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Sepsis after Appendicectomy
195
when ampicillin One of these was in the wound.3,4 put powder criticised vigorously because lactose was used as a " dummy " powder in the control group of patients. The argument was that lactose was a substrate for bacterial culture and might therefore encourage the growth of any organisms infecting the wound and thus bias the study in favour of ampicillin. This criticism was well-founded in theory, but it seems to have been negated by the second trial with ampicillin in which no dummy powder was used in the control group. In theory, this trial might be criticised for this very reason, but the likelihood is that ampicillin does make a genuine difference, since a very highly significant reduction in wound sepsis was achieved when the appendix was acutely inWhen the appendix was perforated or flamed. gangrenous, however, ampicillin seemed to confer no advantage, sepsis being noted in a third of such cases. For the purists, one more trial with a truly inert dummy powder might give final conviction of the contribution of ampicillin to those patients with an acutely inflamed appendix.
tion in the
complication-rate
was
THE LANCET Sepsis
after
Appendicectomy
UNEVENTFUL appendicectomy is so common an experience that the operation has come to be regarded as more or less trivial. This reputation is to some extent undeserved, because complications do happen. Every surgeon can relate, without relish, the disasters he has seen in a few patients after appendicectomy, and most will also readily admit to a fairly high and continuing incidence of lesser complications. These are usually a temporary nuisance only and without permanent sequelse, so they attract little interest. Even so, they cause discomfort and often delay discharge from hospital and return to school or work. The variety of complications is enormous, but the commonest is undoubtedly sepsis, especially in the wound. Estimates of its frequency vary widely up to a figure of 30% or even higher. The wide range depends upon several factors, including the virulence of the infection, the skill of the surgeon, the techniques he uses, and also upon the criteria used for defining wound sepsis. The literature has been scattered liberally with surveys of the problem, but until recently most of them have been retrospective and they have revealed all the disadvantages of this approach. For example, the precise technique would be uncontrolled, and potentially significant changes would develop imperceptibly. Again, data recording would depend more on the enthusiasm and energy of the junior surgical staff at the time rather than on any conscious aim to make objective and comprehensive observations. As a result, the information is not always reliable. Retrospective surveys are useful in revealing what has happened, but they are not usually effective in defining the reasons why. Fortunately, the idea of the prospective trial has now pervaded this area and reports have appeared of well-planned randomised studies of methods of reducing wound sepsis. It is noticeable that these have been conducted largely by junior surgical staff working in busy district hospitals. Their enterprise is to be applauded. Most attention has been given to the possible value of placing antibiotics or antiseptics in the grid-iron wound during closure. In two separate controlled trials, neither chlorhexidine nor noxythiolin reduced the incidence of wound sepsis. 1,2 Two other studies demonstrated a reduc-
surgical
1. 2.
Cresfil, M., Hall, R., London, D. Br. J. Surg. 1969, 56, 906. Bird, G. G., Bunch, G. A., Croft, C. B., Hoffman, D. C., Humphrey, C. S., Rhind, J. R., Rosenberg, I. L., Whittaker, M., Wilkinson, A. R, Hall, R. ibid. 1971, 58, 447.
The use of wound antibiotics is only one preventive Systemic antibiotics and " drainage " are two further techniques. These have been studied by Mr. MAGAREY and his colleagues in a prospective trial reported on p. 179 this week. Patients were allocated at random to one of four groups: systemic antibiotics, drainage, both these, or nothing. Systemic antibiotics helped to reduce duration of fever in patients with a perforated appendix or an appendix abscess. Drainage seemed to have no effect or even a harmful one, both in terms of duration of fever and wound healing. This latter finding will help to settle one aspect of the argument about drainage, but not the whole problem, because the drain was placed through the wound into the peritoneal cavity. Other methods of drainage include draining the wound only and draining the peritoneal cavity via a stab incision placed away from the main incision. Clearly, some progress has been made since we last discussed this subject,5 but more remains to be done to reduce wound sepsis to more acceptable levels. Equally clearly, progress will be made only by properly designed trials. It is questionable, however, whether assessment of one factor alone will do. There are so many variables-both the state of disease and the different methods of treatment-that only a major trial, allowing for the many different combinations, is likely to give a result which would command widespread attention. Mr. MAGAREY and his colleagues have made steps in this direction and perhaps others will follow. measure.
3. 4. 5.
