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CHAPTER 87: Complications of General Surgical Procedures 555 Prevention is the best treatment for clogging of gastrostomy and jejunostomy tubes. Frequent flushing with water and careful crushing of pills usually can prevent this problem. Vomiting and diarrhea can be relieved by decreasing the amount of the feedings and/or diluting the feedings. To unclog the tube, instill warm water or carbonated bever age (cola is most often used) and let it remain for 20 minutes. Then attempt flushing. 26 Alkalinized pancreatic enzymes (12,000 lipase units dissolved in 650 mL bicarbonate) have also proven effective in about 50% of cases.  TUBE REPLACEMENT If the tube cannot be unclogged or if it has fallen out, replacement will be necessary. If the tube was placed by a surgeon or gastroenterologist and has not been replaced, it probably will have a bolster (also called a mushroom or bumper) holding the tube in place (Figure 86-4). This will prevent the tube from being removed. The bolster must be removed endoscopically, or the tube may be cut off and the bolster allowed to pass through the GI tract. 28 The latter technique is generally safe in adults, but passage in children has complications, 29 and tube removal should be done by the endoscopist or surgeon. Endoscopic removal in adults is advisable when there is suspected or potential obstructive disease of the GI tract, such as pyloric stenosis, intestinal pseudo-obstruction, and intestinal stricture (e.g., due to radiation, ischemia, or inflammatory bowel disease). If the tube is cut, an abdominal radiograph should be obtained 1 week later to confirm passage of the internal component. Most reported complications from a retained internal bolster have occurred when the bolster did not pass within 1 to 2 weeks. 30 If the bolster or bumper becomes buried in the abdominal wall, consult with the endoscopist or surgeon who placed the device. Do not attempt removal by traction. Some specially designed tubes have internal bumpers that can be removed by external traction, but consultation with the endos copist or surgeon who placed the device is necessary before any trac tion is applied to verify the type of tube and the appropriate method of removal 31 (Figure 86-4). If the tube has become dislodged or has fallen out, replace it as quickly as possible (within a few hours) to prevent closure of the tract. Most tracts mature after 2 to 3 weeks. Do not attempt to replace a tube with an immature tract. 26 First determine, if possible, which type of tube is being used. If the tube is available, replacement with the same size is usually possible. If the tube is not available, it can be difficult to determine whether the tract is for a jejunostomy or gastrostomy tube. Location site on the abdominal wall is not help ful to differentiate the two. A tract for a gastrostomy tube is usually larger. Old records may be useful and should be obtained, if possible. After determining the type of tract and size of tube used previously, insert the tube using a water-soluble lubricant. If the size of the tube being replaced is not known, it is reasonable to start with a 16- or 18-F replacement gastrostomy tube or Foley catheter. The lubricated tube should pass easily into the stoma without additional equipment. If resistance is met, abandon the attempt. A smaller tube can be tried to keep the tract open.

he size of the tube being replaced is not known, it is reasonable to start with a 16- or 18-F replacement gastrostomy tube or Foley catheter. The lubricated tube should pass easily into the stoma without additional equipment. If resistance is met, abandon the attempt. A smaller tube can be tried to keep the tract open. After replacing the tube, instill a 20- to 30-mL bolus of a water-soluble contrast material (e.g., diatrizoate meglumine and dia trizoate sodium solution [Gastrografin]) through the tube, and obtain a supine abdominal radiograph within 1 to 2 minutes. The radiograph should demonstrate rugae of the stomach for a gastrostomy tube and flow into the small bowel for a jejunostomy tube. US can also be used to verify gastric placement. The tip of the tube can be visualized within the stomach, and confirmation of placement can be done by injecting 10 mL of normal saline into the tube and observing the fluid entering the stomach, using real-time US. Another way of determining placement is to withdraw gastric fluid and check pH to make sure it is acidic. If there is any question of improper placement, obtain immediate consultation. A special caution regarding jejunostomy tubes should be noted. Jejunostomy tracts are smaller, and smaller tubes are used (8- to 14-F). These