Necrotizing anorectal and perineal infections.

Sixteen cases of spontaneous necrotizing infection of the anorectum and perineum are described. Thirteen patients had clostridial infections and three had infections with nonclostridial organisms. Six patients were diabetic and two had leukemia. All 16 patients presented with pain, tenderness, swelling, and crepitation. Four had an ominous black spot on the scrotum or posterior labia. Shortly after initial recognition by the patient, all infections rapidly disseminated to include all surrounding areas such as the external genitalia, the anterior abdominal wall, and thighs. Treatment consisted of radical debridement and antibiotics; hyperbaric oxygen was used in the clostridial cases. Ten of the 16 patients survived. Delayed diagnosis and delayed treatment were the primary factors responsible for death.

Duodenal perforation in blunt abdominal trauma.

Ten patients with duodenal perforation secondary to blunt abdominal trauma are reviewed. All 10 patients survived. Most of the injuries were related to motor vehicle accidents. Early recognition requires a high index of suspicion because preoperative signs and symptoms tend to be nonspecific and x-rays are usually not helpful. A careful exploration of the duodenum at laparotomy including both the Kocher maneuver and the Cattell-Braasch exposure is essential. Suitable methods of surgical repair are numerous, but those providing for restoration of normal gastrointestinal tract continuity are preferred.

A comparative radiographic study of low anterior colon anastomoses in dogs.

A radiographic animal study comparing two-layer and hand-sewn colorectal anastomoses to anastomoses made with an inverting circular stapling device revealed a highly significant difference in anastomotic leak rate: 13 anastomotic dehiscences were demonstrated in 20 dogs with hand-sewn anastomosis (65%), and four leaks (20%) were found in 20 dogs with stapled anastomoses. All leaks occurred between the third and seventh postoperative days and most were not clinically significant. A marginally significant difference in mortality rate was found, with four deaths among the hand-sewn group (20%) and two among the stapled group (10%). The data suggest that the EEA stapling device may be preferable to hand-sewn techniques, particularly for low extraperitoneal colorectal anastomoses.

Control of acute gastroduodenal hemorrhage with cimetidine.

Thirty-four patients with acute gastroduodenal hemorrhage were treated with intravenous Cimetidine. Preliminary endoscopy was done at the onset of bleeding to determine the source of bleeding and to rule out the presence of a brisk arterial bleeding site that would require immediate operation for control. Sixteen of the patients had primary peptic ulcer disease and 18 patients had "stress ulcer" syndrome. The bleeding stopped following Cimetidine administration in 14 of the 16 peptic ulcer patients (88%) and in 13 of 18 stress ulcer patients (72%). There was no subsequent rebleeding. The data suggest that Cimetidine is of value in the immediate nonoperative management of acute gastroduodenal hemorrhage. Further, the availability of Cimetidine for postoperative use may modify the surgical approach to stress ulcer bleeding.

Mallory-Weiss syndrome: analysis of fifty-nine cases.

Fifty-nine patients with Mallory-Weiss gastroesophageal lacerations are described. These patients consisted of 6% of all cases of upper gastrointestinal tract hemorrhage we evaluated. The most common symptoms were hematemesis (92%) and retching (61%). A history of chronic alcoholism was present in 69.5%, and recent binge drinking in 52.5% of our patients. Diagnosis was made endoscopically (55 patients) or surgically (four patients). Two deaths occurred in the 51 patients who were managed nonoperatively and two deaths occurred in the eight patients who underwent surgery. None of the deaths was related to delay in operative treatment. Eleven patients had late rebleeding, but in only three of these patients was this due to recurrent Mallory-Weiss lesions. We believe the Mallory-Weiss laceration can now be considered to be a relatively benign condition that can be managed successfully by nonoperative means in the majority of cases.

Reduction of plasma cholesterol and LDL-cholesterol by continuous intravenous insulin infusion.

We studied lipid profiles in 10 patients with insulin-requiring type II diabetes. Patients began the study under conventional subcutaneous insulin injection therapy. Treatment was then optimized on subcutaneous therapy and finally converted to continuous intravenous therapy from a single flow rate implantable pump. Pump management proved reliable and safe. Implantable pump therapy showed a statistically significant reduction in the average plasma cholesterol level from 205.7 to 184.7 mg/dl. The mean low-density lipoproteins (LDL)-cholesterol level decreased from 114.6 to 108.1 mg/dl, the high-density lipoproteins (HDL)-cholesterol average changed from 50.6 to 51.0 mg/dl, and the HDL/LDL ratio increased from 0.478 to 0.500. Glycemic control did not improve on single-rate intravenous therapy compared with intensive conventional subcutaneous injection during the short observation period. The authors conclude that additional studies should be performed to confirm the improvement in the lipid profile on intravenous pump therapy.

Renal cyst causing afferent loop obstruction and acute pancreatitis.

A patient with afferent loop obstruction caused by a right renal cyst who presented with acute pancreatitis has been described. The obstruction was successfully relieved at operation with resection of the portion of cyst wall extrinsic to the kidney and mobilization of the duodenal loop into its normal location.

Changes in the surgical treatment of acid peptic disease.

The surgical treatment of acid peptic disease at Hennpin County Medical Center (Minneapolis, MN) during two time periods separated by a 12-year interval was reviewed. In comparing the more recent period with the earlier, the following was observed: 1) total number of operations decreased by one-third, but the number of emergency operations was the same; 2) overall operative mortality did not change even though more patients in the recent period had associated systemic disease; 3) the location of ulcers did not change; 4) hemorrhage, as an indication for emergency surgery, increased both relatively and absolutely; and 5) the preferred surgical procedure during both periods was vagotomy and antrectomy, but vagotomy and drainage was done with increased frequency in the more recent period. During both time periods, emergency surgery was associated with almost a tenfold increase in operative mortality.

Overwhelming infections in trauma.

Following trauma, wound contamination with aerobic and/or anaerobic bacteria should always be suspected. Treatment with antibacterial antibiotics should begin immediately in the emergency room, particularly for those patients with fractures. Patients with serious trauma are best treated by a team of specialists including general surgeons, orthopedists, infectious disease specialists, and intensive care specialists. The author recommends transport of seriously injured patients to major hospitals specializing in the care of trauma. Particularly when gas gangrene secondary to clostridial infection is suspected, the patient should be moved to a major trauma center with the capability for hyperbaric oxygen therapy.