Amyand's hernia causing necrotising fasciitis of the anterior abdominal wall.

The finding of appendicitis within an inguinal hernia is a recognized phenomenon: Amyand's hernia. The development of necrotising soft tissue infection-necrotising fasciitis-is associated with high morbidity and mortality. We present a case of Amyand's hernia resulting in a severe, life-threatening necrotising soft tissue infection, which is previously unreported in English literature. We outline features relating to the diagnosis of this rare condition, and improve awareness among clinicians of the possibility of appendicitis within a direct inguinal hernia, and highlight the importance of appropriate initial surgical intervention for necrotising soft tissue infection to improve survival for these patients.

Initial experience of laparoscopic cholecystectomy in a district hospital.

Fifty-five consecutive unselected patients were submitted for laparoscopic cholecystectomy, and the procedure completed laparoscopically in fifty cases. The outcome is presented with particular reference to the duration of surgery, postoperative pain and nausea, the length of hospital stay and the time taken to recover normal activities. This technique is shown to have major advantages over conventional gallbladder surgery for the majority of patients.

Comparison of Greenfield filter and vena caval ligation for experimental septic thromboembolism.

Septic thromboembolism resulting from the placement of infected autologous thrombi was studied in three groups of ten dogs each following vena caval ligation (VCL) or Greenfield filter (GF) placement with or without antibiotic treatment. All the dogs that did not receive antibiotic therapy died, and the shortest survival time was after acute VCL. Dogs with GF and with delayed embolism after VCL survived significantly longer than did the control animals. Antibiotic therapy consisting of ampicillin and clindamycin resulted in survival except for one control dog with lung abscess. Cultures of the GF and contained thrombus were negative after 2 weeks. However, after VCL, two died of sepsis and two survivors had caval abscess. In a group of six dogs with VCL and delayed embolism, there were four deaths from sepsis and one survivor found to have a caval abscess. To test secondary infection of a trapped thrombus, in 12 dogs with GF and a sterile thrombus we created an extremity abscess with a fecally contaminated sponge, which resulted in death from sepsis in six animals within 3 days. Surgical drainage and antibiotic treatment of the remaining six resulted in survival in five dogs. Cultures of filters and emboli showed heavy contamination in the untreated animals and in one treated dog that died within 24 hours. The remainder had sterile filters and emboli. The presence of sepsis does not preclude use of the Greenfield filter, which is well tolerated in the face of septic embolism and allows sterilization with antibiotic treatment. Prophylactic antibiotic therapy seems advisable for any patient with a filter during a procedure that may produce bacteremia.

Hemodynamics and renal function following experimental suprarenal vena caval occlusion.

In this study, the cardiovascular and renal effects of acute suprarenal caval occlusion were investigated in dogs. Marked hemodynamic effects were noted, with an immediate 60 per cent reduction in cardiac output and a 26 per cent drop in mean systemic arterial pressure. In spite of these, there was only a transient disturbance of renal function which had resolved both biochemically and structurally by the end of two weeks. The relevance of these findings to acute occlusion above the renal veins in humans has been reviewed, and we conclude that the Greenfield filter may be inserted in the suprarenal vena cava when indicated with little likelihood of an increase in mortality from recurrent embolism.

Clinical results of suprarenal placement of the Greenfield vena cava filter.

Twelve patients have had Greenfield vena cava filter placement above the renal veins since 1975. The indication for placement was most commonly contraindication to anticoagulation or recurrent pulmonary embolism during treatment. The follow-up consisted of physical examination, isotope phlebography-lung scan, venous Doppler evaluation, serum specimen evaluation of renal function, and abdominal roentgenograms. The follow-up averaged 16.9 +/- 6.2 months (range 5 weeks to 58 months) in 10 patients. Five patients died after filter insertion, but no death was attributable to filter placement or recurrent embolism. Renal function was unchanged in all patients. Recurrent embolism was documented postoperatively in one patient. Migration of the filter was not observed. The vena cava was demonstrated to be patent in all patients. Two patients had evidence of embolus trapped in the filter.

High colloidal uptake in axillary nodes with metastatic disease.

Axillary lymphoscintigraphy using 99Tcm antimony sulphide colloid has been carried out in 29 patients with suspected breast cancer and was correlated with histology. Of the 23 with proved tumour, axillary node metastases were found in 19 and, although 10 did have diminished uptake on the side of the lesion, 5 had an equal uptake in both sides and 4 had an increased uptake on the side of the lesion. Further, some of the nodes in which the high uptake had occurred were those heavily infiltrated by tumour. It is concluded that: a, lymphoscintigraphy with antimony sulphide colloid is not a reliable technique for the detection of metastatic disease in the regional nodes; b, any lymphoscintigraphy with this or any other agent requires more meticulous histological correlation than hitherto before it can be assumed to have any proved clinical value.