Biomedical subjects
Publications and source records attributed to J Wetterfors.
Chronic idiopathic constipation requires surgical treatment in some rare cases. Seven such patients are presented. Subtotal colectomy was performed in six of them and left hemicolectomy in one. All patients were satisfied, with 1-6 bowel movements daily, and none had complications necessitating surgery. Subtotal colectomy seems to be the preferable operation.
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Nine local recurrences have been diagnosed in 38 patients with carcinoma of the rectum operated on with anterior resection using the EEA-stapling instrument. The characteristics of these recurrences have been compared with those of other authors, currently a total of 27 recurrences. The presence of a locally advanced growth with extramural spread, a distal location and a short margin of clearance seems to increase the risk of local recurrence, with often distressing symptoms. It is proposed that even if the EEA-stapler offers technical possibilities for anterior resection in these growths, this operation should be restricted to less advanced tumours.
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Preoperative nutritional status and muscle energy metabolism were studied in 26 patients with gastric carcinoma. Fat stores were reduced in 30% and visceral proteins in 25% to 90% of the patients. According to the nutritional assessment, the patients were divided into well-nourished (group I, n = 8) with no or minor signs of malnutrition and malnourished (group II, n = 13) with signs of pronounced malnutrition. Group I had normal content of muscle energy metabolites despite their malignant disease. In group II, adenine nucleotides (p less than 0.001), phosphorylcreatine (p less than 0.01), creatine (p less than 0.05) and also glycogen (p less than 0.01) were markedly decreased. Weight loss, albumin, and fibronectin levels correlated significantly with adenosine-triphosphate, total adenine nucleotides, and glycogen levels. The most malnourished patients also had the poorest energy metabolite status in the muscle. These findings revive the interest in nutritional assessment.
The EEA-autostapling device was used for the anastomosis in 34 patients operated upon with anterior resection for carcinoma of the rectum. The lower border of the tumours was located between 6 and 20 cm from the anal verge and the distal margin free of tumour in the resected specimen was 4 cm (1-8 cm). The anastomoses were within 10 cm from the anal verge in 27 patients. Technical problems occurred in two patients. Eight cases showed incomplete tissue rings but anastomotic leakage was noted merely in four patients (12%). Wound infections were rare (6%). According to Dukes' classification the material comprised 15% Dukes' A, 32% Dukes' B. 38% Dukes' C and 15% Dukes' D. The patients were followed with clinical examinations, rectal palpation and sigmoidoscopy every 3-6 months after the operation. Early local recurrence (median value 5 months) was diagnosed in seven patients (21%). They had in common tumour in the lower part of the rectum, extramural spread and a short distal margin free of tumour. Three of these were classified as Dukes' D, three as Dukes' C and one as Dukes' B. It is concluded that early local recurrence after anterior resection may be due to local tumour spread but a decreased circular radicality may be another reason. The results demonstrate the need to define patients who might be treated by an abdomino-perineal excision even if the EEA-stapler makes a low rectal anastomosis possible.
Three-hundred and ninety-five cases of massive upper gastrointestinal haemorrhage were treated in the Surgical and Anaesthesiological Departments of the University Hospital in Linköping over a 5-year period. The mortality was 13%, or 10% when oesophageal varicosities are excluded. Results of a consistent policy concerning surveillance, diagnostic measures, and different forms of therapy are described. From the surgeon's point of view, emphasis is laid on the importance of endoscopy as a means of decreasing the number of exploratory gastroduodenotomies and increasing the proportion of patients in whom surgery is directed against a known source of bleeding. This leads to an enhancement of surgical expediency.
During the 4-year period (1974-1977) 1204 operations were performed for cholelithiasis. Of 139 patients who underwent choledocholithotomy, retained stones in the bile ducts were diagnosed in 22 (15.8%). Peroperative cholangiograms taken before and after exploration of the bile duct were re-examined and compared to a control material. A major factor in the occurrence of retained stones was the number of the stones on the pre-explorative cholangiogram. Among patients with retained stones 64% had five or more stones in their bile ducts on the pre-explorative cholangiogram. The corresponding frequency in controls was only 18% and this difference is statistically significant. Neither the size of stones, nor the diameter of the common duct had any bearing on the incidence of retained stones. On the post-explorative cholangiogram an interrupted passage of contrast medium into the duodenum was no proof of retained stones. False negative cholangiograms after surgical exploration of the common duct were seen in 27% and in the control group there were false positive cholangiograms in 47%. Retained stones that are undiagnosed after operation and those that are known, but cannot be removed, reflect, respectively, diagnostic and therapeutic failure. In this context, measures to improve both these areas are discussed.
43 patients were the subject of a comparative trial of the use of tinidazole (n = 22) and doxycycline (n = 21) in the prevention of surgical sepsis in elective colorectal surgery. The trial was open, prospective and randomized with prophylactic treatment instituted parenterally immediately before the operation. Topical ampicillin was supplemented in eight cases with fecal spillage. All patients underwent a standard preoperative mechanical preparation of the bowel. At the end of the trial period, there was one superficial aerobic abdominal wound infection and one deep anaerobic infection in the tinidazole group. Anastomotic dehiscence occurred in one patient treated with doxycycline. There were no significant differences in the results obtained with the two drugs and both regimens appear to be highly effective in the prevention of deep anaerobic postoperative sepsis in elective colorectal surgery.
