Fifty patients operated upon for cecal volvulus were analyzed. The ages ranged from 14 to 88 years and averaged 53 years. Eighteen were males and 32 were females. The presentation was acute, requiring urgent surgery in 41 patients; nine patients presented with chronic symptoms and were operated upon electively. In 14 patients (28%) the cecal volvulus was temporally related to another acute medical problem. The diagnosis was made radiographically in 22 patients (44%) and at operation in 28 patients (56%). Cecal volvulus was correctly diagnosed by barium enema in 20 of the 29 patients (69%) undergoing the study. Eighteen of the patients were treated by cecopexy, 14 by resection, 12 by detorsion alone, and six by tube cecostomy. Mortality was 12% (6/50) and was associated with gangrenous cecum (33%, 3/9), other systemic diseases (24%, 5/21), age over 50 years (19%, 6/31), and acute presentation (15%, 6/41). In the absence of gangrenous cecum, enterotomy was associated with subsequent wound infection in 23% (7/30), as compared to none (0/11) when enterotomy was not performed. There were no recurrences of cecal volvulus in the entire series during follow-up which extended to 17 years, averaged 5.7 years, and was complete in 96% (42/44) of survivors. When gangrenous cecum is present, resection is the treatment of choice. In the absence of gangrenous bowel, cecopexy is recommended because of a low mortality (0/18), low morbidity (3/18), low recurrence rate (0/18) and absence of need to open the unprepped bowel.
Two adjuvant techniques for the intraoperative assessment of small intestinal viability were compared with standard clinical judgment in a prospective, controlled study of 71 ischemic bowel segments in 28 consecutive patients operated on for acute intestinal ischemic disease. Each segment was independently assessed 15 minutes after surgical correction of the underlying lesion by: 1) standard clinical judgment; 2) Doppler-detected pulsatile mural blood flow; and 3) fluorescein ultraviolet fluorescence pattern. Viability endpoint for each segment was determined objectively by patient follow-up or "blinded" microscopic evaluation of histologically unequivocal resection specimens using criteria established by previous animal studies. Seventeen histologically equivocal specimens were excluded from the final results. Standard clinical judgment proved moderately accurate overall (89%) but would have led to a relatively high rate (46%) of unnecessary bowel resection. The Doppler technique did not increase accuracy in any category of evaluation. The fluorescein fluorescent pattern was correct in all 54 determinant bowel segments, and proved more sensitive specific, predictive, and significantly more accurate overall than either standard clinical judgment or the Doppler method. This controlled study suggests that the fluorescein technique is the method of choice for the prediction of small intestinal recovery following ischemic injury.
Background Blacks are disproportionately affected by stroke compared with whites; however, less is known about the relationship between stroke and cigarette smoking in blacks. Therefore, we evaluated the relationship between cigarette smoking and all incident stroke in the JHS (Jackson Heart Study). Methods and Results JHS participants without a history of stroke (n=4410) were classified by self‐reported baseline smoking status into current, past (smoked at least 400 cigarettes/life), or never smokers at baseline (2000–2004). Current smokers were further classified by smoking intensity (number of cigarettes smoked per day [1–19 and ≥20]) and followed up for incident stroke (through 2015). Hazard ratios (HRs) for incident stroke for current and past smoking compared with never smoking were estimated with adjusted Cox proportional hazard regression models. After adjusting for cardiovascular risk factors, the risk for stroke in current smokers was significantly higher compared with never smokers (HR, 2.48; 95% CI, 1.60–3.83) but there was no significant difference between past smokers and never smokers (HR, 1.10; 95% CI, 0.74–1.64). There was a dose‐dependent increased risk of stroke with smoking intensity (HR, 2.28 [95% CI, 1.38–3.86] and HR, 2.78 [95% CI, 1.47–5.28] for current smokers smoking 1–19 and ≥20 cigarettes/day, respectively). Conclusions In a large cohort of blacks, current cigarette smoking was associated with a dose‐dependent higher risk of all stroke. In addition, past smokers did not have a significantly increased risk of all stroke compared with never smokers, which suggests that smoking cessation may have potential benefits in reducing the incidence of stroke in blacks.
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