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FIELDS, W. S., MASLENIKOV, V., MEYER,J. S., HASS, W. K., HEMIKCTON, R . D. and MACDONALD, M. (I970), J . Amer. m e d . Ass., 211 : 1993. FISHER,C. M., GORE, I., OKABE, N. and WHITE, 1’. D. (1965). J . Newopath. exp, Newol., 24: 455. FRIEDMAN, G. D., WILSON,W . S., MOSIER,J. M., COLANDREA, M. A. and NICHAMAN, M. Z. (1969), J . Amer. m e d . Ass., 210: 1428. GILLESPIE,J. A. (1971), Postgrad. wed. J., 47: 282. GILLILAN,L. A. (1959), J . Comp. Neurol., 1 1 2 : 59. GOLI)NER, J. C., W H I S N A N T , J. 1’. and TAYLOR, w. F. (rg71), Stroke, 2 : 160. HAwoEsrY, W. H., WHITACKE, W. B., TOOLE,J. F., RANDALL, P. and ROYSTER, H. P. (1@3), S w g . Gyizer. Ohstet., 116: 662. HASS,W. K., FIELDS, W. S., NORTH,R. R., KRICHEFF, I. I., CHASE,N. E. and RAUER,R. B. (1968), J . Amer. wed. Ass., 203: 159. HUMPHKIES, A. W., YOUNG,J. R., BEVEN,E. G., LE F E ~ R F. E , A. and DE WOLFE,Y. G. (1965). S u r g c r y , 57: 48. HUXHINSON, E. C. and YATES, P. 0 . (1957), Lniaret, I : 2.

IVAN, L. P. and MARIAN,J. J. (1969), J . Neurosurg., 30: 233.

H. (1966), Szwgery, 59: 1147. JAVID.H., DYE,W . S., HUNTER,J. A,. NAJAFI, H., GOLDIN, M. D. and SERRY, C. (1974), S w g . Clin. hT.Amer., 54: 239.

JAVID,

Imm, R. S. A. (1973), M e d . J . Aust., 2 : 32. MARSHALL, J. (1964), Quart. J . Med., 3 3 : 3% RAINER,W. G., QUIAKZON, E. P., LICCETT,M. S., NEWRY,J. P. and BLOOMQUIST, C. D. (1970), Awcev. J . .Surg., 120: 504. SCHWARTZ. C. 1. and MITCHELL,T. R. A. (1961). Brit. w e d . j., 2 : 1057. SIEKERT, K. G., WHISNANT,J. P. and MILLIKAN, C. H. (1963), A m ititern. Med., 58: 637. STEIN, B M., MCCORMIR,W. F. RODRIGUEZ, J. N. and TAVERAS,J. M. (rg62), Arch. Neurol., 7 : 545. SUTYON, D. and D A V I E S , E. R. (1966), Clin. Radiol., 17: 330. TOOLE, J, F.. JANEWAY,R., CHOI, K., CORDELL, R., DAVIS, C., JOHNSTON,F. and MILLER,H. S. (1975), Arrh. Neurol., 32: 5. WESOLOWSKI, S. A., GILLIE, E., MCMAHON,J. D., SANTOS, D. S., CALI, J. R. and UCHIDA, H. (1973). Cirrulntion, Suppl. 48: 2 1 1 . WEINER, L. M., BERRY, R. G. and KUNDIN,J. (1964), Arch. Neurol., 11: 554. WILLIAMS, TI. (1964), Brit. med. J., I : 84. WYLIE,E. J. and EHRENFELD, W . K. (1970), Extracranial Occlusive Cerebrovascular Disease. Diagnosis and Management. W. B. Saunders, Philadelphia. ZEIGLER,D. K. and HASSANEIN,R. s. (1973). Stroke, 4 : 666.

