The scientific basis of the management of injury, wounds, and ulcers to assess the use of peritoneal lavage in peritonitis of colonic origin. One hundred and twenty-six (86%) surgeons replied. In faecal peritonitis 99 lavage and 27 do not lavage. Thirty-four use saline, 47 use noxythiolin, 4 use other antiseptics, and only I4 use antibiotic lavage. In purulent peritonitis 66 lavage and 6o do not lavage. Twenty-four use saline, 27 use noxythiolin, 2 use other antiseptics, and only I 3 use antibiotic lavage. Noxythiolin is also used as an end-operative instillation, irrespective of lavage, by 46 surgeons in faccal peritonitis and 24 surgeons in purulent peritonitis. The popularity of noxythiolin depends almost wholly on an uncontrolled clinical trial by Browne and Stoller6, who reported 20 survivors in 23 patients with faecal peritonitis. However, it is generally overlooked that they lavaged with proflavine solution before instilling noxythiolin and this lavage may have been the important factor in achieving their results. Other studies in the published literature'-" do not suggest therapeutic efficacy of noxythiolin despite its theoretical attraction. Therefore a clinical trial of antibiotic lavage, though ethically justifiable, appears superfluous in the absence of appropriate agents with which it may be compared.
Discussion
243
tonitis is evident, its value in the prophylaxis of residual intraperitoneal sepsis after elective surgery may only be inferred. It is probable, however, that antibiotic lavage of the operative field willl eliminate those infrequent residual abscesses which all surgeons see from time to time.
References I
2
3 4 5
6
7 8 9
1o ii
I2
Palmer, J F (I835) The Works of John Hunter, vol I, pp. 445-446. London, Longman, Rees, Orme, Brown and Longman. Stewart, D J, and Matheson, N A (1978) British Journal of Surgery, 65, 54. Stewart, D J, and Matheson, N A (I978) British Journal of Surgery, 65, 57. Siegel, S (1956) Non-parametric Statistics for the Behavioural Sciences. New York, McGraw-Hill. Crowther, J S ('97') Journal of Applied Bacteriology, 34, 477. Browne, M K, and Stoller, J L (1970) British Journal of Surgery, 57, 525. Gilmore, 0 J A (I977) Annals of the Royal College of Surgeons of England, 59, 93. Cleaver, C L T, Hopkins, A D, Ng, K, Kee Kwong and Raftery, A T (I974) British Journal of Surgery, 6I, 6oi. King, D W, Gurry, J F, Ellis-Pegler, R B, and Brooke, B N (I975) British Journal of Surgery, 62, 645. Pickard, R G (1972) British Journal of Surgery, 59, 642. Gue, S (1974) Australian and New Zealand Journal of Surgery, 44, 375. Leger, L, Moulle, P, Delaitre, B, and Chiche, B (I977) Nouvelle presse medicale, 6, 649. Stoker, T A M, and Ellis, H (I97I) British Medical Journal, 3, 769. Calman, K C, Kennedy, F, Meudell, C M, and Sleigh, J D (I97i) British Medical Journal, 4,
Retrospective studies suggested considerable 13 benefits from antibiotic peritoneal lavage in children with appendicular periton.itis. Animal [4 experiments demonstrated the potential of anti232. biotic lavage in catastrophic faecal peritonitis. 15 Bird, G G, Bunch, G A, Croft, C B, Hoffman, Its effect was dependent both on lavage and on D C, Humphrey, C S, Rhind, J R, Rosenberg, I L, Whittaker, M, Wilkinson, A R, and Hall, antibiotic. An audit of clinical practice showed (1I97I) British Journal of Surgery, 58, 447. that antibiotic lavage is still used infrequently, I6 RMackie, B, Shafi, M S, Grundy, D J, Ralphs, even in faecal peritonitis. D N L, and Haynes, S (1973) British Journal While the value of antibiotic lavage in periof Clinical Practice, 27, 57. PREVENTION OF INFECTION IN SURGICAL WOUNDS M R B Keighley MS FRCS Consultant Surgeon, The General Hospital, Birmingham
Introduction Wound sepsis is defined as the presence of pus in the incision' and is caused by organisms being inoculated into a surgical incision either from the environment (exogenous) or fromn the viscus being operated upon (endogenous).
