Sixty-two patients were admitted to a prospective randomized controlled trial to investigate the influence of a prophylactic antibiotic, lincomycin, on anaerobic sepsis following bowel surgery. The incidence of postoperative sepsis was reduced from 45 to 18 per cent (P less than 0-025). Wound infections were reduced from 38 to 12 percent (P less than 0-05). Intra-abdominal or pelvic abscess occurred in 1 of the treated group compared with 3 controls. Septicaemia occurred after operation in 1 patient receiving lincomycin and in 3 of the controls; in 2 of the latter, pure growths of bacteroides were isolated from the blood cultures and 1 of these patients died. Although lincomycin had no influence on the number of patients who developed aerobic postoperative infections, there was a significant reduction in the incidence of sepsis due to bacteroides, which occurred in 10 of the control group compared with 1 in the lincomycin group (P less than 0-005). No patients developed complications attributable to lincomycin, such as pseudomembranous colitis. These data indicate that the genus Bacteroides are important pathogenic organisms and are responsible for postoperative morbidity. Furthermore, anaerobic sepsis can be reduced by appropriate prophylactic antibiotics.

COL 0 R E eTA L surgery is associated with a high incidence of wound sepsis, intra-abdominal abscess and occasionally septicaemia. These complications are usually caused by the introduction of intestinal organisms into the peritoneal cavity, wound or blood stream at the time of operation (Davidson et al., 1971). The flora of the colon is complex and includes large numbers of aerobic and anaerobic bacteria. Administration of antibiotics such as lincomycin, which are effective against the anaerobic intestinal flora (particularly Bacteroides sp.) will reduce postoperative sepsis (Keighley et al., 1975). The aim of this study is to examine the influence of short-term prophylaxis on postoperative sepsis using tobramycin and lincomycin, and. to determine whether this combination of antibiotics is more effective than lincomycin alone.

Acute superficial fissure-in-ano responds readily to conservative non-surgical treatment. For chronic deep fissures we recommend manual anal dilatation and the post-dilatation regimen but recognise that equally good results follow the simple procedure of subcutaneous lateral internal sphincterotomy. The recurrence rate following these minor procedures is less than 10 per cent and the incidence of poor flatus control and mucus leakage is even lower. It is never necessary to excise fissures nor sentinel piles although it may be desirable to excise large redundant skin tags to facilitate anal hygiene. Painless or atypically sited fissures should suggest the diagnosis of Crohn's disease. Treatment is rarely required for fissure-in-ano in this condition, although severe anal stenosis may need extremely gentle anal dilatation. Postoperative anal stenosis can also be managed successfully by manual dilatation under anaesthesia with a prolonged regimen of self dilatation until healing is complete. Radical or complicated plastic operations are rarely indicated for any patient with fissure-in-ano or stenosis and are strongly contraindicated in Crohn's disease.

Acute superficial fissure-in-ano responds readily to conservative non-surgical treatment. For chronic deep fissures we recommend manual anal dilatation and the post-dilatation regimen but recognise that equally good results follow the simple procedure of subcutaneous lateral internal sphincterotomy. The recurrence rate following these minor procedures is less than 10 per cent and the incidence of poor flatus control and mucus leakage is even lower. It is never necessary to excise fissures nor sentinel piles although it may be desirable to excise large redundant skin tags to facilitate anal hygiene. Painless or atypically sited fissures should suggest the diagnosis of Crohn's disease. Treatment is rarely required for fissure-in-ano in this condition, although severe anal stenosis may need extremely gentle anal dilatation. Postoperative anal stenosis can also be managed successfully by manual dilatation under anaesthesia with a prolonged regimen of self dilatation until healing is complete. Radical or complicated plastic operations are rarely indicated for any patient with fissure-in-ano or stenosis and are strongly contraindicated in Crohn's disease.

