Timing of antibiotic treatment in non-perforated gangrenous appendicitis.

OBJECTIVE: To assess whether antibiotic treatment with cefuroxime and tinidazole started during the operation was as effective as treatment started before operation in patients with gangrenous non-perforated appendicitis. DESIGN: Prospective randomised study. SETTING: University hospital, Sweden. SUBJECTS: 114 patients with gangrenous, non-perforated appendicitis who had had antibiotics started before operation and 120 whose treatment was started during operation out of a total of 575 who presented with a presumptive diagnosis of appendicitis. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: There were no deaths, and the rates of infective complications were 1/114 (0.9%) and 3/120 (3%), respectively. The median hospital stay was four days in both groups. CONCLUSION: Antibiotic treatment started during the operation is not significantly worse at preventing infective complications in non-perforated, gangrenous appendicitis than treatment started before the operation.

Long-term effects on bacterial sensitivity patterns of preoperative antibiotic prophylaxis in colorectal surgery.

Since 1973, when doxycycline was introduced as preoperative prophylaxis in elective colorectal surgery at Malmö General Hospital, Sweden, there has been an unchanged and low rate (8% to 12%) of septic complications in colonic surgery. For treatment of postoperative infections, ampicillin and cefuroxime have been used since 1973 and 1980, respectively. The sensitivity of Escherichia coli to these three antibiotics used for prophylaxis and treatment was followed for five years (1981-1985). Only minor changes were observed during the period. A lower frequency of antibiotic resistance was found in bacterial strains isolated peroperatively than in strains isolated postoperatively after colorectal surgery or from infections in other patients. Considering the low frequency of postoperative infectious complications and the low frequency of antibiotic resistance in peroperative isolates, doxycycline still remains an alternative for prophylaxis in bowel surgery.

Long-term effects on bacterial sensitivity patterns of preoperative antibiotic prophylaxis in colorectal surgery.

Since 1973, when doxycycline was introduced as peroperative prophylaxis in elective colorectal surgery at Malmö General Hospital, Sweden, there has been an unchanged and low rate (8-12%) of septic complications in colonic surgery. For treating postoperative infections ampicillin, cefuroxime and piperacillin have been used since 1973, 1980 and 1982 respectively. The sensitivity pattern of E. coli and Klebsiella against these four antibiotics used for prophylaxis and treatment has been followed for the past five years and only minor changes have occurred through the period. However, a lower frequency of antibiotic resistance was recorded for bacteria isolated peroperatively than postoperatively after colorectal surgery or from infection sites from other patients presumably mostly due to selection caused by antibiotics used within the hospital. Due to the good clinical outcome and seemingly lack of development of antibiotic resistance in peroperative isolates, doxycycline still remains a choice for prophylaxis in bowel surgery.

Evaluation of possibilities for mass screening for colorectal cancer with Hemoccult fecal blood test.

Data from a health survey including the Hemoccult fecal blood test, together with official cause-specific death rates, were used to assess the magnitude of a controlled trial that would be required to prove a 25 percent reduction of the mortality from colorectal cancer associated with screening. All men in three age groups in the city of Malmö, Sweden, were invited, but 46 percent did not participate in, the Hemoccult screening. One carcinoma and 89 adenomas were detected in 56 of the 2422 who did. With the risk function used in our calculation and a compliance rate of 60 percent, a study population among 45- to 69-year-olds of 605,000 is required to prove an expected 25 percent reduction of the mortality with 90 percent power. Considering the size of such a trial, we question whether a controlled trial is feasible. With known risk functions for death from all causes and death from colorectal cancer, the study population was calculated using variable statistical power, participation rate, and risk reduction. Statistical methods and computer programs are given. In addition, alternative study models to assess the benefits associated with screening are discussed.

Antibiotic treatment during surgery for diffuse peritonitis: a prospective randomized study comparing the effects of cefuroxime and of a cefuroxime and metronidazole combination.

In a prospective randomized open study of patients operated upon for diffuse peritonitis, the effects of two different antibiotic regimens were evaluated. Cefuroxime given as a single drug (Group I; n = 59) was compared with a combination of cefuroxime and metronidazole (Group II; n = 63). Bacteriological cultures, both aerobic and anaerobic, were obtained peroperatively and in the event of any complication. The antibiotic sensitivities of isolated bacteria, and the serum and tissue concentrations of cefuroxime were determined. Postoperative infectious complications occurred in 22 per cent of Group I patients (cefuroxime), and in 17.5 per cent of Group II (cefuroxime plus metronidazole). The mortality rates were 5 per cent for Group I and 8 per cent for Group II. Tissue concentrations of cefuroxime were well above the MIC (minimal inhibiting concentration) values for most of the bacteria isolated. From a few patients in Group I, however, cultures were obtained with isolates sensitive to metronidazole but resistant to cefuroxime. Our findings suggest that, in the antibiotic treatment of patients operated for diffuse peritonitis, an agent which is primarily effective against aerobic bacteria (but not entirely without effect on anaerobes) is as effective as combination therapy covering both aerobic and anaerobic bacteria.

