Comparison between oral and systemic antibiotics and their combined use for the prevention of complications in colorectal surgery

Ninety patients were included in this prospective randomized trial. Each required elective colorectal surgery and was prepared for operation with oral preoperative antibiotic therapy, systemic peroperative therapy, or by a combination of both. The number of each type of septic postoperative complication and their total did not differ between the group treated by oral antibiotics prior to operation and the group treated peroperatively with systemic antibiotic therapy. The total number of septic complications (wall abscesses, fistulas, subdiaphragmatic abscesses, septicemia, peritonitis), however, was significantly less (P<0.05) in the group treated by both preoperative oral antibiotics and peroperative systemic antibiotic therapy (3.3 per cent) than in either groups treated only orally preoperatively (30 per cent) or by systemic antibiotic therapy during the operation (23 per cent). The combination of oral antibiotic therapy prior to operation and of systemic peroperative antibiotic therapy, therefore, presents the most effective prophylactic effectiveness.     

Perianal abscesses and fistulas

In a five and one-half year period, 1023 patients with anorectal abscesses and fistulas were treated. Under regional anesthesia the abscesses were unroofed and debrided and a primary fistulotomy was performed whenever a low fistula was identified. In 355 (34.7 per cent) an internal fistulous opening was demonstrated at the time of abscess drainage. Thirty-two patients had suprashincteric fistulas and underwent two-stage fistulotomy using a seton. Perianal abscesses were encountered in 42.7 per cent of the patients, followed by ischiorectal (22.7 per cent), intersphincteric (21.4 per cent), and supralevator (7.33 per cent). The patients with supralevator and intersphincteric abscesses had a high incidence of fistula identified during abscess drainage. The recurrence rates were 3.7 per cent in the group with abscess drainage only and 1.8 per cent in the group that had primary fistulotomy along with abscess drainage. The follow-up period averaged 36 months. To accomplish adequate drainage and identify the deeper components and associated fistulous opening (34.7 per cent of the entire group), careful examination under regional anesthesia is recommended. Early aggressive treatment of an anorectal abscess and fistula significantly reduces the possibility of recurrent abscesses and/or the need for further surgery. Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 5 to 9, 1983. Recipient of the 1983 Rowell Laboratories Education Committee Award.     

Colocolostomy and coloproctostomy utilizing the circular intraluminal stapling devices

Coloproctostomy or colocolostomy by peranal insertion of a circular stapling device was performed on 265 patients between January 1978, and June 1981. A low anterior resection was performed in 174 patients. Stapler-related technical complications occurred in 52 patients (20 per cent). Complementary transverse colostomies were performed in 11 patients, of which seven were performed on the first 30 patients. Intraoperative complications occurred in 18 patients (7 per cent). Twenty-six major postoperative complications occurred (10 per cent), and clinical anastomotic leaks occurred in eight patients (3 per cent). Four postoperative deaths occurred (1.5 per cent). This study concludes that (1)coloproctostomy or colocolostomy can be safely performed by transanal insertion of a circular stapling device, (2) these instruments allow a sphincter-preserving procedure to be performed for lesions in the low and midrectum (5 to 10 cm from the anal verge) with an acceptable early morbidity and mortality, and (3) the majority of stapler-related technical complications can be managed without protecting colostomy. Read at the meeting of the American Society of Colon and Rectal Surgeons, San Francisco, California, May 2 to 6, 1982.     

Recurrent anorectal abscesses

A prospective study of 100 recurrent anorectal abscesses in 97 patients was carried out to elucidate the cause of recurrence. Sixty-four patients had had one, 12 had had two, and the rest had had more than two prior abscesses. In 32 patients, the previous diagnosis was erroneous; the patients had hidradenitis suppurativa which was excised. In 68 patients, the cause of recurrence was insufficient prior treatment. Thirty-one patients (45 per cent) had fistulous abscesses requiring fistulotomy. Twenty-two patients (32 per cent) had large abscesses associated with fistula necessitating unroofing of the abscess along with fistulotomy. In 15 patients (22 per cent), no associated fistula was detected, but they were found to have missed components (i.e., ischiorectal, supralevator, postanal abscesses) and were successfully treated with drainage of the missed abscess component. All recurrent abscesses must be examined carefully under anesthesia to identify associated fistulas or missed components, or to exclude hidradenitis suppurativa. Read at the Meeting of the American Society of Colon and Rectal Surgeons, Colorado Springs, Colorado, June 7 to 11, 1981.     

