Post Op Complications Flashcards
(33 cards)
What is an anastomotic leak?
a leak of luminal contents from a surgical join
an important complication to recognise following gastrointestinal surgery when an anastomosis has been formed
What are some risk factors for developing an anastomotic leak?
Patient Factors:
-Medication (e.g. corticosteroids, immunosuppressants)
-Smoking or alcohol excess
-Diabetes Mellitus
-Obesity or malnutrition
Surgical factors:
-Emergency surgery
-Extended operative time
-Peritoneal contamination (e.g pus, faeces)
-Oesophageal-gastric anastomosis or colo-rectal anastomosis
How soon after surgery does an anastomotic leak typically occur?
usually occur between post-operative days 3 to 5
realistically they can occur any time before or after this period.
How do patients with an anastomotic leak typically present?
Worsening abdominal pain
Clinical features of sepsis
certain patients may present with more subtle signs, such as a prolonged ileus
On examination:
-tender abdomen
-w / w/o signs of peritonism
What investigations should be done in patients with suspected anastomotic leak?
FBC
CRP
Clotting screen
ABG - pH and lactate
CT AP with contrast - assess for presence of gas or enteric contents outside lumen at site of anastomosis
oral contrast or contrast enema
What is the management for an anastomosis leak?
NBM
Broad spec Abx
IV fluid Bolus
Catheter
Consider TPN
Minor leaks - conservative, IV abx, rest and percutaneous drain
Endoluminal vacuum therapy - small leak in a low rectal anastomosis
Large leaks - surgery, washout, refashion anastomosis, formation of defunctioning proximal stoma
What is a post-operative ileus?
deceleration or arrest in intestinal motility after surgery
Functional bowel obstruction
What are some risk factors for a post-op ileus?
Patient Factors:
-Increased age
-Electrolyte derangement (e.g. Na+, K+and Ca2+ derangement)
-Neurological disorders (e.g. Dementia or Parkinson’s Disease)
-Use of anti-cholinergic medication
Surgical Factors:
-Use of opioid medication
-Extensive intra-operative intestinal handling
-Peritoneal contamination (by free pus or faeces)
-Intestinal resection
What are some clinical features of a post-op ileus?
Failure to pass flatus or faeces
Sensation of bloating and distention
Nausea and vomiting (or high NG output)
On examination:
-abdominal distention
-absent bowel sounds
What investigations should be done in suspected post-op ileus?
Rule out more serious pathologies
Routine bloods + Ca2+, PO4^3-, Mg2+
CT AP with contrast
What are some prophylactic measures to reduce the risk of post op ileus?
Minimise intra-operative intestinal handling
Avoid fluid overload (causing intestinal oedema)
Minimise opiate use
Encourage early mobilisation
What is the management for a post-op ileus?
NBM
IV fluids
Start fluid-balance chart
Insert NG tube on free drainage
Daily bloods
Encourage mobilisation
Reduce opiate analgesia
What are bowel adhesions?
Fibrous bands of scar tissue
Many occur secondary to previous surgery or intra-abdominal inflammation
one of the main causes of small bowel obstruction
What are the clinical features of bowel adhesions?
generally asymptomatic
the effect of the adhesions that present with clinical features
obstruction, infertility, or chronic pelvic pain
What investigations are done for suspected bowel adhesions?
directed to that of the subsequent pathology that has developed
When is surgical intervention adhesional bowel obstruction warranted?
In any patient with clinical features of ischaemia or perforation, or failed conservative treatment
What is the surgical correction of bowel adhesions?
adhesiolysis
Open or laparoscopic
What is an incisional hernia?
protrusion of the contents of a cavity (usually the abdomen) through a previously made incision in the compartment’s wall
What are some risk factors for developing an incisional hernia?
Emergency surgery
BMI >25
Midline incision
Post-op wound infection
Diabetes mellitus
Connective tissue disorders
Steroid uses
Advancing age
Current smoker
What is the pathophysiology of an incisional hernia?
Abdominal wall muscles disrupted by surgical incision, structurally weakened
In the presence of increased intra-abdominal pressure and potential risk factors, contents of the abdomen are able to herniate through the weakness, forming an incisional hernia
What are some complications of an incisional hernia?
incarceration, strangulation, or obstruction
What are some clinical features of an incisional hernia?
Reducible, soft, non-tender swelling at or near site of prev surgical wound
If hernia incarcerated, becomes painful, tender and erythematous
On examination:
mass is palpable at or near the site of the surgical incision, which may be reducible into the abdominal cavity
check for clinical features of obstruction and ischaemia
What investigations are done for suspected incisional hernia?
Normally clinical diagnosis
CT AP with contrast
How are incisional hernias managed?
case-by-case basis
The majority of incisional hernias are asymptomatic and can be managed electively
Surgery is typically indicated in patients with symptomatic hernias who are clinically fit enough for surgery
including suture repair (for very small hernias), laparoscopic mesh repair, and open mesh repair. For large incisional hernia, varying degrees of abdominal wall reconstruction may be required
