Prophylaxis of venographically diagnosed deep vein thrombosis in gastrointestinal surgery. Multicentre trials 20 mg and 40 mg enoxaparin versus dextran.

OBJECTIVE: To compare enoxaparin and dextran 70 for the prophylaxis of venographically diagnosed deep vein thrombosis (DVT) after gastrointestinal operations. DESIGN: Part 1: randomised double blind trial; Part 2: single blind study with historical controls. SETTING: Eight Norwegian hospitals. SUBJECTS: 381 Patients undergoing elective gastrointestinal operations. INTERVENTIONS: Part 1 (n = 329): enoxaparin 20 mg subcutaneously starting two hours before operation and continuing until the patient was fully mobilised or had had 10 injections and a placebo infusion of 0.9% sodium chloride, or dextran 70,500 ml at the start of the operation, on the evening of operation, and on the first, third, and fifth postoperative days and placebo subcutaneous injections. Part 2 (n = 52): enoxaparin 40 mg in the same regimen as part 1 (compared with 39 historical controls). Venograms 4-6 days post-operatively. MAIN OUTCOME MEASURE: Venographically confirmed DVT. RESULTS: Part 1: Because of the high overall incidence of DVT an interim analysis was done which showed 33/101 DVT (33%) among high risk patients in the enoxaparin 20 mg group and 33/107 (31%) in the dextran 70 group. The corresponding figures for patients at medium risk were 2/27 (7%) for enoxaparin 20 mg and 5/27 (19%) for dextran 70 (95% confidence interval (CI) for the difference--11.9 to 9.8). Part 2: the dose of enoxaparin was therefore increased to 40 mg and prophylaxis restricted to patients with cancer. There were 6/49 DVT (12%), which was compared with a random sample from the dextran 70 group from part 1 (historical controls) in which the incidence was 15/39 (38%, 95% CI of the difference 4.0 to 8.4). There were no pulmonary emboli, only 4 thrombi were above the knee and there were 4, 1 and 3 clinical DVT in the 20 mg and 40 mg enoxaparin, and dextran 70 groups, respectively. CONCLUSIONS: Enoxaparin 20 mg and dextran 70 are effective prophylaxis for patients at medium risk, but enoxaparin 40 mg is required for those at high risk.

Serum carcinoembryonic antigen in relation to survival, DNA ploidy pattern, and recurrent disease in 406 colorectal carcinoma patients.

Serum carcinoembryonic antigen (CEA) levels in relation to survival, flow cytometric DNA ploidy pattern, Dukes stage, and recurrent disease was prospectively evaluated in 406 patients with colorectal carcinoma. In 246 patients (61%) the carcinomas were DNA aneuploid. Increased preoperative CEA levels (> 5 micrograms/l) were found in 151 of 363 evaluable patients (42%). Dukes stage-B patients with preoperative CEA elevation showed significantly poorer prognosis than those with normal CEA values (p = 0.001). A weak but significant correlation was found between preoperative CEA level and Dukes stage (Kendall's tau = 0.25, p < 0.01). Of 50 evaluable patients with clinical recurrence and postoperative normal or normalized CEA levels, 28 (56%) had a rise in CEA before or at the time of clinical recurrence. The sensitivity of the CEA test for primary and for recurrent disease was not significantly different in the DNA aneuploid and the DNA near-diploid groups.

[Pilonidal cysts. Excision and intracutaneous absorbable primary suture]. / Pilonidalcyste. Ekstirpasjon og intrakutan resorberbar primaersutur.

A retrospective survey revealed a shorter stay in hospital for 22 patients with primarily closed wounds than for 38 patients whose wounds were left open to granulate. There were few complications, and the wounds took no longer to heal than those subjected to primary open treatment. A prospective study of closure of wounds where primary conventional suture (n = 10) was compared with intracutaneous absorbable suture (n = 10) showed no difference in the length of stay in hospital or in the rate of complications. Intracutaneous absorbable suture enhances the patient's comfort. No bandage is needed and the patient can take a shower from the first day after operation. Nor are there any stitches to be removed. We recommend intracutaneous absorbable suture for primary closure of wounds.

[Skin closure. A prospective randomized study]. / Hudlukning. Prospektiv randomisert undersøkelse.