RUPTURED ABDOMINAL AORTIC ANEURYSMS : A REVIEW OF 168 CASES H. R. MAGEE,J. R. COIIENAND S. A. MELLICK Vascular Unit, Princess Alexandra Hospital, Brisbane One hundred and sixty-eight ruptured aortic aneurysms presenting a t the Princess Alexandra Hospital in a n 11-year period have been reviewed. Surgical treatment still carries a high mortality and a very high postoperative morbidity. T h e survival rate i n the Vascular U n i t of this hospital has improved during the period studied and in the last five years has risen t o 61%. T h e operative technique is described i n detail, and the operative problems and complications are discussed. It is f e l t that prompt surgical treatment, and accurate assessment of blood loss with adequate replacement during surgery, combined with attention to early postoperative problems, particularly those o f a respiratory nature, are the most imp’ortant factors i n survival.

RUPTUREof an abdominal aortic aneurysm is its most serious complication, being almost invariably fatal without prompt surgical correction and intensive postoperative care. I n the period of this study, 168 patients were admitted Reprints : H . R. Magee, “Alexandra”, Terrace, Rrisbane, Qld 4000.

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201

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to the Princess Alexandra Hospital with this condition, and these have provided the material for this review.

CLINICALMATERIAL In the II-year period (July I, 1964 to June 3°, I9751 168 Patients ( Is8 male* female), ranging in age from 50 to 94 years, AUST. N Z . J.

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TABLEI

..

Total patients Died without operaiion . . Died a t operation ., Died after operation ,. Operations .. ,. Grafts .. . . . . Survived .. ._

__

.. ., .. .. ..

..

,.

8 3

9

2

I

3

I

5 5

o

15 6

16 10

2

0

6

3 3

9

6 6 5

I

I

0

have been diagnosed as having a ruptured aortic aneurysm. The diagnosis was made clinically in most cases, but in some patients only at operation or autopsy. The annual incidence of the condition, the number of patients subjected to operation, and the number of survivors, are set out in Table I. The yearly average is approximately 15 patients, but in the 19721973 period the number rose to 34. Fifty-nine patients were not subjected to operation, and of these 26 were considered unsuitable because of a previous medical history of respiratory, cardiovascular, and cerehrovascular disease. This group also included two patients, one of whom had been considered technically inoperable when operated on for an elective repair three years earlier, and another aged 87 years who had repair performed in 1962 and was admitted to hospital with a second rupture above the original graft ten years later. Twenty-one patients died while under investigation or treatment for other conditions, and a wrong clinical diagnosis had been made initially in some. Seven patients died almost immediately after admission to hospital, and another five while on their way to the operating theatre, or in the operating theatre itself before the operation could be commenced. This latter group includes one patient who died in the earlv hours of the morning of his planned elective repair.

CLINICAL PRESENTATION AND DIAGNOSIS When a patient, usually male and in the seventh decade of life, presents with a sudden onset of abdominal and back pain associated with hypotension, and the presence of a pulsatile ahdominal mass, the diagnosis is simple. However, the severity of the symptoms and the clinical findings depend on the size and site of the rupture, the rate of bleeding, and the ability of the retroperitoneal tissues AUST. N.Z. J. SURC., VOL.47-No.

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6 3

0 2

3 3 I

16 6 3 7

10

8 4

19 10 I 3

9

9

5

18 4

34

14

13

10 I

0 2

I

2

7 14

8 24

14

12

46 109

'3 5

21

12

II

98

15

9

6

47

168 59 16

4

7

to contain the hzmatoma. Where back or loin pain is the prominent feature, an orthopzdic condition or renal colic may be diagnosed initially. In other patients the clinical picture may not be clear, as illustrated by the number and variety of the provisional diagnoses in patients in this series presented in Table 2 . TABLE2 Prot,irional Diagnoses Renal colic .. Iambosacral diid aiseask .. Diverticulitis or pericolic abscess Respiratory failure .. . . Peritonitis ,, ,. ,. Appendicitis ,, ., .. Hrematemesis from peptic ulcer Bacteraemic shock .. . . Intraabdominal malignancy . .

..

.. .. .. '.

.

.. ., ..

..

._ .. .. .. .. ,, ,

.

