Patient outcomes after treatment with percutaneous cholecystostomy for biliary sepsis.

INTRODUCTION: Acute cholecystitis is among the most common general surgical presentations. There is a cohort of patients who develop systemic sepsis and complications of acute cholecystitis. These patients are often elderly and co-morbid. Conservative management with percutaneous cholecystostomy has been shown to be a safe and effective management option in the acute setting. However, there is currently no consensus for the further management of these patients. In particular, there is a paucity of data on readmission rates and subsequent operative or non-operative management. METHODS: A retrospective study was carried out of patients treated with a percutaneous cholecystostomy for biliary sepsis over a three-year period in a UK teaching hospital. Outcome measures were subsequent operative or conservative management, conversion rates, operative complications and readmission rates. RESULTS: Twenty-five patients had a percutaneous cholecystostomy for the treatment of acute biliary sepsis. The median follow-up duration was 35 months. Thirteen patients (52%) had operative treatment. In the operative group, 6/13 had a laparoscopic cholecystectomy, 2/13 had a planned open cholecystectomy, 2/13 had abandoned procedures and 3/13 had a converted procedure. Complications in the operative group included: postoperative mortality (1/13), common bile duct injury requiring drainage and endoscopic stenting (1/13) and one patient required readmission with recurrent pain. In the non-operative group, 5/12 patients were readmitted with biliary sepsis, 5/12 had no readmissions, 1/12 died in the community and 1/12 was readmitted with biliary colic. CONCLUSIONS: Percutaneous cholecystostomy is a recognised treatment modality for elderly, co-morbid patients with biliary sepsis. Nevertheless, the readmission rate in this group is relatively high at 5/12 (42%). Patients who undergo subsequent operative management have a conversion rate of 3/13 (23%) and a significant complication rate of 2/13 (15%). The further management of patients having undergone percutaneous cholecystostomy requires careful consideration on an individual case basis. The P-POSSUM (Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) may aid decision making.

Surgical management of presacral bleeding.

INTRODUCTION: Presacral venous bleeding is an uncommon but potentially life threatening complication of rectal surgery. During the posterior rectal dissection, it is recommended to proceed into the plane between the fascia propria of the rectum and the presacral fascia. Incorrect mobilisation of the rectum outside the Waldeyer's fascia can tear out the lower presacral venous plexus or the sacral basivertebral veins, causing what may prove to be uncontrollable bleeding. METHODS: A systematic search of the MEDLINE(®) and Embase™ databases was performed to obtain primary data published in the period between 1 January 1960 and 31 July 2013. Each article describing variables such as incidence of presacral venous bleeding, surgical approach, number of cases treated and success rate was included in the analysis. RESULTS: A number of creative solutions have been described that attempt to provide good tamponade of the presacral haemorrhage, eliminating the need for second operation. However, few cases are reported in the literature. CONCLUSIONS: As conventional haemostatic measures often fail to control this type of haemorrhage, several alternative methods to control bleeding definitively have been described. We propose a practical comprehensive classification of the available techniques for the management of presacral bleeding.

Life-threatening haemorrhage secondary to nicorandil-induced severe peri-anal ulceration.

Nicorandil-induced ulceration is rare but has been reported at multiple sites throughout the gastrointestinal tract. We report a life-threatening complication of such ulceration - catastrophic per-rectal haemorrhage requiring emergency surgery with no prior symptoms. Whilst nicorandil should be considered in cases of chronic peri-anal and peristomal ulceration which fail to respond to conventional treatments, this case highlights its importance in the setting of acute surgical presentations.

Electrocoagulation of perianal warts: a word of caution.

BACKGROUND: Perianal warts are common, and may be extensive. Electrocoagulation is a recognised management option. METHOD: A 20-year-old male underwent electrocautery of extensive perianal warts. He presented 3 months postoperatively with constipation and inability to defecate. Examination revealed severe perianal stricture, which necessitated a defunctioning colostomy. RESULT: A gradual and spontaneous resolution of the stricture was observed over the following 18 months. Closure of the colostomy was followed by satisfactory anal function. CONCLUSION: Electrocautery of extensive perianal warts should be used with caution. Preservation of healthy skin bridges between lesions is essential if perianal stricture is to be avoided, and may best be achieved by sharp scissors dissection.

