Amebic peritonitis secondary to amebic liver abscess.

A series of 19 patients who had amebic peritonitis secondary to rupture of an amebic liver abscess is presented. This represents 2.4% of the patients treated for ALA during an 18.5-year period. Eighty-four percent were men and ages ranged from 6 to 70 years. Rupture occurred prior to admission in 17 patients. Abdominal pain and fever were the most common symptoms. Abdominal tenderness, liver enlargment, distention, and jaundice were the predominant physical findings. All patients underwent operation. Removal of necrotic and purulent material combined with wide drainage were carried out. In two patients with amebic cecal disease, intestinal bypass was also done. The mortality rate was 42%. It was significantly increased in patients over 50 years of age and in those in whom a correct preoperative diagnosis was not made.

Typhoid perforation: choice of operation.

Over a 17-year period 93 patients have been treated for typhoid perforation of the bowel. Forty-three of these have been treated by closure of the perforation, and 42 by end-to-side ileotransverse colostomy. These two groups are compared. Although there was no difference in mortality, postoperative morbidity in survivors was less in those having an end-to-side ileotransverse colostomy. End-to-side ileotransverse colostomy is a logical operation based upon the pathological changes in the bowel produced by typhoid fever and is the operation of choice.

Management of thoracic amebiasis.

The thoracic complications of amebiasis frequently necessitate surgical intervention. Experience with 28 patients is presented. Involvement included the pleura in 19 patients, the lungs in 10, and the pericardium in five. In 25%, more than one site was involved. Treatment consisted of measures designed to obliterate the pleural space or widely drain the pericardial sac, as indicated. Concurrent drainage of the associated amebic liver abscess was done in half the cases. The mortality rate was 36%, generally related to the poor general condition of the patients and their delay in seeking hospitalization.

Typhoid perforation of the bowel. Experiences in 78 cases.

Seventy-eight patients ranging from four to 65 years of age were treated for typhoid perforation of the bowel. Sixty-one patients (78%) were males. The average time from perforation to admission was 56 hours. The mortality rate was 32% and was adversely influenced by the duration of illness, duration of perforation, shock, uremia, encephalopathy and fecal peritonitis. Forty-nine patients were treated by closure of the perforation, resection or miscellaneous procedures; the other 29 by closure of the perforation combined with an end-to-end ileotransverse colostomy. Although mortality was the same in both groups, those undergoing bypass had a significantly smoother postoperative course.

Amebiasis causing massive gastrointestinal bleeding.

Three patients had massive bleeding from proved amebic ulcers in the cecum. One had an accompanying amebic liver abscess. All were successfully treated by emergency right hemicolectomy.

Amoebic perforation of the bowel: experiences with 26 cases.

Over a period of 14 1/2 years, 26 instances of amoebic perforation of the bowel occurring in 25 patients were treated surgically. Nineteen perforations occurred in males and 7 in females, whose ages ranged from 3 to 74 years. The duration of symptoms varied from 12 h up to 5 months (average 15 days). All patients were toxic and a right lower quadrant mass was present in 14. The correct diagnosis was made or suspected in 14 (54 per cent). Amoebic perforation of the bowel should be suspected in patients presenting with an acute abdomen if a past history of fever, pain and diarrhoea is obtained, particularly if a large tender mass is present in the right iliac fossa. Resectional surgery was performed in 7 patients, with a mortality of 71 per cent, whereas procedures designed to divert the faecal stream were carried out in 19, with a mortality of 43 per cent. All 6 patients with concomitant liver abscesses died. If these patients are excluded, the mortality from resections was 60 per cent and from faecal diversion 27 per cent. Faecal diversion with wide drainage is the treatment of choice for amoebic perforation of the colon.

The results of surgery in amebic liver abscess: experiences in eighty-three patients.

Experiences with surgery in 83 patients with amebic liver abscess are presented. The patients' ages ranged from 8 months to 72 years; 85% were men. Symptoms had been present for an average of 4.6 weeks. In 36 (43%) the abscess already was ruptured at the time of admission to the hospital and in an additional eight it ruptured later. Rupture occurred more commonly upward through the diaphragm than downward, and into a serous cavity in 36 patients. Because of the poor general condition and associated illnesses of the patients, surgical procedures were limited to the minimum. Indications for operation were rupture or impending rupture of the abscess, failure of response to medical therapy, and inadequacy of aspiration of left lobe abscess. An additional 27 patients underwent operation because of diagnostic problems or symptoms of an acute abdomen. Two thirds of the patients had one or more complication. The overall mortality rate was 34%. Factors adversely affecting mortality rate were lack of preoperative drug therapy, rupture into a serous cavity, and presence of an associated amebic perforation of the colon.

Cricotracheal disruption owing to strangulation. A report of two cases with successful surgical repair.

Two patients with cricotracheal disruption resulting from accidental strangulation of the neck were treated. The first patient had severe respiratory obstruction. In the second patient, a fascial tube maintained airway continuity between the separated larynx and trachea, and she had no difficulty breathing. A preoperative diagnosis of tracheal injury was based on the findings of respiratory obstruction, bloody secretions in the endotracheal tube, and subcutaneous emphysema in the neck. In both cases, an endotracheal tube was easily passed and entered the distal tracheal lumen. This relieved the respiratory obstruction in the first case and allowed administration of general anesthesia and control of ventilation during the operation. Prompt repair with cricotracheal anastomosis was followed by excellent results in both cases.

Arterial injuries of the extremities.

Fifty-eight patients with arterial injuries of the extremities were treated during the past 8 years. Fifty-one had acute injuries and seven had nonacute injuries. Blunt trauma or shotgun wounds caused 74% of the injuries, and 55% were associated with skeletal trauma. All the acute injuries endangered the limb; the average ischemic time was 8.5 hours. Brachial, popliteal, and superficial femoral arterial injuries were seen most frequently. Repair was accomplished with autogenous saphenous vein grafts in 47% and end-to-end anastomosis in 41%. Six patients died, four due to injuries of other organs. The most alarming complication of arterial repair was secondary hemorrhage which occurred in three patients and was caused by local infection. Six patients (13.3% required amputations; the highest number (three) after injuries of the popliteal artery. The injuries leading to amputations had associated prolonged ischemia, severity of injury, and associated venous, soft tissue, and skeletal injury. The nonacute injuries were in the form of false aneurysms, pulsating hematomas, AV fistula, and delayed bleeding. These were easily managed without any significant complication.

The early acidosis of burns: its relationship to extent of burn and management.

Acid-base studies were carried out on 76 consecutive burn patients admitted within 36 hours of injury. Admission blood pH and base excess (BE) values all decreased in a linear relationship to the extent of the burn. Blood Pco-2 changes were unrelated to the extent of the burn. Significant acidosis developed within 2 hours of burn injury. Base requirements for the first two 24 hour periods after burn were linearly proportional to the extent of burn. Base requirements for these two periods were determined and were expressed as: (1) base needed the first 24 hours (milliequivalents per kilogram) equals percent of body surface burned/8; and (2) base needed the second 24 hours (milliequivalents per kilogram) equals base needed the first 24 hours/4. These formulas were found to work satisfactorily in a prospectively treated series of patients.