Surgical Complications
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Surgical Complications

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Surgical Complications Presentation Transcript

  • 1. SURGICAL COMPLICATIONS James Taclin C. Banez, MD, FPCS, FPSGS, DPBS, FPSA
  • 2. General Considerations:
    • Complications are made in the operating rooms.
    • Minimize the risk:
      • Rigorous preoperative evaluations
      • Meticulous operative technique
      • Careful monitoring of patients preoperatively
    • Fever:
      • 1 st postop day --> atelectasis/aspiration/UTI
      • 4 th -5 th postop --> wound infection / anastomotic leak
    • Hypotension:
      • Immediate --> continuous hge / depressive drugs
      • Later ---> sepsis
  • 3. Wound Complications:
    • Wound dehiscence:
  • 4. Wound Complications:
    • Wound dehiscence:
      • Separation of an abd. wound involving the anterior fascial and deeper layers
      • 0.5 – 3.0%
      • Causes:
      • General factors:
        • Age: < 45y/o = 1.3% > 45 y/o = 5.4%
        • Debilitated pts. w/ poor nutrition
          • carcinoma, hyponatremia, obesity
        • Causes of increase intra-abd. pressure
          • pulmonary & urinary problem
  • 5. Wound Complications:
    • Wound dehiscence:
      • Causes:
        • Local Factors:
          • Hemorrhage
          • Infection
          • Poor technique:
            • Excessive suture material
            • Drain and stoma placed along incision
          • Type of incision (> in vertical incision)
      • Manifestation:
        • Sero-sanguinous drainage (pathognomonic)
        • Postoperative ventral hernia
  • 6. Wound Complications:
    • 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
  • 7. Wound Complications:
    • Wound Infection:
      • Major factors:
        • Breaks in surgical technique
        • Host parasite relationship
      • Potential sources of contamination:
        • Patients themselves
        • Operating room and personels
      • Organisms:
        • Staphylococcus aureus
        • Enteric organism (E. coli, Bacteroides, Proteus, Klebsiella, Pseudomonas)
  • 8. Wound Complications:
    • Wound Infection:
      • Factors:
        • Nature of the wound:
          • Clean atraumatic and uninfected operative wound (3.3%)
          • GIT / Respiratory / Urinary tract entered but w/ out unusual contamination (10.8%).
          • Open, traumatic wounds w/ major break in sterile technique (16.3%)
          • Traumatic wound involving abscesses of perforated viscera (28.6%).
        • Age
        • Presence of medical problems (diabetes/steroid tx)
        • Duration of operations and preoperative stay in the hospital
  • 9. Postoperative Infections: (nosocomial)
      • Local factors:
        • Adequacy of tissue blood supply:
          • Devitalized tissues
          • Dead space ----> hematoma, seroma
        • Foreign bodies
      • Systemic factors:
        • Age: very young (neonates) and elderly
        • Obesity: poor blood supply in adipose tissue
        • Systemic illnesses:
          • Malignancy
          • Diabetes
          • Hepatic cirrhosis
        • Medications taken (steroids)
  • 10. Postoperative Infections: (nosocomial)
    • Pulmonary infections:
      • Atelectasis
      • Endotracheal intubation and ventilation
      • Aspiration pneumonia
    • Urinary tract infection: indwelling urinary catheter
      • E. coli, Pseudomonas, klebsiella
    • Intra-abdominal infection: abdominal abscess
      • Sites:
        • Sub-phrenic ---> most common
        • Pelvis
        • Liver
        • Lateral gutters / intestinal loop
      • Treatment: drain ---> explor lap / needle aspiration
    • Wound infection
  • 11. Postoperative Pulmonary Complications
    • Atelectasis:
      • 90% postoperative pulmonary complications
      • Etiology:
        • Obstruction of the tracheobronchial airway
          • Changes in bronchial secretions
          • Defects in expulsion mechanism
          • Reduction in bronchial caliber
        • Pulmonary insufficiency (hypoventilation)
          • Decrease surfactant
  • 12. Postoperative Pulmonary Complications
    • Atelectasis:
      • Predisposing factors:
        • Smoking
        • Pulmonary problem (bronchitis, asthma, etc)
        • Anesthesia:
          • GA - duration and depth
          • Postop narcotics – depress cough reflex
        • Depress cough reflex
          • Chest pain
          • Immobilization
          • Splinting w/ bandages
        • NGT – increased secretions and predisposed aspiration
        • Congestion of the bronchial walls
  • 13. Postoperative Pulmonary Complications
    • Atelectasis:
      • Manifestations:
        • 1 st 24 hrs postop ----> fever, tachycardia, rales, decrease breath sound ----> persist ----> pneumonia (increase fever, dyspnea, tachycardia and cyanosis) ---> lung abscess
  • 14. Postoperative Pulmonary Complications
    • Atelectasis:
      • Treatment:
      • Preop prophylaxis:
        • No smoking (2 wks)
        • Treatment of pulmonary problem
      • Postop prophylaxis:
        • Minimal use of depressant drugs
        • Prevent pain
        • Early ambulation
        • Changes body position
        • Deep breathing and coughing exercises
      • Drugs:
        • Expectorants
        • Mucolytic
        • bronchodilators
  • 15. Postoperative Pulmonary Complications
    • Pulmonary Aspiration:
      • General anesthesia – pts are in supine position and absence of normal protective reflexes.
      • Increased risk:
        • Pregnant
        • Elderly
        • Obese
        • Pts w/ bowel obstruction
  • 16. Postoperative Pulmonary Complications
    • 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
  • 17. Postoperative Pulmonary Complications
    • Pulmonary Edema:
      • Etiology:
        • Circulatory overload (infusion of fluid during operation)
            • Most common cause
        • 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
        • Negative pressure in airway.
  • 18. Postoperative Pulmonary Complications
    • Pulmonary Edema:
      • Treatment:
        • 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)
  • 19. Postoperative Pulmonary Complications
    • 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
  • 20. Postoperative Pulmonary Complications
    • Respiratory Failure:
      • Etiologic Factors:
        • Sepsis
        • Massive transfusion
        • Fat embolism
        • Pancreatitis
        • 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)
  • 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:
      • Over sedation
      • Effect of anesthesia
  • 22. Postoperative Shock
    • Categories:
    • 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
  • 23. Postoperative Shock
    • Categories:
    • Cardiogenic shock (MI / cardiac tamponade)
    • Septic shock:
      • Due to gram (-) infection; nosocomial
      • Uro-genital infection (foley catheter) > resp. tract > integumentary
  • 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
  • 25. Postoperative Renal Failure
    • Etiologies:
      • Catheter obstruction
      • Pre-renal failure;
        • Diminished circulating blood volume
      • Acute parenchymal renal failure
        • Fluid restriction (daily allowance 500ml plus previous 24 hrs. UO)
        • Electrolyte imbalance (hyperkalemia)
        • Hemodialysis
  • 26. Diabetes Mellitus:
    • Challenge to the surgeon for:
    • Impairment of homeostatic mechanism for glucose (ketoacidosis/hyperglycemia)
    • 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
  • 27. Diabetes Mellitus:
    • Effect of Anesthetic agents to CHO metabolism
      • Hyperglycemia
      • 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
  • 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
  • 29. Complication of Gastrointestinal Surgery
    • Vascular Complication:
    • Intestinal Obstruction:
      • Mechanical Obstruction
      • Non-mechanical obstruction
    • Anastomotic Leak
      • Fistula
      • Peritoneal abscess ----> Peritonitis
  • 30. Vascular Complication:
    • 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
  • 31. Vascular Complication:
    • Gangrene:
      • Due to poor tissue perfusion
      • Stomach:
        • Following subtotal gastrectomy w/ ligation of left gastic and splenic arteries; thrombosis
      • Small bowel and colon:
