Surgical management of critical limb ischaemia in the French West Indies

This retrospective study analyses the clinical presentation, surgical management and early outcome of 174 patients (mean age ñ SEM:73 ñ 15 yrs) admitted for critical limb ischaemia. 145 (84 percent) had tissue loss at admission: toe gangrene or ischaemic ulcer in 77, and gangrene extending beyond the forefoot in 68. 87 primary limb amputations and 107 revascularisation were performed at iliofemoral (n = 20), suprapopliteal (n = 22) or infrapopliteal level. The postoperative mortality rate was 14 percent in the "Amputation" group and 9 percent in the "Revascularisation" group but the difference was not statistically significant. Infective complications were comparable in both groups, although 5 to 14 deaths after amputation were directly related to infection and all deaths after revascularisation resulted from cardiovascular complications. The early limb salvage rate after revascularisation was 82 percent. 19 secondary limb amputations were performed for bypass failure. Patients in whom primary amputations were required were older (p < 0.03) and had significantly higher rates of heart disease and nonambulatory status (respectively, 24 vs 17 percent, p < 0.05; and 37 vs 13 percent, p < 0.001) than patients in whom revascularisation was performed. Ischaemic rest pain and tissue loss confined to digit gangrene or ischaemic ulcer occurred more frequently than extensive gangrene in the "Revascularisation" group (p < 0.0001), while extensive gangrene extending beyond the forefoot occurred more frequently than ischaemic rest pain and tissue loss in the "Amputation" group (p < 0.0001). Late presentation of patients and enhanced tissue loss are probably the reasons for the higher primary amputation rate in our patients compared to that observed elsewhere. In patients amenable to revascularisation (56 percent), arterial reconstruction for critical limb ischaemia improves the chances of limb salvage.(AU)

Cancrum oris (noma) in a patient with acute lymphoblastic leukaemia. A complication of chemotherapy induced neutropenia

Cancrum oris (noma) has been most commonly described in malnourished debilitated children with poor oral hygiene following systemic childhood infections such as measles, pertussis or scarlet fever. We describe a patient who developed this condition during a period of profound neutropenia following cytotoxic chemotherapy for acute lymphoblastic leukaemia(AU)

Surgical management of critical limb ischaemia in Guadeloupe, French West Indies - abstract

This retrospective study analyses the clinical presentation, surgical management and early outcome of 174 patients (mean age, 71 ñ 15 years) admitted for critical limb ischemia. 145 (84 percent) had tissue loss at admission including toe gangrene or ischemic ulcer in 77 and gangrene extending beyond the forefoot in 68. 87 primary limb amputations and 107 revascularizations were performed at iliofemoral (n=20), suprapopliteal (n=22) or infrapopliteal level. Postoperative mortality rate was not significantly different in the "Amputation" group (14 percent) and "Revascularizations" groups 9 percent. Infective complications were comparable in both groups although 5/14 deaths after amputations were were directly related to infections while all deaths after revascularizations resulted from cardiovascular complications. The early limb salvage after revascularizations was 82 percent. 19 secondary limb amputations were performed for bypass failure. Patients in whom primary amputations were required were older (p<0.03) and with significantly higher rates of heart diseases and non-ambulatory status (respectively 24 vs 17 percent, p<0.05 and 37 vs 13 percent, p<0.001) than patients in whom revascularizations were performed. The major findings were that ischemic rest pain and tissue loss confined to digit gangrene or ischemic ulcer were significantly more frequent in the group "Revascularizations" (p<0.0001), while extensive gangrene extending beyond the forefoot (p<0.0001) was significantly more frequent in group "Amputations". Therefore, late presentation of patients and enhanced tissue loss are very likely to play a role in our primary amputation rate, higher than those observed elsewhere. In patients amenable to revascularizations (56 percent), arterial reconstructiions for critical limb icshemia performed in the West Indies provide for a fair likelihood of limb salvage. (AU)

Primary penile gangrene - abstract

Penile gangrene is an uncommon clinical entity and invariably secondary to the spreading perineal necroticzing cellulitis, Fournier's gangrene. Penile gangrene as a primary event is exceedingly rare with less than 30 cases cited in the literature. From a 3-year urological practice in the Bahamas, I present a series of 13 cases of penile gangrene occurring as a primary event. In 3 cases the entire glans and proximal penile shaft underwent necrosis; in the other 10 cases the necrosis was confined to the prepuce and/or skin of the shaft of the penis. Clinical evidence supports the pathogenesis as a necrotizing balanoposthitis occurring in a previously uncircumcised phimotic glans with poor penile hygiene. With surgical debridement as the definitive mangement, 8 patients required circumcision only, 2 needed denuding the entire penile skin with subsequent skin grafting, 2 required partial penectomy and 1 a radical penectomy. The age group ranged from 23 to 86 years. Only one patient was a diabetic and another had an underlying urethral stricture. The bacteriology was a mixed perineal flora suggesting the bacterial synergistic event. From the literature review, this represents the largest series of primary penile gangrene to date; the pathogenesis argues in favour of the routine neonatal circumcision for penile hygiene in the tropics (AU)

