The incidence of wound infection after stapled or sutured bowel anastomosis and stapled or sutured skin closure in humans and guinea pigs.

In a study of antimicrobial prophylaxis in colorectal surgery, a higher incidence of wound sepsis was noted in patients who underwent stapled rather than sutured anastomoses and skin closures. There were six wound infections in 69 patients (8.7%) who underwent nonstapled anastomoses compared with seven in 28 (25%) in whom GIA or EEA staplers were used (p = 0.003). Excluding the EEA-stapled cases, the infection rate was 29% (p = 0.022). In patients who underwent sutured anastomoses, there were no wound infections in 21 whose skin was closed with sutures compared with five in 38 patients (13%) with stapled skin closure (p = 0.082). In an experimental guinea pig model dual incisions were infected with Bacteroides fragilis and Escherichia coli. One incision was then closed with staples, the other with sutures. There was a statistically significant (p = 0.016) advantage to the use of staplers. The possible significance of these results is discussed.

Metronidazole in the treatment of intra-abdominal sepsis.

A study of antibiotic treatment of intra-abdominal sepsis was conducted between May 1978 and May 1981. In the first phase, clindamycin (C) was compared with metronidazole (M), each combined with tobramycin (T), in a prospective, double-blind, randomized study. Twenty-three patients received C + T and 34 patients received M + T. The two groups were similar with respect to age, gender, underlying disease, presence of abscess, clinical condition, severity of illness, duration of illness before treatment and bacteriology. Anaerobic organisms outnumbered facultative and aerobic organisms. Bacteroides fragilis and Escherichia coli predominated. In the C + T group of patients, 74% had a good response. In the M + T group, 83% had good results. Adverse effects were few and minor in the two treatment groups. Three patients on C + T and one who received M + T followed by C + T died of infections; two patients died of underlying disease. In the second, open phase of the study, M + T was used to treat 45 patients with 46 courses. Twenty patients had intra-abdominal abscesses, which represented all grades of severity of illness. Five patients received long-term corticosteroid therapy. Almost half the patients had peritonitis complicating appendicitis. Good results were obtained in 81%. One patient died of the underlying disease and one died of infection complicating severe trauma and hypovolemic shock.

Evaluation of the use of a protocol in the antimicrobial treatment of intra-abdominal sepsis.

A protocol was established aimed at limiting the duration of antimicrobial therapy in two patient groups with peritonitis. One group had perforated or gangrenous appendicitis and the other non-appendiceal disease. The duration of treatment given to patients treated according to the protocol was compared retrospectively to that of similar patients treated without the protocol. Patients with perforated or gangrenous appendicitis required significantly less antimicrobial therapy than those with peritonitis due to non-appendiceal disease. In non-appendiceal intra-abdominal sepsis the use of the protocol was associated with a significantly reduced duration of antimicrobial therapy, compared with that observed without the protocol.

Teaching and evaluation of basic surgical techniques: the University of British Columbia experience.

Surgical technical education has traditionally followed an apprenticeship format. The need for innovative undergraduate programs using dry and wet labs prior to clinical exposure continues to be an area of debate. Specific programs have been described to improve surgical skills; however, an accepted platform for training and evaluation of surgical skills programs has not been recognized. Therefore, introduction of specific programs to teach undergraduate medical students surgical skills is essential. This article describes the Basic Surgical Technique (BST) program taught at the University of British Columbia and reports the effectiveness of this program in improving the practical skills of undergraduate medical students. The program includes BST I for third-year students performed in a dry lab setting, and BST II for medical student interns (MSI) performed at the animal laboratories using female domestic swine as subjects. A total of 87 students participated in the study. The program is designed using Piaget's and Vygotsky's pedagogical philosophy of "learning by doing." A semiquantitative method is used to measure and analyze the outcome of this project. Data were validated using student self-evaluation tests and by quantitative evaluation by surgical staff from the surgical wards. Results of this prospective project indicated that the BST program significantly (p < .05) improved the surgical performance of undergraduate students, and that the time lapse between BST I and II has had a negative impact in retention of acquired surgical skills. This study concludes that the BST program taught at the University of British Columbia significantly improves the surgical skills of medical students and improves their self-confidence during their internship.

Peritoneal tap and lavage in patients with blunt abdominal trauma: their contribution to surgical decisions.

In a study of 51 patients with a history of blunt abdominal trauma, peritoneal tap and lavage made a positive contribution to the diagnostic process in 15 cases. Thirteen patients had early definitive operation on the basis of tap and lavage evidence which overruled the clinical evaluation, and two patients were managed conservatively when a negative tap and lavage contradicted the clinical decision.

Prospective, randomized, double-blind comparison of metronidazole and tobramycin with clindamycin and tobramycin in the treatment of intra-abdominal sepsis.

In a prospective, double-blind study, clindamycin was compared with metronidazole, each combined with tobramycin and all by the intravenous route in the treatment of intra-abdominal sepsis. Twenty-three patients received clindamycin and 34 patients received 35 courses of metronidazole. Analysis of the clinical responses of patients indicates that the two antibiotic regiments are of equal efficacy in that there was no difference between them in terms of defervescence or duration of infection. Few adverse effects were noted, and all appeared to be of a minor nature.

Choledochocholecystojejunostomy: a quick, effective method of biliary decompression for carcinoma of the pancreas.

The frequency of pancreatic carcinoma appears to be increasing. Effective treatment is essential for most patients whose tumours are unresectable. Definitive treatment by stenting techniques are currently limited to those patients who are high surgical risks, elderly, present with metastatic disease or refuse the surgical option. Surgical bypass offers the best palliation and should reliably decompress the biliary obstruction caused by the tumour with the least surgical trauma. Roux-en-Y choledochojejunostomy (CDJ), with or without a gastroenterostomy, is usually the preferred method of bypass; however, for patients with a distended gallbladder this procedure is often made easier by its removal. Even then providing a proximal, tension-free anastomosis can be challenging. In 13 consecutive patients who still had a gallbladder and required a biliary bypass for carcinoma of the pancreas, the authors interposed the gallbladder between the proximal bile ducts and a Roux-en-Y loop. This procedure could be done more quickly than CDJ and performed well.

Diaphragmatic resection in association with right hepatectomy.

Ten cases of combined diaphragmatic and hepatic resection for tumours involving both structures are described. A complete work-up, including ultrasonography and computed tomography, usually can predict potential direct spread to the diaphragm. Up to 50% of the diaphragm can be excised and reconstructed without the need for prosthetic mesh or tissue transfer. Diaphragmatic resection does not appear to cause long-term postoperative morbidity. Diaphragmatic invasion by primary or secondary tumours does not preclude resection for cure. Pulmonary function studies are not necessary if there is no serious pre-existing lung disease.

Metronidazole and tobramycin in intra-abdominal sepsis.

In an open study of 49 episodes of intra-abdominal sepsis in 48 patients, metronidazole was used in combination with tobramycin, and each was given by intravenous infusion. All patients were also treated by appropriate surgical operation. The ages of the patients ranged from 21 to 89 years, and both sexes were equally represented. Twenty-two patients had abscesses drained. Thirty-eight of 49 treatment courses gave good results. Eight patients recovered, although slowly, and three were classified as failures. Of the failures, one instance was attributed to infection with Staphylococcus aureus, and recovery was satisfactory when cloxacillin sodium was given. The other two failures were due, in part, to shock caused by trauma and blood loss in one instance and disseminated anaplastic lymphoma in the other. No significant adverse effects were attributable to the antibiotics.