SURGICAL COMPLICATIONS

1. SURGICAL COMPLICATIONS James Taclin C. Banez, MD, FPSGS, FPCS

2. General Considerations: • Complications are made in the operating rooms. • Minimize the risk: • Rigorous preoperative evaluations • Meticulous operative technique • Careful monitoring of patients preoperatively • Fever: • 1st postop day --> atelectasis/aspiration/UTI • 4th-5th postop --> wound infection / anastomotic leak • Hypotension: • Immediate --> continuous hge / depressive drugs • Later ---> sepsis

3. Wound Complications: • Wound dehiscence: • Separation of an abd. wound involving the anterior fascial and deeper layers • 0.5 – 3.0% • Causes: • General factors: • Age: < 45y/o = 1.3% > 45% = 5.4% • Debilitated pts. w/ poor nutrition • carcinoma, hyponatremia, obesity • Causes of increase intra-abd. pressure • pulmonary & urinary problem

4. Wound Complications: • Wound dehiscence: • Causes: • Local Factors: • Hemorrhage • Infection • Poor technique: • Excessive suture material • Drain and stoma placed along incision • Type of incision (> in vertical insicion) • Manifestation: • Sero-sanguinous drainage (pathognomonic) • Postoperative ventral hernia

5. Wound Complications: • Wound dehiscence: • Treatment: • secondary operative procedure (if medical condition allows) • conservatively with an occlusive wound dressing and binder ----> postoperative hernia. • Prognosis: • Mortality = 0.5 – 0.3% due to pathologic conditions

6. Wound Complications: • Wound Infection: • Major factors: • Breaks in surgical technique • Host parasite relationship • Potential sources of contamination: • Patients themselves • Operating room and personels • Organisms: • Staphylococcus aureus • Enteric organism (E. coli, Bacteroides, Proteus, Klebsiella, Pseudomonas)

7. Wound Complications: • Wound Infection: • Factors: • Nature of the wound: • Clean atraumatic and uninfected operative wound (3.3%) • GIT / Respiratory / Urinary tract entered but w/ out unusual contamination (10.8%). • Open, traumatic wounds w/ major break in sterile technique (16.3%) • Traumatic wound involving abscesses of perforated viscera (28.6%). • Age • Presence of medical problems (diabetes/steroid tx) • Duration of operations and preoperative stay in the hospital

8. Postoperative Infections: (nosocomial) • Local factors: • Adequacy of tissue blood supply: • Devitalized tissues • Dead space ----> hematoma, seroma • Foreign bodies • Systemic factors: • Age: very young (neonates) and elderly • Obesity: poor blood supply in adipose tissue • Systemic illnesses: • Malignancy • Diabetes • Hepatic cirrhosis • Medications taken (steroids)

9. Postoperative Infections: (nosocomial) • Pulmonary infections: • Atelectasis • Endotracheal intubation and ventilation • Aspiration pneumonia • Urinary tract infection:indwelling urinary catheter • E. coli, Pseudomonas, klebsiella • Intra-abdominal infection:abdominal abscess • Sites: • Sub-phrenic ---> most common • Pelvis • Liver • Lateral gutters / intestinal loop • Treatment: drain ---> explor lap / needle aspiration • Wound infection

10. Postoperative Pulmonary Complications • Atelectasis: • 90% postoperative pulmonary complications Etiology: • Obstruction of the tracheobronchial airway • Changes in bronchial secretions • Defects in expulsion mechanism • Reduction in bronchial caliber • Pulmonary insufficiency (hypoventilation) • Decrease surfactant

11. Postoperative Pulmonary Complications • Atelectasis: Predisposing factors: • Smoking • Pulmonary problem (bronchitis, asthma, etc) • Anesthesia: • GA - duration and depth • Postop narcotics – depress cough reflex • Depress cough reflex • Chest pain • Immobilization • Splinting w/ bandages • NGT – increased secretions and predisposed aspiration • Congestion of the bronchial walls

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

13. Postoperative Pulmonary Complications • Atelectasis: Treatment: • Preop prophylaxis: • No smoking (2 wks) • Treatment of pulmonary problem • Postop prophylaxis: • Minimal use of depressant drugs • Prevent pain • Early ambulation • Changes body position • Deep breathing and coughing exercises • Drugs: • Expectorants • Mucolytic • bronchodilators

14. Postoperative Pulmonary Complications • Pulmonary Aspiration: • General anesthesia – pts are in supine position and absence of normal protective reflexes. • Increased risk: • Pregnant • Elderly • Obese • Pts w/ bowel obstruction

15. Postoperative Pulmonary Complications • Pulmonary Aspiration: Prevention: • NPO 6hrs prior to surgery • Emergency – NGT do gastric lavage and give antacid to prevent dev. of Mendelian’s Syndrome. Treatment: • Continuous mechanical ventilation • antibiotics

16. Postoperative Pulmonary Complications • Pulmonary Edema: Etiology: • Circulatory overload (infusion of fluid during operation) • Most common cause • 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 • Negative pressure in airway.