,, ,,

6 4 3 3 2 2 2 2

I

Two patients died while convalescing from surgical treatment of a fractured femur, and another died 18 days after a craniotomy for a head injury sustained in a motor vehicle accident in the course, of which there had been no known trauma to the abdomen. Six patients were transferred to this Hospital after having had the diagnosis of a ruptured aneurysm established by laparotomy elsewhere.

PRESENT SURGICAL MANAGEMENT A patient admitted to hospital with the diagnosis of a ruptured aneurysm should be taken immediately to the operating theatre if considered suitable for surgery. This decision is made on the basis of the patient's preceding history of cardiac, pulmonary, renal or cerebrovasctilar disease, and the quality of life resulting therefrom. Advanced chronological age alone is no bar to operation, nor is severe shock, for rapid operative control of the bleeding, together with good pulmonary ventilation and copious blood replacement, may surprisingly convert a mortally ill patient into a good operative risk. 49

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Initially, two large-calibre intravenous lines should be inserted in the upper limbs, and several litres of blood crossmatched. No time should be wasted in extensive resuscitation, for the most urgent need is to control the aortic bleeding, and if much intravenous fluid is given before this is achieved abdominal distension will increase, aggravating the technical difficulties of exposure and access. The patient should be anaxthetized at once, and the abdomen opened quickly through a full-length left paramedian incision. Compression of the aorta above the retroperitoneal mass will usually control some of the bleeding, and the aorta is quickly clamped below the renal arteries just proximal to the lesion. Distal clamps are applied to the aorta beyond the aneurysm, or to the common iliac arteries as anatomy dictates. and once clamping is achieved, the patient is given heparin intravenously in a dosage of 1.5 mg per kg of body weight. This has helped to save limbs which otherwise might have been lost by reason of clotting of their contained static blood. Suprarenal aortic clamping may he needed as a first stage to gain control of bleeding, and this is quite safe, particularly in the heparinized patient. for the short titne needed to gain infrarenal control. If the aneurysmal sac extends well up into the renal segment, and exposure in this region is made difficult by the tightly stretched left renal vein passing across the sac, this latter vessel should simply he divided to faditate clamp application. At this stage, compatible whole blood should be given rapidly through a warming coil to restore the circulating blood colume. Central venous monitoring is a useful aid, but in general it is hetter to give too much than too little blood. as any overload can be easily cleared by intravenously administered diuretics. Sodium hicarbonate and mannitol are added as needed. I t is our present policy to give methicillin and cephaloridine intravenously for antibiotic cover early during the operative procedure, and this is continued for five days after operation. Surgical repair is now begun by removing thrombus and debris from within the aneurysmal sac, to provide clean ends for grafting. Bleeding lumbar, middle sacral, and inferior tiiesenteric orifices should be over-sewn, and in most cases, a straight Dacron graft can be inserted in end-to-end fashion within the sac

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itself. I n placing sutures, deep bites should be taken in the host aorta, rolling up a ridge of vessel as a cuff. Prolene is recommended as the best material for this suture, and woven Dacron is the material of choice for the graft. If gross iliac disease is present, a bifurcation graft will be necessary. Occasionally the host vessel is so diseased, particularly proximally, that sutures tear out readily from its wall, and then a Dacron sleeve should be laid around the host-graft junction. When the graft has been sutured in place, and gradual release of the proximal clamp is begun, the patient’s heparin is neutralized with protamine sulphate in dosage of 1.5 mg per mg of heparin. Complete heparin neutralization is shown immediately by the appearance of clots in any shed blood in the area. When the region is satisfactorily dry, the remnants of the original aneurysmal sac are wrapped over the sac to cover the suture lines, and to isolate these from the third part of the duodenum. If the graft cannot be completely isolated in this way, adjacent pre-aortic retroperitoneal tissue should be used as a cover, or failing this, omentum can be placed in this area. Separation of the suture lines from the duodenum is probably the most important factor in preventing a subsequent aortoduodenal fistula. The posterior parietal peritoneum is then closed over the repaired sac, and the abdominal wall is repaired in layers with continuous monofilament nylon. Michel clips are used for skin closure, and no deep through-and-through sutures are required. At the conclusion of the operation, the patient is transferred to the intensive care unit. Nasogastric suction is needed whilst the patient requires assisted ventilation and other supportive therapy, but after extubation it can usually be discontinued. In most instances, the patient is ready for transfer hack to the vascular ward within three days of operation.

