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Parenteral antibiotics in elective colon surgery? A prospective, controlled clinical study
104
ABSTRACTS
ciated with distention of the gastrointestinal tract and one had no underlying abnormality. One patient died with:dyspnea and cyanosis and one child is being followed. Mesenteroaxial volvulus (volvulus around an axis joining the lesser and greater curvatures) on plain films shows a distended spherical stomach often with a double fluid level on upright views. The gaseous distention of the inverted antrum, pylorus, and proximal duodenum produces a "beak" where the esophagogastric junction is seen in normals. If barium passes the esophagogastric junction the upside down position of the stomach is revealed. With organoaxial volvulus (around an axis joining the esophagogastric junction and pylorus) the stomach is horizontal, no beak is seen and the upright film often shows only one air-fluid level. The esophagogastric junction is positioned lower than normals on barium study. Complete volvulus results in the clinical triad of sudden onset of epigastric pain, intractable retching without vomitus, and inability to pass a tube into the stomach. Four patients in this series presented with complete volvulus.--Randall W. Powell Prenatal
Ultrasound
Diagnosis of Jejunal
Atresia,
V. Hofmann and G. Kunze. Z Kinderchir 26:205-210, (March), 1979.
Nowadays the prenatal diagnosis of congenital malformations is becoming important. In pediatric surgery those patients are of special interest who require surgery immediately after birth. Diagnostic measures like ultrasonography and anmiofetography allow malformations like hydrocephalus, myelomeningocele, chylothorax, anal atresia, and urogenital disorders to be diagnosed prenatally. Here a case is demonstrated in which atresia of the small gut was diagnosed by ultrasonography during the 34th week of pregnancy. The diagnosis was confirmed by amniofetography. The infant was delivered at term by caesarean section followed by immediate surgical intervention. Intraoperatively a jejunal atresia combined with an atresia of the transverse colon and a volvulus was found. The authors conclude that ultrasonic investigation in cases of hydramnios because scanning is harmless, reproducible and, therefore, practicable as a screening method. Prenatal diagnosis enables to plan delivery and surgical correction accurately under optimal conditions.--Karl-Ludwig Waag Home Parenteral Nutrition in Children With Crohn's Disease: An Effective Management Alternative. C. T. Stro-
bel, W. J. Byrne, and M. E. Ament. Gastroenterology 77:272-279, (August), 1979.
Seventeen pediatric patients, ages 9-20 yr, were treated by home total parenteral nutrition (HPN) because of growth failure (6 patients), enterocutaneous fistula (4 patients), diffuse symptomatic disease (2 patients), rectal fissure, chronic pancreatitis, short bowel syndrome, duodenal and antral disease, and partial small bowel obstruction (1 patient each). Previous therapy included sulfasalazine (4 patients), adrenocorticosteroids (12 patients) and inpatient parenteral alimentation (6 patients). All had active disease based on abnormal radiologic studies. Ten had granulomas identified on surgically obtained biopsies. Five other patients had acute and chronic inflammation noted on section mucosal biopsies.
Ten of 17 had hypoalbuminemia and 12 were anemic. A Broviac catheter was placed and 209"0--25% glucose, 4.25% crystalline amino acids, or 5% casein hydrolysate was infused at 3-4 1/day, providing 60-80 kcal/kg/day. HPN was continued until resolution of symptoms for at least 6 wk. Twelve patients went into remission on HPN alone, four had recurrence of symptoms on refeeding and required operation, and one required ongoing steroid therapy. Eight of 12 patients relapsed in 18-133 days (mean duration of remission: 68 days). Four of 12 remained in remission on therapy for 76-539 days (mean 331). Five of seven relapsing patients responded to a second course (108--134 days, mean 119 days) of HPN. Normal serum albumin concentrations were obtained with HPN without albumin or plasma infusions. Growth improved in all patients but only 10 had "catch up growth." Catheter-related complications included dislodgement (3), sepsis (2), local infection (2), and thrombosis and subcutaneous leak (1 each). Catheter removal rate was 1 per 469 days. Two patients developed zinc deficiency dermatitis. Neither radiographic findings nor erythrocyte sedimentation rate correlated with maintenance of remission, but relapse was heralded by intestinal albumin loss 4 mo earlier in 5 patients. Although short-lived in most patients, improved growth, decreased symptoms and a better quality of life, allowing near-normal participation in school and other activities, resulted. The costs ($2,000-$3,000/mo), although high, compare favorably with a similar regimen delivered in the hospital ($7,000-$8,000/mo).--Wallace A. Gleason, Jr. Parenteral Antibiotics in Elective Colon Surgery? A Prospective, Controlled Clinical Study, M, S, Barber, B. C.
