Surgical Complications

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Surgical Complications

  1. 1. SURGICAL COMPLICATIONS James Taclin C. Banez, MD, FPCS, FPSGS, DPBS, FPSA
  2. 2. General Considerations: <ul><li>Complications are made in the operating rooms. </li></ul><ul><li>Minimize the risk: </li></ul><ul><ul><li>Rigorous preoperative evaluations </li></ul></ul><ul><ul><li>Meticulous operative technique </li></ul></ul><ul><ul><li>Careful monitoring of patients preoperatively </li></ul></ul><ul><li>Fever: </li></ul><ul><ul><li>1 st postop day --> atelectasis/aspiration/UTI </li></ul></ul><ul><ul><li>4 th -5 th postop --> wound infection / anastomotic leak </li></ul></ul><ul><li>Hypotension: </li></ul><ul><ul><li>Immediate --> continuous hge / depressive drugs </li></ul></ul><ul><ul><li>Later ---> sepsis </li></ul></ul>
  3. 3. Wound Complications: <ul><li>Wound dehiscence: </li></ul>
  4. 4. Wound Complications: <ul><li>Wound dehiscence: </li></ul><ul><ul><li>Separation of an abd. wound involving the anterior fascial and deeper layers </li></ul></ul><ul><ul><li>0.5 – 3.0% </li></ul></ul><ul><ul><li>Causes: </li></ul></ul><ul><ul><li>General factors: </li></ul></ul><ul><ul><ul><li>Age: < 45y/o = 1.3% > 45 y/o = 5.4% </li></ul></ul></ul><ul><ul><ul><li>Debilitated pts. w/ poor nutrition </li></ul></ul></ul><ul><ul><ul><ul><li>carcinoma, hyponatremia, obesity </li></ul></ul></ul></ul><ul><ul><ul><li>Causes of increase intra-abd. pressure </li></ul></ul></ul><ul><ul><ul><ul><li>pulmonary & urinary problem </li></ul></ul></ul></ul>
  5. 5. Wound Complications: <ul><li>Wound dehiscence: </li></ul><ul><ul><li>Causes: </li></ul></ul><ul><ul><ul><li>Local Factors: </li></ul></ul></ul><ul><ul><ul><ul><li>Hemorrhage </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Infection </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Poor technique: </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Excessive suture material </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Drain and stoma placed along incision </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Type of incision (> in vertical incision) </li></ul></ul></ul></ul><ul><ul><li>Manifestation: </li></ul></ul><ul><ul><ul><li>Sero-sanguinous drainage (pathognomonic) </li></ul></ul></ul><ul><ul><ul><li>Postoperative ventral hernia </li></ul></ul></ul>
  6. 6. Wound Complications: <ul><li>Wound dehiscence: </li></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>secondary operative procedure (if medical condition allows) </li></ul></ul></ul><ul><ul><ul><li>conservatively with an occlusive wound dressing and binder ----> postoperative hernia. </li></ul></ul></ul><ul><ul><li>Prognosis: </li></ul></ul><ul><ul><ul><li>Mortality = 0.5 – 0.3% due to pathologic conditions </li></ul></ul></ul>
  7. 7. Wound Complications: <ul><li>Wound Infection: </li></ul><ul><ul><li>Major factors: </li></ul></ul><ul><ul><ul><li>Breaks in surgical technique </li></ul></ul></ul><ul><ul><ul><li>Host parasite relationship </li></ul></ul></ul><ul><ul><li>Potential sources of contamination: </li></ul></ul><ul><ul><ul><li>Patients themselves </li></ul></ul></ul><ul><ul><ul><li>Operating room and personels </li></ul></ul></ul><ul><ul><li>Organisms: </li></ul></ul><ul><ul><ul><li>Staphylococcus aureus </li></ul></ul></ul><ul><ul><ul><li>Enteric organism (E. coli, Bacteroides, Proteus, Klebsiella, Pseudomonas) </li></ul></ul></ul>
