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PubMed1991

Risk of strangulation in groin hernias.

Although the elective repair of groin hernias is advised to prevent strangulation, the likelihood of this complication occurring is unknown. To quantify this risk, the cumulative probability of strangulation in relation to the length of history has been calculated for inguinal and femoral hernias presenting to this hospital between 1987 and 1989. Of 476 hernias (439 inguinal, 37 femoral), there were 34 strangulations (22 inguinal, 12 femoral). After 3 months the cumulative probability of strangulation for inguinal hernias was 2.8 per cent, rising to 4.5 per cent after 2 years. For femoral hernias the cumulative probability of strangulation was 22 per cent at 3 months and 45 per cent at 21 months. The rate at which the cumulative probability of strangulation increased was in both cases greatest in the first 3 months, suggesting that patients with a short history of herniation should be referred urgently to hospital and given priority on the waiting list.

Adolescent↗
PubMed1982

[Suicidal strangulation by ligature (author's transl)].

Out of sample of about 15,000 medico-legal autopsies seven cases of suicidal strangulation by ligature were selected. Suicidal strangulation has a frequency of about 0.1% among all suicides and a frequency of about 5% in all fatalities due to strangulation by ligature. In two cases strangulation was achieved by auxiliary mechanisms other than by the own hands. In four other cases the tool was wound around the neck many times with or without a final knot in the frontal position. In another case there was only a single surrounding of rope around the neck with a single knot. The hands of the corpses were rarely found firmly attached to the ends of the tools (two cases), an observation, which does not necessarily indicate the involvement of an additional person. All cases showed extensive congestion of the head and the neck above the level of strangulation with multiple petechial hemorrhages, swelling of the soft tissues, and hemorrhagic infarction of the tongue and the bottom of the mouth. Histologically, these lesions exhibited expressed vital reactions with leukocytosis and incipient emigration of inflammatory cells. These reactions were obviously due to prolonged agony. It is tentatively concluded that suicidal strangulation usually shows a pattern of findings that allows the differentiation of homicide.

Adult↗
PubMed2006

Is the Lichtenstein operation of strangulated groin hernia a safe procedure?

BACKGROUND: In spite of many published articles describing the hernia repairs, there are only a few original reports concerning the polymer mesh application during emergency procedures for strangulated inguinal hernias. The aim of our study was to evaluate the results of the Lichtenstein and Bassini operations for strangulated groin hernias and to show the changing number of the tension-free repairs. METHODS: From 1997 to 2004, the Bassini procedure was performed in 21 patients, 6 of whom underwent small intestine resection and 2 others required resection of the necrotic omentum. The strangulated intestinal loop or omentum were released in 13 cases. After the repair 1 patient died of shock caused by intestinal necrosis. Of 56 patients who underwent an emergency Lichtenstein procedure, 55 were followed-up. A small intestine resection was performed in 2 cases to correct segmental necrosis. The gangrenous omental appendix of the sigmoid colon was excised in 1 patient, and necrotic omental fragments were resected in 2 cases. The strangulated intestinal loop or omentum was released in 51 patients. All patients were given wide-spectrum antibiotics intravenously. RESULTS: Between 1997 and 2000 tension-free procedures were performed in half of the patients undergoing emergency operation for strangulated hernia; between 2001 and 2004 such procedures were employed in more than 90% of the cases. In 2 patients we observed a small inflammatory infiltration of the wound that resolved within several days after Lichtenstein repair. A serous fluid collection was present in 2 cases. The treatment consisted of puncture and was successful in both cases. CONCLUSIONS: The use of monofilament polypropylene mesh for strangulated inguinal hernia repair is safe, and the risk of the local infectious complications is low.

Aged↗
PubMed2006

Hernias are the most common cause of strangulation in patients presenting with small bowel obstruction.