tubes usually are not sutured in place and frequently become dislodged. They can be replaced with catheters made specifically for jeju nostomies or with Foley catheters. If a Foley catheter is used to replace a lost jejunostomy catheter, the balloon should never be inflated because it can cause a bowel obstruction or damage the jejunum. The tube is lubricated, inserted into the stoma, and advanced 20 cm. These tubes are easily replaced if the tract is mature; however, if resistance is met, referral to a radiologist for fluoroscopic placement using guide wires is recommended. OSTOMY COMPLICATIONS Emergency physicians frequently encounter patients with ostomies and their complications. Common ostomies include colostomies, ileostomies, catheterizable ileal pouches, and ileal conduits. As expected, ostomy surgery can result in the following surgical complications: wound infection, dehiscence, parasomal herniation, bowel obstruction, including from volvulus, and bleeding. These complications generally require surgical consultation. Dermatitis is commonly caused by exposure to urine or feces, abrasion, or allergy to adhesive or ostomy material. 32 Remedies include resizing ostomy contact and changing ostomy material, perhaps guided by referral for patch testing. Ostomy powder is available to help dry skin, and ostomy paste can be used to prevent leakage from poor ostomy contact. The ileum is commonly used for two types of urinary diversion—ileal conduit and catheterizable ileal pouch. In either case, a part of the ileum is detached from the alimentary canal and reformed into a reservoir; the remaining ileum is reconnected end-to-end. The ileal conduit, which is more common, does not require catheterization, has a small reservoir, and has a relatively continuous ostomy output. 33 In the catherizable ileal pouch, the patient catheterizes a larger reservoir and can maintain con tinence. Both reservoirs are prone to urinary infection and colonization, and patients with a catheterizable pouch must irrigate periodically to minimize the risk of urinary infection. REFERENCES The complete reference list is available online at www.TintinalliEM.com. Complications of General Surgical Procedures Edmond A. Hooker INTRODUCTION Outpatient surgical procedures are common, and with increasing pres sure for cost containment, admitted patients are being discharged earlier in their postoperative course.

The complete reference list is available online at www.TintinalliEM.com. Complications of General Surgical Procedures Edmond A. Hooker INTRODUCTION Outpatient surgical procedures are common, and with increasing pres sure for cost containment, admitted patients are being discharged earlier in their postoperative course. As a result, more patients are coming to the ED with postoperative fever, respiratory complications, GU com plaints, wound infections, vascular problems, and complications of drug therapy (Table 87-1). This chapter reviews the complications common to all surgical procedures and those specific to a specific procedure. The operating surgeon should be called when one of his or her patients appears in the ED with a surgical complication. This is not just a courtesy, but provides continuity of care important for the patient’s well-being. FEVER Fever is a common presenting complaint ( Table 87-2). A mnemonic for the common causes of postoperative fever is the “five Ws”: wind (atelectasis or pneumonia), water (urinary tract infection), wound , walking (deep vein thrombosis), and wonder drugs (drug fever or pseu domembranous colitis).1 Respiratory complications, such as atelectasis, CHAPTER Tintinalli_Sec09_p0473-0562.indd 555 8/2/19 6:51 PM

uses of postoperative fever is the “five Ws”: wind (atelectasis or pneumonia), water (urinary tract infection), wound , walking (deep vein thrombosis), and wonder drugs (drug fever or pseu domembranous colitis).1 Respiratory complications, such as atelectasis, CHAPTER Tintinalli_Sec09_p0473-0562.indd 555 8/2/19 6:51 PM 556 SECTION 9: Gastrointestinal Disorders TABLE 87-1 Complications of General Surgical Procedures Complication Important Points Fever “Five Ws” (wind, water, wound, walking, wonder drugs) are common causes Pulmonary complications Atelectasis <24 h, treat with pulmonary toilet, discharge unless ill or hypoxemic Pneumonia 2–7 d, polymicrobial, most require admission Pneumothorax Multiple causes, consider expiratory views, consider needle aspiration Pulmonary embolism Dyspnea is main symptom, high index of suspicion GI complications Intestinal obstruction Obtain radiographs, search for causes Intra-abdominal abscess CT diagnosis, early administration of broad-spectrum antibiotics Pancreatitis Always