Surgical Complications - Dr. Salcedo.pdf

SURGICAL COMPLICATIONS Dr. Salcedo September 18, 2013 Group 2 Outline 1. Risk factors 2. Clinical presentation of complications 3. Surgical complication COMMON to any operation a. Wound problems b. Respiratory problems c. Urinary problems 4. Surgical complication SPECIFIC to a procedure a. Gastrointestinal surgery complications

Immediate (1-3 days postop) Atelectasis -most common -collapse of alveoli

” Every surgical procedure has a risk for complications” - must be anticipiated for early management Risk Factors 1. Nutritional Status – poor surgical complications; more complications 2. Asepsis/Antisepsis – dirty operation; more complications 3. Immune Status – Diabetes, HIV; more complications 4. Hemodynamic Stability – Shock, hypotension 5. Comorbidities – pneumonia, cardiac problems, etc. 6. Emergency Procedures Surgical Complications I. Fever II. Pulmonary Complications III. Genitourinary Complications IV. Wound Complications FEVER - Heralds the onset of complications - Usual presentation of surgical complication - Significant only if >38°C and is persistent for 2 days post operation day (POD) Different conditions can be determined according to the onset of the fever

Early (3-5 days postop) Wound infection Respiratory infection Catheter related

Late (5-12 days postop) Abscess formation Anastomotic leaks Wound dehiscence

a.

Fever within the first 24 hours could be due to: 1. Atelectasis - most common 2. Necrotizing wound infections (more severe than surgical site infections)

b.

Fever 24-72 hours after surgery could be due to: 1. Respiratory complications (ARDS, pneumonia) 2. Indwelling Catheter - related (most commonly on the IV site and cause thrombophlebitis)

Onset of fever after 72 hours (usually of infectious causes) 1. 3-5 days- UTI 2. 4-7 days – Intra abdominal Abscess/ Leaks 3. 7-10 days – Surgical Wound Infections These are merely guides to rule in possible conditions. c.

-

RESPIRATORY COMPLICATIONS Commonly occur after an upper abdominal (gastric, gallbladder and liver surgery) and thoracic surgery This is because post-op pain alters the mechanics of respiration of the patient (patient avoid breathing deeply – the alveoli will not expand) Patients tend to have shallow breathing because their surgical wound is painful Accumulation of secretions 

SPLINTING – predisposes to surgical complications; caused by pain a. Atelectasis

MOST COMMON CAUSE OF FEVER IN THE 1st 24 HOURS - Collapse of alveoli - Accumulation of secretions - Lungs inflation o Coughing, deep breathing o Incentive spirometry o Chest tapping Bronchodilators, expectorant Main problem is collapse of alveoli because of the accumulation of secretions inside the alveoli due to shallow breathing of patients (* poor alveolar inflation) Atelectasis - usually focal or one sided Don’t give antibiotics because the problem is not infectious -

-

-



DIRECT PULMONARY INJURY  Aspiration  Inhalation injury  Pulmonary contusion UNRELATED DISORDERS  Multiple transfusions  Factures  Pancreatitis

Injury Initiation of inflammatory mediators Increase microvascular permeability

PREVENTION: deep breathing exercises Chest Tapping – excretion of secretions

Proteinaceous fluid deposition in alveolar/capillary interface

Treatment:  inflation of the lung  Coughing  Bronchodilators- clear airway  Expectorant- clear airway  Early mobilization of the patient  Sit to breath more easily  Incentive Spirometry  Objective is to make the patient breath for a long time and keep the balls on top as long as possible  At least 10x per hour

-

-

-

-

-

c.

Acute Respiratory Distress Syndrome (ARDS) - Fluid in the alveoli b.

Can happen to patient after any surgical procedure even unrelated procedures (whether direct or indirect) Due to a direct pulmonary injury such as aspiration, inhalation injury, pulmonary contusion Blood transfusion, fractures Basic problem is increase in vascular permeability due to release of inflammatory mediators leading to leakage of fluid such as deoxygenated blood in capillary membrane and deposited in alveoli Proteinaceous fluid = no exchange of gases End result is abnormal V/Q; ventilation perfusion mismatch because tissues are not well- ventilated Although it is receiving blood resulting to unrelenting Hypoxemia Patchy infiltrates in the lungs High mortality rate (higher mortality rate than atelectasis) Involves both lungs Opaque on x-ray (usually bilateral) due to fluid in the lungs

