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Slide 1: SURGICAL COMPLICATIONS James Taclin C. Banez, MD, FPCS, FPSGS, DPBS, FPSA
Slide 2: 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:  
Slide 3: Wound Complications: A. Wound dehiscence:
Slide 4: Wound Complications: A. Wound dehiscence:   Separation of an abd. wound involving the anterior fascial and deeper layers 0.5 – 3.0% General factors: 1) Age: < 45y/o = 1.3%  Causes:  > 45 y/o = 5.4% 2) Debilitated pts. w/ poor nutrition carcinoma, hyponatremia, obesity 3) Causes of increase intra-abd. pressure  pulmonary & urinary problem
Slide 5: 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 incision)  Manifestation: 1. Sero-sanguinous drainage (pathognomonic) 2. Postoperative ventral hernia
Slide 6: 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: 
Slide 7: Wound Complications: A. 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)
Slide 8: Wound Complications: A. 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. 3. 4. Age Presence of medical problems (diabetes/steroid tx) Duration of operations and preoperative stay in the hospital
Slide 9: Postoperative Infections: (nosocomial)  Local factors: 1. Adequacy of tissue blood supply: − Devitalized tissues − Dead space ----> hematoma, seroma 1. 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)
Slide 10: 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
Slide 11: 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
Slide 12: Postoperative Pulmonary Complications A. Atelectasis: Predisposing factors: 1. Smoking 2. 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
Slide 13: 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
Slide 14: Postoperative Pulmonary Complications A. Atelectasis: Treatment: 1. Preop prophylaxis: a. No smoking (2 wks) b. Treatment of pulmonary problem 1. Postop prophylaxis: Minimal use of depressant drugs Prevent pain Early ambulation Changes body position Deep breathing and coughing exercises 2. Drugs: a. Expectorants b. Mucolytic c. bronchodilators − − − − −
Slide 15: Postoperative Pulmonary Complications A. 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
Slide 16: Postoperative Pulmonary Complications A. Pulmonary Aspiration: Prevention:   NPO 6hrs prior to surgery Emergency – NGT do gastric lavage and give antacid to prevent dev. of Mendelian’s Syndrome. (It is marked by bronchoconstriction and destruction of the tracheal mucosa, progressing to a syndrome resembling acute respiratory distress syndrome. Also called pulmonary acid aspiration syndrome.) Treatment:   Continuous mechanical ventilation antibiotics
Slide 17: Postoperative Pulmonary Complications A. 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.
Slide 18: Postoperative Pulmonary Complications A. 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)
Slide 19: Postoperative Pulmonary Complications A. 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
Slide 20: Postoperative Pulmonary Complications A. 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)
Slide 21: 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
Slide 22: 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
Slide 23: Postoperative Shock Categories: 1. Cardiogenic shock (MI / cardiac tamponade) 2. Septic shock:   Due to gram (-) infection; nosocomial Uro-genital infection (foley catheter) > resp. tract > integumentary
Slide 24: Postoperative Renal Failure Oliguria – considered acute renal failure Renal failure index: (Urine Na x Plasma creatinine) Urine creatinine < 1 usually indicates pre-renal oliguria > 1 indicates acute renal failure
Slide 25: Postoperative 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   
Slide 26: Diabetes Mellitus: Challenge to the surgeon for: 1. Impairment of homeostatic mechanism for glucose (ketoacidosis/hyperglycemia) 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
Slide 27: 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) Type of anesthesia:   least effect on CHO metabolism
Slide 28: 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
