The hemodynamic determinants of myocardial oxygen utilization were ascertained in the isolated, metabolically supported, nonfailing canine heart. The primary determinant was found to be the total tension developed by the myocardium as indicated by the area beneath the systolic pressure curve (Tension-Time Index). The significance of these findings for the understanding of the low efficiency of the failing heart and the consequently increased importance of Laplace's law are discussed.
The hazards of dealing with infected false femoral aneurysms resulting from intra-arterial narcotic injection are highlighted in six patients. Two patients were human immunodeficiency virus positive and three patients were hepatitis B surface antigen positive. Because of these infections exploration of groin swellings as presumed soft tissue abscesses is potentially hazardous without proper proximal vascular control. All patients underwent reconstruction following arterial ligation and five grafts became infected, with life threatening haemorrhage occurring in four patients. Five grafts have subsequently occluded or have been removed without loss of limb viability, although two patients have been regrafted. A high index of suspicion and assessment by a vascular surgeon, with angiography if indicated, is required in any intravenous drug abuser presenting with a groin swelling following injection. Because of the great risk of graft infection, it is suggested that ligation and debridement alone be carried out, with immediate arterial reconstruction only for non-viability.
The presentation and subsequent management of 53 patients with volvulus of the small bowel are reviewed. Important features of the presentation are the acute onset of the abdominal pain and its severity which is often inconsistent with the findings on clinical examination. The diagnosis was made preoperatively from plain abdominal x-rays in only 1 patient, although several radiological features are described. In 16 patients there were no obvious predisposing factors, although in the remaining 37 patients the volvulus occurred as a consequence of a predisposing anatomical abnormality. The mortality rate associated with volvulus in the presence of gangrenous small bowel is 47%. In the management of a patient presenting with small bowel obstruction, the possibility of volvulus must be considered in order to reduce this high mortality.Small bowel volvulus is a condition in which there is a torsion of all or a segment of the small bowel and its mesentery. It is a well-recognized entity in neonates as a consequence of anomalies of midgut rotation [1]. Although the condition is one of the more common surgical emergencies in the adult population of Central Africa, Asia, and Middle Eastern nations [2], small bowel volvulus occurs only rarely among Europeans and North Americans. The purpose of this study is to review the experience in 53 adult patients with small bowel volvulus over a 15-year period with reference to the etiology, presentation, and survival.
Patients and MethodsThe clinical details of 53 patients presenting with small bowel volvulus during the 15-year period from
Although the general dependence of coronary flow on myocardial qo2 was confirmed in an in situ heart preparation, changes in aortic pressure and cardiac output were observed to be capable of influencing this relationship. Neither myocardial qo2 nor coronary flow were found to be dependent on left ventricular filling pressure.
Fifty patients presenting with acute volvulus of the sigmoid colon have been analyzed. The diagnosis was made in 39 patients from the presenting features and abdominal radiographs. Deflation by sigmoidoscopy and flatus tube was performed in 19 patients with initial success in 15. Recurrent volvulus occurred in 6 of these patients. Laparotomy was carried out in 36 patients and colonie gangrene was present in 6 patients. The operative mortality rate was 42%. Mortality was related to a combination of age, intercurrent medical illness, and sepsis. Simple operative reduction was associated with a lower mortality when compared to resection but had a higher incidence of recurrent volvulus. This study supports the use of sigmoidoscopic reduction as the primary treatment of acute sigmoid volvulus. Laparotomy and colonic resection should be reserved for those patients who are medically fit and should ideally be performed on an elective basis after preliminary decompression. In unfit patients in whom sigmoidoscopic reduction fails, detorsion and colopexy is advocated.
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