Surgical complications - part 5 ppt

Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch11 384 P. B. Boulos & A. O’Bichere be revised by local exploration. Necrosis below the fascia and therefore intra- peritoneally requires immediate exploratory laparotomy. If there is concern about recurrent necrosis because of tension or body wall thickness, a loop- end stoma or divided-end-loop stoma should be constructed in order to avoid skeletonisation of the bowel. Retraction Tension on the stoma, improper construction or siting and ischaemia are responsible factors. An abdominal opening that is wider than the bowel lumen causes tension on the mucocutaneous sutures which break and the stoma separates from the skin. This is more likely to occur when forming a colostomy than an ileostomy, and is an emergency if the colostomy recedes into the peritoneal cavity. Otherwise colostomy retraction is not as clinically significant as retraction of an ileostomy as with flush stoma the appliance adheres poorly and the skin is damaged by intestinal effluent. Stoma retraction may occur as a late complication if a patients gains excessive weight. Local revision involves measures to secure the ileostomy spout eversion and these include bidirectional seromyotomies to induce fibrosis, sutures to include the bowel edge, serosa at skin level and the skin edge, sutures between the serosa and fascia around the stoma, stapling the everted stoma with a bladeless linear cutting stapling instrument. Colostomy refashioning may demand mobilisation of the splenic flexure of the colon or even division of the inferior mesenteric artery at its origin in the obese patient to prevent tension on the colostomy. Obstruction This is commonly due to food bolus obstructing an oedematous newly fashioned ileostomy. Stenosis complicating ischaemia is a common cause of colostomy and ileostomy obstruction. The obstruction resolves spontaneously or by saline irrigation of the ileostomy through a Foley catheter and a careful dilatation with the finger or graduated dilators can be attempted in a stenosed stoma. Only if these measures fail to relieve obstruction, refashioning the stoma is considered and this will probably require re-exploration as at this early stage Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch11 Complications of Colorectal Surgery 385 local revision can be technically difficult and not safe because of inflammation and odema at the site of the stoma. Late Complications Prolapse Ileostomy prolapse is rare and is usually associated with parastomal hernia, and is more common in obese patients. Repair requires refashioning of the ileostomy with local repair of the parastomal hernia which is rarely successful in the long term. Colostomy prolapse is also not common and is associated with parastomal hernia, but is seen more frequently in paraplegic patients who had a stoma for constipation, rectal prolapse, incontinence and in right sided or transverse colostomies. The prolapse which is an intussusception of the proximal bowel is easily reducible and patients learn how to reduce their own prolapse. Elective treatment is to excise the redundant colon with local repair of the parastomal hernia if present and if the prolapse recurs, resiting the stoma or colectomy with ileostomy might be required. Hernia Parastomalherniais the commonest complicationamongpatientswith stomas. Obesity, chronic respiratory disease, and a predilection to other abdominal hernias are predisposing factors. There is no evidence that a stoma through the rectus muscle reduces the risk of a parastomal hernia. A parastomal hernia is repaired if it is causing psychological stress, interfer- ing with the adherence of the appliance, causing pain from intestinal incarcer- ation or obstruction, associated with prolapse or is cosmetically unacceptable. Local repair may involve suture approximation of the defect with or without mesh reinforcement and if this fails, resiting of the stoma might be necessary. Stenosis This is commonly due to ischaemic superficial necrosis at the time the stoma was formed. Stenosis andfistulation can be a manifestation ofrecurrent Crohn’s disease. Obstructive symptoms and difficulty with the appliance are the main Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch11 386 P. B. Boulos & A. O’Bichere reasons for revision of the stoma. Local revision is feasible at least 3 months after the initial procedure as fibrosis becomes established and the tissue planes are better defined to allow exteriorisation of a fresh segment of the bowel for fashioning a new stoma. However in Crohn’s disease the extent of the disease should be defined with a barium study as a laparotomy might be more appropriate. Fistulation This usually follows subcutaneous infection which can be avoided by keeping the size of the