SURGICAL COMPLICATIONS

James Taclin C. Banez, MD, FPSGS, FPCS

General Considerations:

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

1. Rigorous preoperative evaluations

2. Meticulous operative technique

3. 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

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.

Prognosis: Mortality = 0.5 – 0.3% due to pathologic

conditions

Wound Complications:

B. Wound Infection: Major factors:

1) Breaks in surgical technique

2) Host parasite relationship Potential sources of contamination:

1) Patients themselves

2) Operating room and personels Organisms:

1) Staphylococcus aureus

2) 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. Age3. 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 elderly2. Obesity: poor blood supply in adipose tissue3. Systemic illnesses:

a. Malignancyb. Diabetesc. Hepatic cirrhosis

4. Medications taken (steroids)

Postoperative Infections: (nosocomial)

A. Pulmonary infections:1. Atelectasis2. Endotracheal intubation and ventilation3. Aspiration pneumonia

B. Urinary tract infection: indwelling urinary catheter E. coli, Pseudomonas, klebsiella

C. Intra-abdominal infection: abdominal abscess Sites:

1. Sub-phrenic ---> most common2. Pelvis3. Liver4. Lateral gutters / intestinal loop

Treatment: drain ---> explor lap / needle aspiration

D. Wound infection

Postoperative Pulmonary ComplicationsA. 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 ComplicationsA. Atelectasis:

Predisposing factors:1. Smoking2. Pulmonary problem (bronchitis, asthma, etc)3. Anesthesia:

GA - duration and depth Postop narcotics – depress cough reflex

4. Depress cough reflex Chest pain Immobilization Splinting w/ bandages

5. NGT – increased secretions and predisposed aspiration

6. Congestion of the bronchial walls

Postoperative Pulmonary ComplicationsA. Atelectasis:

Manifestations:1st 24 hrs postop ----> fever, tachycardia, rales,

decrease breath sound ----> persist ----> pneumonia (increase fever, dyspnea, tachycardia and cyanosis) ---> lung abscess

Postoperative Pulmonary ComplicationsA. 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. Expectorantsb. Mucolyticc. bronchodilators

Postoperative Pulmonary ComplicationsB. Pulmonary Aspiration:

General anesthesia – pts are in supine position and absence of normal protective reflexes.

Increased risk:1. Pregnant

2. Elderly

3. Obese

4. Pts w/ bowel obstruction

Postoperative Pulmonary ComplicationsB. 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

Postoperative Pulmonary ComplicationsC. 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 ComplicationsC. Pulmonary Edema:

Treatment:1. Provide oxygen (increase inspired

concentration)

2. Remove obstructing fluid (diuretics, head up or sitting position, phlebotomy, spinal anesthesia, ganglionic blocking agents)

3. Correcting the circulatory overload

4. Increase airway pressure (PEEP)

Postoperative Pulmonary ComplicationsD. 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 ComplicationsD. Respiratory Failure:

Etiologic Factors:1. 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

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. Over sedation

2. 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. Catheter obstruction

2. Pre-renal failure; Diminished circulating blood volume

3. Acute parenchymal renal failure 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:− 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 metabolism1. Hyperglycemia2. 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

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 SurgeryA. 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 SurgeryA. Vascular Complication:2. Gangrene:

a. Stomach: Following subtotal gastrectomy w/ ligation of left

gastic and splenic arteries; thrombosis

b. Small bowel and colon: Thrombosis; mechanical strangulation (internal

herniation) – volvulus, adhesions

Treatment: Resection of gangrenous segment, re-

established continuity

Complication of Gastrointestinal SurgeryB. 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 SurgeryB. Mechanical Problem:

2. Other causes:a. Intussuceptionb. Volvulusc. Post-operative adhesiond. Herniation

S/Sx: 3rd – 4th postop day Abdominal distention, pain, increase NGT

drainage, bilious material

Complication of Gastrointestinal SurgeryB. Mechanical Problem:

Diagnosis: Flap plate of abdomen (FPA)

Small bowel obstruction Large bowel obstruction Sigmoid volvulus

Complication of Gastrointestinal SurgeryB. Mechanical Problem:

Treatment:1. Proximal decompression (NPO / NGT)

2. Correct fluid and electrolyte imbalance

3. Hyperalimentation (TPN): No improvement ------> re-operation

Complication of Gastrointestinal SurgeryMechanical 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 SurgeryMechanical Problem:

Blind Loop Syndrome:

2. Intestinal blind loop:a. Volvulus of small bowel

b. Complete large bowel obstruction w/ a competent ileocecal valve

c. Internal bowel herniation

Complication of Gastrointestinal SurgeryMechanical 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 abdomenTreatment:

NGT decompression, NPO, correct fluid and electrolyte imbalance

Surgical intervention – adhesiolysis w/ or w/o resection

Complication of Gastrointestinal SurgeryNon-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 SurgeryC. Anastomotic Leak:Etiologic factor:

1. Poor surgical technique2. Distal obstruction3. Inadequate proximal decompression

Can manifest as localized or generalized peritonitisTreatment:

Small leaks:1. Conservative w/ NPO2. Proximal decompression3. Antibiotic

Large leaks:1. Surgical intervention

Complication of Gastrointestinal SurgeryD. Fistula:

Abnormal communication between two lining epithelium

Etiology:1. Anastomotic leak

2. Poor blood supply

3. Trauma

4. Infection

5. Inadvertent suturing of bowel wall while closing the fascia

6. carcinoma

Complication of Gastrointestinal SurgeryD. 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 obstruction2. large leak3. Infection4. Cancer

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

Complication of Gastrointestinal SurgeryD. 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 SurgeryD. 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 SurgeryD. Fistula:

3. Colonic fistula:Treatment:

1. Nutrition (low residue or elemental diet)2. 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 ----> surgerya. Defunctionalizing colostomies for descending colonb. Ileal transverse colostomies for ascending and distal ileal

fistulas If w/ generalized peritonitis do emergency resection

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