Primary and repeated perineal stapled prolapse resection.

BACKGROUND: Previous studies of the outcome after perineal stapled prolapse resection (PSPR) have included a limited number of patients with a short follow-up and high recurrence rates. The present study was designed to assess the initial results, complications, recurrence rate, and outcomes up to 4 years after PSPR, as well as the need for a repeated procedure. METHODS: Fifty-four consecutive patients with rectal prolapse (mean age 77.2 years, range 46-93 years; n = 3 men) were selected for PSPR between May 2009 and February 2015. Prolapse length was measured at baseline and after surgery. Patients were asked to grade intensity of symptoms as a satisfaction score of 1-10, 10 representing being symptom-free. RESULTS: The mean operation time was 45.3 min (SD = 17.5, range 25-95 min). The mean rectal prolapse length was reduced significantly from 9.5 cm (SD = 5.0, range 4-30 cm) to 1.2 cm (SD = 2.6, range 0-10 cm; p < 0.0001). Bleeding requiring surgical intervention occurred in two patients (3.7%). Postoperative satisfaction score increased from a mean of 2.2 (SD = 0.9) to a mean of 6.4 (SD = 2.8, p ≤ 0.0001). After a mean follow-up of 13.4 months (SD = 14.1), six patients with recurrence underwent a new PSPR and five patients underwent colostomy, mainly because of incontinence, resulting in a recurrence rate of 20.4%. There were no complications after redo PSPR, and after a median of 10-month follow-up (range 6-37), there were no recurrences. CONCLUSIONS: PSPR is a rather new surgical procedure for external rectal prolapse. Immediate complications are few and not serious. Although recurrences can be treated with a second PSPR, the operation may only be the best option for old and fragile patients with comorbidities and a short life expectancy.

Randomized clinical trial of symptom control after stapled anopexy or diathermy excision for haemorrhoid prolapse.

BACKGROUND: : This multicentre randomized clinical trial studied how symptoms improved after either stapled anopexy or diathermy excision of haemorrhoids. METHODS: : The study involved 18 hospitals in Sweden, Denmark and the UK. Some 207 patients were randomized to either anopexy or Milligan-Morgan haemorrhoidectomy, of whom 90 in each group were operated on. Patients reported symptoms before surgery and after 1 year. Daily postoperative pain scores were recorded in a patient diary. Surgeons evaluated the anal anatomy before surgery and after 1 year. RESULTS: : Correction of prolapse in the anopexy and haemorrhoidectomy groups was similar at 1 year (88 and 90 per cent respectively; P = 0.80). Freedom from symptoms was obtained in 44 and 69 per cent respectively (P = 0.002). Stapled anopexy was associated with less postoperative pain, which resolved more quickly (P = 0.004). Significant improvements were noted in anal continence and well-being 1 year after both operations (P < 0.001). Excessive pain was the most common complication after diathermy excision and disturbed bowel function after stapled anopexy. CONCLUSION: : Haemorrhoidal prolapse was corrected equally by either operation. Diathermy haemorrhoidectomy gave better symptom relief but was more painful. Neither operation provided complete cure but well-being was greatly improved. REGISTRATION NUMBER: ISRCTN68315343 (http://www.controlled-trials.com).

Operative precautions in HIV and other bloodborne virus diseases.

Mathematical means have suggested that the surgical team is at particular risk of acquiring HIV (or other bloodborne viruses) from a source patient. To reduce this risk, it is mandatory to avoid accidental injuries during operative procedures. The surgeon must handle tissues with instruments and must minimize finger use. Sharp instruments should be passed through a neutral zone to ensure that the surgeon and nurse do not touch the same instrument at the same time. Instruments should not be handled blindly, but instead should be accompanied by eye and verbal contact. We find these changes in surgical technique are necessary for present and future generations of surgeons.

Velvet pad surface sampling of anaerobic and aerobic bacteria: an in vitro laboratory model.

Velvet pads have been evaluated in an experimental, laboratory model, simulating intraoperative sampling of Staphylococcus epidermis, Escherichia coli and Bacteroides fragilis. After sampling, the pad was placed in a transport medium and kept in an anaerobic atmosphere, before being shaken and rinsed, followed by anaerobic and aerobic culture. This technique permitted quantitatively high recoveries of the test bacteria. Velvet pad sampling could be a measure to determine the density of aerobic and anaerobic bacteria during operation in an effort to predict the risk of postoperative wound sepsis.

Anaerobic and aerobic skin bacteria before and after skin-disinfection with chlorhexidine: an experimental study in volunteers.