abdominal wall opening to the size of the bowel and preserv- ing the subcutaneous fat, in order not to create a potential dead space for haematoma and infection, and by not suturing the serosa to the fascia espe- cially in Crohn’s disease. Recurrent Crohn’s disease in the efferent limb to a stoma can fistulate through the stoma. Pain around the stoma, discharge, poor adherence of the appliance and skin irritation are reasons for local revision of a stoma that might involve proximal bowel resection in Crohn’s disease or resiting of the stoma if the skin and subcutaneous tissues are inflamed. Complications of Stoma Closure The closure of a stoma has its morbidity and should not be delegated to an inexperienced surgeon. The main complications are intestinal leak and intestinal obstruction. A leak is either from the suture line or unrecognised inadvertent intra- peritoneal damage to the bowel from traction or sharp injury while freeing the stoma through a narrow abdominal aperture. It is therefore safer to extend the incision or convert to a standard laparotomy if the stoma is densely adherent. A leak often manifests as an enterocutaneous fistula than with peritonitis. Intestinal obstruction is due to oedema or stenosis at the anastomosis and is more common with ileostomy than colostomy closure because of the narrower lumen of the bowel.When the intestinal ends are judged to be narrow, side-to-side anastomosis is easily performed with a linear stapler and provides a wider lumen than an end-to-end anstomosis. In either complication, conservative management is adopted before surgical intervention is considered. Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch11 Complications of Colorectal Surgery 387 SEPSIS In abdominal operations signs of sepsis in the postoperative period after rul- ing out extra-abdominal causes are either due to wound or intra-abdominal infection. Wound infections Wound infection depends on the size and virulence of the bacterial inoculum, local wound environment and the host organism defenses. Risk factors for wound infection are operations on the abdomen, operations lasting more than 2 hours, and a clean or dirty operation. Therefore the patient’s general condition is optimised, tissue damage is avoided and contamination prevented by mechanical bowel preparation and prophylactic systemic antibiotics. Wounds at high risk of infection should be left open and packed until delayed primary closure is carried out once the wound has filled with healthy granulation tissue and there is minimal exudate and no pathogenic organisms are isolated on wound culture. Otherwise the wound is left to heal by secondary intention. A closed wound that shows erythema, tenderness or exudates, is managed by removing the sutures or staples, and any purulent material is drained and the wound dressed appropriately. If there is fascial dehiscence the wound is debrided and closed with retention sutures with the option to limit the closure to the abdominal wall leaving the skin and fat layers open for local dressings. Antibiotics are prescribed according to bacteriological analysis. The most serious wound infections are the necrotising soft tissue infec- tions because of associated mortality and should be suspected, in the case of unusually severe pain in the incision, spreading erythema, oedema or crepi- tus when a clinical microbiologist should be involved. This is an emergency that requires prompt debridement with the excision of all necrotic tissue to the margins of viable tissues. Initial broad spectrum antibiotic therapy is with peni- cillin, aminoglycoside or clindamycin until tissue cultures are available. These patients usually require repeated debridements, prolonged intensive wound care and subsequently skin grafting. Perineal wound infection This is associated with closure rather than with open packing of the per- ineal wound especially when excision of the rectum is complicated by faecal Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch11 388 P. B. Boulos & A. O’Bichere contamination. Treatment is by opening the wound and local care. However the wound might not heal and if it remains unhealed for more than six months it is then defined as a perineal sinus. Although soft tissue excision is more exten- sive for cancer than for inflammatory bowel disease where the levators and the external anal sphincters are preserved by performing intersphincteric excision, persistent perineal sinuses are more common with inflammatory bowel disease or when rectal excision is performed after radiation therapy. With pelvic floor and sphincter muscle repair, the reconstituted anal canal creates tension on the perineal incision that is responsible for skin ischaemia and necrosis, wound disruption and infection. It is safer to carry out partial closure of the wound