Dipslide culture in colonic surgery: a tool for assessment of surgical performance and a guide to antibiotic use.

We evaluated a bacterial culture system for the assessment of surgical performance during colorectal operations, and for assessing the impact of selective postoperative antibiotics in contaminated cases. Surgically related infections were recorded and their risk factors were estimated, using univariate and multivariate methods, in 1079 patients undergoing elective colorectal operations. (Study period 1 was prospective, controlled and randomized, and study period 2 was prospective and open). All the patients were given metronidazole, 1 g i.v., at induction of anaesthesia and 12 h postoperatively. The number of colony-forming units (CFU) on an intraoperative dipslide culture was classified as 0, 1-4 or > or = 5 (n = 591, 183 and 305). Patients with > or = 5 CFU were randomized to receive either no further antibiotics or cefuroxime (1.5 g, i.v. every 8 h for 2 days) during the first study period (30 months). During the second period (84 months), all patients with > or = 5 CFU were to be given cefuroxime. Increasing age (p = 0.014), postoperative transfusion of packed red blood cells (p < 0.001), and high bacterial numbers (p < 0.001) were independently associated with infection. Surgeon-related rates of operative bacterial contamination varied between 12 and 50% (p < 0.001). In patients given only metronidazole, the likelihood of infection rose as the density of bacteria in the wound increased according to a sigmoid dose-response curve (5.1, 9.8 and 47.5% with CFU 0, 1-4 and > or = 5, respectively). In the category with > or = 5 CFU, 265 patients were treated with cefuroxime and 23 (8.7%) subsequently had infections [corrected]. Of 40 patients with > or = 5 CFU who did not receive cefuroxime postoperatively, 19 developed infections (p < 0.001, relative risk 5.47; 95% confidence interval 3.29-9.10). In conclusion, dipslide culture can identify patients at high risk of infection after colonic operations. It can be used to assess surgical performance. The addition of postoperative antibiotic cover for aerobic bacteria, detected by the dipslide, reduced the risk of infection more than 5-fold and almost eliminated the risk of contamination.

Predictors of intraoperative bacterial contamination and postoperative infection in elective colorectal surgery.

This prospective study of 238 patients undergoing colorectal operations attempted to identify the risk factors for intraoperative bacterial contamination and postoperative infection. The degree of contamination was assessed by the recovery of Enterobacteriaceae spp. or Staphylococcus aureus in peritoneal irrigation fluid using dip-slides. Uni- and multivariate analyses comprised 17 parameters. Intraoperative contamination was strongly associated with postoperative infection (P less than 0.001). Abdominal drains were correlated with contamination (P = 0.019), but not with infection. Decompressive colostomy was over-represented in patients with contamination (P less than 0.001) but contributed to infection independent of its association with contamination (P less than 0.05), as did advanced age (P less than 0.05).

Pyoderma gangrenosum after colectomy for inflammatory bowel disease. Case report.

Pyoderma gangrenosum appeared parastomally after proctocolectomy and ileostomy for ulcerative colitis in two patients. The cases are described and diagnosis and treatment are discussed.

Long-term effects of surgery for normocalcaemic hyperparathyroidism.

A retrospective study of the long-term effects of surgery for normocalcaemic hyperparathyroidism in 82 patients is presented. The median postoperative follow-up time was 96 months. In most of the patients recurrent renal calculi had been the main preoperative symptom, and intermittent peaks of hypercalcaemia were recognized in more than 50% of them. Of the 19 patients with severe tendency to calculus formation, 12 appeared to have been cured by parathyroidectomy. These cured patients were found at operation to have parathyroid adenoma or hyperplasia, or even normal glands. Preoperatively depressed renal function normalized in about 50% of cases, as assessed by the desmopressin test. No patient had paralysis of the recurrent laryngeal nerve, and all were normocalcaemic during follow-up. Parathyroid surgery should be considered for this category of patients, although it is very difficult to distinguish between those who stand to benefit and those who do not.

Dip slide culture of intraoperative peritoneal irrigation fluid for prediction of septic complication in elective colorectal surgery.

