Complications of General Surgical Procedures

Fever

• causes of postoperative fever 5 Ws:

  1. wind (respiratory),

  2. water (urinary tract infection [UTI]),

  3. wound,

  4. walking (deep venous thrombosis [DVT]),

  5. wonder drugs (drug fever or pseudomembranous colitis [PMC]).

• Fever in the first 24 hours: due to

  1. atelectasis,

  2. wound infections with necrotizing fasciitis, or clostridal infection 

• In the first 72 hours:

  1. pneumonia,

  2. atelectasis,

  3. intravenous catheter related thrombophlebitis,

  4. infections

• 1 to 5 days : UTIs

• 5 days after the procedure: DVT

• 7 to 10 days after surgery : wound infection

• 6 weeks : Antibiotic-induced PMC

Respiratory Complications

• atelectasis : causes :

  • Postoperative pain,

  • splinting,

  • inadequate clearance of secretions

    symptoms :

  • Fever,

  • tachypnea,

  • tachycardia,

  • mild hypoxia .

• Pneumonia : develop 24 to 96 hours later (see Chapter 30).

• Pulmonary embolism can occur any time postoperatively (see ch 25

Genitourinary Complications

• UTIs :

  • instrumentation of the GU tract or bladder catheterization.

• urinary retention: presenting with lower abdominal pain and the inability to urinate (see Chapter 54).

  • Elderly men,

  • patients undergoing anorectal

  • prolonged operations,

  • those receiving spinal or epidural anesthesia

• Decreased urine output should raise concerns for renal failure resulting from multiple causes, particularly volume depletion (see Chapter 50).

Wound Complications

• Hematomas with pain and swelling at the surgical site result from inadequate hemostasis. A small portion of the wound may be opened to rule out infection.

• Seromas are collections of clear fluid under the wound.

• Wound infections present with pain, swelling, erythema drainage and tenderness.

• Risk factors include extremes of age, diabetes, poor nutrition, necrotic tissue, poor perfusion, foreign bodies, and hematomas.

• Necrotizing fasciitis should be considered in a systemically ill patient with rapidly expanding infection and pain out of proportion to examination (see Chapter 90).

• Superficial or deep fascial wound dehiscence can occur due to diabetes, poor nutrition, chronic steroid use, and inadequate or improper closure of the wound. Operative exploration may be required to determine the extent of dehiscence.

Vascular Complications

• Superficial thrombophlebitis manifests with erythema, warmth, and full- ness of the affected vein. It usually occurs in the upper extremities after intravenous catheter insertion or in the lower extremities due to stasis in varicosities.

• DVT most commonly occurs in the lower extremities postop- eratively (see Chapter 25)

Drug Therapy Complications

Numerous medications cause fever without associated concomitant infec- tion. Many antibiotics prescribed perioperatively can cause antibiotic- induced diarrhea. PMC, the most serious diarrheal complication, is caused by Clostridium difficile toxin. Watery or even bloody diarrhea, fever, and crampy abdominal pain are the usual complaints.

Complications of Gastrointestinal Surgery

• causes : Stimulation of the splanchnic nerves during intraabdominal surgery may lead to dysmotility and a paralytic ileus.

• After gastrointestinal surgery, small bowel tone returns to normal within 24 hours and colonic function within 3 to 5 days.

• Symptoms: Patients develop nausea, vomiting, constipation, and abdominal disten- tion and pain.

• An adynamic ileus typically resolves after bowel rest, naso- gastric suction and intravenous hydration.

• Prolonged ileus should prompt an investigation for nonneuronal causes like peritonitis, intra-abdominal abscesses, hemoperitoneum, pneumonia, sepsis, electrolyte imbalance, or medications.

• Abdominal imaging, complete blood cell count, basic meta- bolic panel, and urinalysis should be obtained.

• Occasionally, surgical inter- vention may be necessary for obstruction due to adhesions.

1. Intraabdominal abscesses are caused by

   • preoperative contamination,

   • intra- operative spillage of bowel contents

   • postoperative anastomotic leaks.

     Diag- nosis is confirmed by computed tomography or ultrasonography.

     Antibiotic therapy as well as either percutaneous or surgical drainage will be required.

2. Pancreatitis occurs especially after direct manipulation of the pancreatic duct.

   • The clinical spectrum extends from mild nausea and vomiting to severe abdominal pain and hemodynamic instability.

   • Complications like pleural effusion and severe hemorrhage may occur.

   • Serum amylase mea- surements are not specific and measurement of a lipase is more reliable.