The amount, composition, and localization of anaerobic and aerobic bacteria in the normal skin before and after disinfection were the subject of a volunteer study. The superficial bacterial flora were sampled by velvet pad imprints, and the deep flora were determined from whole skin biopsies. Only one anaerobic species, Propionebacterium acnes, was encountered even though other and more strict anaerobic bacteria could have been grown with the anaerobic technique employed. Staphylococcus albus dominated among the aerobic superficial bacteria, while diphtheroids, Micrococcus spp., and lactobacilli occurred sporadically. The deep aerobic bacteria were present in a significantly greater amount than the anaerobic. A two-step cleansing/disinfection procedure was evaluated in vivo in volunteers as well as in surgical patients, and aqueous cetrimide/chlorhexidine (Savlon) followed by chlorhexidine in alcohol (Hibitane) almost eradicated both the superficial and deep anaerobic and aerobic skin flora.

The infective dose of aerobic and anaerobic bacteria in postoperative wound sepsis.

Surgery for perforated appendicitis was used to estimate the infective dose of aerobic and anaerobic bacteria in postoperative wound sepsis. The wound sepsis rates were 22.6% (7/31) after treatment with intravenous ampicillin sodium and metronidazole and 23.5% (8/34) after penicillin G sodium, streptomycin, and metronidazole, a nonsignificant difference. Intraoperative sampling by velvet pads demonstrated that the density of aerobes did not differ significantly from that of anaerobes, either on the surface of the appendix, in peritoneal exudate (aspirated), or in the wound before closure. The predominant pathogens were Escherichia coli and Bacteroides fragilis. In 15 patients who developed wound sepsis, the density of aerobes and anaerobes was significantly higher at all sampling sites than in 50 noninfected patients. The median infective dose of aerobes and anaerobes together was 4.6 X 10(5) colony forming units.cm-2 in the operative wound. There was a significantly high correlation between the densities of bacteria during operation and subsequent wound sepsis.

New operative technique to reduce surgeons' risk of HIV infection.

The surgical team is potentially at risk of acquiring human immunodeficiency virus (HIV) from the patient. Assuming that the probability of an accidental injury during surgery is 0.01 (P2), the prevalence of HIV is 0.01 (P3) and the seroconversion rate is 0.01 (P1), we have estimated the risk (actuarial model) for a surgeon as 0.2% per year, and 5.82% for 30 years of surgery. In view of this we have made changes in surgical technique to reduce the risk to the surgical team from splash or injury. The surgeon must handle tissue with instruments only and minimize the use of fingers. Whenever possible, sharp instruments should be replaced by a blunt type. The surgical nurse loads needles to the needle carrier using forceps. Sharp instruments are placed in a neutral zone on the nurse's stand so that the surgeon and the nurse never touch the same sharp instrument at the same time. Movements should be controlled, and instrument handling accompanied by eye contact. We consider that these changes will reduce the risk of accidental injuries and thereby the transmission of HIV during operations to a greater degree than knowledge of the patient's HIV status.

Computer-aided surveillance of surgical infections and identification of risk factors.

A continuous record of postoperative surgical infections was carried out by electronic data processing (EDP) of 4340 orthopaedic and general operations. The overall infection rate was 6.3%, ranging from 2.3% (clean wounds) to 27.1% (dirty wounds). The corresponding deep infection rates were 1.6%, 0.4% and 4.6%. Employing a multiple logistic regression analysis, 10 risk factors were evaluated. Factors found to be significant were: wound contamination, department, duration of operation, date of operation and age, and in addition for the department of general surgery: surgeon, planning of operation, length of preoperative stay and anatomic groups. A statistical model for identification of risk patients is described. Postoperative stay was on average 20.5 days longer in infected patients. We find that EDP-recording may result in an annual cost reduction of at least 175,000 pounds for our hospital.

[AIDS/HIV: risk for surgeons--new surgical routines]. / AIDS/HIV: Risiko for kirurger--nye operative rutiner.

The surgical team is at risk of transmission of human immunodefiency virus (HIV) from the patient, which could progress to AIDS and death. In our hospital, we have estimated a probability of 0.20% per year, and 5.82% for 30 years in surgery. In view of this we have designed new procedures for surgical handicraft to reduce the risk from splash or injury to the surgical team. The surgeon must handle tissue with instruments only and minimize the use of fingers. Sharp instruments should, if possible be replaced by blunt types. The nurse loads needles to the needle carrier using a forceps. Sharp instruments are placed in a neutral zone on the nurse's stand so that the surgeon and nurse never touch the same sharp instrument at the same time. Movements must be controlled and accompanied by eye contact. The measures to prevent injury would hardly affect the individual skill of the surgeon or prolong operation time. We consider that the new routines suggested prevent transmission of HIV during surgical procedures better than by knowing the HIV status, of the patients.

