Surgical complications

Post-operative fever

• Five W’s: Wind (atelectasis, pneumonia), water (UTI), wound, walking (DVT) and wonder drugs (drug fever and pseudomembranous colitis)
• Atelectasis and thrombophlebitis predominate in first 72 hours
  • Necrotising streptococcal and clostridial infection also occur early
• UTI 1-5 days post-op
• Wound infection – 7-10 days post-op
• DVT usually after 5 days
• Pseudomembranous colitis can occur up to 6 weeks post-op
• Need thorough septic screen and close examination of all potential sites of infection
  • If source identified: Admit and treat
  • If no source identified: Admit, observe, change all lines and cease any medication that could be causing drug fever

Atelectasis

• Contributing factors: Inadequate clearance of secretions after GA, decreased intra-alveolar pressure, post-operative pain
• Usually most pronounced after upper abdominal and thoracic surgery
• May cause isolated fever, tachypnoea, dyspnoea and tachycardia
• Admission warranted for debilitated patients, underlying lung disease, hypoxaemia, hypercarbia or diagnosis not certain

Pneumonia

• 24-96 hours post-op usually
• Usually polymicrobial

Pneumothorax

• Can occur following thoracic wall surgery, breast biopsy, laparoscopic abdominal surgery, abdominal paracentesis, NG and feeding tube insertion, thoracic surgery, CVL insertion, endoscopic procedures, shoulder arthroscopy and tracheostomy

PE

• Can occur anytime

Urinary retention

• Due to catecholamine stimulation of alpha-receptors in bladder neck  and urethral smooth muscle
• Increased incidence in elderly men, excessive fluid administration, anorectal surgery, procedures >2 hours, spinal or epidural use
• Can drain quickly and no evidence of haematuria, post-obstructive diuresis or hypotension in this situation
• If normal renal function and no anatomical obstruction, continued catheter drainage is not necessary
• If post-GU surgery, d/w Urology first
• Can give antibiotics if genitourinary tract had been instrumented, if retention is prolonged or if patient is at risk of infection

Wound complications

• Haematoma
  • May be febrile and have sanguinous or serous discharge
  • A few sutures can be removed to allow wound to drain and take cultures
  • If no evidence of infection and haemostasis able to be maintained, can discharge after notification to treating surgeon
  • If in neck or have undergone vascular surgery – extreme caution and consultation warranted
• Seromas
  • Usually due to inadequate lymphatic control during dissection
  • Can occur under split-thickness skin grafts and in large dead spaces e.g. axillae, groin, neck, pelvis
  • Aspiration confirms the diagnosis and alleviates the problem but may need to be repeated

Wound complications

• Infection
  • Local factors e.g. necrotic tissue, poor perfusion, foreign bodies are of greatest significance vs. systemic factors
  • If remote infected source e.g. UTI, wound infection is often from the same organism
  • If operation involved GU/pulmonary/alimentary tract, infection is far more likely
  • If wound not associated with these or perineum – cover Staph/Strep and may consider outpatient care
  • Wounds associated with the perineum or associated with the GI or biliary tract are often polymicrobial and warrant cover for Gram-negative and anaerobes in addition to Staph/Strep – need admission and IV empirical broad-spec

Wound complications

• Necrotising fasciitis
  • Usually direct contamination of wound with GAS or Staph
  • Mixed aerobic and anaerobic infection can occur
  • Risk factors – DM, alcoholism, immunosuppression, PVD
  • CT may show fascial thickening, gas tracking or local fluid collection
  • MRI is sensitive but not specific
  • Marked systemic toxicity and pain out of proportion are typical
  • Deep pain with patchy surface hyperaesthesia +- crepitation/bullae
  • Treatment – Triple Ab’s and surgical debridement

Wound complications

• Wound dehiscence
  • May be due to inadequate closure or host factors such as malnutrition, immunosuppression, glucocorticoids or diabetes
  • If evisceration of abdominal dehiscence is not apparent, abdominal binders may be effective
  • If any uncertainy of depth, surgical exploration is required

Vascular complications

• Superficial thrombophlebitis
  • Usually secondary to stasis in varicose veins
  • Usually aseptic
  • If no evidence of cellulitis/lymphangitis or DVT on USS – Treatment is local heat, elevation and NSAID’s
  • Suppurative superficial lymphangitis is characterised by erythema, palpable tender cord, lymphangititis and pain warranting excision of affected vein
• DVT
  • Should repeat doppler USS if negative initial scan and high-risk within 3 days or sooner if symptoms worsen