Aspiration Pneumonia

-

-

Common in patients with cranial surgery, comatose with poor gag reflex leading to aspiration of their fluid secretions (gastric contents and saliva) Gastric contents can reflux and enter the tracheobronchial tree Common in right lung (shorter, wider, and more vertical) than left lung due to anatomy

Prevention: - NPO prior to OR or NGT before surgery (to decrease risk of aspiration pneumonia Treatment: • Bronchoscopy • Lavage of upper airway (flushing with water) ▪ Suction the food in the tracheophageal tract • Antibiotics WOUND COMPLICATIONS 1. Hematomas 2. Seromas 3. Wound infections (SSI) 4. Wound dehiscence Factors that retard wound healing o Malnutrition o Uremia o Sepsis o Diabetes o Anemia o Liver Failure o Steroid Therapy 1. HEMATOMAS - collection of blood in a contained space that can intervene with tissue apposition - Main cause is inadequate hemostasis because you fail to ligate a vessel - If it occurs in the neck, it can cause airway compression (requires immediate management) (impingement of the trachea) so the first thing to do is to remove the sutures then bring the patient to OR - Skin Thickness Skin Grafting can lead to graft failure - Soft Tissue Flaps can lead to flap necrosis - Fertile ground for bacterial proliferation

Manifestation Early:  Pain, Swelling  Serosanguinous wound discharge (blood and serous fluid) Late:  Skin Discoloration (bluish) Management Early: evacuate hematoma Late: Expectant management, warm compress to dissolve the accumulation of blood  Closed Suction Drain o Jackson Pratt Drainage – To remove serous fluid – Should always be on a negative pressure – 15-100ml capacity – Expect 50-70ml in 8 hours Hemostasis – Should ligate a blood vessel Neck, Graft, Flaps Evacuate immediately 2. SEROMAS - Accumulation of serous fluid - Usually due to: Modified Radical Mastectomy, Axillary Dissection, Inguinal exploration (*fertile ground for infection) - Impairs wound healing (same principle with hematoma) - Prevents closure of upper and lower layers Management - Closed Suction Drains to evacuate seroma - Compressive Dressings 3. WOUND INFECTION (SURGICAL SITE INFECTION/SSI) Three Types 1. Superficial Incisional SSI – skin and subcutaneous tissue (most common and easy to manage) 2. Deep Incisional SSI - deep soft tissue (fascia and muscle) 3. Organ/Space SSI - abscess in peritoneal cavity or peritonitis (peritoneal cavity)

      

Open and drain pus Debridement or remove necrotic tissue Local Wound Care Topical antibiotics Betadine/Alcohol on raw area Dakin Solution - NSS and zonrox (5-10cc)  More economical; Effective Drain Intra-abdominal abscess

External evidence of wound sepsis appears on the third post-op day, (i.e. “Reactive, brown, murky” wound drainage)  Usually begins at the subcutaneous and goes down to involve the muscles and the fascia 

Prevention  Prophylactic antibiotic – in elective surgery  30 minutes – 1 hour before incision so that antibiotic would be high on tissue level in time of incision  Type of antibiotic is dependent on the location of the surgery  Necessary only once for clean wounds and within 24 hours  Skin Preparation – waxing and betadine o Waxing is a better option because shaving causes microabrasions  Bowel Preparation in colonic surgery - cleansing enema to remove fecal contents Surgical Techniques  Irrigation: NSS(use this) vs Antibiotic based(same effect)  Sutures: Monofilament (nylon) vs Braided (higher chance of infection)  Delayed wound closure - Tertiary for 3 days - Only skin and subcutaneous layers will be left open - Good perfusion, better healing  Duration of Operation - Good granulation & no purulent discharges * Common site of SSI: subcutaneous layer (poor blood supply) Clinical Manifestations of SSI:  Erythema and Swelling around the incision site  Inordinate Pain-pain out of proportion  Purulent Discharge  Ileus, Abscess formation Treatment:

4.

NECROTIZING FASCITIS - Fascia is necrotic - Remove all necrotic material

5.

FOURNIERE’S GANGRENE –around perineal area - Remove all necrotic tissue

6.