Hirschberg, C. L. Rice, et al. Surgery 86:23-29, (July), 1979.
Prior to elective colon resections, 59 adult patients had standard mechanical and oral neomycin/erythromycin base bowel preparation. In a randomized, double-blinded fashion, 31 also received 1 preoperative and 1 postoperative intravenous dose of both gentamycin and clindamycin while 28 received placebos. There were no wound infections in either group. Three of 28 (11%) in the placebo group and 2 of 31 (7%) in the treated group suffered intra-abdominal septic complications. The authors concluded there is no benefit from systemic antibiotics for elective colon surgery when standard preoperative mechanical antibiotic bowel preparation is employed. It should be noted that the discussants of this paper questioned the statistical validity and the design of this study.--Eugene S. Wiener The Use of Plain Abdominal Radiographs in the Diagnosis of Acute Appendicitis in Infants and Children M.M. McNair
and P. A. M. Rain. Z Kinderchir 26:3 t 2-320, (April), 1979.
Plain abdominal radiographs were taken in t00 children with acute appendicitis and in another 100 children with abdominal pain for various other reasons. Both groups were compared considering the incidence of radiologic signs like local intestinal obstruction, general intestinal obstruction, soft tissue mass, free fluid, fecolith, absent right psoas shadow, loss of peritoneal line, scoliosis, fecal accumulation and no signs. A calcified fecolith and scoliosis concave to the left due to psoas spasm were suggestive for acute appendici-
ABSTRACTS
ciated with distention of the gastrointestinal tract and one had no underlying abnormality. One patient died with:dyspnea and cyanosis and one child is being followed. Mesenteroaxial volvulus (volvulus around an axis joining the lesser and greater curvatures) on plain films shows a distended spherical stomach often with a double fluid level on upright views. The gaseous distention of the inverted antrum, pylorus, and proximal duodenum produces a "beak" where the esophagogastric junction is seen in normals. If barium passes the esophagogastric junction the upside down position of the stomach is revealed. With organoaxial volvulus (around an axis joining the esophagogastric junction and pylorus) the stomach is horizontal, no beak is seen and the upright film often shows only one air-fluid level. The esophagogastric junction is positioned lower than normals on barium study. Complete volvulus results in the clinical triad of sudden onset of epigastric pain, intractable retching without vomitus, and inability to pass a tube into the stomach. Four patients in this series presented with complete volvulus.--Randall W. Powell Prenatal
Ultrasound
Diagnosis of Jejunal
Atresia,
V. Hofmann and G. Kunze. Z Kinderchir 26:205-210, (March), 1979.
Nowadays the prenatal diagnosis of congenital malformations is becoming important. In pediatric surgery those patients are of special interest who require surgery immediately after birth. Diagnostic measures like ultrasonography and anmiofetography allow malformations like hydrocephalus, myelomeningocele, chylothorax, anal atresia, and urogenital disorders to be diagnosed prenatally. Here a case is demonstrated in which atresia of the small gut was diagnosed by ultrasonography during the 34th week of pregnancy. The diagnosis was confirmed by amniofetography. The infant was delivered at term by caesarean section followed by immediate surgical intervention. Intraoperatively a jejunal atresia combined with an atresia of the transverse colon and a volvulus was found. The authors conclude that ultrasonic investigation in cases of hydramnios because scanning is harmless, reproducible and, therefore, practicable as a screening method. Prenatal diagnosis enables to plan delivery and surgical correction accurately under optimal conditions.--Karl-Ludwig Waag Home Parenteral Nutrition in Children With Crohn's Disease: An Effective Management Alternative. C. T. Stro-
bel, W. J. Byrne, and M. E. Ament. Gastroenterology 77:272-279, (August), 1979.
