Removable subcuticular skin suture in acute appendicitis: a prospective comparative clinical trial Standard surgical teaching advises the use of interrupted sutures for skin closure in potentially infected wounds.'-3 Trials supporting or refuting this premise are few. So far as we are aware no trial has been performed using a removable subcuticular stitch for skin closure in acute appendicitis. We report the results of a prospective trial to compare the two methods of skin closure. Patients, methods, and resultsOne hundred and eighty-four patients with acute appendicitis were entered into a prospective trial to compare skin wounds closed by a continuous subcuticular Prolene suture with those closed with interrupted Prolene sutures. Only patients with appendicitis subsequently confirmed histologically were included; perforation of the appendix did not contraindicate entry into the trial.All skin incisions were transverse or oblique, and the abdomen was entered through standard grid-iron or transrectus approaches. Drains (17/146; 12 %) and antibiotics (53/146; 35°%) were used at the discretion of the surgeon. Dexon was used for peritoneal and muscle closure in all cases. Neither peritoneal nor wound lavage was performed and, no topical agents were applied to the wound. After closure of the muscle layer a randomly selected sealed envelope was opened to determine the choice of skin suture. The severity of the appendicitis was classified as: (a) acute inflammation, (b) pus present, or (c) perforation. All wounds were examined daily and again two weeks after the patient left hospital; those with a discharge were considered to be infected. Skin sutures were removed between five and seven days after operation.

To determine the need for prophylactic nasogastric decompression following laparotomy and the influence of cimetidine, 200 consecutive patients who underwent major abdominal procedures were prospectively randomized into one of four limbs: no tube-placebo; no tube-cimetidine; tube-placebo; and tube-cimetidine. Patients were evenly distributed among these groups with respect to age, sex, alcohol and tobacco use, previous operations, and types of operations. There was significantly longer time until passage of flatus, bowel movement, and cessation of intravenous fluids in the tube group (p less than 0.05). Duration of postoperative stay increased from 11.4 to 14.1 days in the intubated patients (p less than 0.05). There was also significantly more pain with and frequency of swallowing, and nose/throat discomfort in the tube group. Nasogastric tubes reduced the incidence of vomiting from 28 in the no-tube group to 10 in the tube group (p less than 0.05), but most had only one or two episodes. Cimetidine did not affect either the incidence of vomiting or the duration of intubation, but was associated with a significant increase in pneumonias (p less than 0.05). Five patients without tubes initially, and seven patients with tubes had to have them inserted or replaced for vomiting or abdominal distention, which occurred equally in the placebo and cimetidine limbs. There were no cases of aspiration pneumonia, gastric dilatation, or wound dehiscence in the trial, and the four anastomotic leaks were divided equally between the tube and no-tube groups. The results indicated that prophylactic decompression was unnecessary in most patients and associated with increased morbidity and delayed return of gastrointestinal function. Cimetidine lowered nasogastric output on the first postoperative day (p less than 0.05), but did not prevent vomiting.

SUMMARY Biliary excretion scintigraphy with a cholagogic test meal may be used to assess patients with suspected disorders of gall bladder motility. The interpretation of results is frustrated, however, by the lack of information about the range of normal responses in a form suitable for comparative analysis. We present the results of 41 gall bladder emptying studies on 32 normal healthy subjects (14 men, 18 women) 30 minutes after intravenous injection of 74 MBq 'Tcm-EHIDA. Gall bladder emptying was provoked by the ingestion of 300 ml milk. Gamma camera scintigraphy was used to plot gall bladder activity against time. Gall bladder emptying occurred within 10 minutes in all men and 12/18 women (p=002). Gall bladder ejection fractions were significantly greater in women (p<0-05). Duplicate studies in nine subjects showed good reproducibility (r=0.959). A plot of mean and (m+2 SD) values of gall bladder activity against time has been derived. The data provide an estimate of normal gall bladder emptying response, which may be used to aid interpretation of clinical studies.It is now possible to quantify gall bladder emptying in response to a standard cholagogic stimulus, using biliary excretion scintigraphy.' The technique is simple to do, well tolerated by patients, and inexpensive. The equipment required is now standard in most larger hospitals. The clinical requirement for such a test is limited, but recent reports' identify groups of patients with abnormalities of gall bladder emptying, for whom the use of such a test might provide valuable diagnostic information.At present the normal range of responses to a standard gall bladder emptying test is poorly defined. It is therefore difficult to view an individual patient's response to testing and say with any confidence that it is abnormal. The purpose of this report is to present an analysis of 41 gall bladder emptying studies carried out on 32 normal healthy volunteers. These studies, carried out between November 1980 and May 1981 were part of a research protocol developed for the study of enterogastric reflux.' Ethical Committee approval was obtained for the study of patients and

The effects of somatostatin (SRIF) and its long-acting analogue, SMS 201-995 on the prevention and treatment of acute pancreatitis were studied in rats. Acute pancreatitis was established by ligating the bile duct at the point of entry into the duodenum, thereby allowing reflux of bile into the pancreas. Administration of SRIF (4 micrograms kg-1 body wt IV followed by a 12 h infusion of 4 micrograms kg-1 body wt h-1) or SMS 201-995 (2 micrograms kg-1 body wt SC) at the time of bile duct ligation prevented the increase in the serum concentrations of amylase and lipase observed in control rats 12 h after bile duct ligation. Moreover, SRIF and SMS 201-995 administration prevented development of the histological changes consistent with acute pancreatitis observed in control animals. These results suggest that SRIF or SMS 201-995 may be of value in preventing acute pancreatitis following ERCP or after surgery on the pancreas. In rats with established pancreatitis, SRIF (IV bolus of 4 micrograms kg-1 body wt followed by a 24 h continuous infusion of 4 micrograms kg-1 body wt h-1) or SMS 201-995 (2 micrograms kg-1 body wt SC followed by a similar dose 12 h later): (1) significantly improved survival; (2) produced histological changes in the pancreas consistent with organization and healing; (3) prevented the accumulation of ascitic fluid; (4) reduced the serum levels of amylase and lipase. These results suggest that SRIF and SMS 201-995 may prove valuable in the treatment of established acute pancreatitis in man.

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