WOUND DEHISCENCE Opening of suture (can happen at different levels of suture) due to poor surgical technique - if in the skin, you do healing with secondary intention - Separation of fascial layer can lead to evisceration or extrusion of peritoneal contents (manage by covering with clean cloth and place NSS )

Risk Factors:  Wound Hematoma/SSI  Coughing  Malnutrition  Diabetes  Immunocompromised  COPD  Ascites Clinical Manifestation of evisceration:  Classical: Serosanguinous discharge on the 4th 5th POD  After forceful activity  Complete vs. Partial Dehiscence  Late- Incisional Hernia o Incisional hernia results from partial wound dehiscence

Management: Partial  Non-Operative  Incisional Hernia better than evisceration Complete  Evisceration  Retention Sutures - One suture includes full thickness of abdomen - Plastic tubes(bumpers) to prevent suture from digging into the skin/ wound - Wait for 2 weeks before removing the sutures URINARY COMPLICATIONS a.

URINARY RETENTION - Common after anal surgery such as hemorhoidectomy due to pain that can constrict anal sphincter with a reflex constriction of urinary tract - Prolonged catheterization due to bladder atony

b.

URINARY TRACT INFECTION - Most common Nosocomial Infection - Secondary to Indwelling Catheters

c.

ACUTE RENAL FAILURE - Secondary to inadequate resuscitation - Secondary to blood transfusion reactions - Secondary to nephrotoxic drugs - Temporary dialysis until kidney recovers

CIRCULATORY COMPLICATIONS 1. Hemorrhage 2. Sepsis 3. Myocardial Infarction 4. Pulmonary Embolism Hemorrhage Recognition: 1. Overt bleeding on incision site 2. Bloody drain output 3. Distended abdomen 4. Hypovolemia/ Hemorrhagic Shock - Tachycardia - Hypotension - Tachypnea - ↓ urine output - Cold clammy skin

Management: 1. Control the source of bleeding - Re-op may be necessary 2. Correction of coagulopathy 3. Fluid resuscitation/ Blood transfusion Sepsis/ Septic Shock - OR carried out in the presence of sepsis - Technical failure - Spread from a focus - Bloodstream contamination (Infected CVP line, IV catheter) Manifestations: 1. Warm periphery 2. Fever 3. Hypotension 4. Tachycardia 5. Tachypnea 6. Changes in sensorium Management: 1. Look for the focus - Undrained abscess, catheters - Re-exploration - GS, C/S 2. Fluid resuscitation 3. Star empiric antibiotic treatment MI/ Pulmonary Embolism Risk Factors: - Ischemic Heart Disease - Arrythmia - Prolonged immobilization - Malignancy - Elderly - Lower limb fracture GASTRIC SURGERY COMPLICATIONS Acute  Duodenal Stump Blowout – requires immediate surgical intervention  Rebleeding  Gastroparesis – Failure of stomach to contract  Anastomotic leak

Long term  Dumping syndrome  Afferent and Efferent loop syndrome  Reflux gastritis  Gastric Stump carcinoma  Anemia AFFERENT LOOP SYNDROME Proximal to anastomosis Present as intestinal obstruction obstruction at junction of afferent limb and gastric remant - Postparandial abdominal pain and nonbillous vomiting (accumulation of secretions; bile is obstructed) - Kinking and angulation - Internal herniation behind efferent limb - Stenosis of gastrojejunal anastomosis - Redundant twisted afferent limb (volvulus) - adhesions involving afferent limb

a.

 

Clinical Manifestations  Abdominal Pain o SBO- colicky; more painful o Ileus- constant  Abdmominal Distention  Obstipation – failure to pass out flatus and fecal material  Bowel Sounds o SBO- hyperactive with metallic sound o Ileus- hypoactive bowel sounds o SBO- Air-fluid level on X-ray; Stepladder sign C.

EFFERENT LOOP SYNDROME - Epigastric pain and bilious vomiting

b.

DUMPING SYNDROME - Rapid Movement of hypertonic food bolus to small intestine - Inc. ECF, diarrhea (distention)  GI: Nausea, Vomiting, Epigastric fullness, crampy abdominal pain, explosive diarrhea  CVS : Palpitation, tachycardia, diaphoresis, fainting, dizziness, flushing, blurred vision

c.

INTESTINAL SURGERY COMPLICATIONS A. -

B.