  8. 8. Wound Complications: <ul><li>Wound Infection: </li></ul><ul><ul><li>Factors: </li></ul></ul><ul><ul><ul><li>Nature of the wound: </li></ul></ul></ul><ul><ul><ul><ul><li>Clean atraumatic and uninfected operative wound (3.3%) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>GIT / Respiratory / Urinary tract entered but w/ out unusual contamination (10.8%). </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Open, traumatic wounds w/ major break in sterile technique (16.3%) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Traumatic wound involving abscesses of perforated viscera (28.6%). </li></ul></ul></ul></ul><ul><ul><ul><li>Age </li></ul></ul></ul><ul><ul><ul><li>Presence of medical problems (diabetes/steroid tx) </li></ul></ul></ul><ul><ul><ul><li>Duration of operations and preoperative stay in the hospital </li></ul></ul></ul>
  9. 9. Postoperative Infections: (nosocomial) <ul><ul><li>Local factors: </li></ul></ul><ul><ul><ul><li>Adequacy of tissue blood supply: </li></ul></ul></ul><ul><ul><ul><ul><li>Devitalized tissues </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Dead space ----> hematoma, seroma </li></ul></ul></ul></ul><ul><ul><ul><li>Foreign bodies </li></ul></ul></ul><ul><ul><li>Systemic factors: </li></ul></ul><ul><ul><ul><li>Age: very young (neonates) and elderly </li></ul></ul></ul><ul><ul><ul><li>Obesity: poor blood supply in adipose tissue </li></ul></ul></ul><ul><ul><ul><li>Systemic illnesses: </li></ul></ul></ul><ul><ul><ul><ul><li>Malignancy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Diabetes </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hepatic cirrhosis </li></ul></ul></ul></ul><ul><ul><ul><li>Medications taken (steroids) </li></ul></ul></ul>
  10. 10. Postoperative Infections: (nosocomial) <ul><li>Pulmonary infections: </li></ul><ul><ul><li>Atelectasis </li></ul></ul><ul><ul><li>Endotracheal intubation and ventilation </li></ul></ul><ul><ul><li>Aspiration pneumonia </li></ul></ul><ul><li>Urinary tract infection: indwelling urinary catheter </li></ul><ul><ul><li>E. coli, Pseudomonas, klebsiella </li></ul></ul><ul><li>Intra-abdominal infection: abdominal abscess </li></ul><ul><ul><li>Sites: </li></ul></ul><ul><ul><ul><li>Sub-phrenic ---> most common </li></ul></ul></ul><ul><ul><ul><li>Pelvis </li></ul></ul></ul><ul><ul><ul><li>Liver </li></ul></ul></ul><ul><ul><ul><li>Lateral gutters / intestinal loop </li></ul></ul></ul><ul><ul><li>Treatment: drain ---> explor lap / needle aspiration </li></ul></ul><ul><li>Wound infection </li></ul>
  11. 11. Postoperative Pulmonary Complications <ul><li>Atelectasis: </li></ul><ul><ul><li>90% postoperative pulmonary complications </li></ul></ul><ul><ul><li>Etiology: </li></ul></ul><ul><ul><ul><li>Obstruction of the tracheobronchial airway </li></ul></ul></ul><ul><ul><ul><ul><li>Changes in bronchial secretions </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Defects in expulsion mechanism </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Reduction in bronchial caliber </li></ul></ul></ul></ul><ul><ul><ul><li>Pulmonary insufficiency (hypoventilation) </li></ul></ul></ul><ul><ul><ul><ul><li>Decrease surfactant </li></ul></ul></ul></ul>
  12. 12. Postoperative Pulmonary Complications <ul><li>Atelectasis: </li></ul><ul><ul><li>Predisposing factors: </li></ul></ul><ul><ul><ul><li>Smoking </li></ul></ul></ul><ul><ul><ul><li>Pulmonary problem (bronchitis, asthma, etc) </li></ul></ul></ul><ul><ul><ul><li>Anesthesia: </li></ul></ul></ul><ul><ul><ul><ul><li>GA - duration and depth </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Postop narcotics – depress cough reflex </li></ul></ul></ul></ul><ul><ul><ul><li>Depress cough reflex </li></ul></ul></ul><ul><ul><ul><ul><li>Chest pain </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Immobilization </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Splinting w/ bandages </li></ul></ul></ul></ul><ul><ul><ul><li>NGT – increased secretions and predisposed aspiration </li></ul></ul></ul><ul><ul><ul><li>Congestion of the bronchial walls </li></ul></ul></ul>