Exogenous wound sepsis is usually caused by staphylococci2 froM the patient's nose or skin, the theatre environment, or a member of the surgical team. Late infections may also occur from cross-infection on the ward3. Staphylococcal sepsis is the most important
244
The scientific basis of the management of injury, wounds, and ulcers
cause of wound sepsis in 'clean' operations when there is no intestinal contamination, as in hemiorrhaphy, elective orthopaedic operations, and peripheral vascular surgery. However, wound sepsis is uncommon after these procedures and is usually recorded in less than 2 To of patients4. Endogenous wound sepsis is much more common and is due to release of bacteria from the intestinal tract, usually at the time of operation, though late sepsis can occur following dehiscence of an intestinal anastomosis. Endogenous wound sepsis is particularly common after emergency operations for peritonitis complicating perforation or infarction of the intestinal tract. In the unprotected patient endogenous wound sepss occurs in I0-20% of, cases after elective gastnc or biliary operations5 and in up to 5o% after
Prophylactic antimicrobials Endogenous wound sepsis frequently occurs despite careful preparation and meticulous operative technique because large numbers of organisms are released into the incision during operation. The risk of wound sepsis froom this source can be minimised by the use of pro. phylactic antimicrobials. The aim of antibacterial prophylaxis is to provide the patient with an adequate serum concentration of an antimicrobial effective against the endogenous bacterial flora immediately before the infected viscus is opened"' 12. The first dose of antibiotic shouild therefore be given at the start of the operation. Furthermore, shorttenn cover for 24 h is just as effective as, and preferable to, longer periods of antibiotic administration,3' . Systemic antibiotics are pref erable to topical or oral therapy because they will provide predictable serum concentratioins, and the risks of bacterial resistance and superinfection are also minimised. Because of the potential dangers of toxcity, hypersensitivity reactions, resistant organisms, superinfecdon, and antibiotic-induced colitis it is important to avoid unnecessary antibiotic prophylaxis. Prophylactic antibiotics should therefore be restricted to patients in whom the intestinal tract is likely to contain more that IO5 organiisms per ml5. These patients include the following elective operative groups: resection for gastro-oesophageal carcinoma, biliary operations for non-malignant jaundice, smallintestinal resection in Crohn's disease, and all patients requirng partial or complete resection of the colon and rectuml`. The antimicrobial chosen should be one which is effective against streptococci and coliforms for gastric and biliary surgery, but for colorectal operations cover should also be provided against the anaerobic intestinal flora, particularly Bac-
elective colonic resections6' 7. Preventive measures Wound sepsis may be minimiised by careful preoperative preparation of the patient. Eradication of established skin sepsis and repeated application of antiseptics to the skin8 will help to prevent exogenous sepsis. Poor nutritional state will incrase the risk of sepsis and should be corrected before elective operations. The timing of operation is important, since the risk of wound sepsis is greater if there is walled-off intra-abdominal pus. Conservative management should therefore be encouraged in patients with peridiverticular abscess or acute cholecystitis because the risks of sepsis are reduced if operative treatment can later be performed as an interval pro. cedure. Endogenous sepsis may be reduced after elective colonic resection by careful mechanical bowel preparation. The risk of wound sepsis is influenced by operative techilque. Exogenous sepsis in teroides fragilis'7. orthopaedic surgery has been dramatically reduced by ediminating bacterial contamiation of the theatre atmosphere0. Endogenous References Research Council (I964) Annals of sepsis can also be muinimsed by meticulous I National I 6o, SuppI. 2, p. I . Surgery, care in isolating sites of potential contaminaH J (I959) New England Journal of Weinstein, 2 tion, adequate haemostasis, satisfactory in260, Medicine, testinal anastomosis without tension, and wound 3 Mitchell, A A B,1303. Pettigrew, J B, Timbury, M G, closure after changing instruments and gloves'0. and Hutchinson, T (I959) Lancet, 2, 503. In grossly contaminated wounds sepsis can 4 Cruse, P J E (1970) Canadian Medical Association Journal, 102, 251. also be avoided by delayed primary suture.
The scientific basis of the management of injury, wounds, and ulcers 5 Stone, H H, Hooper, C A, Lauxa, B A, Kolb, B S, Geheber, B S, and Dawkins, E J (1976) Annals of Surgery, 184, 443 6 Burton, K C (I973) British Journal of Surgery, 6o, 363. 7 Goldring, J, Scott, A, McNaught, W, and Gillespie, G (I975) Lancet, 2, 997. 8 Lowbury, E J L, and Lilly, H A (I973) British Medical Journal, I, 510. 9 Chamley, J, and Eftekhar, N (I969) British Journal of Surgery 56, 641. Io Hughes, E S R (1972) Annals of the Royal College of Surgeons of England, 5I, 347. i IBurke, J F (i96I) Surgery, 50, i6i. I2 Alexander, J W, and Altemeier, W A (I965) Surgery, Gynecology and Obstetrics, I520, 243.