17. Postoperative Pulmonary Complications • Pulmonary Edema: Treatment: • 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)

18. Postoperative Pulmonary Complications • 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

19. Postoperative Pulmonary Complications • Respiratory Failure: Etiologic Factors: • Sepsis • Massive transfusion • Fat embolism • Pancreatitis • 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 Treatment: • Mechanical ventilation (PEEP)

20. Postoperative Shock • Poor tissue perfusion ---> hypotension, pallor, sweating, tachycardia, oliguria, peripheral vasoconstriction ----> progressive metabolic acidosis ----> multiple organ failure ---> death. • Hypotension in early post-operation: • Over sedation • Effect of anesthesia

21. Postoperative Shock Categories: • 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

22. Postoperative Shock Categories: • Cardiogenic shock (MI / cardiac tamponade) • Septic shock: • Due to gram (-) infection; nosocomial • Uro-genital infection (foley catheter) > resp. tract > integumentary

23. Postoperative Renal Failure Oliguria – considered acute renal failure Etiologies: • Catheter obstruction • Pre-renal failure; • Diminished circulating blood volume • Acute parenchymal renal failure • Fluid restriction (daily allowance 500ml plus previous 24 hrs. UO) • Electrolyte imbalance (hyperkalemia) • Hemodialysis

24. Diabetes Mellitus: Challenge to the surgeon for: • Impairment of homeostatic mechanism for glucose (ketoacidosis/hypoglycemia) • 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

25. Diabetes Mellitus: Effect of Anesthetic agents to CHO metabolism • Hyperglycemia • Exaggerates the hyperglycemia epinephrine response and increase resistance to exogenous administration of insulin Type of anesthesia: • Spinal anesthesia – little tendency to cause hyperglycemia • GA – (NO2, trichloroethylene, halothane) least effect on CHO metabolism

26. 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

27. Complication of Gastrointestinal Surgery • Vascular Complication: • 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

28. Complication of Gastrointestinal Surgery • Vascular Complication: • Gangrene: • Stomach: • Following subtotal gastrectomy w/ ligation of left gastic and splenic arteries; thrombosis • Small bowel and colon: • Thrombosis; mechanical strangulation (internal herniation) – volvulus, adhesions Treatment: • Resection of gangrenous segment, re-established continuity

29. Complication of Gastrointestinal Surgery • Mechanical Problem: • Stomal obstruction (due to local edema) Causes of edema: • Electrolyte imbalance • Incomplete hemostasis • Hypoprotenemia • Leakage from anastomosis • Inadequate proximal decompression • Incorporation of too much tissue w/in the suture

30. Complication of Gastrointestinal Surgery • Mechanical Problem: • Other causes: • Intussuception • Volvulus • Post-operative adhesion • Herniation S/Sx: • 3rd – 4th postop day • Abdominal distention, pain, increase NGT drainage, bilious material

31. Mechanical Problem: Diagnosis: Flap plate of abdomen (FPA) Complication of Gastrointestinal Surgery Large bowel obstruction Sigmoid volvulus Small bowel obstruction

32. Complication of Gastrointestinal Surgery • Mechanical Problem: Treatment: • Proximal decompression (NPO / NGT) • Correct fluid and electrolyte imbalance • Hyperalimentation (TPN): • No improvement ------> re-operation

33. Complication of Gastrointestinal Surgery Mechanical Problem: Blind Loop Syndrome: • 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)

34. Complication of Gastrointestinal Surgery Mechanical Problem: Blind Loop Syndrome: • Intestinal blind loop: • Volvulus of small bowel • Complete large bowel obstruction w/ a competent ileocecal valve • Internal bowel herniation

35. 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

36. 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

37. Complication of Gastrointestinal Surgery • Anastomotic Leak: Etiologic factor: • Poor surgical technique • Distal obstruction • Inadequate proximal decompression Can manifest as localized or generalized peritonitis Treatment: • Small leaks: • Conservative w/ NPO • Proximal decompression • Antibiotic • Large leaks: • Surgical intervention

38. Complication of Gastrointestinal Surgery • Fistula: • Abnormal communication between two lining epithelium Etiology: • Anastomotic leak • Poor blood supply • Trauma • Infection • Inadvertent suturing of bowel wall while closing the fascia • carcinoma

39. Complication of Gastrointestinal Surgery • Fistula: • 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 • distal obstruction • large leak • Infection • Cancer • Surgery – resect the fistula and the bowel segment then re-anastomosis

40. Complication of Gastrointestinal Surgery • Fistula: • 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

41. Complication of Gastrointestinal Surgery • Fistula: • 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

42. Complication of Gastrointestinal Surgery • Fistula: • Colonic fistula: Treatment: • Nutrition (low residue or elemental diet) • Antibiotics • 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 • Ileal transverse colostomies for ascending and distal ileal fistulas • If w/ generalized peritonitis do emergency resection

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