A controlled prospective study of a simplified technique, the dip slide culture method, for assessment of bacterial concentration in peritoneal irrigation fluid at the end of an elective colorectal operation is presented. The prediction of postoperative surgical infection based on intraoperative culture was compared between this method and a standard streak-plate technique in 190 patients. One gram of metronidazole was given intravenously as prophylaxis on induction of anesthesia and 12 h postoperatively. Intraoperative growth of members of the family Enterobacteriaceae or Staphylococcus aureus was strongly correlated to infection (P less than 0.001). By using this finding as a single criterion for the prediction of sepsis, sensitivity and specificity for the dip slide method were 70.8 and 94.3%, respectively, compared with 79.2 and 94.6%, respectively, for the streak-plate method. Of the 24 infections, 20 (83.3%) were correctly predicted when a combination of the two methods was used. An increasing number of Enterobacteriaceae or S. aureus in the dip slide culture resulted in a steady rise in the rate of infections from 5.7% at 0 CFU to 57% at greater than or equal to 80 CFU compared with 4.1% at 0 CFU/ml and 45.4% at greater than or equal to 800 CFU/ml with the streak-plate method. The differences were statistically significant at the greater than or equal to 5 CFU level with regard to wound infection (P less than 0.001) and deep surgical infection (P less than 0.01). It is concluded that the dip slide is a simple, rapid, and reliable method for the routine assessment of bacterial contamination in colorectal operations.

Selective cefuroxime prophylaxis following colorectal surgery based on intra-operative dipslide culture.

The concept of a very limited effective period for prophylactic antibiotic action was challenged in a prospective, controlled and randomized study featuring a simplified method for assessing the degree of contamination in the operative field during colorectal surgery. The 226 patients were given 1 g metronidazole IV on induction of anaesthesia and 12 h postoperatively. Following standardized saline irrigation of the abdominal cavity, a uriculture dipslide was dipped in the residual fluid just before abdominal closure. The dipslide was incubated for 18 h, and colony counts of coliforms and Staphylococcus aureus were made. The number of colony-forming units (CFU) was classified as 0, 1-4 or greater than or equal to 5 (n = 123, 33 and 70). The patients with CFU greater than or equal to 5 were randomized to receive cefuroxime (1.5 g IV/8 h for 2 days) or no more antibiotics. In the patients given only metronidazole, the incidence of postoperative infections rose with the colony counts (5.7, 9.1 and 41.2 per cent with CFU 0, 1-4 and greater than or equal to 5). Addition of cefuroxime reduced the 41.2 per cent infection rate to 8.3 per cent (P = 0.003). The method thus identified a high-risk group in which a short postoperative course of cefuroxime significantly lowered the rate of sepsis.

Microflora of the gallbladder related to duration of acute cholecystitis.

The microflora of the bile and wall of the gallbladder was prospectively investigated in 104 nonselected consecutive patients treated with early cholecystectomy for acute cholecystitis after an average hospital stay of 1.8 days. The chief purpose was to relate the findings of cultures to duration of the illness. Special attention was paid to anaerobic isolation techniques. The cultures yielded 107 strains, representing 36 species, with overall agreement between four different sampling procedures. Aerobic gram-negative rods predominated, followed by streptococci and anaerobes (48, 31 and 15 per cent, respectively). The incidence of positive culture results (always greater than or equal to 10(6) colon forming units per milliliter) was 81 per cent among the patients who underwent operation within two days from the onset of symptoms and 50 to 65 per cent after longer preoperative intervals. The shorter interval was significantly more often associated with growth solely of anaerobes (p = 0.03). Postoperative sepsis was caused by biliary bacteria and not related to preoperative duration of illness. Appropriate perioperative antibiotic coverage significantly reduced sepsis--3 versus 20 per cent (p = 0.05).

[Comparison of indomethacin and ketobemidone as analgesics in acute cholecystitis]. / Vergleich von Indometacin und Ketobemidon als Analgetikum bei akuter Cholecystitis.

In an open, randomized prospective clinical trial the analgesic effect of indomethacin and ketobemidon was compared in 67 patients with acute cholecystitis (28 received 5 mg ketobemidon and 39 received 50 mg indomethacin). Both drugs showed a good and significant pain relief, exhibiting no significant difference in the analgesic effect and no serious adverse reactions. It was concluded that indomethacin administered intravenously is an alternative to ketobemidon intravenously in the treatment of pain resulting from acute cholecystitis and may offer some advantages.