Rickett, J. W., Jackson, B. T. Br. med. J. 1969, iv, 206. Mountain, J. C., Seal, P. V. Br. J. clin. Pract. 1970, 24, 111. Lancet, 1970, i, 930.
when ampicillin One of these was in the wound.3,4 put powder criticised vigorously because lactose was used as a " dummy " powder in the control group of patients. The argument was that lactose was a substrate for bacterial culture and might therefore encourage the growth of any organisms infecting the wound and thus bias the study in favour of ampicillin. This criticism was well-founded in theory, but it seems to have been negated by the second trial with ampicillin in which no dummy powder was used in the control group. In theory, this trial might be criticised for this very reason, but the likelihood is that ampicillin does make a genuine difference, since a very highly significant reduction in wound sepsis was achieved when the appendix was acutely inWhen the appendix was perforated or flamed. gangrenous, however, ampicillin seemed to confer no advantage, sepsis being noted in a third of such cases. For the purists, one more trial with a truly inert dummy powder might give final conviction of the contribution of ampicillin to those patients with an acutely inflamed appendix.
tion in the
complication-rate
was
THE LANCET Sepsis
after
Appendicectomy
UNEVENTFUL appendicectomy is so common an experience that the operation has come to be regarded as more or less trivial. This reputation is to some extent undeserved, because complications do happen. Every surgeon can relate, without relish, the disasters he has seen in a few patients after appendicectomy, and most will also readily admit to a fairly high and continuing incidence of lesser complications. These are usually a temporary nuisance only and without permanent sequelse, so they attract little interest. Even so, they cause discomfort and often delay discharge from hospital and return to school or work. The variety of complications is enormous, but the commonest is undoubtedly sepsis, especially in the wound. Estimates of its frequency vary widely up to a figure of 30% or even higher. The wide range depends upon several factors, including the virulence of the infection, the skill of the surgeon, the techniques he uses, and also upon the criteria used for defining wound sepsis. The literature has been scattered liberally with surveys of the problem, but until recently most of them have been retrospective and they have revealed all the disadvantages of this approach. For example, the precise technique would be uncontrolled, and potentially significant changes would develop imperceptibly. Again, data recording would depend more on the enthusiasm and energy of the junior surgical staff at the time rather than on any conscious aim to make objective and comprehensive observations. As a result, the information is not always reliable. Retrospective surveys are useful in revealing what has happened, but they are not usually effective in defining the reasons why. Fortunately, the idea of the prospective trial has now pervaded this area and reports have appeared of well-planned randomised studies of methods of reducing wound sepsis. It is noticeable that these have been conducted largely by junior surgical staff working in busy district hospitals. Their enterprise is to be applauded. Most attention has been given to the possible value of placing antibiotics or antiseptics in the grid-iron wound during closure. In two separate controlled trials, neither chlorhexidine nor noxythiolin reduced the incidence of wound sepsis. 1,2 Two other studies demonstrated a reduc-
surgical
1. 2.
Cresfil, M., Hall, R., London, D. Br. J. Surg. 1969, 56, 906. Bird, G. G., Bunch, G. A., Croft, C. B., Hoffman, D. C., Humphrey, C. S., Rhind, J. R., Rosenberg, I. L., Whittaker, M., Wilkinson, A. R, Hall, R. ibid. 1971, 58, 447.
The use of wound antibiotics is only one preventive Systemic antibiotics and " drainage " are two further techniques. These have been studied by Mr. MAGAREY and his colleagues in a prospective trial reported on p. 179 this week. Patients were allocated at random to one of four groups: systemic antibiotics, drainage, both these, or nothing. Systemic antibiotics helped to reduce duration of fever in patients with a perforated appendix or an appendix abscess. Drainage seemed to have no effect or even a harmful one, both in terms of duration of fever and wound healing. This latter finding will help to settle one aspect of the argument about drainage, but not the whole problem, because the drain was placed through the wound into the peritoneal cavity. Other methods of drainage include draining the wound only and draining the peritoneal cavity via a stab incision placed away from the main incision. Clearly, some progress has been made since we last discussed this subject,5 but more remains to be done to reduce wound sepsis to more acceptable levels. Equally clearly, progress will be made only by properly designed trials. It is questionable, however, whether assessment of one factor alone will do. There are so many variables-both the state of disease and the different methods of treatment-that only a major trial, allowing for the many different combinations, is likely to give a result which would command widespread attention. Mr. MAGAREY and his colleagues have made steps in this direction and perhaps others will follow. measure.
3. 4. 5.
Rickett, J. W., Jackson, B. T. Br. med. J. 1969, iv, 206. Mountain, J. C., Seal, P. V. Br. J. clin. Pract. 1970, 24, 111. Lancet, 1970, i, 930.