and rely on healing by secondary intention for complete healing. Intra-abdominal infection This should be suspected if the patient exhibits fever, prolonged ileus, abdom- inal pain or leucocytosis. Abdominal examination for tenderness or an intra- abdominal mass is limited by the abdominal incision. Ultrasonography in the postoperative period is hampered by the wound, dressings and drainage tubes and is unhelpful in surveying the abdomen and pelvis for fluid or gas collections especially if there is intestinal gas distension from ileus. Abdominal and pelvic CT is the investigation of choice and it allows the placement of a percutaneous catheter for the drainage of abdominal or pelvic abscesses avoiding the morbidity of surgical drainage, although it might not be as successful in complex abscesses. The organisms usually isolated include facultative gram negative bacilli, aerobic gram negative bacilli, obli- gate and aerobic organisms and enterococci or other faecal streptococci. A combination of an antianaerobe plus aminoglycoside or a third generation cephalosporin is recommended, but it may have to be modified according to culture results. The effectiveness of treatment is determined by the res- olution of the signs of sepsis within 48 hours and diminution in the size of the abscess on repeated CT scans. Otherwise re-exploration should be considered. Abscesses and enteric fistulas associated with anastomotic dehiscence are managed as described already. Dehiscence of the rectal stump after Hartmann’s or subtotal colectomy for acute fulminating colitis can be the cause of pelvic Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch11 Complications of Colorectal Surgery 389 sepsis unless the rectal stump had been exteriorised as mucus fistula, although a mucus fistula can be the source of infection if it retracts into the pelvis. Instillation of contrast material into the rectum may confirm extravasation from the apex of the rectal stump, which can be successfully managed by percutaneous drainage of the abscess and catheter irrigation of the rectal stump to evacuate residual faecal material. It is prudent that the rectal stump is always washed out at the time of the primary operation. ABDOMINAL COMPARTMENT SYNDROME Abdominal compartment syndrome (ACS) is a potentially fatal consequence of increased intra-abdominal pressure related to the prolonged exposure of the bowel and massive intravenous fluid replacement associated with condi- tions that colorectal surgeons frequently encounter namely intra-abdominal haemorrhage, pelvic fractures, intestinal obstruction and colonic cancer. Pro- longed unrelieved elevation of intra-abdominal pressure can cause pulmonary compromise, renal impairment, cardiac failure, shock and death. Pathophysiology Oliguria is often the first evidence of excessive intra-abdominal pressure attributed to renovascular rather than ureteric compression from occlusive pressure on the inferior vena cava and renal veins, and to a lesser extent direct pressure on the renal arteries as well as direct extrinsic pressure on the kidneys. Ventilation is impeded from compromised inspiration because the lungs are compressed. Progressive increase in the peak inspiratory pressure is required to maintain tidal volume. Hypercarbia and potentially fatal respiratory acidosis may develop. Elevated pCO2 and rising peak inspiratory pressures are signs of significant abdominal pressure. Pressure on the inferior vena cava reduces cardiac return while the heart pumps against increased aortic and peripheral vascular resistance. Cardiac output is diminished, and cardiovascular failure and shock are terminal events. Compression on the inferior vena cava leads to peripheral venous stasis causing severe oedema of the lower extremities and potential for thrombosis and pulmonary embolism. Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch11 390 P. B. Boulos & A. O’Bichere Diagnosis and Treatment Postoperative ACS develops within the first 24 hours. Oliguria manifests within 12 hours after surgery. Renal scan, renogram and excretory urograms are likely to be normal. Intravesical pressure measurement is the most useful and it corresponds with the intra-abdominal pressure when the patient is in the supine position, but is less accurate when the patient is in the Trendelen- burg or reversed Trendelenburg position. In most critically ill patients a Foley catheter is already in place, which can be connected to a water manometer via a three-way stopcock. A pressure above 25 mmHg should cause concern because when prolonged the risk of renal failure is considerable especially in patients with compromised renal function. Hypovolaemic and seriously ill patients are at risk of ACS at even lower pressure when other clinical parameters should also be considered. Re-opening