Seventeen pediatric patients, ages 9-20 yr, were treated by home total parenteral nutrition (HPN) because of growth failure (6 patients), enterocutaneous fistula (4 patients), diffuse symptomatic disease (2 patients), rectal fissure, chronic pancreatitis, short bowel syndrome, duodenal and antral disease, and partial small bowel obstruction (1 patient each). Previous therapy included sulfasalazine (4 patients), adrenocorticosteroids (12 patients) and inpatient parenteral alimentation (6 patients). All had active disease based on abnormal radiologic studies. Ten had granulomas identified on surgically obtained biopsies. Five other patients had acute and chronic inflammation noted on section mucosal biopsies.
Ten of 17 had hypoalbuminemia and 12 were anemic. A Broviac catheter was placed and 209"0--25% glucose, 4.25% crystalline amino acids, or 5% casein hydrolysate was infused at 3-4 1/day, providing 60-80 kcal/kg/day. HPN was continued until resolution of symptoms for at least 6 wk. Twelve patients went into remission on HPN alone, four had recurrence of symptoms on refeeding and required operation, and one required ongoing steroid therapy. Eight of 12 patients relapsed in 18-133 days (mean duration of remission: 68 days). Four of 12 remained in remission on therapy for 76-539 days (mean 331). Five of seven relapsing patients responded to a second course (108--134 days, mean 119 days) of HPN. Normal serum albumin concentrations were obtained with HPN without albumin or plasma infusions. Growth improved in all patients but only 10 had "catch up growth." Catheter-related complications included dislodgement (3), sepsis (2), local infection (2), and thrombosis and subcutaneous leak (1 each). Catheter removal rate was 1 per 469 days. Two patients developed zinc deficiency dermatitis. Neither radiographic findings nor erythrocyte sedimentation rate correlated with maintenance of remission, but relapse was heralded by intestinal albumin loss 4 mo earlier in 5 patients. Although short-lived in most patients, improved growth, decreased symptoms and a better quality of life, allowing near-normal participation in school and other activities, resulted. The costs ($2,000-$3,000/mo), although high, compare favorably with a similar regimen delivered in the hospital ($7,000-$8,000/mo).--Wallace A. Gleason, Jr. Parenteral Antibiotics in Elective Colon Surgery? A Prospective, Controlled Clinical Study, M, S, Barber, B. C.
Hirschberg, C. L. Rice, et al. Surgery 86:23-29, (July), 1979.
Prior to elective colon resections, 59 adult patients had standard mechanical and oral neomycin/erythromycin base bowel preparation. In a randomized, double-blinded fashion, 31 also received 1 preoperative and 1 postoperative intravenous dose of both gentamycin and clindamycin while 28 received placebos. There were no wound infections in either group. Three of 28 (11%) in the placebo group and 2 of 31 (7%) in the treated group suffered intra-abdominal septic complications. The authors concluded there is no benefit from systemic antibiotics for elective colon surgery when standard preoperative mechanical antibiotic bowel preparation is employed. It should be noted that the discussants of this paper questioned the statistical validity and the design of this study.--Eugene S. Wiener The Use of Plain Abdominal Radiographs in the Diagnosis of Acute Appendicitis in Infants and Children M.M. McNair
and P. A. M. Rain. Z Kinderchir 26:3 t 2-320, (April), 1979.
Plain abdominal radiographs were taken in t00 children with acute appendicitis and in another 100 children with abdominal pain for various other reasons. Both groups were compared considering the incidence of radiologic signs like local intestinal obstruction, general intestinal obstruction, soft tissue mass, free fluid, fecolith, absent right psoas shadow, loss of peritoneal line, scoliosis, fecal accumulation and no signs. A calcified fecolith and scoliosis concave to the left due to psoas spasm were suggestive for acute appendici-