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Antibiotics in Surgery of the Colon
Antibiotics in Surgery of the Colon CHARLES A. SCHIFF, M.D., F.A.C.S.*
THERE has been a great reduction in the mortality from colon surgery since the introduction of intestinal antisepsis. 10 The mortality rate from colon resections with primary anastomosis is at present less than 2 per cent as compared with figures as high as 30 to 35 per cent prior to 1940. 12 There has been an even greater reduction in the necessity for temporary and permanent colostomies in connection with colon surgery. These advances can be ascribed not only to the introduction of antibacterial agents but also to improvements in intestinal decompression, improvements in anesthesia, and a better understanding of the therapy of anemia, hypoproteinemia, depleted blood volume, and electrolyte imbalance. A colon anastomosis does not heal well in the presence of the ordinary bacterial flora consisting of Escherichia coli, Clostridium welchii, streptococci, Proteus, Aerobacter aerogenes and others. These organisms may produce infection at the suture line. In addition, Altemeier1 has emphasized that some anaerobes produce enzymes which cause either necrosis or coagulation of tissue. Antibacterial agents are used to eliminate or reduce the bacterial flora in the colon and so help prevent slough, perforation and leakage. After the use of antibacterial agents, healing at the site of anastomosis resembles that of primary union rather than the secondary healing of infected or contaminated wounds. These drugs may be administered by mouth preoperatively, parenterally before and after operation, intraluminally in the bowel at operation, or intraperitoneally at the time of intervention. Each of these routes of administration has been used singly or in combination. Antibiotics have been shown to protect animals with experimentally produced strangulating obstructions.2, 3 It has also been shown that devascularized segments of bowel can survive if antibiotics are administered. 4 , 6, 6, 9 These antibiotics are administered parenterally and/or intraluminally. Cohn and his associates4 , 6, 6 experimented with loops of large bowel that had been devascularized at the site of an anastomosis. They were able to reduce the mortality rate in these dogs by administering antibiotics intraluminally via an indwelling, fine plastic tube. Pre-
* Associate in Surgery, Chicago Medical School, and Associate Attending Surgeon, Michael Reese Hospital, Chicago, Illinois. 75
76
Charles A. Schiff
operative mechanical cleansing of the bowel and preoperative preparation with oral antibacterial agents further reduced the mortality and morbidity in these experiments. Cohn6 has also shown that oral antibacterial agents do not inhibit bacterial growth beyond the first day following cessation of the drug. The bacterial population of the· stool returns to pretherapy levels within 24 hours after antibacterial therapy is stopped. Cohn, therefore, advocates the use of an indwelling intraluminal plastic tube for the continued administration of antibiotics postoperatively. Poth,ll on the other hand, feels that intraluminal therapy is unnecessary when the colon has been adequately prepared with poorly absorbed antibacterial agents. I agree with Poth in this matter and would reserve the use of the intraluminal route to cases which had not had the benefit of adequate oral antibacterial agents preoperatively. Clinically, Poth 9 has noted the advantages of mechanical cleansing of the colon and preoperative administration of antibacterial agents. In 102 cases with an open anastomosis following resection for carcinoma of the colon, the following results were obtained: In 18 cases with only preoperative mechanical cleansing, there were two deaths and all patients had a temperature of 101 0 F. or more at some time during the postoperative period; 78 per cent of this series had wound infections. In 35 cases prepared with Sulfasuxidine alone, there were no deaths; 54 per cent of the patients had wound infections. In 49 cases prepared with neomycin plus Sulfathalidine, there were no deaths and only one patient had a wound infection. Only 35 per cent of the patients in this series had a temperature over 101 0 F. at some time postoperatively. ANTIBACTERIAL AGENTS
