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.

Survival of patients with surgical wound infection: a case-control study of common surgical interventions.

A cohort of 4515 surgical patients was selected from ten different surgical intervention groups, and 291 of 317 with a postoperative wound infection were matched 1:1 with controls with regard to intervention, sex and age. The mortality rate was investigated from the time of operation, with a follow-up period from 4 years 4 months to 8 years 4 months. Eighty-seven patients with a deep infection had a significantly increased mortality rate, with a risk ratio of 1.7. Without a distinction between superficial and deep infection the former might mask the higher mortality rate associated with the latter.

Estimated costs of postoperative wound infections. A case-control study of marginal hospital and social security costs.

A cohort of 4515 surgical patients in ten selected intervention groups was followed. Three hundred and seventeen developed postoperative wound infections, and 291 of these cases were matched 1:1 to controls by operation, sex and age. In comparison to the controls the cases stayed longer in hospital after the intervention and had more contact after discharge with the social security system. Using data from a national sentinel reference database of the incidence of postoperative wound infections, and using national activity data, we established an empirical cost model based on the estimated marginal costs of hospital resources and social sick pay. It showed that the hospital resources spent on the ten groups, which represent half of the postoperative wound infections in Denmark, amounted to approximately 0.5% of the annual national hospital budget. This stratified model creates a better basis for selecting groups of operations which need priority in terms of preventive measures.

Effectiveness of single dose prophylaxis with cefotaxime and metronidazole compared with three doses of cefotaxime alone in elective colorectal surgery.

OBJECTIVE: To compare three doses of cefotaxime alone with a single dose of cefotaxime and metronidazole for the prophylaxis of infection after elective colorectal operations. DESIGN: Prospective random control trial. SETTING: Hillerød and Frederiksberg Hospitals, Copenhagen, Denmark. SUBJECTS: 660 consecutive patients who were to undergo elective colorectal operations during a 48 month period (January 1987-January 1991); 93 (14%) were withdrawn after randomisation leaving 567 for assessment. INTERVENTIONS: Mechanical bowel preparation, and then either cefotaxime (Claforan) 2 g intravenously at induction of anaestesia and 3 and 9 hours later (n = 280) or a single dose of cefotaxime 2 g plus metronidazole (Flagyl) 1.5 g intravenously at induction of anaestesia (n = 287). RESULTS: 44 patients in the cefotaxime group developed wound infection (16%) compared with 19 (7%) in the combined group (p < 0.001). In the cefotaxime group 22 of the 241 patients who had an anastomosis developed leaks (9%) compared with 8 of the 239 in the cefotaxime/metronidazole group (3%). There were no differences in the incidence of intra-abdominal abscesses or burst abdomens. The most common organisms isolated from wounds were Escherichia coli and Bacteriodes fragilis. CONCLUSION: One dose of cefotaxime and metronidazole is active against a wide range of organisms and resulted in significantly fewer wound infections than three doses of cefotaxime alone.

Wound contamination and postoperative infection. A review.

The risk of postsurgical infection is closely related to the type of operation performed. Wound sampling by Raahave's velvet pad method shows that operation wounds harbour ordinary aerobic and anaerobic commensals after incision (exogenous flora). When bacteria-containing viscera are opened or found perforated, bacterial densities increase significantly before wound closure (endogenous flora). Contamination level justifies the criteria for use of wound class, i.e. clean, potentially contminated, contaminated and dirty. There is a dose-response relationship between the density of bacteria during operation and postsurgical wound sepsis. The median infective dose of aerobic and anaerobic bacteria is 4.6 x 10(5) CFU x cm-2 wound. The surgeon opens up tissue planes which are primarily sterile and breaks natural barriers. However, using a trained technique, the surgeon should be able to control wound contamination safely throughout the operation. Although hos immunity and tissue resistance intervene between contamination and infection, the magnitude of contamination seems crucial. It ought to be axiomatic by now that reducing bacterial contamination reduces infection.

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.

[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.

Perineal seeding of prostatic carcinoma after Trucut biopsy.

Perineal seeding of cancer of the prostate is a rare complication after transperineal prostatic biopsy. In the present case the biopsy responsible for the seeding was false-negative, but microscopy of the perineal lesion showed a differentiated adenocarcinoma.

[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.

No effect of topical ampicillin prophylaxis in elective operations of the colon or rectum.

Whether or not topical application of ampicillin is necessary in patients undergoing elective colorectal operations was investigated. After mechanical preparation, 193 patients received 2 grams of cefotaxime administered intravenously from the start of the operation; patients received two more doses within the next 12 hours. In addition, patients were randomized to receive or not receive prophylaxis against infection of 2 grams of ampicillin in the site of the incision at closure. Twenty-three patients did not complete the study. Wound infection occurred in five of 81 patients who had topical application of ampicillin compared with six of 89 patients who did not receive prophylaxis; the difference was not significant. There were no significant differences in rates of wound dehiscence, intra-abdominal abscess or anastomotic leakage. Escherichia coli and Bacteroides fragilis were the predominant microorganisms isolated. Thus, topical application of ampicillin did not lower the wound infection rate when there was a preoperative antibiotic administered intravenously.

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.

[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.

Surgical scarlet fever.

A case of surgical scarlet fever is described in a 57-year-old woman. Identification of beta-haemolytic streptococci and treatment with penicillin is essential to prevent spread of surgical scarlatina.