the abdomen to release the mounting pressure in the abdominal cavity before irreversible damage occurs is life-saving. It is preferable that ACS is anticipated and prevented. During a protracted surgical procedure intravesical and/or ventilatory pressures are helpful mea- surements and if wound closure is difficult, the wound is left open. A variety of materials are used for temporary cover of the bowel, including sterilised plastic material fashioned from intravenous or irrigation fluid bags termed “Bogota bag.” A staged abdominal repair is deferred until the patient has recovered. CONCLUSION This account is not by any means comprehensive, but it provides an overall insight into common postoperative complications associated with colorectal surgery and highlights preventive measures that rely on sensible judgement in decision-making, caution and technical skill. Complications due to functional disturbance are related to the nature of the procedure; they are not within the theme of this chapter and should be taken into account when considering the overall morbidity. Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch12 Chapter 12 COMPLICATIONS OF MAJOR HEPATOBILIARY SURGERY David J. Reich, Hoonbae Jeon, Jorge A. Ortiz and Cosme Manzarbeitia In this chapter, the authors seek to describe the various complications that may occur during or after major hepatobiliary surgery, to provide treatment options, and to discuss perioperative steps that minimise the risk of these prob- lems. The authors try to provide a broad coverage of what has been learned by leading hepatobiliary surgeons, and also to share our personal experience in this field. The topics covered include complications related to procedures routinely performed by hepatobiliary surgeons, including hepatic resection, biliary resection for malignancy and radiofrequency ablation (RFA). Compli- cations of cholecystectomy, common bile duct exploration and other biliary procedures for benign disease, the domain of the general surgeon, are not covered in this chapter. Several developments in the 1990s have led to a significant improvement in results after major hepatobiliary surgery. Perhaps most importantly, there are a growing number of hepatobiliary surgeons, many of whom work as 391 Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch12 392 D. J. Reich et al. part of experienced liver transplant and hepatobiliary surgical teams. There is increasing communication and collaboration among these groups, even at a global level, that facilitates learning. Patients benefit from hepatobiliary sur- geons’ increased focus on liver anatomy and physiology. For example, the better understanding of these disciplines gleaned from living donor and other reduced size liver transplant procedures has been applied to non-transplant resectional techniques. As more cutting edge hepatobiliary surgery is per- formed, more effective equipment for imaging, resection and ablation con- tinues to be invented, including magnetic resonance imaging (MRI) vascular studies and cholangiography, laparoscopic ultrasonography, the cavitron ultra- sonic surgical aspirator (CUSA), the harmonic scalpel, more versatile stapling devices, RFA, and so on. Paralleling these surgical advances, has been a finer understanding of coagulation and the development of a wide array of haemo- static agents that have led to reduced morbidity from hepatobiliary surgery. Complementing all these advances are further improvement in the fields of anaesthesia and critical care. The aforementioned progress has greatly facil- itated the safer performance of increasingly aggressive hepatobiliary surgery and has made it possible to offer valuable surgical therapy to more patients afflicted with diseases of the liver and bile ducts. COMPLICATIONS OF HEPATIC RESECTION The general approach to major hepatobiliary resection used by groups in the United States, Europe and Asia is similar, and includes careful selection of patients, care by a highly experienced and skilled surgical team, preoperative radiological evaluation, and an attempt at minimal blood transfusion. A recent nationwide study in the United States demonstrated that procedure volume is an important predictor of mortality after major hepatobiliary resection. 1 Strict adherence to operative principles is the most important strategy for the prevention of complications. Local complications such as bleeding, necrosis, biliary fistula and sepsis can be prevented to alarge degree by precise application of modern techniques of liver surgery. Results of Hepatic Resection As a result of the aforementioned advances, the current mortality rate after major hepatobiliary resection even in cirrhotic patients is less than 1% at Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch12 Complications of Major Hepatobiliary Surgery 393 Fig. 1. Depiction of various factors that either increase or decrease the risk of complications following hepatobiliary resection. some large centres. 