[Late postoperative wound infection]. / Sene postoperative sårinfektioner.

In a retrospective study during the last ten years of postoperative wound infections, six cases of late infections were found with a maximum latency of 30 years. A combination of non-absorbable suture materials together with underlying disease seems to have initiated the late formation of wound abscesses. The use of non-absorbable suture seems to involve a life long risk of infection.

[4-year experiences with computer-assisted registration of postoperative wound infections and identification of risk factors]. / Fire års erfaringer med edb-registrering af postoperative sårinfektioner og identifikation af risikofaktorer.

A continuous record of postoperative surgical infections was carried out by electronic data processing of 9,181 orthopaedic and general operations. The overall infection rate was 5.7%, ranging from 2.0% (clean wounds) to 22.1% (dirty wounds). The corresponding deep infection rates were 1.7%, 0.4% and 5.4%, respectively. Employing a multiple logistic regression analysis, ten risk factors were evaluated. Factors found to be significant for both departments were: wound contamination, duration of operation and age. In addition, in the department of orthopaedic surgery: date of operation and surgeon, and in the department of general surgery: planning of operation, length of preoperative stay and anatomic groups. Sex had no influence on postoperative infection. Significant factors altered during the four years. Postoperative stay was, on an average, 13.9 days longer in infected patients.

[Difficulties in continuous computer-assisted registration of postoperative wound infections]. / Vanskeligheder ved kontinuerlig edb-registrering af postoperative sårinfektioner.

To improve the frequency of primary registration and reduce the time spent on continuous registration of postoperative wound infections by electronic data processing (EDP), we analysed the failures made during a two year period, where and by whom they were made. 16.9% of the operations and 0.4% of the infections had not been registered primarily, and all involved groups had made mistakes, but the surgeons were responsible for 69.2% of the missing registrations. This study shows that reliable registration of infections requires frequent instruction of all groups, especially the surgeons, frequent reports of infections in the ward and for each surgeon, and that the registrations are continuously controlled and at the end of year.

Penetration of penicillin into laparotomy wounds to reduce bacterial contamination during intestinal operations.

Serum and tissue specimens from the surgical wound were taken simultaneously during colo-rectal operations (i) at the start, (ii) when entering the peritoneal cavity, (iii) during bowel procedures and (iv) before closure of the wound. A dose of 5 megaunits penicillin intravenously after incision gave a median serum concentration of 140.0 IU/ml and a tissue concentration of 33.8 IU/mg at the time the peritoneum was incised. During operation the concentration in serum fell significantly, being 18.5 IU/ml after more than 3 h of operation, while that in wound tissue decreased to 7.2 IU/mg. After concentration was 16.0 IU/ml in serum and 1.9 IU/mg in wound tissue at the time of incision and when entering the peritoneal cavity; thereafter the concentrations decreased with operation time. The concentrations in serum exceeded markedly those in wound tissue, being linearly correlated throughout operation. Only the intravenous bolus produced concentrations of penicillin antibacterial to a variety of aerobic organisms.

Bacterial density in laparotomy wounds during gastro-instestinal operations.

Operation wounds were sampled quantitatively for aerobic bacteria in 56 patients by the velvet pad rinse technique in a prospective, randomised study of abdominal operations (1) truncal vagotomy and pyloroplasty, (2) gastric or (3) colo-rectal operations, and (4) exploratory laparotomy. On entering the peritoneal cavity and prior to incision of the gastro-intestinal tract the bacterial density in the wounds did not differ significantly between these four types of operations, the median being 5.4X10(-1) viable counts/cm2 (range 0.7-135.8). In all series of operations the median bacterial density was increased prior to closure of the wounds, significantly so after colo-retal operations, being 21.3X10(-1) viable counts/cm2 (range 1.1-144.4), caused by a rise in density of aerobic intestinal species, especially Escherichia coli. Regardless of type of operation, all wounds were contaminated during operation by aerobic commensals of the skin and mucous membranes of the upper respiratory tract, in particular by Staphylococcus epidermidis, this species not differing significiantly in density from the beginning to the end of operation. This same study revealed that within the operation wound, sites of low or even zero bacterial density were close to sites with a high density. It is suggested that postoperative wound infection is closely related to the density of the different species of bacteria present in the operation wound at closure.