Many drugs have been tested for their efficacy in preparing the colon for operation. PothlO has set down the requirements for an ideal, orally administered antibacterial agent for this purpose. The most important requisites are: (1) broad bacterial spectrum, (2) low toxicity for the host, (3) minimal irritation of the gastrointestinal tract, (4) minimal absorption from and maximal stability in the gastrointestinal tract, (5) capacity to prevent the development of resistant bacterial strains, and (6) rapidity of action. Sulfathalidine (phthalylsulfathiazole) must be given for about five to seven days preoperatively, 8 grams daily in divided doses. Absorption of the drug is not appreciable. This drug when used alone does not have a broad spectrum of antibacterial activity and is more bacteriostatic than bactericidal. Sulfasuxidine (succinylsulfathiazole) is one-half as effective as Sulfathalidine gram for gram. Although Sulfathalidine causes the stools to have a more tenacious consistency, it is more generally used because of the smaller dosage required. Neomycin was first used by Poth in 1947. When used alone, it is given for 24; 48 or 72 hours preoperatively. One gram is given every hour for
Antibiotics in Surgery of the Colon
77
four hours and then 1 gram every four hours for 24 to 72 hours. This drug is· not absorbed from the gastrointestinal tract in appreciable amounts and is nontoxic orally in doses up to 10 grams daily. When used alone there is an overgrowth of Aerobacter aerogenes in 10 per cent of cases. There is also some overgrowth of yeasts. However, no complications from the yeasts were noted by Poth in 526 patients prepared with neomycin. When used alone, neomycin is relatively ineffective against anaerobes. There is at present no good evidence that a vitamin K deficiency will develop following the preoperative administration of the poorly absorbed sulfa drugs and/or neomycin. Sulfathalidine and neomycin in combination have proved to be highly effective and are widely used for intestinal antisepsis. Minimal adverse side effects have been noted with this combination. A 72 hour period of preparation is generally used, administering 1.5 grams of Sulfathalidine and 1 gram of neomycin every hour for four hours, then every four hours for 72 hours. A 24 hour regimen has been found to be quite effective by Leo. 7 The same schedule of dosage of these drugs as above is used, but for 24 hours only. I prefer to give Sulfathalidine in doses of 8 grams daily in divided doses for three to five days preoperatively. Neomycin is then added about 36 hours before operation, according to the dosage schedule outlined above. Streptomycin has, in general, proved to be unsatisfactory as an oral antibiotic for colon surgery because of the rapid development of resistant organisms. Streptomycin and dihydrostreptomycin have proved to be of value when administered parenterally pre- and postoperatively. Chloromycetin (chloramphenicol) is absorbed too readily to be of value as an orally administered drug for preoperative sterilization of the colon. It may be of benefit when administered parenterally in selected cases, especially in infections caused by resistant strains of staphylococci. Chloromycetin has a rather wide range of antibacterial activity. BaCitracin is mildly nephrotoxic and should be reserved for rare cases. It is orally effective against a wide range of organisms, especially grampositive ones. Achromycin (tetracycline) is not effective enough to be used alone for intestinal antisepsis. Achromycin plus neomycin has proved to be highly satisfactory for preoperative colon preparation. 5 Cohn prefers this combination to neomycin and Sulfathalidine.· Two hundred milligrams of Achromycin and 1 gram of neomycin are given every hour for four hours, then every six hours for 72 hours. Minimal side reactions are seen with this regimen. Also, yeasts appear fairly late and disappear rapidly after the cessation of the drugs . . Erythromycin and neomycin together have been found to be an effe.ctive combination. 5 The use of this combination should be reserved for patients who have been on prolonged antibiotic therapy other than erythromycin, especially if there have developed resistant strains of staphy-
Charles A. Schiff
78
lococci. The dosage schedule would be the same as noted above for Achromycin and neomycin. The same remarks that were made relative to erythromycin and neomycin are applicable to the combination of novobiocin and neomycin. A word must be said about the possibility of development of fatal or near fatal enterocolitis. There have been reports of the rare development of this complication after the oral and parenteral use of antibiotics in patients undergoing colon surgery. It is also known that this severe type of enterocolitis can occur without antibiotic therapy. Furthermore, the incidence of this serious complication is so rare that it should not preclude the use of antibiotics when they are indicated. CLINICAL APPLICATION