Prevention of post-operative infection in appendicectomy by single dose intravenous metronidazole. An open prospective randomised study.

In an open prospective randomized study of appendicectomy, single-dose (1 g) intravenous metronidazole prophylaxis (and continued metronidazole plus nalidixic acid in perforated appendices) resulted in a lower overall post-operative infection rate (1.4%) than no prophylaxis and doxycycline therapy in the case of perforation (16%, p less than 0.025). In patients with an unperforated appendix no infections occurred after single-dose metronidazole prophylaxis as opposed to 8.2% infections in untreated controls (p less than 0.025).

Single-dose intravenous metronidazole v. doxycycline prophylaxis in colorectal surgery. An open prospective, randomized trial.

In an open prospective, randomized study of antimicrobial prophylaxis in colorectal surgery, using a single intravenous dose, metronidazole (1 g) was more effective than doxycycline (0.2 g). The difference in infection rates (2/41 = 5% v. 7/33 = 21%) was statistically significant. Prolonged administration of either agent (2-7 days) yielded results comparable to those with single doses. Five emergency cases were admitted to the study. In two of them, a metronidazole-based therapeutic regimen prevented postoperative infection, whereas infection occurred in all 3 patients given doxycycline therapy. The total infection rate after elective surgery was 4% with metronidazole and 25% with doxycycline prophylaxis. The infections in the metronidazole group were superficial and caused by Escherichia coli, whereas half of the infections in the doxycycline group were intra-abdominal and due to intestinal aerobic and/or anaerobic bacteria. In contrast to doxycycline, therefore, metronidazole prevented postoperative anaerobic infection and was associated with low incidence of aerobic infection.

Plesiomonas shigelloides in acute cholecystitis: a case report.

Plesiomonas shigelloides was isolated as the sole pathogen from gallbladder bile and wall in a 58-year-old woman with acute cholecystitis. The patient developed an unusual postoperative complication characterized by culture-negative discharge from the wound in combination with extensive abdominal cellulitis and afebrility. Agglutinating antibodies to P. shigelloides were demonstrated in the serum of the patient by the microscopic Widal agglutination test.

Indomethacin as prophylaxis against recurrent ureteral colic.

In a prospective, randomized study, the prophylactic effect of indomethacin (150 mg daily) in regard to recurrence of ureteral colic was investigated in 78 patients. Severe recurrent attacks were experienced in 78 patients. Severe recurrent attacks were experienced by 4 of 37 patients in the test group and by 16 of the 41 controls without indomethacin. The mean duration of recurrent pain including the severe attacks was 5.6 +/- 1.1 hour/patient/week in the test group and 12.5 +/- 2.9 in the control group. Passage of stone within 7 days was not influenced by indomethacin (22/37 and 25/41 cases). Indomethacin administration for 7 days after an acute attack of ureteral colic thus reduced the frequency of severe attacks and the total duration of recurrent pain, without influencing the stone passage.

Biliary microflora in acute cholecystitis and the clinical implications.

A prospective bacteriologic investigation was made in 43 consecutive patients (mean age 63 years) operated on for acute cholecystitis. Gallbladder bile and wall were cultured, using four methods and with special attention to optimal anaerobic technique. Cultures were positive in 72% of the patients, yielding a wide variety of species (21 species among 48 isolates). Anaerobes constituted 23% of the isolates. Cultures from gallbladder bile and from gallbladder wall gave almost identical results, as did sampling at the beginning and at the end of cholecystectomy. Bactibilia was found in all patients operated on within 48 hours after the onset of symptoms. Bactibilia and postoperative septic complications showed statistically significant correlation with high patient age. Bactibilia and gallbladder gangrene were significantly correlated with preoperative temperature greater than 38.5 degrees C. There was coincidence of strains isolated from local wound sepsis and from peroperatively sampled gallbladder bile. Adequate preoperative or peroperative antibiotic therapy according to susceptibility testing was associated with significantly reduced rate of postoperative septic complications. The study indicates that bacteria are present early in the course of acute cholecystitis and that they are causally important for postoperative morbidity and mortality.

Separation of tendon ends after suture of achilles tendon.

