Biapenem versus imipenem/cilastatin in the treatment of complicated intra-abdominal infections: report from a Swedish Study Group.

118 patients with complicated intra-abdominal infections participated in an open randomized comparative multicenter trial in order to compare the clinical and microbiological efficacy and safety of biapenem with imipenem/cilastatin (Tienam). 31 men and 27 women (mean age 52.3 years) were enrolled in the biapenem group, and 43 men and 17 women (mean age 52.3 years) in the imipenem/cilastatin group. The patients received either biapenem 500 mg every 8 h or imipenem/cilastatin 500 mg/500 mg every 6 h by intravenous infusion for up to 13 days (mean 6.5 days). 28/43 evaluable patients (65.1%) receiving biapenem and 27/40 evaluable patients (67.5%) in the imipenem/cilastatin group were clinically cured. The microbiological response was satisfactory in 28/43 evaluable patients (65.1%) receiving biapenem and in 27/40 evaluable patients (67.5%) receiving imipenem/cilastatin. No significant differences in clinical or microbiological efficacy between the two treatment groups were found. The present study shows that biapenem may be useful in the treatment of intra-abdominal infections.

A comparison of imipenem/cilastatin with the combination of cefuroxime and metronidazole in the treatment of intra-abdominal infections.

515 patients with intra-abdominal infection participated in an open randomized comparative multicenter trial in order to compare the efficacy, safety, and tolerance of imipenem/cilastatin with cefuroxime/metronidazole. 258 patients (mean age 56 years) received imipenem/cilastatin 1.5-2.0 g/day, and 257 patients (mean age 54 years) received cefuroxime 3.0-4.5 g/day plus metronidazole 1.0-1.5 g/day for at least 3 days. 130/161 evaluable patients (80.8%) receiving imipenem/cilastatin and 124/145 evaluable patients (85.5%) receiving cefuroxime/metronidazole were clinically cured. The microbiological response was favorable in 86.9% in the imipenem/cilastatin group and in 90.8% in the cefuroxime/metronidazole group. The two treatment groups were similar with respect to median time to defervescence which was 4 days. The median duration of treatment was 6 days and the median time to discharge from hospital was 9 days in both groups. Drug-related adverse reactions were observed in 14 patients receiving iminpenem/cilastatin and in 8 patients receiving cefuroxime/metronidazole. 19 patients in the imipenen/cilastatin group and 12 patients in the cefuroxime/metronidazole group died. No correlation was found between the deaths and the study drugs. The present study shows that intra-abdominal infections can be treated successfully with imipenem/cilastatin as well as with cefuroxime/metronidazole.

Amebic colitis presenting as acute inflammatory bowel disease. Case report.

A 41-year-old woman who had lived in the tropics for 23 years developed a clinical picture of inflammatory bowel disease 4 years after resettlement in Sweden. Search for ova and trophozoites in stools was negative. As medical treatment was unsuccessful, total colectomy was considered. Repeated colonic endoscopy with multiple biopsies initially failed to show amebiasis, but subsequently the trophozoites were identified in biopsies from the rectosigmoid mucosa. The diagnosis was serologically confirmed. Metronidazole treatment was rapidly and lastingly effective.

Registration of post-operative wound infections: a method for reducing the rate of infections.

Continuous registration of postoperative wound infections reduces the rate of infection per se at the same time as enabling special risk groups to be identified. By improving or changing hygiene and antibiotic routines, the rate of infection in these especially exposed groups can be reduced. Major postoperative infectious complications prolong postoperative hospital stay by 17 days on average. Reduction of the rate of infections would save hundreds of treatment days.

A retrospective analysis of a consecutive series of patients splenectomized for various hematologic disorders.

At our hospital, 47 out of 184 consecutive splenectomies performed over 7 recent years were carried out on patients afflicted with various hematologic diseases. The results of these 47 splenectomies were the subject of a careful retrospective analysis. The majority of the splenectomies (81%) were therapeutic. Cytopenia, particularly thrombocytopenia, was the most common indication for surgery. As a whole, good therapeutic responses with rapid improvements in peripheral blood picture and/or diminished symptoms of pressure discomfort from an enlarged spleen were obtained. There was no peri- or postoperative mortality; 23% major and 26% minor postoperative complications were recorded. In patients with perioperative bleeding and various postoperative complications, the spleens were larger than in subjects who run an uneventful peri- and postoperative course. During the follow-up period, 4 septicemias occurred in 3 patients. In 2 of these patients, the septicemias coincided with a cholecystitis and a pneumonia, respectively. None of the infections was lethal. It is concluded that elective splenectomy for hematologic disease in well selected and carefully prepared patients is beneficial and can be performed without mortality or major hazards.

