Drowning in antibiotics.

INTRODUCTION: The National Confidential Enquiry into Perioperative Deaths (NCEPOD) report recommended that 'fluid prescribing be given the same value as drug prescribing', yet fluid prescription is commonly delegated to junior doctors despite being a notoriously challenging topic. When antibiotics are given as an infusion they are diluted in 100ml of fluid, which is often unaccounted for when thinking about a patient's fluid requirements. This closed-loop audit aimed to assess first, intravenous (IV) fluid therapy and second, electrolyte prescribing compliance with National Institute for Health and Care Excellence (NICE) guidelines, with and without the additional fluid given with antibiotic administration. METHODS: Two retrospective audits were performed. Total fluid and electrolyte volume received with and without antibiotic fluids was correlated with recommendations in the NICE guidelines. Between cycles 1 and 2, potassium chloride with sodium chloride and glucose (PSG) was introduced as an alternative to IV maintenance fluid, and bolusing of antibiotics was mandatory. RESULTS: When analysing total fluid volume input per day, 10.4% and 7.45% of patients met their fluid requirement accurately in the first and second cycles, respectively. Within cycle 1, the mean total additional fluid that was given over 3 days with antibiotics was 1,572.73ml. In cycle 2, this decreased to 469.44ml when antibiotics were given as a bolus. CONCLUSIONS: In this closed-loop audit we noted that patients receiving IV fluids and IV antibiotics received too much additional fluid when the antibiotic dilution fluid was taken into account. Additional fluid was reduced alongside the proportion of electrolyte complications when bolusing of antibiotics was introduced. We recommend that that all nurses are trained to give antibiotics as a bolus because it can help to reduce fluid-related complications.

Meta-analysis of oral antibiotics, in combination with preoperative intravenous antibiotics and mechanical bowel preparation the day before surgery, compared with intravenous antibiotics and mechanical bowel preparation alone to reduce surgical-site infections in elective colorectal surgery.

BACKGROUND: Surgical-site infection (SSI) is a potentially serious complication following colorectal surgery. The present systematic review and meta-analysis aimed to investigate the effect of preoperative oral antibiotics and mechanical bowel preparation (MBP) on SSI rates. METHODS: A systematic review of PubMed, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials was performed using appropriate keywords. Included were RCTs and observational studies reporting rates of SSI following elective colorectal surgery, in patients given preoperative oral antibiotic prophylaxis, in combination with intravenous (i.v.) antibiotic prophylaxis and MBP, compared with patients given only i.v. antibiotic prophylaxis with MBP. A meta-analysis was undertaken. RESULTS: Twenty-two studies (57 207 patients) were included, of which 14 were RCTs and eight observational studies. Preoperative oral antibiotics, in combination with i.v. antibiotics and MBP, were associated with significantly lower rates of SSI than combined i.v. antibiotics and MBP in RCTs (odds ratio (OR) 0·45, 95 per cent c.i. 0·34 to 0·59; P < 0·001) and cohort studies (OR 0·47, 0·44 to 0·50; P < 0·001). There was a similarly significant effect on SSI with use of a combination of preoperative oral aminoglycoside and erythromycin (OR 0·40, 0·25 to 0·64; P < 0·001), or preoperative oral aminoglycoside and metronidazole (OR 0·51, 0·39 to 0·68; P < 0·001). Preoperative oral antibiotics were significantly associated with reduced postoperative rates of anastomotic leak, ileus, reoperation, readmission and mortality in the cohort studies. CONCLUSION: Oral antibiotic prophylaxis, in combination with MBP and i.v. antibiotics, is superior to MBP and i.v. antibiotic prophylaxis alone in reducing SSI in elective colorectal surgery.

Laparoscopic and minilaparotomy cholecystectomy: a randomized trial comparing postoperative pain and pulmonary function.