Ultrasound-guided unilateral neck exploration for sporadic primary hyperparathyroidism: is it worthwhile?

The role of preoperative localisation tests before initial neck exploration for primary hyperparathyroidism (PHP) remains controversial, as does the optimal surgical approach. We report our experience with preoperative ultrasound (US) and the operative management of sporadic PHP between 1990 and 1995. Preoperative US was carried out by an experienced radiologist. Three surgeons adopted a policy of 'selective' US-guided unilateral neck exploration (UNE); the fourth surgeon performed routine bilateral neck exploration (BNE). There were 72 patients: 26 men and 46 women, with a mean age of 57.4 +/- 12.5 years (range 21-80 years). All patients underwent initial neck exploration for 'sporadic' PHP, of whom 63 had preoperative US. This was positive in 52 patients; 27 of whom underwent a UNE, 23 had a BNE, and two patients had a UNE converted to a BNE. Patients with 'negative' US (n = 11), and those receiving no preoperative localisation test (n = 90) underwent a BNE. The sensitivity, specificity and accuracy of US were 80% (52/65), 100% (61/61), and 90% (113/126), respectively. Comparable success rates were achieved (BNE: 97% (33/34) vs UNE: 93% (27/29), P < 0.05), with very low morbidity. Failures with the scan-guided UNE were caused by missed contralateral adenomas. An experienced radiologist and a low incidence of multiglandular disease (MGD) are essential prerequisites for the scan-guided unilateral approach. An experienced surgeon, on the other hand, is the only prerequisite for the 'gold standard' bilateral approach.

The impact of guidelines on peri-operative antibiotic administration.

A survey has shown that peri-operative antibiotic therapy was inappropriate in 83% of patients undergoing abdominal or arterial surgery. Missed doses at induction or postoperatively, a questionable choice of antibiotics and unnecessarily long postoperative courses were major problems. The introduction of formal guidelines was partially successful with appropriate prescribing improving from 17 to 60% of cases. There was, in addition, a marked reduction in prescribing costs.

A comparison of three imaging techniques in the assessment of an abdominal aortic aneurysm.

Twenty-five patients undergoing elective surgery for large abdominal aortic aneurysms (AAAs) were investigated by preoperative ultrasonography (US), computed tomography (CT) or intravenous digital subtraction angiography (IV-DSA). The accuracy of each modality in assessing the upper and lower extent of aneurysmal disease was then compared. IV-DSA proved 100% accurate in assessing the relationship of the renal arteries to the aneurysm sac. Both CT and US overestimated the incidence of juxta or suprarenal AAAs and only had a predictive value for suprarenal disease of 13% and 14% respectively. If, however, US or CT stated the aneurysm to be infrarenal this was likely to be true though both investigations classified one suprarenal aneurysm as infrarenal. The distal extent of aneurysmal disease was again most accurately predicted by IV-DSA (predictive value 88%). Bowel gas frequently prevented US from visualizing the iliac arteries (19 of 25 cases). IV-DSA is a safe and accurate method for defining the relationship of an aneurysm to the renal arteries and should be adopted as a routine preoperative investigation of abdominal aneurysmal disease.

Controlled trial of cephradine versus cefuroxime in vascular surgery.

Two hundred and three consecutive patients undergoing acute or elective vascular reconstructions (N = 162) or amputations (N = 41) were randomized to receive either a single dose of cephradine 2 g intravenously or cefuroxime 1.5 g intravenously at induction of anaesthesia. Infective morbidity in both groups was assessed post-operatively as was therapeutic antibiotic prescribing. No significant differences in septic complications were found between patients receiving cefuroxime or cephradine. In addition, tissue penetration of each antibiotic was assessed by assay of serum and tissue specimens. Serum levels of cefuroxime were significantly less than cephradine 10 min after injection (median concentrations 115 micrograms/ml versus 182 micrograms/ml, p less than 0.01 Wilcoxon), but there were no differences in tissue penetration.