245
13 Stokes, E J, Waterworth, P M, Franks, V, Watson, B, and Clark, C G (I974) British Journal of Surgery, 6x, 739. 14 Downing, R, McLeish, A R, Burdon, D W, Alexander-Williams, J, and Keighley, M R B (1977) Diseases of the Colon and Rectum, 20, 401. 15 Howe, C W (I97I) Surgery, 66, 570. i6 Keighley, M R B (I977) British Journal of Surgery, 64, 315. 17 Willis, A T, Ferguson, I R, Jones, P H, Phillips, K D, Tearle, P V, Fiddian, R V, Graham, D F, Harland, D H C, Hughes, D F R, Knight, D, Mee, W M, Pashby, N, Rothwell-Jackson, R L, Sachdeva, A K, Sutch, I, Kilbey, C, and Edwards, D (I977) British Medical Journal, i, 607.
Vascular problems CLOTTING IN ARTERIES AND VEINS V V Kakkar FRCS Professor of Surgical Sciences and Director of Thrombosis Research Unit, King's College Hospital Medical School, London
Introduction Since most clinicians deal with the problems caused by either thrombosis or embolism, the consequences of such acute occlusive vascular insults are well known. Thromboembolism now represents the commonest cause of morbidity and mortality among the middle-aged and elderly populations. For example, in England and Wales in I974 nearly one-third of all deaths recorded in the Registrar General's report were due to ischaemic heart disease. If cerebral thrombosis and venous thromboembolism are also included the figure then rises to almost 5070 of all deaths'. Furthermore, despite the availability and use of anticoagulants, as well as developments in vascular surgery, episodes of such thromboembolic events appear to be increasing in number. Therefore there is a real need for the development of new measures for the prevention of and therapy for thromboembolic disease. This in turn depends upon a better understanding of the basic mechanism involved in thrombogenesis. A very brief review of the current concepts of pathogenesis of both venous and arterial thrombi and what can be done to prevent their occurrence is presented in this paper.
Pathogenesis VENOUS THROMBI
Venous thrombin are generally regarded as an expression of blood coagulation and fibrin formation in the presence of venous stasis. The great pathologist Virchow postulated in 1856 that three main components are essential for the formation of venous thrornbi-changes in the composition of blood, damage to the blood vessels, and decreased rate of blood flow -the essential components of Virchow's
triad2.
There is no doubt that changes in the composition of the blood, the so-called 'hypiercoagulable' state, and abnonrmalities in the blood flow play an important role in the initiation and growth of a thrombus. However, the controversy concerns the part which is played by the damage to the vessel wall or injury to the endothelial cells. Several recent experimental studies have shown that although endothelial injury plays an important role in the development of arterial thrombi, this is not a prerequisite for the formation of venous thrombi. The results of one such experimental study are shown in Figure i. It is now generally accepted that stasis of
Discussion
243
tonitis is evident, its value in the prophylaxis of residual intraperitoneal sepsis after elective surgery may only be inferred. It is probable, however, that antibiotic lavage of the operative field willl eliminate those infrequent residual abscesses which all surgeons see from time to time.
References I
2
3 4 5
6
7 8 9
1o ii
I2
Palmer, J F (I835) The Works of John Hunter, vol I, pp. 445-446. London, Longman, Rees, Orme, Brown and Longman. Stewart, D J, and Matheson, N A (1978) British Journal of Surgery, 65, 54. Stewart, D J, and Matheson, N A (I978) British Journal of Surgery, 65, 57. Siegel, S (1956) Non-parametric Statistics for the Behavioural Sciences. New York, McGraw-Hill. Crowther, J S ('97') Journal of Applied Bacteriology, 34, 477. Browne, M K, and Stoller, J L (1970) British Journal of Surgery, 57, 525. Gilmore, 0 J A (I977) Annals of the Royal College of Surgeons of England, 59, 93. Cleaver, C L T, Hopkins, A D, Ng, K, Kee Kwong and Raftery, A T (I974) British Journal of Surgery, 6I, 6oi. King, D W, Gurry, J F, Ellis-Pegler, R B, and Brooke, B N (I975) British Journal of Surgery, 62, 645. Pickard, R G (1972) British Journal of Surgery, 59, 642. Gue, S (1974) Australian and New Zealand Journal of Surgery, 44, 375. Leger, L, Moulle, P, Delaitre, B, and Chiche, B (I977) Nouvelle presse medicale, 6, 649. Stoker, T A M, and Ellis, H (I97I) British Medical Journal, 3, 769. Calman, K C, Kennedy, F, Meudell, C M, and Sleigh, J D (I97i) British Medical Journal, 4,
Retrospective studies suggested considerable 13 benefits from antibiotic peritoneal lavage in children with appendicular periton.itis. Animal [4 experiments demonstrated the potential of anti232. biotic lavage in catastrophic faecal peritonitis. 15 Bird, G G, Bunch, G A, Croft, C B, Hoffman, Its effect was dependent both on lavage and on D C, Humphrey, C S, Rhind, J R, Rosenberg, I L, Whittaker, M, Wilkinson, A R, and Hall, antibiotic. An audit of clinical practice showed (1I97I) British Journal of Surgery, 58, 447. that antibiotic lavage is still used infrequently, I6 RMackie, B, Shafi, M S, Grundy, D J, Ralphs, even in faecal peritonitis. D N L, and Haynes, S (1973) British Journal While the value of antibiotic lavage in periof Clinical Practice, 27, 57. PREVENTION OF INFECTION IN SURGICAL WOUNDS M R B Keighley MS FRCS Consultant Surgeon, The General Hospital, Birmingham
Introduction Wound sepsis is defined as the presence of pus in the incision' and is caused by organisms being inoculated into a surgical incision either from the environment (exogenous) or fromn the viscus being operated upon (endogenous).