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A prospective randomized double-blind study comprising 118 patients was performed to evaluate the effects of doxycycline as a prophylactic antimicrobial in elective colonic surgery. Fifty-eight patients were treated and 60 were controls. 200 mg of active substance or placebo was given 4-6 hours before operation and 100 mg daily for the next five postoperative days. Levels of doxycycline in serum and tissues were determined and related to the MIC-values of the contaminants. A significantly lower incidence of abdominal wound sepsis, intra-abdominal complications and septicaemia was found in the doxycycline group (12.4%) compared to the controls (45%). The positive effects were most pronounced in the non-contaminated cases, and especially in the cases with negative wound culture at operation. In order to evaluate the effect of prophylaxis in clinical routine an open study comprising 182 patients was carried out. In the group of patients receiving adequate prophylaxis (159 patients) the abdominal wound sepsis rate was 8.1%. 11 other patients who had received doxycycline preoperatively for some time because of intra-abdominal infection developed wound sepsis in 63.4%. In 12 patients where incomplete or no prophylaxis was given, the wound sepsis rate was 33.2%. The frequency of abdominal septic complications did not differ between non-contaminated, 10.9%, and contaminated operations, 13.8%, partly because of the topical application of ampicillin in some of the patients belonging to the latter category. Preoperative treatment with doxycycline because of some intra-abdominal was evidently the single risk factor associated with a high septic complication rate. No adverse ecological effects were seen during the 19 months study.
The effects of prophylactic treatment with doxycycline on additional antimicrobial use and on postoperative hospital stay in elective colorectal surgery were evaluated in a prospective and randomized study, where the incidence of abdominal sepsis was significantly reduced from 45% in the control to 12.1% in the doxycycline group. Results from a subsequent comprehensive series, where prophylaxis was used routinely in elective intestinal surgery are also reported. With prophylaxis the average number of postoperative days decreased with 7 days (p less than 0.01). In cases with abdominal sepsis this difference was more prominent. With prophylactic treatment it prolonged hospital stay with 7 days compared to 22 days without. Without prophylactic treatment 65% of the patients received antimicrobial treatment during the postoperative course, whereas less than 20% among the treated patients did so. The period of exposure to antimicrobials was longer in patients in the control group than among patients receiving prophylaxis. Thus prophylaxis significantly reduced the rate of abdominal sepsis, the time of and the need for postoperative nursing, the total use of and time of exposure to antimicrobials. Furthermore, microbiological disturbances have not been observed during four years of extensive use of doxycycline.
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A prospective double-blind study on the effects of doxycycline as a prophylactic antimicrobial in elective colonic surgery is presented. One hundred-eighteen patients were evaluated. Fifty-eight were treated and 60 were controls. Two hundred milligrams, doxycycline or placebo (two capsules) were given orally four to six hours prior to surgery and 100 mg or placebo (one capsule) for five days postoperatively. Doxycycline levels in serum and tissues were determined and related to the MICvalues of the contaminants of the operative field. A significantly lower incidence of abdominal wound sepsis, intra-abdominal complications, and septicemia was recorded in the doxycycline group compared to the control group, 12.1 and 45% respectively. The prophylactic effect was most pronounced in patients with a negative wound culture upon closure. Macroscopical peritoneal contamination was associated with less severe consequencies in the doxycycline group. Infections in the perineal field, 3/15 vs 8/17, appeared alone in the doxycycline group, whereas they were combined with abdominal sepsis in 6/8 among the controls. Treatment also reduced the incidence of repeat laparotomy due to septic complications, 0 vs 8. Thus systemic per and postoperative prophylaxis with doxycycline significantly reduced both the incidence and the severity of postoperative sepsis in potentially contaminated elective colorectal surgery without any adverse reactions.
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An investigation on the relation between the effect of doxycycline as prophylactic antibiotic in colonic surgery and levels of doxycycline in serum and bowel tissue with reference to MIC-values of bacterial strains isolated at surgery or after postoperative septic complications is presented. 200 mg doxycycline orally 4-6 hours preoperatively resulted in a serum concentration of 4.0 +/- 0.3 mug/ml at the onset of operation. Tissue samples removed at surgery were assayed for doxycycline. High levels were observed in bowel tissue, ileum 7.5 +/- 1.2 mug/ml and colon 3.9 +/- 0.3 mug/ml. The effects of dosage, time of administration and bowel pathology on tissue levels are discussed. Aerobic and anaerobic bacterial strains were tested for in vitro susceptibility to doxycycline using a standardized disc-diffusion method according to Eriksson and Sherris. 75% of the strains belonged to sensitivity groups 1 and 2 (sensitive-fairly sensitive). That is, MIC-values in 75% of the strains were below the average serum and intestinal tissue concentration during the operation. The implications of these results are that the dosage and time of administration of the drug must be adjusted so that serum and tissue levels are adequate during surgery.