BACKGROUND: Upper abdominal surgery is associated with severe postoperative pain and a concomitant reduction in pulmonary function and oxygen saturation. Laparoscopic cholecystectomy is said to result in less postoperative pain compared with open cholecystectomy. METHODS: In a pragmatic, randomized trial, postoperative pain, opiate analgesic consumption, oxygen saturation, and pulmonary function (forced vital capacity, forced expiratory volume in 1 second, and peak expiratory flow rate) were assessed after laparoscopic (n = 67) and minilaparotomy (n = 65) cholecystectomy. RESULTS: Compared with minilaparotomy cholecystectomy, laparoscopic cholecystectomy was associated with lower linear analogue pain scores (median 40 vs 59, p < 0.001), lower patient-controlled morphine consumption (median 22 vs 40 mg, p < 0.001), a smaller reduction in postoperative pulmonary function (mean peak expiratory flow rate 64% of preoperative value vs 49%, p < 0.001), and better oxygen saturation (mean 92.9% vs 91.2%, p = 0.008). CONCLUSIONS: This study confirms that the postoperative pain and pulmonary changes associated with upper abdominal surgery are significantly reduced by the laparoscopic technique. These findings suggest that laparoscopic cholecystectomy may result in a reduced risk of postoperative pulmonary complications.

Oesophageal carcinoma and hypercalcaemia: a clinical study.

Out of a retrospective series of 89 consecutive cases of squamous oesophageal carcinoma, twelve cases (13.3%) had hypercalcaemia (one of which is described in detail). Four out of the seven patients (57%) who had bone surveys had bone metastases. In hypercalcaemic patients the median survival was 17 weeks, while in normocalcaemic patients median survival was 19 weeks. The hypercalcaemia was overlooked or ignored in eleven out of the twelve cases. The high incidence of hypercalcaemia in oesophageal carcinoma may not be well recognised. Since a significant percentage of cases may not have bone metastases, the occurrence of a raised calcium does not necessarily preclude attempted curative treatment and, in addition, treatment of the hypercalcaemia may provide valuable relief of what are sometimes distressing symptoms.

Squamous carcinoma of the colon: primary or metastatic?

A patient is reported who developed a tumour of the transverse colon, which at presentation appeared histologically and clinically to be a primary squamous cell keratinizing carcinoma, arising from an area of in situ carcinoma in the colonic epithelium. However, she had had a stage 1 cervical carcinoma treated by Wertheim's hysterectomy 7 years previously and although there were no other signs of recurrence, this raised the possibility that the lesion might be metastatic. Thirty-seven previously reported cases of primary squamous carcinoma of the colon and those of squamous carcinoma metastasizing to the colon and mimicking primary lesions are reviewed.

Diabetes insipidus developing after subarachnoid haemorrhage from an anterior communicating artery aneurysm.

I describe a patient with an anterior communicating artery aneurysm who developed transient diabetes insipidus two days after a subarachnoid haemorrhage. I have reviewed similar cases in the literature and discuss the pathogenesis of the diabetes insipidus in such cases.

Alcoholic ketoacidosis: a case report.

A 43-year-old alcoholic presented in coma with ketoacidosis, after three days of nausea and feeling generally unwell, which had been preceded by a prolonged three-week period of heavy alcohol consumption with poor dietary intake. The acidosis responded rapidly to intravenous dextrose. This is the first Scottish report of a case of alcoholic ketoacidosis.

Amitriptyline overdose complicated by intestinal pseudo-obstruction and caecal perforation.

I report a case of intestinal pseudo-obstruction, spontaneous caecal perforation and faecal peritonitis caused by an overdose of amitriptyline. This rare but serious complication should be borne in mind in patients who remain constipated while convalescing after self-poisoning with tricyclic antidepressants.

Primary appendicitis epiploicae mimicking acute appendicitis.

We report two cases of primary appendicitis epiploicae, caused by torsion, whose presentation mimicked acute appendicitis.

Clinical investigation of acute lower gastrointestinal haemorrhage.

Over a four-year period (1984-1987) nine consecutive patients presented with acute lower gastrointestinal haemorrhage requiring emergency investigation with scintigraphy (using radionuclide-labelled blood-pool agent), angiography or colonoscopy or a combination of these. Angiography in two patients was unhelpful. Of three colonoscopic examinations, two were technically unsatisfactory. In two patients with persistent bleeding requiring urgent surgery, scintigraphy located the bleeding site pre-operatively, while in five patients with negative scintigraphy bleeding settled spontaneously without operative intervention. The relative merits of the above investigations are discussed.

