Gurjit Singh

Aggressiveness — the key to a successful outcome in Fournier's Gangrene

Nine patients with Fourniers gangrene were managed during last five years in various service hospitals. Mean age was 51 years (range 21-81 years). Most of these patients were from middle and upper class. Common predisposing factors included diabetes mellitus, alcohol abuse and poor personal hygiene. Streptococcus haemolyticus, Staphylococcus aureus and E coli were the commonest organisms cultured in most of these patients. Our experience indicates that the lower gastrointestinal tract should be considered as a possible cause of infection in all patients with Fourniers gangrene as 5 patients developed this condition following anorectal abscesses. All these patients were treated with a common approach of resuscitation, broad spectrum antibiotics, immediate surgical excision of all necrotic tissue, nutritional therapy and early skin coverage without any mortality. The surgeon should be more aggressive in the initial therapy and make the first surgery more definitive. There is no place for conservative management. The patients with perianal sepsis in elderly should be referred early for surgery.

Aggressiveness — The key to a Successful Outcome in Necrotizing Soft Tissue Infection

16 patients with necrotizing soft tissue infections were managed during last three years in various service hospitals. The experience indicates that there is considerable overlap in clinical findings and bacteriology. The infections seem to be variations of the same disease process, a spreading necrotizing infection. The number of these patients suggests that there is an increasing incidence of this entity. Staphylococcus and coliforms were the commonest organisms cultured in most of these patients. Because of the high mortality rate upto 50% as reported, we advocate aggressive and early treatment of this condition. Urgent radical exploration, excision of all necrotic tissue and adequate drainage of the deep fascial planes was done in all patients until healthy tissue planes were reached. A strong index of suspicion aids early diagnosis which ensures a favourable outcome. Our study indicates that the lower gastrointestinal tract should be considered as a possible cause of infection in all patients with synergistic gangrene. The involvement of the perineum and scrotum was most common. All these patients were treated with a common approach of resuscitation, broad spectrum antibiotics, immediate surgical excision of all necrotic tissue, aggressive nutritional therapy and early skin coverage with 20% mortality. The infection was primary in 8, postsurgical in 4 and following trauma in 4 cases. In majority of patients, Staphylococcus with beta haemolytic streptococci and E coli were the organisms isolated initially. Mortality was highest in intensive infections extending the abdomen and chest. Aggressive, effective and early treatment of necrotizing soft tissue infections is imperative to prevent a fatal outcome. Urgent radical exploration by the most experienced surgeon available is essential and includes wide excision of all necrotic tissue and adequate drainage of the deep fascial planes until indubitably healthy tissue is experienced. The surgeon must be prepared to proceed to a laparotomy, diverting colostomy or a suprapubic cystotomy where there exists any element of doubt. Aggression is also of significance in resuscitation, early institution of empirical broad spectrum antibiotic therapy, elaborate repeated daily dressings with hydrogen peroxide and to allow further debridement till the process is controlled.

Study of Disabled Treated at Artifical Limb Centre

BACKGROUND Artificial Limb Centre (ALC), Pune provides comprehensive rehabilitation care to disabled soldiers of Armed Forces. A retrospective study of 16308 Armed Forces personnel treated at ALC, Pune was carried out to analyse the factors resulting in disability and their distribution among the soldiers. METHODS Records of disabled soldiers treated at ALC, Pune from 14 May 1944 to 31 Dec 2003 were analysed with respect to their age, rank structure, nature of disability, causation and body part involved to find out various factors contributing to disablement and its distribution amongst the soldiers. RESULT Trauma was the commonest cause of disability in Armed forces personnel and mine blast injury was the most frequent mode of trauma followed by road traffic accident. Study also revealed that lower limb amputation is the most common type of disability and below knee amputation is the most common level of amputation. Maximum disabled personnel were in the age group of 21 to 40 years and other ranks accounted for 92.58 % of the total number. CONCLUSION War related injuries were the most common cause of disability in the Armed Forces personnel, which affect the young soldiers in their most productive period of life.

