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Surgical Complications

Christopher P. Michetti, MD, FACSAssistant Professor of SurgeryInova CampusVCU School of Medicine

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Introduction

How to define “complication”?– Webster: a secondary disease or condition

developing in the course of a primary disease or condition

– Any deviation from the normal course of recovery after surgery

– Any adverse event in recovery that results in a suboptimal outcome

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Introduction

Why is this important?– Recognition & management– Prevention– Obtaining informed consent

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Goals

How to think about complications:

PREVENTABLE

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GoalsHow to recognize (vs. diagnose) complications

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Background: local review

Surgical Morbidity & Mortality conference

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Background: national level

Institute of Medicine reports44,000 - 98,000 preventable deaths each year

1999 2001

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Background

Institute for Healthcare Improvement (IHI) “save 100,000 lives” campaignApplying “best practices” to hospitals across the countryResearch shows many proven best practices are ignored or unknown

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Topics

WoundsPulmonaryGastrointestinalBiliaryHematological

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Wound

Infection – Surgical Site Infection

DehiscenceIncisional herniaHematomaSeroma

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Surgical Site Infection (SSI)CDC definitions:Superficial incisional SSI– involves only skin and subcutaneous tissue

Deep incisional SSI– involves deep soft tissue (muscle & fascia)

Organ/space SSI– involves areas other than the incision that

are opened or manipulated during surgery (e.g. abdominal/pleural cavity)

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Surgical Site Infection (SSI)Superficial Incisional SSI– Occurs within 30 days of surgery AND– Involves only skin or subcutaneous tissue of the

incision– and 1 of the following

• Purulent drainage +/- culture• Organisms isolated from an aseptically

obtained culture of fluid or tissue from the superficial incision

• pain,tenderness,localized swelling,redness,or heat AND the wound is opened by the surgeon

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Risk Factors forSurgical Site Infection (SSI)

Patient related factors– old age – severity of disease – physical-status (ASA classification) – morbid obesity– malnutrition– immunosuppression – smoking– coexistent infection at a remote body site

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Risk Factors forSurgical Site Infection (SSI)

Operative factors– method of hair removal– inappropriate use of antimicrobial prophylaxis

• timing, duration– duration of operation– hand scrubbing & site prepping techniques– wound classification

• clean, clean-contaminated, contaminated, dirty– intraoperative blood transfusion– use of drains– surgical techniques

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SSI - Prevention

Use prophylactic antibiotics for clean - contaminated or contaminated casesGive antibiotics within 2 hours of incision to achieve tissue levelsDo not continue antibiotics > 24 hours

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SSI - Prevention

Avoid shaving• if necessary use clippers not razors

Avoid transfusionAvoid hypothermiaAvoid hyperglycemiaUse appropriate hand and operative site antisepsis

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SSI - PresentationRubor– Erythema

Calor– Wound warm to the touch

Dolor– Subjective (pain) & objective (tenderness)

FeverPurulent drainage

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SSI - TreatmentIncisional infections or abscesses are treated by opening the wound and healing by secondary intentionAntibiotics NOT indicated for incisional infections except with: – Cellulitis– Systemic infection– Prosthetic material

Treatment for any abscess (except lung and brain) begins with drainage

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Wound DehiscenceDefinition– Separation of fascial layer of abdomen in

the early postoperative period– with or without evisceration

2% of abdominal operationsEtiology– technical error +/- other factors

Prevention– proper technique and preoperative

preparation20

Wound Dehiscence

Contributing factors– increased intraabdominal pressure or

tension– elderly– chronic diseases– malnutrition– drugs (steroids, chemotherapy)– wound factors (hematoma, infection,

ischemic tissue)

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Wound DehiscencePresentation– classic acute

serosanguinous drainage

– palpable fascial defect– evisceration

Treatment– return to OR for closure

+/- retention sutures– search for cause Dehiscence with

evisceration

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Incisional HerniaDefinition– Separation of fascia under healed skin incision– ~11% of midline abdominal incisions

• increased risk with dehiscence, infection, reoperation, smoking, emergent laparotomy

Etiology– poor healing or disruption of fascia

Prevention– good technique, low tension closure, avoid

straining or high intraabdominal pressure

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Incisional Hernia

Presentation– range: asymptomatic to

strangulated– palpable defect (unless

obese)Treatment– surgical repair– underlay synthetic mesh,

biologic tissue options– primary closure less effective

Fat-containing ventral incisional hernia on CT scan

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Wound Hematoma

Definition– Collection of blood in a wound cavity

Prevention– reversal of anticoagulants prior to surgery– meticulous intraoperative hemostasis– approximation of wound dead space– temporary placement of drains in select

cases

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Wound Hematoma

Presentation– pain, tenderness, swelling in wound– oozing of dark or old blood from wound

