GASTROINTESTINAL COMPLICATIONS
scope
1. Early Postoperative Bowel Obstruction2. Acute Abdominal Compartment Syndrome3. Postoperative Gastrointestinal Bleeding4. Stomal Complications5. Anastomotic Leak6. Intestinal Fistula7. Pancreatic Fistulas
scope
1. Early Postoperative Bowel Obstruction2. Acute Abdominal Compartment Syndrome3. Postoperative Gastrointestinal Bleeding4. Stomal Complications5. Anastomotic Leak6. Intestinal Fistula7. Pancreatic Fistulas
Early Postoperative Bowel Obstruction
Early Postoperative Bowel Obstruction
Obstruction occurring within 30 days after surgery Functional Obstruction
adynamic or paralytic ileus Mechanical Obstruction
luminal, mural, or extraintestinal
Postoperative bowel motilitySmall bowel motility within several hoursGastric motility within 24 to 48 hoursColonic motility within 48 to 72 hours
Presence of bowel sounds, flatus, and bowel movements.
Causes of Intestinal Paralytic Ileus• prolonged surgical procedure and exposure of abdominal
contents • Intra-abdominal infection (peritonitis or abscess) • Retroperitoneal hemorrhage and inflammation • Electrolyte abnormalities • Medications (narcotics, psychotropic agents)
Causes of Mechanical postoperative small bowel obstruction
• Adhesions (92%)• Phlegmon or abscess• Internal hernia• Intestinal ischemia• Intussusception
Differentiation between adynamic ileus and mechanical obstruction
Adynamic ileus -Diffuse discomfort -No sharp colicky pain and distended abdomen. -Quiet abdomen with few
bowel sounds- Radiographs : reveal diffusely dilated bowel throughout the intestinal tract
Mechanical obstruction -High-pitched -Tinkling sounds -Fever and sepsis -Tachycardia -Hypovolemia - Radiographs : small bowel dilation with air-fluid levels and thickened valvulae conniventes in the bowel proximal to the point of obstruction and little or no gas in the bowel distal to the obstruction
Management
Three-step approach – Resuscitation– Investigation– Surgical intervention
Treatmento Adynamic ileus
o expectantly waiting for resolution
o Partial mechanical small bowel obstruction o initially managed expectantly 7 to 14 days, o If stable and clinical and radiologic improvement continues
o Emergency relaparotomy o (closed-loop, high-grade, or complicated small bowel obstruction,
intussusception, or peritonitis)
During this time nutritional support and surgical intervention are signs of deterioration or no improvement.
scope
1. Early Postoperative Bowel Obstruction2. Acute Abdominal Compartment Syndrome3. Postoperative Gastrointestinal Bleeding4. Stomal Complications5. Anastomotic Leak6. Intestinal Fistula7. Pancreatic Fistulas
Acute Abdominal Compartment Syndrome
Acute Abdominal Compartment Syndrome
• Increased intra-abdominal pressure greater than 12 mm.Hg • Associated with
– Rising peak airway pressure– Hypoxia– Difficult ventilation– Oliguria or anuria
Most commonAbdominal Compartment Syndrome
Multiple traumaileus, coagulopathy, capillary leak, and massive fluid
resuscitation and transfusion
ICU setting (nontrauma setting)ascites, retroperitoneal hemorrhage
Presentation and DiagnosisDifficulty breathing ,elevated peak airway pressure,
hypoxia, worsening hypercapniaAbdomenal distention and tenseReduced Cardiac outputOliguriaNeurologic deterioration
Prevention of Abdominal Compartment Syndrome
Organ function is monitored and assessed: Lungs: hypercapnia, hypoxia, difficult ventilation, elevated pulmonary artery
pressure, drop in PaO2/FIO2 ratio, decreased compliance, intrapulmonary shunt, increased dead space
Heart: decreased cardiac output and cardiac index and need for vasopressors
Kidneys: oliguria unresponsive to fluid therapy Central nervous system: Glasgow Coma Scale score less than 10 or neurologic
deterioration in the absence of neurotrauma Abdomen: distention. Computed tomography scan to check for fluid
collections, narrowing of the inferior vena cava, compression of the kidneys, and rounding of the abdomen
Treatmentsurgical