RESULTS One hundred and nine patients were subjected to operation. and grafts were inserted in 98. One gravely ill patient aged 89 years was found to have aortic and iliac aneurysms, hut the hzemorrhage arose from a left internal iliac aneurysm, and this was adequately controlled by over-sewing and obliterating that lesion without any major grafting being performed. AUST.N.Z. J. SURG., VOL.47-No.

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Sixteen patients died on the operating table and 46 died after operation. T h e time interval between completion of the procedure and death varied from an hour to four weeks. Forty-seven patients survived to be discharged from hospital (Table I ) . Overall, the survival rate was 43% in the 11-year period, but in the last five years this has risen to 61%~with 40 survivors from 46 operations in the course of which grafts have been inserted. 60-

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A G E IN Y E A R S

FIGUREI :

Histogram showing numbers of patients and survivors in each decade. Vertical scale shows numbers o i patients; decades are shown in horizontal scale.

The numbers of patients and survivors in each decade are presented in Figure I . The majority of patients were in the seventh and eighth decades, with most of the survivors in the seventh. The smallest lesions which ruptured were two aneurysms each 5 cm in diameter. However, both these patients died from respiratory complications, one 14 days and the other 2 1 days after surgery. Blood loss during operation was estimated by weighing of dry sponges and measurement of the blood aspirated. In the past two years the blood loss in 15 survivors has varied between 700 ml and 8 litres, with an average of 4'1 litres. I n the patients who died the AUST.N.Z. J. SURG., VOL.47-No.

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figures have been much higher, the average being 6.5 litres. Many complications were seen in the postoperative period and were often multiple in any one patient. Chest infection and respiratory failure were frequent, no fewer than 23 patients requiring tracheostoniy and the use of a ventilator for prolonged periods. Cardiac problems arose in many patients, and these varied from temporary irregularities of rhythm to myocardial infarction. Jaundice supervened in ten patients, and five of these died. Wound dehiscence occurred in five patients, and peripheral embolism requiring catheter clearance occurred in four patients. Limb infarction was seen three times (two patients required ahove-knee amputation and another had necrosis of both feet). Ischaxia of the colon occurred on three occasions. I t was suspected in one patient who survived. and of two others who died, one was found at autopsy to have an infarcted sigmoid colon and the other an area of necrosis of the rectum. Renal failure requiring dialysis occurred in three patients. Disseminated intravascular coagulation supervened twice, cholecystitis once. One patient had infection of the graft which was followed by further hzemorrhage and death, and a second developed a small-bowel fistula with an infected retroperitoneal hEmatoma. In the latter patient, there had been extensive peritoneal adhesions which made dissection and exposure and control of the aorta very difficult. Both of these patients developed Gram-negative septicamia. One patient developed an aortoduodenal fistula and was readmitted to hospital with melama three weeks after discharge following repair of a ruptured aneurysm. H e died during operation for attempted repair of this fistula. Two patients died from further rupture of the aorta, one occurring three months and the other ten years after successful repair of a leaking aneurysm. DISCUSSION Although it has been reported that a patient has survived without operative treatment after the rupture of an abdominal aortic aneurysm (Barratt-Boyes, 1957), this outcome is most unusual, and for all practical purposes such a rupture must be considered as a fatal condition. Therefore any patient who has an asymptomatic aortic aneurysm discovered on routine examination should be advised to undergo

