Prophylactic antibiotics in elective colorectal surgery

In an effort to determine whether or not the addition of parenteral antibiotics to orally administered erythromycin and neomycin would diminish postoperative septic complications in elective colorectal operations, a randomized, double-blind, controlled trial was conducted comparing three groups. All patients received vigorous preoperative mechanical bowel preparation, 3 g erythromycin and 3 g neomycin orally, the day prior to operation. Patients in Group O received three doses of saline intravenously as placebo, patients in Group C received cefazolin, 1 g, immediately preoperatively and 1 g every 6 hours postoperatively, intravenously, for two doses, and patients in Group T received a single immediate preoperative dose of 6 g of ticarcillin intravenously and two saline placebo doses intravenously, postoperatively. The patients' progress was followed in the hospital and for one month postoperatively. Septic complications occurred in 35 per cent of patients in Group O, 7 per cent of patients in Group C, and 5 per cent of patients in Group T. Wound infections comprised most of these complications, occurring in 29 per cent of Group O, 4.7 per cent of Group C, and 2.3 per cent of Group T patients. Thus, the addition of either parenteral cefazolin or ticarcillin in this study significantly reduced wound infections in elective colorectal surgery.

The changing distribution of large intestinal cancer

In recent years, several accounts have reported a proximal migration of colorectal cancer. To determine the experience at the Jewish General Hospital in Montreal, 1044 cases of large-bowel cancer that presented between the years 1955 and 1978 were analyzed. The colon was arbitrarily divided into five anatomic regions, and the distribution of cancer in each region for each of eight three-year periods was calculated. An increase in right-sided lesions occurred from 15.6 per cent in the first three-year period to 37.6 per cent in the final three-year period (P less than 0.01). No significant change occurred in transverse and left-colon lesions. An increase in sigmoid carcinomas occurred from 14 per cent to 35 per cent (P less than 0.01). A dramatic decrease in rectal carcinoma from 53 per cent to 2.1 per cent occurred (p less than 0.001). These findings imply that methods for the early detection and screening of large-bowel carcinoma should be directed at the entire colon rather than the distal 25 cm.

Palliative resection for colorectal carcinoma

In an attempt to identify those patients who would benefit from palliative resection of the colon or rectum and those who would not, an analysis of ten years of resections was undertaken. For the 81 patients who underwent palliative resection, the operative mortality was 10 per cent and the postoperative morbidity was 50 per cent. The mean survival was 11.4 months and the median survival nine months. Poor prognostic factors deduced were patients with extensive liver metastases, those over the age of 75 years, and a previous history of cardiovascular disease. It is believed that patients with a combination of these factors may not benefit from palliative resection. Otherwise, resections satisfactorily relieve patients of the symptoms of impending obstruction and rectal bleeding and are, therefore, believed to be worthwhile.

Fistula-in-Ano: perineal fistula of intra-abdominal or intrapelvic origin simulating fistula-in-ano--report of seven cases

Fistulas manifesting in the perianal region but originating in the abdomen often have their true origin not recognized for extended periods. Examples of seven such complex cases are presented and discussed. Removal of the abdominal abnormality is mandatory before any cure can be effected; the perianal portion usually heals without any special local treatment.

Perianal endometrioma: report of five cases

One of the gynecologists' commonest findings at pelvic laparotomy is endometriosis. Despite the fact that the presence of endometrial tissue in ectopic locations is commonplace, the finding of a perianal endometrioma is no more than a surgical curiosity. Very few cases have been reported. The present report describes five such verified cases. Interestingly enough, only two of the five cases were diagnosed preoperatively. The pathogenesis of endometriosis has been, and continues to be, controversial. The prevailing theories include 1) transtubal regurgitation of menstrual blood, 2) the coelomic metaplasia doctrine, 3) lymphatic dissemination, and 4) hematogenous spread. Pathologically the lesions may vary grossly from red-blue to yellowish-brown implants, ranging in size from microscopic to 1-2 cm in diameter. The definitive histologic diagnosis requires two of the following three features-glands, stroma, and hemosiderin pigment. The clinical manifestations depend upon the functional activity of the involved tissue and may range from an asymptomatic mass to the classic presentation of a mass increasing in size and becoming acutely painful during menstruation but subsiding in size and decreasing in tenderness between menstrual periods. These protean manifestations are readily illustrated by the cases presented. Anatomically the lesions are usually found in old episiotomy scars. Because these lesions are usually readily accessible, and because their exact nature is frequently not known preoperatively, the treatment of choice is local excision. Complementary hormonal therapy has been suggested, but the value of such treatment is not yet proven. Ovarian ablative therapy is also considered.

A classification of fistula-in-ano

A classification of anal fistulas is presented, which is the result of an analysis of 400 cases treated over the past 15 years, based on the pathogenesis of the disease and the normal muscular anatomy of the pelvic floor. Four main types were found but numerous variations of each occur, which are described. It is hoped that this will alert the surgeon to the various complex situations that he may encounter.

Treatment of rectal prolapse

There are two schools of thought concerning the aetiology of rectal prolapse. On the one hand it was conceived to be a sliding hernia through a defect in the pelvic fascia, while on the other hand radiological studies have demonstrated prolapse to be represented by an intussusception of the rectum. Various operative procedures have been proposed for the treatment of rectal prolapse based on the belief in one or the other of these concepts. The anatomic defects which have been described with prolapse include a defect in the pelvic floor with diastasis of the levatores ani, loss of the normal horizontal position of the rectum, an abnormally deep cul-de-sac of Douglas, a redundant rectosigmoid, and a patulous anal sphincter. The popularly used procedure in Great Britain is that in which a sheet of Ivalon sponge is sutured to the sacrum and wrapped around the rectum thus anchoring it in place. Various authors have reported good results using this technique. The mortality and morbidity rate appear to be acceptable. In the U.S.A. a popular procedure is the Ripstein technique where a sheet of Teflon is wrapped around the rectum anteriorly anchoring the rectum to the sacrum. This technique also has its proponents who rport satisfactory results. Abdominal proctopexy and sigmoid resection, although not in common general use, has been found to be effective with an acceptable morbidity and mortality rate. These three procedures have some drawbacks but the one problem common to all the repairs so far developed for prolapse is their inability to guarantee to restore continence. Probably half the patients operated upon continue to be incontinent. Faradic stimulation of the sphincter has not proved to be as helpful as initially hoped.

Cystathionine synthase from rat liver: partial purification and properties

Cystathionine synthase which has been purified about 1000-fold from rat liver has absorbance maxima at 280, 360, and 428 mμ. Treating the enzyme with cysteine apparently affects the removal of pyridoxal phosphate and destroys the enzyme activity. So does reduction with borohydride. However, in neither case is the spectrum affected. These observations suggest that pyridoxal phosphate may be bound to cystathionine synthase in an atypical fashion.Mercuric ions strongly inhibit the enzyme, but not in the presence of serine; hydroxylamine inhibits, but not in the presence of substrates. Other carbonyl reagents inhibit little if at all. Sulfate ions activate the enzyme.A new assay procedure for cystathionine synthase has been devised. In the presence of 5,5′-dithiobis-(2-nitrobenzoic acid), the enzyme catalyzes the degradation of cystathionine to serine and homocysteine. The rate of increase in absorbance at 412 mμ is a measure of enzyme concentration.