Is mechanical bowel preparation mandatory for elective colon surgery? A prospective randomized study

BACKGROUND: Bowel preparation prior to colonic surgery usually includes antibiotic therapy together with mechanical bowel preparation (MBP). Mechanical bowel preparation may cause discomfort to the patient, prolonged hospitalization, and water and electrolyte imbalance. It was assumed that with the improvement in surgical technique together with the use of more effective prophylactic antibiotics, it was possible that MBP would no longer be necessary. HYPOTHESIS: There is no statistical difference in the postoperative results of patients who undergo elective colon resection with MBP as compared with those who have no MBP.Design and PATIENTS: The study includes all patients who had elective large bowel resection at Campus Golda between April 1, 1999, and March 31, 2002. Emergency operations were not included. The patients were randomly assigned to the 2 study groups (with or without MBP) according to identification numbers. All patients were treated with intravenous and oral antibiotics prior to surgery. The patients in the MBP group received Soffodex for bowel preparation. RESULTS: A total of 329 patients participated in the study, 165 without MBP and 164 with MBP. The 2 groups were similar in age, sex, and type of surgical procedure. Two hundred sixty-eight patients (81.5%) underwent surgery owing to colorectal cancer and 61 patients (18.5%) owing to benign disease. The hospitalization period was longer in the bowel-prepared group (mean +/- SD, 8.2 +/- 5.1 days) as compared with the nonprepared group (mean +/- SD, 8.0 +/- 2.7 days). However, this difference was not statistically significant. The time until the first bowel movement was similar between the 2 groups: a mean +/- SD of 4.2 +/- 1.3 days in the nonprepared group as compared with a mean +/- SD of 4.3 +/- 1.1 days in the prepared group (P = NS). Four patients (1.2%) died in the postoperative course owing to acute myocardial infarction and pulmonary embolism. Sixty-two patients (37.6%) of the non-MBP group suffered from postoperative complications as compared with 77 patients (46.9%) of the MBP group. CONCLUSION: Our results suggest that no advantage is gained by preoperative MBP in elective colorectal surgery.     

Increased activity of Pgp multidrug transporter in patients with Helicobacter pylori infection

AIM: To determine whether local antibiotic resistance involves P-glycoprotein (Pgp)-mediated active drug out-pumping during Helicobacter pylori (H pylori) infection treatment with classic antibiotic therapy. METHODS: Pgp activity was determined in gastric mucosa biopsy specimens obtained from 53 patients with pathohistologically verified gastritis and microbiologically confirmed H pylori infection, and compared with the Pgp activity in 12 control subjects with normal endoscopic findings. The H pylori positive patients were treated with short-term 7-d therapy consisting of two antibiotics (amoxicillin and azithromycin/metronidazole and clarithromycin) and a proton pump inhibitor. Pgp activity was determined by flow cytometry in the test of rhodamine dye efflux and quantified as mean fluorescence ratio (RMF). RESULTS: Upon the first cycle, H pylori was successfully eradicated in 20 patients, whereas therapy was continued in 33 patients. In the course of antibiotic therapy, RMF increased (P＜0.05) and gastric cells showed higher rhodamine dye efflux. The mean pre-treatment RMF values were also higher (P＜0.0001) in patients with multiple therapeutic failure than in those with successful H pylori eradication and control subjects. CONCLUSION: Pgp might be one of the causes of therapy failure in patients with H pylori and antibiotic therapy could be chosen and followed up on the basis of the Pgp transporter local activity.     