Mechanical cleansing of the bowel is an extremely important part of the preoperative preparation of the patient for elective colon surgery. In fact, there are many surgeons who feel that this is more important than the antibacterial agents. Patients undergoing urgent or emergency colon surgery cannot be given the benefit of this mechanical cleansing. This includes patients who have a partial or complete obstruction, a subacute or acute inflammatory process in the colon, or traumatic wounds of the' colon. In addition to mechanical cleansing and oral antibacterial agents, parenteral antibiotics are used in many cases. Some surgeons recommend routine parenteral use of such antibiotics as Achromycin or penicillin combined with streptomycin (or dihydrostreptomycin). Other surgeons reserve the parenteral administration of such drugs for patients with a postoperative temperature over 101 0 F. or in patients in whom preoperative preparation of the colon could not be used. Patients undergoing colon surgery can be divided into three categories: 1. Patients Who Have No Obstruction and Are Undergoing Elective Surgery. These patients require 24 to 72 hours for preoperative preparation, depending on the method used. The patient is placed on a low residue diet for three days prior to operation. Phosphosoda, 10 to 15 ce. daily, or a similar cathartic is given every morning for three days. Castor oil, 60 cc., is given by mouth just before the oral antibacterial agent is started. Sulfathalidine and neomycin are given by mouth for 24 to 72 hours according to the dosage schedule outlined in the section on antibacterial drugs. Cleansing enemas of water or saline are given for one to three days prior to operation, the last one generally about six to eight hours before it. 2. Patients with a Partial Obstruction. These patients require gradual decompression with nasogastric suction and cessation of food and oral fluid intake. No catharsis can be used. When the bowel is decompressed and there is evidence that the obstruction is no longer complete, one can
Antibiotics in Surgery of the Colon
79
then prescribe the oral antibacterial agents. In these cases, the antibacterial drugs must be given for longer periods of time because mechanical cleansing cannot be safely employed. If the danger of recurrence of the obstruction is not imminent, Sulfathalidine is given for about five days preoperatively and then neomycin is added for the last 36 hours before operation. 3. Acute Cases. In these patients, there is either a complete obstruction, an acute inflammatory process, or a traumatic wound of the colon. These cases require urgent or emergency surgery. If it is necessary to do a resection and primary anastomosis or close a defect in the small or large bowel, 500 to 1000 cc. of a 1 per cent neomycin solution is instilled into the colon near the site of the anastomosis. This is injected intraluminally with a syringe and fine needle. More recently, Poth has recommended the addition of 500 units per cc. of bacitracin to the 1 per cent solution of neomycin. It is his opinion that viable bacteria cannot be subcultured after being in contact with this solution for 30 minutes. Cohn5 has recommended the instillation of antibiotics into the lumen of the colon at operation and postoperatively via an indwelling plastic tube. The tube can be threaded through a 14 gauge or smaller needle which has been introduced through the wall of the colon. The needle is withdrawn after the plastic tube is in place. A purse-string serosal suture of fine silk is placed around the plastic tube to hold it in place and prevent leakage. The end of the plastic tube is brought out through a stab wound. At operation, 250 mg. of Achromycin and 1.5 grams of neomycin are introduced in'to the colon via the plastic tube. Postoperatively 150 mg. of Achromycin and 750 mg. of neomycin dissolved in 15 cc. of sterile saline are similarly introduced into the lumen of the colon every eight hours for five days. Cohn recommends this intraluminal antibiotic therapy for all patients with colon resections, not only for the patients who have been inadequately prepared preoperatively. I would question the need for this regimen in cases which have had adequate preoperative mechanical cleansing and oral antibacterial agents. I would reserve this type of intraluminal therapy for the patient in whom the colon had not been adequately prepared. In the acute cases, that is, in those not prepared with oral antibacterial agents, Poth ll also recommends placing in the abdominal cavity 200 cc. of a 0.5 per cent solution of neomycin to which has been added 500 units per cc. of bacitracin. This solution is aspirated or is allowed to run out and a similar instillation of this solution is repeated as the abdomen is closed. However, great caution must be exercised because of several reports of respiratory suppression with the intraperitoneal use of neomycin. It is true that in most of these cases an unusually large dose of neomycin was used. I believe that we must await further experimental and clinical experience with the use of neomycin intraperitoneally before it can be recommended for general use. If respiratory suppression should
