Successful treatment of mediastinal gas gangrene due to esophageal perforation.

Esophageal perforation and mediastinal gas gangrene developed in a 55-year-old male after the endoscopic ethanol injection of a Mallory-Weiss ulcer. Initially, extensive gangrene of the esophagus and the mediastinum was treated by esophagectomy; however, an abundance of Clostridium perfringens in the Gram stain verified the presence of gas gangrene. Subsequently, the patient was transferred to a hyperbaric oxygen center, wherein a total of seven hyperbaric treatments were administered. The patient survived, and 4 months later, after having undergone several reoperations because of pleural empyema, mediastinal abscess, splenic rupture, and acalculous cholecystitis, was discharged and is still surviving.

Results of incisional hernia repair. A retrospective study of 172 unselected hernioplasties.

The records of 172 patients with repair of incisional hernia in 1976-1985 were reviewed. Follow-up data were collected with a questionnaire and the 40% of patients with symptoms were clinically re-examined. The follow-up time was 3 months to 12 years, mean 4.5 years. The median time between primary operation and first symptoms of incisional hernia was 7 months. Sex, age, smoking, chronic lung disease, obesity, fascial diastasis, site of hernia, surgeon's experience, closure method and suture material were among the factors evaluated as possibly causal. At the time of follow-up 34% of the patients had recurrent hernia. A multifactorial logistic regression analysis revealed obesity as the only factor clearly impairing the result of incisional hernioplasty--good in 87% of the patients with normal weight and in 61% of the overweight. Repeat hernioplasty was performed in 35 cases, but succeeded in only 17. In obese patients repair of an incisional hernia that does not cause serious symptoms is not indicated. More careful selection of patients would improve the results of incisional hernia repair.

Prognosis of patients over 75 years of age with a ruptured abdominal aortic aneurysm.

Forty-seven patients (34 males and 13 females) over 75 years of age (mean: 79.7 +/- 3.8 SD) suffering from a ruptured abdominal aortic aneurysm were operated on between 1977 and 1986. In 16 patients (34%), the aneurysm had been diagnosed previously. Seventeen patients (36%) had a delay of 6 hours or more in the beginning of the treatment and 26 (55%) were in shock preoperatively. The mean diameter of the aneurysms was 8.9 +/- 2.6 cm (SD) and the mean operative bleeding was 8.5 +/- 7.8 (SD) liters. The mean operating time was 220 +/- 96 (SD) minutes. The 1-month mortality was 60% (28 patients) and 63% (12 patients) of survivors had postoperative complications, mostly pneumonia. The 5-year survival rate was 26%. In the analysis of risk factors associated with death, preoperative shock, old age, and a previously diagnosed but untreated abdominal aortic aneurysm were associated with a significantly worse prognosis.