-

ILEUS Non-mechanical obstruction; temporary Hypomotility problem Very common complication of abdominal surgery Passage of flatus or regaining function after surgery:  Small bowel: within 24 hours  Stomach: 24 – 48 hours  Colon: 3-5 days SBO -

Mechanical Problem Post op adhesions- most common cause

(* kinking and twisting) Bands

ANASTOMOTIC LEAKS POORLY PREPARED PATIENT  Inadequate resuscitation  Emergency OR  Inadequate proximal decompression  (-)Bowel Prep  Malnutrition POOR SURGICAL TECHNIQUE  Adequate Blood Supply  Tension Free  Meticulous Hemostasis  No Contamination

Sequelae of Leaks 1. Peritonitis/Acute Abdomen 2. Abscess Formation 3. Fistula Formation Complications of Intestinal Anastomosis  Leakage: Peritonitis, Intra-Abdominal Abscess, Fistula  Stricture: Intestinal Obstruction, Obstructive jaundice, Dysphagia  Bleeding: Hypovolemic Shock ENTEROCUTANEOUS FISTULA 

FISTULA - Anastomotic leak that has developed a pathway to the skin - 4th – 5th POD - Manifest like SSI except that there is leakage of intestinal obstruction - Increased wound pain and redness - Purulent discharge

-

Leakage of intestinal contents Path of least resistance

Fistula causes: FRIEND F - Foreign Body R - Radiation I - Inflammation, Ischemia, Infection E - Epithelialization of tract N - Neoplasia D - Distal Obstruction

LOW OUTPUT FISTULA: 500cc  The lower the output, the higher the chance of spontaneous closure 

Unlikely to close spontaneously: After 4-5 weeks Sepsis–free Adequate Nutrition Management:  OPERATIVE Resect and Anastomose GOAL: Resuscitate Predictive Factors of Spontaneous Closure

Anatomic Location

Nutritional Status Sepsis

Appendicitis, Diverticulitis, Postop

Crohn’s Dse., Cancer, Radiation, Foreign Body

Bowel Condition

Healthy Adjacent Tissue, No abscess, Small Leak Tract > 2cm Defect 3mons will not close anymore 1. Resuscitate: Fluid and Electrolytes 2. Nutritional Support 3. Sepsis Control 4. Wound Care - discharges can excoriate the skin 5. Assessment of anatomy: Fistulogram

Factor

Etiology

Likely to close

Unlikely to close

Edophageal, Duodenal Stump, Jejunal, Pancreaticobiliary Well nourished

Gastric, Lateral Duodenal, Lig of Treitz, Ileal

Absent

Present

Malnourished

COMPLEX FISTULA D.

ABDOMINAL COMPARTMENT SYNDROME Result of those with multiple injuries; edematous or distended bowel - Multi-system trauma, peritonitis, massive fluid resuscitation - Intraabdominal Hypertension - Decrease in venous return to the heart so hypotension - (impingement of vena cava) - Decrease renal output leading to renal failure - Pulmonary dysfunction due to pressure of increased size of peritoneal organs (diaphragm goes up, decreased space for lung expansion) - Can cause increased ICP

-

Management  Open the incision and apply Bogota Bag  Incisional Hernia  Pressure-induced Dysfunction  Decreased Venous Return, Decreased Cardiac Output  Decreased Renal Flow  Decreased Intestinal Perfusion  Pulmonary Dysfunction Diagnosis  Intrabdominal pressure > 25-30 mmHg With any of the following: Compromised respiration, Oliguria or anuria  Increased Intracranial Pressure Treatment: Open the incision  Bogota Bags  Attempt closure every 2-3 days



A.

B.





Skin Closure – may lead to incisional hernia

STOMA COMPLICATIONS NOT on incision site NOT near bony prominence Protruded Stoma RETRACTION Inadequate length of intestine - Skin Irritation, peristomal infection and intraab infection - As a rule, all retracted stoma should be revised Adequate length, good blood supply

Pyloroplasty J. Gastric Reconstruction Billroth II Roux-en-y Anastomosis K. Skin Irritation Allergic reaction to adhesive Abrasive effects of effluents Peristomal Infection SQ infection around Stoma Fecal contamination especially in retracted stoma L. Gangrene Compromised blood supply Treatment is by resection M. Prolapse and Intussusception Bowel Distention Abdominal wall opening larger than the normal caliber Prevention: not too large an abdominal wall opening I.

A wise surgeon learns from his mistakes. A wiser surgeon learns from the mistakes of others.

C.

D. E. F. G. H.

PERISTOMAL EVISCERATION AND PARASTOMAL HERNIATION Large Fascial and/or Skin defect Poor Anchoring Repair of Fascial Defect

Postgastrectomy Syndromes Alkaline Reflux gastritis Small Remnant Syndrome Gastric Stump Carcinoma Anemia Iron Deficiency Megaloblastic - Vit. B12, intrinsic factor