Laparoscopic cholecystectomy for treating acute cholecystitis -- possibilities and limitations

Our study analysed a batch of 1402 A.C., operated on within the S.U.U.B. First Surgical Clinic between 1993-2010. L.C. was possible in 90% of the cases, and conversion to open surgery was required in 10% of the cases. The causes that determined the necessity for this conversion were pericholecystic plastron - 49%, unclear anatomical orientation - 46.5%, haemorrhage - 9.7%, iatrogenic injury of the main bile duct - 0.23% etc. Statistical analysis has shown that male gender, over 50 yrs. age groups, gangrenous A. C. and fibrous plastron represent risk factors for the conclusion of L.C. Reinterventions were performed on 20 patients (1.4%). Postoperative mortality was not encountered.

[Predicting the risk of septic and necrotic complications in femoral amputation stump]

Treatment results of 430 patients with ischemic gangrene of lower limbs were analyzed and major risk factors of postoperative complications considering the femoral amputation stump were outlighted. These are: the high level of artery occlusion, ligature muscle compression in the stump, absence of active drainage and elderly age (more than 80 years), anemia. The intraoperative use of laser Doppler flowmetry gives the possibility to assess the potential viability of muscles at the amputation level. Predicting the risk of local postoperative complications allowed the differential approach to the stump formation and improved the treatment results.

Resection and primary anastomosis with modified blow-hole colostomy or Hartmann's procedure. Which method should be performed for gangrenous sigmoid volvulus?

AIM

To evaluate the efficacy of Hartmann's procedure and RPA with modified blow-hole colostomy for gangrenous sigmoid volvulus.

METHODS

Sixty-one patients operated on between January 2004 to September 2010 were reviewed retrospectively. The demographic data of the patients,clinical features, type of surgical procedure performed, postoperative complications, mortality and duration of hospital stay (DHS) after surgery were reviewed.

RESULTS

The mean hospital stay, wound infection and mortality did not differ significantly between the groups. Superficial wound infection rate was higher in group A (32% vs15%). Development of leaks secondary to stoma closure was not observed in any patient. During hospitalisation period; the postoperative complications were wound infection in four patients, intraabdominal abscess in two, evisceration and wound dehiscence in two, arrhythmia in six, pneumonia in eight.Medical and surgical complication rates of the groups were not different (p>0.05). When compared, the durations of intensive care unit (ICU) stay were not statistically different (p>0.05), but mean duration of hospital stay (DHS) was longer in group A than group B (p less than 0.05).

CONCLUSION

Sigmoidectomy should be the basic principle in the management of sigmoid volvulus.RPA with modified blow - hole colostomy provides satisfactory results. It is easy to perform in patients with sigmoid volvulus. RPA with modified blow - hole colostomy can be performed safely in selected patients without increasing morbidity and DHS.

Procedural trends in the treatment of peripheral arterial disease by insurer status in New York State

BACKGROUND

Type or lack of insurance may affect access to care, treatment, and outcomes. We evaluated trends for surgical management of all peripheral arterial disease (PAD) in-hospital admissions by insurer status in New York State.

STUDY DESIGN

Statewide Planning and Research Cooperative System (SPARCS) data were obtained and cross-referenced for diagnostic and procedure codes. Data from 2001 to 2002 were averaged and used as a baseline. Change in indication, volume of admissions, procedures, and amputations were calculated for the years 2003 to 2008 and were analyzed by insurer status.

RESULTS

There were 83,949 admissions. Endovascular intervention (EVI) increased tremendously for all indications and was used equally in the insured and uninsured. Among critical limb ischemia admissions, patients with private insurance were significantly more likely to be admitted for rest pain and significantly less likely to be admitted for gangrene (p < 0.001). Admission for gangrene declined for all. As EVI increased, amputation decreased and was significantly lowest in patients with private insurance (p < 0.001). Amputation was significantly higher in Medicaid than other insured (Medicaid vs private, p < 0.001; Medicaid vs Medicare, p = 0.003), but comparable to the uninsured (p = 0.08). Age greater than 65 years and low socioeconomic class or minority status were significant risks for gangrene (p = 0.014; p < 0.001) and ultimate amputation (p = 0.05; p < 0.001). Lack of insurance may pose a similar risk.

CONCLUSIONS

EVI increased tremendously and was used without disparity across insurer status. Amputation declined steadily and may have been related to increased EVI or to decreased admission for gangrene. Advanced age, low socioeconomic class or minority status, and lack of insurance negatively affect presentation and limb salvage. Universal health care may be beneficial in improving outcomes but must address root causes for delayed presentation.