consider in postoperative patients with abdominal pain Cholecystitis Usually in older patients, can be acalculous Fistulas Can be high output, admit if concerns over output GU complications Urinary tract infection 2–5 d, oral antibiotics, most discharged Urinary retention Rapid catheter drainage, most discharged Acute renal failure Prerenal, renal, and postrenal causes, most admitted Wound complications Hematoma Caused by poor hemostasis, can drain most, but be careful with neck hematomas and hematomas after vascular surgery Seroma Painless swelling, clear fluid, drain and discharge Infection Open, drain, and culture specimens; be careful with wounds associated with respiratory tract, GI tract, or GU tract, or secondary to trauma Necrotizing fasciitis Pain out of proportion to physical findings Dehiscence Be careful with abdominal incisions (potential for evisceration) Vascular complications Superficial thrombophlebitis Usually aseptic, provide local therapy and discharge Deep venous thrombosis Upper and lower extremity, perform Doppler studies Complications of drug therapy Diarrhea Consider pseudomembranous colitis Drug fever Many drugs implicated, requires admission Tetanus Can occur after GI surgery Procedure-specific complications See text and IV catheter–related problems, such as thrombophlebitis, are the predominant causes of fever in the first 72 hours. Necrotizing streptococcal and clostridial infections also occur in surgical wounds early in the postoperative course. Urinary tract infections become evident 1 to 5 days postoperatively. Seven to 10 days postoperatively, clinical manifestations of wound infections develop. Deep venous thrombosis can result in fever any time but usually not until the fifth postoperative day. Antibiotic-induced pseudomembranous colitis occurs up to 6 weeks postoperatively. An approach for evaluating and managing fever in postoperative patients is presented in Table 87-3. RESPIRATORY COMPLICATIONS  ATELECTASIS Atelectasis, the collapse of pulmonary alveoli, is very common. Con tributing factors include inadequate clearance of secretions after general anesthesia, decreased intra-alveolar pressure, and postoperative pain, which results in hypoventilation. Although atelectasis can occur after any procedure, it frequently occurs after upper abdominal and thoracic surgery. The presentation varies from an isolated fever to tachypnea, dyspnea, and tachycardia. Evaluation includes chest radiography, pulse oximetry, and a CBC. Chest radiographs may show normal findings or exhibit platelike linear densities, triangular densities, or lobar consolidation. CT scan can be done when other diagnoses are a consideration. US may be useful in confirming the diagnosis of atelectasis.

ia. Evaluation includes chest radiography, pulse oximetry, and a CBC. Chest radiographs may show normal findings or exhibit platelike linear densities, triangular densities, or lobar consolidation. CT scan can be done when other diagnoses are a consideration. US may be useful in confirming the diagnosis of atelectasis. 2 Mild hypoxemia from ventila tion and perfusion mismatch is common, but hypercarbia is uncom mon. Patients with mild atelectasis and no evidence of hypoxemia may be managed as outpatients with pain control and increased deep breathing. Admission is indicated for aggressive pulmonary toilet and supple mental oxygenation in debilitated patients, patients with underlying lung disease, patients with hypoxemia, or those in whom the diagnosis is in question.  PNEUMONIA Pneumonia usually becomes evident between 24 and 96 hours postoperatively. Predisposing factors include prolonged ventilatory support and atelectasis. Presenting symptoms can include dyspnea, chest pain, pro ductive cough, fever, and tachypnea. Postoperative pneumonia is likely to be polymicrobial. After specimens of sputum and blood are obtained for culture, parenteral antimicrobial therapy is given. There are many options for polymicrobial coverage. Follow local recommendations for hospital-acquired pneumonia.  