RUPTURED ABDOMINAL AORTIC ANEURYSMS

elective repair and grafting, as this procedure carries a mortality no higher than that following other major surgery in this age group. Average mortality figures quoted by Graham et alii (1971) for elective resection of an abdominal aortic aneurysm are approximately 5%, and our results have been similar. Once the aneurysm ruptures, the only hope for survival is prompt surgical treatment with its much higher mortality. Johannsen ( 1964) stressed that the mortality rate attending surgery for a ruptured aneurysm is four to ten times that following a planned resection. I n reports of series of ruptured aortic aneurysms in the past 12 years, the highest reported survival rate has been 66% (DeBakey et alii, 1964). Rapid exposure and control of the aneurysm are essential, hut there should be no compromise in aseptic precautions, for graft infection is a complication which is nearly always fatal (Graham et a%, 1971). In this series, there was only one definite case of infection of the graft with the subsequent complication of haemorrhace. Antibiotics were used in the patients reported here. but principally hecause of chest problems and not as a purely prophylactic measure. However, over the past 18 months we have made it our policy to give antibiotic cover to all patients in whom a prosthetic graft has been inserted. Another problem has been the presence of a large amount of retroperitoneal hzmatoma. which obscures the anatomy and results in damage to other structures, especially veins. The ideal situation is control of the vessels above and below the lesion with the minimum of dissection. In patients in this age group, obstructive airways disease is common, and bronchopneumonia has been a frequent postoperative complication. I n the earlier years of this series it was our policy to perform tracheostomy in patients who required intuhation for longer than 4 8 hours, but with the introduction of less irritant endotracheal tubes and better control of ventilation this period has been extended to one week. Myocardial disease is common in these patients, and infarction has been responsible for deaths at operation and in the postoperative period. A period of hypotension before or during operation mav be responsible for thrombosis in cerebral or peripheral arteries, but this may he miti-ated by total body heparinization. 52

MAGEE ET ALII

Ischzmia of the colon following aortic surgery with division of the inferior mesenteric artery has been most uncommon in our experience. This vessel has often been noted to be involved in atheromatous disease of the aorta, with the orifice frequently occluded. Graham et alii (1971) have stressed that care must be taken to divide the inferior mesenteric artery close to its origin and preserve its junction with the left colic artery to decrease the degree of colonic ischzmia. Two of our patients who died after operation were found at aiitopsy to have infarction, and another who survived was suspected of having ischzmic colitis in the early postoperative period. Renal failure mav contribute to mortalitv. and three of the patients in this series required dialysis. Possible ztioloqical factors include renal vessel atherosclerosis, hypotension before and during the operative period, and temporarv ischzmia and muscle devitalization of the lower extremities. mechanical obstruction due to the clampiny of the renal vessels occurrinq with cross-clamping of the aorta. The incidence. although unpredictable, may be hich in patients with ruptured aneurysms presentinq in shock or who have severe hypotension during oneration. Mannitol is a most effective osmotic diuretic, and it has been shown to prevent depression of renal plasma flow, glomerular filtration rate, and urinary flow, therebv exertinp; a protective action on the kidnevs. Its infusion durinq the oneration and the postoperative period is therefore iustified when there is reduced urinarv output (Payne et alii. 1967: Packham et alii, 1967: Sheil et alii. 1968). Jaundice seen in the postoperative period iisually appeared about the seventh day and was presumablv of hemtocellular origin, as the results of most liver function tests were abnormal. T h e hmnolysis of retroperitoneal hamatoma nrohablv contribiited to the condition. but ischzmia of the henatic tiqsue due t o hypotension was the most likely zetiological factor, and these patients often had evidence of renal and cardiac ischzmic damage at the same time. Five of the ten iaundiced patients in this series died, all having other complications as well. I n the selection of patients for surgery. age by itself is no contraindication. A historv of severe cardiovascular, renal, or respiratory AUST.

