A systematic approach to severe hand ischemia.

Because severely symptomatic hand ischemia is not common and because there are a wide variety of clinical conditions which can cause arterial insufficiency of the upper extremity, a retrospective study has been done to determine the efficacy of various diagnostic manipulations used in managing 65 patients with severe hand ischemia at the Northwestern University McGaw Medical Center, Traumatic, thermal, and iatrogenic causes of hand ischemia were diagnosed by simple history taking, as was advanced uremic arteritis. Doppler ultrasound and digital arterial pressure recording were confirmative, rather than diagnostic. These aided in defining precise degrees of ischemia and identifying proximal arterial occlusions. Invasive total extremity angiography clarified atherosclerotic, atheroembolic, and other chronic occlusive lesions while serum electrophoresis and immunoelectrophoresis defined the polyclonal and monoclonal gammopathies. When digital necrosis was present, organic arterial occlusions usually were found. These responded best to direct arterial reconstruction down to the mid-palm level. Transpleural, transthoracic sympathectomy was useful as an adjuvant or as definitive treatment for distal digital arterial occlusions. Selective vasodilator therapy was used as dictated by the cause of ischemia and its eventual outcome.

Palliative resections in the treatment of primary colorectal cancer.

Seventy-eight patients underwent palliative resections for adenocarcinoma of the colon or rectum. The operative mortality was 6.4 per cent. The high morbidity rate of 43.5 per cent, mostly attributable to errors in operative technic and sepsis, could not be related to the extent of tumor spread. In fifty-nine patients long-term follow-up revealed a mean survival time of 12.4 months and a median of 9.1 months. Thirty-eight patients (64.4 per cent) survived six months, twenty patients (33.8 per cent) one year, seven patients two years, and one patient five years. Patients with only local extension of disease had the most favorable duration of survival. Hepatic or peritoneal involvement alone did not preclude long-term survival, but with the two combined the outlook was less favorable. There is a small group of patients with extensive metastatic disease who will not benefit from resection. Otherwise, adenocarcinoma of the colon or rectum with local or distant metastases should be resected when feasible.