1. SURGICAL COMPLICATIONS
James Taclin C. Banez, MD, FPSGS, FPCS

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:
1st postop day --> atelectasis/aspiration/UTI
4th-5th postop --> wound infection /
anastomotic leak
Hypotension:
Immediate --> continuous hge / depressive drugs
Later ---> sepsis

3. 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% = 5.4%
Debilitated pts. w/ poor nutrition
carcinoma, hyponatremia, obesity
Causes of increase intra-abd. pressure
pulmonary & urinary problem

4. Wound Complications: Wound dehiscence: Causes: Manifestation:
Local Factors:
Hemorrhage
Infection
Poor technique:
Excessive suture material
Drain and stoma placed along incision
Type of incision (> in vertical insicion)
Manifestation:
Sero-sanguinous drainage (pathognomonic)
Postoperative ventral hernia

5. Wound Complications: Wound dehiscence: Treatment: Prognosis:
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

6. 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)

7. 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

8. 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)

9. 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

10. 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

11. 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

12. Postoperative Pulmonary Complications
Atelectasis:
Manifestations:
1st 24 hrs postop ----> fever, tachycardia, rales, decrease breath sound ----> persist ----> pneumonia (increase fever, dyspnea, tachycardia and cyanosis) ---> lung abscess

13. 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

14. 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

15. 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.
Treatment:
Continuous mechanical ventilation
antibiotics

16. 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.

17. 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)

18. 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

19. 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)

20. 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

21. 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

22. Postoperative Shock Categories:
Cardiogenic shock (MI / cardiac tamponade)
Septic shock:
Due to gram (-) infection; nosocomial
Uro-genital infection (foley catheter) > resp. tract > integumentary

23. Postoperative Renal Failure
Oliguria – considered acute 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

24. Diabetes Mellitus: Challenge to the surgeon for:
Impairment of homeostatic mechanism for glucose (ketoacidosis/hypoglycemia)
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

25. 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

26. 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

27. Complication of Gastrointestinal Surgery
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

28. Complication of Gastrointestinal Surgery
Vascular Complication:
Gangrene:
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

29. Complication of Gastrointestinal Surgery
Mechanical Problem:
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

30. Complication of Gastrointestinal Surgery
Mechanical Problem:
Other causes:
Intussuception
Volvulus
Post-operative adhesion
Herniation
S/Sx:
3rd – 4th postop day
Abdominal distention, pain, increase NGT drainage, bilious material

31. Complication of Gastrointestinal Surgery
Mechanical Problem:
Diagnosis:
Flap plate of abdomen (FPA)
Large bowel obstruction
Sigmoid volvulus
Small bowel obstruction

32. Complication of Gastrointestinal Surgery
Mechanical Problem:
Treatment:
Proximal decompression (NPO / NGT)
Correct fluid and electrolyte imbalance
Hyperalimentation (TPN):
No improvement > re-operation

33. Complication of Gastrointestinal Surgery
Mechanical Problem:
Blind Loop Syndrome:
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
Treatment:
Incomplete – conservative
Complete: re-operation and anastomosis between the afferent and efferent loops by Roux-en-Y or convert to Billroth I (gastroduodenostomy)

34. Complication of Gastrointestinal Surgery
Mechanical Problem:
Blind Loop Syndrome:
Intestinal blind loop:
Volvulus of small bowel
Complete large bowel obstruction w/ a competent ileocecal valve
Internal bowel herniation

35. Complication of Gastrointestinal Surgery
Mechanical Problem:
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
Treatment:
NGT decompression, NPO, correct fluid and electrolyte imbalance
Surgical intervention – adhesiolysis w/ or w/o resection

36. Complication of Gastrointestinal Surgery
Non-mechanical intestinal obstruction:
Ileus:
Physiologic/functional bowel obstruction
Stomach --> w/in few hours
Small bowel ---> hrs
Large bowel ---> hrs.
Treatment:
NGT decompression
NPO
Fluid & electrolyte balance (hypo K)
Metaclopromide or bethanechol

37. Complication of Gastrointestinal Surgery
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

38. Complication of Gastrointestinal Surgery
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

39. Complication of Gastrointestinal Surgery
Fistula:
Gastric and duodenal fistula:
Subtotal gastrectomy ---> gastrojejunal (tears of surrow) and duodenal stump
Due to suture line failure
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

40. Complication of Gastrointestinal Surgery
Fistula:
Small bowel fistula:
Drainage is less compared to duodenal fistula, but jejunal fistula have a poorer prognosis than ileal 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

41. Complication of Gastrointestinal Surgery
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

42. Complication of Gastrointestinal Surgery
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

43. THANK YOU