Towards no incisional hernias: lateral paramedian versus midline incisions.

A prospective randomized controlled clinical trial is reported which compares midline with lateral paramedian incisions in relation to the development of incisional hernias at one year. Of 431 patients randomized, 329 were available for assessment one year later. Two patients suffered burst abdomen, both being in the lateral paramedian group. Twenty-two incisional hernias occurred, 2 in the lateral paramedian group and 20 in the midline group (P less than 0.001). Of the two types of incision, the lateral paramedian incision takes longer to perform, requires a longer incision, rarely results in dehiscence, and does confer protection against incisional hernia.

Effects of muramyl dipeptide and lead acetate on carbon clearance and endotoxin-induced mortality in mice.

Muramyl dipeptide (MDP) is a nonspecific immune adjuvant thought to affect the macrophage. MDP had been used safely without immunosuppressive or toxic side effects in our laboratory and others. Endotoxin, or lipopolysaccharide (LPS), is thought to be responsible for many of the systemic toxic effects of gram-negative infection. Lead acetate potentiates the lethal effects of endotoxin, an effect attributed to increased hepatotoxicity involving both hepatocytes and Kupffer macrophages. This study was undertaken to examine putative mechanism of action of MDP relating to the reticuloendothelial system. Endotoxin was given intraperitoneally to susceptible mice that were pretreated with MDP, lead acetate, or both, and to unmodified controls. Lead acetate significantly enhanced lethality due to LPS, but pretreatment with MDP did not alter mortality. Carbon clearance was measured in mice treated with MDP, lead, or both. There was no difference in the phagocytic index of control mice and those mice treated with lead acetate at various times prior to the injection. Carbon clearance increased significantly in mice pretreated with MDP but was unaltered by the addition of lead acetate. We conclude that if hyperphagocytosis of endotoxin occurs in MDP-pretreated mice, it does not cause additional mortality. Muramyl dipeptide appeared to be a safe reticuloendothelial stimulant that did not enhance the toxicity of lead or LPS in this experimental model.

Muramyl dipeptide enhances in vitro peritoneal macrophage phagocytic activity.

There is little agreement as to the precise mechanism of action of muramyl dipeptide (MDP) despite a steadily unfolding series of experiments designed for clarification. This report further defines the role of MDP in nonspecific enhancement of host defenses by examining its effect on in vitro macrophage phagocytosis. Peritoneal macrophages were incubated in vitro with muramyl dipeptide. Phagocytic indices were determined using the iodination technique. The macrophages treated with MDP had a significant increase in their phagocytic function compared to control cells, adding to the understanding of the mechanism of action of MDP and raising the possibility of a trial peritonitis in humans.

Does mass closure of midline laparotomies stand the test of time? A random control clinical trial.

We compared the incidence of wound failure (burst abdomen and incisional herniation up to 4 years after operation) in a consecutive series of 282 major laparotomies closed with continuous monofilament nylon, and randomly allocated to mass (all layers except skin) or layered (anterior and posterior aponeuroses separately sutured) techniques. Surgeons were free to choose the site and direction of incision which resulted in a preponderance of midline incisions in the mass, and of paramedian incisions in the layered, group. One patient in the former, and two in the latter, burst their abdomens during early convalescence, and 17 incisional hernias were discovered within four years in the mass group compared with four in the layered group (log rank X2 7.16, P less than 0.01). Seven hernias in the former, and one in the latter, group were not detected within eight months of operation. We conclude that layered closure of a paramedian incision results in a lower incidence of incisional hernias than mass closure of a midline incision and that many hernias are not discovered until years after operation.

Muramyl dipeptide increases tolerance to shock and bacterial challenge in mice.