PNEUMOTHORAX Pneumothorax can occur as a complication of thoracic wall surgery, breast biopsy, laparoscopic abdominal surgery, abdominal paracentesis, nasogastric and feeding tube insertion, thoracic surgery, central venous catheter insertion, endoscopic procedures, shoulder arthroscopy, and tracheostomy. For further discussion, see Chapter 68, “Pneumothorax. ”  PULMONARY EMBOLUS Pulmonary embolism may present any time during the postoperative period. For further discussion of signs, symptoms, and treatment, see Chapter 56, “Venous Thromboembolism Including Pulmonary Embolism. ” GU COMPLICATIONS  URINARY TRACT INFECTION Urinary tract infections can occur after any surgical procedure, but the incidence increases in patients who have undergone instrumentation of the GU tract or bladder catheterization. The cause is direct contamina tion of the urinary bladder, most commonly with Escherichia coli. Other organisms isolated include Staphylococcus aureus, Staphylococcus epidermidis, Proteus mirabilis, Klebsiella, Pseudomonas, and enterococci. Oral antibiotics (ciprofloxacin, 500 milligrams PO twice daily, or levofloxa cin, 750 milligrams PO once daily) are appropriate for most infections, and choice of antibiotic should be based on local susceptibility patterns. Elderly or debilitated patients and those with sepsis require admis sion for parenteral administration of antibiotics (usually levofloxacin, 750 milligrams IV once daily).  URINARY RETENTION Postoperative acute urinary retention is a common problem for surgical patients. Urinary retention occurs as the result of catecholamine stimulation of α-adrenergic receptors in the bladder neck and urethral smooth Tintinalli_Sec09_p0473-0562.indd 556 8/2/19 6:51 PM

n, 750 milligrams IV once daily).  URINARY RETENTION Postoperative acute urinary retention is a common problem for surgical patients. Urinary retention occurs as the result of catecholamine stimulation of α-adrenergic receptors in the bladder neck and urethral smooth Tintinalli_Sec09_p0473-0562.indd 556 8/2/19 6:51 PM CHAPTER 87: Complications of General Surgical Procedures 557 TABLE 87-2 Common Causes of Postoperative Fevers in General Surgical Patients Cause of Fever Presentation Signs and Symptoms Diagnostic Test Treatment Atelectasis First 24 h Isolated fever; may have tachypnea, dyspnea, and/or tachycardia Chest radiography Pulmonary toilet; admission if unsure or patient is ill appearing Pneumonia 3–7 d Dyspnea, chest pain, productive cough, fever, and/or tachypnea Chest radiography Admission and coverage with broad-spectrum antibiotics Urinary tract infections 2–5 d Often none; possibly dysuria Urinalysis Admission if patient is elderly or toxic Skin and soft tissue infection 5–10 d Increasing pain, erythema, swelling, drainage, and tenderness at incision site Examination, aspiration and/or opening of wound Drainage, packing, and outpatient antibiotic therapy Thrombophlebitis (septic and sterile) <3 d Warm, tender, and swollen vein None If not septic, warm soaks If septic, surgical removal Deep vein thrombosis 4–6 d Extremity swelling and pain US Admission and anticoagulation Intra-abdominal abscesses 4–21 d Fever and elevated WBC count without specific focal abdominal findings CT Admission and antibiotic administration Pseudomembranous colitis Anytime Diarrhea Stool testing using immunoassay Metronidazole or vancomycin Peritonitis 4–21 d Tachycardia and abdominal pain, peritoneal irritation CT Admission and antibiotic administration Pulmonary embolism Anytime Shortness of breath, tachypnea, and/or hemodynamic instability CT or ventilation–perfusion scanning Admission and anticoagulation Transfusion reaction First 24 h Fever, chills Transfusion check for incompatibility Admission depending on condition of patient TABLE 87-3 Evaluation and Management of Postoperative Fever History •  Presenting  signs and symptoms •  Onset  of symptoms, time since procedure •  Procedures  performed and complications •  Medications •  History  of blood transfusion Physical examination •  Particular  attention to •  Operative  sites and contiguous areas •  Sites  of catheters and invasive monitors •  Signs  of deep venous thrombosis and pulmonary embolism •  Decubitus  ulcers •  Lungs Ancillary studies •  CBC  with differential •  Chest  radiograph •  Gram  stain and culture of wound exudate •  Urinalysis  (urine culture if infected) •  Sputum  Gram stain and culture •  Blood  cultures •  CT  to exclude intra-abdominal pathology •   If diarrhea  present,  consider  immunoassay  of specimen  for Clostridium difficile toxin •  Further  tests as indicated (e.g., CT, radionuclide studies, venography, arteriography) Treatment •  If  source identified, start antibiotics; admission based on condition of patient •   If no source identified, consider admission, change all catheters and culture catheter specimens, stop all medication that might cause fever muscle. Increased incidence of urinary retention is likely to occur in elderly patients, females, patients receiving excessive fluid adminis tration during surgery, those undergoing anorectal surgery, patients undergoing longer procedures (>2 hours), and those for whom spinal or epidural anesthesia was used. 3,4 Patients with urinary retention present with lower abdominal discomfort, urinary urgency, and inability to void. The diagnosis is confirmed by US.