Intestinal obstruction

• Ileus
  • Functional obstruction due to stimulation of splanchnic nerves with neuronal inhibition of coordination intrinsic bowel wall motor activity
  • Expected after any intraperitoneal surgery
  • Small bowel tone returns to normal within 24 hours, and colonic within 3-5 days
  • Prolonged ileus is seen in peritonitis, intra-abdominal abscess, haemoperitoneum, pneumonia, electrolyte disturbance, sepsis and medications

Intra-abdominal abscess

• Usually due to preoperative contamination, spillage of bowel contents during surgery, contamination of a haematoma or post-operative anastamotic leaks
• Obtain CT or USS and administer triples
• Percutaneous drainage or surgical exploration are warranted

Pancreatitis

• Secondary to direct manipulation or retraction of the pancreatic duct
• Usually seen after gastric resection, biliary tract surgery, ERCP
• Treatment is as for non-operative pancreattis

Cholecystitis

• Post-operative biliary colic, acute calculous cholecystitis and acalculous cholecystitis can all occur
• USS studies are warranted but cause often not clear
• Early diagnosis of acalculous cholecystitis is critical as early operative intervention can reduce morbitidy and mortality

Tetanus

• C. tetani found in GI tract of 1% of population
• During GI surgery, spillage of C. tetani can result in proliferation around devitalised tissue
• Incubation can be 0-73 days with subsequent fever, non-specific abdominal discomfort, abdominal wall rigidity as+- clinical tetanus including trismus, opisthotonos

Anastomotic leaks

• Mostly after oesophageal and colonic operations (single circular muscle layer to support sutures, less vigorous blood supply, lots of bacteria)
• Mainly related to surgical technique
• Intrathoracic oesophageal leaks
  • Manifest within 10 days of surgery with fever, chest pain, tachypnoea, tachycardia +- shock
  • CXR may show pneumothorax with pleural effusion
  • Can confirm with oesophageal contrast imaging
  • Very high morbidity and mortality rates
• Colonic leaks
  • Usually 7-14 days post-operatively with fever and abdominal pain

Bariatric surgery patients

• Restrictive operations
  • Vertical banded gastroplasty (stomach stapling)
  • Laparoscopic adjustable gastric banding
• Primarily malabsorptive; mildly restrictive
  • Biliopancreatic diversion
  • Duodenal switch
• Primarily restrictive; mildly malabsorptive
  • Roux-en-Y gastric bypass

Biliopancreatic diversion with duodenal switch

Roux-en-Y

Complications of bariatric surgery

• Post-operative complications are common (although overall mortality <2%) and likely related to surgical skill
• Gastroplasty
  • Staple breakdown – sudden intolerance to food or GORD
• Banding
  • Band slippage – sudden intolerance to food or GORD
  • Obstruction or erosion
• Malabsorptive procedures
  • Diarrhoea and/or vitamin/protein deficiencies

Specific complications of Roux-en-Y

• Bowel obstruction (internal hernia and volvulus of Roux limb)
  • EMERGENCY as distension of biliopancreatic limb and distal stomach can result in gastric rupture and peritonitis
  • Bilious emesis is pathognomic for common channel obstruction requiring immediate surgical intervention
• Cholelithiasis
  • Increased gallstone formation in period of rapid weight loss
• Dumping syndrome
  • Rapid postprandial gastric emptying with release of gastric hormones and splanchnic vasodilation
  • Early dumping (30-60min):
    • Hyperosmolar food results in fluid shifts into the bowel with hypotension and sympathetic nervous system response, colicky abdominal pain, diarrhoea, nausea, sweating and tachycardia.
    • Avoid high simple sugar foods and replace with complex carbohydrates, high fibre and protein-rich foods.
    • Small, frequent meals and separating solids and liquids by 30 minutes also helps.
    • Usually self-limited and resolves within 7-12 weeks.
  • Late dumping (1-3hrs after meals):
    • aka Postprandial hyperinsulinaemic hypoglycaemia (PHH)
    • 0.1-0.3% of patients, most commonly after Roux-en-Y
    • Dizziness, fatigue, diaphoresis, weakness
    • Often starts months to years after bypass surgery
    • Usually associated with documented hypoglycaemia
    • Thought to be due to alterations in glycaemic hormons e.g. incretin levels
    • Manage with same dietary modifications (avoid simple sugars, promote complex carbs/protein-rich/fibre-rich foods with small meals often.
    • Hyperinsulinaemic and hypoglycaemic state
  • SC octreotide may be an option

