A meta-analysis of randomized, controlled trials assessing the prophylactic use of ceftriaxone. A study of wound, chest, and urinary infections.

BACKGROUND: Ceftriaxone is an effective prophylactic antibiotic. However, there is no consensus about whether ceftriaxone should be used as a first-line antibiotic for the prevention of incisional surgical site infection (SSI). Its role in preventing urinary tract infection (UTI) and pneumonia also is controversial. METHODS: A meta-analysis of randomized, controlled trials assessing the prophylactic use of ceftriaxone between 1983 and 2005 was performed. Medline, Embase, and Cochrane registers were reviewed. Additional references, review papers, and proceedings from meetings were searched. The Jadad score was used to assess study quality. A meta-analysis with sensitivity analyses was performed for SSI, UTI, and pneumonia. RESULTS: Of 231 reviewed papers, 90 were included. Ceftriaxone prophylaxis was superior to other antibiotics in each category. Sixty-one studies assessed the prevention of SSI (odds ratio (OR), 0.68; 95% confidence interval (CI), 0.53-0.7, p < 0.001; Cochran's Q statistic, p = 0.93). The difference was greatest for abdominal surgery. There was no difference for cardiac surgery. Thirty-five studies assessed the prevention of UTI (OR 0.53; 95% CI 0.43-0.63, p = 0; Cochran's Q statistic, p = 0.97). The difference was greatest in obstetric and gynecological and colorectal surgery. Thirty-seven studies assessed the prevention of pneumonia (OR 0.66; 95% CI 0.54-0.81, p = 0; Cochran's Q statistic, p = 0.65). The difference was greatest in upper abdominal surgery. CONCLUSIONS: The meta-analysis confirms that prophylactic ceftriaxone is more effective than most other prophylactic antibiotics. This reduces SSI, UTI, and pneumonia in procedures where there is an increased risk of these infections. In such procedures, the data support using ceftriaxone as a first-line prophylactic antibiotic.

Algorithms for the surgical management of retrorectal tumours.

BACKGROUND: Retrorectal tumours are uncommon and may present a surgical challenge. The aim of this study was to identify a surgical strategy based on information gained from the multidisciplinary management of retrorectal tumours. METHODS: This was a retrospective review of 27 patients who had resection of retrorectal tumours between 1998 and 2006. RESULTS: The tumours included ten cystic lesions, two mature teratomas, four chordomas, seven neurogenic tumours, two sarcomas, one angiomyxoma and one gastrointestinal stromal tumour. The diagnosis was suggested initially by non-specific clinical presentation and palpation of a retrorectal mass on examination (16 patients), pelvic imaging (six), obstructed labour (one), recurrent pilonidal sinus (one), recurrent perianal sepsis (one) and return of symptoms after resection (two). Magnetic resonance imaging (MRI) confirmed the diagnosis and enabled surgical planning. The operative approach was perineal (12 patients), abdominal (11) or combined (four). Factors that influenced the operative approach were tumour position, its neoplastic nature, involvement of the pelvic sidewall or pelvic viscera, and size. The retrorectal tumour recurred in three patients. CONCLUSION: A successful multidisciplinary surgical strategy, based on preoperative localization by MRI, has been developed for the treatment of retrorectal tumours.

Clinical variables associated with positive angiographic localization of lower gastrointestinal bleeding.

BACKGROUND: Localizing the source of severe lower gastrointestinal (GI) bleeding is often difficult but is important to plan the extent of colonic resection. The purpose of the present paper was to audit the Auckland Hospital experience of selective angiography, in localizing lower GI bleeding. METHODS: Patients admitted to Auckland Hospital with rectal bleeding and who subsequently had angiography were evaluated by reviewing their clinical notes and radiological results during a 7-year period (1997-2003). Data collected included demographic details, haemodynamic parameters, change in haemoglobin level, requirement of blood transfusion within 24 h before the procedure, site of the bleeding and pathology. RESULTS: The notes of 88 patients (male, n = 51; median age 69 years, range 8-99 years) were available for review and analysis. The site of bleeding was localized in 38 (51%); 30 of them had bleeding in the right colon or small bowel and eight in the left colon. Positive localization correlated with: haemodynamic instability P < 0.0001; drop in haemoglobin level of > or =50 from previous admission (P = 0.02); transfusion requirement of > or =5 units of blood within 24 h (P < 0.0001). Logistic regression analysis showed transfusion requirement of > or =5 units to achieve haemodynamic stability to be the most powerful predictor of accurate localization (odds ratio, 40). CONCLUSION: Catheter angiography for acute lower GI bleeding will successfully localize a point of bleeding in approximately 50% of patients. The most useful clinical indicator for positive angiography was haemodynamic instability particularly in those who require transfusion of > or =5 units of blood to achieve haemodynamic stability.

Peritoneal gallstones following laparoscopic cholecystectomy: incidence, complications, and management.

BACKGROUND: Gallstone spillage during laparoscopic cholecystectomy (LC) is a common intraoperative event. Although gallstones left in the peritoneal cavity were initially considered harmless, a significant number of complications have been reported. Our aim was to quantify the likelihood, and to document the range, of subsequent complications. METHODS: A Medline search from 1987 to January 2003 was performed. Articles with more than 500 LCs that quantified the frequency of complications due to peritoneal gallstones were reviewed, as were representative case studies of different stated complications. RESULTS: Six studies, covering 18,280 LCs, were found. The incidence of gallbladder perforation was 18.3%, that of gallstone spillage was 7.3%, and that of unretrieved peritoneal gallstones was estimated to be 2.4%. There were 27 patients with complications. The likelihood of a complication when gallstone spillage occurred was 2.3%, which increased to 7.0% when unretrieved peritoneal gallstones were documented. CONCLUSION: Spilt gallstones have a small but quantifiably real risk of causing a wide range of significant postoperative problems.