tration during surgery, those undergoing anorectal surgery, patients undergoing longer procedures (>2 hours), and those for whom spinal or epidural anesthesia was used. 3,4 Patients with urinary retention present with lower abdominal discomfort, urinary urgency, and inability to void. The diagnosis is confirmed by US. The bladder can be safely drained quickly with a Foley catheter, and there appears to be no foundation for the fears of hematuria, post obstructive diuresis, and hypotension. For patients with normal renal function and no anatomic obstruction, continued catheter drainage is not necessary. For patients with retention after GU procedures, a urologist should be consulted prior to instrumentation. Antibiotics can be given if the GU tract has been instrumented, if retention is prolonged, or if the patient is at risk for infection (see “Urinary Tract Infection” section above).  ACUTE RENAL FAILURE Acute renal failure is classified according to the primary cause: prerenal, intrinsic, or postrenal. Volume depletion is the most common prerenal cause. Treatment is a fluid bolus. Intrinsic causes include acute tubular necrosis and drug nephrotoxicity. Obstructive uropathy is a common cause of postrenal failure. In patients with urinary outlet obstruction, placement of a urinary catheter is diagnostic and therapeutic. Renal US is needed to identify hydronephrosis or hydroureter. WOUND COMPLICATIONS Inform the operative surgeon about all postoperative wound complications.  HEMATOMAS Wound hematomas result from unrecognized inadequate hemostasis. Patients have pain, pressure, and swelling within the wound. Patients with wound hematomas may be febrile and have sanguineous or serous wound drainage. Differentiating between hematoma and wound infec tion can be difficult. A few sutures should be removed to allow the hematoma to drain, and culture of wound specimens should be per formed. If there is no evidence of infection and hemostasis can be maintained, the patient can be discharged. In patients who have a hematoma of the neck or who have undergone vascular surgery, extreme caution and consultation are appropriate.  SEROMAS A seroma, a collection of serous fluid, is usually the result of inad equate control of lymphatics during dissection but can occur under Tintinalli_Sec09_p0473-0562.indd 557 8/2/19 6:51 PM

who have a hematoma of the neck or who have undergone vascular surgery, extreme caution and consultation are appropriate.  SEROMAS A seroma, a collection of serous fluid, is usually the result of inad equate control of lymphatics during dissection but can occur under Tintinalli_Sec09_p0473-0562.indd 557 8/2/19 6:51 PM 558 SECTION 9: Gastrointestinal Disorders split-thickness skin grafts and in areas with large dead spaces (e.g., axilla, groin, neck, or pelvis). Patients have painless swelling below the wound or graft, and needle aspiration yields a serous fluid. Aspiration confirms the diagnosis and alleviates the problem, although aspiration may have to be repeated later.  INFECTION Systemic factors (e.g., extremes of age, poor nutrition, or diabetes) contribute to wound infections. However, local factors (e.g., necrotic tissue, poor perfusion, foreign bodies, and hematomas) are of greatest significance. In nontraumatic, uninfected operative wounds in which the respiratory, alimentary, and GU tracts were not entered, infection rates are low. In such cases, the infecting organism is usually from the skin but can originate from remote infected sources (e.g., urinary tract infection). If there is a remote infected source, the organism is probably the same in both infections. Wounds associated with entering the respiratory, alimentary, or GU tract or wounds secondary to trauma have a higher risk of infection. Presenting signs and symptoms of wound infections include increasing pain, erythema, swelling, drainage, and tenderness at the incision site. Wounds not involving the perineum and not associated with entry into the GI or biliary tract are most often infected with S. aureus or streptococci. Such wounds can be safely managed with drainage, culture of a wound sample, irrigation, loose packing with gauze, and outpatient administration of antibiotics. Wounds involving the perineum or associated with the GI or biliary tract are often infected with multiple organisms, including gram-negative bacteria and anaerobes. Parenteral broad-spectrum antibiotics are administered, and hospital admission is necessary.  NECROTIZING FASCIITIS Necrotizing fasciitis is a feared complication. The usual cause is direct contamination of the wound with group A streptococci or S. aureus. However, mixed aerobic and anaerobic infections have been reported. Risk factors include diabetes mellitus, hypertension, obesity, alcoholism, immunosuppression, and peripheral vascular disease, but necrotizing fasciitis also occurs in young, otherwise healthy individuals. 5 Early clinical differentiation from cellulitis can be difficult. CT may show asymmetric fascial thickening, gas tracking along fascial planes, or focal fluid collections. MRI is sensitive but not totally specific for necrotiz ing fasciitis and can be a useful adjunct. 6 Hallmarks of fasciitis are the presence of marked systemic toxicity and pain out of proportion to local findings. In more advanced cases, there may be deep pain with patchy areas of surface hypesthesia, crepitation, or bullae. Treatment should include antibiotics and immediate surgical debridement. Antibiotic choice is controversial, but triple antibiotic therapy with penicillin or a cephalosporin, an aminoglycoside, and clindamycin probably should be used. 6 For further discussion, see Chapter 152, “Soft Tissue Infections. ”  WOUND DEHISCENCE Wound dehiscence can be superficial or can extend into the deeper fascial planes. Dehiscence is caused by inadequate closure or intrinsic host factors, such as malnutrition, glucocorticoid use, or diabetes. Serosanguineous fluid may leak from the wound. Dehiscence of abdominal incisions has the potential for evisceration.

