Surgical Complications: Postoperative

Surgical Management
Written By Sydney Oesch

Episode Notes

  1. Diagnostic Structure

    1. Six “Ws”: wind, water, walking, wound, wonder drugs, waves

  2. Timing

    1. First 48 hours: noninfectious causes

      1. Fever within 24 hours postop often benign; if no concerning findings on exam, observation and routine postop care recommended (often spontaneously resolve)

    2. After 48 hours: infectious causes

  3. Waves

    1. MI is the most common serious postop complication of POD#0

    2. 8% of pts undergoing non-cardiac surgery show evidence of myocardial injury and 2% suffer significant morbidity or mortality

    3. Dyspnea most common complaint

      1. Often lack classic chest pain/pressure due to postoperative analgesia

    4. EKG not classic - show non-Q-wave variant

    5. Get serial troponins

    6. Correct hypotension, anemia, arrhythmias

    7. Continue beta-blockers perioperatively!

      1. Don’t start w/i 1 day of surgery - increased risk of death overall, even though MI events are decreased

  4. Wind

    1. Postop pulm complications in ~1-3% of gynecologic surgeries

    2. Examples: pneumonia, acute respiratory distress syndrome (ARDS), obstructive sleep apnea exacerbations, acute respiratory failure

    3. Acute Respiratory Failure

      1. Type I: inadequate exchange of oxygen, “hypoxia without hypercapnia”

        1. Atelectasis, pneumonia, PE, ARDS

        2. paO2 <60 mmHg, normal or decreased paCO2

      2. Type II: inadequate exchange of carbon dioxide; “hypoxia with hypercapnia”

        1. paCO2 >45 mmHg, paO2 < 60 mmHg, pH < 7.35

        2. Caused by pump failure or increased CO2 production

        3. Pump failure

          1. “Can’t breathe”: muscle fatigue/chest wall, narrow airway, restrictive defects

          2. “Won’t breathe”: central respiratory drive issues, anesthesia overdose

    4. Physical Exam

      1. Pneumonia: fever, purulent secretions, focally diminished breath sounds, cough/dyspnea

    5. Labs: ABG, CBC, coags

    6. Imaging

      1. Atelectasis: linear densities in lower lung fields

      2. Pneumonia: new or progressive infiltrates

      3. ARDS: bilateral opacities

    7. ARDS

      1. Acute, diffuse, inflammatory lung injury which leads to increased permeability of the alveolar-capillary barrier and non-cardiogenic pulmonary edema

      2. V-Q mismatch leading to hypercapnic state and respiratory acidosis

      3. Diagnostic criteria: impaired oxygenation plus:

        1. Onset within 1 week of a defined insult

        2. CXR w/ diffuse, bilateral infiltrates

        3. Respiratory failure which cannot be fully explained by fluid overload or cardiac failure

      4. Assess severity with Berline criteria

        1. Uses combo of PO2, FiO2, and PEEP

      5. If mechanical ventilation needed -> use low tidal volumes w/ permissive hypercapnia

    8. Pneumonia

      1. Distinguish between community- and hospital-acquired

        1. Must be diagnosed > 48 hrs into admission with no signs at time of admission

    9. Asthma

      1. Scheduled albuterol, nebulizers

    10. COPD

      1. Noninvasive ventilation - high-flow O2, CPAP, BIPAP

      2. Nebulizers, steroids, antibiotics

    11. Mechanical Ventilation

      1. Aim to keep O2 above 90-92% and pO2 > 65 mmHg

      2. RR > 35/min or PCO2 > 55 mmHg → indication for intubation

      3. Other indications: apnea/respiratory arrest, altered consciousness level impairing normal respiration, hemodynamic instability

  5. Water

    1. Ureteral injury (identified postop)

      1. Signs/symptoms: abdominal or flank pain, fever, leukocytosis, elevated BUN, postoperative ileus

      2. Obtain fluid and serum creatinine

        1. Elevated fluid creatinine (from abdomen) very suspicious for injury

        2. If serum Cr rises < 0.3 mg/dL, 98% sensitivity and NPV of 100% in confirming bilateral ureteral patency

      3. Imaging: pyelogram, CT, MRI

      4. Depending on surrounding inflammation, sometimes can primarily repair; otherwise, wait 6-8 for inflammation to subside; may need to place PCNs as a temporizing measure

    2. Hypovolemic Shock/Hemorrhage

      1. Defined as > 1L of blood loss or blood loss requiring transfusion

      2. Signs/symptoms postop: abdominal pain or rigidity, rebound or guarding, anxiety, diaphoresis, orthostatic hypotension, decreased pulse pressure

