Pulmonary complications following major head and neck surgery with tracheostomy: a prospective, randomized, controlled trial of prophylactic antibiotics.

OBJECTIVE: To test the hypothesis that extended postoperative antibiotic cover would reduce the incidence of pulmonary complications in patients undergoing major head and neck surgery with tracheostomy. DESIGN: A prospective, randomized, controlled trial was carried out to determine the efficacy of an extended course (5 days) of intravenous amoxicillin-clavulanic acid in reducing the rate of atelectasis and pulmonary infections postoperatively. Other possible risk factors that might predispose to pulmonary complications were also evaluated. SETTING: Tertiary referral center for head and neck surgery. PATIENTS: Consecutive patients younger than 80 years with planned surgery for carcinoma of the oral cavity, pharynx, or larynx were enrolled. Patients with diabetes, those who had received antibiotics within 1 week before surgery, and those with preexisting pulmonary disease were excluded. INTERVENTION: Patients were randomly assigned no antibiotics or a 5-day course of intravenous amoxicillin-clavulanic acid postoperatively. MAIN OUTCOME MEASURES: The development of pulmonary complications (pulmonary infection or atelectasis). RESULTS: Eighty-six patients were enrolled; 73 patients met the criteria for analysis. Thirty-four (47%) developed pulmonary complications; 29 (40%) had a pulmonary infection. An extended course of antibiotics did not reduce the rate of pulmonary infections (P =.57). Positive risk factors for a pulmonary infection were presence of preoperative obstructive lung function and postoperative atelectasis. CONCLUSIONS: An extended course of antibiotics did not prevent the development of postoperative pulmonary infections in patients undergoing major head and neck surgery with tracheostomy. Poor pulmonary function and postoperative atelectasis emerged as significant risk factors for pulmonary infection.

Management of gallstone pancreatitis in Auckland: progress and compliance.

BACKGROUND: Recent advances in the management of acute gallstone pancreatitis include the introduction of laparoscopic cholecystectomy,defining the role of endoscopic retrograde cholangiopancreatography(ERCP) and early cholecystectomy to prevent recurrent pancreatitis. The aim of the present study was to review the current management of gallstone pancreatitis in Auckland Hospital, compare findings with a similar study published a decade ago and to determine the extent to which the management is compliant with recently published consensus guidelines. METHODS: A retrospective review of consecutive patients admitted with acute pancreatitis during a 39-month study period was undertaken. Data were recorded regarding demographics, diagnosis, predicted and actual severity of gallstone pancreatitis (index and recurrent attacks), the role of ERCP and computed tomography scanning, the timing of cholecystectomy (open and laparoscopic), intraoperative cholangiography, duration of hospital stay, complications and mortality. RESULTS: : There were 216 patients admitted with acute pancreatitis,106 of whom had proven gallstones. An ERCP was performed in 62(59%) patients with gallstone pancreatitis but not more commonly in patients with severe pancreatitis, and common bile duct stones were identified in 26% of these patients. Of the 70 (66%)patients who had a cholecystectomy, 56 (80%) had it within 3 weeks of admission. Although the proportion of patients with gallstone pancreatitis who had a cholecystectomy is similar to the earlier study, there has been a significant increase in the proportion of patients having a cholecystectomy during the index admission (chi2 = 3.83; P = 0.05). This has resulted in a reduction in recurrent pancreatitis (P < 0.001). Although the overall mortality from gallstone pancreatitis has not significantly decreased, it has for patients with predicted severe gallstone pancreatitis (P = 0.02). CONCLUSION: : There has been reasonable compliance with published guidelines and some progress in the management of gallstone pancreatitis,particularly in relation to performing timely laparoscopic cholecystectomy with a reduction in the incidence of recurrent pancreatitis. Concerns remain regarding the overuse of diagnostic ERCP in patients with mild pancreatitis.