Early local complications following colostomy closure in cancer patients

Early surgical complications following colostomy closure in 65 cancer patients operated on at the Istituto Nazionale Tumori of Milan were evaluated retrospectively. The overall complication rate was 24.6 per cent, including infections (13.8 per cent), fistulas (6.1 per cent), wound dehiscence (3.0 per cent), and distal stenosis (1.5 per cent). Type and rate of complications were analyzed to find a correlation with type, site, and location of colostomy, technique of closure, presence or absence of drains, or time interval between construction and closure of colostomy. No statistically significant association between the aforementioned factors and occurrence and rate of complications was found. The authors think, therefore, that surgical attention, including meticulous manipulation of the stoma, avoidance of contamination of the wound, tension of sutures, dead spaces, and collection of blood in the wound, and use of antibiotics and antiseptics are the most important principles to minimize postoperative complications.     

Enterocutaneous fistulas

Fifty patients with 68 enterocutaneous fistulas were retrospectively reviewed at Hennepin County Medical Center from 1967 to June 1981. Eleven of 28 patients, treated with total parenteral nutrition (TPN) as the initial therapy for their fistulas, had spontaneous closure of 22 of 44 fistulas (three gastroduodenal, 17 small-bowel, two colonic fistulas). There were 35 operative procedures resulting in the closure of 26 fistulas, ten of which had failed to close with TPN (two gastroduodenal, ten small-bowel, and fourteen colonic fistulas). Overall mortality was 22 per cent, with five postoperative deaths and four deaths of patients treated with TPN. Aggressive use of TPN has not obviated the need for surgical closure in the authors' experience, particularly low in the gastrointestinal tract. Management should include TPN for up to four weeks and surgery if there has been no improvement with conservative therapy.     

Eight hundred and seventy-five cases of bacterial meningitis. Part I of a three-part series: clinical data, prognosis, and the role of specialised hospital departments

Between 1966 and 1976, 875 patients with bacterial meningitis were treated at the Department of Infectious Diseases, Rigshospitalet. Among 495 patients admitted directly to the department, fatality rates were 0.4 per cent for meningococcal infections (including septicaemia), 3.7 per cent for haemophilus meningitis and 8.7 per cent for pneumococcal meningitis. The total fatality rate for directly admitted patients was 3.8 per cent, and 4.0 per cent had sequelae on discharge. Patients transferred from other hospitals often had complications, and their fatality rate (20.1 per cent) was markedly higher than that for directly admitted patients, but not significantly higher than that for patients treated elsewhere in Denmark (17.6 per cent). The low fatality at a specialised unit may reflect an open and swift admission procedure and the preparedness of staff familiar with the management of meningitis. During the first five years after discharge, the relative death risk was increased among meningitis patients but later declined to that found in the general population.     

Site,emergency, and duration of symptoms in the prognosis of colorectal cancer

Four prognostic factors,i.e., site of the tumors, mode of presentation, duration of symptoms, and pathologic staging, were correlated to the results of surgical treatment,i.e., curative resectability, postoperative complications and mortality, and five-year survival, in 161 patients operated upon for colorectal cancer. Only 31 (19 per cent) of the growths were right-sided; 71 patients (44 per cent) had symptoms less than six months. Fifty-four of them had a localized cancer; a radical procedure was performed in 114 (71 per cent), and postoperative complications occurred in 42 cases (26 per cent). The overall crude five-year survival was 38 per cent (53 of the 140 followed-up patients). The length of the clinical history did not correlate with the pathologic staging, which greatly influenced curability and survival. A statistically significant poorer prognosis was observed in patients with left-sided tumors, with an emergency presentation and with a duration of symptoms shorter than six months. A better prognosis can be achieved by means of a presymptomatic diagnosis. Supported by CNR.     

Cefamandole preparation for colonic surgery

A controlled, prospective, randomized study of 457 patients undergoing colonic surgery was done to compare systemic cefamandole therapy to neomycin-erythromycin in reducing postoperative septic complications. Parenteral cefamandole and cephalothin were given before, during, and after surgery to achieve maximal antimicrobial coverage in the blood, tissues, peritoneum, and urine. Such protection is not obtained with oral antibiotic preparation. Major surgical indications were carcinoma in 216 patients and diverticulitis in 107 patients. More than half the patients had colonic perforations, obstruction, or fistulas. All patients were operated upon by a single surgeon during 1975–1980. Cephalothin (151 patients), combined with neomycin-erythromycin, resulted in an 11.3 per cent rate of post-operative septic complications. Cefamandole treatment in 112 patients resulted in an 8.9 per cent postoperative infection rate compared with 16.3 per cent in 141 matched control patients. Read at the meeting of the American Society of Colon and Rectal Surgeons, Colorado Springs Colorado, June 7 to 11, 1981.     