Charles A. Schiff
80
be encountered in patients who have received neomycin intraperitonealiy, artificial respiration must be instituted and continued until the effect has been overcome. There is some difference of opinion regarding the necessity for the use of parenteral antibiotics postoperatively in patients who have undergone elective colon surgery with adequate preoperative preparation. Some feel that one should not give postoperative antibiotics unless there has been unusual contamination at the time of operation. These workers prefer to withhold such antibiotics unless a temperature elevation above 101 0 F. is noted. I am an advocate of the more or less routine use of penicillin (600,000 units) along with streptomycin or dihydrostreptomycin (0.5 gram) every 12 hours for three to five days postoperatively in patients who have had colon surgery. Intravenous Achromycin (1 to 1.5 grams daily) may be substituted for the penicillin and streptomycin. It has been shown that antibiotics can protect a strangulated or devascularized segment of bowel during the healing period. There is sufficiently good clinical and experimental evidence to indicate that parenteral antibiotics reduce the morbidity and mortality following colon surgery.
SUMMARY 1. Antibacterial agents (antibiotics and poorly absorbed sulfonamides) have been important factors in lowering the morbidity and mortality from colon resections. 2. Various antibacterial agents are discussed anli evaluated with reference to their ability to reduce the bacterial flora when administered by mouth prior to elective colon surgery. 3. Neomycin and Sulfathalidine used together are the:drugs o(choice for preoperative preparation of the colon. 4. Neomycin and Achromycin administered orally also represent a very effective combination for preoperative intestinal antisepsis. 5. Parenterally administered antibiotics are valuable in the postoperative care of the patient who has undergone colon surgery. ~~ 6. The intraluminal administration of antibiotics after a colon anastomosis appears to offer additional help against the development of complications at the suture line, particularly in acute cases in which preoperative preparation of the colon has not been possible.
REFERENCES 1. Altemeier, W. A.: In discussion of reference No.4. 2. Cohn, I. Jr.: Strangulation Obstruction: Antibiotic Protection. Surgery 39: 630 (April) 1956. 3. Cohn, I. Jr.: Strangulation Obstruction-Postoperative Antibiotic Protection. Ann. Surg. 143: 386 (March) 1956. 4. Cohn, I. Jr. and Rives, J. D.: Protection of Colonic Anastomoses with Antibiotics. Ann. Surg. 144: 738 (Oct.) 1956. 5. Cohn, I. Jr.: Antibiotics and Colon Surgery. Am. J. Gastroenterol. 28: 298 (Sept.) 1957.
Antibiotics in Surgery of the Colon
81
6. Cohn, I. Jr., Langford, D. and Rives, J. D.: Antibiotic Support of Colon Anastomoses. Surg., Gynec. & Obst. 104: 1 (Jan.) 1957. 7. Leo, W. A., Von Riesen, V. L., Roberts, G. G. and Schloerb, P. R.: Twentyfour Hour Preparation of the Large Bowel for Surgery Using NeomycinSulfathalidine or Neomycin-Oxytetracycline: A Comparative Evaluation. Ann. Surg. 147: 359 (March) 1958. 8. Cohn, I. Jr. and Longacre, A. B.: Erythromycin and Erythromycin-Neomycin for Intestinal Antisepsis. Am. J. Surg. 94: 402 (Sept.) 1957. 9. Poth, E. J.: In discussion of reference No.4. 10. Poth, E. J.: Intestinal Antisepsis in Surgery. J.A.M.A. 153: 1516 (Dec.) 1953. 11. Poth, E. J.: Critical Analysis of Intestinal Antisepsis. J.A.M.A. 163: 1317 (April) 1957. 12. Rowland, B. S. and Scorer, E. M. C.: Preoperative Preparation of the Bowel with Neomycin. Lancet 269: 950 (Nov.) 1955. 104 S. Michigan Avenue Chicago 3, Illinois
THERE has been a great reduction in the mortality from colon surgery since the introduction of intestinal antisepsis. 10 The mortality rate from colon resections with primary anastomosis is at present less than 2 per cent as compared with figures as high as 30 to 35 per cent prior to 1940. 12 There has been an even greater reduction in the necessity for temporary and permanent colostomies in connection with colon surgery. These advances can be ascribed not only to the introduction of antibacterial agents but also to improvements in intestinal decompression, improvements in anesthesia, and a better understanding of the therapy of anemia, hypoproteinemia, depleted blood volume, and electrolyte imbalance. A colon anastomosis does not heal well in the presence of the ordinary bacterial flora consisting of Escherichia coli, Clostridium welchii, streptococci, Proteus, Aerobacter aerogenes and others. These organisms may produce infection at the suture line. In addition, Altemeier1 has emphasized that some anaerobes produce enzymes which cause either necrosis or coagulation of tissue. Antibacterial agents are used to