Don M. Morris

Factors influencing the morbidity of colostomy closure

In a series of 80 colostomy closures, a total complication rate of 26 per cent was found, with a wound infection rate of 14 per cent and an anastomotic leak rate of four per cent. Patients having preoperative systemic antibiotics had fewer wound infections than those who did not (eight per cent versus 19 per cent). Delayed primary skin closure or closure by secondary intention was associated with less wound morbidity than was primary closure (ten per cent versus 17 per cent). However, the use of preoperative systemic antibiotics decreased the incidence of wound infection in those having primary skin closure (five per cent versus 27 per cent). Patients having diverticular disease had more wound infections (40 per cent) and greater overall morbidity (70 per cent). Older patients had a higher incidence of complications (24 per cent if less than 40 years and 45 per cent if greater than 50 years). Closure of left-sided colostomies was associated with a higher infectious complication rate (26 per cent versus 13 per cent). The time interval to colostomy closure was found to alter subsequent morbidity with a waiting period of one to two months associated with zero complications.

Infection among 210 patients with surgically staged Hodgkin's disease

To determine the incidence and types of infections in Hodgkins disease, particularly those related to the overwhelming pneumococcal sepsis syndrome, 210 consecutive patients with previously untreated Hodgkins disease who underwent staging laparotomy with splenectomy from March 1968 to October 1979 were reviewed. For 178 patients (85 percent) alive at the end of the study, the mean follow-up time was 68.1 months. Eighty-two serious infections occurred among 59 (28 percent) of the patients; 47 (57 percent) serious infections were microbiologically documented and 35 (43 percent) were clinically documented. Forty-seven microbiologically documented serious infections occurred in 34 patients and consisted of 23 episodes of pneumonia, 10 cases of bacteremia, seven wound infections, two cases of disseminated herpes zoster, one subphrenic abscess, and four miscellaneous infections. Microbiologically documented serious infections occurring during initial treatment or remission had lower incidences of leukopenia (29 versus 58 percent) (p = 0.09) and death (11 versus 53 percent) (p = 0.005) than those occurring after relapse of Hodgkins disease. Of the microbiologically documented serious infections, 76 percent were associated with a predisposing factor(s) (leukopenia, postoperative state, steroids, peripheral neuropathy, leukemia), of which 34 percent were fatal. Microbiologically documented serious infections unassociated with a predisposing factor were never fatal, including the only episode of pneumococcal sepsis in the series. In contrast to microbiologically documented serious infections, only 14 percent of clinically documented serious infections (versus 38 percent) were fatal. The overwhelming pneumococcal sepsis syndrome and other infections thought to be associated with the asplenic state are uncommon problems in patients with Hodgkins disease after splenectomy.

Effect of postoperative radiotherapy on the development of small, bowel obstruction in patients undergoing staging laparotomy for Hodgkin's disease

TWO HUNDRED AND TEN PREVIOUSLY UNTREATED PATIENTS WITH HODGKINS DISEASE underwent staging laparotomy at one institution. Medical records of these patients were retrospectively reviewed. The incidence of small bowel obstruction (SBO); whether or not the patient received abdominal radiotherapy and the portals used; whether or not the patient had undergone a previous operation for unrelated disease; and the outcome of operative treatment for the SBO were noted. Mean follow-up for all patients was 62.6 months (1 to 125 months). Ninety-two patients (Group I) were treated without radiotherapy; two developed SBO (2.2%). Patients treated with abdominal radiotherapy numbered 118 (Group II); seven developed SBO (5.9%). The difference between Groups I and II is not significant. Eighty-two received only paraaortic radiotherapy; two (2.4%) developed SBO. Thirty-six patients underwent combined paraaortic and bilateral iliac radiotherapy (Group IV); five developed SBO (13.9%). Data for Groups III and IV approach statistical significance (p = 0.053; Fisher Exact Test [two-Tail]). All obstructions were secondary to adhesions. Four patients in Group IV had significant morbidity associated with operative treatment of SBO. This was an infection in each case. Infections developed in these patients even when the bowel was not entered. Pneumonia and wound infections were most common. Careful evaluation postoperatively for signs of infection and aggressive pulmonary toilet are recommended.

Doxorubicin plus VP-16-213 for the treatment of refractory breast carcinoma.

Thirty patients with refractory advanced breast cancer who had no prior treatment with doxorubicin or VP-16-213 received doxorubicin 45 mg/m2 I.V. on day 1 and VP-16-213 50 mg/m2 I.V. on days 1 through 5. Courses were repeated every 21 days when hematologic recovery permitted. Among 30 evaluable patients, one had a complete response and 11 had a partial response. Four patients had stabilization of their disease. There was thus a 40% response rate with a median response duration of 146 days (range 35-540). Toxicity included moderate to severe myelosuppression, infections, hemorrhage, and mucositis. In these poor prognoses in previously treated patients, the combination of doxorubicin and VP-16-213 appears to be an effective secondary treatment for metastatic breast cancer.

Scientific Reporting Questioned-Reply

In Reply .—We certainly appreciate Dr Levitts concern about the three patients we reported. These three patients, however, had stage IV (advanced metastatic) disease and they were thus appropriately treated with combination chemotherapy. Furthermore, all three patients achieved complete remission, which continued for greater than 30,19, and 16 months, respectively. This remission duration is greater than the median duration of survival for patients with advanced metastatic disease and is therefore remarkable in itself for three sequential patients. The more significant feature was that the combination chemotherapy shrank the primary masses, allowed for simple localized surgery to produce hygienic results, and perhaps more interestingly, this debulking procedure in two patients after they had achieved a stable partial response allowed the remaining measurable metastatic disease to respond even further and the patients achieved complete remission. It would be logical to hypothesize that a similar event may occur with micrometastases, and thus our