Lincoln County Hospital ULH Trust

POST-OPERATIVE COMPLICATIONS
12/01/2012
Chris Neophytou CT1 General Surgery Ali Qureishi CT1 ENT

Introduction
This was not my patient . . . I was not present for this case . . . I never saw this patient . . .

If you do enough operations you are bound to have this

happen It was an act of God . . . I did a perfect operation . . . the ungrateful patient died . . .

Introduction
I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work Harvey Cushing You are a true surgeon from the moment you are able to deal with your complications Owen H. Wangensteen

Introduction
Classification

General vs. Specific

Time after surgery

By system affected

General post-operative complications

Immediate:
Pain
Primary

haemorrhage Shock: haemorrhagic - cardiogenic - septic Low urine output Basal atelectasis

General post-operative complications

Early:
Acute confusion N+V Fever Secondary haemorrhage (infection vessel erosion) Infections: Wound - Urinary - Respiratory Wound / anastomosis dehiscence Deep vein thrombosis Acute urinary retention Bowel obstruction (fibrinous adhesions) Paralytic ileus (if prolonged sepsis)

General post-operative complications

Late:
Bowel

obstruction (fibrous adhesions) Incisional hernia Persistent sinus Recurrence of reason for surgery

Post-operative pain

Post-operative pain

Post-operative pain

2007 League table of number needed to treat (NNT) for at least 50% pain relief over 4-6 hours in patients with moderate to severe pain

Post-operative fever

Post-operative fever
Pathophysiology of fever: Fever is manifestation of cytokine release in response to stressful stimuli Cytokines released include interleukin-1, TNF-, IFN- Fever-associated cytokines released by tissue trauma and do not necessarily signal infection

Fever < 38 is common in first few days after major surgery Most early post-op fever caused by inflammatory stimulus of surgery resolves spontaneously

Post-operative fever

Immediate questions
Common

causes: 5 Ws Fever pattern

Spiking

fever: closed spaces Continuous fever: systemic disease

Chills

/ rigors Fever before procedure Associated complaints Immunocompromised patient

Post-operative fever

First 24 hours: Systemic response trauma, pre-existing infection 24 to 72 hours

Pulmonary atelectasis Chest infection Chest infection Wound infection Intraperitoneal sepsis Urinary tract infection Anastomotic leak Deep venous thrombosis Pulmonary embolus

3 to 7 days

7 to 10 days

Post-operative fever - DDx

Atelectasis: 12 - 48h post-op
Anaesthesia - pain - anaelgesia - obese/smokers alveoli collapse (secretions / non-expansion) secondary infection
O/E: Low-grade fever - malaise - diminished lung sounds - tachycardia / tachypnoea (severe cases) Diagnosis: Clinical further work-up in severe cases Management: Chest physio - nebs - anaelgesia - ?

Post-operative fever - DDx

Since 1988, the Centers for Disease Control and Prevention (CDC) has published 2 articles in which nosocomial infection and criteria for specific types of nosocomial infection for surveillance purposes for use in acute care settings have been defined

Post-operative fever - DDx

Symptomatic urinary tract infection: Patient has at least 1 of the following signs or symptoms with no other recognized cause:
Fever

LUTs:

urgency, frequency, dysuria, or suprapubic tenderness

And Positive urine culture (105 microorganisms per cc)

Post-operative fever - DDx

Post-operative fever - DDx

P N E U M O N I A

Post-operative fever - DDx

Surgical site infection (SSI): Infection occurs within 30 days after the operative procedure And involves only skin and subcutaneous tissue of the incision And Patient has at least 1 of the following:

Purulent drainage from the superficial incision Organisms isolated from an aseptically obtained culture of fluid At least 1 of the signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat Diagnosis of superficial incisional SSI by the surgeon

Management of wound infections

Release pus, remove any retaining sutures, and ensure adequate drainage Debride necrotic non-viable tissue Antibiotic empirical therapy (or based on microbiological analyses) Topical antimicrobials (iodine or chlorhexidine) Keep wound moist with appropriate surgical dressings In the presence of clean granulations consider grafting or secondary suture

Low urine output - Shock

Recommendation 1 Because of the risk of inducing hyperchloraemic acidosis in routine practice, when crystalloid resuscitation or replacement is indicated, balanced salt solutions e.g. Hartmanns solution should replace 0.9% saline, except in cases of hypochloraemia e.g. from vomiting or gastric drainage. Evidence level 1b

Paralytic ileus

Ileus: disruption of the normal propulsive ability of the GI tract Paralytic ileus: ileus that persists for more than 3 days following surgery After surgery there is a delay in return to normal bowel function.

