Imipenem prophylaxis in elective colorectal surgery.

In a randomized controlled study of 411 patients undergoing elective colorectal surgery, the efficacy and safety of two different regimens of imipenem were compared with those of a control regimen of cefuroxime plus metronidazole. Surgical infections occurred in 92 (26.4 per cent) of 349 evaluable patients. There were no major differences between the three treatment groups. It is concluded that imipenem is as effective as cefuroxime plus metronidazole in the prevention of sepsis after elective colorectal procedures.

Does selective peroperative cholangiography result in missed common bile duct stones?

A prospective randomized trial was undertaken to determine if selective peroperative cholangiography resulted in greater morbidity and mortality from missed common bile duct (CBD) stones. Five hundred and thirty-nine consecutive cholecystectomies were performed over a 3-year period. Two hundred and fifty-four had indications for mandatory peroperative cholangiography and were excluded from the trial. The remaining 285 patients, without a history of jaundice, pancreatitis or abnormal liver function tests, were randomized blindly into two groups. Group 1 underwent peroperative cholangiography (PC) and group 2 did not. If the surgeon found a dilated CBD at surgery then these patients were also excluded from the trial. Selective peroperative cholangiography revealed an unsuspected CBD calculus in 16 of the 132 patients (12%). Up to the time of review no patient from group 2 presented with symptoms or complications from retained CBD stones. One patient in group 1 had endoscopic removal of a retained CBD calculus 16 months after cholecystectomy. All patients were sent a questionnaire at least three years after surgery and 210 responded (74%). One hundred and thirty (62%) of the respondents had peroperative cholangiography. There were 11 deaths from unrelated causes. No difference between the two groups was found for postoperative dietary habit, dyspepsia, pain, flatulence, diarrhoea or signs of biliary obstruction. It seems from these results that a policy of selective cholangiography in our hands may miss a 12% incidence of unsuspected stones but, importantly, this does not appear to influence postoperative morbidity or mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

A totally diverting loop colostomy.

A technique is described where the distal limb of a loop colostomy is tied with nylon or polydioxanone. This ensures total faecal diversion and dispenses with the supporting rod, enabling early application of stoma appliances. The technique does not interfere with the traditional transverse closure of a loop colostomy.

Value of a centralised approach in the management of haematemesis and melaena: experience in a district general hospital.

All patients presenting with acute upper gastrointestinal bleeding between November 1986 and April 1988 were admitted to a centralised joint medical/surgical unit, with a policy of early clinical and endoscopic assessment and rapid surgical intervention in those at high risk. Of the 430 patients admitted 69.5% were over the age of 60 and 30% had significant additional medical conditions. 50.4% were bleeding from peptic ulcers and one third had been taking non-steroidal anti-inflammatory agents. Fifty five patients underwent surgery, which in two thirds was carried out within 24 hours of admission, usually for continued bleeding. In patients with peptic ulcer the operation rate was 21.6%. Overall mortality was 3.7%, and in those with bleeding gastric or duodenal ulcers 5.5%; surgical mortality in the later group was 15.2%. All patients who died had serious concomitant pathology and 87% were over 70 years of age. Adoption of a centralised approach to management of haematemasis and melaena is feasible in a District General Hospital and associated with an improved survival.

Use of ultrasound localization to improve results of fine needle aspiration cytology of breast masses.

A prospective randomized controlled trial of 116 patients with breast masses was conducted to compare the accuracy of 'blind' aspiration cytology performed in the clinic with aspiration cytology using ultrasound localization. The unsatisfactory aspiration cytology rate was significantly reduced by ultrasound localization (P = 0.028). This was mainly due to an improvement in the unsatisfactory rate for tumours less than 3 cm in diameter (P = 0.036). The results were influenced by the number of needle manoeuvres performed, less than 10 needle manoeuvres being associated with a 54% unsatisfactory aspiration rate compared with 25% when greater than 10 manoeuvres were performed (P = less than 0.02). One experienced aspirator in the clinic had results comparable to those achieved with ultrasound localization. It is concluded that experience and technique are the most important factors in obtaining a satisfactory aspirate from breast masses. Routine ultrasound localization prior to aspiration confers some benefit. Consideration should be given to the use of the ultrasound-assisted technique following a previous unsatisfactory aspiration, particularly if the tumour is less than 3 cm in diameter.

Fine needle aspiration cytology of breast masses: an evaluation of its accuracy and reasons for diagnostic failure.

A study of 1458 patients who had undergone breast aspiration cytology was conducted to determine the diagnostic accuracy of the technique. The effect of tumour histology and size on the unsatisfactory aspirate and false negative rate was examined. Seven hundred and thirty one patients (50%) had histological diagnoses. The sensitivity of aspiration cytology for malignancy was 64% for the first aspiration, but was 91% in patients who had had 3 aspirates. The specificity was 56%, this low figure was almost entirely due to inadequate or unsatisfactory cytological preparations. The positive and negative predictive values of aspiration cytology were 99.4% and 85% respectively demonstrating high diagnostic accuracy given a satisfactory aspirate. Invasive lobular carcinoma yielded a significantly higher unsatisfactory rate than invasive ductal carcinoma (P less than 0.001) and fibroadenoma yielded a significantly lower unsatisfactory rate than fibroadenosis (P less than 0.001). Mass size influenced the unsatisfactory rate for invasive ductal carcinoma (P less than 0.05) and fibroadenoma, but not for invasive lobular carcinoma or fibroadenosis. Only 2 of the 32 false negatives were due to misinterpretation, the remainder resulted from the aspiration needle missing the mass. We conclude that aspiration cytology is an accurate preoperative diagnostic procedure for the evaluation of breast masses. Unsatisfactory or negative aspirates should be regarded as 'non-results' if there is clinical or radiological suspicion of malignancy.

