Mortality in perforated duodenal ulcer depends upon pre-operative risk: a retrospective 10-year study.

INTRODUCTION: Most patients presenting with acutely perforated duodenal ulcer undergo operation, but conservative treatment may be indicated when an ulcer has spontaneously sealed with minimal/localised peritoneal irritation or when the patient's premorbid performance status is poor. We retrospectively reviewed our experience with operative and conservative management of perforated duodenal ulcers over a 10-year period and analysed outcome according to American Society of Anesthesiologists (ASA) score. METHODS: The records of all patients presenting with perforated duodenal ulcer to the Department of Surgery, Mayo General Hospital, between January 1998 and December 2007 were reviewed. Age, gender, co-morbidity, ASA-score, clinical presentation, mode of management, operative procedures, morbidity and mortality were considered. RESULTS: Of 76 patients included, 48 (44 operative, 4 conservative) were ASA I-III, with no mortality irrespective of treatment. Amongst 28 patients with ASA-score IV/V, mortality was 54.5% (6/11) following operative management and 52.9% (9/17) with conservative management. CONCLUSION: In patients with a perforated duodenal ulcer and ASA-score I-III, postoperative outcome is uniformly favourable. We recommend these patients have repair with peritoneal lavage performed, routinely followed postoperatively by empirical triple therapy. Given that mortality is equivalent between ASA IV/V patients whether managed operatively or conservatively, we suggest that both management options are equally justifiable.

Recurrent sigmoid volvulus - early resection may obviate later emergency surgery and reduce morbidity and mortality.

INTRODUCTION: Acute sigmoid volvulus is a well recognised cause of acute large bowel obstruction. PATIENTS AND METHODS: We reviewed our unit's experience with non-operative and operative management of this condition. A total of 27 patients were treated for acute sigmoid volvulus between 1996 and 2006. In total, there were 62 separate hospital admissions. RESULTS: Eleven patients were managed with colonoscopic decompression alone. The overall mortality rate for non-operative management was 36.4% (4 of 11 patients). Fifteen patients had operative management (five semi-elective following decompression, 10 emergency). There was no mortality in the semi-elective cohort and one in the emergency surgery group. The overall mortality for surgery was 6% (1 of 15). Five of the seven patients managed with colonoscopic decompression alone who survived were subsequently re-admitted with sigmoid volvulus (a 71.4% recurrence rate). The six deaths in our overall series each occurred in patients with established gangrene of the bowel. With early surgical intervention before the onset of gangrene, however, good outcomes may be achieved, even in patients apparently unsuitable for elective surgery. Eight of the 15 operatively managed patients were considered to be ASA (American Society of Anesthesiologists) grade 4. There was no postoperative mortality in this group. CONCLUSIONS: Given the high rate of recurrence of sigmoid volvulus after initial successful non-operative management and the attendant risks of mortality from gangrenous bowel developing with a subsequent volvulus, it is our contention that all patients should be considered for definitive surgery after initial colonoscopic decompression, irrespective of the ASA score.

Lymph nodes and vessels in primary lymphoedema. Their relative importance in aetiology.

The classification of lymphoedemas is reviewed and the various primary lymphoedemas distinguished from the secondary. The early lymphographic studies of primary lymphoedemas (many of which arise from genetic factors) probably laid undue emphasis on changes in the lymphatic vessels. Oil contrast media in leter use in lymphography have given much information onchanges in the nodes. In 89% of patients reviewed both nodes and vessels were diseased and in the majority the changes were worse in the nodes. This suggests that in many patients with primary hypoplastic lymphoedema the pathological process has arisen first in the nodes.

Biliary excretion of diazepam in man.

In a study of diazepam metabolism, diazepam 10 mg was administered i.m. to four patients who had biliary T-tube drainage. Blood and bile diazepam metabolite concentrations were measured for 12 hr. The expected fluctuations in blood diazepam concentrations were seen, and conjugated diazepam metabolites were present in human bile. Bile diazepam concentrations were insufficient to account for an enterohepatic circulation.