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disease would probably preclude operation, but any patient who was leading a satisfactory and independent life up until the time of the rupture would be considered suitable. Thus the concept of physiological age is far more important than that of chronological age, and each patient must be considered on his or her merits (Cannon e t alii, 1963). Other writers (Sheil et alii, 1968) state that pronounced preoperative shock is a grave prognostic sign. This has also been our experience, especially in those patients who responded poorly to cross-clamping of the aorta combined with adequate transfusion. Trial resuscitation, which these workers also describe, has not been undertaken i n any of the patients reported in this series. \Ye have also noted that patients who travel well to hospital often have a better prognosis. This Unit has received patients from as far north as Mt Isa and Cairns, and from Byron Bay and Lismore in the south, some having already been subjected to laparotomy, and these are distances of up to 1,600 kilometres. The grafts used have all been of woven Dacron, either a straight or bifurcation type, laid inside the aneurysmal sac after clearance of clot and atheroniatous material. It has been stressed by other wirters that the graft should be covered by peritoneum and connective tissue to minimize adhesive small-bowel obstruction ; also, the interposition of resistant tissue between the graft and duodenum may prevent erosion of the latter organ (Tolstedt et dii, 1963 ; De Weese and Fry, 1962). In this series, the aortic sac was closed over the graft before suture of the posterior abdominal wall peritoneum, and only one aortoduodenal fistula has occurred. Dilatation often extends beyond the aorta. and the graft used depends upon the state of the aortic bifurcation and iliac vessels. Four patients had such extensive disease that it was necessary for the distal anastomosis to be made to the common femoral arteries. Precise measurement of the blood loss is not possible, althouqh a fairly accurate estimation may be made by progressive weighing of sponges and measurement of suction return. It is impossible to measure the amount sequestered in the retroperitoneal tissues. Replacement must be accurate and rapid, especially early in the operation, and the use of a blood-warminq device is essential. A central venous pressure monitor has been most AUST.N Z . J. SURG., VOL.47-No.

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helpful in the estimation of the amount and rate of administration of fluids during the operative procedure and in the early postoperative period. In all cases, the amount of fluid required during the operative procedure exceeded the estimated blood loss. Tracy and Reeve (1965) stated that blood loss was the most important single factor affecting the mortality rate, and in their series the survivors had a loss of less than five litres, while those who died had a loss in excess of this figure. Our experience has been similar. It is gratifying to record that results in this Unit have progressively improved (Table I ) , and in the last five years the operative survival rate has risen to 61% when a curative procedure has been possible. This has been due to the establishment of a special vascular unit within the hospital, and an increased medical awareness of the condition, whilst improved surgical technique combined with good resuscitation are other factors. Fewer patients have been refused operation solely because of age, size of lesion, or condition on admission to hospital, and more emphasis has been placed on the quality of life preceding rupture. Prompt surgical treatment with rapid control and resuscitation may convert a poor-risk patient into a relatively good risk. T h e ready availability of such facilities as assisted pulmonary ventilation, blood gas analysis, and cardiac monitoring, allows many of the postoperative complications to be treated early and adequately. That rupture may occur in small aneurysms has been illustrated in this series, where two of the lesions were 5 cm in diameter, and it has also been pointed out by Barratt-Boyes (1957). As elective resection can be carried out with a high degree of success and a minimum of stress on the operating team, it is our policy to advise resection whenever a confident clinical diagnosis can be made. As a general rule, all aortic aneurysms which have a diameter of at least twice that of the adjacent host aorta are resected as soon as practicable after diagnosis.

REFERENCES BARRATT-BOYES, B. G. (1957), Lancet, 2 : 716. CANNON,J. A,, VAN DE WATER,J. and BARKER, W. F. (1963), Amer. J. Surg., 106: 128.

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DEBAKEY,M. E., CRAWFORD, E. S., COOLEY,D. A., T . S. and ABBMT,W. P. MORRIS,G. C., ROYSTER, (1964), Ann. Surg., 160: 622.’ DE WEESE,M. S. and FRY, W. J. (1962), J. A m e r . med. Ass., 179: 882. GRAHAM,K. J., COLE, D. S. and BARRATT-BOYES, B. G. (1971), AUST. N.Z. J. SURG.,41: 113. JOHANSSON, L. (1964), Acta chir. scand., 128: 630. PACKHAM, N., SHEIL, A. G. R. and LOEWENTHAL, J. (1967), Med. J . Aust., 2 : 833.