CT-guided percutaneous pelvic abscess drainage in Crohn’s disease

Background Percutaneous abscess drainage (PAD) is the current therapy for abdominal or pelvic collections. PAD has poorer curative rate for abscesses in Crohn’s disease (CD), commonly complicated by wide fistulas and multiloculations. Methods We retrospectively evaluated abscess cure rate, complications and final outcome in 87 CD patients, 70 with spontaneous and 17 with postoperative pelvic abscesses, all treated with CT-guided PAD during the last 7 years. Results A 77% primary success rate and an 84.3% secondary success rate were obtained without major complications. The higher success rate for PAD was for postoperative (88.2%) rather than spontaneous abscesses (74.2%). Seventy-two percent of treated patients did not develop recurrent abscesses and underwent elective surgery up to 40 months later. Conclusion PAD in pelvic abscess complicating CD is an effective alternative to early surgery with satisfactory curative success rates. In unsuccessful cases, due to wide fistulas or postoperative anastomotic dehiscence, PAD helped in planning elective surgery, reducing surgical complications.     

Colorectal carcinoma in patients less than 40 years of age

Between 1960 and 1979, 37 patients, ranging in age from 18 to 40 years, were treated for colorectal cancer. Symptoms typical of colorectal malignancy had been present for an average of 10.4 months; a positive family history, previous colonic disease, or immunosuppression was present in 22 patients (59 per cent). Distribution of lesions was unusual in that only 40 per cent were within reach of the sigmoidoscope, and only 7.5 per cent could be palpated on rectal examination. Dukes' staging at diagnosis was improved in distribution to that reported in the adult population (51 per cent localized vs. 40.1 per cent). Histologic characteristics of the tumors were not unusual; however, incidence of poorly differentiated (18.9 per cent) and mucin-producing (10.8 per cent) cancers was increased. Perineural invasion was associated with disseminated disease. Vascular invasion was associated with disseminated disease and poor prognosis. Overall fiver-year survival was 56.8 per cent. Five-year survival in 24 patients undergoing potentially curative resection increased to 70.8 per cent. Colorectal carcinoma in patients under 40 years of age is unusual, and delay in diagnosis is common. The distribution of lesions is more homogeneous than that seen in older patients, and high-grade malignancies are more frequent. Survival data in this series are more favorable than those generally reported. Improved five-year survival following potentially curative resection (70.8 per cent) stresses the need for early diagnosis and treatment Read at the meeting of the American Society of Colon and Rectal Surgeons, Hollywood, Florida, May 11 to 16, 1980. Supported in part by the Roessler Foundation and the American Cancer Society.     

Thymic irradiation. An approach to chronic lymphocytic leukemia

Twenty-two patients with active chronic lymphocytic leukemia were treated with thymic irradiation; a full remission was achieved in 14 and a partial response in 7. In a similar group of 28 patients treated with chlorambucil, there were 7 full remissions, 5 partial responses, 6 with white cell control and 10 with no response. Thymic irradiation restored the leukocyte count to normal in 76 per cent of the cases (16 of 21) and the differential in 32 per cent (7 of 22), with complete resolution of lymphadenopathy in 81 per cent (17 of 21), hepatomegaly in 75 per cent (12 of 16), splenomegaly in 76 per cent (11 of 14) and symptoms in 100 per cent (20 of 20). Chlorambucil restored the leukocyte count to normal in 50 per cent (14 of 28) and the differential in 7 per cent (2 of 28), with complete resolution of lymphadenopathy in 43 per cent (9 of 21), hepatomegaly in 43 per cent (9 of 21), splenomegaly in 24 per cent (4 of 22) and symptoms in 64 per cent (16 of 25). Thymic irradiation produced a more rapid response even in patients resistant to chemotherapy and was more effective (11 of 12 or 92 per cent) than chlorambucil (7 of 22 or 33 per cent) in patients with hematocrit readings of less than 30 per cent and/or greater than 75 per cent infiltration of the bone marrow and a leukocyte count of more than 40,000 cells/mm³ and in patients with splenomegaly. Anemia was corrected in all three patients and thrombocytopenia in two of six patients treated with thymic irradiation. Chlorambucil corrected anemia in 2 of 11 patients and thrombocytopenia in 2 of 5 patients. Anemia developed in 5 of 17 patients and thrombocytopenia in 4 of 23 patients treated with chlorambucil and in no patients treated with thymic irradiation.     