Gastric stasis for <24 hours Small bowel ileus for 23 days Colonic ileus for 45 days

Paralytic ileus

Traditionally patients had oral intake withheld until passage of flatus

little evidence to support this practice Patients are increasingly encouraged to E+D (enhanced recovery programmes)

A small proportion of patients do not tolerate early feeding and develop paralytic ileus

Paralytic ileus
Clinical features Absence of abdominal pain No passage of flatus Abdominal distension Vomiting often effortless Respiratory compromise if abdomen is tympanic Bowel sounds are usually absent

Management?

Anastomotic leak
Clinical features

Failure to progress, lethargy, anorexia Cardiac dysfunction

AF, dysrhythmia, hypotension circulatory collapse

Respiratory signs dyspnoea or tachypnoea Fever Prolonged ileus, abdominal distension, or hiccups High WCC and CRP Metabolic acidosis

Anastomotic leak
Risk factors

Poor blood supply to the anastomosis Tension at the anastomosis Distal obstruction Surgical technique Poor nutrition Steroids Local infection or haematoma

Colorectal leak

Usually early signs and symptoms

loose

bowel action with increased frequency incontinence with distension

Abdominal pain may relate to local or generalized peritonitis, usually with sepsis

Colorectal leak
Management Unstable patient with peritonitis

Resuscitation Reoperation

Anastomosis is taken down Peritoneal lavage Proximal stoma formation

Low grade sepsis and localized peritonitis

CT scan/contrast enema

Percutaneous drainage of a perianastomotic abscess ? Reoperation if intraperitoneal free leak

Subclinical leaks

Conservative management Broad spectrum antibiotics for abscesses <3cm may

Bile duct injury

0.20.5% incidence (open cholecystectomy: 0.06%) Types of injury to bile duct complete transection complete transection with missing segment partial transection clip occlusion diathermy injury sectoral or accessory duct leak

Bile duct injury

Presentation Intra-operative recognition Bile in the drain Clinical presentation
Abdominal

pain Nausea and vomiting Fever Jaundice Sepsis

Bile duct injury

Management Investigation: LFTs, WCC, USS abdomen Broad spectrum antibiotics ERCP + stent (there is a cystic duct or lateral duct leak) or PTC drain Specialized hepatobiliary unit: Roux-en-Y hepaticojejunostomy

Enterocutaneous fistula

Drainage of intestinal contents for >48hrs through a wound or drain More common than fistulas arising from diseased bowel

Causes Unrecognized intestinal injury Breakdown of enterotomy repair Breakdown of anastomosis Breakdown of exposed bowel in a laparostomy wound

Enterocutaneous fistula
Management Resuscitation

Patients often unwell due to sepsis and fluid depletion IVI: 0.9% saline with added potassium

Nutrition

Dietician input Replace vitamins mineral trace element deficiencies Consider TPN for high output fistulas

Contrast studies (once the patient is stable)

Define the anatomy of the fistula Check the condition of the proximal and distal gut

Define an associated abscess cavity Exclude distal obstruction

Enterocutaneous fistula
Spontaneous closure of a post-operative fistula is likely if:
no

distal obstruction no diseased bowel no abscess or foreign body no muco-cutaneous continuity

Surgical reconstruction

Adhesions
Inevitable consequence of abdominal surgery Responsible for 75% of cases of small bowel obstruction 5% five year readmission rate after surgery Chronic abdominal and pelvic pain Causes congenital (band adhesion) surgical trauma-denuded peritoneal membrane foreign body reaction starch on gloves, sutures peritoneal blood

Adhesions
Conservative management usually (up to 80% resolution) Resuscitation, intravenous rehydration, electrolyte correction Naso-gastric tube with free drainage and 4-hourly aspiration Indications for surgery Tachycardia Raised inflammatory markers Abdominal tenderness Failure of conservative management (48 hours is the usual allowed time).

Chronic pain due to adhesions Radiological investigation to exclude underlying pathology Laparoscopic division of adhesions