Robert E. Casali

Postoperative necrotizing fasciitis of the abdominal wall

Abstract Postoperative necrotizing fasciitis of the abdominal wall is usually caused by peritonitis in patients who have undergone multiple procedures for complications of emergency laparotomy. Better patient survival may be achieved by the following method: thorough peritoneal exploration to drain abscesses, excision of necrotic fascia, temporary Marlex placement, and delayed closure of the wound with skin flaps.

Arterial embolectomy in the leg. Results in a referral hospital.

The clinical characteristics and course of 90 patients in whom 121 arterial emboli occurred from 1968 to 1978 were reviewed. The factor that correlated most significantly with a favorable outcome was the interval from onset of symptoms until arterial embolectomy was performed. The results of embolectomy were excellent in the patients operated on within 6 hours of symptoms (amputation rate 4 percent, mortality rate 15 percent), but less favorable in the patients operated on within 6 to 12 hours of onset of symptoms (amputation rate 27 percent, mortality 40 percent). Mortality (48 percent) and amputation (52 percent) rates in the patients operated on 12 to 48 hours after onset of symptoms were excessive. It is recommended that immediate embolectomy be performed in all potentially viable extremities in patients who present within 12 hours of symptoms, but that after 12 hours only those limbs with obvious viability (not paralyzed or anesthetic) should be operated on. Alternatives for the remainder are high dose intravenous heparinization or expedient amputation. In patients who present greater than 60 hours after the onset of symptoms, embolectomy can be performed with low morbidity and mortality.

Advanced hidradenitis suppurativa: Review of surgical treatment in 23 patients☆

Abstract Hidradenitis suppurativa remains a poorly understood disease involving the apocrine sweat glands. Management of 23 patients with the advanced form of the disease has been reviewed. Local therapy and incision and drainage all have an unacceptable rate of recurrence. From our experience, we recommend wide and deep excision of the area involved combined with individualized closure.

Total infrarenal aortic occlusion

Our experience from 1960 to 1976 with total infrarenal aortic thrombosis (Leriche syndrome) was reviewed. Sixteen heavy smokers (14 men and 2 women) with an average age of fifty-four years underwent thrombectomy with aortoiliac (12 patients) or aortofemoral (4) Dacron bypasses. The last ten patients were hydrated for 12 hours preoperatively with 3,000 ml of Ringers solution containing supplemental potassium. Mannitol (25 g), furosemide (20 mg), and heparin (120 u/kg) were given intraoperatively. Thrombectomy was accomplished by transection of the aorta, with proximal manual control of the aorta after the renal arteries were occluded. With this technic there were no deaths or renal complications, whereas previously, three of the six patients developed renal complications and one died. Ninety-two per cent of the grafts have remained open. We recommend that the direct transabdominal approach be continued rather than the extraanatomic bypass (axillobilateral-femoral), since further propagation of the aortic thrombosis may then lead to infarction of the kidneys or other viscera.

Acute perforations of the sigmoid colon secondary to diverticulitis.

Diverticulitis is a complex disease and demands careful cooperation between physician and surgeons, because although it is a benign disease, the presence of complications makes it potentially lethal. For successful management, knowledge of the treatment in past decades should be integrated with current surgical technics. A retrospective review of forty-one patients with perforated diverticulitis revealed a significant decrease in morbidity and hospital stay for the group of patients undergoing the Hartmann procedure versus the group undergoing the classic three stage approach. In addition, the Hartmann group required fewer additional surgical procedures for drainage of abscesses. In view of these results as well as those of others, we believe that resection is the primary goal of therapy. The two stage approach therefore offers significant decrease in morbidity with acceptable mortality.

Primary malignant retroperitoneal tumors: Current management☆☆☆

Our experience with 16 retroperitoneal tumors seen over a 13 year period has been reported. Patients presented with either an abdominal mass or abdominal pain associated with a large retroperitoneal tumor. Delineation of the tumor is best accomplished with computerized tomography and venacavography. Exploration and resection is possible in most patients. Postoperative radiotherapy and chemotherapy are recommended in most patients. Local recurrence frequently occurs and should be diagnosed early and resected aggressively if found.

Results of interposition "H" grafts for portal hypertension.

During the past nine years, 54 patients underwent interposition graft shunting for variceal bleeding in 48 and intractable ascites in six, either electively (35 instances) or as an emergency (13 instances). Autogenous jugular was used in 41 instances, homologous vena cava in nine and Dacron® in five. The interposition graft was placed between superior mesenteric vein and vena cava in 36 instances and the portal vein and vena cava in 19. Using Childs Clinical Classification 44 were Class C and 10 Class B. There were six (11%) operative deaths with one (2.4%) in the elective and five (38%) in the emergency group. Encephalopathy was seen in 4 (10%) of those surviving more than one year. Two Dacron and two homografts thrombosed. Eight of the autografts were patent at autopsy, 18 on angiography and 15 assumed to be patent because patients were asymptomatic. Only one of 12 late deaths was related to graft failure. Apparently the operation controls ascites and the autogenous jugular vein is the ideal material. Interposition “H” grafting is a simple safe procedure that can be used for portal decompression‘ in patients with bleeding varices.

The surgical significance of hyperosmolar coma

Summary The syndrome of nonketotic hyperglycemic hyperosmolar coma is described in six patients and the pathophysiologic mechanisms responsible for production of the abnormalities are discussed. Attention is directed to the surgical significance of this disorder and the frequency with which diagnosis was delayed and or inadequate or inappropriate therapy was given. Early recognition and treatment of this disorder should result in improvement in the reported 40 to 50 per cent mortality.

What constitutes the proper solution for resuscitation of the severely burned patient

Abstract This is a report of thirteen patients with major burns resuscitated with hypertonic lactated saline solution. The average gain in body weight was only 7.4 per cent. The total volume of fluid given in the first forty-eight hours was 23 per cent less and the sodium load administered 86 per cent greater than would have been given using the formula of the Brooke Army Hospital. All patients developed hypernatremia and increased serum osmolality which was well tolerated and lasted only for as long as treatment continued. No patients developed pulmonary edema or required tracheostomy or escharotomy. In addition, clinical ileus preventing oral intake did not occur. Urine production was prompt and of good volume, and no patients showed oliguria on this treatment. The BUN was mildly elevated in six patients, but this is no greater a number or degree than would be expected with other treatments.