Questionable specificity of lipid antigen in the Mycoplasma pneumoniae complement fixation test in patients with extrapulmonary manifestations

The clinical spectrum in serologically verified Mycoplasma pneumoniae infections was studied in a series of 387 in-patients traced from the laboratory records of mycoplasmal and viral screening tests. The proportion of patients with extrapulmonary manifestations was unexpectedly high, 115 (29·7 per cent). Of these, 69 patients (17·8 per cent) had only non-respiratory manifestations. Two hundred and seventy-two patients (70·3 per cent) had respiratory symptoms only, without extrapulmonary complications.The commonest complications of respiratory infection due to M. pneumoniae were carditis and central nervous system infections. In the group without respiratory symptoms the heart, the central nervous system and the gastro-intestinal tract were most commonly affected. Some laboratory and epidemiological features of patients with respiratory infection only were compared with those of patients with respiratory infection and some extrapulmonary complication and with those of patients who had extrapulmonary manifestations only. Differences were found between the first and third groups, whereas the first and second groups resembled each other.The explanation of these differences, and of the unexpectedly high frequency of extrapulmonary manifestations may be lack of specificity of the complement fixation test with glycolipid antigen used for diagnosis.     

Factors influencing the morbidity of colostomy closure

In a series of 80 colostomy closures, a total complication rate of 26 per cent was found, with a wound infection rate of 14 per cent and an anastomotic leak rate of four per cent. Patients having preoperative systemic antibiotics had fewer wound infections than those who did not (eight per cent versus 19 per cent). Delayed primary skin closure or closure by secondary intention was associated with less wound morbidity than was primary closure (ten per cent versus 17 per cent). However, the use of preoperative systemic antibiotics decreased the incidence of wound infection in those having primary skin closure (five per cent versus 27 per cent). Patients having diverticular disease had more wound infections (40 per cent) and greater overall morbidity (70 per cent). Older patients had a higher incidence of complications (24 per cent if less than 40 years and 45 per cent if greater than 50 years). Closure of left-sided colostomies was associated with a higher infectious complication rate (26 per cent versus 13 per cent). The time interval to colostomy closure was found to alter subsequent morbidity with a waiting period of one to two months associated with zero complications.     

Complete prolapse of the rectum treated by modified Orr operation

During a 25-year period 24 patients were treated for complete rectal prolapse with a modification of the operation described by Orr in 1947. After a median follow-up of five years two recurrences occurred (8 per cent). Of 11 patients who were incontinent for fluid feces or flatus preoperatively, five gained continence after the operation. An actuarial analysis of the data revealed a cure rate after five years of 91 per cent (95 per cent confidence limits: 76–100 per cent).     

Immediate and long-term results of the treatment of patients with lung abscess

The immediate results of conservative (116 subjects) and surgical (37 subjects) treatment of patients with lung abscesses were studied and the remote outcomes were followed up for periods of 1 to 8 years in 104 therapeutically treated and 33 surgically treated patients. 13.7 and 40.4 per cent of the patients, respectively, were discharged from the hospital after complete and clinical recovery. In 41.6 per cent of the patients, chronic abscesses were stated. 4.3 per cent of the patients died. After the surgical treatment postoperative complications were observed in 51.3 per cent of the patients, fatal outcomes were stated in 10.8 per cent and 21.7 per cent of the patients were qualified as invalids. In the remote periods complete and clinical recovery was stated in 26.8 and 52.8 per cent of the patients respectively, 4 (4.1 per cent) patients died and 7.4 per cent of the patients previously engaged in manual work and 3.0 per cent of the patients previously engaged in mental work were qualified as permanent invalids.     