Pre- and post-operative complications in Crohn's disease with special reference to duration of preoperative disease history.

In an analysis of a consecutive series of 133 patients with a diagnosis of Crohn's disease established preoperatively and in which early surgical intervention was the prevailing policy, the median time between diagnosis and operation was short. For patients with predominantly small-bowel disease it was 4 months and for patients with predominantly colonic involvement 8 months. The frequencies of preoperative and early postoperative complications were low compared with those in other reports. Local complications, such as intra-abdominal fistulae and abscesses, were preoperatively seen in only 4% of the patients. Arthritis, iritis, or erythema nodosum was not seen in patients with predominantly small-bowel disease. The early postoperative death rate was 1.5%, the late mortality rate related to Crohn's disease 2.3%. In conclusion, early resectional surgery seems to be justified as one form of treatment for Crohn's disease in that it diminishes the rate of serious complications. The risk of recurrence is, however, not influenced by early surgical intervention.

Recurrence rate after surgical treatment of Crohn's disease.

In an unselected series of 207 consecutive patients with Crohn's disease diagnosed between 1958 and 1974, 170 underwent a resection of all the macroscopically involved bowel ('radically' resected). Two patients died during the first postoperative month. The crude recurrence rate for the surviving 168 patients was 49%. The cumulative recurrence rate, calculated by the actuarial method, was 53% at 15 years. Age, sex, length of preoperative disease history, localization of the lesions in the bowel, and primary surgical procedures performed had no influence on the recurrence rate. However, the histopathological appearance of the resection margins seemed to influence the prognosis, since the presence of ulcers and/or granulomas was correlated with a significantly increased recurrence rate.

Is CEA analysis of value in screening for recurrences after surgery for colorectal carcinoma?

The progress of 139 patients operated upon for cure of colorectal carcinoma, was followed postoperatively with a standardized protocol. A CEA test was performed for comparison with other parameters. Median observation time was four years. When an upper limit for CEA of 7.5 micrograms/1 was allowed, sensitivity was found to be 78 per cent, specificity 91 per cent, and predictive value of an elevated CEA concentration, 83 per cent. In general, CEA measurement traced recurrence six months before clinical diagnosis. In only a few cases was recurrence first heralded by an abnormality in other blood chemistry test results. CEA may thus be used in postoperative screening for recurrence even though most recurrences, when detected, are not curable.

Surgery for fulminating colitis during pregnancy.

Two cases of fulminating colitis presenting during pregnancy are described. In both cases, resectional surgery was performed. In the first case, cesarean section was combined with subtotal colectomy and ileostomy during the 32nd week of gestation. In the second case, cesarean section was performed during the 33rd week of gestation and proctocolectomy in the puerperium. In both cases, histopathologic examination showed colitis more consistent with Crohn's disease. It is concluded that if fulminating colitis appears during pregnancy it should be treated in the same manner as in the nonpregnant state.

Crohn's disease in a defined population course and results of surgical treatment. I. Small bowel disease.

In a total, unselected series of 207 patients with Crohn's disease diagnosed between 1958 and 1974, 87 of the 182 patients operated upon during the investigated period were, at a comprehensive reevaluation, found to have the disease predominantly or exclusively confined to the small bowel. In five of these cases wide-spread lesions were present. The frequency of preoperative sequelae or complications was low. Postoperative complications were comparatively few with only one death. The calculated recurrence rate at 15 years was 43%. In spite of the fact that some patients needed repeated resections, the outcome of surgery as assessed at the end of the observation time was good in most cases.

Crohn's disease in a defined population course and results of surgical treatment. Part II. Large bowel disease.

