Prophylaxis against anaerobic sepsis in bowel surgery.

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.

Perianal vaccinia: a case report.

Accidental perianal vaccinia is a rare condition, presenting acutely with severe pain and characteristic superficial ulceration. There is no specific treatment, and complete resolution occurs. A case is described of autogenous perianal vaccinia occurring in an adult.

Preparation of the bowel by whole-gut irrigation.

Experience with whole-gut irrigation as a method of bowel preparation in eightyone patients is described. The mean (+/-S.D.) weight-gain during irrigation was 1-9 +/- 0-8 kg; potassium losses in the effluent after one hour (4-0 +/- 2-5 g) were not significantly altered by adding potassium chloride to the irrigant. Eight irrigations were unsatisfactory, three being due to unrecognised obstructive neoplasms. The method provided excellent preparation for colonoscopy and large-bowel resection with anastomosis and was well tolerated by the patients.

Conservative management of haemorrhoids. Part I: injection, freezing and ligation.

Of 111 consecutive patients treated by partial internal sphincterotomy for a haemorrhoidal disease in the course of a prospective study, 101 could be re-examined between 24 and 36 months after operation. There were no major complications but 11 patients had some significant complaints at some time after operation. There were six recurrences, five of which could be attributed to inadequate sphincterotomy. One patient had an excessive sphincterotomy which led to difficulties with continence of fluid stools. One patient developed a peri-anal abscess two years after partial sphincterotomy and four patients with marked soiling will require surgical correction of the posterior gutter. The gutter is due to secondary epithelialisation after open sphincterotomy in the posterior midline. The recommended technique entails the division of the internal sphincter up to a few millimeters above the dentate line and reconstruction of the anal mucosa with a continuous absorbable suture. 'Landscaping' by partial resections of the prolapsed haemorrhoids is recommended to avoid sclerotic tags. Submucosal sphincterotomy should be considered by the very experienced only and then provided that the anal mucosa shows little scarring.

Fissure-in-ano and anal stenosis. Part I: conservative management.

Acute superficial fissure-in-ano responds readily to conservative non-surgical treatment. For chronic deep fissures we recommend manual anal dilatation and the post-dilatation regimen but recognise that equally good results follow the simple procedure of subcutaneous lateral internal sphincterotomy. The recurrence rate following these minor procedures is less than 10 per cent and the incidence of poor flatus control and mucus leakage is even lower. It is never necessary to excise fissures nor sentinel piles although it may be desirable to excise large redundant skin tags to facilitate anal hygiene. Painless or atypically sited fissures should suggest the diagnosis of Crohn's disease. Treatment is rarely required for fissure-in-ano in this condition, although severe anal stenosis may need extremely gentle anal dilatation. Postoperative anal stenosis can also be managed successfully by manual dilatation under anaesthesia with a prolonged regimen of self dilatation until healing is complete. Radical or complicated plastic operations are rarely indicated for any patient with fissure-in-ano or stenosis and are strongly contraindicated in Crohn's disease.