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SURGICAL COMPLICATIONS

James Taclin C. Banez, MD, FPSGS, FPCS

General Considerations:

Complications are made in the operating rooms. Minimize the risk:


1. 2. 3.

Rigorous preoperative evaluations Meticulous operative technique Careful monitoring of patients preoperatively 1st postop day --> atelectasis/aspiration/UTI 4th-5th postop --> wound infection / anastomotic leak Immediate --> continuous hge / depressive drugs Later ---> sepsis

Fever:

Hypotension:

Wound Complications:
A. Wound dehiscence:

Separation of an abd. wound involving the anterior fascial and deeper layers 0.5 3.0% Causes:

General factors:
1) Age: < 45y/o = 1.3%

> 45% = 5.4% 2) Debilitated pts. w/ poor nutrition carcinoma, hyponatremia, obesity 3) Causes of increase intra-abd. pressure pulmonary & urinary problem

Wound Complications:
A. Wound dehiscence:

Causes:

Local Factors:
1) Hemorrhage 2) Infection 3) Poor technique: a. Excessive suture material b. Drain and stoma placed along incision 4) Type of incision (> in vertical insicion)

Manifestation: 1. Sero-sanguinous drainage (pathognomonic) 2. Postoperative ventral hernia

Wound Complications:
A. Wound dehiscence:

Treatment:

secondary operative procedure (if medical condition allows) conservatively with an occlusive wound dressing and binder ----> postoperative hernia. Mortality = 0.5 0.3% due to pathologic conditions

Prognosis:

Wound Complications:
B. Wound Infection:

Major factors:
1) 2)

Breaks in surgical technique Host parasite relationship Patients themselves Operating room and personels Staphylococcus aureus Enteric organism (E. coli, Bacteroides, Proteus, Klebsiella, Pseudomonas)

Potential sources of contamination:


1) 2)

Organisms:
1) 2)

Wound Complications:
B. Wound Infection: Factors:
1. Nature of the wound:
a. Clean atraumatic and uninfected operative wound (3.3%) b. GIT / Respiratory / Urinary tract entered but w/ out unusual contamination (10.8%). c. Open, traumatic wounds w/ major break in sterile technique (16.3%) d. Traumatic wound involving abscesses of perforated viscera (28.6%).

2. Age 3. Presence of medical problems (diabetes/steroid tx) 4. Duration of operations and preoperative stay in the hospital

Postoperative Infections: (nosocomial)

Local factors:
1. Adequacy of tissue blood supply: Devitalized tissues Dead space ----> hematoma, seroma 2. Foreign bodies

Systemic factors: 1. Age: very young (neonates) and elderly 2. Obesity: poor blood supply in adipose tissue 3. Systemic illnesses:
a. Malignancy b. Diabetes c. Hepatic cirrhosis

4. Medications taken (steroids)

Postoperative Infections: (nosocomial)


A. Pulmonary infections: 1. Atelectasis 2. Endotracheal intubation and ventilation 3. Aspiration pneumonia B. Urinary tract infection: indwelling urinary catheter E. coli, Pseudomonas, klebsiella C. Intra-abdominal infection: abdominal abscess Sites: 1. Sub-phrenic ---> most common 2. Pelvis 3. Liver 4. Lateral gutters / intestinal loop Treatment: drain ---> explor lap / needle aspiration D. Wound infection

Postoperative Pulmonary Complications


A. Atelectasis:

90% postoperative pulmonary complications Etiology:

1. Obstruction of the tracheobronchial airway a) Changes in bronchial secretions b) Defects in expulsion mechanism c) Reduction in bronchial caliber 2. Pulmonary insufficiency (hypoventilation) Decrease surfactant

Postoperative Pulmonary Complications


A. Atelectasis: Predisposing factors:
1. 2. 3.

Smoking Pulmonary problem (bronchitis, asthma, etc) Anesthesia:


GA - duration and depth Postop narcotics depress cough reflex


Chest pain Immobilization Splinting w/ bandages

4.

Depress cough reflex


NGT increased secretions and predisposed aspiration 6. Congestion of the bronchial walls
5.

Postoperative Pulmonary Complications


A. Atelectasis: Manifestations:
1st 24 hrs postop ----> fever, tachycardia, rales, decrease breath sound ----> persist ----> pneumonia (increase fever, dyspnea, tachycardia and cyanosis) ---> lung abscess

Postoperative Pulmonary Complications


A. Atelectasis:
Treatment: 1. Preop prophylaxis: a. No smoking (2 wks) b. Treatment of pulmonary problem 2. Postop prophylaxis:
Minimal use of depressant drugs Prevent pain Early ambulation Changes body position Deep breathing and coughing exercises 3. Drugs: a. Expectorants b. Mucolytic c. bronchodilators

Postoperative Pulmonary Complications


B. Pulmonary Aspiration:

General anesthesia pts are in supine position and absence of normal protective reflexes. Increased risk:
1. 2. 3. 4.