Exogenous wound sepsis is usually caused by staphylococci2 froM the patient's nose or skin, the theatre environment, or a member of the surgical team. Late infections may also occur from cross-infection on the ward3. Staphylococcal sepsis is the most important
244
The scientific basis of the management of injury, wounds, and ulcers
cause of wound sepsis in 'clean' operations when there is no intestinal contamination, as in hemiorrhaphy, elective orthopaedic operations, and peripheral vascular surgery. However, wound sepsis is uncommon after these procedures and is usually recorded in less than 2 To of patients4. Endogenous wound sepsis is much more common and is due to release of bacteria from the intestinal tract, usually at the time of operation, though late sepsis can occur following dehiscence of an intestinal anastomosis. Endogenous wound sepsis is particularly common after emergency operations for peritonitis complicating perforation or infarction of the intestinal tract. In the unprotected patient endogenous wound sepss occurs in I0-20% of, cases after elective gastnc or biliary operations5 and in up to 5o% after
Prophylactic antimicrobials Endogenous wound sepsis frequently occurs despite careful preparation and meticulous operative technique because large numbers of organisms are released into the incision during operation. The risk of wound sepsis froom this source can be minimised by the use of pro. phylactic antimicrobials. The aim of antibacterial prophylaxis is to provide the patient with an adequate serum concentration of an antimicrobial effective against the endogenous bacterial flora immediately before the infected viscus is opened"' 12. The first dose of antibiotic shouild therefore be given at the start of the operation. Furthermore, shorttenn cover for 24 h is just as effective as, and preferable to, longer periods of antibiotic administration,3' . Systemic antibiotics are pref erable to topical or oral therapy because they will provide predictable serum concentratioins, and the risks of bacterial resistance and superinfection are also minimised. Because of the potential dangers of toxcity, hypersensitivity reactions, resistant organisms, superinfecdon, and antibiotic-induced colitis it is important to avoid unnecessary antibiotic prophylaxis. Prophylactic antibiotics should therefore be restricted to patients in whom the intestinal tract is likely to contain more that IO5 organiisms per ml5. These patients include the following elective operative groups: resection for gastro-oesophageal carcinoma, biliary operations for non-malignant jaundice, smallintestinal resection in Crohn's disease, and all patients requirng partial or complete resection of the colon and rectuml`. The antimicrobial chosen should be one which is effective against streptococci and coliforms for gastric and biliary surgery, but for colorectal operations cover should also be provided against the anaerobic intestinal flora, particularly Bac-
elective colonic resections6' 7. Preventive measures Wound sepsis may be minimiised by careful preoperative preparation of the patient. Eradication of established skin sepsis and repeated application of antiseptics to the skin8 will help to prevent exogenous sepsis. Poor nutritional state will incrase the risk of sepsis and should be corrected before elective operations. The timing of operation is important, since the risk of wound sepsis is greater if there is walled-off intra-abdominal pus. Conservative management should therefore be encouraged in patients with peridiverticular abscess or acute cholecystitis because the risks of sepsis are reduced if operative treatment can later be performed as an interval pro. cedure. Endogenous sepsis may be reduced after elective colonic resection by careful mechanical bowel preparation. The risk of wound sepsis is influenced by operative techilque. Exogenous sepsis in teroides fragilis'7. orthopaedic surgery has been dramatically reduced by ediminating bacterial contamiation of the theatre atmosphere0. Endogenous References Research Council (I964) Annals of sepsis can also be muinimsed by meticulous I National I 6o, SuppI. 2, p. I . Surgery, care in isolating sites of potential contaminaH J (I959) New England Journal of Weinstein, 2 tion, adequate haemostasis, satisfactory in260, Medicine, testinal anastomosis without tension, and wound 3 Mitchell, A A B,1303. Pettigrew, J B, Timbury, M G, closure after changing instruments and gloves'0. and Hutchinson, T (I959) Lancet, 2, 503. In grossly contaminated wounds sepsis can 4 Cruse, P J E (1970) Canadian Medical Association Journal, 102, 251. also be avoided by delayed primary suture.