eliminate or reduce the bacterial flora in the colon and so help prevent slough, perforation and leakage. After the use of antibacterial agents, healing at the site of anastomosis resembles that of primary union rather than the secondary healing of infected or contaminated wounds. These drugs may be administered by mouth preoperatively, parenterally before and after operation, intraluminally in the bowel at operation, or intraperitoneally at the time of intervention. Each of these routes of administration has been used singly or in combination. Antibiotics have been shown to protect animals with experimentally produced strangulating obstructions.2, 3 It has also been shown that devascularized segments of bowel can survive if antibiotics are administered. 4 , 6, 6, 9 These antibiotics are administered parenterally and/or intraluminally. Cohn and his associates4 , 6, 6 experimented with loops of large bowel that had been devascularized at the site of an anastomosis. They were able to reduce the mortality rate in these dogs by administering antibiotics intraluminally via an indwelling, fine plastic tube. Pre-
* Associate in Surgery, Chicago Medical School, and Associate Attending Surgeon, Michael Reese Hospital, Chicago, Illinois. 75
76
Charles A. Schiff
operative mechanical cleansing of the bowel and preoperative preparation with oral antibacterial agents further reduced the mortality and morbidity in these experiments. Cohn6 has also shown that oral antibacterial agents do not inhibit bacterial growth beyond the first day following cessation of the drug. The bacterial population of the· stool returns to pretherapy levels within 24 hours after antibacterial therapy is stopped. Cohn, therefore, advocates the use of an indwelling intraluminal plastic tube for the continued administration of antibiotics postoperatively. Poth,ll on the other hand, feels that intraluminal therapy is unnecessary when the colon has been adequately prepared with poorly absorbed antibacterial agents. I agree with Poth in this matter and would reserve the use of the intraluminal route to cases which had not had the benefit of adequate oral antibacterial agents preoperatively. Clinically, Poth 9 has noted the advantages of mechanical cleansing of the colon and preoperative administration of antibacterial agents. In 102 cases with an open anastomosis following resection for carcinoma of the colon, the following results were obtained: In 18 cases with only preoperative mechanical cleansing, there were two deaths and all patients had a temperature of 101 0 F. or more at some time during the postoperative period; 78 per cent of this series had wound infections. In 35 cases prepared with Sulfasuxidine alone, there were no deaths; 54 per cent of the patients had wound infections. In 49 cases prepared with neomycin plus Sulfathalidine, there were no deaths and only one patient had a wound infection. Only 35 per cent of the patients in this series had a temperature over 101 0 F. at some time postoperatively. ANTIBACTERIAL AGENTS
Many drugs have been tested for their efficacy in preparing the colon for operation. PothlO has set down the requirements for an ideal, orally administered antibacterial agent for this purpose. The most important requisites are: (1) broad bacterial spectrum, (2) low toxicity for the host, (3) minimal irritation of the gastrointestinal tract, (4) minimal absorption from and maximal stability in the gastrointestinal tract, (5) capacity to prevent the development of resistant bacterial strains, and (6) rapidity of action. Sulfathalidine (phthalylsulfathiazole) must be given for about five to seven days preoperatively, 8 grams daily in divided doses. Absorption of the drug is not appreciable. This drug when used alone does not have a broad spectrum of antibacterial activity and is more bacteriostatic than bactericidal. Sulfasuxidine (succinylsulfathiazole) is one-half as effective as Sulfathalidine gram for gram. Although Sulfathalidine causes the stools to have a more tenacious consistency, it is more generally used because of the smaller dosage required. Neomycin was first used by Poth in 1947. When used alone, it is given for 24; 48 or 72 hours preoperatively. One gram is given every hour for
Antibiotics in Surgery of the Colon
77