Bidirectional effects of benzodiazepine binding site ligands in the passive avoidance task: differential antagonism by flumazenil and beta-CCt

Recent research on genetically modified mice has attributed the amnesic effect of benzodiazepines mainly to the alpha1-containing GABA(A) receptor subtypes. The pharmacological approach, using subtype selective ligands, is needed to complement genetic studies. We tested the effects of the non-selective antagonist flumazenil (0-20.0 mg/kg), the preferential alpha1-subunit selective antagonist beta-carboline-3-carboxylate-t-butyl ester (beta-CCt) (0-30.0 mg/kg), the non-selective agonist midazolam (0-2.0 mg/kg), the preferential alpha1-subunit selective agonist zolpidem (0-3.0 mg/kg), and the non-selective inverse agonist methyl 6,7-dimethoxy-4-ethyl-beta-carboline-3-carboxylate (DMCM) (0-2.0 mg/kg) in the one-trial step-through passive avoidance task in rats. The compounds were administered intraperitoneally, before the acquisition test. Flumazenil and beta-CCt did not affect retention performance. Midazolam and zolpidem induced amnesia in a dose-dependent manner. The complete reversal of amnesia was unattainable. The effects of zolpidem were significantly attenuated by the both, flumazenil (10.0 mg/kg) and beta-CCt (30.0 mg/kg); by contrast, only flumazenil was considerably effective when combined with midazolam. DMCM exerted promnesic effects at 0.2mg/kg, in an inverted U-shape manner. Both antagonists tended to abolish this action. The results indicate that some other alpha-subunit(s), in addition to the alpha1-subunit, contribute to the amnesic actions of non-selective benzodiazepine site agonists in the passive avoidance task. On the other hand, a significant part of the DMCM-induced promnesic effect could involve the alpha1-subunit and/or other putative beta-CCt-sensitive binding site(s).     

Early results of cementless hip arthroplasty in the treatment of femoral head posttraumatic and atraumatic osteonecrosis

AIM: To evaluate the value of cementless hip arthroplasty in the treatment of posttraumatic and atraumatic osteonecrosis (ON) of the femoral head. METHODS: The study was conducted at the Department of Orthopedics and Traumatology, Military Medical Academy, between January 1st, 1999 and December 31st, 2003. Twenty-five patients with 27 implanted endoprostheses, and the diagnosis of osteonecrosis of the femoral head, and radiographically confirmed Arlet-Ficat stage III and IV were evaluated retrospectively. The results were evaluated according to Harris Hip Score (HHS). The research included 10 patients with traumatically induced osteonecrosis and 15 patients (17 endoprothesis) with osteonecrosis of the femoral head. The mean age of the patients in the group with posttraumatic osteonecrosis of the femoral head was 41 (19-62) years, and in the group of the patients with atraumatic osteonecrosis of the femoral head it was 40.2 (21-53) years. Complications included one case with postoperative luxation, and one case with iatrogenic sciatic nerve palsy. RESULTS: The average Harris Hip Scores in the group of posttraumatic osteonecrosis were 31 points preoperatively and 86 points postoperatively. In the group of osteonecrosis of atraumatic etiology, the average Harris Hip Score was 28 points preoperatively, and 77 points postoperatively. Postoperative Harris Hip Scores were compared with the Student's t-test and the results showed no statistically significant difference (p = 0,125). CONCLUSIONS: Our study did not find any significant difference between the results of posttraumatic and atraumatic osteonecrosis of the femoral head treated with cementless endoprosthesis.     

Acute leg compartment syndrome after exertion

A case of a 22-year old soldier, with a history of pain in the leg during heavy exercise, which desisted at rest, was presented. One day before admission, the patient had felt an extreme exertion-induced pain in his right leg which had not lessenned at rest. At the same time, the patient noticed persistent severe leg edema. On physical examination, the intracompartmental pressure was 62 mmHg (> 30 mmHg). The patient was urgently operated on, and fasciotomy according to Mubarak was used. At second surgery, the debridement of the muscles of the posterior group of the leg, and the evacuation of hemathoma from the anterior and lateral group of the right leg muscles were perfomed. Postoperative recovery was uneventful. Fasciotomy wounds were closed within 14 days of the surgery. The complete physical treatment was done. Follow-up examinations 1, 3, and 6 months afterwards were satisfactory. The soldier completed his compulsory military service without any sequelae. Laboratory results were normal. Overlooked, unrecognized or surgically untreated compartment syndrome can cause severe damage, including even the loss of the extremity.     