organ dysfunction + intra-abdominal hypertension (15 to 20 mm Hg )
Decompression abdomen is tense + signs of extreme ventilatory
dysfunction + oliguria
scope
1. Early Postoperative Bowel Obstruction2. Acute Abdominal Compartment Syndrome3. Postoperative Gastrointestinal Bleeding4. Stomal Complications5. Anastomotic Leak6. Intestinal Fistula7. Pancreatic Fistulas
Postoperative Gastrointestinal Bleeding
Postoperative Gastrointestinal Bleeding
• Stress ulceration is a serious complication• Clinically significant bleeding
o Hemodynamic instabilityo Transfusion of blood productso Operative intervention less than 5% o Associated with significant mortality
Risk Factors for Stress Erosions
• Multiple trauma • Head trauma • Major burns • Clotting abnormalities • Severe sepsis • Systemic inflammatory response syndrome • Cardiac bypass • Intracranial operations
Presentation and DiagnosisMelenaHematemesisHematocheziaHemodynamic compromiseDecrese hematocrit
TreatmentThe basic principles of management of postoperative GI bleeding include the following:
1. Fluid resuscitation2. Checking and monitoring clotting parameters and correcting abnormalities3. Identification and treatment of aggravating factors 4. Transfusion of blood products 5. Identification and treatment of the source of the bleeding
scope
1. Early Postoperative Bowel Obstruction2. Acute Abdominal Compartment Syndrome3. Postoperative Gastrointestinal Bleeding4. Stomal Complications5. Anastomotic Leak6. Intestinal Fistula7. Pancreatic Fistulas
Stomal Complications
EtiologyStomas are widely used in the treatment of
colorectal, intestinal, and urologic diseasesileostomy, colostomy, or urostomyoccur within 30 days after surgery
Stomal ComplicationsEarly Late
Stoma Poor location Prolapse
Retraction Stenosis
Ischemic necrosis Parastomal hernia
Detachment Fistula formation
Abscess formation Gas
Peristomal skin Excoriation Parastomal varices
Dermatitis Dermatoses
Cancer
Skin manifestations of inflammatory bowel disease
Systemic High output Bowel obstruction
Nonclosure
Treatment Surgical technique is imperative Ischemia immediate revision
Necrosis beyond the fascia immediate reoperation. Ischemia limited to a few millimeters is observed
Stenosis can be repaired via laparotomy
Chemical dermatitis cleaning, barriersCandida dermatitis NystatinTraumatic dermatitis patient education ,application of a skin barrier Allergic dermatitis symptomatic relief with oral antihistamine,
topical or oral steroid therapy
Technical Aspects of Stoma Construction
Abdominal Wall Aperture Excision of a circular piece of skin about 2 cm in size Preservation of subcutaneous fat to provide support for the stoma Transrectus muscle placement of the stoma Fascial aperture to admit two fingers
Stoma Selection of normal bowel for the stoma Adequate mobilization of bowel to avoid tension on the stoma Preservation of blood supply to the end of bowel (the marginal artery of the colon and the last vascular arcade of the small bowel mesentery must be preserved) The small bowel serosa must not be denuded of more than 5 cm of mesentery
Maturation Primary maturation of the end stoma or the afferent limb of the loop ileostomy Avoidance of traversing the skin with sutures during maturation
Other ManeuversTunneling of bowel through the extraperitoneal space of the abdominal wall Mesenteric-peritoneal closure Fixation of mesentery/bowel to the fascial ring Use of a supportive rod with loop stomas
scope
1. Early Postoperative Bowel Obstruction2. Acute Abdominal Compartment Syndrome3. Postoperative Gastrointestinal Bleeding4. Stomal Complications5. Anastomotic Leak6. Intestinal Fistula7. Pancreatic Fistulas
Anastomotic Leak
Etiologylevel of the anastomosis
o esophageal, pancreatico-enteric, and colorectalMicrocirculation at resection marginsIntraluminal distentionEmergency bowel surgery
Presentation and Diagnosis The clinical manifestations result of intestinal contents