  13. 13. Postoperative Pulmonary Complications <ul><li>Atelectasis: </li></ul><ul><ul><li>Manifestations: </li></ul></ul><ul><ul><ul><li>1 st 24 hrs postop ----> fever, tachycardia, rales, decrease breath sound ----> persist ----> pneumonia (increase fever, dyspnea, tachycardia and cyanosis) ---> lung abscess </li></ul></ul></ul>
  14. 14. Postoperative Pulmonary Complications <ul><li>Atelectasis: </li></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><li>Preop prophylaxis: </li></ul></ul><ul><ul><ul><li>No smoking (2 wks) </li></ul></ul></ul><ul><ul><ul><li>Treatment of pulmonary problem </li></ul></ul></ul><ul><ul><li>Postop prophylaxis: </li></ul></ul><ul><ul><ul><li>Minimal use of depressant drugs </li></ul></ul></ul><ul><ul><ul><li>Prevent pain </li></ul></ul></ul><ul><ul><ul><li>Early ambulation </li></ul></ul></ul><ul><ul><ul><li>Changes body position </li></ul></ul></ul><ul><ul><ul><li>Deep breathing and coughing exercises </li></ul></ul></ul><ul><ul><li>Drugs: </li></ul></ul><ul><ul><ul><li>Expectorants </li></ul></ul></ul><ul><ul><ul><li>Mucolytic </li></ul></ul></ul><ul><ul><ul><li>bronchodilators </li></ul></ul></ul>
  15. 15. Postoperative Pulmonary Complications <ul><li>Pulmonary Aspiration: </li></ul><ul><ul><li>General anesthesia – pts are in supine position and absence of normal protective reflexes. </li></ul></ul><ul><ul><li>Increased risk: </li></ul></ul><ul><ul><ul><li>Pregnant </li></ul></ul></ul><ul><ul><ul><li>Elderly </li></ul></ul></ul><ul><ul><ul><li>Obese </li></ul></ul></ul><ul><ul><ul><li>Pts w/ bowel obstruction </li></ul></ul></ul>
  16. 16. Postoperative Pulmonary Complications <ul><li>Pulmonary Aspiration: </li></ul><ul><ul><li>Prevention: </li></ul></ul><ul><ul><ul><li>NPO 6hrs prior to surgery </li></ul></ul></ul><ul><ul><ul><li>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.) </li></ul></ul></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>Continuous mechanical ventilation </li></ul></ul></ul><ul><ul><ul><li>antibiotics </li></ul></ul></ul>
  17. 17. Postoperative Pulmonary Complications <ul><li>Pulmonary Edema: </li></ul><ul><ul><li>Etiology: </li></ul></ul><ul><ul><ul><li>Circulatory overload (infusion of fluid during operation) </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Most common cause </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Left ventricular failure (incomplete cardiac emptying) </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Due to anesthetic, narcotic or hypnotic agents w/c decrease myocardial contractility </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Decrease peripheral perfusion -----> peripheral vasoconstriction ----> cause blood to shift centrally ----> pulmonary edema </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Negative pressure in airway. </li></ul></ul></ul>
  18. 18. Postoperative Pulmonary Complications <ul><li>Pulmonary Edema: </li></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>Provide oxygen (increase inspired concentration) </li></ul></ul></ul><ul><ul><ul><li>Remove obstructing fluid (diuretics, head up or sitting position, phlebotomy, spinal anesthesia, ganglionic blocking agents) </li></ul></ul></ul><ul><ul><ul><li>Correcting the circulatory overload </li></ul></ul></ul><ul><ul><ul><li>Increase airway pressure (PEEP) </li></ul></ul></ul>