In a total consecutive series of 182 patients operated upon for Crohn's disease, 95 (52%) had the lesions predominantly or exclusively confined to the colon. A "radical" operation was performed in 88 of these 95 patients. The general policy was to spare the rectum, if possible. It was found that when the rectum was primarily involved the lesions did not disappear after subtotal colectomy. Ileorectal anastomosis was only successful in 9 of 22 cases. In all these nine cases the rectum was uninvolved preoperatively. The overall mortality rate related to Crohn's disease was 6% and the overall recurrence rate 62%. All patients with an anastomosis between a disease-free small intestine and a diseased colon developed recurrence in the ileum. Therefore, a thorough preoperative examination of the whole colon is essential.

The value of intensive follow-up after curative resection for colorectal carcinoma.

A previous study undertaken by this department showed follow-up to be of little value in tracing curable recurrences in patients with colorectal cancer who had curative operations. The aim of the present investigation was to determine if more intensified follow-up would result in earlier diagnosis of recurrences and thus lead to earlier and more effective treatment. Altogether 599 patients with colorectal cancer were treated between 1973 and 1977. The 363 (61 per cent) patients who were operated upon for cure entered the study and were followed up until December 1979. The same incidence of recurrence was seen in both series, but, with the more detailed protocol, they were more frequently detected before symptoms developed. However, the rate of curative reoperation for recurrence was not changed and only few patients survived after such reoperations. The conclusion is that the previous protocol is as efficient as the detailed one while no effective treatment of disseminated disease exists.

Crohn's disease confined to the appendix.

Crohn's disease confined to the appendix is a rare entity, less than 50 cases having been reported. The present study reports on another 12 cases representing 6 per cent of all 194 patients operated upon for Crohn's disease in a total, unselected series. The indications for surgery were appendicitis in eight patients, appendiceal abscess in two, suspected pyosalpinx in one, and an ovarian cyst in one. The appendices were in all cases strikingly enlarged. Giant-cell granulomas, without microabscesses were detected in all but one patient. Two patients had early septic postoperative complications. Fistulization from the cecum did not occur. The median observation time after operation was 13.8 years. Since none of the patients had further manifestations of the disease, it is concluded that patients with Crohn's disease confined to the appendix have a favorable prognosis.

Carcinoma of the anal canal.

A 20-year retrospective study of all anal canal carcinomas in the city of Malmö has been performed. The series consists of 29 patients, 23 women and 6 men, with a mean age of 66 years. Eight patients had non-keratinizing squamous cell carcinoma, 7 had keratinizing squamous cell carcinoma, 12 had basaloid squamous cell carcinoma, and 2 patients had mucoepidermoid carcinoma. Two of four patients operated on for curative purposes with local excision survived 5 years, as did seven of nine patients operated on curatively with abdominoperineal resection. In discussing the results, an overview of the literature is presented. It is concluded that adjuvant combined chemotherapy and radiotherapy appears to result in a higher survival rate for patients with tumours growing at or above the dentate line.

Early diagnosis of metachronous colorectal carcinoma.

The frequency of metachronous colorectal tumours in a prospective 20-year series of patients with colorectal cancer is reported. Thirty-one patients, that is 2.1% of the patients operated on for cure, had metachronous carcinomas, and 5.4% had metachronous polyps. One-third of the metachronous carcinomas were diagnosed at scheduled postoperative control examinations, and the others because of their symptoms or at autopsy. The reported metachronous carcinomas are considered to represent failures of follow-up only and not to indicate their true incidence, since their natural course has been arrested by removal of adenomas whenever found. Several of the metachronous tumours were judged to be overlooked synchronous ones, and therefore a thorough postoperative examination of the remaining large bowel is advocated. The finding of subsequent tumours in this series indicates that continuous follow-up is worthwhile.

Single dose doxycycline prophylaxis and peroperative bacteriological culture in elective colorectal surgery.

A prospective study was performed on 196 consecutive patients undergoing elective colonic surgery to evaluate the prophylactic effect of a single dose of doxycycline. The patients were randomized into four groups: group I 200 mg i.v. preoperatively, group III 600 mg i.v. preoperatively, group III 600 mg i.v. postoperatively, and group IV 200 mg i.v. preoperatively and 200 mg i.v. daily 3 days postoperatively. The rate of septic complications for the different groups were: I 13 per cent, II 7 per cent, III 20 per cent, and IV 19 per cent. There was no statistically significant difference in occurrence of septic complications between the groups. The degree of bacterial contamination during operation was estimated by culture from wound irrigation fluid and from cotton swabs. Bacteria were recovered from the irrigation fluid in 97 per cent, while culture from cotton swabs proved to be much less sensitive. A high number of bacteria in the irrigation fluid was significantly correlated to a high complication rate. It is suggested that direct plating from irrigation fluid can be used for defining a high risk group of patients in colonic surgery.