

Spontaneous mesenteric venous thrombosis without recognizable aetiology is a rare condition. Only 10 cases have been described in world literature as a complication of oral contraceptives. The case report is presented of a 51 year-old married woman who had been taking oral contraceptives for 7 years. After abdominal pain for weeks segmental mesenteric venous thrombosis with a gangrenous small bowel loop was diagnosed. The gangrenous small bowel loop was treated by resection. Subsequently after discontinuance of contraceptive medication she was symptom free. The problems of diagnosis are pointed out and it is suggested that immediate discontinuance of oral contraceptives in women with unexplained abdominal pain might prevent gangrene of small bowel.

Extensive gangrene of the bowel after haemorrhagic shock: a case report

A 20-year-old man presented with an acute abdominal condition within 15 hours after having sustained severe extra-abdominal injuries with associated hypovolaemic shock. At laparotomy virtually the whole bowel was found to be ischaemic and perforation had occurred at the site of maximum ischaemia. No trauma to the bowel, mesenteric vessels or any other abdominal organ was noted, and it was concluded that the ischaemia had resulted from a prolonged splanchic vasospasm in an attempt to compensate for hypovolaemic shock. The condition is well recognized in animals, but has rarely been recorded in humans. Early resuscitation of the shocked patient is mandatory in order to prevent not only renal shutdown but also mesenteric ischaemia. It is possible that some patients who suffer from 'irreversible shock' may develop endotoxaemia owing to the absorption of toxins from partially ischaemic bowel which does not proceed to frank gangrene.

[Massive lung necrosis in klebsiella pneumonia (so-called massive lung gangrene)]

In the literature only 13 cases of voluminous necrosis of lung tissue, generally referred to as massive pulmonary gangrene, could be found. This disease constitutes an unusual, very severe complication of lobar pneumonia, mostly due to Klebsiella. This type of pneumonia generally affects old or otherwise debilitated persons, quite often chronic alcoholics. It has a high lethality of 20%. Our own observation in a 48-year-old man is presented. He suffered from recurrent massive hemoptysis in relation with a huge cavity of the right lung, filled with necrotic lung tissue. Following right pneumonectomy empyema developed, also due to Klebsiella; it was successfully treated with thoracic fenestration according to Clagett. Knowledge of this severe infrequent complication of pneumonia is necessary since it requires early operative treatment: Out of the 14 patients four were treated medically only and died, while the remaining ten underwent surgery and were all cured.

Extremity amputation: disseminated intravascular coagulation syndrome

There are occasional reports in medical literature of peripheral gangrene and subsequent extremity amputation following systemic infection. Although the authors of these case reports speculated that the gangrene was due to septic embolization, pathologic study of the amputated tissue failed to reveal evidence of septic emboli. In reviewing reports of amputation following scarlet fever, varicella, pneumococcemia, and appendicitis, we found cases with clinical, hematologic, and pathologic evidence of disseminated intravascular coagulation (DIC). We describe 2 patients who required extremity amputation following an acute, systemic infection: transmetatarsal and Lisfranc amputation following meningococcal meningitis and bilateral below-knee amputation following pneumococcal meningitis. Both of these patients had clinical, hematologic, and pathologic evidence of DIC. Following amputation, both of these patients had significant problems with skin healing and prosthetic fitting. The presence of an acute systemic bacterial or viral infection, coagulation abnormalities and pathologic tissue indicative of DIC, and skin lesions of the extremities progressing to dry gangrene and ultimately requiring bilateral amputation are the key clinical features of this syndrome. We conclude that DIC is a major pathophysiologic mechanism responsible for peripheral gangrene following systemic infection.