BACKGROUND: Small bowel obstruction (SBO) is a leading cause of admission to surgical emergency units. Strangulation is associated with a 10-fold increase in mortality. The aim of the present study was to identify the most frequent causes of strangulation in patients presenting with small bowel obstruction. METHODS: A prospective study was conducted of all patients presenting with SBO in one teaching hospital between 2003 and 2004. RESULTS: One hundred and sixty-one patients with symptoms and signs of small bowel obstruction were admitted. Eighty-three were confirmed with contrast studies. The male:female ratio was 1:1.6. The aetiology of obstruction was adhesions in 97 patients (60.2%), hernia in 29 (18%), malignancy in 17 (10.6%) and miscellaneous causes in 18 (11.2%). Operative procedures were performed on 74 patients (46%), 31 of them (42%) with adhesions, 25 (34%) with hernias and 18 (24%) due to other causes. Strangulated bowel occurred in 15 patients (9.3%); 12 had hernias whilst three had adhesions (P < 0.0001). Of the strangulated hernias, ten were femoral, one was inguinal and one was paraumbilical. There were seven deaths; three occurred in patients declared unfit for surgery, while four occurred post-operatively - two had strangulated bowel, the other two had advanced cancer. CONCLUSION: Whilst adhesions are the most common cause of small bowel obstruction, hernias remain the most frequent cause of strangulation in patients presenting with this condition.

Aged↗
PubMed1994

Pulmonary micromorphology in fatal strangulations.

Pulmonary histopathology was studied in a group of 106 fatal strangulations including cases of hanging (n = 55; typical, n = 20; atypical, n = 35), ligature strangulation (n = 12), throttling (n = 15), combinations of throttling and ligature strangulation (n = 7) and other compressing force against neck (n = 17). The control group (n = 10) consisted of cases of sudden cardiovascular death. The following results were obtained: intra-alveolar edema of different degree and strong hyperemia could be regularly observed in nearly all cases, especially in fatal hanging (apart from the control cases, in this group the highest mean lung weights were observed). Further frequent histological patterns were perivascular and intra-alveolar hemorrhages, local dystelectasis and focal emphysema. Alterations of the lung vessel contents could be detected in a varying extent: fat embolism (n = 7), mainly of minor degree, embolism of bone marrow tissue (n = 5) and intravascular cell accumulations (n = 22). Embolism of fat and bone marrow tissue was nearly always restricted to cases with accompanying blunt force or resuscitation measures. Whereas only 4 out of 55 cases of hanging revealed intravascular cell accumulations (including different types of leukocytes and immature bone marrow cells), 18 out of 51 cases with the other forms of strangulation exhibited this phenomenon. These accumulations mainly occurred in a discrete and widely scattered manner, appeared in 3 out of 10 control cases (resuscitation measures) as well, and were limited to cases with either protracted courses or accompanying blunt violence. The following conclusions are drawn: the regularly observed general changes of lung microstructure (e.g. edema, hyperemia) are undoubtedly non-specific for strangulation; the alterations of blood vessel contents may serve as a general vitality marker, if resuscitation measures are excluded, but not as an evidence of strangulating force. In cases without signs of blunt force they point to protracted agony courses (shock equivalents).

Adult↗
PubMed2005

Strangulation deaths during 1993-2002 in East Delhi (India).

Strangulation is one of the common modes of violent asphyxias. Frequently, the deaths from strangulation are homicidal in nature. To study the pattern of the strangulation deaths in the capital city of Delhi, a retrospective analysis of 10 years records from the period 1993-2002 was undertaken in the department of Forensic Medicine and Toxicology at UCMS and GTB Hospital. During the above period, 8385 Forensic autopsies were conducted out of these 98 (1.17%) cases were found to be of strangulation. These 98 cases were analyzed in detail and showed that: (a) incidence of strangulation have increased many folds in comparison in 1970s; (b) maximum incidence of strangulation is amongst individuals in third decade of life; (c) male, female ratio was 3:2; (d) ligating material was found present in neck in 40% cases; (e) fractures of the neck bones/cartilage were observed in 80% cases; and (f) other associated injuries were seen in as high as approximately 90% of cases. The paper describes and discusses the findings in detail.

Accidents↗
PubMedDate not supplied

A new mechanism of serum creatine phosphokinase elevation in strangulated small bowel obstruction: an experimental rat model.