Pregnant Elderly Obese Pts w/ bowel obstruction

Postoperative Pulmonary Complications


B. Pulmonary Aspiration:

Prevention:

NPO 6hrs prior to surgery Emergency NGT do gastric lavage and give antacid to prevent dev. of Mendelians Syndrome. Continuous mechanical ventilation antibiotics

Treatment:

Postoperative Pulmonary Complications


C. Pulmonary Edema:

Etiology:
1.

Circulatory overload (infusion of fluid during operation)


Most common cause

2.

Left ventricular failure (incomplete cardiac emptying)


Due to anesthetic, narcotic or hypnotic agents w/c decrease myocardial contractility Decrease peripheral perfusion -----> peripheral vasoconstriction ----> cause blood to shift centrally ----> pulmonary edema

3.

Negative pressure in airway.

Postoperative Pulmonary Complications


C. Pulmonary Edema:

Treatment:
1.

2.

3. 4.

Provide oxygen (increase inspired concentration) Remove obstructing fluid (diuretics, head up or sitting position, phlebotomy, spinal anesthesia, ganglionic blocking agents) Correcting the circulatory overload Increase airway pressure (PEEP)

Postoperative Pulmonary Complications


D. Respiratory Failure:

25% of postoperative deaths PaO2 is below 50 torr while the patient is breathing room air; PaCO2 is above 50 torr in the absence of metabolic alkalosis Usually seen in patients who underwent operations for major trauma or who have multisystem disease. Mechanism is unknown

Postoperative Pulmonary Complications


D. Respiratory Failure: Etiologic Factors:
Sepsis 2. Massive transfusion 3. Fat embolism 4. Pancreatitis 5. Aspiration Associated w/ a decreased Functional Residual Lung Capacity, indicating that the amount of air w/ in the lung at the end of normal expiration is reduced ----> diminished ventilation-perfusion ratio and ultimately arterial hypoxemia
1.

Treatment:
Mechanical ventilation (PEEP)

Postoperative Shock
Poor tissue perfusion ---> hypotension,

pallor, sweating, tachycardia, oliguria, peripheral vasoconstriction ----> progressive metabolic acidosis ----> multiple organ failure ---> death. Hypotension in early post-operation:
1. 2.

Over sedation Effect of anesthesia

Postoperative Shock
Categories: 1. Hypovolemia most common

Uncorrected volume deficit (preop, intraop, postop) Continuing hge postop period 30-40% loss of ECV Monitored w/ UO/hr, CVP Crystalloid hydration / blood transfusion

Postoperative Shock
Categories: 2. Cardiogenic shock (MI / cardiac tamponade) 3. Septic shock:

Due to gram (-) infection; nosocomial Uro-genital infection (foley catheter) > resp. tract > integumentary

Postoperative Renal Failure


Oliguria considered acute renal failure Etiologies:
1. 2.

Catheter obstruction Pre-renal failure;

Diminished circulating blood volume


Fluid restriction (daily allowance 500ml plus previous 24 hrs. UO) Electrolyte imbalance (hyperkalemia) Hemodialysis

3.

Acute parenchymal renal failure

Diabetes Mellitus:
Challenge to the surgeon for: 1. Impairment of homeostatic mechanism for glucose (ketoacidosis/hypoglycemia) 2. Associated incidence of generalized vascular disease. Pathogenesis:

Defect is decrease insulin Hyperglycemia due to decrease utilization of peripheral tissue, increase output in the liver Catabolism of FA (ketoacidosis) Osmotic diuresis ---> dehydration/loss of Na and K

Diabetes Mellitus:
Effect of Anesthetic agents to CHO metabolism
1.
2.

Hyperglycemia Exaggerates the hyperglycemia epinephrine response and increase resistance to exogenous administration of insulin
Spinal anesthesia little tendency to cause hyperglycemia GA (NO2, trichloroethylene, halothane) least effect on CHO metabolism

Type of anesthesia:

Diabetes Mellitus:
Surgery is not done until the level is below

200md/dl Ketoacidosis in frank diabetic coma ----> no surgical treatment regardless of indication Treatment:

Continuous low dose insulin Correct fluid and electrolyte imbalance

Complication of Gastrointestinal Surgery


A. Vascular Complication: 1. Hemorrhage:

Occurs gastrointestinal anastomosis Manifest hematemesis, melena, hematochezia Bleeding arise from the suture line (usually after gastric resection

Treatment: Ist conservative: irrigation w/ cold lavage / endoscopy Reoperation direct control

Complication of Gastrointestinal Surgery


A. Vascular Complication: 2. Gangrene: a. Stomach:

Following subtotal gastrectomy w/ ligation of left gastic and splenic arteries; thrombosis Thrombosis; mechanical strangulation (internal herniation) volvulus, adhesions Resection of gangrenous segment, reestablished continuity

b.