Treatment– based on location and timing– open drainage– percutaneous aspiration or drainage– observation

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Wound Seroma

Definition– collection of serum/lymph in wound cavity

Etiology– disruption of tissue lymphatics

Prevention– approximation of wound dead space– temporary placement of drains in select

cases

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Wound Seroma

Presentation– pain, tenderness, swelling, serous oozing– no erythema or warmth

Treatment– aspiration– observation

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Pulmonary Complications

AtelectasisAspirationPneumoniaALI/ARDS

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AtelectasisDefinition– area of collapsed, nonaerated alveoli– remains perfused = shunt– colonization of retained mucous

• may lead to pneumonia– most common pulmonary complication

Etiology– alveolar collapse, usually in dependent segments,

from decreased lung expansion or accumulation of secretions

– decreased cough, sigh; low Vt30

AtelectasisPresentation:asymptomatic

dyspnealocalized decreased breath soundsfever (association vs. cause/effect)localized opacity on CXR, usually at bases

Basilar atelectasis

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Atelectasis

Prevention– good pulmonary

toiletTreatment– good pulmonary

toilet, chest PT, IPPB

– bronchoscopy for lobar collapse + hypoxemia

Collapsed right upper lobe 32

Aspiration

Definition– entry of gastric or oropharyngeal fluids into

the airwaysEtiology– normal occult event in everyone– increased risk with induction of anesthesia,

mechanical ventilation, supine position, sedation/obtundation, nasogastric tube

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Aspiration

Prevention– early NGT removal– elevate HOB >30o esp. if intubated– precautions during anesthesia induction

Presentation– occult respiratory distress– dyspnea, hypoxemia, recent vomiting– inflammatory response: fever, leukocytosis

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Aspiration

Diagnosis– clinical– infiltrate on CXR (RML common)

Treatment– supportive– empiric or prophylactic antibiotics not

indicated

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Pneumonia

Definition– inflammation, infection, & consolidation

Etiology– postop pneumonia: HAP or VAP– bacterial (usually) contamination of lower

respiratory tract, from aspiration, overgrowth of colonized secretions, or hematogenous seeding

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PneumoniaPrevention– aspiration precautions– deep breathing exercises– incentive spirometry– coughing– avoiding supine position– early ambulation– CPAP / BIPAP / IPPB– avoid inappropriate antibiotic use– avoid unnecessary transfusions– avoid hyperglycemia

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PneumoniaPresentation & Diagnosis– CDC criteria

• fever• leukocytosis• purulent secretions

or + sputum culture• new infiltrate on CXR• increased oxygen

needs– Lower respiratory tract

sampling: • BAL & PSB Right lower lobe infiltrate

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PneumoniaTreatment– antibiotics

• early treatment decreases mortality• must cover suspected pathogens

adequately• narrow ABX when specific bacteria

isolated– pulmonary toilet– optimize nutrition: enteral feeding

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ALI / ARDSDefinition– Syndrome of lung cellular injury and

inflammation, characterized by hypoxemia, shunting, decreased compliance, edema, and alveolar damage

– heterogeneous patternEtiology– acute event that incites inflammatory

cascade• e.g. sepsis, trauma, pancreatitis, major

surgery, multiple transfusions, infection40

ALI / ARDS

Diagnosis:pO2/FIO2 ratio <300/<200bilateral patchy, fluffy infiltratesPCWP < 18, or no clinical signs of CHF

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ALI / ARDS

Prevention– not totally preventable– adequate resuscitation and treatment of

shock, sepsisTreatment– treat underlying inflammatory source– supportive; mechanical ventilation– ventilation strategies focused on avoiding

further alveolar damage42

Abdominal Complications

IleusAnastomotic LeakFistulaStress GastritisAbdominal Compartment Syndrome

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IleusDefinition– Absence of bowel motility

Common Etiologies– Abdominal surgery– Opioids– Electrolyte abnormalities– Nitrous oxide anesthesia– Intra- or retroperitoneal hematoma– Lower spine surgery– Diabetic neuropathy (gastroparesis)

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IleusPresentation– Abdominal distention– Vomiting– Obstipation– Minimal abd tenderness– Abdominal xrays

• Dilated, air-filled sm bowel ( )

• Air present in distal colon ( )

Abdominal xray with ileus

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Ileus

Prevention– Decrease bowel manipulation– Avoid overexposure of bowel to air– Avoid intraoperative bowel trauma– Quick weaning of narcotics postoperatively– Use of epidural anesthesia– Laparoscopic vs. open surgery

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IleusTreatment– Bowel rest– NPO– Avoid dehydration– Correct electrolyte abnormalities