Above-elbow amputation and death following human bite mismanaged by quacks: a case report and review of literature

BACKGROUND

Human bite is a common injury sustained during a fight, love passion, self mutilation, cannibalism or vampirism. Although widely reported as being more dangerous than animal bites, such complications as limb amputation from gangrene and eventually death is either uncommon or scarcely reported in our environment.

OBJECTIVE

To highlight the dangers of human bite as a potential cause of severe morbidity and mortality especially when poorly managed.

METHODOLOGY

A 30 year old Fulani herdsman with gangrene of the right hand, and distal forearm presenting in coma 10 days after sustaining human bite is presented and relevant related literature reviewed.

CASE REPORT

M.U. is a 30 year old Fulani herdsman who presented to us at the accident and emergency unit with 10 days history of human bite to the first web space of the right hand, 5 days history of gangrenous hand and distal foreman, and 2 days history of loss of consciousness. The injury was inflicted by a fellow herdsman during a fight. He then commenced treatment with a patent medicine dealer. A few days later the hand became swollen with associated severe pains, serous discharge and subsequent darkish discoloration, frank pus exudates and loss of hand function. Two days prior to presentation, he lapsed into unconsciousness after complaining of severe weakness and fever. Following his presentation, clinical examination and investigation, he was offered a below elbow guillotine amputation. However by the next day, he deteriorated with GCS of 5/15 and subsequently died after 24 hours of presentation.

CONCLUSION

Human bite can be a cause of severe morbidity and mortality. Treatment by quacks should be discouraged while early presentation, surgical debridement and delayed wound closure should be emphasized along with other surgical principles.

[The importance of early surgical intervention in the treatment of necrotizing vasculitis]

Vasculitides are an etiologically heterogeneous group of vascular affections leading to vascular wall damage followed by ischaemia of the tissues supplied by the affected vessels. Damage to the vessels of lower extremities is frequent; in serious cases a complete destruction of soft tissue as well as skeletal lesions may occur. This then results in a situation which, without a well-timed surgical intervention, often requires an amputation of the limb. We are presenting a case of a 61-year-old female patient with a large plantar defect of the right foot and gangrene of three toes of the same limb which developed as a result of necrotizing vasculitis.

Unusual presentation of the urogenital myiasis caused by Luciliasericata (Diptera: Calliphoridae)

INTRODUCTION AND OBJECTIVE

The case report describes the unusual presentation of the urogenital myiasis caused by Luciliasericata in two Slovakian men.

MATERIAL AND METHODS

The first patient, aged 66, who suffered from a locally advanced and inoperable urinary bladder dedifferentiated TCC with bilateral ureteral obstruction, chronic renal insufficiency and non-functioning left kidney. After surgical exploration the patient developed a malignant vesico-intestino-cutaneous fistula with stool leakage through the open wound. Because of very poor hygiene, and unsatisfactory attendance by staff, a fly deposited ova in the patient's necrotic wound. The patient died three months later of metastatic cancer disease. The second patient, a 43-year old homeless alcoholic male had gangrene of the scrotum and penis, urethro-cutaneous urinary fistula with numerous live and motile larvae on the surfaces. In both patients, some larvae were removed and sent to the lab for identification. The larvae were identified as maggots of the fly Luciliasericata. Antibiotic therapy, disinfection and debridement with sterile covering of the wound were used.

RESULTS

For both patients, complex treatment of myiasis was successful and patient recovered without parasitic consequences.

CONCLUSIONS

To our knowledge, this is the first report of the unusual presentation of the urogenital myiasis in Slovakian men with poor social habits and hygiene.

[Peculiar "appendicitis" turning out to be an internal hernia]

After abdominal muscle exercises a young man suffered from upper abdominal pains and vomiting. The pain moved to the lower abdomen and the abdominal wall hardened. Clinical picture and laboratory findings were in agreement with acute appendicitis, and the patient was operated. Unexpectedly the small intestine and the ascending colon appeared almost entirely gangrenous upon gridiron incision, and the surgical incision was widened. An extensive internal herniation was revealed, with the small intestine having protruded through the sigmoid mesentery, causing a disturbance of the blood circulation and necrosis of the bowel. Swift and sufficient resection of the bowel saved the patient's life.

The role of chronic kidney disease as a predictor of outcome after revascularisation of the ulcerated diabetic foot

AIMS/HYPOTHESIS

The aim of the study was to stratify the risk of diabetic patients with leg ulcer or gangrene undergoing infrainguinal revascularisation for critical limb ischaemia.