Small bowel and colon:

Treatment:

Complication of Gastrointestinal Surgery


B. Mechanical Problem:
1.

Stomal obstruction (due to local edema)


Causes of edema: a. Electrolyte imbalance b. Incomplete hemostasis c. Hypoprotenemia d. Leakage from anastomosis e. Inadequate proximal decompression f. Incorporation of too much tissue w/in the suture

Complication of Gastrointestinal Surgery


B. Mechanical Problem: 2. Other causes:
a. b. c. d.

Intussuception Volvulus Post-operative adhesion Herniation

S/Sx:

3rd 4th postop day Abdominal distention, pain, increase NGT drainage, bilious material

Complication of Gastrointestinal Surgery


B. Mechanical Problem:

Diagnosis:

Flap plate of abdomen (FPA)

Small bowel obstruction

Large bowel obstruction Sigmoid volvulus

Complication of Gastrointestinal Surgery


B. Mechanical Problem:

Treatment:
1. 2.

3.

Proximal decompression (NPO / NGT) Correct fluid and electrolyte imbalance Hyperalimentation (TPN): No improvement ------> re-operation

Complication of Gastrointestinal Surgery


Mechanical Problem:
Blind Loop Syndrome: 1. Afferent loops syndrome:
Cases of Billroth gastroenterostomy Afferent loop maybe partially or rarely completely obstructed. Eructation of a mouthful of green biliary fluid 1 hr. after a meal. Sensation of fullness and pain in the epigastrum Treatment:

Incomplete conservative Complete: re-operation and anastomosis between the afferent and efferent loops by Roux-en-Y or convert to Billroth I (gastroduodenostomy)

Complication of Gastrointestinal Surgery


Mechanical Problem:
Blind Loop Syndrome: 2. Intestinal blind loop:
a. b.

c.

Volvulus of small bowel Complete large bowel obstruction w/ a competent ileocecal valve Internal bowel herniation

Complication of Gastrointestinal Surgery


Mechanical Problem: Postoperative fibrous adhesion:
The most common cause of bowel obstuction Could be partial or complete Fluid and electroyte imbalance Usually present a colicky abdominal pain with abdominal distention w/o bowel movement. Late cases might present with silent abdomen Treatment:

NGT decompression, NPO, correct fluid and electrolyte imbalance Surgical intervention adhesiolysis w/ or w/o resection

Complication of Gastrointestinal Surgery


Non-mechanical intestinal obstruction: Ileus:

Physiologic/functional bowel obstruction


Stomach --> w/in few hours Small bowel ---> 12-36 hrs Large bowel ---> 24-72 hrs.

Treatment:

NGT decompression NPO Fluid & electrolyte balance (hypo K) Metaclopromide or bethanechol

Complication of Gastrointestinal Surgery


C. Anastomotic Leak:
Etiologic factor:
1. Poor surgical technique 2. Distal obstruction 3. Inadequate proximal decompression

Can manifest as localized or generalized peritonitis Treatment:


Small leaks: 1. Conservative w/ NPO 2. Proximal decompression 3. Antibiotic Large leaks:

1. Surgical intervention

Complication of Gastrointestinal Surgery


D. Fistula:
Abnormal communication between two lining epithelium

Etiology:
1. 2. 3. 4. 5. Anastomotic leak Poor blood supply Trauma Infection Inadvertent suturing of bowel wall while closing the fascia 6. carcinoma

Complication of Gastrointestinal Surgery


D. Fistula: 1. Gastric and duodenal fistula:
Subtotal gastrectomy ---> gastrojejunal (tears of surrow) and duodenal stump Due to suture line failure

Treatment:

NPO / TPN Place NGT past the leak and give elemental diet Antibiotic Majority close spontaneously w/in 6 wks
Failure to close 1. distal obstruction 2. large leak 3. Infection 4. Cancer

Surgery resect the fistula and the bowel segment then re-anastomosis

Complication of Gastrointestinal Surgery


D. Fistula:
2. Small bowel fistula: Drainage is less compared to duodenal fistula, but jejunal fistula have a poorer prognosis than ileal fistula Treatment:

Supportive: correct fluid & electrolyte imbalance Give proper nutrition Proximal jejunal fistula: - Distal feeding jejunostomy Distal ileal fistula: - low residue diet Control diarrhea ----> lomotil / protect the skin

Complication of Gastrointestinal Surgery


D. Fistula:
3. Colonic fistula: Fluid & electrolyte imbalance less common but has higher infection can lead to peritonitis, peritoneal abscess and wound infection. Skin digestion and irrigation are rare

Complication of Gastrointestinal Surgery


D. Fistula:
3. Colonic fistula: Treatment:
Nutrition (low residue or elemental diet) 2. Antibiotics
1.

Spontaneous healing of fistula is the rule rather than the exception Medical management is generally indicated for 6 wks to permit active inflammation to subside ---> fails ----> surgery
Defunctionalizing colostomies for descending colon b. Ileal transverse colostomies for ascending and distal ileal fistulas
a.

If w/ generalized peritonitis do emergency resection

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