A prospective randomized trial was performed to determine the value of tetracycline lavage in addition to systemic antibiotic prophylaxis in 159 patients undergoing elective and emergency intestinal operations. Tetracycline lavage was associated with a significant overall reduction in postoperative infection rates in 25 of 74 patients (34 percent) receiving saline lavage compared with 15 of 85 patients (18 percent) having tetracycline lavage (P less than 0.05). Tetracycline lavage was associated with a significant reduction in the counts of aerobic and anaerobic bacteria in the peritoneal fluid at the end of the operation (P less than 0.05 and P less than 0.01, respectively) and with a significant reduction of aerobes 24 hours postoperatively (P less than 0.02). Tetracycline lavage would appear to confer clinical benefit in preventing postoperative infection.
Perinuclear antineutrophil cytoplasmic antibodies (pANCAs) have previously been demonstrated in patients with various forms of vasculitis and more recently in those with inflammatory bowel disease (IBD) by an indirect immunofluorescence technique. Sera from 194 patients were tested for pANCAs: 101 with ulcerative colitis (43 with varying grades of disease severity, 19 after subtotal colectomy, 39 following restorative proctocolectomy), 40 with Crohn's disease, five with indeterminate colitis, 24 patients without IBD and 24 healthy volunteers (controls). The overall prevalence of pANCAs in patients with ulcerative colitis was 70.3 per cent (71 of 101). These antibodies were still present in 29 of 39 patients after restorative proctocolectomy, in whom the median follow-up after surgery was 2 years. All five patients who had pouchitis after restorative proctocolectomy were pANCA positive. By contrast, only ten of 40 patients with Crohn's disease had pANCAs, nine of whom had Crohn's colitis. No pANCAs were detected in controls. These results show that pANCAs are more prevalent in colonic IBD, especially ulcerative colitis. The persistence of pANCAs in the sera for 2 years after restorative proctocolectomy suggests that the antigens are not fully eradicated and, therefore, that it is not just the colon that is targeted immunologically in ulcerative colitis.
County, Denmark, blood samples were drawn in the fasting state at 8 a.m. for determination of serum levels of calcium, protein, cholesterol, and triglyceride.The serum calcium levels were corrected to a constant serum protein level.2All determinations were made in duplicate, and the co- efficients of variation (C.V.) of duplicate measurements and the mean values and standard deviations (S.D.) are given in the table.A ihighly significant inverse corre- lation was found between serum calcium and serum triglyceride (r= -0-36, P<0001).No significant correlation was found between serum calcium and serum cholesterol (r = 0-03, P>0 05). C.v. (from Serum LevelsNo. of Mean S.D. duplicate Subjects measurements)Calcium (mmol/l) 80 2-46 0-06 0m8nt Cholesterol (mmol/l) 80 7-04 1-48 1-50°O Triglyceride (mmol/l) 80 1-27 0-95 2-6 ,Conversion: SI to Traditional Units-Calcium: 1 mmol/l -4 mg!100 ml.Cholesterol: 1 mmol/l -38-6mg'100 ml.Triglyceride: 1 mmol/l 88 5 mg/100 ml.Our results seem to be supported by the findings that serum cholesterol is lower than normal in patients with hyperparathyroidism and that the seruim concentration of lipids increases after operation.3They indicate that in the elderly serum calcium levels in the lower part of the normal range are not pro- tective against raised serum lipid levels.-We are, etc.
Stripping of the long saphenous vein under femoral nerve block has been preformed on 21 patients (27 limbs). There has been no complication from the nerve block and this form of anaesthesia was found acceptable to all patients in a subsequent questionnaire.
Hemolytic uremic syndrome is seen occasionally by the surgeon in adult patients with colorectal manifestations. Two cases of hemolytic uremic syndrome are presented here, one misdiagnosed clinically as acute appendicitis and the other as acute ulcerative colitis. In each case the diagnosis was only established postoperatively and both patients died of this disease. These cases serve to remind colorectal surgeons that this potentially lethal diseases may occur with symptoms and signs suggestive of more common colorectal pathology.