or fat excess in the trochanteric region, the medial side of the thigh, or the knee, may be excised with good result by the methods described by Pitanguy (1971). Thick ankles are frequently due to low insertion of the fibres of soleus or of flexor hallucis longus. Surgery in these cases is best avoided. Excess fat in this region may be excised with medial and lateral incisions parallel to the anterior border of the Achilles tendon. Scars are frequently unsatisfactory, and surgery should not be lightly undertaken. Any correction of excess fat or skin folds by a surgical method is inevitably associated with a scar in the skin. It is imperative that any patient considered for such surgery should be appraised in detail of the nature and extent of scarring and of possible complications. A contour defect is a most difficult abnormality to disguise or hide. Surgery may correct this deformity, and most patients are delighted to accept the stigma of a pale, albeit stretched, scar in return for a normal shape. REFERENCES Dufourmontel C & Mouly R (1961) Annales de chirurgic plastique 6, 45 McKissock P K (1972) Plastic and Reconstructive Surgery 49, 245-252 Moran R E, Letterman G S & SchurterM (1972)'Plastic and Reconstructive Surgery 49, 595 Penn J (1960) In: Transactions of the Second International Congress on Plastic Surgery. Ed. A B Wallace et al. Livingstone, Edinburgh; p 502 Pitanguy I (1971) Surgical Clinics ofNorth America 51, 479-489 Strombeck J 0 (1960) British Journal ofPlastic Surgery 13, 79

County, Denmark, blood samples were drawn in the fasting state at 8 a.m. for determination of serum levels of calcium, protein, cholesterol, and triglyceride.The serum calcium levels were corrected to a constant serum protein level.2All determinations were made in duplicate, and the co- efficients of variation (C.V.) of duplicate measurements and the mean values and standard deviations (S.D.) are given in the table.A ihighly significant inverse corre- lation was found between serum calcium and serum triglyceride (r= -0-36, P<0001).No significant correlation was found between serum calcium and serum cholesterol (r = 0-03, P>0 05). C.v. (from Serum LevelsNo. of Mean S.D. duplicate Subjects measurements)Calcium (mmol/l) 80 2-46 0-06 0m8nt Cholesterol (mmol/l) 80 7-04 1-48 1-50°O Triglyceride (mmol/l) 80 1-27 0-95 2-6 ,Conversion: SI to Traditional Units-Calcium: 1 mmol/l -4 mg!100 ml.Cholesterol: 1 mmol/l -38-6mg'100 ml.Triglyceride: 1 mmol/l 88 5 mg/100 ml.Our results seem to be supported by the findings that serum cholesterol is lower than normal in patients with hyperparathyroidism and that the seruim concentration of lipids increases after operation.3They indicate that in the elderly serum calcium levels in the lower part of the normal range are not pro- tective against raised serum lipid levels.-We are, etc.

Of 111 consecutive patients treated by partial internal sphincterotomy for a haemorrhoidal disease in the course of a prospective study, 101 could be re-examined between 24 and 36 months after operation. There were no major complications but 11 patients had some significant complaints at some time after operation. There were six recurrences, five of which could be attributed to inadequate sphincterotomy. One patient had an excessive sphincterotomy which led to difficulties with continence of fluid stools. One patient developed a peri-anal abscess two years after partial sphincterotomy and four patients with marked soiling will require surgical correction of the posterior gutter. The gutter is due to secondary epithelialisation after open sphincterotomy in the posterior midline. The recommended technique entails the division of the internal sphincter up to a few millimeters above the dentate line and reconstruction of the anal mucosa with a continuous absorbable suture. 'Landscaping' by partial resections of the prolapsed haemorrhoids is recommended to avoid sclerotic tags. Submucosal sphincterotomy should be considered by the very experienced only and then provided that the anal mucosa shows little scarring.

Experience with whole-gut irrigation as a method of bowel preparation in eightyone patients is described. The mean (+/-S.D.) weight-gain during irrigation was 1-9 +/- 0-8 kg; potassium losses in the effluent after one hour (4-0 +/- 2-5 g) were not significantly altered by adding potassium chloride to the irrigant. Eight irrigations were unsatisfactory, three being due to unrecognised obstructive neoplasms. The method provided excellent preparation for colonoscopy and large-bowel resection with anastomosis and was well tolerated by the patients.