An experimental rat model was used to investigate the mechanisms of serum creatine phosphokinase (CPK) elevation in strangulated small bowel obstruction. Two models were used: a strangulated ileus model with the bowel lumen and blood flow obstructed simultaneously, and a control ileus model with only the bowel lumen occluded. The experiments demonstrated that CPK was released into the blood when the mesenteric blood flow was restored, and that CPK was released into the intestinal lumen in the strangulated ileus model but not the control ileus model. CPK activity in the mucosal layer of the strangulated ileus model was significantly decreased compared with that in the control ileus model. Purified CPK injected into the intestinal lumen was absorbed by the healthy intestine. These results suggest a new mechanism of serum CPK elevation in strangulated small bowel obstruction in which serum CPK is elevated with a significant decrease in mucosal CPK. Strangulated bowel content including mucosal CPK may be reabsorbed by the healthy distal intestine when bowel obstruction is incomplete.

Animals↗
PubMed1978

Strangulating obstruction of the bowel: a reevaluation of radiographic criteria.

Fifty consecutive cases of strangulating obstruction were compared with 100 consecutive cases of surgically proven simple obstruction due to adhesions or hernia. All cases were studied by the usual supine and either erect or decubitus abdominal films, and by two successive supine films made at 5 min intervals. Radiographic criteria previously described as signs of possible strangulation were evaluated in the two series. Reduced activity of the small bowel loops on the successive supine films was the only frequent sign (58% of the cases with strangulating obstruction) which showed a statistically significant difference in incidence between the two groups. Other signs seen with some frequency (22%-28% of the group with strangulation) were long air-fluid levels, loss of valvulae conniventes, retention of bubbly fecal matter in the right colon, and predominance of fluid-filled loops; however, they occurred with the same frequency in simple obstruction. The more specific signs of bowel congestion and necrosis (i.e., a narrow rigid loop or intramural gas) were seen in 10% and 2% of the cases, respectively. Only the incidence of a narrow rigid loop in strangulation reached statistical significance. This study confirms the difficulty of diagnosing strangulating obstruction using plain films of the abdomen. Successive abdominal films were shown to be valuable in providing information about small bowel activity, which can help in the differential diagnosis.

Diagnosis, Differential↗
PubMed1999

Incarcerated and strangulated inguinal hernias in children in Zaria, Nigeria.

OBJECTIVE: To reappraise the problem of incarcerated and strangulated inguinal hernias in children in Zaria, Nigeria. DESIGN: A retrospective study. SETTING: Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. PATIENTS: Eighteen children aged below two years with incarcerated and strangulated inguinal hernias managed over a 10 year period. MAIN OUTCOME MEASURES: Incarceration and strangulation rate, resection rate, testicular infarction, wound infection. RESULTS: The overall incarceration and strangulation rate was 4.8%. The rate in neonates was 80%, 33% in those less than six months and 21% in those below one year. There was no incarceration or strangulations after two years of age. The intestinal resection rate for gangrene was 11% (two neonates) and ipsilateral orchidectomy was necessary for testicular infarction in two neonates (11%). Wound infection occurred in three patients (17%) and there were no deaths. Overall, there has been an improvement in the incarceration and strangulation rate, resection rate and wound infection rate over earlier years (5.7%, 28% and 50% respectively for earlier years) due largely to early presentation. Testicular infarction, however, remains a major risk particularly in neonates. CONCLUSION: The policy of early repair of inguinal hernias in children especially below two years and particularly in neonates should be continuously emphasised to avoid morbidity.

Abdominal Pain↗
PubMed1992

Delay in presentation and misdiagnosis of strangulated hernia: prospective study.

The purpose of this study was to examine the presentation and management of strangulated hernia. The clinical course of 54 patients was recorded. Twenty-one patients (39%) presented after 48 h from the onset of symptoms. Fifteen (28%) had a bowel resection and two (4%) died. Twenty (37%) patients had previously consulted their general practitioner about the hernia, but only seven had been referred for surgery. Five (25%) had been warned of the risk of strangulation. In the 32 (59%) patients previously aware of a hernia, delayed presentation was related to ignorance of the risk of strangulation (P less than 0.01). The strangulated hernia was misdiagnosed by the general practitioner in 17 (33%) patients (necessitating a second visit) and by the hospital registrar in eight (15%). We conclude that strangulated hernia is too often misdiagnosed and all patients who present with a hernia must be referred to a surgeon and warned about strangulation.

Adult↗
PubMed1988

[Diagnosis and timing of operation for strangulation ileus--especially concerning the usefulness of ultrasonography].