  19. 19. Postoperative Pulmonary Complications <ul><li>Respiratory Failure: </li></ul><ul><ul><li>25% of postoperative deaths </li></ul></ul><ul><ul><li>PaO2 is below 50 torr while the patient is breathing room air; PaCO2 is above 50 torr in the absence of metabolic alkalosis </li></ul></ul><ul><ul><li>Usually seen in patients who underwent operations for major trauma or who have multisystem disease. </li></ul></ul><ul><ul><li>Mechanism is unknown </li></ul></ul>
  20. 20. Postoperative Pulmonary Complications <ul><li>Respiratory Failure: </li></ul><ul><ul><li>Etiologic Factors: </li></ul></ul><ul><ul><ul><li>Sepsis </li></ul></ul></ul><ul><ul><ul><li>Massive transfusion </li></ul></ul></ul><ul><ul><ul><li>Fat embolism </li></ul></ul></ul><ul><ul><ul><li>Pancreatitis </li></ul></ul></ul><ul><ul><ul><li>Aspiration </li></ul></ul></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>Mechanical ventilation (PEEP) </li></ul></ul></ul>
  21. 21. Postoperative Shock <ul><li>Poor tissue perfusion ---> hypotension, pallor, sweating, tachycardia, oliguria, peripheral vasoconstriction ----> progressive metabolic acidosis ----> multiple organ failure ---> death. </li></ul><ul><li>Hypotension in early post-operation: </li></ul><ul><ul><li>Over sedation </li></ul></ul><ul><ul><li>Effect of anesthesia </li></ul></ul>
  22. 22. Postoperative Shock <ul><li>Categories: </li></ul><ul><li>Hypovolemia – most common </li></ul><ul><ul><li>Uncorrected volume deficit (preop, intraop, postop) </li></ul></ul><ul><ul><li>Continuing hge postop period </li></ul></ul><ul><ul><li>30-40% loss of ECV </li></ul></ul><ul><ul><li>Monitored w/ UO/hr, CVP </li></ul></ul><ul><ul><li>Crystalloid hydration / blood transfusion </li></ul></ul>
  23. 23. Postoperative Shock <ul><li>Categories: </li></ul><ul><li>Cardiogenic shock (MI / cardiac tamponade) </li></ul><ul><li>Septic shock: </li></ul><ul><ul><li>Due to gram (-) infection; nosocomial </li></ul></ul><ul><ul><li>Uro-genital infection (foley catheter) > resp. tract > integumentary </li></ul></ul>
  24. 24. Postoperative Renal Failure <ul><li>Oliguria – considered acute renal failure </li></ul><ul><li>Renal failure index: </li></ul><ul><ul><ul><li>( Urine Na x Plasma creatinine ) </li></ul></ul></ul><ul><ul><ul><li>Urine creatinine </li></ul></ul></ul><ul><ul><ul><li>< 1 usually indicates pre-renal oliguria </li></ul></ul></ul><ul><ul><ul><li>> 1 indicates acute renal failure </li></ul></ul></ul>
  25. 25. Postoperative Renal Failure <ul><li>Etiologies: </li></ul><ul><ul><li>Catheter obstruction </li></ul></ul><ul><ul><li>Pre-renal failure; </li></ul></ul><ul><ul><ul><li>Diminished circulating blood volume </li></ul></ul></ul><ul><ul><li>Acute parenchymal renal failure </li></ul></ul><ul><ul><ul><li>Fluid restriction (daily allowance 500ml plus previous 24 hrs. UO) </li></ul></ul></ul><ul><ul><ul><li>Electrolyte imbalance (hyperkalemia) </li></ul></ul></ul><ul><ul><ul><li>Hemodialysis </li></ul></ul></ul>
  26. 26. Diabetes Mellitus: <ul><li>Challenge to the surgeon for: </li></ul><ul><li>Impairment of homeostatic mechanism for glucose (ketoacidosis/hyperglycemia) </li></ul><ul><li>Associated incidence of generalized vascular disease. </li></ul><ul><li>Pathogenesis: </li></ul><ul><ul><li>Defect is decrease insulin </li></ul></ul><ul><ul><li>Hyperglycemia due to decrease utilization of peripheral tissue, increase output in the liver </li></ul></ul><ul><ul><li>Catabolism of FA (ketoacidosis) </li></ul></ul><ul><ul><li>Osmotic diuresis ---> dehydration/loss of Na and K </li></ul></ul>