Complications of Roux-En-Y

• Enteric leak
  • Clinical presentation varies widely. Usually gastrojejunostomy anastamotic leaks with sepsis
  • CT may show extravasation of oral contrast
• Marginal ulcer
• Metabolic complications (B12, iron, thiamine, hyperoxaluria)
• Stenosis of gastrojejunostomy site

Bariatric surgery complications

• Anastomotic leak – 0-28 days: Tachycardia, fever, abdo pain, nausea, vomiting. CT scan warranted
• Intra-abdominal bleeding
  • 0-28 days: Tachycardia, abdo pain, hypotension. CT scan warranted
• Intraluminal bleeding – Urgent endoscopy
• Bowel obstruction – 1 week to 8 months. CT
• Cholelithiasis/cholecystitis – Months to years
• Wernicke’s encephalopathy must be considered in any bariatric surgery patient with confusion, memory disturbance, cerebellar signs, ophthalmoplegia and weakness

Non-bariatric gastric surgery

• Partial or complete gastrectomy
  • Dumping syndrome
  • Alkaline reflux gastritis
  • Afferent loop syndrome
    • Severe epigastric pain 1-2 hours after eating, relieved by vomiting
    • Vomitus is bilious without food
  • Post-vagotomy diarrhoea
    • Increased bowel movement not associated with food intake
    • Often unpredictable, explosive and can lead to weight loss, malnutrition and social anxiety
    • Treatment is symptomatic and usually improves with time

Laparoscopy

• Complications of cholecystectomy
  • Bile leak
    • If peritonitic early after operation – CT and surgical input
    • May require repair or conservative approach with percutaneous drain of small collection
    • ERCP can confirm site of leakage
  • Bile duct stricture
    • ERCP usually required and can attempt stenting first +- surgical repair
  • Bleeding
  • Bowel injury
  • Intra-abdominal abscess
  • MI

Laparoscopy

• Complications of cholecystectomy
  • Pancreatitis
  • Peritonitis
  • Retained common duct stones or stoned spilled into peritoneum
    • USS may show dilated CBD or CT may show intra-abdominal collection. ERCP can confirm and treat
    • Stones spilled can lead to abdominal pain, pelvic pain, dysmenorrhoea, intra-abdominal abscess, colocutaneous fistula and implantation into ovary with infertility
  • Splenic injury
  • Umbilical hernia
  • Wound infection

Stomas

• Complications
  • Crohn’s disease or carcinoma at stomal site
  • Stomal ischaemia and necrosis
    • Seen early with inadequate blood supply
    • Needs surgical evaluation
  • Peristomal skin irritation
    • Usually due to poor seal of stomal appliance. Get stomal nurse involvement
  • Peristomal herniation
    • Due to too large an abdominal wall opening. Assess for incarceration, reduce if able and ultimately requires revision
  • Stomal prolapse
    • Usually inadequate stomal fixation of intra-abdominal portion or too large an abdominal wall opening
    • If looks healthy, can attempt reduction and then surgical referral
    • Definitive therapy is stomal revision

Colonoscopy

• Complications
  • Haemorrhage – May be intraluminal or intraperitoneal
  • Perforation
    • If presenting after 1-2 days and appear well, can manage conservatively – otherwise laparotomy
  • Retroperitoneal abscess
  • Pneumoscrotum
  • Pneumothorax
  • Volvulus
  • Post-colonoscopy distension
  • Splenic rupture
  • Appendicitis
  • Bacteraemia

Rectal surgery

• Management of constipation is the same as for any other patient
• Delayed bleeding after haemorrhoidectomy can be caused by sepsis of the pedicle, disruption of clot, sloughing of tissue
• Temporary balloon tamponade with Foley can temporise bleeding until surgical ligation
• Rectal prolapse may occur due to damage to puborectalis muscle. Requires reduction and surgical consultation
• Infection is surprisingly uncommon
• Fournier’s gangrene can occur and if suspicious requires triples and immediate surgical debridement

Last Updated on December 10, 2020 by Andrew Crofton