3. Cholecystitis and biliary colic : Elderly patients are more prone to develop acalculous cholecystitis.

4. Fistulas, internal or external,

   • may result from technical complica- tions or direct bowel injury.

   • can lead to electrolyte abnormalities and require surgical consultation and possible hospitalization.

4. Anastomotic leaks occur primarily after esophageal, gastric and colonic procedures and can cause devastating consequences as a result of infection. Esophageal leaks occur within 10 days of the operation and carry very high morbidity and mortality rates.

6. Complications of bariatric surgery .

   • In the weeks after surgery, patients are at risk for leaks and bleeding.

   • Dumping syndrome is seen in gastric bypass proce- dures due to the rapid influx of hyperosmolar chyme into the small intestine resulting in fluid sequestration and hypovolemia.

   • Patients experience nausea, vomiting, epigastric discomfort, palpitations, dizziness, and some- times syncope.

   • Other complications include gastroesophageal reflux, vitamin and electrolyte deficiencies, ulcers, obstruction, gastric slippage, and band erosion.

7. Complications of laparoscopic procedures include

   • problems related to pneumoperitoneum,

   • traumatic injury from insertion of the needle and trocar,

   • retained stones after cholecystectomy.

8. Complications of transabdominal feeding tubes and percutaneous endo- scopic gastrostomy tubes include :

   • infections,

   • hemorrhage,

   • peritonitis,

   • aspiration,

   • wound dehiscence,

   • sepsis,

   • obstruction of the tube.

     Dislodged tubes should be replaced with the appropriately sized tube (same type if possible, or a temporary foley catheter).

9. Acute complications arising from stomas (ileostomy or colostomy) are usually due to technical errors of stoma placement.

   • Later complications can be from the underlying disease, such as Crohn’s disease or cancer. Isch- emia, necrosis, skin maceration, bleeding, parastomal hernia, and prolapse may be seen.

10. The most common complications of colonoscopy are hemorrhage and perforation.

    • Hemorrhage occurs typically due to polypectomy, biopsies, or mucosal lacerations or tearing.

    • Perforation may be immediately apparent or symptoms may be delayed for several hours to days.

    • Upright chest or abdominal radiographs may reveal free air but CT is most sensitive.

11. Rectal surgery complications include urinary retention (frequently after hemorrhoidectomy), constipation, prolapse, bleeding, and infections.

12. Tetanus has been known to occur in surgical wounds although, by far, this rare disease is more common after minor trauma.

DIAGNOSIS AND DIFFERENTIAL

• chest x-rays: demonstrate atelectasis, pneumonia, or pneumothorax.

• CT or ultrasound may be indicated based on the operative procedure performed.

• Patients with oliguria or anuria should be evaluated for signs of hypovo- lemia or urinary retention.

• Diagnosis of PMC is established by demonstrat- ing C difficile cytotoxin in the stool. Nevertheless, in 27% of cases, the assay may be negative.

Treatment

1. Patients with mild atelectasis and no evidence of hypoxemia may be managed as outpatients with pain control and increased deep breathing.

2. Postoperative pneumonia may be polymicrobial.Admission and antibiotic therapy to cover nosocomial infections such as Pseudomonas and methicillin-resistant Staph aureus are usually recommended (see Chapter 30).

3. Nontoxic patients with UTI can be managed as outpatients with oral antibiotic therapy geared toward appropriate organisms. Consider gram- positive flora when instrumentation has occurred. Ill-appearing patients require admission.

4. Wound hematomas may require removal of some sutures and evacuatoon. Consultation with the surgeon before treatment is appropriate. Seromas can be confirmed and treated with needle aspiration.

5. Wound Infections are often treated with oral antibiotics unless patient shows signs of systemic toxicity or carries significant comorbidities. Perineal infections are often polymicrobial requiring parenteral antibiot- ics and admission. Necrotizing fasciitis needs immediate surgical debridement and broad-spectrum parenteral antibiotics (see Chapter 90).

6. Patients with superficial thrombophlebitis may be treated as outpatients with nonsteroidal anti-inflammatory drugs (NSAIDs), local heat appli- cation and elevation. Antibiotics may be indicated if surrounding cellu- litis or lymphangitis are noted. Suppurative thrombophlebitis requires hospitalization and surgical excision.

7. Patients with suspected antibiotic-induced PMC will require fluid resuscitation and likely empiric therapy. Oral or intravenous metronidazole and oral vancomycin are treatments for this condition.