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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 . . .
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
Immediate:
Pain
Primary
haemorrhage Shock: haemorrhagic - cardiogenic - septic Low urine output Basal atelectasis
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)
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
Post-operative fever
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
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
LUTs:
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
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
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
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
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
Abdominal pain may relate to local or generalized peritonitis, usually with sepsis
Colorectal leak
Management Unstable patient with peritonitis
Resuscitation Reoperation
CT scan/contrast enema
Subclinical leaks
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
Define the anatomy of the fistula Check the condition of the proximal and distal gut
Enterocutaneous fistula
Spontaneous closure of a post-operative fistula is likely if:
no
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