This prospective randomized study included 100 patients with inguinal hernia and 66 patients operated on for acute appendicitis. In half of each group the skin was closed with a continuous subcuticular resorbable suture, and in the other half with a monofilament nylon matress suture. The patients were followed up after three weeks and again after three months. There was no obvious difference in cosmetic result between the two methods of skin closure. In the patients with inguinal hernia or non-perforated appendicitis there was no increase in postoperative infection of the wound after subcuticular suture. In the case of perforated appendicitis there may have been an increase in infection of the wound after subcuticular suture. Continuous, subcuticular resorbable suture used on the right indications can give a good cosmetic result and few complications of the wound. Further more, a separate outpatient visit for removal of skin sutures or staples can be avoided.

Plasma prekallikrein, functional kallikrein inhibition, antithrombin III, plasminogen, kallikrein activity and proenzyme functional inhibition index in 172 acute ill surgical patients on admission.

The present study was performed in order to study disturbances in plasma proteolysis in acute ill surgical patients on admission. The paper describes the distribution of values for plasma PKK, KKI, AT III, Plg, KK and PFI-index. In early stages of the disease process rather minimal information can be obtained by these data in addition to clinical examination. The study indicates that chromogenic peptide substrate assays should be reserved for surgical patients treated in the intensive care unit.

Heterotopic ossification of the intestinal mesentery. Report of a case following intraabdominal surgery.

In a 55-year-old male a nodular mass of heterotopic ossification developed in the intestinal mesentery two weeks after coloproctectomy for severe ulcerative colitis. The lesion was located close to the ileostoma where it encroached upon the intestinal wall and led to luminal obstruction. Histological examination of the tumour mass showed actively proliferating mesenchymal cells forming irregular areas of primitive osteoid and bone. The process appeared consistent with an early stage of heterotopic ossification where the short history explains the absence of the "zone phenomenon" usually characterizing such lesions. By reviewing the literature the reported case appears unique as other cases of intraabdominal heterotopic ossification have not been encountered.

A single dose tinidazole and doxycycline prophylaxis in elective surgery of colon and rectum. A prospective controlled clinical multicenter study.

Antimicrobial prophylaxis with agents active against aerobic and anaerobic micro-organisms leads to a significant reduction of infectious complications following colorectal surgery. A single dose (1600 mg) of tinidazole (a nitroimidazole derivate) and doxycycline (400 mg) will provide serum and tissue values well above minimum inhibitory concentration (MIC) values for more than 24 hours. To reduce the unwanted side effects and cost of prolonged antimicrobial prophylaxis, a prospective controlled clinical multicenter study comparing the effect of a single dose before operation of tinidazole and doxycycline to five days of prophylaxis before operation in 234 patients undergoing elective colorectal surgery was undertaken. Six patients given a single dose of prophylaxis before operation (n = 118) developed infectious complication (5.1%). Prolongation of prophylaxis before operation for four days after operation (n = 116) did not lead to any further reduction of infectious complications. A single dose of tinidazole and doxycycline before operation is a simple and effective prophylaxis against infectious complications following elective colorectal surgery.

Combined tinidazole and doxycycline prophylaxis in colorectal surgery. An interhospital trial.

There were no significant differences between randomized groups on either preoperative tinidazole or placebo added to pre-, per, and postoperative doxycycline. Cases of anaerobic infection among the placebos patients as well as a general trend of the parameters studied suggest that tinidazole gives added protection, i.e. that antibiotic prophylaxis should also comprise anaerobic microbes.

Continent ileostomy. A pilot study in dogs.

Nipple valve ileostomies with and without a performed pouch as well as conventional ileostomies were compared in dogs. In both groups with a nipple valve, a 150-200 ml reservoir developed. It was about 30 cm long when not preformed by an operation. Equal dilatation of the proximal bowel was observed in both groups with a nipple valve and both these groups had a substantial loss of weight which seemed to correspond with mucosal changes indicating malabsorption. For continent ileostomy function in dogs, the performed pouch thus seems unnecessary.

Mental disorders in ulcerative colitis: suicide, divorce, psychosis, hospitalization for mental disease, alcoholism, and consumption of psychotropic drugs in 178 patients subjected to colectomy.

The population in the Nordic countries is relatively homogenous. In 178 Norwegian patients subjected to colectomy for ulcerative colitis the frequencies of suicide, divorce, psychosis, and hospitalization for mental disorders, and consumption of psychotropic drugs, did not differ significantly from corresponding frequencies in the general population.

Giant pseudopolyposis causing colonic obstruction. Report of a case seemingly associated with Crohn's disease of the colon.

Gian pseudopolyposis is uncommon and only one obstructive case has previously been reported. In that case the underlying disease was ulcerative colitis while the present case seemed associated with Crohn's disease. Clinically this condition imitates a malignant tumour, and because of the rarity we failed to reach the right preoperative diagnosis in spite of correct colonoscopy and biopsy findings.