Transcript SURGICAL COMPLICATIONS

SURGICAL
COMPLICATIONS
James Taclin C. Banez, MD, FPSGS, FPCS
General Considerations:
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
Complications are made in the operating rooms.
Minimize the risk:
1.
2.
3.
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Fever:
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Rigorous preoperative evaluations
Meticulous operative technique
Careful monitoring of patients preoperatively
1st postop day --> atelectasis/aspiration/UTI
4th-5th postop --> wound infection /
anastomotic leak
Hypotension:
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Immediate --> continuous hge / depressive drugs
Later ---> sepsis
Wound Complications:
A. Wound dehiscence:
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Separation of an abd. wound involving the
anterior fascial and deeper layers
0.5 – 3.0%
Causes:
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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:
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Causes:
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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:
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Treatment:
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secondary operative procedure (if medical
condition allows)
conservatively with an occlusive wound dressing
and binder ----> postoperative hernia.
Prognosis:
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Mortality = 0.5 – 0.3% due to pathologic conditions
Wound Complications:
B. Wound Infection:
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Major factors:
1)
2)
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Potential sources of contamination:
1)
2)
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Breaks in surgical technique
Host parasite relationship
Patients themselves
Operating room and personels
Organisms:
1)
2)
Staphylococcus aureus
Enteric organism (E. coli, Bacteroides, Proteus,
Klebsiella, Pseudomonas)
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)
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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
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E. coli, Pseudomonas, klebsiella
C. Intra-abdominal infection: abdominal abscess
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Sites:
1.
Sub-phrenic ---> most common
2.
Pelvis
3.
Liver
4.
Lateral gutters / intestinal loop
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Treatment:
drain ---> explor lap / needle aspiration
D. Wound infection
Postoperative Pulmonary
Complications
A. Atelectasis:
90% postoperative pulmonary complications
Etiology:
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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:
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4.
GA - duration and depth
Postop narcotics – depress cough reflex
Depress cough reflex
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Chest pain
Immobilization
Splinting w/ bandages
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:
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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:
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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:
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NPO 6hrs prior to surgery
Emergency – NGT do gastric lavage and give
antacid to prevent dev. of Mendelian’s
Syndrome.
Treatment:
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Continuous mechanical ventilation
antibiotics
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:
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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:
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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
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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:
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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;
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3.
Diminished circulating blood volume
Acute parenchymal renal failure
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Fluid restriction (daily allowance 500ml plus
previous 24 hrs. UO)
Electrolyte imbalance (hyperkalemia)
Hemodialysis
Diabetes Mellitus:
Challenge to the surgeon for:
1. Impairment of homeostatic mechanism for glucose
(ketoacidosis/hypoglycemia)
2. Associated incidence of generalized vascular
disease.
Pathogenesis:
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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
Type of anesthesia:
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Spinal anesthesia – little tendency to cause
hyperglycemia
GA – (NO2, trichloroethylene, halothane)
least effect on CHO metabolism
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:
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Continuous low dose insulin
Correct fluid and electrolyte imbalance
Complication of
Gastrointestinal Surgery
A. Vascular Complication:
1. Hemorrhage:
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Occurs gastrointestinal anastomosis
Manifest – hematemesis, melena,
hematochezia
Bleeding arise from the suture line (usually after
gastric resection
Treatment:
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Ist conservative: irrigation w/ cold lavage /
endoscopy
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Reoperation – direct control
Complication of
Gastrointestinal Surgery
A. Vascular Complication:
2. Gangrene:
a. Stomach:
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b.
Following subtotal gastrectomy w/ ligation of left
gastic and splenic arteries; thrombosis
Small bowel and colon:
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Thrombosis; mechanical strangulation (internal
herniation) – volvulus, adhesions
Treatment:
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Resection of gangrenous segment, reestablished continuity
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:
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3rd – 4th postop day
Abdominal distention, pain, increase NGT
drainage, bilious material
Complication of
Gastrointestinal Surgery
B. Mechanical Problem:
Diagnosis:
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Flap plate of abdomen (FPA)
Small bowel obstruction
Large bowel obstruction
Sigmoid volvulus
Complication of
Gastrointestinal Surgery
B. Mechanical Problem:
Treatment:
1.
2.
3.
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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
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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:
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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
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Could be partial or complete
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Fluid and electroyte imbalance
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Usually present a colicky abdominal pain with
abdominal distention w/o bowel movement.
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Late cases might present with silent abdomen
Treatment:
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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:
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Physiologic/functional bowel obstruction
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Stomach --> w/in few hours
Small bowel ---> 12-36 hrs
Large bowel ---> 24-72 hrs.
Treatment:
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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:
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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:
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NPO / TPN
Place NGT past the leak and give elemental diet
Antibiotic
Majority close spontaneously w/in 6 wks
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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:
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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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