This is a clinical report on the usefulness of ultrasonography in the diagnosis of strangulation ileus and the timing of operation for this entity. Fifty-eight cases of strangulation ileus were investigated retrospectively and twenty-five cases had undergone ultrasonography. Ultrasonography delineated the strangulated intestinal tract as an akinetic distended intestinal tract and the intestinal tract on the oral side of the strangulated part as a movable distended tract with peristalsis and to-and-fro movement of the intestinal content. Retention of ascites was seen in many cases. Utilization of ultrasonography improved the rate of accurate preoperative diagnosis of strangulation ileus to 92%, resulting in timely surgery. Consequently, the number of cases requiring enterectomy because of intestinal necrosis sharply decreased. Shock, peritoneal irritation sign, leukocytosis, roentgenographic findings were inferior to ultrasonography in the preoperative diagnosis for the prediction of intestinal necrosis in strangulation ileus.

Humans↗
PubMed1988

Increased plasma malondialdehyde in patients with small intestinal strangulation obstruction.

Plasma malondialdehyde (MDA) was evaluated as an index of lipid peroxidation in 20 patients with small intestinal obstruction, with or without strangulation. The gut proved to be strangulated in nine cases--irreversibly in five and reversibly in four--while 11 patients had simple obstruction. The MDA levels in these cases were compared with values obtained from 29 healthy control subjects. The mean MDA level in the control group was 2.3 +/- 0.7 (range 1.5-4.0) mumol/l. In the patients with strangulation obstruction the MDA concentration was 6.7 +/- 1.6 mumol/l, and in those with simple obstruction it was 2.9 +/- 0.5 mumol/l. The difference between the MDA level in strangulation and in the other investigated groups was statistically significant. Values above 4 mumol/l were found in all the patients with intestinal strangulation, whereas those with simple obstruction had lower values. The heightened MDA level in patients with intestinal strangulation may be used for diagnostic purposes.

Adolescent↗
PubMed1989

[Erythrocytes in cervical lymph nodes of the human as a sequela of stasis and/or lymph drainage. Questionable diagnostic significance in strangulation and mechanical injuries of the head].

Information on the diagnostic significance of follicular hemorrhage and/or presence of red blood cells in the lymph node sinus was obtained by microscopic investigation of the superficial and deep human cervical lymph nodes. Fifty cases were selected on the basis of the following criteria: (1) cases without strangulation or mechanical head trauma; (2) cases in which death occurred by strangulation without additional mechanical head trauma; (3) cases without strangulation but with mechanical head trauma; (4) cases with strangulation and mechanical head trauma. The usual degree of stasis and hemorrhages and the dilation of the veins and/or capillaries are not sufficient to discriminate between cases with and cases without strangulation. Moreover, erythrocytes, erythrophages, and siderophages were encountered in the lymph node sinus of both cases with and cases without mechanical head trauma. Neither follicular hemorrhage nor the presence of red blood cells in the sinus is therefore diagnostically significant in forensic pathology.

Asphyxia↗
PubMedDate not supplied

CT differentiation between necrotic and nonnecrotic small bowel in closed loop and strangulating obstruction.

BACKGROUND: The purpose of this study was to evaluate computed tomographic (CT) findings for predicting the presence of intestinal necrosis in patients with closed loop and strangulating obstruction of the small bowel. METHODS: Twenty-five patients with surgically confirmed closed loop and strangulating obstruction were divided into two groups with (n = 16) and without (n = 9) intestinal necrosis. By using univariate and multivariate statistical procedures, we evaluated the differences in CT findings between the two groups on the basis of the following six findings: bowel dilatation of strangulated loops (bowel dilatation), wall thickening of strangulated intestines (wall thickening), ascites, vascular dilatation of affected mesenteries (vascular dilatation), elevation of mesenteric attenuation (mesenteric attenuation), and radial distribution of the mesenteric vessels (radial distribution). RESULTS: Of the six findings, ascites, vascular dilatation, mesenteric attenuation, and radial distribution provided significant discriminating findings between the two groups on univariate analysis. On multivariate analysis, mesenteric attenuation was the most important discriminative factor, followed by radial distribution and ascites. Using these three parameters, the CT was correlated with the surgical findings in 15 of the 16 patients in the necrosis group (sensitivity = 93.8%) and in eight of the nine patients in the nonnecrosis group (specificity = 88.9%). The overall accuracy was 92.0%. CONCLUSIONS: Mesenteric attenuation, radial distribution, and ascites, depicted on CT differentiate well between necrosis and nonnecrosis of the small bowel in patients with closed loop and strangulating obstruction.