o purulent discharge o Malaise, fever, abdominal pain, ileus, localized erythema
around the surgical incision, and leukocytosis, o Bowel obstruction, pneumaturia, fecaluria, and pyuria
Treatment Resuscitation is started immediately
crystalloid fluids , blood transfusion NPO NG tube Incised and drained Reoperation (peritonitis, intra-abdominal
hemorrhage, suspected intestinal ischemia)
scope
1. Early Postoperative Bowel Obstruction2. Acute Abdominal Compartment Syndrome3. Postoperative Gastrointestinal Bleeding4. Stomal Complications5. Anastomotic Leak6. Intestinal Fistula7. Pancreatic Fistulas
Intestinal Fistula
Intestinal FistulaAbnormal communication between
o two epithelialized surfaces or o two digestive organs or o hollow organ and the skin
most commonly iatrogenic
Presentation and DiagnosisSeverity depend on the surgical anatomy and physiology of the fistula
Anatomy-enteroenteric fistula-Enterovesical-enterocutaneous and pancreatic fistula-enterovaginal fistula
Physiology-low output (<200 mL/24 hr)-moderate output (200-500 mL/24 hr)-high output (>500 mL/24 hr)
Hypovolemia and dehydration, electrolyte and acid-base imbalance, loss of protein and trace elements, and malnutrition
Skin and surgical wound -irritation, excoriation, ulceration, and infection of the skin
Treatment• IV fluid and electrolyte imbalance is corrected.• NPO• Broad-spectrum IV antibiotic• H2 antagonists or proton pump inhibitors • Somatostatin analogues• Skin protection• surgical procedure
scope
1. Early Postoperative Bowel Obstruction2. Acute Abdominal Compartment Syndrome3. Postoperative Gastrointestinal Bleeding4. Stomal Complications5. Anastomotic Leak6. Intestinal Fistula7. Pancreatic Fistulas
Pancreatic Fistulas
Pancreatic Fistulas
o Diagnosis o Cloudy fluid with a high amylase content
o management o Octreotide therapyo ERCPo Fistuloenterostomy
HEPATOBILIARY COMPLICATIONS
Bile Duct InjuriesThe most dreaded complication of gallbladder
surgery is injury to the extrahepatic bile duct
o Iaparoscopic cholecystectomy 0.4% to 0.7%
o Open cholecystectomy 0.2%
Bile Duct Injuries Presentation– Bile leak upper quadrant pain, fever, nausea,
abdominal distention, and malaise– Bile duct strictures cholangitis, pain, fever,
chills,jaundice,leukocytosis and elevated bilirubin
Diagnosis CT scan ERCP Percutaneous transhepatic cholangiography Magnetic resonance cholangiopancreatography
Bile Duct InjuriesPrevention
proper surgical technique + adequate identification of the anatomy
Treatment adequate resuscitation, antibiotics, and drainage,Sphincterotomy or stentSurgical intervention
EAR, NOSE, THROAT COMPLICATIONS
scope• Epistaxis• Acute Hearing Loss• Nosocomial Sinusitis• Parotitis
EpistaxisAssociated with leukemia and hemophilia, excessive
anticoagulation, and hypertension.Two general categories:
o anterioro Posterior
Management o Firm pressure to the nasal ala and held for 3 to 5 minutes o packing with strip gauze for 10 to 15 minuteso Foley catheter with a 30-mL balloon o ligation of the sphenopalatine a. or anterior ethmoidal a.
Acute Hearing Loss Abrupt loss of hearing in the postoperative period is an
uncommon event
Unilateral hearing loss o obstruction or edema related to an NG or feeding tube
Bilateral hearing losso Neural , pharmacologic (aminoglycosides and diuretics)
Nosocomial Sinusitiso Majority occurs in the second week of hospitalizationo Maxillary sinuses are the most commono classic signs
o facial pain, malaise, fever, and purulent nasal dischargeo CT scan
o thickened mucosa and air-fluid level or opacification of the sinus
Managemento Remove Nasal tubes, decongestant, antibiotic therapy (S. aureus and
Pseudomonas spp.)o Surgical drainage
Parotitis• Obstruction or infection of the salivary ducts• Edema and focal tenderness the parotid gland, edema of the
floor of the mouth• Sepsis mediastinum and partial airway obstruction
• Management– High-dose, IV broad-spectrum antibiotics (Staphylococcus spp.)– Incision and drainage– Emergency tracheostomy