Amputation in Diabetic Patients

BACKGROUND Foot ulcers and their complications are an important cause of morbidity and mortality in diabetes. The present study examines the amputation risk criterion and the long term outcome in terms of amputations and mortality in patients with diabetic foot. METHODS 27 patients with diabetic foot lesions were studied. There were 15 patients with early lesions and 10 with advanced lesions. 15 patients were managed conservatively including local amputations and 12 with lower extremity amputations. 80% patients were males in 45-59 years of age group and all patients had more than 6 years of poorly controlled diabetes. RESULTS Precipitating factors included walking barefoot, history of minor trauma, infection, callosities or burns in 86% of patients. Major lower limb amputations were common in irregularly treated, poorly controlled diabetics due to infection in a limb devitalized by angiopathy and desensitised by neuropathy. CONCLUSION Diabetic foot ulcers are associated with high morbidity and mortality. Mortality was higher in ischaemic ulcers than neuropathic ulcers.

Clinical Appraisal of Indigenous Below Knee Endoskeletal Carbon Fibre Prosthesis

BACKGROUND Amputation is a catastrophe, which results in physical, social, psychological and economic handicap. Provision of suitable prosthesis (artificial limb) is a major step towards rehabilitation of these patients. METHODS With an aim to provide comfortable, prosthesis to these patients, Artificial Limb Centre (ALC) Pune, developed Below Knee Carbon Fibre Shaft Endo-Skeletal (BK ES CF) Prosthesis in collaboration with DEBEL, Bangalore, a DRDO establishment. 815 Below Knee Amputee patients have been provided with the newly developed Endo-skeletal prostheses at ALC Pune till 31 Dec 2003. New BK ESCF prosthesis was evaluated for its performance by feedback received from 500 patients. RESULTS More than 86% patients were satisfied with the performance of new prosthesis and they achieved almost normal gait. CONCLUSION The performance of new BK ESCF prostheses was excellent and it achieved good clientele satisfaction.

Congenital Absence of Gall Bladder

Although biliary system variants are extremely common, isolated congenital absence/agenesis of gall bladder (AGB) is extremely rare, with a reported incidence ranging between 0.013 and 0.075% [1]. More than 50% of the patients with AGB are symptomatic for biliary tract disease and require some form of surgical intervention [1]. Inspite of all available diagnostic modalities pre-operative diagnosis of AGB may be illusive and present a surprise to the abdominal surgeon at laparotomy. We present a case of AGB who presented with features of obstructive jaundice and at operation was found to have AGB with choledocholithiasis.

Ahmad AHaiRabindra BShrivastavaThe ASI, Text Book of SurgeryFirst Edition2003Published by Tata McGraw. Hill Publishing Company Limited, 7 West Patel NagarNew DelhiISBN 007-462149-1, Associate Editor, 110 008. Pages - 1444, Printed in India by Tata Mc Graw Hill Publishing Company Limited. Price- Rs. 1395/-

A comprehensive text book for surgical student and trainee, guiding the reader through Key Core Surgical topics which are encountered throughout an integrated medical curriculum as well as subsequent practice. Written and published by a team of highly experienced teaching and operating surgeons, with contribution from 138 doctors, under the aegis of The Association of Surgeons of India, covering all general and allied surgical problems with particular emphasis on those that are prevalent in India and nearby Asian countries. A holistic approach has been employed to describe all aspects of surgical conditions in a systematic manner using a simple and student friendly language.

The ASI, Text Book of Surgery

A comprehensive text book for surgical student and trainee, guiding the reader through Key Core Surgical topics which are encountered throughout an integrated medical curriculum as well as subsequent practice. Written and published by a team of highly experienced teaching and operating surgeons, with contribution from 138 doctors, under the aegis of The Association of Surgeons of India, covering all general and allied surgical problems with particular emphasis on those that are prevalent in India and nearby Asian countries. A holistic approach has been employed to describe all aspects of surgical conditions in a systematic manner using a simple and student friendly language.

INVESTIGATION OF A CASE OF CLOSTRIDIAL MYONECROSIS

C lostridial myonecrosis (gas gangrene) occurs in a setting of common muscle injury and contamination with soil or other foreign material containing the spores of C perfringens or other histotoxic clostridia; (a) penetrating war wounds (b) accidental traumatic civilian injuries (c) surgical wounds particularly after bowel or billiary tract surgery. Rarely, cases of gas gangrene have been reported following parentral injections and at sites of venepuncture in granulopenic patients [1]. Clostridia commonly associated with gas gangrene are C perfringens (80%), C novyi (40%), C septicum (20%) followed occasionally by C histiolyticum, C sordelli, C fallax, C bifermentans and C sporogenes. Gas gangrene may occasionally develop in the absence of an obvious external wound . This form of gas gangrene is designated as spontaneous nontraumatic gas gangrene and is caused by C septicum.