Sequence of return of motility– Small bowel (minutes to days) – stomach (2-3 days) – colon (3-5 days)

• Flatus = resolution of ileus

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Anastomotic LeakEtiology – Ischemia / poor blood supply– Tension– Bleeding at anastomotic site– Technical error– Poor nutrition/steroids/poor health

Presentation– Subtle: fever, abdominal pain, ileus– Overt: dehiscence, sepsis, pneumoperitoneum,

peri-anastomotic abscess48

Anastomotic LeakPrevention– Ensure good blood supply– Tension-free– Meticulous hemostasis– Treat malnutrition

Treatment Options– Usually takedown of anastomosis, creation of

ostomy– Diversion of fecal stream– Percutaneous abscess drainage, TPN

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FistulasDefinition– abnormal communication between two

organs, two cavities, or between an internal organ and the outside surface

– internal or external– enteric– biliary– pancreatic– other

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FistulasEtiology– surgery: anastomotic

leak, bowel injury– erosion:

inflammation, infection, Crohn’s

– trauma– intentional drainage

to outside • controlled fistula Enterocutaneous fistula

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Fistulas: PresentationSigns of infection/inflammation Enteric – enteric drainage into wound or drain,

intraabdominal abscessBiliary– bile leak, bile peritonitis, high serum

bilirubin, external bile leakagePancreatic– fluid leak into drain for >7 days, or body

cavity, pseudocyst, high serum amylase52

Fistulas: Treatment

Most biliary & pancreatic close with time, proper drainageProximal enteric may require bowel rest and parenteral nutrition; hydration, electrolyte replacementDistal enteric may require diversion of stool, ostomy formation

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Principles of Fistula Management

Determine anatomy of fistulaDetermine and treat causeControl infectionMaintain hydration, nutrition, and electrolyte balance

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Non-healing Fistulas

F foreign bodyR radiationI infectionE epithelializationN neoplasmD distal obstructionS short tracts

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Stress GastritisDefinition– Gastric mucosal breakdown resulting in

occult or clinically apparent bleedingEtiology– Hypoperfusion ischemia– Occurs only in critically ill patients on

mechanical ventilation, in shock, sepsis, severe coagulopathy

– NOT from hyperacidity– NOT from being NPO

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Stress Gastritis

Prevention– Treat shock & optimize gut perfusion– Enteric feeds early– Tube feeding or Sucralfate or H2 blockers

or Proton pump inhibitors– Prophylaxis not needed in non-critically ill

Treatment– See GI bleeding lecture

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Abdominal Compartment Syndrome

Definition– Pathologic increase in intra-abdominal

pressure causing decreased venous return to heart, decreased visceral perfusion, & increased upward pressure on diaphragm

Etiology– Reperfusion of gut after ischemia– Massive 3rd spacing & bowel edema after

resuscitation58

Abdominal Compartment SyndromePresentation– tense distended

abdomen– cardiac output– oliguria– airway pressures– hypoventilation– abd (bladder)

pressureTreatment– Decompression of

abdomen

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BiliaryBile Duct InjuryBile Leak

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Bile Duct InjuryRare but major complication of cholecystectomy and laparoscopic surgery#1 cause for litigation in GI surgeryEtiology– Most from misidentification

• cystic duct as common duct, or aberrant bile duct as cystic duct

– Common Bile Duct injured, cut, clipped, or transected

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Bile Duct InjuryIncidence– 0.25% or 1/400

laparoscopic cholecystectomies

Prevention– meticulous dissection to

identify cystic duct– cholangiogram to show

anatomy if uncertain, or with severe inflammation

– may occur even in optimal conditions

CD

CBDCHD

Transection of CBD, mistaken for CD

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Bile Duct InjuryPresentation– Immediately recognized in OR– Delayed recognition / Post op

• bile leak: RUQ pain, shoulder pain, increasing bilirubin (reabsorption), jaundice, fever, RUQ fluid collection

• biliary obstruction: RUQ pain, increasing bilirubin (obstruction), jaundice, fever

• common duct stricture: obstructive symptoms, late presentation

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TreatmentIf recognized immediately in OR– T-tube or

hepatojejunostomy– never direct repair or

end-to-end anastomosis

If recognized late– hepatojejunostomy

Bile Duct Injury

Roux-en-Y hepatojejunostomy to

CHD bifurcation64

Bile Leak

Definition– leak of bile into peritoneal cavity after

biliary surgery – localized (biloma) or diffuse

Etiology– gallbladder bed in liver (ducts of Luschka) – cystic duct stump (slipped tie or clip)– CBD or CHD injury (less common)

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Bile LeakPresentation– RUQ pain, shoulder pain, increasing

bilirubin (reabsorption), jaundice, fever, RUQ fluid collection (ultrasound)