Transplantable colonic adenocarcinomas in rats.

The induction of colonic adenocarcinoma using two different regimens of dimethylhydrazine (DMH) in Fischer F344 rats is described. Rats receiving 20 mg/kg of DMH per week for 20 weeks developed primary tumors with metastases, whereas rats receiving the same weekly dose for 15 weeks developed primary tumors only. The most common route of metastases was transcelomic which often was associated with ascites. The epithelial origin of malignant ascites cells was confirmed by immunofluorescent staining with antidesmosomal antibodies and demonstration of desmosomes by electron microscopy. When transplanted into syngeneic rats, the cells of the malignant ascites resulted in the development of adenocarcinomatous metastases.

Imipenem pharmacokinetics in elective colorectal surgery.

A study of the pharmacokinetics of imipenem in 22 patients undergoing elective colorectal surgery was performed. Samples of plasma, fat, muscle and viscera were assayed at various intervals following intravenous injection of 1 g imipenem and 1 g cilastatin. The concentration of imipenem in plasma was approximately ten times that found in the tissues. The half-life was similar in plasma, muscle and fat (approximately 1 h). Visceral levels showed a slower fall (T 1/2 83 min). Plasma and tissue levels exceeded the MIC90 for all common pathogens for at least the first two hours of surgery. We conclude that imipenem is a suitable agent for antibiotic prophylaxis in colorectal surgery.

Staples or sutures for low colorectal anastomoses: a prospective randomized trial.

One hundred and eighteen patients undergoing low colorectal anastomoses were randomly allocated to reconstitution by either single layer interrupted extramucosal sutures or circular staple gun. In the 60 patients undergoing sutured anastomosis there were 2 (3 per cent) clinical leaks and 4 (7 per cent) radiological leaks, and no failures. Of the 58 patients who underwent stapled anastomosis there were 4 failures, 7 (12 per cent) clinical leaks, 14 (24 per cent) radiological leaks and 1 death. Stapled anastomoses were more than ten times as expensive as sutured anastomoses and there were no savings in time or numbers of associated colostomies. An interrupted extramucosal suture technique remains the ultimate standard for low colorectal anastomosis.

Out-patient treatment of haemorrhoids: a randomized clinical trial to compare rubber band ligation with phenol injection.

A prospective randomized clinical trial comparing rubber band ligation (RBL) with phenol injection in 269 patients with symptomatic haemorrhoids presenting to one surgical clinic over a 6 year period, has been carried out. Questionnaires were completed by 215 patients (106 RBL and 109 injection) with an average follow up of 2.75 years. A successful outcome was achieved in 89 per cent of those receiving RBL compared with 70 per cent for injection (P less than 0.001). All symptoms tended to respond more favourably to RBL, the results achieving statistical significance in patients complaining of bleeding and prolapse (P less than 0.01 and P less than 0.05 respectively). Complications from either technique were minimal. It is concluded that RBL is superior to phenol injection in the out-patient treatment of haemorrhoids.

Choledochoscopy: are stones missed? A controlled study.

Although the choledochoscope has been available for several years, its use had not achieved universal acceptance. Enthusiasts claim that the incidence of retained stones in the common bile duct would be reduced by using the instrument, but no controlled study by the same team has been reported. Patients undergoing biliary surgery by one surgical team in Southampton were operated upon in one of three hospitals. The choledochoscope was available for use at only one hospital, but the other two were otherwise fully equipped, and no selection of patients was made for any particular hospital. Over a period of 7 years, 707 patients underwent elective or emergency cholecystectomy. Routine choledochography was performed and stones were found or suspected in the bile ducts in 103 (14.6 per cent). The choledochoscope was used in 54 of the bile duct explorations and in 10 patients residual calculi following routine exploration were identified by the instrument. Postoperative T-tube choledochography was performed in 35 patients following choledochoscopy, 31 with choledocholithiasis at operation, and no unsuspected retained stones were demonstrated. In the 49 patients undergoing duct exploration by the same team without the choledochoscope, 32 were found to have choledocholithiasis. Thirty-six postoperative choledochograms were performed and six patients were found to have retained stones. There were no additional complications attributed to the use of the instrument. We conclude that the use of the choledochoscope should reduce the incidence of retained bile duct stones.

Renal dysplasia and duplex kidneys.

34 children with double ureters (n = 26), bifid ureters (n = 7) or bifid renal pelvis (n = 1) had heminephrectomy, leaving a normal portion of kidney. Patients with ectopic ureteroceles and ectopic ureters had upper pole lesions (18 of 18) whilst the lower pole was more often involved in those with vesico-ureteric reflux (9 of 11). Histological changes of renal dysplasia were present in both upper and lower pole lesions, being generally less severe at the lower pole. These findings suggest that prolonged urinary obstruction plays a major role in the formation of dysplasia in developing kidneys.

Pancreatic abscess.

Three cases of pancreatic abscess are described to show the difficulties in diagnosis and that inadequate treatment is invariably fatal. Early recognition and prompt surgical drainage, together with biliary decompression if indicated, are advised.