2–8 Prior to the 1990s, this mortality rate was reported as being 3% to 8%. 2,9 Interpreting mortality rates for hepatobiliary resection is not straightforward because there are multiple variables that can potentially effect patient outcomes, including the nature of the resection (i.e. the amount of resected hepatic parenchyma, the surface area of the transection plane, and proximity of the lesion to major vasculature); the underlying condition of the hepatic parenchyma (i.e. the presence of steatosis, hepatitis, cirrhosis, and/or obstructive jaundice); and technical aspects of the surgery (i.e. the amount of intra-operative blood loss and transfusion, the duration of vascular occlusion, and the skill and experience of the surgeon). The distribution of these factors varies among case series from different centres. Thus, reports of morbidity and mortality rates after major hepatobiliary resection should be cautiously interpreted. Figure 1 depicts various factors that either increase or decrease the risk of complications following hepatobiliary resection. Anatomic and Technical Principles of Hepatic Resection A surgeon’s knowledge of liver anatomy is critical in ensuring good outcomes after hepatobiliary surgery (Fig. 2). The liver has segmental subdivisions in its [...]... Am J Surg 1 85: 316–318 Jan 23, 2007 10:8 SPI-B404 416 Surgical Complications ch12 D J Reich et al 56 Heinemann A, Wischhusen F, Puschel K, Rogiers X (1999) Standard liver volume in the Caucasian population Liver Transpl Surg 5: 366–368 57 Urata K, Kawasaki S, Matsunami H, et al (19 95) Calculation of child and adult standard liver volume for liver transplantation Hepatology 21: 1317–1321 58 Abdalla... Am J Surg 184: 441–4 45 53 Liu CL, Fan ST, Lo CM, et al (2004) Abdominal drainage after hepatic resection is contraindicated in patients with chronic liver diseases Ann Surg 239: 194–201 54 Bhattacharjya S, Puleston J, Davidson BR, Dooley JS (2003) Outcome of early endoscopic biliary drainage in the management of bile leaks after hepatic resection Gastrointest Endosc 57 : 52 6 53 0 55 Reed DN, Jr., Vitale... hepatic artery must be immediately reconstructed, preferably via microvascular technique Jan 23, 2007 10:8 SPI-B404 406 Surgical Complications ch12 D J Reich et al Biliary Reconstruction Biliaryenteric continuity is re-established with a hepaticojejunostomy to a Roux-en-Y loop The Roux-en-Y loop is prepared and brought cephalid, usually in retrocolic fashion For a very high biliary anastomosis in... cell size and mass.84, 85 Segmental or lobar atrophy may result from portal venous occlusion or biliary obstruction.86 Jan 23, 2007 10:8 SPI-B404 Surgical Complications ch12 Complications of Major Hepatobiliary Surgery 4 05 Appreciation of the anatomical distortions on preoperative imaging is important to individualise the treatment strategy.87 Preoperative imaging predicts non-resectability based on... segments is possible,13 under ultrasonographic guidance14 or via the extra-glissonian approach. 15 During the infancy of modern hepatobiliary surgery, the thoracoabdominal incision was almost exclusively used in order to maximise exposure of Jan 23, 2007 10:8 SPI-B404 Surgical Complications ch12 Complications of Major Hepatobiliary Surgery 3 95 the operative field However, since the introduction of costal arch... abdominal cavity, retrogastric placement of the jejunal loop may provide better exposure and angle for manipulation Mucosa-to-mucosa approximation is mandatory for the hepaticojejunostomy The authors’ preference is to perform the end-to-side anastomosis with a single layer of 5- 0 or 6-0 PDS interrupted sutures Additional layers of suture do not provide extra security It is preferable to place and tie... are somewhat technically challenging Jan 23, 2007 10:8 SPI-B404 Surgical Complications ch12 Complications of Major Hepatobiliary Surgery 409 Table 2 Complications of Hepatic Radiofrequency Ablation (RFA) Overall, the reported incidence of complications following RFA is low (2% to 10%).94−97 and procedure related mortality is rare ( . arterial pseudo-aneurysm is an unusual compli- cation that can occur in the setting of intra-abdominal abscess or leakage Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch12 Complications. 2007 10:8 SPI-B404 Surgical Complications ch11 Complications of Colorectal Surgery 387 SEPSIS In abdominal operations signs of sepsis in the postoperative period after rul- ing out extra-abdominal. thoracoabdom- inal incision was almost exclusively used in order to maximise exposure of Jan. 23, 2007 10:8 SPI-B404 Surgical Complications ch12 Complications of Major Hepatobiliary Surgery 3 95 the