Treatment– percutaneous drainage of localized

collections• vast majority heal with drainage & time

– ERCP with CBD stent• for cystic duct stump leaks

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Hemostasis & Perioperative Bleeding

Following slides review:– preoperative– intraoperative– postoperative

assessment of bleeding and hemostasis

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Hemostasis:Preoperative evaluation

H&P better than labsDefects in 1° hemostasis (platelet plug)– excessive oozing from cuts, mucosa; easy

bruisingDefects in 2° hemostasis (coagulation proteins)– hemarthrosis, intramuscular hematomas

Medication history importantRoutine pre-op coagulation tests not indicatedBleeding Time: insensitive, nonspecific, may not predict intraoperative bleeding

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Hemoactive Drugs

CoagulationCascadeheparinwarfarin low molecular weight heparin

lepirudinantithrombin IIIargatrobanfondaparinux

Plateletsaspirinibuprofentirofiban (Aggrastat)anagrelide (Agrylin)dipyridamole(Persantine)eptifibatide (Integrelin)clopidrogel (Plavix)cilostazol (Pletal)abciximab (Reopro)ticlopidine (Ticlid)

Fibrin/Thrombinurokinasestreptokinasealteplase/ tPAretaplase (Retavase)tenectaplase (TNKase)anistreplase (Eminase)bivalirudin (Angiomax)

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Hemostasis:Intraoperative evaluation

Surgical (mechanical) bleeding– visible vessel or gross tissue bleeding– tie, suture, or clamp

Nonsurgical (microvascular) bleeding– clinical diagnosis: diffuse oozing from all

cut or injured surfaces– “nothing to tie”– 1o causes: hypothermia, thrombocytopenia

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Hemostasis:Postoperative evaluation

History– review op note for exact procedure– review pre/intra/postop medications– review medical history

Examination: find source– check wounds, drains– multiple sites oozing or localized?– Loss of surgical hemostasis vs.

coagulopathy

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Hemostasis:Intraoperative evaluation

Loss of surgical hemostasis– bleeding from operative site– slipped ligature, inadequate hemostasis, etc.– usually requires reoperation– Dx: signs of hypovolemia, blood in drains

Nonsurgical bleeding / coagulopathy– failure of primary hemostasis– failure of secondary hemostasis

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Hypothermia

Slows coagulation enzyme reactions– abnormal clotting at 34°– lab PT/PTT done at 37°

Causes platelet dysfunction– decreases TXA production

room temp fluid and cold PRBCs can significantly drop core body temp

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Approach to Patients with Bleeding

Ongoing Bleeding

Surgical bleeding Nonsurgical bleeding

Early signs of shock?Blood in drain,

tubes, or wound?

Control source

H&P, draw labsHemoactive drugs?Bleeding disorder?

See next slide

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Approach to Patients with Bleeding

Nonsurgical Bleeding

Assessplatelets &

coagulation status

Temp normal Temp low

Warm patient

Still bleeding

Bleedingstops

next slide

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Approach to Patients with Bleeding

Platelet count, INR/PTT, TEG

Plt function test

10 Hemostaticproblem

20 Hemostaticproblem

Quantitativedefect

Qualitativedefect

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Quantitative Platelet Defect: Thrombocytopenia

Low = < 100,000/mm3 inc. risk of bleeding after surgery or injury from 50,000 - 100,000spontaneous bleeding <10,000transfuse for:– <100,000 with active bleeding– <50,000 if surgery/intervention planned– <10,000 absolute count

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Quantitative Platelet Defect: Thrombocytopenia

Platelets <100K

Decreasedproduction

Increasedconsumption Dilution Immune

mechanism

Malignancy,chemotherapy

Sepsis, DIC,TTP,

hypersplenism

Massivetransfusion

Drugs(heparin, H2

blockers)

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Qualitative Platelet Defect

Hypothermia - warm patientDrugs - stop responsible drugsRenal Failure - DDAVP?Congenital disease– vWD: DDAVP, F8 concentrate,

cryoprecipitate (last choice)• depends on type of vWD• DDAVP harmful in type 2

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Secondary Hemostatic Defect

normal INRhigh PTT

high INRnormal PTT

high INRhigh PTT

Heparinfactor deficiency

vWD

warfarinhepatic failure

vit. K deficiency

ProtamineFactors

vWD therapy

FFPvitamin K

Correct cause ofDIC, give FFP

D-dimer high: DICD-dimer normal:

renal failure, multi-factor deficiency

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SummarySurgical complications are often, but not always, preventablePatients must be thoroughly informed about the possibility of all common and serious complications before surgeryPrioritizing patient safety and practicing evidence-based medicine can minimize incidence of complicationsDevelop skills to recognize complications early