        • Thrombosis; mechanical strangulation (internal herniation) – volvulus, adhesions
      • Treatment:
        • Resection of gangrenous segment, re-established continuity
  • 32. Intestinal Obstruction
    • Mechanical Problem:
      • Intestinal Obstruction:
        • S/Sx:
        • 3 rd – 4 th postop day
        • Abdominal distention, colicky pain, increase NGT drainage, bilious material
  • 33. Intestinal Obstruction
    • Mechanical Problem:
      • Intestinal Obstruction:
        • Stomal obstruction (due to local edema)
          • Causes of edema:
            • Electrolyte imbalance
            • Incomplete hemostasis
            • Hypoprotenemia
            • Leakage from anastomosis
            • Inadequate proximal decompression
            • Incorporation of too much tissue w/in the suture
  • 34. Intestinal Obstruction
    • Mechanical Problem:
      • Other causes of intestinal obstruction
        • Intussuception
        • Volvulus
        • Post-operative adhesion
        • Herniation
  • 35. INTUSSUCEPTION
  • 36. INTUSSUCEPTION
  • 37. VOLVULOUS
  • 38. Intestinal Obstruction
    • Mechanical Problem:
    • Diagnosis:
      • Flap plate of abdomen (FPA)
    Small bowel obstruction Large bowel obstruction Sigmoid volvulus
  • 39. Intestinal Obstruction
    • Mechanical Problem:
    • Treatment:
      • Proximal decompression (NPO / NGT)
      • Correct fluid and electrolyte imbalance
      • Hyperalimentation (TPN):
      • No improvement ------> re-operation
  • 40. Intestinal Obstruction
    • Mechanical Problem:
    • Blind Loop Syndrome:
    • Afferent loops syndrome:
      • Cases of Billroth gastro-enterostomy
      • 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
  • 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)
  • 42. Intestinal Obstruction
    • Mechanical Problem:
      • Blind Loop Syndrome:
      • Intestinal blind loop:
        • Volvulus of small bowel
        • Complete large bowel obstruction w/ a competent ileocecal valve
        • Internal bowel herniation
  • 43. Small bowel volvulous
  • 44. Small bowel internal herniation
  • 45. Large Bowel Obstrucion due to Ascariasis
  • 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
  • 47. Intestinal Obstruction
    • Treatment:
      • NGT decompression, NPO, correct fluid and electrolyte imbalance
      • Surgical intervention – adhesiolysis w/ or w/o resection
  • 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
  • 49. Anastomotic Leak:
    • Etiologic factor:
      • Poor surgical technique
      • Distal obstruction
      • Inadequate proximal decompression
    • Can manifest as localized or generalized peritonitis
    • Treatment:
      • Small leaks:
        • Conservative w/ NPO
        • Proximal decompression
        • Antibiotic
      • Large leaks:
        • Surgical intervention
  • 50. Anastomotic Leak:
    • Complication:
      • Fistula
      • Peritoneal abscess
      • Peritonitis
      • Sepsis
  • 51. Fistula:
    • Abnormal communication between two lining epithelium
    • Etiology:
      • Anastomotic leak
      • Poor blood supply
      • Trauma
      • Infection
      • Inadvertent suturing of bowel wall while closing the fascia
      • Carcinoma
  • 52. Fistula:
    • Gastric and duodenal fistula:
        • Subtotal gastrectomy ---> gastrojejunal (tears of surrow) and duodenal stump
        • Due to suture line failure
  • 53. Fistula:
    • 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
            • distal obstruction
            • large leak
            • Infection
            • Cancer
        • Surgery – resect the fistula and the bowel segment then re-anastomosis
  • 54. Fistula:
    • Small bowel fistula:
      • Drainage is less compared to duodenal fistula, but jejunal fistula have a poorer prognosis than ileal fistula
  • 55. Fistula:
    • 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
  • 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
  • 57. Fistula:
    • Colonic fistula:
      • Treatment:
      • 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
      • Ileal transverse colostomies for ascending and distal ileal fistulas
        • If w/ generalized peritonitis do emergency resection
  • 58. PERITONEAL ABSCESS
  • 59. THANK YOU