Extended ankle and foot fasciotomy as an enhancement to the surgical treatment of patients with prolonged ischemia of the lower extremities

AIM: To present the technique and efficacy of extended ankle and foot fasciotomy, as a surgical limb-salvage procedure associated with the successful revascularization after the gold interval. METHOD: A retrospective review of six patients at the age of 16- 79 years (mean 39) in the period from 1996 to 2003, treated with the extended ankle and foot fasciotomy. There were four males undergoing the delayed treatment of war injuries to the lower extremity, and two females with atherosclerotic occlusive disease (a. illiacae dex and a. poplitealis dex.). The average ishemic time in the wounded patients was 22 hours (range, 14-30 hours), and ischemic time in occlusive disease (range, 48-72 hours). Clinical signs, indications, surgical access and the technique of extended ankle and foot fasciotomy was reported. RESULTS: The obtained results were classified as early and late.There was no cases with lethal outcome. Incisional wounds closed 15 days after the intervention, using secondary suture or skin transplant sec. Thiersch. The satisfactory functional results were achieved in 4 of the patients, 1 had a small edema, while amputation was performed in 1 patient. CONCLUSION: In cases of prolonged foot ischemia with edema and paresthesia in the toes, extended ankle and foot fasciotomy should be performed as a surgical limb-salvage procedure.     

Tertiary blast injury to the intestines

BACKGROUND: To present the first case of the tertiary blast injury to the intestine, and the tertiary blast injury in general. CASE REPORT: A parachutist of the Army of Serbia and Montenegro was injured when descended from the 1 200m height by parachute which did not expand. The force of stroke to the ground, caused the reactive transfer of energy and the subsequent blast injury to the intestine. After 24 hours, the secondary perforation of the small intestine, contusioned by the blast, developed which was the indication of explorative laparotomy. The resectioned small intestine showed the histologic characteristics of a blast injury, so the tertiary blast injury was diagnosed on the basis of these and of the mechanism of the injury. CONCLUSION: Tertiary blast injuries fall into the group of indirect blast injuries. The only difference between indirect injuries as compared to direct ones, is in the manner of inflicting, otherwise the traumatic mechanisms are alike, and include the transfer of the energy of stroke through the tissue of different density.     

Prolonged survival of a female patient with total pelvic exenteration

BACKGROUND: To present a female patient who lived 5 years after total pelvic exenteration (TPE). CASE REPORT: The female patient underwent TPE due to retrovesicovaginal fistula as a consequence of locoregional irradiation after the operation for the malignoma of the vaginal part of the uterus. In the formation of Bricker conduit, the ureter antireflux was achieved by the application of the "tobacco sack muff" made of the intestines around the ureter. By the use of this technique, the occurrence of pyelonephritis, as the leading cause of death in such patients, was prevented. CONCLUSION: TPE is a hope for significantly prolonged survival of patients with advanced pelvic malignomas, or with a postirradiatiation fistula.     

Umbilical metastasis (Sister Mary Joseph's nodule) diagnosed by fine-needle aspiration

Sister Mary Joseph's nodule is the eponym for metastatic involvement of the umbilicus. This less common entity is the sign of disseminated malignant disease, mainly of digestive and gynecologic origin, and is associated with a poor prognosis. A case of Sister Mary Joseph's nodule in a 76-year-old woman in whom the umbilical metastasis was the first sign of malignant disease in presented. The diagnosis of metastatic adenocarcinoma was established by fine needle aspiration cytology of the umbilical nodule. Radiological and ultrasonographic investigation disclosed carcinoma of the gallbladder with pancreas, stomach, and colon invasion as well as peritoneal dissemination. The diagnosis was confirmed by exploratory laparatomy and histological examination of the excised umbilical nodule.