To determine whether mechanical bowel preparation influences the incidence of anastomotic dehiscence following colorectal surgery, 186 patients undergoing elective left colonic or rectal resection were randomized before surgery to bowel preparation (n = 89) or no bowel preparation (n = 97). Surgical technique was standardized and no patient had a defunctioning colostomy. Seventeen patients were excluded (seven with preparation, ten without). Indications for surgery in the remaining 169 patients were carcinoma (133 patients), diverticular disease (26), inflammatory bowel disease (six) and miscellaneous conditions (four). Operations performed were left colonic resection or reversal of Hartmann's procedure (26 with preparation, 28 without) and anterior resection (56 versus 59). The overall morbidity rate (18 per cent) was similar in the two groups. All seven clinical anastomotic leaks occurred after low anterior resection, in three of the 39 patients who had undergone bowel preparation and four of the 36 who had not (P > 0.9). Two deaths occurred, both of patients who had received bowel preparation, one being secondary to anastomotic leakage. Bowel preparation does not influence outcome after elective colorectal surgery.
Hypoalbuminemia is an independent risk factor for the development of SSI following gastrointestinal surgery and is associated with deeper SSI and prolonged inpatient stay.
Acute whiplash injuries are a common cause of soft tissue trauma for which the standard treatment is rest and initial immobilisation with a soft cervical collar. Because the efficacy of this treatment is unknown a randomised study in 61 patients was carried out comparing the standard treatment with an alternative regimen of early active mobilisation. Results showed that eight weeks after the accident the degree of improvement seen in the actively treated group compared with the group given standard treatment was significantly greater for both cervical movement (p<005) and intensity of pain (p<0-0125). IntroductionRear end collisions causing soft tissue injuries of the neck are common and constitute about 20% of all vehicle accidents.' The term whiplash has been coined to describe those injuries due to sudden flexion and hyperextension of the cervical spine. Hyperextension is thought to be the main cause of damage,2 and the severity of injury depends on the degree of movement of the head and neck on the trunk and the acceleration.3 These injuries frequently result in prolonged disability, but because of subsequent litigation the authenticity of such symptoms has been queried.43 Recently Merskey reviewed published reports and concluded that many patients genuinely have protracted symptoms.6 The reports, however, have not placed any emphasis on treatment, concentrating instead on prognosis because of its medicolegal importance. 8 Treatment of whiplash injuries entails a period of immobility using a soft cervical collar and simple analgesia before gradual mobilisation. As the efficacy of this treatment is unknown we examined the response of patients to the standard treatment compared with that of another group given alternative treatment of daily neck exercises and mobilisation using the Maitland technique.
SUMMARYThe proinflammatory cytokines play a central role in mediating cellular and physiological responses, and levels may reflect immune system effectiveness. In this study, the effect of ageing on the inflammatory response was examined using a novel method to detect production of the proinflammatory cytokines, i.e. tumour necrosis factor-alpha (TNF-a), IL-6 and IL-1b. Peripheral blood mononuclear cells (PBMC) obtained from healthy donors of different ages were incubated for 0, 24, 48 and 72 h with or without phorbol 12-myristate 13-acetate (PMA) stimulation. At each time point these cells were permeabilized and incubated with secondary conjugated FITC MoAbs specific for each cytokine. A flow cytometric system was developed to quantify specific intracellular fluorescence in T cells (CD3 þ ) and monocytes (CD14 þ ). TNF-a, IL-6 and IL-1b production in cell culture supernatants was also measured using ELISAs. In older subjects, flow cytometry detected significant increases in intracellular T cell TNF-a and IL-6 (P < 0·05). IL-1b was not detected in any of the T cell samples. Likewise, the monocytes of older subjects demonstrated increased intracellular levels of all three cytokines, but these increases were not significant (P > 0·05). These changes in intracellular proinflammatory cytokine levels may explain some of the exaggerated inflammatory responses seen in elderly patients.
The need to defunction the anastomosis at anterior resection remains controversial. As the policy in this unit has been not to perform a defunctioning colostomy during anterior resection, the outcome of a consecutive series of 114 anterior resections, all carried out without a covering colostomy, was studied. During the period February 1985 to September 1991, 21 abdominoperineal resections, six Hartmann's procedures and two resections with coloanal anastomosis were also performed. Within the anterior resection group six clinical leaks (5.3 per cent) occurred, all in the low anastomosis group (8 per cent leak rate) and all of which required an end colostomy. The perioperative mortality rate within the anterior resection group was 3.5 per cent; of the four deaths one was attributable to anastomotic dehiscence and sepsis and the others were due to unassociated medical conditions. The results demonstrate similar leakage and mortality rates to published studies where anterior resection is frequently performed with a defunctioning colostomy. These results indicate that the routine use of a defunctioning colostomy at anterior resection should now be questioned.
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