The ability of normal and Crohn9s disease neutrophils to kill Candida albicans has been studied using neutrophils isolated from peripheral blood and suspended in phosphate buffered saline at 5 x 10(6) cells per ml. C albicans was grown to a stationary phase in broth culture and suspended in phosphate buffered saline at 10(7) organisms/ml. Neutrophils and Candida were then incubated together at 37 degrees C in a shaking water bath in the presence of fresh serum. At 30 and 60 minutes samples were withdrawn, neutrophils lysed, and Candida survival assessed by colony counting. Results were compared with control suspensions of Candida incubated with serum alone. After 30 and 60 minutes in the presence of autologous serum normal neutrophils had killed significantly more Candida than Crohn9s disease neutrophils (mean (SD) 61.0 (16.7)% v 40.5 (16.2)% at 30 minutes, p less than 0.0001; 83.2 (7)% v 70.8) 16)% at 60 minutes, p less than 0.005). The results did not alter significantly when normal neutrophils were incubated with Candida in the presence of Crohn9s disease serum instead of normal serum. When Crohn9s disease neutrophils were incubated with Candida in the presence of normal serum instead of autologous serum there was some improvement in candidacidal ability at 30 minutes (48.9 (20.6)% v 40.5 (16.2)%, p less than 0.03) but not at 60 minutes. Phagocytosis, measured using a radiometric assay, was normal. Neutrophils from patients with Crohn9s disease have an impaired ability to kill this granuloma provoking organism. It is not due to serum inhibitors or defective phagocytosis.
Sixty-two patients were admitted to a prospective randomized controlled trial to investigate the influence of a prophylactic antibiotic, lincomycin, on anaerobic sepsis following bowel surgery. The incidence of postoperative sepsis was reduced from 45 to 18 per cent (P less than 0-025). Wound infections were reduced from 38 to 12 percent (P less than 0-05). Intra-abdominal or pelvic abscess occurred in 1 of the treated group compared with 3 controls. Septicaemia occurred after operation in 1 patient receiving lincomycin and in 3 of the controls; in 2 of the latter, pure growths of bacteroides were isolated from the blood cultures and 1 of these patients died. Although lincomycin had no influence on the number of patients who developed aerobic postoperative infections, there was a significant reduction in the incidence of sepsis due to bacteroides, which occurred in 10 of the control group compared with 1 in the lincomycin group (P less than 0-005). No patients developed complications attributable to lincomycin, such as pseudomembranous colitis. These data indicate that the genus Bacteroides are important pathogenic organisms and are responsible for postoperative morbidity. Furthermore, anaerobic sepsis can be reduced by appropriate prophylactic antibiotics.
A consecutive series of 12 patients with stenosis secondary to duodenal ulceration were treated by proximal gastric vagotomy (PGV) and duodenoplasty or PGV and dilatation of the stenosis. Three months after operation the rate and pattern of gastric emptying of a solid meal was measured in each patient and compared with 18 patients with uncomplicated duodenal ulcer treated by PGV alone. Two patients developed gastric stasis in the early postoperative period which resolved with medical treatment. All patients were asymptomatic and were eating normally three months after operation. There was no significant difference in the rate of gastric emptying postoperatively between the patients who had stenosis and those who had uncomplicated duodenal ulcers. These results indicate that despite early postoperative difficulties in some patients pyloric dilatation or duodenoplasty with PGV are both effective treatments for stenosis due to duodenal ulceration.
We have analysed the activities of a hospital-based stomatherapy service between 1980 and 1983. The average numbers of patients seen per annum included 395 out-patients, 307 in-patients and 116 home visits. Of the 276 in-patients with colostomies, 72% had underlying malignant disease; 17% were performed as emergencies and 51% were temporary stomas. Hospital mortality for patients with a temporary stoma was 19% and only 59% had their temporary stoma reversed. Only 45% of colostomy patients received preoperative counselling and 11% had no regular follow-up. Complications were recorded at some stage after colostomy in 25% but only 10% required surgical refashioning. Of the 184 in-patients with ileostomies, 52% had ulcerative colitis and 41% had Crohn's disease. Only 13% of ileostomies were performed as emergencies, and only 11% were temporary. In contrast to colostomy, 83% of ileostomy patients received preoperative counselling and adequate follow-up was provided for 98% of patients. Complications were recorded in 57% of patients after ileostomy but surgical reconstruction was needed in only 18%.
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