METHODS

The study cohort included 732 revascularisation procedures performed in 597 diabetic patients with ulcer or gangrene. Logistic regression and CART analysis were used for identification of predictors of 1-year outcome.

RESULTS

Logistic regression showed that chronic kidney disease (CKD) class (OR 1.38, 95% CI 1.16, 1.65) was an independent predictor of 1-year leg salvage (area under the receiver operating characteristic [ROC] curve 0.60, 95% CI 0.54, 0.65). The terminal nodes of the CART for 1-year leg salvage were CKD classes 4-5, the level (infrapopliteal vs femoropopliteal revascularisation), type of revascularisation (bypass surgery vs percutaneous transluminal angioplasty) and gangrene (area under the ROC curve 0.62, 95% CI 0.57, 0.68). Logistic regression showed that pulmonary disease (OR 1.76, 95% CI 1.11, 2.78), CKD class (OR 1.43, 95% CI 1.24, 1.65), foot gangrene (OR 1.76, 95% CI 1.21, 2.60) and patient age (OR 1.02, 95% CI 1.01, 1.04) were independent predictors of 1-year amputation-free survival (area under the ROC curve 0.65, 95% CI 0.60, 0.69). The terminal nodes of the CART for 1-year amputation-free survival were CKD classes 3-5, patient's age of ≥ 75 years and foot gangrene (area under the ROC curve 0.64, 95% CI 0.60, 0.68).

CONCLUSIONS/INTERPRETATION

CKD is a formidable risk factor for poor intermediate outcome after infrainguinal revascularisation in diabetic patients with foot ulcer or gangrene. CART analysis indicates that foot gangrene is also a significant risk factor for adverse outcome.

[Munchausen syndrome in an extreme form of factitious disorder]

Patients suffering from this disorder mimic symptoms of diseases and seek medical procedures and operations. We present a case of a patient who underwent a thorough investigation for unexplained persistent hypoglycemia. According to the algorithm approach to the non-diabetic patient, we measured insulin and c-peptide plasma levels while glucose levels were low and looked for sulphonylurea, blood and urine traces. Following the above, an endoscopic ultrasound demonstrated a small pancreatic lesion and an explorative laparotomy was performed to detect an insulinoma. This procedure was complicated by partial colectomy due to colonic gangrene. Following the patient's recovery, hypoglycemia recurred and the laboratory tests were repeated, revealing trace amounts of glipizide in her serum and urine. Studies which examined the prevalence of the phenomenon among cases of unexplained hypoglycemia, including patients who were operated for presumed insulinoma, were reviewed. No specific therapy for factitious disorder has been established. Management is based upon psychotherapy which is often not very effective. We recommend that one has to keep in mind that negative tests for sulphonylurea traces in serum and urine, do not contradict the diagnosis of factitious disorder, and it is recommended to repeat these tests several times.

[Treatment of chronic critical ischemia by neuroischemic form of the diabetic foot syndrome]

Treatment results of 203 patients with critical ischemia by neuroischemic form of the diabetic foot sindrome were analyzed. 45 patients had open, endovascular or hybrid vascular reconstructions. The method was decised basing on the results of angiographic studies. The support function was saved in 34 (75,6%) cases of 45 operated patients. Revascularization proved to be an effective and reasonable method of surgical intervention by critical ischemia caused by the neuroischemic form of the diabetic foot syndrome.

Diabetic gangrene in multiple fingers and toes after a dog bite in an elderly patient with type 2 diabetes

A 78-year-old diabetic woman experienced multiple sites of gangrene not only in fingers that were directly bitten by a dog but also in fingers and toes that had not beenbitten. Her glycemic control was fair and microvascular complications were mild. There were no clinical findings related to angitis, collagenosis or severe infection. The fingers and toes with gangrene were amputated. The pathological diagnosis was diabetic gangrene. This report presents a case of multiple sites of gangrene of the fingers and toes after a dog bite in an elderly patient with type 2 diabetes.

Adult intussusception: is associated bowel gangrene common?

INTRODUCTION

Adult intussusception is a rare clinical entity in contrast to pediatric intussusception. Varied and non-specific clinical features, delayed presentation, and lack of awareness among attending surgeons to consider it as differential diagnosis complicates the clinical course of the disease.