        1. Late signs: altered mental status, marked tachycardia, syncope, oliguria, AKI

      3. Initial management: IVF replacement w/ LR, blood products prn, identifying source of bleed

        1. If stable: CT scan (consider angiography)

        2. If unstable: FAST scan or diagnostic peritoneal lavage

      4. Ultimate management:

        1. If stable: consider IR embolization vs transfusion and wait for bleed to stabilize

        2. If unstable: return to OR

  6. Walking

    1. DVT/PE

      1. Cancer is hypercoagulable state

        1. Clear cell carcinomas with highest risk of VTE

        2. Perioperative VTE in Gyn Onc surgery up to 26%

        3. PE after Gyn Onc surgery up to 9%

      2. Caprini score

        1. Validated online calculator about VTE prophylaxis

          1. Does not stratify/modify for MIS surgery so may overestimate VTE risk in these patients

      3. In cancer surgery, discharge w/ 28 days of prophylaxis for open cases and none for MIS cases

      4. Signs/symptoms: sinus tachycardia, mild fever, nonspecific CXR findings, EKG w/ R heart strain for larger PEs

      5. Formal diagnosis:

        1. If unstable: reasonable to start empiric anticoagulation

        2. If stable: Well criteria to assess pre-test probability → CT angiogram to confirm PE

      6. Management

        1. If unstable: vasopressor support, fluids, oxygen, potential need for mechanical ventilation, consider thrombolytic therapy

        2. If stable: therapeutic anticoagulation

          1. LMWH less risk of thromboembolism and less major bleeding risk than IV unfractionated heparin

          2. Can transition to DOAC with duration of therapy at least 3 months

  7. Wound

    1. Necrotizing soft tissue infection

      1. Signs/symptoms: dishwater/grey drainage from the wound, crepitus in the skin, rapid progression

      2. Management: if above seen → start broad spectrum antibiotics and head straight to OR for wound debridement; consider tetanus prophylaxis

    2. Surgical site infections

      1. Classically present postoperative day 5-7

      2. Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection

        1. Risk factors: cancer, immunosuppression, age >= 65, diabetes, obesity

        2. QSofa, NEWS calculators

        3. Key to management is early antibiotics - ideally within 30 min of presentation

          1. Great to get blood cultures before, but don’t delay abx to get these

            1. Get a blood culture from any indwelling lines like a mediport

    3. Wound Dehiscence

      1. Can be superficial or deep (fascial)

      2. Signs/symptoms: erythema, induration, drainage (especially copious fluid)

      3. Diagnosis; make sure to open the skin and probe the fascia to evaluate

        1. If fascia not intact → needs immediate surgical intervention

        2. If intact → often needs debridement and reapproximation

      4. STITCH trial 2015

        1. Multicentre double-blinded RCT

        2. Small bite fascial closure (5 mm x 5 mm) vs large bite (1 cm x 1 cm) showed decreased rates of midline laparotomy incision hernia at 1 year of 13% vs 21%

    4. Vaginal Cuff Dehiscence

      1. Diagnosed on physical exam

        1. If you see bowel, can mark with a surgical marker to know the area at risk

  8. Wonder Drugs/Wonder About Drugs/What Did We Do

    1. Iatrogenic causes

  9. Bowel Obstruction, Ileus

    1. Symptoms: nausea, vomiting, abdominal discomfort/distension, lack of passage of flatus and stool

    2. Physical Exam

      1. Ileus: hypoactive bowel sounds

      2. Bowel obstruction: high pitched bowel sounds, tachycardia, oliguria, sometimes w/ fever

    3. Imaging

      1. Xray

        1. Ileus: uniform gaseous distension of both large and small bowel

        2. SBO: distended loops of small bowel and air-fluid levels, with a paucity (or complete lack of) gas in the colon

        3. LBO: enlarged cecum

      2. CT w/ oral and IV contrast can help distinguish

        1. Gastrograffin administration can aid in resolution of small bowel edema due to high osomotic gradient

    4. Management

      1. Conservative

        1. First line, 90% will resolve

        2. Electrolyte and IV fluid repletion, antiemetics, NGT, limitation of opioids and other meds which reduce bowel motility, early ambulation, PPI

      2. Surgery

        1. Complete will often not resolve

        2. Closed loop are surgical emergency; obstruction at two points - can lead to bowel ischemia, necrosis, perforation due to trapped gas and secretions causing increased pressure

  10. Anastomotic Leak

    1. Occurs after 2-7% of bowel anastomoses

      1. Lowest: ileocolic (1-3%); highest: coloanal (10-20%)

    2. Risk factors: emergency surgery, prolonged operative time > 4 horus, contamination of the peritoneum, hypoalbuminemia, smoking or alcohol excess, obesity, immunosuppression (diabetes, cancer), ASA class III-IV, h/o radiation, distance from anal verge < 6 cm

    3. Can use triage algorithms to determine who will need a protective diversion, most can successfully be reversed

    4. Drains are controversial - do not prevent leaks and do not improve postoperative outcomes; some advocate for it for early detection of leak