PAYNE,J. H., WOOD,D. L. and GOETHAL,J. A. (1963), A m e r . Surg., 29: 713. SHEIL, A. G. R., LITTLE, J. M., MAY, J., SHELDON, D., STEWART, G. R. and LOEWENTHAL, J. (1968), M e d . J . Aust., 2 : 383. TRACY,G. D. and REEVE,T. S. (1965), AUST. N.Z. J. SURG.,35: 85. TOLSTEDT,G. E., JESS==, J. E. and BELL, J. w. (1963), Surg. Gynec. Obstef., 1 1 6 : 42.

ACUTE MESENTERIC ISCHBMIA Ivo U. VELLAK A N D J O H N C. DOYLE St Vincent’s Hospital, Melbozcrne The experience of acute mesenteric ischaemia a t St Vincent’s Hospital, Melbourne, has been reviewed over 17 years. The mortality remains appallingly high. T h i s applies particularly t o those patients who had thrombosis of the superior mesenteric artery, amongst whom t h e mortality in this series was 97%. The m o r t a l i t y was slightly less in the group suffering f r o m embolic occlusion of the superior mesenteric artery (66%), and in those suffering f r o m thrombosis of t h e superior mesenteric vein (60%). A m o r t a l i t y of 66% was also found in patients suffering f r o m non-occlusive gut ischaemia. Delay in diagnosis accounted for t h i s high mortality. Early diagnosis is all-important, and this depends on the performance of mesenteric angiography in any patient suspected of having mesenteric ischaemia. Appropriate surgery may then be carried out i n the occlusive group and supportive treatment, including intraarterial papaverine infusion, given t o those w i t h non-occlusive ischamia. There i s a pressing need f o r simple non-invasive tests t o segregate those patients suffering f r o m acute mesenteric ischaernia f r o m those whose acute abdomen i s due t o some other cause. L)EsPrrE significant advances in radiological diagnosis, chemotherapy, intravenous therapy and anaesthesia, over the past 50 years, the present-day management of acute mesenteric ischsmia leaves much to be desired. To elucidate the causes of the continuing high mortality and to formulate guidelines in the diagnosis and management of acute mesenteric ischamia, we have reviewed the records of all patients with acute mesenteric ischzmia admitted to St Vincent’s Hospital, Melbourne, between 1958 and 1975. For patients to be included in the series a diagnosis of mesenteric ischamia had to be proven by angiography, at operation, or at post-mortem examination. Fifty-two patients satisfied these criteria and form the basis of this communication. The

Reprints: M r I. D. Vellar, 141 Grey Street, East Melbourne, Victoria, 3002.

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pathological conditions in these 52 patients were classified as follows:

Non-Occlusive Mesenteric Ischavnia In this group of six patients ischremic damage of the bowel occurred in the presence of a patent celiac axis, and patency of the superior and inferior mesenteric arteries. A summary of the clinical details appears in Table I. These six cases of the low output syndrome constitute 12% of all the cases of acute bowel ischzemia in the series. There were two cases of complete heart block. T h e first, a woman aged 78 years, presented with a seven-day history of upper abdominal pain and bloody diarrhea. X-ray examination following a barium enema showed the classic thumb-printing of the colon, and a similar examination carried out later showed diffuse colonic ulceration. She was treated with isoprenaline, but died of pneumonia. At postmortem examination ulceration of the entire colon was found. All the mesenteric vessels were patent. The second case of complete heart block occurred in a woman of 83 years. Intense vasoconstriction and hypotension were found. These were corrected AUST. N.Z. J. SURG.,VOL. 47-No.

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MAGEE ET ALII R U P T U R E D ABDOMINAL AORTIC ANEURYSMS FIELDS, W. S., MASLENIKOV, V., MEYER,J. S., HASS, W. K., HEMIKCTON, R . D. and MACDONALD, M...
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