nd dehiscence can be superficial or can extend into the deeper fascial planes. Dehiscence is caused by inadequate closure or intrinsic host factors, such as malnutrition, glucocorticoid use, or diabetes. Serosanguineous fluid may leak from the wound. Dehiscence of abdominal incisions has the potential for evisceration. If evisceration is not pres ent, conservative management using abdominal binders is appropriate. However, if there is any uncertainty about the extent of dehiscence, operative exploration is indicated. VASCULAR COMPLICATIONS  SUPERFICIAL THROMBOPHLEBITIS Superficial thrombophlebitis of the lower extremities is most frequently secondary to stasis in varicose veins. It is usually aseptic. There is redness and warmth of the affected vein. If there is no evidence of surrounding cellulitis or lymphangitis and no evidence of deep vein involvement on US, treatment is local heat, elevation, and NSAIDs. Suppurative super ficial thrombophlebitis is characterized by erythema, palpable tender cord, lymphangitis, and pain. Suppurative thrombophlebitis requires excision of the affected vein.  DEEP VENOUS THROMBOSIS When lower extremity superficial thrombophlebitis is seen in a postop erative patient, consider the possibility of concurrent deep venous thrombosis. Deep venous thrombosis is typically characterized by leg pain or swelling, or both. For suspected deep venous thrombosis, Doppler US is the preferred diagnostic test. Patients with normal color flow Doppler study results should be treated with elevation and bed rest. Repeat color flow Doppler US studies should be performed in 3 days if symptoms persist, but sooner if symptoms worsen. For further discussion, see Chapter 56, “Venous Thromboembolism Including Pulmonary Embolism. ” COMPLICATIONS OF DRUG THERAPY Complications of drug therapy are numerous, but the most common implicated classes of drugs are anticoagulants, diabetic medications, antibiotics, and opioids. 7 Another common problem is antibiotic-associated diarrhea. Many antibiotics can cause diarrhea, but the greatest concern in postoperative patients is pseudomembranous colitis. Pseudomembranous colitis is due to the toxin produced by the bacterium Clostridium difficile. Pseudomembranous colitis is related to antibiotic use, which destroys the normal enteric bacterial flora, allowing an overgrowth of C. difficile. Even short courses of antibiotics have been associated with pseudomembranous colitis. Patients have watery and sometimes bloody diarrhea, fever, and crampy abdominal pain. There are three common ways to diagnose C. difficile: nucleic acid amplification tests, glutamate dehydrogenase, and enzyme immunoassay. The current recommenda tion for symptomatic patients is to use a nucleic acid amplification test technology like polymerase chain reaction. 8 For patients with moderate disease, discontinue the offending antibiotic and prescribe metronida zole. For severe disease, discontinue the offending antibiotic and give vancomycin. 8 For further discussion, see Chapters 71, “ Acute Abdominal Pain” and 73, “Disorders Presenting Primarily With Diarrhea. ” Many medicines can cause drug fever, but antibiotics are the drug class most commonly implicated. The mechanisms proposed are hypersensitivity reactions, pyogenic effect, and disturbed thermoregulation. In patients in whom no source for fever can be found, it is appropriate to consider stopping medications known to cause drug fever. Most often, the patient will require admission to rule out this diagnosis. COMPLICATIONS OF BREAST SURGERY Complications of breast surgery are infrequent, but patients can develop minor wound infections and hematomas. Rarely, pneumothorax has been reported. Wound hematomas frequently require operative control for proper evacuation and hemostasis.

