© Springer International Publishing Switzerland 2016
Abe Fingerhut, Ari Leppäniemi, Raul Coimbra, Andrew B. Peitzman, Thomas M. Scalea and Eric J. Voiglio (eds.)Emergency Surgery Course (ESC®) Manual10.1007/978-3-319-21338-5_55. Postoperative Complications
(1)
Jane and Donald D. Trunkey Professor and Vice Chair, Department of Surgery, University of Washington Surgeon-in-Chief, Harborview Medical Center, Seattle, WA 98104, USA
(2)
Department of Surgical Research, Clinical Division for General Surgery, Medical University of Graz, Graz, Austria
Objectives
Discuss common serious complications of operations for complex disease.
Understand underlying pathophysiology.
Explore decision-making process in approach to care.
Elucidate prevention and treatment options.
Note: see individual chapters for specific complications.
5.1 Peritonitis/Abscess
Both are manifestations of intra-abdominal infections:
Peritonitis: diffuse infection of the peritoneal space
Site
Somewhat localized to one quadrant
Or generalized to two or more quadrants with a significantly increased risk of mortality
Abscess: localized infection in the abdomen
Forms anywhere
Within the peritoneal space
In the extraperitoneal space, primarily the retroperitoneum
Or within the organs themselves, primarily the liver and spleen
Both occur more often today, postoperatively, due to the increasing severity of disease and complexity of procedures (including damage control) performed currently and the associated increased survival of the patient.
Causes:
By far the most common cause is anastomotic leakage.
Management depends on patient status.
Stable: nonoperative management is possible.
Unstable: surgery is indicated.
Laparotomy or for some laparoscopy
If early intervention, the anastomosis can be redone, with or without protective stoma, if not, and most often.
The two extremities should be brought out (double-barrel ileostomy or colostomy).
Hartmann’s procedure.
Complete peritoneal toilet.
Drainage.
Other causes are rare.
Collections (abscess) in a stable patient can be drained percutaneously.
There are no good guidelines on prevention of postoperative infections.
The current assumption is that factors that decrease SSI will also have a beneficial effect on the incidence of deep organ space infections, both peritonitis and abscesses.
These factors include:
Avoidance of unintended injury to the bowel or other organs during any operative procedure (critical)
Avoidance of hypoxia, hypothermia, and hyperglycemia
Appropriate antibiotic prophylaxis and treatment
Adequate delay in definitive completion of the surgery or closure of the wounds
Diagnosis:
Primarily: pain and abdominal tenderness.
Fever and elevated WBC are frequent but may be absent early in the disease process.
Specific to diffuse peritonitis:
Diffuse physical findings of tenderness, rebound, and guarding, such as following intestinal leak.
Diagnosis can be made on physical examination leading to prompt surgical intervention.
Conversely, postoperative abscess or tertiary peritonitis can be significantly more difficult to diagnose.
The clinical picture is less straightforward, and additional studies are frequently necessary to make the diagnosis.
Current multi-slice abdominal CT scans are the most useful.
Treatment requires both source control and appropriate antibiotics.
Diffuse peritonitis (almost always indicating an uncontrolled GI source of contamination) mandates operative exploration for source control.
In contrast, intra-abdominal abscess may be sufficiently treated by drainage alone.
Drainage is the appropriate initial step in the stable patient or patient responsive to initial therapy.
Frequently can be placed percutaneously using radiologic guidance including fluoroscopy, CT, ultrasound, or laparoscopy.
There are no randomized prospective trials comparing open drainage to percutaneous drainage, but solid cohort studies suggest that the net success and mortality appear to be equal between the approaches, but percutaneous or laparoscopy avoid the potential iatrogenic morbidity of open drainage.
Open drainage is usually reserved for the patient in whom percutaneous drainage has failed or is not technically feasible.
Importantly, approximately one fourth of cases will require an additional intervention to resolve the infection.
Need for reintervention is indicated when the patient fails to improve or worsens following intervention or when infection recurs.
Mandatory or scheduled relaparotomies have not been shown to reduce the morbidity or mortality in these complex cases.
5.2 Paralytic Ileus
Common postoperative disorder:
Occurring to some extent in most patients undergoing abdominal surgery
Most often transient, usually lasting 2–3 days, but may last for more than 7–10 days
Caused by neural, humoral, and metabolic factors:
Direct intestinal exposure, manipulation, and desiccation
Retroperitoneal bleeding
Severe infection, both intraperitoneal and extraperitoneal, such as pneumonia
Electrolyte imbalances, particularly hypokalemia
Drugs, primarily narcotics
Morphine binds to μ-opioid receptors in the CNS and colon causing nonpropulsive electrical activity.
Of clinical importance, should increase suspicion and help identify preemptively the onset of intestinal ischemia or an intra-abdominal infectious process, such as a localized abscess or diffuse peritonitis, while still reversible
Treatment:
Watchful support is in most cases appropriate and safe:
NG suction and fluid resuscitation.
Rapid correction of electrolyte imbalances, especially hypokalemia.
The use of thoracic epidurals enhances return of bowel function.
In contrast, the development of secondary ileus after initial return of bowel function mandates evaluation for mechanical obstruction or intra-abdominal sepsis from abscess or peritonitis:
Modern multi-slice CT scanners is exceptionally effective.Related posts:
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