four hours and then 1 gram every four hours for 24 to 72 hours. This drug is· not absorbed from the gastrointestinal tract in appreciable amounts and is nontoxic orally in doses up to 10 grams daily. When used alone there is an overgrowth of Aerobacter aerogenes in 10 per cent of cases. There is also some overgrowth of yeasts. However, no complications from the yeasts were noted by Poth in 526 patients prepared with neomycin. When used alone, neomycin is relatively ineffective against anaerobes. There is at present no good evidence that a vitamin K deficiency will develop following the preoperative administration of the poorly absorbed sulfa drugs and/or neomycin. Sulfathalidine and neomycin in combination have proved to be highly effective and are widely used for intestinal antisepsis. Minimal adverse side effects have been noted with this combination. A 72 hour period of preparation is generally used, administering 1.5 grams of Sulfathalidine and 1 gram of neomycin every hour for four hours, then every four hours for 72 hours. A 24 hour regimen has been found to be quite effective by Leo. 7 The same schedule of dosage of these drugs as above is used, but for 24 hours only. I prefer to give Sulfathalidine in doses of 8 grams daily in divided doses for three to five days preoperatively. Neomycin is then added about 36 hours before operation, according to the dosage schedule outlined above. Streptomycin has, in general, proved to be unsatisfactory as an oral antibiotic for colon surgery because of the rapid development of resistant organisms. Streptomycin and dihydrostreptomycin have proved to be of value when administered parenterally pre- and postoperatively. Chloromycetin (chloramphenicol) is absorbed too readily to be of value as an orally administered drug for preoperative sterilization of the colon. It may be of benefit when administered parenterally in selected cases, especially in infections caused by resistant strains of staphylococci. Chloromycetin has a rather wide range of antibacterial activity. BaCitracin is mildly nephrotoxic and should be reserved for rare cases. It is orally effective against a wide range of organisms, especially grampositive ones. Achromycin (tetracycline) is not effective enough to be used alone for intestinal antisepsis. Achromycin plus neomycin has proved to be highly satisfactory for preoperative colon preparation. 5 Cohn prefers this combination to neomycin and Sulfathalidine.· Two hundred milligrams of Achromycin and 1 gram of neomycin are given every hour for four hours, then every six hours for 72 hours. Minimal side reactions are seen with this regimen. Also, yeasts appear fairly late and disappear rapidly after the cessation of the drugs . . Erythromycin and neomycin together have been found to be an effe.ctive combination. 5 The use of this combination should be reserved for patients who have been on prolonged antibiotic therapy other than erythromycin, especially if there have developed resistant strains of staphy-
Charles A. Schiff
78
lococci. The dosage schedule would be the same as noted above for Achromycin and neomycin. The same remarks that were made relative to erythromycin and neomycin are applicable to the combination of novobiocin and neomycin. A word must be said about the possibility of development of fatal or near fatal enterocolitis. There have been reports of the rare development of this complication after the oral and parenteral use of antibiotics in patients undergoing colon surgery. It is also known that this severe type of enterocolitis can occur without antibiotic therapy. Furthermore, the incidence of this serious complication is so rare that it should not preclude the use of antibiotics when they are indicated. CLINICAL APPLICATION
Mechanical cleansing of the bowel is an extremely important part of the preoperative preparation of the patient for elective colon surgery. In fact, there are many surgeons who feel that this is more important than the antibacterial agents. Patients undergoing urgent or emergency colon surgery cannot be given the benefit of this mechanical cleansing. This includes patients who have a partial or complete obstruction, a subacute or acute inflammatory process in the colon, or traumatic wounds of the' colon. In addition to mechanical cleansing and oral antibacterial agents, parenteral antibiotics are used in many cases. Some surgeons recommend routine parenteral use of such antibiotics as Achromycin or penicillin combined with streptomycin (or dihydrostreptomycin). Other surgeons reserve the parenteral administration of such drugs for patients with a postoperative temperature over 101 0 F. or in patients in whom preoperative preparation of the colon could not be used. Patients undergoing colon surgery can be divided into three categories: 1. Patients Who Have No Obstruction and Are Undergoing Elective Surgery. These patients require 24 to 72 hours for preoperative preparation, depending on the method used. The patient is placed on a low residue diet for three days prior to operation. Phosphosoda, 10 to 15 ce. daily, or a similar cathartic is given every morning for three days. Castor oil, 60 cc., is given by mouth just before the oral antibacterial agent is started. Sulfathalidine and neomycin are given by mouth for 24 to 72 hours according to the dosage schedule outlined in the section on antibacterial drugs. Cleansing enemas of water or saline are given for one to three days prior to operation, the last one generally about six to eight hours before it. 2. Patients with a Partial Obstruction. These patients require gradual decompression with nasogastric suction and cessation of food and oral fluid intake. No catharsis can be used. When the bowel is decompressed and there is evidence that the obstruction is no longer complete, one can