require admission to rule out this diagnosis. COMPLICATIONS OF BREAST SURGERY Complications of breast surgery are infrequent, but patients can develop minor wound infections and hematomas. Rarely, pneumothorax has been reported. Wound hematomas frequently require operative control for proper evacuation and hemostasis. Early complications seen with mastectomies include wound infection, necrosis of skin flaps, and the accumulation of seromas. The incidence of postmastectomy lymphedema ranges from a low of 5.5% to a high of 80%, and it is increased with the more extensive the surgery. COMPLICATIONS OF GI SURGERY In addition to the complications already reviewed, patients who have undergone any GI surgery may have intestinal obstruction, intraabdominal abscess, pancreatitis, cholecystitis, fistulas, and tetanus. Certain procedures, such as anastomoses, bariatric surgery, placement of gastrostomy tubes, biliary tract surgery, other laparoscopic surgery, stoma creation, colonoscopy, and rectal surgery, are associated with specific complications.  INTESTINAL OBSTRUCTION Ileus, a functional obstruction of the bowel, is postulated to be the result of stimulation of the splanchnic nerves, leading to neuronal inhibi tion of coordinated intrinsic bowel wall motor activity. It is expected after any operation in which the peritoneal cavity is violated. After GI Tintinalli_Sec09_p0473-0562.indd 558 8/2/19 6:51 PM

bstruction of the bowel, is postulated to be the result of stimulation of the splanchnic nerves, leading to neuronal inhibi tion of coordinated intrinsic bowel wall motor activity. It is expected after any operation in which the peritoneal cavity is violated. After GI Tintinalli_Sec09_p0473-0562.indd 558 8/2/19 6:51 PM CHAPTER 87: Complications of General Surgical Procedures 559 surgery, small bowel tone usually returns to normal within 24 hours, and colonic function returns within 3 to 5 days. Ileus can also occur after non-GI procedures and is usually secondary to anesthetic agents; function returns to normal after 24 hours. Prolonged ileus can be caused by peritonitis, intra-abdominal abscess, hemoperitoneum, pneumonia, electrolyte imbalance, sepsis, and medications. Presenting symptoms of ileus include nausea, vomiting, obstipation, constipation, abdominal distention, and abdominal pain. When these symptoms are present in the first few days after surgery, they are most often due to adynamic ileus. The symptoms of adynamic ileus are most often mild and respond to nasogastric suction, bowel rest, and IV hydration. However, in cases of prolonged ileus, look for an underlying cause. Evaluation includes abdominal radiography to identify air-fluid levels, chest radiography, CBC, measurement of electrolyte levels, and urinalysis to search for secondary causes of ileus. Mechanical ileus of the bowel is most often secondary to adhesions, and is discussed in detail in Chapter 83, “Bowel Obstruction. ” In the ED, differentiating between functional ileus and mechanical bowel obstruc tion can be difficult. Abdominal CT scanning is helpful to identify ischemia or obstruction due to bowel strangulation. 10 Although CT is still more definitive, US has a sensitivity of approximately 85% and does not involve exposing the patient to radiation. 11 The results of CT may have an impact on the decision to manage the obstruction expectantly or not. Once the diagnosis of mechanical obstruction is suspected or confirmed, surgical consultation is indicated.  INTRA-ABDOMINAL ABSCESS Intra-abdominal abscess is caused most frequently by preoperative contamination, spillage of bowel contents during surgery, contamina tion of a hematoma, or postoperative anastomotic leaks. Patients may have abdominal pain, nausea, vomiting, ileus, abdominal distention, fever, chills, anorexia, and abdominal tenderness. If the diagnosis is suspected, obtain CT or US of the abdomen. The patient should receive broad-spectrum antibiotics (see Chapter 71, “ Acute Abdominal Pain”). Treatment is percutaneous drainage or surgical exploration.  PANCREATITIS Pancreatitis after abdominal surgery is secondary to direct manipulation or retraction of the pancreatic duct. Pancreatitis most commonly occurs after gastric resection, biliary tract surgery, and endoscopic retrograde cholangiopancreatography. Clinical presentation varies from mild nausea, vomiting, and abdominal discomfort to intractable vomiting, leukocytosis, and left-sided pleural effusion. Severe hemorrhage can cause lumbar pain accompanied by blue-gray discoloration of the skin in the flank area (Turner sign) or similar changes around the umbilicus (Cullen sign). Although the serum amylase level rises in acute pancreatitis, it is also elevated in patients with severe cholecystitis, renal insufficiency, intes tinal obstruction, perforated ulcer, or ischemic bowel. A serum lipase measurement may help to identify those with true pancreatitis, although it may be elevated in a patient with a perforated viscus and other conditions. Abdominal radiographs may show localized ileus in the region of the pancreas (sentinel loop). US and CT are useful in defining pancre atic fluid collections or abscesses.