  27. 27. Diabetes Mellitus: <ul><li>Effect of Anesthetic agents to CHO metabolism </li></ul><ul><ul><li>Hyperglycemia </li></ul></ul><ul><ul><li>Exaggerates the hyperglycemia epinephrine response and increase resistance to exogenous administration of insulin </li></ul></ul><ul><li>Type of anesthesia: </li></ul><ul><ul><li>Spinal anesthesia – little tendency to cause hyperglycemia </li></ul></ul><ul><ul><li>GA – (NO2, trichloroethylene, halothane) </li></ul></ul><ul><ul><li>least effect on CHO metabolism </li></ul></ul>
  28. 28. Diabetes Mellitus: <ul><li>Surgery is not done until the level is below 200md/dl </li></ul><ul><li>Ketoacidosis in frank diabetic coma ----> no surgical treatment regardless of indication </li></ul><ul><li>Treatment: </li></ul><ul><ul><li>Continuous low dose insulin </li></ul></ul><ul><ul><li>Correct fluid and electrolyte imbalance </li></ul></ul>
  29. 29. Complication of Gastrointestinal Surgery <ul><li>Vascular Complication: </li></ul><ul><li>Intestinal Obstruction: </li></ul><ul><ul><li>Mechanical Obstruction </li></ul></ul><ul><ul><li>Non-mechanical obstruction </li></ul></ul><ul><li>Anastomotic Leak </li></ul><ul><ul><li>Fistula </li></ul></ul><ul><ul><li>Peritoneal abscess ----> Peritonitis </li></ul></ul>
  30. 30. Vascular Complication: <ul><li>Hemorrhage: </li></ul><ul><ul><li>Occurs gastrointestinal anastomosis </li></ul></ul><ul><ul><li>Manifest – hematemesis, melena, hematochezia </li></ul></ul><ul><ul><li>Bleeding arise from the suture line (usually after gastric resection </li></ul></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>Ist conservative: irrigation w/ cold lavage / endoscopy </li></ul></ul></ul><ul><ul><ul><li>Reoperation – direct control </li></ul></ul></ul>
  31. 31. Vascular Complication: <ul><li>Gangrene: </li></ul><ul><ul><li>Due to poor tissue perfusion </li></ul></ul><ul><ul><li>Stomach: </li></ul></ul><ul><ul><ul><li>Following subtotal gastrectomy w/ ligation of left gastic and splenic arteries; thrombosis </li></ul></ul></ul><ul><ul><li>Small bowel and colon: </li></ul></ul><ul><ul><ul><li>Thrombosis; mechanical strangulation (internal herniation) – volvulus, adhesions </li></ul></ul></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>Resection of gangrenous segment, re-established continuity </li></ul></ul></ul>
  32. 32. Intestinal Obstruction <ul><li>Mechanical Problem: </li></ul><ul><ul><li>Intestinal Obstruction: </li></ul></ul><ul><ul><ul><li>S/Sx: </li></ul></ul></ul><ul><ul><ul><li>3 rd – 4 th postop day </li></ul></ul></ul><ul><ul><ul><li>Abdominal distention, colicky pain, increase NGT drainage, bilious material </li></ul></ul></ul>
  33. 33. Intestinal Obstruction <ul><li>Mechanical Problem: </li></ul><ul><ul><li>Intestinal Obstruction: </li></ul></ul><ul><ul><ul><li>Stomal obstruction (due to local edema) </li></ul></ul></ul><ul><ul><ul><ul><li>Causes of edema: </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Electrolyte imbalance </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Incomplete hemostasis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Hypoprotenemia </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Leakage from anastomosis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Inadequate proximal decompression </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Incorporation of too much tissue w/in the suture </li></ul></ul></ul></ul></ul>
  34. 34. Intestinal Obstruction <ul><li>Mechanical Problem: </li></ul><ul><ul><li>Other causes of intestinal obstruction </li></ul></ul><ul><ul><ul><li>Intussuception </li></ul></ul></ul><ul><ul><ul><li>Volvulus </li></ul></ul></ul><ul><ul><ul><li>Post-operative adhesion </li></ul></ul></ul><ul><ul><ul><li>Herniation </li></ul></ul></ul>
