Complications on a general surgery service: incidence and reporting.

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.

Pulmonary aspiration complicating intraoperative small-bowel decompression: a case report and literature review.

When conservative management of intestinal obstruction fails, the surgeon has two operative choices for decompression: the open procedure with enterotomies and suction and the closed procedure consisting of retrograde stripping and nasogastric suction. A previously undocumented complication of the latter procedure-pulmonary aspiration-is reported in a 20-year-old man with small-bowel obstruction. Practical modifications to the technique of small-bowel decompression are suggested. They include feeding the nasogastric tube into the distal duodenum, using a wider bore tube, inserting an esophageal balloon before extubation, using a nasogastric tube with suction throughout extubation and, immediately postoperatively, making a more conscious effort to remove all gastric contents before extubation, and milking the contents distally through the ileocecal valve.

Delayed rupture of the spleen and streptokinase therapy.

Delayed rupture of the spleen is a rare but serious complication of blunt abdominal trauma. A 47-year-old woman with a history of fractured pelvis from a motor vehicle accident 6 months earlier presented with evidence of a myocardial infarction. Subsequent streptokinase administration was complicated by splenic rupture, which was managed by evacuation of the clotted blood and splenectomy. The patient made a complete recovery. The risk of splenic rupture and bleeding complications resulting from thrombolytic therapy for myocardial infarction is discussed, as are the controversy over whether delayed splenic rupture is a true diagnosis, the mechanism of rupture and the clues to impending rupture.

Blue rubber bleb nevus syndrome.

Blue rubber bleb nevus syndrome, an uncommon condition, is manifested by gastrointestinal and skin hemangiomas and gastrointestinal hemorrhage causing anemia. The authors report a unique case of the syndrome in association with a congenital cardiac malformation. A 26-year-old woman presented with iron-deficiency anemia after the birth of her first child. She had a history of skin and gastrointestinal hemangiomas and tetralogy of Fallot. Endoscopy revealed multiple new intestinal hemangiomas, which were removed through enterotomies with resolution of the anemia. Iron therapy was prescribed, and her condition was stable at follow-up 5 years later.

Benefit of palliative surgery for bowel obstruction in advanced ovarian cancer.

OBJECTIVES: To determine the benefit of palliative surgery for patients with advanced ovarian cancer and bowel obstruction and to identify criteria for selecting patients who are most likely to benefit from palliation. DESIGN: A retrospective study of patients treated between 1982 and 1992. SETTING: A university-affiliated hospital. PATIENTS: Fifty-three patients with complete and unresolved bowel obstruction caused by ovarian cancer. INTERVENTION: Surgery for relief of bowel obstruction. MAIN OUTCOME MEASURES: Postoperative survival longer than 60 days, return home and relief of bowel obstruction for longer than 60 days, factors associated with failure of palliative surgery. RESULTS: Successful palliation was achieved in 27 (51%) patients and was associated with the absence of four prognostic factors: palpable abdominal and pelvic masses, ascites exceeding 3 L, multiple obstructive sites and preoperative weight loss greater than 9 kg. Age, time interval between diagnosis of ovarian cancer and bowel obstruction, stage of disease at initial diagnosis, tumour type and grade, site and degree of obstruction, presence of gross residual tumour after initial operation and preoperative use of chemotherapy or radiotherapy did not indicate the success or failure of palliative surgery. CONCLUSIONS: Palliative surgery for bowel obstruction in advanced ovarian cancer can be worthwhile, and there are four prognostic factors that indicate the likely failure of palliation.

Nonparasitic splenic cysts: a case report and review.

Cysts of the spleen are rare but usually benign. The authors describe the case of a young woman with a splenic cyst who underwent splenectomy. Ultrasonography and computed tomography have helped improve the preoperative diagnosis of nonparasitic splenic cysts, and as the use of ultrasonography increases, so will the finding of incidental splenic cysts. Whether all splenic cysts enlarge is unknown, and it is uncertain whether all small asymptomatic cysts need treatment. The cysts may enlarge, become infected or rupture. Total splenectomy has been the most common treatment in the past, but, because of the risk of postsplenectomy sepsis, partial splenectomy may be preferred when technically possible.