Antibiotics in Surgery of the Colon
79
then prescribe the oral antibacterial agents. In these cases, the antibacterial drugs must be given for longer periods of time because mechanical cleansing cannot be safely employed. If the danger of recurrence of the obstruction is not imminent, Sulfathalidine is given for about five days preoperatively and then neomycin is added for the last 36 hours before operation. 3. Acute Cases. In these patients, there is either a complete obstruction, an acute inflammatory process, or a traumatic wound of the colon. These cases require urgent or emergency surgery. If it is necessary to do a resection and primary anastomosis or close a defect in the small or large bowel, 500 to 1000 cc. of a 1 per cent neomycin solution is instilled into the colon near the site of the anastomosis. This is injected intraluminally with a syringe and fine needle. More recently, Poth has recommended the addition of 500 units per cc. of bacitracin to the 1 per cent solution of neomycin. It is his opinion that viable bacteria cannot be subcultured after being in contact with this solution for 30 minutes. Cohn5 has recommended the instillation of antibiotics into the lumen of the colon at operation and postoperatively via an indwelling plastic tube. The tube can be threaded through a 14 gauge or smaller needle which has been introduced through the wall of the colon. The needle is withdrawn after the plastic tube is in place. A purse-string serosal suture of fine silk is placed around the plastic tube to hold it in place and prevent leakage. The end of the plastic tube is brought out through a stab wound. At operation, 250 mg. of Achromycin and 1.5 grams of neomycin are introduced in'to the colon via the plastic tube. Postoperatively 150 mg. of Achromycin and 750 mg. of neomycin dissolved in 15 cc. of sterile saline are similarly introduced into the lumen of the colon every eight hours for five days. Cohn recommends this intraluminal antibiotic therapy for all patients with colon resections, not only for the patients who have been inadequately prepared preoperatively. I would question the need for this regimen in cases which have had adequate preoperative mechanical cleansing and oral antibacterial agents. I would reserve this type of intraluminal therapy for the patient in whom the colon had not been adequately prepared. In the acute cases, that is, in those not prepared with oral antibacterial agents, Poth ll also recommends placing in the abdominal cavity 200 cc. of a 0.5 per cent solution of neomycin to which has been added 500 units per cc. of bacitracin. This solution is aspirated or is allowed to run out and a similar instillation of this solution is repeated as the abdomen is closed. However, great caution must be exercised because of several reports of respiratory suppression with the intraperitoneal use of neomycin. It is true that in most of these cases an unusually large dose of neomycin was used. I believe that we must await further experimental and clinical experience with the use of neomycin intraperitoneally before it can be recommended for general use. If respiratory suppression should
Charles A. Schiff
80
be encountered in patients who have received neomycin intraperitonealiy, artificial respiration must be instituted and continued until the effect has been overcome. There is some difference of opinion regarding the necessity for the use of parenteral antibiotics postoperatively in patients who have undergone elective colon surgery with adequate preoperative preparation. Some feel that one should not give postoperative antibiotics unless there has been unusual contamination at the time of operation. These workers prefer to withhold such antibiotics unless a temperature elevation above 101 0 F. is noted. I am an advocate of the more or less routine use of penicillin (600,000 units) along with streptomycin or dihydrostreptomycin (0.5 gram) every 12 hours for three to five days postoperatively in patients who have had colon surgery. Intravenous Achromycin (1 to 1.5 grams daily) may be substituted for the penicillin and streptomycin. It has been shown that antibiotics can protect a strangulated or devascularized segment of bowel during the healing period. There is sufficiently good clinical and experimental evidence to indicate that parenteral antibiotics reduce the morbidity and mortality following colon surgery.