    5. Typically present 5-7 days postoperatively, but in 10% cases may not present until after 30 days

    6. Management: NPO, broad spectrum abx, IV fluids

      1. Definitive mgmt depends on size/severity of leak

        1. If small abscess < 3 cm: bowel rest, abx

        2. If > 3 cm: consider percutaneous drainage, bowel rest, abx

        3. Major defect (> ⅓ of circumference of anastomosis), can’t be drained, gross spillage, free intraperitoneal leak, clinical deterioration: exlap w/ creation of end colposcopy vs resection of anastomosis with reanastomosis and proximal diversion vs primary repair w/ proximal diversion

  11. Bowel Perforation

    1. Symptoms: sudden severe abdominal or chest pain, sepsis picture, abdominal mass, fistula

    2. Physical exam: focal tenderness OR normal, eventually w/ distension

    3. VS dependent on how “sick” the patient is: tachycardia, hypothermia

    4. Labs: elevated WBC, elevated lactate or CRP, elevated amylase

    5. Imaging w/ gas outside the GI tract is characteristic

      1. Perform abdominal series first -> CT w/ PO and/or rectal contrast better at localizing the perforation

    6. Management

      1. Conservative: IV, NPO, broad spectrum abx, IV PPI

      2. Surgical: exlap (indications: abdominal sepsis, worsening/continuing pain, diffuse peritonitis, signs of bowel ischemia)

  12. Pancreatic Leak

    1. Can occur during splenectomy (injury of pancreatic tail reported as high as 22%)

    2. Leaks can lead to pancreatitis, pancreatic fistula

      1. Symptoms: LUQ pain, fever, leukocytosis

    3. Diagnosis: ultrasound and/or CT scan; confirmed by image guided percutaneous fluid sampling to check for amylase rich fluid

      1. Also perform cultures to r/o abscess

    4. Amylase levels?

      1. Cochrane review 2017

        1. Used different cutoffs and concluded that drain fluid amylase of the 5th postop day, using a threshold of 3x the serum amylase, provided the best sensitivity with high specificity

          1. Negative test more or less rules out pancreatic leak, but positive test is less certain


References


1. Mirabile VS, Shebl E, Sankari A, Burns B. Respiratory Failure in Adults. Published online June 11, 2023. Accessed August 28, 2024. https://www.ncbi.nlm.nih.gov/books/NBK526127/

2. Guntupalli SR, Brennecke A, Behbakht K, et al. Safety and Efficacy of Apixaban vs Enoxaparin for Preventing Postoperative Venous Thromboembolism in Women Undergoing Surgery for Gynecologic Malignant Neoplasm: A Randomized Clinical Trial. JAMA Netw Open. 2020;3(6):e207410-e207410. doi:10.1001/JAMANETWORKOPEN.2020.7410

3. Felder S, Rasmussen MS, King R, et al. Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane Database Syst Rev. 2019;3(3). doi:10.1002/14651858.CD004318.PUB4

4. Wagar MK, Sobecki JN, Chandereng T, Hartenbach EM, Wallace SK. Postoperative venous thromboembolism in gynecologic oncology patients undergoing minimally invasive surgery: Does modality matter? Gynecol Oncol. 2021;162(3):751-755. doi:10.1016/J.YGYNO.2021.06.011

5. Davidson TBU, Yaghoobi M, Davidson BR, Gurusamy KS. Amylase in drain fluid for the diagnosis of pancreatic leak in post‐pancreatic resection. Cochrane Database Syst Rev. 2017;2017(4). doi:10.1002/14651858.CD012009.PUB2

6. Straubhar AM, Stroup C, Manorot A, et al. Small bite fascial closure technique reduces incisional hernia rates in gynecologic oncology patients. International Journal of Gynecologic Cancer. 2024;34(5):745-750. doi:10.1136/IJGC-2023-004966

7. Kalogera E, Nitschmann CC, Dowdy SC, Cliby WA, Langstraat CL. A prospective algorithm to reduce anastomotic leaks after rectosigmoid resection for gynecologic malignancies. Gynecol Oncol. 2017;144(2):343-347. doi:10.1016/J.YGYNO.2016.11.032

8. Kalogera E, Dowdy SC, Mariani A, Aletti G, Bakkum-Gamez JN, Cliby WA. Utility of closed suction pelvic drains at time of large bowel resection for ovarian cancer. Gynecol Oncol. 2012;126(3):391-396. doi:10.1016/J.YGYNO.2012.05.021

9. Richardson DL, Mariani A, Cliby WA. Risk factors for anastomotic leak after recto-sigmoid resection for ovarian cancer. Gynecol Oncol. 2006;103(2):667-672. doi:10.1016/J.YGYNO.2006.05.003

 


Sydney Oesch
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Surgical Complications: Intraoperative