Ten patients treated for an acute rupture of the achilles tendon were studied. During the operation a marker was attached to each tendon end. The postoperative separation of the markers was studied by repeated X-ray examinations. Despite immobilization a small initial separation was found during the first 4 days, followed by a period of no separation. After about 20 days a second separation started. No re-ruptures occurred. Both in the rabbit and in man a small initial separation of sutured tendon ends seemed to indicate an adequate tendon suture and therefore also a good tendon healing.

Antidiuretic hormone levels and the effect of indomethacin on ureteral colic.

We treated 25 patients with ureteral colic and urographically verified stones with 50 mg. indomethacin intravenously. Pain was relieved completely in 17 patients, while in 8 incomplete or no pain relief was achieved after the infusion of indomethacin. Patients completely relieved of pain had significantly higher levels of antidiuretic hormone in plasma before the infusion of indomethacin (18.2 plus or minus 3.4 pg./ml.) than patients with incomplete or no pain relief (7.2 plus or minus 1.3 pg./ml.) (p less than 0.01). These findings indicate that the volume status and/or the level of antidiuretic hormone may be of critical importance for pain relief after infusion of indomethacin in patients with ureteral colic.

Cholescintigraphy: a valuable diagnostic method in acute cholecystitis.

In 91 patients (36 men, 55 women) who were hospitalized with symptoms of acute cholecystitis, cholescintigraphy was performed with 99m-Tc-ethyl-IDA, in order to evaluate the method in the diagnosis of acute inflammatory disease of the gallbladder. Five groups of patients were recognized: (A) abnormal scintigraphy and verified gallbladder disease, (B) abnormal scintigraphy without verified gallbladder disease (false positive). (C) normal cholescintigraphy but cholelithiasis (false negative), (D) normal cholescintigraphy and no gallbladder disease, and (E) cholescintigraphy in icteric patients. In the diagnosis of acute cholecystitis the sensitivity was 92% and the specificity was 88%. Cholescintigraphy is a useful method for proving or disproving a diagnosis of acute cholecystitis with non-patent cystic duct. It does not reveal calculi in biliary ducts or in a gallbladder with patent cystic duct. In icteric patients, cholescintigraphy has restricted usefulness at serum bilirubin level around 120 mumol or more.

Separation of sutured tendon ends when different suture techniques and different suture materials are used. An experimental study in rabbits.

Calcaneal tendons in rabbits were divided and then sutured with varying suture techniques and suture materials. The separation of the tendon ends after suturing was registered with an X-ray technique--the tendon ends being identified by thin steel wires. Independently of the suture techniques and the suture materials a biphasic separation of the tendon ends was registered. The first separation took place during the first 4-5 days while the second separation began after 20-24 days. A small initial separation seems to indicate that the tendon suture used is adequate. The initial separation can therefore be used to evaluate a suturing technique and how the result is influenced by the suture material used. In the present study we could show that steel wire was ideal for a Bunnell suture. Prolene and Ethiflex cannot be recommended. A suture technique with a single short loop gave good results with all suture materials. Dexon ligatures placed around the tendon ends according to Schink in order to prevent the strands of the suture from cutting the tissue, did not reduce the initial separation. When a complex suture technique, like a Bunnell suture, is used the physical properties of the suture material influence the result. With a simple suture technique, a single short loop, good results can be achieved with every suture material.

Experimental evaluation of immobilization in operative and non-operative treatment of Achilles tendon rupture. A radiographic study in the rabbit.

Achilles tenotomy in rabbits was followed by operative or non-operative management. Various immobilization periods were used (0, 7, 16 and 35 days). Steel markers were fixed on the tendon ends to allow continuous X-ray monitoring of the distance between them. The separation of the tendon ends followed a biphasic course, with (I) and initial separation, 0-7 days, (II) no separation, 8-12 days, and (III) late separation, 22-35 days, irrespective of the therapeutic procedure. When the tendon was sutured, the initial separation was small if the leg was immobilized, but large if no immobilization was used. When no suture was applied, the initial separation was always large, whether or not the leg was immobilized. Large initial separation of the tendon ends always resulted in disturbed healing of the tendon. The final tendon end separation was independent of duration of immobilization. Good healing of cut Achilles tendon in rabbits thus requires immediate suture and immobilization for at least 7 days. The possible validity of these observations for tendon rupture in man offers interesting prospects.