Slide 29: Complication of Gastrointestinal Surgery A. Vascular Complication: B. Intestinal Obstruction: A. Mechanical Obstruction B. Non-mechanical obstruction C. Anastomotic Leak A. Fistula B. Peritoneal abscess ----> Peritonitis
Slide 30: 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
Slide 31: Vascular Complication: 1. Gangrene:  Due to poor tissue perfusion 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: 
Slide 32: Intestinal Obstruction Mechanical Problem: 1. Intestinal Obstruction: S/Sx:   3rd – 4th postop day Abdominal distention, colicky pain, increase NGT drainage, bilious material
Slide 33: Intestinal Obstruction Mechanical Problem: 1. Intestinal Obstruction: a. 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
Slide 34: Intestinal Obstruction Mechanical Problem: 1. Other causes of intestinal obstruction a. Intussuception b. Volvulus c. Post-operative adhesion d. Herniation
Slide 35: INTUSSUCEPTION
Slide 36: INTUSSUCEPTION
Slide 37: VOLVULOUS
Slide 38: Intestinal Obstruction Mechanical Problem: Diagnosis: Flap plate of abdomen (FPA) Small bowel obstruction Large bowel obstruction Sigmoid volvulus
Slide 39: Intestinal Obstruction Mechanical Problem: Treatment: 1. Proximal decompression (NPO / NGT) 2. Correct fluid and electrolyte imbalance 3. Hyperalimentation (TPN):  No improvement ------> re-operation
Slide 40: Intestinal Obstruction 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
Slide 41: Intestinal Obstruction Mechanical Problem: Blind Loop Syndrome: Treatment:   Incomplete – conservative Complete: re-operation and anastomosis between the afferent and efferent loops by Roux-en-Y or convert to Billroth I (gastroduodenostomy)
Slide 42: Intestinal Obstruction Mechanical Problem: Blind Loop Syndrome: 1. Intestinal blind loop: a. b. c. Volvulus of small bowel Complete large bowel obstruction w/ a competent ileocecal valve Internal bowel herniation
Slide 43: Small bowel volvulous
Slide 44: Small bowel internal herniation
Slide 45: Large Bowel Obstrucion due to Ascariasis
Slide 46: Intestinal Obstruction 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
Slide 47: Intestinal Obstruction Treatment:   NGT decompression, NPO, correct fluid and electrolyte imbalance Surgical intervention – adhesiolysis w/ or w/o resection
Slide 48: 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
Slide 49: Anastomotic Leak: Etiologic factor: Poor surgical technique 2. Distal obstruction 3. Inadequate proximal decompression Can manifest as localized or generalized peritonitis 1. Treatment: Small leaks: 1. Conservative w/ NPO 2. Proximal decompression 3. Antibiotic Large leaks: 1. Surgical intervention
Slide 50: Anastomotic Leak: Complication: 1. 2. 3. 4. Fistula Peritoneal abscess Peritonitis Sepsis
Slide 51: Fistula: Abnormal communication between two lining epithelium Etiology: 1. 2. 3. 4. 5. 6. Anastomotic leak Poor blood supply Trauma Infection Inadvertent suturing of bowel wall while closing the fascia Carcinoma
Slide 52: Fistula: 1. Gastric and duodenal fistula:  Subtotal gastrectomy ---> gastrojejunal (tears of surrow) and duodenal stump  Due to suture line failure
Slide 53: Fistula: 1. Gastric and duodenal fistula: Treatment:  NPO / TPN  Place NGT past the leak and give elemental diet  Antibiotic  Majority close spontaneously w/in 6 wks Failure to close 1. 2. 3. 4. distal obstruction large leak Infection Cancer Surgery – ressect the fistula and the bowel segment then re-anastomosis
Slide 54: Fistula: 1. Small bowel fistula:  Drainage is less compared to duodenal fistula, but jejunal fistula have a poorer prognosis than ileal fistula
Slide 55: Fistula: 1. Small bowel 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 
Slide 56: 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 
Slide 57: Fistula: Colonic fistula: Treatment: 1. 2. 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 4. Ileal transverse colostomies for ascending and distal ileal fistulas 3.  If w/ generalized peritonitis do emergency resection
Slide 58: PERITONEAL ABSCESS
Slide 59: THANK YOU