  35. 35. INTUSSUCEPTION
  36. 36. INTUSSUCEPTION
  37. 37. VOLVULOUS
  38. 38. Intestinal Obstruction <ul><li>Mechanical Problem: </li></ul><ul><li>Diagnosis: </li></ul><ul><ul><li>Flap plate of abdomen (FPA) </li></ul></ul>Small bowel obstruction Large bowel obstruction Sigmoid volvulus
  39. 39. Intestinal Obstruction <ul><li>Mechanical Problem: </li></ul><ul><li>Treatment: </li></ul><ul><ul><li>Proximal decompression (NPO / NGT) </li></ul></ul><ul><ul><li>Correct fluid and electrolyte imbalance </li></ul></ul><ul><ul><li>Hyperalimentation (TPN): </li></ul></ul><ul><ul><li>No improvement ------> re-operation </li></ul></ul>
  40. 40. Intestinal Obstruction <ul><li>Mechanical Problem: </li></ul><ul><li>Blind Loop Syndrome: </li></ul><ul><li>Afferent loops syndrome: </li></ul><ul><ul><li>Cases of Billroth gastro-enterostomy </li></ul></ul><ul><ul><li>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 </li></ul></ul>
  41. 41. Intestinal Obstruction <ul><li>Mechanical Problem: </li></ul><ul><li>Blind Loop Syndrome: </li></ul><ul><li>Treatment: </li></ul><ul><ul><li>Incomplete – conservative </li></ul></ul><ul><ul><li>Complete: re-operation and anastomosis between the afferent and efferent loops by Roux-en-Y or convert to Billroth I (gastroduodenostomy) </li></ul></ul>
  42. 42. Intestinal Obstruction <ul><li>Mechanical Problem: </li></ul><ul><ul><li>Blind Loop Syndrome: </li></ul></ul><ul><ul><li>Intestinal blind loop: </li></ul></ul><ul><ul><ul><li>Volvulus of small bowel </li></ul></ul></ul><ul><ul><ul><li>Complete large bowel obstruction w/ a competent ileocecal valve </li></ul></ul></ul><ul><ul><ul><li>Internal bowel herniation </li></ul></ul></ul>
  43. 43. Small bowel volvulous
  44. 44. Small bowel internal herniation
  45. 45. Large Bowel Obstrucion due to Ascariasis
  46. 46. Intestinal Obstruction <ul><li>Postoperative fibrous adhesion: </li></ul><ul><li>The most common cause of bowel obstuction </li></ul><ul><li>Could be partial or complete </li></ul><ul><li>Fluid and electroyte imbalance </li></ul><ul><li>Usually present a colicky abdominal pain with abdominal distention w/o bowel movement. </li></ul><ul><li>Late cases might present with silent abdomen </li></ul>
  47. 47. Intestinal Obstruction <ul><li>Treatment: </li></ul><ul><ul><li>NGT decompression, NPO, correct fluid and electrolyte imbalance </li></ul></ul><ul><ul><li>Surgical intervention – adhesiolysis w/ or w/o resection </li></ul></ul>
  48. 48. Non-mechanical intestinal obstruction: <ul><li>Ileus: </li></ul><ul><li>Physiologic / functional bowel obstruction </li></ul><ul><ul><li>Stomach --> w/in few hours </li></ul></ul><ul><ul><li>Small bowel ---> 12-36 hrs </li></ul></ul><ul><ul><li>Large bowel ---> 24-72 hrs. </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>NGT decompression </li></ul></ul><ul><ul><li>NPO </li></ul></ul><ul><ul><li>Fluid & electrolyte balance (hypo K) </li></ul></ul><ul><ul><ul><li>Metaclopromide or bethanechol </li></ul></ul></ul>
  49. 49. Anastomotic Leak: <ul><li>Etiologic factor: </li></ul><ul><ul><li>Poor surgical technique </li></ul></ul><ul><ul><li>Distal obstruction </li></ul></ul><ul><ul><li>Inadequate proximal decompression </li></ul></ul><ul><li>Can manifest as localized or generalized peritonitis </li></ul><ul><li>Treatment: </li></ul><ul><ul><li>Small leaks: </li></ul></ul><ul><ul><ul><li>Conservative w/ NPO </li></ul></ul></ul><ul><ul><ul><li>Proximal decompression </li></ul></ul></ul><ul><ul><ul><li>Antibiotic </li></ul></ul></ul><ul><ul><li>Large leaks: </li></ul></ul><ul><ul><ul><li>Surgical intervention </li></ul></ul></ul>