The scientific basis of the management of injury, wounds, and ulcers 5 Stone, H H, Hooper, C A, Lauxa, B A, Kolb, B S, Geheber, B S, and Dawkins, E J (1976) Annals of Surgery, 184, 443 6 Burton, K C (I973) British Journal of Surgery, 6o, 363. 7 Goldring, J, Scott, A, McNaught, W, and Gillespie, G (I975) Lancet, 2, 997. 8 Lowbury, E J L, and Lilly, H A (I973) British Medical Journal, I, 510. 9 Chamley, J, and Eftekhar, N (I969) British Journal of Surgery 56, 641. Io Hughes, E S R (1972) Annals of the Royal College of Surgeons of England, 5I, 347. i IBurke, J F (i96I) Surgery, 50, i6i. I2 Alexander, J W, and Altemeier, W A (I965) Surgery, Gynecology and Obstetrics, I520, 243.
245
13 Stokes, E J, Waterworth, P M, Franks, V, Watson, B, and Clark, C G (I974) British Journal of Surgery, 6x, 739. 14 Downing, R, McLeish, A R, Burdon, D W, Alexander-Williams, J, and Keighley, M R B (1977) Diseases of the Colon and Rectum, 20, 401. 15 Howe, C W (I97I) Surgery, 66, 570. i6 Keighley, M R B (I977) British Journal of Surgery, 64, 315. 17 Willis, A T, Ferguson, I R, Jones, P H, Phillips, K D, Tearle, P V, Fiddian, R V, Graham, D F, Harland, D H C, Hughes, D F R, Knight, D, Mee, W M, Pashby, N, Rothwell-Jackson, R L, Sachdeva, A K, Sutch, I, Kilbey, C, and Edwards, D (I977) British Medical Journal, i, 607.
Vascular problems CLOTTING IN ARTERIES AND VEINS V V Kakkar FRCS Professor of Surgical Sciences and Director of Thrombosis Research Unit, King's College Hospital Medical School, London
Introduction Since most clinicians deal with the problems caused by either thrombosis or embolism, the consequences of such acute occlusive vascular insults are well known. Thromboembolism now represents the commonest cause of morbidity and mortality among the middle-aged and elderly populations. For example, in England and Wales in I974 nearly one-third of all deaths recorded in the Registrar General's report were due to ischaemic heart disease. If cerebral thrombosis and venous thromboembolism are also included the figure then rises to almost 5070 of all deaths'. Furthermore, despite the availability and use of anticoagulants, as well as developments in vascular surgery, episodes of such thromboembolic events appear to be increasing in number. Therefore there is a real need for the development of new measures for the prevention of and therapy for thromboembolic disease. This in turn depends upon a better understanding of the basic mechanism involved in thrombogenesis. A very brief review of the current concepts of pathogenesis of both venous and arterial thrombi and what can be done to prevent their occurrence is presented in this paper.
Pathogenesis VENOUS THROMBI
Venous thrombin are generally regarded as an expression of blood coagulation and fibrin formation in the presence of venous stasis. The great pathologist Virchow postulated in 1856 that three main components are essential for the formation of venous thrornbi-changes in the composition of blood, damage to the blood vessels, and decreased rate of blood flow -the essential components of Virchow's
triad2.
There is no doubt that changes in the composition of the blood, the so-called 'hypiercoagulable' state, and abnonrmalities in the blood flow play an important role in the initiation and growth of a thrombus. However, the controversy concerns the part which is played by the damage to the vessel wall or injury to the endothelial cells. Several recent experimental studies have shown that although endothelial injury plays an important role in the development of arterial thrombi, this is not a prerequisite for the formation of venous thrombi. The results of one such experimental study are shown in Figure i. It is now generally accepted that stasis of
