Search

Objectives: To determine the incidence and nature of complications on a general surgery service and to compare these results with pre-existing institutional recording and reporting methods., Design: A single observer prospectively monitored the presence and documentation of complications for all patients admitted to the general surgery service at the Wellesley Central Hospital over a 2-month period, through daily chart reviews, attendance at rounds and surgical operating rooms, frequent patient visits on the ward and interviews with the health care team., Setting: The general surgery service of an urban, university-affiliated teaching hospital., Patients: One hundred and ninety-two general surgery inpatients over 1277 patient-days from June 16, 1996, until Aug. 15, 1996. Same-day surgery patients were not included., Results: Seventy-five (39%) of the 192 patients suffered a total of 144 complications. Two complications (1%) were fatal, 10 (7%) were life threatening, 90 (63%) were of moderate severity and 42 (29%) were trivial. Of these 144 complications, 26 (18%) were deemed potentially attributable to error. One hundred and twelve (78%) of the complications occurred during or after a surgical operation and were related directly or indirectly to it. Only 9 (6%) complications were not documented in the progress notes of the patients' charts. However, 115 (80%) were not presented at weekly morbidity and mortality rounds, and 95 (66%) were not documented on the face sheet of the patients' final medical records., Conclusions: Complications are common and are underreported by traditional methods. Since hospital funding and quality improvement efforts depend on accurate identification and recording of adverse events, strategies to improve the recording and reporting of complications must be developed.

When used appropriately, antimicrobial prophylaxis is highly beneficial and cost effective. Antibiotics are not indicated for "clean procedures" such as hernia and breast surgery. A single preoperative dose will suffice, followed by an intraoperative dose if the operation takes more than 3 hours. For vascular (prosthesis or groin wound), head and neck (pharynx entered), thoracic (gastrointestinal or respiratory entrance) and high-risk gastroduodenal and biliary procedures, cefazolin, 1 g intravenously, is indicated. For procedures involving small intestine, appendix or penetrating abdominal trauma, cefoxitin or cefotetan, 2 g intravenously, is indicated. For colorectal procedures, either oral neomycin plus erythromycin or intravenous aminoglycoside plus clindamycin (or metronidazole) are effective. If valvular heart disease is present, endocarditis prophylaxis should be administered.

Campylobacter pyloridis has been associated with acid-peptic disease in centres outside Canada. The authors conducted a pilot study to see if this association existed in Toronto. Patients in whom esophagogastroscopy was indicated on clinical grounds were arbitrarily selected for determination of the presence of C. pyloridis. Included in the study were 100 patients who underwent 105 endoscopies. In 75 patients (80 endoscopies) there was some form of acid-peptic disease (inflammation or ulceration of stomach or duodenum). Of those with acid-peptic disease, 34% had C. pyloridis compared with 4% among patients without acid-peptic disease (p less than 0.01). Men with acid-peptic disease were more likely to harbour C. pyloridis than women (48% versus 16%, p less than 0.01). The organisms were curved gram-negative rods that appeared as small colonies after 4 days of incubation under microaerobic conditions. They were strongly urease positive. There was considerable heterogeneity of endoscopic diagnoses. Future clinical studies of C. pyloridis need careful endoscopic and histologic classification.

Twenty-three surgeons at three McGill University hospitals were interviewed about their treatment of intra-abdominal sepsis. They described their use of antibiotics, operative practices and other treatment of generalized peritonitis and intra-abdominal abscesses. If more than 75% of respondents used a given method, its use was considered "uniform" unless substantial interhospital variation existed for that method. Treatment was variable in 18 situations. Only four of these involved systemic antibiotic use--drug regimens in appendicitis and intra-abdominal abscess, and duration of antibiotic therapy following appendicitis and perforated duodenal ulcer. The other 14 examples of variation were in operative management. In generalized peritonitis, they were: use of diagnostic paracentesis; abdominal lavage with saline alone versus saline plus antibiotic use; whether the peritoneum should ever be left open; the use or avoidance of drains; primary versus delayed wound closure in appendicitis, bowel perforation and trauma with gastrointestinal perforation and, finally, wound lavage with saline alone or with antibiotics. Treatment of intra-abdominal abscesses varied in regard to the diagnostic and therapeutic roles of percutaneous needle aspiration, the preferred route of drainage of a pelvic abscess, the use of an extra- or trans-serosal approach to a subphrenic abscess, local versus full abdominal exploration for a single abscess and the type of drain used. The authors conclude that operative management of intra-abdominal sepsis varies widely among surgeons. This fact invalidates many "controlled" trials of antibiotics and should focus attention less on drugs and more on surgical treatment.

The prophylactic use of antibiotics in elective surgery of the colon is accepted practice, but it has inherent risks. The authors report the case of a 70-year-old woman who had wound infection and severe, relapsing pseudomembranous colitis due to Clostridium difficile after a short course of antibiotics given orally and parenterally at the time of elective resection of the colon. Perioperatively, she received erythromycin base and neomycin orally, plus netilmicin and metronidazole intravenously. Although the concomitant administration of parenteral antibiotics may enhance the benefit of antibiotics given orally before operation, this does not entirely prevent wound infection. Until the relation between the number of drugs and risk of antibiotic-associated colitis is more clearly defined, caution should be exercised in the use of multiple antibiotics in elective colonic surgery.