We measured the phagocytic capacity of the reticulo-endothelial system by assay of the clearance of colloidal carbon from the blood stream in both normal mice and mice in which shock had been induced by intraperitoneal injection of hypertonic glucose. The group of shocked mice was further subdivided into those pretreated with the immunoadjuvant, muramyl dipeptide (MDP), and those given placebo. Shock reduced reticulo-endothelial phagocytosis (P less than 0.01), whereas pretreatment of shocked mice with MDP led to a hyperphagocytic state (P less than 0.01). In a second series of experiments we subjected shocked mice, pretreated with MDP or placebo, to a virulent Klebsiella pneumoniae infection. MDP significantly improved survival (P less than 0.01).

The role of muramyl dipeptide in the therapy of established experimental bacterial infection.

Muramyl dipeptide (MDP) actively potentiates host defences and confers protection when given before a bacterial challenge. Experiments were undertaken to characterize its actions when used alone or in combination with cephaloridine in a manner analogous to clinical therapy, i.e. after initiation of bacterial infection. MDP, alone or in combination, significantly decreased the systemic manifestations of infection compared with placebo when administered up to 6 h following bacterial contamination. Its effect on the primary lesion was less marked, but it may potentiate host defences sufficiently to have an impact on the decisive period. Benefits observed in this study were of lesser magnitude than those observed following administration of the dipeptide before bacterial inoculation.

Latamoxef for the prophylaxis of abdominal surgical wound infection: a controlled clinical trial.

In a series of 236 abdominal operations, patients were allocated at random to receive a single intravenous dose of either 1 g cephaloridine or 1 g latamoxef (at induction of anesthesia) for the prophylaxis of postoperative wound infection. Of the 116 patients given latamoxef, one developed major and seven minor wound infections, whereas five major and 21 minor infections occurred in the cephaloridine group (P less than 0.01). Latamoxef has now replaced cephaloridine as our prophylactic antibiotic of choice in potentially contaminated abdominal operations.

Nonspecific enhancement of resistance to bacterial infection: evidence of an effect supplemental to antibiotics.

Experiments have been undertaken to further characterize the actions of the synthetic immunoadjuvant compound, muramyl dipeptide (MDP), in an animal model simulating surgical infection. When used prophylactically in combination with antibiotics, MDP proved to be significantly additive in terms of local and systemic effects, and survival, to both chloramphenicol (p less than 0.01) and cephaloridine (p less than 0.05). The combined use of MDP and cephaloridine therapy, initiated four or six hours following infectious challenge and including a surgical foreign body in starved and refed animals, showed statistically significant decreases in bacteremia during early time periods, as well an increased early survival (p less than 0.02), compared with the use of cephaloridine alone. Benefits observed in the therapeutic mode were of lesser magnitude than those observed following prophylactic use, but the model used was a much more significant physiologic challenge. Evidence indicating additive effects to those of antibiotics is essential prior to the use of MDP in clinical trials.

Levamisole and postoperative complications: a controlled clinical trial.

We studied the relationship between cell-mediated immunity (assessed by preoperative skin reactions to four recall antigens) and postoperative infective complications in 166 patients undergoing major laparotomies. They were randomly allocated to receive 150 mg of levamisole or placebo on the day of operation and for the following 2 days; their course was followed for at least 1 month. Neither the degree of preoperative anergy nor the administration of levamisole resulted in any significant differences in numbers of postoperative deaths or infective complications, but the levamisole group had significantly less postoperative pyrexia than the control group.

Delayed hypersensitivity testing for the prediction of postoperative complications.

One hundred and sixty-six patients undergoing elective major laparotomy were skin tested preoperatively with four common recall antigens in an attempt to correlate preoperative cell-mediated immune status with postoperative septic complications. Nineteen patients were anergic, 22 relatively anergic and the remaining 125 reacted to two or more of the antigens and were regarded as normally reactive. No significant differences in morbidity or mortality were found between patients who had depressed delayed cutaneous hypersensitivity reactions and those who reacted normally. We conclude that identification of those patients with depressed cell-mediated immunity preoperatively does not help in predicting postoperative problems.