Summary Two hundred and fifty patients were admitted to a prospective randomized trial of single dosage prophylaxis against wound infection after appendicectomy. There were 12 exclusions, 72 patients received placebo, 81 received 600 mg i.m. clindamycin phosphate and 85 received 1 g i.m. cefazolin sodium, the agent being given in the anaesthetic room. Clindamycin produced a significant reduction in the overall rate of wound infection from 33 per cent in the controls to 17 per cent. In cases with a gangrenous or perforated appendix the infection rate in controls was 78 per cent; this was reduced to 44 per cent by a single dose of clindamycin. Cefazolin significantly reduced the number of aerobic organisms isolated from wound infections, but did not significantly reduce the incidence of wound infection. We conclude that anaerobic organisms are more important than faecal aerobic organisms in the pathogenesis of wound infection after appendicectomy.

A prospective randomized trial has compared manual dilatation of the anus (MDA) during general anesthesia with lateral subcutaneous sphincterotomy (LSS) during local anesthesia for the management of anal fissure in 156 patients. The two groups were similar with respect to age, sex and symptoms. There was no difference in the duration of time off work or early complications of treatment but, four months after operation, 93 per cent claimed to have been improved by MDA compared with 78 per cent after LSS (P<0.05). Recurrent fissure was recorded in 13 patients after LSS (29 per cent) compared with four (10 per cent) after MDA (P<0.02). There was a significant reduction in anal pressure at four months (P<0.02) after MDA, (123±31 to 97±33) and LSS (127±36 to 104±32), but the anal pressure remained unchanged by operation in all patients where pressures were measured with recurrent fissure. These data indicate that MDA gives better results than LSS for treatment of anal fissure and that successful treatment is associated with a reduction in anal pressure.

Gastric aspirates were obtained from 12 healthy volunteers, 49 patients with duodenal ulcer, 14 with gastric ulcer and 35 with gastric carcinoma. The mean total viable bacterial counts in these groups were as follows: volunteers 0, duodenal ulcer 3.8 X 10(1), gastric ulcer 6.95 X 10(4), carcinoma 1.9 X 10(7) organisms/ml. The incidence of wound sepsis in patients without antibiotic cover was; duodenal ulcer 17 per cent, gastric ulcer 38 per cent, carcinoma 56 per cent. Regardless of the underlying pathology, patients with counts greater than 5 X 10(6) organisms/ml in the gastric aspirate had a 93 per cent incidence of wound sepsis, compared with 16 per cent in patients with counts of less than 5 X 10(6) organisms/ml (P less than 0.001). In the group with high counts all except one of the wound infections were caused by organisms present in the stomach at the time of operation. There was a good correlation in the bacteriology of apirates obtained during preoperative endoscopy compared with operative nasogastric samples (n = 31) both for viable counts (r = 0.93) and for the counts of individual organisms. Therefore, preoperative endoscopy can be used to identify patients who are at risk of developing wound sepsis after gastric surgery.

Abstract A randomized trial has been conducted to compare treatment for first- and second-degree haemorrhoids by rubber band ligation and lateral subcutaneous sphincterotomy. The symptomatic results of both procedures were similar at one year, though the initial results of sphincterotomy were poor. Eleven patients later required haemorrhoidectomy—5 after lateral subcutaneous sphincterotomy and 6 after rubber band ligation. Rebanding was necessary in 11 patients treated by rubber band ligation (22 per cent). Immediate complications of pain and bleeding were reported in 27 per cent of patients treated by rubber band ligation compared with 14 per cent after lateral subcutaneous sphincterotomy, whereas 2 patients developed a fistula after lateral subcutaneous sphincterotomy. Lateral subcutaneous sphincterotomy was associated with a 30 per cent reduction in anal sphincter pressure at 4–6 months and the anal pressure was also reduced (by 24 per cent) at 1 year. Rubber band ligation had no influence on anal pressure. The poor results of lateral subcutaneous sphincterotomy occurred in patients with prolapse and with anal pressures of less than 100 cm H2O. Although lateral subcutaneous sphincterotomy is a satisfactory means of treating patients with first- and second-degree haemorrhoids, it requires admission to a day case unit. For this reason lateral subcutaneous sphincterotomy is unlikely to be preferred to rubber band ligation in the outpatient management of piles.