METHODS

A retrospective study was conducted in a tertiary care teaching hospital in north India. Nine adult patients who presented with intussusception over a period of six years were analyzed. Their clinical profile, management and underlying pathology were studied.

RESULTS

Five out of nine patients had acute presentation while remaining four presented with subacute/chronic symptoms. Median duration of presentation was 8 days (range 2-180 days). Clinical diagnosis of intussusception was considered in only one patient. Ultrasonography clinched the diagnosis in all four patients who presented with subacute/chronic symptoms. Ileo-ileal intussusception was present in five patients, with one having associated jejuno-jejunal intussusception. Other four patients had ileo-colic intussusception. Seven of the 9 patients (77%) were found to have associated bowel gangrene. Resection of the bowel segment having intussusception was done in all patients. Five patients had associated benign intestinal pathology while idiopathic intussusception was present in four patients.

CONCLUSION

The patients presented in the series are distinct from cases reported earlier in literature in term of late presentation, manifesting as acute intestinal obstruction, high frequency of associated intestinal gangrene, and absence of associated intestinal malignancy. Patients presenting with features of intestinal obstruction and abdominal lump should be subjected to urgent imaging studies to examine the possibility of intussusception. The high frequency of bowel gangrene encountered in patients of adult intussusception mandates prompt surgical intervention soon after diagnosis.

[Pheochromocytoma presenting as ischaemic gangrene of lower limbs]

We describe a 71-year-old woman who was admitted with pneumonia. She quickly developed severe pain and gangrene in all four extremities and had several fingers and crurae amputated. Pheochromocytoma was diagnosed by a 2 x 2 24-hour urine collection, computerized axial tomography and MIBG scintigraphy. The patient was suppressed with phenoxybenzamine hydrochloride and propanolol for three weeks and was subsequently laparoscopically adrenalectomized on her left side.

Infections and treatment of wounds in survivors of the 2004 Tsunami in Thailand

On 26 December 2004, a tsunami devastated the west coast of Thailand and caused 8457 injuries and 5395 deaths. Data were collected from 26 December 2004 to 31 January 2005 at four public hospitals to describe the character and treatment of wounds of 523 persons who were injured during tsunami and sought medical treatment. Wounds were contaminated with mud, sand, debris and sea water and had an infection rate of 66.5% (674/1013). Most wounds (45%) had poly-microbial infection with gram-negative rods such as Escherichia coli, Klebsiella pneumoniae, Proteus and Pseudomonas species. The risk of wound infection increased with size of the wound and presence of an open fracture. Infections occurred more frequently on the lower than upper trunk of the body. Early treatment with antibiotics was protective against wound infection. Many patients asked to have their wounds sutured so that they could return to their village to look for their families and to repair damage. This report suggests that wounds should be aggressively debrided and suturing postponed if possible. Patients should be given broad spectrum antibiotics to assist with wound healing.

Gangrene of the limb complicating Salmonella typhi septicaemia in a Nigerian child

We report an unusual case of lower limb gangrene in a pubertal boy following a typical clinical presentation of septicaemia due to Salmonella typhi. After an initial response to presumed appropriate antibiotic and supportive therapy, the patient developed tissue ischaemia in both feet. There were no clinical or laboratory evidence suggestive of DIC or coagulopathy. Following conservative management which included oral administration of vitamin C, there was gradual regression of ischaemic changes, progressive healing and recovery of function of the left foot while the condition of the right foot deteriorated with extensive tissue necrosis and dry gangrene that extended to the distal one third of the foot. This necessitated surgical disarticulation of the metatarsophalangeal joints two months after admission. This report is to alert clinicians about this rare complication of a common curable disease with a view to anticipating the possibility of it occurring as well as considering appropriate preventive measures.

Aluminum foil treatment combined with basic fibroblast growth factor (bFGF) for gangrene of the fingertip caused by collagen disease

Although basic fibroblast growth factor (bFGF) is used for the treatment of various intractable ulcers, there have been no reports of using it for gangrene of the fingertips caused by collagen diseases. We successfully treated gangrene as a result of malignant rheumatoid arthritis with aluminum foil combined with bFGF.

Axial torsion and gangrene of a giant Meckel's diverticulum mimicking acute appendicitis

Meckel's diverticulum is the most common congenital anomaly of gastrointestinal tract, occurring in 2% of the population. More than 80% of patients are asymptomatic. Complications like intestinal obstruction, bleeding and inflammation of Meckel's diverticulum occur in 4% of patients. The case of a 42-year-old male patient with axial torsion and gangrene of giant Meckel's diverticulum is presented.