Histamine2-receptor antagonists in gastroduodenal ulcer haemorrhage.

This paper reviews randomised trials in which the effects of histamine2-receptor antagonists have been studied in gastroduodenal ulcer haemorrhage. There is a trend in these studies that histamine2-receptor antagonists may reduce the number of rebleedings, especially in elderly patients with gastric ulcers. A randomised trial comparing cimetidine and ranitidine in high risk patients with massive gastroduodenal haemorrhage is also presented. The total mortality in this study was 12%, 15% for gastric ulcer patients and 11% for duodenal ulcer patients. There was no difference in mortality, amount of blood transfusion required, rebleedings or need for emergency surgery between the two treatment models.

Operative treatment in massive peptic ulcer bleeding.

Guidelines are given for surgical intervention in patients with bleeding peptic ulcer. It is noted that the rate of operation for bleeding peptic ulcer has decreased in Göteborg from 1976 to 1983. The mortality in operated patients over 60 years remains unchanged at around 30%. The results of medical treatment have improved and the total mortality has consequently decreased from 23% to 11% in patients over 60 years.

Effect of cimetidine on augmented gastric blood flow in duodenal ulcer patients.

Blood flow in the human stomach was measured during operation with a 85Krypton washout method which made simultaneous determinations of total blood flow and intramural flow distribution possible. The antrum and the corpus of the stomach could be investigated separately. Eleven patients with duodenal ulcer disease were studied during pentagastrin infusion and after the addition of cimetidine, 3 mg/kg bw, to evaluate the effect of the drug on augmented gastric blood flow. Eight recordings were made over the corpus of the stomach and three recordings over the antrum. Cimetidine caused a 66 +/- 5% decrease (mean +/- SE; range 56-86) in acid secretion and a 62 +/- 5% decrease (range 44-91) in the corpus mucosal blood flow within 15 minutes. Changes were only seen in the acid secreting part of the stomach while the antral circulation remained unaltered. It is concluded that the decrease in pentagastrin induced vasodilatation in the stomach seen after giving cimetidine was secondary to an inhibition of acid secretion.

Ranitidine in the treatment of gastric, prepyloric and duodenal ulcer--a controlled prospective double-blind trial.

Fifty adult outpatients with endoscopically proven gastric, prepyloric or duodenal ulcers were included in a prospective, randomised double-blind trial of ranitidine (40 mg X 3 daily and 80 mg at bedtime) versus placebo. After 4 weeks the ulcers had healed in 21 of 25 patients receiving ranitidine compared with 7 of 23 in patients receiving placebo (p less than 0.001). The ranitidine treated patients had fewer days of pain (p less than 0.001) and lower consumption of antacids (p less than 0.01) than placebo patients. Patients whose ulcers were not healed after 4 weeks went into an open 4 weeks trial with ranitidine. After the second 4 week period there were still 5 unhealed ulcers, all located in the prepyloric region. No serious side effects or haematological or biochemical abnormalities were observed. It is concluded that ranitidine is a very potent and safe ulcer healing substance. Patients with prepyloric ulcers may need a higher dose or a longer period of treatment.

Treatment of acute massive gastroduodenal haemorrhage with cimetidine in elderly patients.

Ninety-two patients over the age of 60 with acute upper GI-haemorrhage were included in a prospective randomized doubleblind three-centre study of the effect of a five day treatment with cimetidine. Twenty patients had to be excluded because of different reasons. The remaining 72 patients bled from either erosive gastritis, gastric ulcer or duodenal ulcer. Thirty-two patients received cimetidine and 39 placebo. There was no difference in the number of transfusions, rebleedings or operative interventions. Mortality was 1/33 (3%) in the cimetidine group compared to 5/39 (13%) in the placebo group (NS). In the gastric ulcer group there was no mortality among 10 cimetidine patients compared to a mortality of 4 of 12 (33%) patients receiving placebo (p less than 0.05). It is concluded with caution that cimetidine might be effective in haemorrhage from gastric ulcer in patients 60 years and older. For convincing conclusions a larger study of patients with bleeding ulcers is desirable.

Transcatheter occlusion of an intrarenal arteriovenous fistula.

A patient with a large intrarenal arteriovenous fistula in the left kidney is presented. Successful transcatheter occlusion of the fistula was performed and the patient followed angiographically. The diagnostic value of angiography and its therapeutic potential is discussed.

Surgical management of pancreatic injuries. Report of three cases with major pancreatic trauma.

