Effect of topical and systemic antibiotics on bacterial growth kinesis in generalized peritonitis in man

Outcome of a conservative policy for managing acute sigmoid diverticulitis

Background

A conservative policy for patients presenting with acute sigmoid diverticulitis is associated with a low operation rate, and low overall and operative mortality rates. The long-term consequences of such a policy were investigated.

Methods

Data were collected prospectively for 232 patients with acute sigmoid diverticulitis between 1990 and 2004. Details of all subsequent readmissions were obtained and survival to August 2005 was analysed.

Results

Of the 232 patients admitted, 60 (25·9 per cent) were known to have diverticulosis; in 172 patients it was a new diagnosis. Thirty-eight patients (16·4 per cent) underwent sigmoid resection, with one death. Three elderly patients in whom a decision was made not to operate had perforated diverticulitis at autopsy. Of 191 patients discharged without resection, 35 (18·3 per cent) subsequently underwent sigmoid resection: 26 (13·6 per cent) elective and nine (4·7 per cent) emergency, with one death.

Conclusion

A conservative policy is safe in both the short term and the long term.

Principles and limitations of operative management of intraabdominal infections

Operative management of intraabdominal infections still rests on the principles of elimination of focus, reduction of contamination of the peritoneal cavity, and treatment of residual infection. To control the source of contamination from a perforated viscus primary closure, exclusion or resection may be considered with respect to the severity of peritonitis and to the underlying disease. The principle of "peritoneal toilet" with complementary use of systemic and/or local antibiotics is generally accepted even if the value of aggressive debridement is still debated controversely. For the treatment of residual and the prevention of recurrent infection, closed and open lavage techniques, the left-open abdomen, and planned relaparotomy represent the major approaches in severe generalized peritonitis when the infectious focus might not be securely controlled. The values and disadvantages of different regimens are discussed, additional measures are briefly described, and an outlook on areas of further research is given.

Proposed definitions for diagnosis, severity scoring, stratification, and outcome for trials on intraabdominal infection. Joint Working Party of SIS North America and Europe

Analysis of the experience with scientific studies on patients with secondary intraabdominal infection has revealed that problems of interpretation and comparability between studies exist as they relate to variable diagnostic criteria, unmeasured severity of disease, and unclear outcome measures. A consistent system of definitions has been developed to address these deficiencies. Intraabdominal infection is defined as clinical peritonitis requiring both operative and microbiological confirmation for proof of infection. The APACHE II system is proposed for grading the severity of the infection and for stratification of patient risk of mortality. Mortality and time until death, on one hand, and recovery and time until recovery, on the other, are proposed as the main outcome measures, both being independently and positively defined. It is anticipated that this system of minimum rules will produce studies that can be compared, hence, accelerating knowledge and understanding about intraabdominal infection and its best treatment.

Management of obstructed and perforated large bowel carcinoma

Obstructed large bowel carcinoma is a disease of the aged, often with concomitant disease and also advanced malignancy. The immediate mortality rate of operation is high and long-term prognosis is poor in comparison with elective surgery. It is important before operation that the diagnosis be established by sigmoidoscopy and emergency contrast studies. Staged procedures based on considerations of safety have given way to immediate resection. For right-sided colonic obstruction immediate resection and anastomosis is now almost universal and for left-sided tumours primary resection has overtaken staged resection in the UK. An anticipated survival advantage for primary resection has not, however, been confirmed. Obstruction complicated by perforation is an absolute indication for resection. After left-sided resection, making an anastomosis is associated with higher risk of leakage than after an elective operation. In the most adverse circumstances of associated sepsis, Hartmann's operation retains its place but immediate anastomosis is the most frequent option for many. Additional manoeuvres to make this safe include peroperative antegrade colonic irrigation and subtotal colectomy, although segmental resection with anastomosis and without bowel preparation is also practised and may be safe in selected patients. When major resectional surgery is undertaken in aged patients at high risk of mortality, the rule that the operator should be fully trained in elective large bowel surgery is incontrovertible. It is at least equally important that the anaesthetist is experienced and capable of instituting, interpreting and acting upon sophisticated cardiopulmonary monitoring.

Preventing wound infection after appendicectomy: a review

An exponential increase in the number of published prospective studies reflects both a continuing interest in, and a lack of consensus on, the optimal prophylaxis of wound sepsis after appendicectomy. Review of the literature over the last 25 years leads us to emphasize both the importance of adequate study size and of stratification of the severity of the sepsis found at operation. For critical comparison of prophylactic regimens the high percentage of wound infections disclosed after discharge from hospital must be taken into account. Antibiotics reduce the frequency of wound sepsis and although low wound sepsis rates have been reported with systemic antibiotics active against only anaerobes, the cumulative evidence favours a spectrum of antibacterial activity against both aerobic and anaerobic organisms. Topical antiseptics have no significant effect but topical antibiotics are beneficial. Wide variations in outcome for similar antibiotic regimens reflect the importance of technical factors in determining the frequency of wound sepsis.

Ten-year computerized audit of infection after abdominal surgery

A prospective audit of the frequency of infective complications after all abdominal operations was carried out between January 1977 and December 1986. A total of 3100 abdominal procedures (2041 elective; 1059 emergency) were performed in 3056 patients. There were 50 (1.6 per cent) in-hospital and 66 (2.1 per cent) late wound infections (overall 3.7 per cent). Fifty-four (1.8 per cent) patients developed postoperative intraperitoneal sepsis. Ninety-eight patients died (overall mortality 3.2 per cent) and intraperitoneal sepsis was a related factor in twelve (0.4 per cent). Wound infection, peritoneal sepsis and mortality were related to the degree of operative contamination and to reoperation. The results support the traditional, although sometimes inadequately stressed, teaching that technique is an important factor in preventing infection. Infection is also reduced by peroperative antibiotic lavage. The limited value and the potential difficulties of the unstructured introduction of computerized audit should be recognized.