An association between anti-inflammatory medication and internal pelvic fistulas.

Spontaneous internal fistulas involving intestine, rectum, bladder, or vagina in patients without predisposing illnesses were studied. Twelve of 20 (60 percent) were receiving steroids or other anti-inflammatory medication at the time the fistulas developed. Fifteen of the 20 patients subsequently had diverticular disease identified. It is proposed that there is an association between anti-inflammatory medication and fistulas that develop from intestine to other pelvic viscera, spontaneously or in association with colonic diverticula.

The double stapling technique for low anterior resection of rectal carcinoma.

The double stapling technique (TA-55 and EEA staplers) was used to perform low anterior resections for rectal carcinomas in 79 patients (49 men, 30 women). The mean age was 66 years (range, 38 to 85 years). Curative resections were performed in 68 patients, and palliative resections in 11 patients. The mean level of the cancer from the dentate line was 9 cm (range, 5 to 16 cm). The mean follow-up has been 29 months (range, four to 58 months). Perioperative mortality was 2.5 percent (two patients). Technical problems related to the stapling technique occurred in 6 percent (five patients). The clinical anastomotic leak rate was 8 percent (six patients). There were 11 local recurrences among 68 curative resections (16 percent). Local recurrence according to individual surgeon showed marked variability (range, 0-43 percent, P greater than 0.05). There were no differences in location, differentiation, or stage in those that recurred. The mean distal resection margin for the recurrent cancer group was 3.0 cm and for the nonrecurrent group, 2.9 cm. Disturbances of continence were seen commonly (56 percent) in the first three months after surgery, but 85 percent of patients became fully continent with an acceptable bowel habit at later follow-up. The double stapling technique is useful for the restorative resection of suitable mid and low rectal cancers. The anastomotic leak rate, local recurrence rate, and functional results are acceptable.

Synergistic action of cimetidine and chlorpheniramine in prevention of restraint stress gastric ulceration in rats.

The role of histamine H1 and H2 receptors in acute gastric ulceration was studied using a rat restraint-stress model. Cimetidine, an H2 receptor antagonist, afforded some protection at all doses. A dose response study showed that the mean number of ulcers per rat decreased exponentially with increased doses, and the proportion of animals protected from any ulceration increased in a simple linear progression. A dose of cimetidine was chosen which gave only partial protection from ulceration, and to this was added chlorpheniramine, an H1 antagonist. H1 antagonism alone was found to give partial protection, but when both H1 and H2 blocker were given a synergistic effect was seen thus indicating that H1 receptors do have a role in acute gastric ulceration.

Left intrahepatic cholangiojejunostomy for proximal obstruction of the biliary tract.

Good palliation from high neoplastic obstruction of the biliary system was achieved by direct anastomosis of the duct draining hepatic segment III to a Roux-en-Y loop of jejunum in six patients. Roentgenologically guided transcutaneous drainage of intrahepatic ducts may be desirable as a preliminary to surgical drainage in severely icteric patients. With improvements in methods of transcutaneous intubation, the selection of proper patients for surgical drainage will be a fine point of judgment.

A clinical evaluation of impedance rheography in peripheral arterial disease.

The impedance rheograph has been shown to give values of blood flow consistent with a history of vascular insufficiency; normal limbs having a mean flow of 6.9 +/- 1.6 milliliters per minute per 100 milliliters of limb volume and diseased limbs having a proportionately reduced flow. The most reduced flow was found in those with rest pain or severe claudication, 1.7 +/- 0.8 milliliters per minute per 100 milliliters of limb volume. It is suggested that this technique may be useful clinically in assessing patients before treatment and, subsequently, as an objective evaluation of that treatment.