  50. 50. Anastomotic Leak: <ul><li>Complication: </li></ul><ul><ul><li>Fistula </li></ul></ul><ul><ul><li>Peritoneal abscess </li></ul></ul><ul><ul><li>Peritonitis </li></ul></ul><ul><ul><li>Sepsis </li></ul></ul>
  51. 51. Fistula: <ul><li>Abnormal communication between two lining epithelium </li></ul><ul><li>Etiology: </li></ul><ul><ul><li>Anastomotic leak </li></ul></ul><ul><ul><li>Poor blood supply </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Inadvertent suturing of bowel wall while closing the fascia </li></ul></ul><ul><ul><li>Carcinoma </li></ul></ul>
  52. 52. Fistula: <ul><li>Gastric and duodenal fistula: </li></ul><ul><ul><ul><li>Subtotal gastrectomy ---> gastrojejunal (tears of surrow) and duodenal stump </li></ul></ul></ul><ul><ul><ul><li>Due to suture line failure </li></ul></ul></ul>
  53. 53. Fistula: <ul><li>Gastric and duodenal fistula: </li></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>NPO / TPN </li></ul></ul></ul><ul><ul><ul><li>Place NGT past the leak and give elemental diet </li></ul></ul></ul><ul><ul><ul><li>Antibiotic </li></ul></ul></ul><ul><ul><ul><li>Majority close spontaneously w/in 6 wks </li></ul></ul></ul><ul><ul><ul><ul><li>Failure to close </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>distal obstruction </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>large leak </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Infection </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cancer </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Surgery – resect the fistula and the bowel segment then re-anastomosis </li></ul></ul></ul>
  54. 54. Fistula: <ul><li>Small bowel fistula: </li></ul><ul><ul><li>Drainage is less compared to duodenal fistula, but jejunal fistula have a poorer prognosis than ileal fistula </li></ul></ul>
  55. 55. Fistula: <ul><li>Small bowel fistula: </li></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><li>Supportive: </li></ul></ul><ul><ul><ul><li>correct fluid & electrolyte imbalance </li></ul></ul></ul><ul><ul><ul><li>Give proper nutrition </li></ul></ul></ul><ul><ul><li>Proximal jejunal fistula: - Distal feeding jejunostomy </li></ul></ul><ul><ul><li>Distal ileal fistula: - low residue diet </li></ul></ul><ul><ul><li>Control diarrhea ----> lomotil / protect the skin </li></ul></ul>
  56. 56. Fistula: <ul><li>Colonic fistula: </li></ul><ul><ul><li>Fluid & electrolyte imbalance less common but has higher infection can lead to peritonitis, peritoneal abscess and wound infection. </li></ul></ul><ul><ul><li>Skin digestion and irrigation are rare </li></ul></ul>
  57. 57. Fistula: <ul><li>Colonic fistula: </li></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><li>Nutrition (low residue or elemental diet) </li></ul></ul><ul><ul><li>Antibiotics </li></ul></ul><ul><ul><ul><li>Spontaneous healing of fistula is the rule rather than the exception </li></ul></ul></ul><ul><ul><ul><li>Medical management is generally indicated for 6 wks to permit active inflammation to subside ---> fails ----> surgery </li></ul></ul></ul><ul><ul><li>Defunctionalizing colostomies for descending colon </li></ul></ul><ul><ul><li>Ileal transverse colostomies for ascending and distal ileal fistulas </li></ul></ul><ul><ul><ul><li>If w/ generalized peritonitis do emergency resection </li></ul></ul></ul>
  58. 58. PERITONEAL ABSCESS
  59. 59. THANK YOU

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