SUMMARY 1. Antibacterial agents (antibiotics and poorly absorbed sulfonamides) have been important factors in lowering the morbidity and mortality from colon resections. 2. Various antibacterial agents are discussed anli evaluated with reference to their ability to reduce the bacterial flora when administered by mouth prior to elective colon surgery. 3. Neomycin and Sulfathalidine used together are the:drugs o(choice for preoperative preparation of the colon. 4. Neomycin and Achromycin administered orally also represent a very effective combination for preoperative intestinal antisepsis. 5. Parenterally administered antibiotics are valuable in the postoperative care of the patient who has undergone colon surgery. ~~ 6. The intraluminal administration of antibiotics after a colon anastomosis appears to offer additional help against the development of complications at the suture line, particularly in acute cases in which preoperative preparation of the colon has not been possible.
REFERENCES 1. Altemeier, W. A.: In discussion of reference No.4. 2. Cohn, I. Jr.: Strangulation Obstruction: Antibiotic Protection. Surgery 39: 630 (April) 1956. 3. Cohn, I. Jr.: Strangulation Obstruction-Postoperative Antibiotic Protection. Ann. Surg. 143: 386 (March) 1956. 4. Cohn, I. Jr. and Rives, J. D.: Protection of Colonic Anastomoses with Antibiotics. Ann. Surg. 144: 738 (Oct.) 1956. 5. Cohn, I. Jr.: Antibiotics and Colon Surgery. Am. J. Gastroenterol. 28: 298 (Sept.) 1957.
Antibiotics in Surgery of the Colon
81
6. Cohn, I. Jr., Langford, D. and Rives, J. D.: Antibiotic Support of Colon Anastomoses. Surg., Gynec. & Obst. 104: 1 (Jan.) 1957. 7. Leo, W. A., Von Riesen, V. L., Roberts, G. G. and Schloerb, P. R.: Twentyfour Hour Preparation of the Large Bowel for Surgery Using NeomycinSulfathalidine or Neomycin-Oxytetracycline: A Comparative Evaluation. Ann. Surg. 147: 359 (March) 1958. 8. Cohn, I. Jr. and Longacre, A. B.: Erythromycin and Erythromycin-Neomycin for Intestinal Antisepsis. Am. J. Surg. 94: 402 (Sept.) 1957. 9. Poth, E. J.: In discussion of reference No.4. 10. Poth, E. J.: Intestinal Antisepsis in Surgery. J.A.M.A. 153: 1516 (Dec.) 1953. 11. Poth, E. J.: Critical Analysis of Intestinal Antisepsis. J.A.M.A. 163: 1317 (April) 1957. 12. Rowland, B. S. and Scorer, E. M. C.: Preoperative Preparation of the Bowel with Neomycin. Lancet 269: 950 (Nov.) 1955. 104 S. Michigan Avenue Chicago 3, Illinois