Survival of 727 patients with single carcinomas of the large bowel

The outcome of 727 patients presenting with solitary colorectal carcinoma over a seven-year period is reviewed. Of the patients, 52 per cent were females 45 per cent were over 70 years and 31 per cent had an emergency admission. Of the tumors, 43 per cent occurred in the rectum and 40 per cent were stage D (not treated curatively). Predisposing causes included inflammatory bowel disease (n=12) and abdominal irradiation (n=6); associated adenomatous polyps were present in 22 per cent of resection specimens. Hospital mortality rates (20 per cent overall) were adversely affected by emergency admission (36 per cent), age>70 years (29 per cent) and advanced, stage D disease (31 per cent). Corrected overall five-year survival rate was 32 per cent and, after curative resection, 59 per cent. Of patients in whom curative resection included contiguous organs, 47 per cent survived five years. Survival was reduced in patients over 70 years (26 per cent), in emergency admissions (24 per cent), in poorly differentiated tumors (18 per cent), and if tumor fixity was present (14 per cent). Factors contributing to a favorable outlook included a long history (greater than one year) and a tumor situated in the left colon. Recurrence developed in 47 per cent of patients surviving curative resection and was seldom diagnosed at a curable stage. This work was supported by a grant from the Wellcome Trust, United Kingdom. Presented at the Association of Surgeons of Great Britain and Ireland, Dundee, April 1984.     

Myocardial infarction in patients aged 70 years and over

109 subjects aged 70 years (58 women, 51 men; average age 77 years) were hospitalized in the CICU (Cardiology Intensive Care Unit) over the period stretching from 1984 to 1986. The average length of stay in the CICU was 1 week, completed by an average stay of 5 days in the cardiology department. 100 per cent of the patients were followed up. Of the clinical parameters made evident by this study, the authors note that hypertension was the predominant risk factor (52.2 per cent); a history of coronary disease was noted in 60.5 per cent; 26.6 per cent of the patients were hospitalized before the 6th hour, chest pain being typical in 78 per cent versus painless in 11 per cent of patients; topographically, the infarction was anterior in 55 per cent, posterior in 40.4 per cent, and around the circumference in 4.6 per cent of cases; 80.8 per cent of the infarctions were transmural versus 19.2 per cent of infarctions without the Q wave--the latter accounted for a higher hospital mortality rate (38 per cent versus 27.3 per cent). The main complications were disturbances in rhythm (60.6 per cent) and LVI (56.9 per cent). Complications on the form of infections were noted in 15.6 per cent. Apart from the usual indicators of severity (cardiogenic shock, VF, LVI), infarction of the RV and AF had a serious effect on the prognosis. latrogenic disease accounted for 18.9 per cent. From the point of view of prognosis, hospital mortality was 30 per cent; mortality after one year was 44 per cent and 47.7 per cent after 2 years (in a group of 76 subjects).(ABSTRACT TRUNCATED AT 250 WORDS)     

Malignant retrorectal tumors: 28 years' experience at memorial sloan-kettering cancer center

From 1949 to 1977, 39 patients with localized malignant retrorectal tumors were treated at Memorial Sloan-Kettering Cancer Center. Chordomas were the most frequent histologic type (38 per cent of patients) followed by neurogenic tumors (15 per cent) chondrosarcomas, hemangiopericytomas, and embryonal adenocarcinomas (8 per cent each). Treatment consisted of surgical excision in 28 patients (18 of whom received adjuvant radiotherapy and/or chemotherapy). Ten patients were treated nonsurgically, receiving radiation and/or chemotherapy alone. Large tumors were most successfully managed by a combined surgical approach consisting of exploratory celiotomy, rectal mobilization, and bilateral hypogastric artery (with middle sacral artery and vein) ligation, followed by transsacral tumor excision with incontinuity sacrectomy. For all treated patients, survival at 5, 10, 15 and 20 years was 69 per cent, 50 per cent, 37 per cent and 20 per cent, respectively. Long-term disease-free survival (17 to 25 years post treatment) was noted in six patients Read at the meeting of the American Society of Colon and Rectal Surgeons, Colorado Springs, Colorado, June 7 to 11, 1981.     

Background mucosal changes of primary advanced large intestinal cancer in patients without familial polyposis coli

In 337 cases of primary advanced large intestinal cancer in patients without familial polyposis coli, the risk factor for cancer was discussed chiefly from the background mucosa surrounding and apart from the cancers. The following findings were obtained: (1) in the mucosa surrounding cancers, adenoma was seen in 23 cases (6.8 per cent), adenomatous changes of the basal cells in 211 cases (62.6 per cent), and hyperplastic glands in 167 cases (49.6 per cent), (2) in the mucosa at least 10 mm from the cancers, adenoma, adenomatous changes of the basal cells, and hyperplastic glands were seen in 42 cases (12.5 per cent), 129 cases (38.3 per cent), and 40 cases (11.9 per cent), respectively. Therefore, it is suggested that microscopic adenoma and adenomatous changes of the basal cells might be a sign of premalignancy in patients without familial polyposis coli.