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Forty-two patients with necrotizing soft tissue infection are reviewed. Bacterial culture revealed between two and seven types of micro-organism in each patient. All patients were treated with radical surgical debridement and a combination of antibiotics. In 30 patients, early diagnosis and treatment resulted in only two deaths. Delayed surgical intervention in 12 patients transferred from outside hospitals was followed by nine deaths. Predisposing factors and site of infection did not affect outcome. Of 26 patients with systemic manifestations of sepsis, 16 survivors responded well to initial surgical debridement.

Arterial reconstruction utilizing the profunda femoris artery was performed for rest pain and pre-gangrene in 45 limbs. The preoperative mean ankle arterial pressure index of 0-21 (s.d. 0-12) was increased to 0-52 (s.d. 0-16) in the 22 limbs salvaged by the reconstruction. In 38 limbs a proximal reconstruction was necessary in addition to profundaplasty. At a mean follow-up time of 15-4 months 41-6 per cent of the 36 patients were dead.

Twenty patients with acute dermal gangrene following surgery, trauma or sepsis are described. In 12 the skin became gangrenous secondary to a necrotizing process affecting the subdermal fascia, and in 8 the condition arose primarily in the skin. In the first group mortality was high unless radical excision of the necrotic fascia was performed at an early stage; in 3 of the recent patients the overlying skin was removed, defatted and stored for later grafting. In the second group, incision and adequate drainage combined with antibiotics seemed to suffice. Hyperbaric oxygen was of dubious value in the first group but appeared to contribute to arrest of the lesion in the second group.

Amputation for peripheral ischaemia still has a depressingly high early and late mortality, and morbidity and the end result are usually less than satisfactory. Individual surgeons probably see too few amputees to treat them with maximal efficiency, and these patients create a large burden on beds and resources. There is room for improvement in all aspects of our management of amputees. Primary healing rates might be better with less heroic attempts to obtain a distal amputation. Sepsis is lessened by the use of prophylactic antibiotics. Tight bandaging and the intra-operative fitting of prostheses are undesirable. Simple tests of skin blood pressure may aid prediction of the degree of ischaemia at the proposed level of limb section and the chances of healing. The late mortality is high and merits study of methods designed to reduce it such as long term anticoagulation.

The mortality and morbidity of 151 elderly patients (greater than 64 years of age) undergoing biliary surgery for benign disease were prospectively studied. The overall mortality was 3.3 per cent. This comprised a 0.77 per cent mortality in the elective group and a 19 per cent mortality in the emergency group. In spite of 77 per cent of the emergency group having a gangrenous gallbladder, a complication difficult to predict preoperatively, the majority of deaths were from cardiovascular disease. The overall incidence of common bile duct exploration was 36 per cent, which was similar in the elective and emergency groups. A comparison between the old (65-74 years) and the aged (over 74 years of age) revealed twice the number of emergency cases in the aged. Considering elective biliary surgery, there was no difference between the mortality, morbidity, or common bile duct exploration rate comparing the old with the aged. This suggests that elective biliary surgery is safe even in the aged.

A case is reported of incipient gangrene of the right arm developing after a Blalock-Taussig (subclavian-pulmonary) shunt operation in an infant. The ischaemia was reversed by immediate common carotid-axillary artery-vein bypass, using a microvascular technique.

The results of extended deep femoral angioplasty (EDFA) have been alaysed for 74 legs in 72 patients. In 69 per cent a femoropopliteal bypass would have been possible, so DEFA is considered here as an alternative operation. The success rate was 66-9 per cent, the failure rate 25-6 per cent and no effect was achieved in 7-5 per cent. Diabetes adversely affected the results. Of the failures, 45 per cent were diabetic, while the incidence of diabetes was only 14 per cent in the group where the operation was successful. The long term results of the operation were reasonable, 75 per cent being successful for 10-39 months. Age had no bearing on success or failure. The effects of EDFA were most dramatic on intermittent claudication. In 52 per cent it was abolished and in 92 per cent claudication distance was increased to over 200 yards. Good results were achieved after failed lumbar sympathectomy and failed femoropopliteal bypass. Successful results of EDFA could be predicted best by inspection of angiograms. Success or failure could have been predicted from the state of the run-off in 81 per cent of the cases. Claudication and rest pain were the most relieved by EDFA, followed by isachaemic ulceration of the leg. Gangrene of digits was helped but less than had been hoped. We conclude that the indications for femoropopliteal bypass are limited to cases of digital gangrene where angiography shows that bypass is possible or where an EDFA operation has failed.