Combined predeposit and salvage autotransfusion in elective aortic aneurysm repair.

In this study assessing the safety and value of the routine use of autotransfusion in elective aortic aneurysm surgery, the first 16 patients (control group) received homologous transfusion only, while the subsequent 38 patients (autotransfusion group) received a combination of predeposit and salvage autotransfusion (Solcotrans device). Between 1 and 3 units of blood were venesected preoperatively, and a median of 0.80 (0.20-2.75) litres of unwashed shed blood was salvaged and re-infused (48% of the measured blood loss). A median of 4 units of banked blood was required in the control group compared with 2 units in the autotransfused group, an average saving of 2 units per patient (P < 0.001). Banked blood was avoided completely in 37% of patients in the autotransfusion group. There were no haematological or biochemical complications. Predeposit and salvage autotransfusion is simple and safe, and reduces banked blood requirement in aortic aneurysm surgery.

Compression-fixation of long bone fractures: problems and pitfalls revisited.

We have carried out a retrospective study, over a 2.5 year period, of the results of compression-fixation for diaphyseal long bone fractures (forearm 49, tibia 18, others 9). The method was used in forearm fractures mainly for fresh fractures, whilst in fractures of the tibia it was predominantly for delayed union. In forearm fractures, although 10 per cent showed failure of fixation, only 2 per cent developed infection, and 90 per cent recovered a full range of movement. Conversely, plating of fractures of the tibia with delayed union resulted in a 37 per cent deep infection rate. It is concluded that while compression-fixation gives excellent results when applied to displaced forearm fractures, alternative methods should be used in fractures of the tibia with delayed union. This unexpected finding illustrates the value of periodic audit of surgical results.

Ventilatory and blood gas changes during laparoscopic and open cholecystectomy.

As part of a randomized trial, ventilatory and arterial blood gas changes were assessed during open (n = 30) and laparoscopic (n = 30) cholecystectomy. Measurements were made during anaesthesia before the start of surgery and at the time of removal of the gallbladder. Despite an increase in minute ventilation from a mean(s.d.) of 5.7(1.4) to 6.1(1.2) litres, mean(s.d.) arterial carbon dioxide tension (PaCO2) rose from 5.3(0.9) to 6.0(0.9) kPa during laparoscopic cholecystectomy. End-tidal carbon dioxide tension (PE'CO2) had poor precision in predicting PaCO2 (95 per cent interval of agreement -0.61 to 1.93 kPa). Mean(s.d.) peak airway pressure increased from 17(4) to 23(4) cmH2O. The mean PaCO2--PE'CO2 value did not change significantly, although there was significant within-patient variation. Arterial oxygen levels did not change significantly. By comparison, no clinically significant changes in ventilation or blood gas values occurred during open cholecystectomy. In conclusion, laparoscopic cholecystectomy requires a substantial but variable increase in minute ventilation to compensate for carbon dioxide absorption from the peritoneum.

Impact of laparoscopic cholecystectomy: a population-based study.

BACKGROUND: We assessed the effect of the introduction of laparoscopic cholecystectomy on surgical outcomes in routine practice. METHODS: Hospital discharge and death-certificate data were linked for all patients undergoing cholecystectomy (n=85120) in Scottish public-sector hospitals (n=51) between January, 1981, and June, 1999. The primary endpoints were cholecystectomy rate, hospital stay, and postoperative mortality. Regression methods were used to examine the effect of laparoscopic experience and surgeon caseload on postoperative mortality and hospital stay. FINDINGS: From 1989 to 1999, the proportion of cholecystectomies done laparoscopically rose from none to 80%, and the age-standardised cholecystectomy rate increased by 20% (95% CI 15-26). Postoperative mortality did not change in the 1990s (odds ratio 0.99 [0.7-1.4], p=0.99). The mean postoperative hospital stay fell from 8.0 (SD 3.7) to 2.9 (3.2) days. There was wide variation between hospitals in the proportion of cholecystectomies done laparoscopically and in average hospital stay. For individual surgeons, increasing laparoscopic experience and annual caseload were associated with higher proportions of laparoscopic procedures and shorter hospital stays. Postoperative mortality was higher during the first ten laparoscopic cholecystectomies done by a surgeon (compared with >200 procedures, odds ratio 2.3 [1.2-4.6], p=0.015). INTERPRETATION: The laparoscopic method reduced hospital stay but had no overall effect on postoperative mortality. Studies to assess the appropriateness of the increased cholecystectomy rate are merited. The wide variation in the proportion done laparoscopically, together with evidence of better results for surgeons doing more procedures, suggests scope for further reductions in hospital stay and morbidity.