Pancreatic trauma is associated with high mortality and high incidence of complications. A pancreatic injury is easily overlooked at laparotomy, unless complete exploration of the gland is performed. There are often associated visceral and vascular injuries. Three cases of severe pancreatic trauma treated during the past three years are discussed as regards surgical management and the treatment of subsequent complications.

Gastric blood flow and distribution in anesthetized cat and man as studied by an inert gas elimination method.

Gastric blood flow and its intramural distribution were studied in anesthetized cat and man by recording the elimination of intra-arterially injected krypton-85. The elimination was monitored with two external detectors--a scintillation detector recording the disappearance of gamma-activity from the entire gastric wall and a G-M tube recording the disappearance of beta-activity from the muscle layer only. Total and muscle layer blood flow could be calculated from the washout curves, and, knowing these variables, the blood flow to the mucosa-submucosa could be indirectly calculated. Gastric blood flow in the cat and man closely resembled each other, both in magnitude and distribution. Total blood flow in man 'at rest' was 12 +/- 4 ml/min and 100 g tissue (mean +/- S.D.; no. = 20), muscle blood flow amounting to 7 +/- 3 and mucosa-submucosa flow to 16 +/- 8 ml/min and 100 g muscle and mucosa-submucosa tissue, respectively. The distribution to the muscle layer was 26 +/- 14% and to the mucosa-submucosa 74 +/- 14% of total gastric blood flow.

Gastric blood flow and distribution: the effect of pentagastrin in anesthetized cat and man as studied by an inert gas elimination method.

Using a krypton-85 elimination method previously described, the effect of pentagastrin on gastric blood flow has been studied in 28 anesthetized patients, 12 control patients, and 16 patients with duodenal ulcer disease. Both in control and duodenal ulcer patients a significant increase in total blood flow was found, reflecting an increase of flow in the mucosa-submucosa layer of the corpus. In normal subjects a 5-fold increase in flow was found in this tissue layer, whereas the corresponding increase in duodenal ulcer patients was 12-fold. Concomitantly, a significant decrease of flow distribution to the muscle layer was seen. In the antrum pentagastrin did not cause any significant changes in either mucosa-submucosa or muscle layer blood flow. No qualitative differences in the response to pentagastrin, with regard to the gastric blood flow, was found between normal subjects and duodenal ulcer patients.

Short-term systemic prophylaxis with cefoxitin and doxycycline in colorectal surgery. A prospective, randomized study.

The efficacy of cefoxitin or doxycycline as antibiotic prophylaxis in colorectal surgery was compared in 102 elective operations. Both drugs were used perioperatively only. Cefoxitin was used in 55 cases and doxycycline in 47. Ten patients in the cefoxitin group and 4 in doxycycline group had wound infections. Three intraabdominal abscesses were seen, one after cefoxitin and two after doxycycline prophylaxis. All three were due to anastomotic leakage. Bacteriologic studies revealed no negative ecologic effects of prophylaxis. The short-term prophylaxis used did protect against serious infectious complications. The extended spectrum of cefoxitin provided no added benefit in prophylaxis. Patients with inflammatory bowel disease treated preoperatively with salicylazosulfapyridine run a greater risk of postoperative infection in spite of the prophylaxis.

Management of massive gastroduodenal haemorrhage.

A special program for management of massive gastrointestinal bleeding was 1976 introduced in the surgical service of Sahlgren's Hospital in Göteborg. The main points in this program were: careful observation in an intensive care unit, standardized treatment, early diagnostic gastroduodenoscopy, strict indications for emergency operation and recommendation of type operation. This paper deals with 55 patients subjected to emergency operations in 1976 with the diagnosis erosive gastritis, gastric ulcer or duodenal ulcer. The results are compared to an earlier study in 1962-71 in the same hospital. It was found that the mortality was unchanged during the two periods, 25% during 1962-71 and 24% during 1976. At a first glance the new program might seem ineffective. However, the part of elderly patients was much higher during 1976 than during 1962-71. Thus, the patients during 1976 must be considered much more of a surgical challenge. As old patients often have coexisting severe diseases they are surgically most unfit. Probably a more conservative attitude is justified in this particular group of patients.

Total small bowel strangulation: a case report.

A case of strangulation of the entire small intestine caused by an internal incarcerated hernia is presented. At laparotomy the small intestine was severely discoloured, paralytic and the viability of the bowel was questionable. No resection was performed. At a second laparotomy 10 h later the intestine was hyperaemic and exhibited lively motor activity. Recovery was complete. The importance of prolonged conservative management in avoiding extensive resection is stressed.