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This study investigated the clinical picture of gangrenous sigmoid volvulus presented by Indian patients to describe the various patterns of gangrene and to identify the risk factors leading to the very high mortality from this disease.A structured protocol including nine parameters was used to study risk factors in 76 patients treated at two major teaching hospitals in India. The clinical picture of patients at the two hospitals did not differ significantly.Contrary to expectations, we found gangrene in 26% of cases extending beyond the area of constriction into the rectum/descending colon. This extension was sometimes patchy and had an ill defined line of demarcation, which may lead to an error in judgment and cause a failure of anastomosis, which can be fatal. Risk factors were age over 60 years, the presence of shock on admission and a history of previous episodes of volvulus.This study identified three risks for survival. It is suggested that all patients with nongangrenous sigmoid volvulus undergo a recurrence-prevention procedure immediately or electively. We also found that extension of gangrene beyond the confines of the constriction is not uncommon, calling for caution on the part of the treating surgeon.

Gall bladder perforation is a potentially life-threatening condition. Spontaneous perforation is infrequent and rarely seen in the absence of gallstones but gall bladder perforation is an occasional complication of typhoid fever. If such perforations are not treated in time, mortality rates are very high. We report a case of gall bladder perforation complicating typhoid fever following enteric perforation of the ileum necessitating sequential laparotomies during the same admission.

There is a suspicion that mortality in gangrenous sigmoid volvulus has considerably declined over the recent years. This study was aimed to assess if this is a genuine trend, applicable to the patients, of this study too, and to identify factors responsible for the change, if any. Seventy-eight patients operated for gangrenous sigmoid volvulus, in the last four decades of the just gone century, were analysed. Nine clinical parameters were studied to identify factors responsible for mortality and to see if there was a change in clinical presentation in the later decades. Mortality in the 4 studied decades varied between 15.4% and 65%. Differences were significant (p0.05) only between the decades of the seventies and eighties and between bunched pre 1980 (48%) and post 1980 (20%) decades. A sea change in survival scene occurred at the end of the decade of the seventies. The change was not accompanied by a concomitant improvement in clinical presentation (p0.05). Two facts which could explain improved survivals in the post. 1980 period were, the increased recognition of gangrene extending beyond the area of constriction and improved survival after primary anastomoses (p0.05). These indicated a more accurate assessment of viability and the distance between the cut bowel ends, a stricter selection of cases for primary anastomosis and using Hartmann operation in doubtful situations. Mortality in gangrenous sigmoid volvulus, without knotting in the Indian population has genuinely declined from over 50% in an earlier time to 20% in the later 20 years of the last century, the watershed in the changed scenario being the year 1980.

A male patient of 60 years presented with a swelling in the left groin of 10 months duration. Past records showed bilateral lumbar sympathectomy and omentopexy done 20 and 6 years back, respectively, for Buerger's disease. Abdominal examination revealed a huge hernial swelling in the left groin extending from the symphysis pubis to anterior superior iliac spine measuring 25 x 18 cm. On exploration, the contents were intestines and omentum, which were coming out through a defect of 5 x 3 cm in the lower fibers of the conjoint muscle 4 cm cephalad to the deep ring, a finding which made the final diagnosis as an incisional hernia. We present this interesting case as a very rare complication of omentopexy, probably not reported previously, and an unusual case of an incisional hernia presenting as an inguinal hernia which is very difficult to diagnose unless encountered before. Its rarity and clinical challenge is highlighted.

PURPOSE: Recurrence in sigmoid colon volvulus is a very vexing problem, because it occurs after all types of treatment including a resection of the sigmoid. A nonresective procedure that prevents recurrence in the long term has been devised and tried during the period 1968 to 1992. METHODS: The procedure involves extraperitonealization of the whole sigmoid colonvia a left paracolic gutter incision in a manner akin to an extraperitonealized colostomy and placing it in the left half of the infraumbilical abdominal wall. This article presents a study of 84 patients who underwent this operation and who were followed-up. Some very useful practical points for ensuring the success of the procedure are also presented. RESULTS: The subjects comprised 58 male and 26 female patients, aged 10 to 81 (median, 60) years. The operating time ranged from 40 to 70 (median, 50) min. The operative mortality (9 percent) and morbidity of the procedure including cardiopulmonary complications (7 percent), incidence of small-bowel obstruction (1 percent), and incisional hernia formation (2.3 percent), were reasonably low. The incidence of woundhealing problems was significantly (P