Case-Control Studies↗
PubMed2005

Predictive value of procalcitonin for the diagnosis of bowel strangulation.

Intestinal obstruction is responsible for 3% of admissions to hospital emergency surgical departments, but it is difficult to distinguish simple obstruction from strangulation. Simple criteria for this distinction are sought. In this experimental study, procalcitonin, a known marker of bacterial inflammation, was used to detect strangulation. The predictive value of procalcitonin for small bowel strangulation was evaluated. Thirty male New Zealand rabbits (mean weight: 3.0 kg) were divided into three groups. In the first (control) group, only laparatomy was performed. In the second group, simple obstruction was created by ligating a 10-cm distal ileum segment. In the third group, distal strangulation was created by ligating a 10-cm distal ileum segment with the mesentery. Blood (1 cc) was taken from the right auricular vein of each animal for measuring the procalcitonin level. In both the control group and the simple obstruction group the procalcitonin levels were normal. In the strangulation group, elevation of procalcitonin was detected after 30 minutes, and the elevation was statistically significant at 120th minute compared with the control and simple obstruction groups. In patients with small bowel obstruction, measurement of procalcitonin levels is easy to perform and can be used in the follow-up. A more extensive clinical study is needed to evaluate the accuracy of the test as a marker.

Animals↗
PubMed2005

Laparoscopic repair of strangulated hernias.

BACKGROUND: Although laparoscopic transabdominal preperitoneal polypropylene (TAPP) hernia repair is now a recognized procedure for groin hernia repair in patients undergoing elective surgery, there is a scarcity of data on TAPP repair in emergency situations such as those involving strangulated hernias. METHODS: Unless contraindicated, the authors' department considers laparoscopic TAPP repair the procedure of choice for all strangulated hernias. A prospective database of 1,532 consecutive hernia repairs performed between May 1998 and April 2004 was reviewed. RESULTS: A total of 28 irreducible strangulated hernias were observed and repaired through laparoscopic TAPP. There were three conversions (10.7%): one because of extensive adhesions and two because of bowel distention. Resection became necessary in 9 (36%) of the 25 cases involving effective TAPP repair of strangulated hernias. The mean operation time, with and without resection, was 103 and 55 min, respectively. The rate of postoperative morbidity was 4% because of one inguinal hematoma case. During a mean follow-up period of 340 days, there were no recurrences after TAPP repair. CONCLUSIONS: For selected patients, the TAPP approach appears to be a good therapeutic option for strangulated hernias.

Adolescent↗
PubMed2004

Delayed traumatic diaphragmatic hernias presenting with strangulation.

Traumatic diaphragmatic injuries commonly occur following blunt and penetrating trauma, and that may be missed during a first evaluation, resulting in chronic diaphragmatic hernia and/or strangulation. In this study, we present three cases of delayed traumatic diaphragmatic hernias presenting with strangulation. The type of trauma was blunt in two and penetrating in one patient. In all three cases, the diagnoses of diaphragmatic injuries were missed in acute and chronic settings. While two patients had transverse colonic strangulation, the other one had strangulated stomach and spleen. Transverse colon resection was performed in one patient. Two patients had postoperative complications, and no postoperative mortality was detected. Patients complaining of upper abdominal pain and dyspnea with past history of thoracoabdominal trauma should be evaluated for a missed diaphragmatic injury. A high index of suspicion, physical examination of the chest, and x-ray film are helpful for diagnosis of delayed traumatic diaphragmatic hernias presenting with strangulation.

Adult↗
PubMed2001

A review of 300 attempted strangulation cases. Part I: criminal legal issues.

Three hundred strangulation cases, submitted for misdemeanor prosecution to the San Diego City Attorney's Office, were evaluated to determine the signs and symptoms of attempted strangulation that could be used to corroborate the victim's allegation of being "choked" for purposes of prosecution. The study reveals that a lack of training may have caused police and prosecutors to overlook symptoms of strangulation or to rely too heavily on the visible signs of strangulation. Because most victims of strangulation had no visible injuries or their injuries were too minor to photograph, opportunities for higher level criminal prosecution were missed.

Adult↗