Acute-phase protein response, survival and tumour recurrence in patients with colorectal cancer.

INTRODUCTION: An acute-phase protein response (APPR) has been associated with reduced crude survival rates and increased recurrence following apparently curative resection in patients with colorectal cancer. This study investigated the prognostic significance of a preoperative and postoperative APPR in relation to disease-specific mortality rate. METHODS: Some 202 patients with colorectal cancer were followed for at least 5 years. C-reactive protein concentration, measured before and at 3 months after operation, was used as an index of the APPR. Univariate and multivariate analyses were performed on a number of potential prognostic factors. RESULTS: Thirty-six per cent of patients had an APPR and this was associated with a higher rate of local tumour invasion, fewer curative resections and a higher carcinoembryonic antigen (CEA) concentration. There was no difference in Dukes' stage between patients with or without an APPR. The most important prognostic factor related to both disease-specific and crude survival was Duke's stage (P < 0.0001). Subgroup analysis demonstrated that APPR had prognostic significance only in patients with advanced disease (P = 0.013). An APPR was present in a minority of patients (11 per cent) after operation and was not associated with increased likelihood of tumour recurrence. CONCLUSION: The APPR is increased in more than a third of patients presenting with colorectal cancer and is associated with more frequent local tumour invasion, fewer curative resections and a higher CEA level. An APPR at 3 months after operation does not have the prognostic significance reported by earlier studies.

Laparoscopic interventions in the gut: yesterday, today, and tomorrow.

The development of laparoscopic interventional surgery has brought about a revolution in general surgery over the past 5 years. Laparoscopic cholecystectomy has now become the treatment of choice for symptomatic cholelithiasis because of a reduction in access trauma, resulting in less postoperative pain and a faster recovery. Laparoscopic fundoplication for gastroeosophageal reflux also looks to be a promising procedure which will probably become generally accepted. Laparoscopic hernia repair, although widely practised, has raised question marks because of doubt about recurrence rates and major complications such as intestinal obstruction. Laparoscopic colectomy has similarly raised concerns about complication rates and tumour recurrence rates. Laparoscopic appendicectomy offers marginal benefits over open appendicectomy. Virtually every other intra-abdominal procedure has been performed laparoscopically, but most require further evaluation.

Laparoscopic versus open cholecystectomy and the need for a randomized trial: a survey of surgeons and ethical committees in the British Isles.

A questionnaire on the necessity and ethics of a randomized trial to compare laparoscopic cholecystectomy and open cholecystectomy was sent to 200 randomly selected surgeons in the British Isles, of whom 117 replied. Of these, 58% thought that a trial was needed to compare laparoscopic cholecystectomy with open cholecystectomy by either minilaparotomy or the conventional approach. Nearly half (45%) expressed interest in participating in such a trial. A hypothetical protocol for a trial was sent to 40 ethical committees; 25 gave approval and only 3 considered that a trial was unethical (12 refused to comment). This survey shows wide support for a trial comparing laparoscopic cholecystectomy with open cholecystectomy.

Bile duct injury and bile leakage in laparoscopic cholecystectomy.

The introduction of laparoscopic cholecystectomy has been associated with an increased incidence of bile duct injury. This review presents the incidence of bile duct injury in reported series and examines the role of the learning curve and other contributing factors. There is good evidence to suggest that, with adequate training and experience, the incidence of biliary injury can be reduced to a level comparable to that of open cholecystectomy. Continued audit is required to ensure that the low complication rates achieved in selected centres with wide experience are reproduced by the surgical community in general.