Bacteriological study of diabetic foot ulcers

Bacteriological study of 61 patients with diabetic gangrene of non-gangrenous foot ulcers was undertaken to determine the pattern of infection and antimicrobial susceptibility with a view to suggest optimal antibiotic therapy for these patients. Grangrenous ulcers showed a higher frequency of mixed infection: the predominant organisms being enterococci, Proteus sp., Pseudomonas sp. and Klebsiella sp. Infected nongrangrenous ulcers showed Staph. pyogenes, and beta haemolytis Streptococcus as single organism in 12 patients. Anaerobes were more frequent isolated in gangrenous lesions than in non-gangrenous ulcers. Antimicrobial susceptibility showed that gram positive organisms were sensitive to co-trimoxazole, cephaloridine, ampicillin and penicillin. Gram negative aerobic bacilli were sensitive to gentomycin, chloramphenicol, cotrimoxazole and streptomycin. Anaerobes were sensitive to chloramphenicol, clindamycin and metronidazole. Antibiotics of choice for gangrenous lesions with spreading infection and septicaemia are a combination of gentamycin, ampicillin and metronidazole as an adjuvant to surgical treatment. (AU)

The prevention of gangrene in diabetes - abstract

The diabetic patient with incipient or developed gangrene of the hand or foot has been a major problem in the surgical practice of all our hospitals. The possibility that gangrene caused by diabetes might be avoided by adequate preventive measures has been the aim of this study. A Public Health Nurse and Home Health Visitor attended the Diabetic Clinics at the University Hospital and Kingston Public Hospital regularly and at the Spanish Town Hospital, Princess Margaret Hospital and Mandeville Hospital occasionally. They carried out individual interviews with patients to discuss their problems, promote their understanding of their disease and detect the early signs of incipient peripheral disease. Two thousand and fifty-nine such interviews have been made. Fifty-three cases of incipient foot or hand disease were discovered. It is the progress of these cases with which this paper is concerned. Of these fifty-three patients, forty-three have been able to retain their affected limbs. The ten whose legs needed amputation all were successfully managed by a below knee amputation. This again stresses that the performance of the vastly more disabling but easier above-knee amputation should be the exception rather than the rule, because it produces a much greater disability, virtually the impossibility of walking again. In order to detect which cases are likely to respond to conservative measures and which will need amputation, every patient under-went serial investigation with the Doppler machine. The Doppler ratio of pedal systolic pressure divided by the brachial systolic pressure was less than 0.5 in all cases where amputation became necessary. The presence of persistent severe pain was found to accompany a Doppler ratio of less than 0.5 and was of an equally bad prognostic significance. Cases with a Doppler ratio of less than 0.7 were treated with either Persantin or Stugeron. It was observed that in certain cases the pain disappeared, ulceration healed rapidly and the Doppler ratio became normal while treatment continued. It is interesting that no patient defaulted, denoting the remarkably high patient acceptance of the clinic. Of the two thousand patients interviewed only ten progressed to amputation which compares very favourably with previously reported series where the preventive aspect of treatment had not been implemented (AU)

An analysis of acute intestinal obstruction

250 cases of acute intestinal obstruction treated at the University Hospital over a ten year period were analysed. The incidence of the various causes of obstruction have been recorded. The overall mortality was 8.4 percent. The single most important factor contributing to this mortality was delay in diagnosis and operation. (AU)

Pathology and treatment of urethral structure and its complications in Jamaica

The pathology and treatment of 66 severe or complicated strictures of the urethra are reviewed. There is little evidence from this series that lymphogranuloma venereum is an important cause of urethral stricture and its complications. The importance of avoiding the formation of false passages with bougies is emphasized. Fistulous tracks fall into definite patterns. A study of these in association with the urethrograms will allow pre-operative assessment of the extent of the lesions, and therefore of the extent of resection likely to be required. The suggestion is made that when unilateral hydronephrosis is present, obstruction at the lower end of the affected ureter is sometimes the result of infection which spread from the prostate gland or which was initiated by the passage of a bougie outside the urethra posterior to the base of the bladder. Patients with long-standing cystitis in association with stricture of the urethra may develop a carcinoma which is usually squamous celled and situated away from the base of the bladder. Impassable strictures and those complicated by fistula and abscess formation are best treated by excision and anastomosis in one stage when short and situated in the bulbo-membranous urethra, and by two-stage excision and reconstruction when long, multiple or in the penile urethra. (Summary)

Abdominal actinomycosis associated with idiopathic gangrene of scrotum: a case report

The case of abdominal actinomycosis is, as far as we are aware, the first to be recorded from Jamaica. In addition, no reports on the occurrence of gangrene of the scrotum are known from this island. The presence of a member of the family, Pseudomonadaceae, which is at present under study is intriguing. Its possible role as the cause of the gangrene is discussed (AU)