easurement may help to identify those with true pancreatitis, although it may be elevated in a patient with a perforated viscus and other conditions. Abdominal radiographs may show localized ileus in the region of the pancreas (sentinel loop). US and CT are useful in defining pancre atic fluid collections or abscesses. In general, the treatment of postoperative pancreatitis is similar to the treatment of nonoperative pancreatitis (see Chapter 79, “Pancreatitis and Cholecystitis”).  CHOLECYSTITIS Postoperative complications related to the gallbladder include biliary colic, acute calculous cholecystitis, or acute acalculous cholecystitis. The cause of these disorders in the postoperative period is not clear. US studies of the gallbladder and pancreas should be performed to aid in the diagnosis. Acalculous cholecystitis is of particular concern in the postoperative period. The disorder seems to be more common in elderly men, but can occur in any sex and age group. There is no single test with adequate diagnostic accuracy to either diagnose or exclude the possibility of acalculous cholecysticis. 12 Clinicians must use a combination of high diagnostic suspicion, a good history and physical, as well as appropriate diagnositic testing. Signs and symptoms are similar to those for calculous cholecystitis. Results of liver function studies and the neutrophil count may be normal. Important findings on US include gallbladder enlargement, wall thickening, and pericholecystic fluid collection, but no gallstones. Hepatobiliary scintigraphy may be helpful. Early diagnosis is critical because early operative intervention can reduce morbidity and mortality.  FISTULAS Enterocutaneous fistulas can occur almost anywhere in the GI tract and are usually the result of technical complications or direct bowel injury. High-output fistulas can result in electrolyte abnormalities and volume depletion. Fistulas involving the proximal GI tract are frequently high output and are of the greatest concern. Sepsis is the other major complication. Most patients require admission, although many fistulas ultimately close spontaneously.  TETANUS Although most cases of tetanus in the United States occur after minor trauma, there have been numerous reports of tetanus after general surgical procedures. 13 Clostridium tetani is found in the GI tract of 1% of the population. During GI surgery, there is spillage of C. tetani. Proliferation of the organism is facilitated by the presence of devitalized tissue, blood clots, and surgical suture. Incubation can take from 0 to 73 days, at which time the toxin leads to clinical tetanus. The classic symptoms of tetanus, trismus, and opisthotonos may not be evident initially. Patients may present with nonspecific symptoms of abdominal discomfort, fever, and abdominal wall rigidity. Diagnosis is based on physical examination and a history of inadequate immunization.  ANASTOMOTIC LEAKS Anastomotic leaks occur most frequently after esophageal and colonic surgeries and least frequently after gastric and small intestinal anastomoses. The cause of anastomotic leakage is related mainly to surgical technique. Intrathoracic esophageal anastomotic leaks usually manifest within 10 days of surgery. The presentation is dramatic, with fever, chest pain, tachypnea, tachycardia, and possibly shock. Chest radiograph may reveal a pneumothorax with pleural effusion. Disruption can be confirmed by contrast esophagography using a water-soluble contrast agent. Even with immediate reoperation, morbidity and mortality rates are high. The signs and symptoms of gastric anastomotic leaks include abdominal pain, fever, leukocytosis, gastric outlet obstruction, hyperamylas emia, hyperbilirubinemia, peritonitis, and shock.

ontrast esophagography using a water-soluble contrast agent. Even with immediate reoperation, morbidity and mortality rates are high. The signs and symptoms of gastric anastomotic leaks include abdominal pain, fever, leukocytosis, gastric outlet obstruction, hyperamylas emia, hyperbilirubinemia, peritonitis, and shock. Plain radiographs may reveal pneumoperitoneum or air-fluid levels. Provide volume resuscitation, parenteral broad-spectrum antibiotics, and nasogastric tube drainage. Immediate surgery is required. Small intestinal anastomoses infrequently leak because of the excel lent blood supply and rapid healing of the area. However, if a leak occurs, the patient usually presents with local abscess formation or peritonitis. Treatment is immediate reoperation. Colorectal anastomoses are prone to disruption because of the large number of pathogenic bacteria found, the propensity for colonic distention, and the presence of only a single thin layer of circular muscle to support sutures. Patients usually present 7 to 14 days postoperatively with fever and abdominal pain. CT confirms the diagnosis. Patients should receive broad-spectrum parenteral antibiotics, nasogastric tube drainage, and adequate fluid resuscitation in preparation for surgery.  BARIATRIC SURGERY COMPLICATIONS Four main bariatric procedures are currently being performed for morbid obesity: laparoscopic adjustable gastric banding using the LAP- BAND® device (Allergan, Inc., Irvine, CA), sleeve gastrectomy, Rouxen-Y gastric bypass, and biliopancreatic diversion with duodenal switch. Overall operative mortality is <2%, but postoperative complications are common and are likely related to the technical skill of the surgeon. Common complications are listed in Table 87-4.15,16 Nausea, vomiting, and abdominal pain are common symptoms in ED patients with a history of bariatric surgery. In the first few postoperative Tintinalli_Sec09_p0473-0562.indd 559 8/2/19 6:51 PM

ons are common and are likely related to the technical skill of the surgeon. Common complications are listed in Table 87-4.15,16 Nausea, vomiting, and abdominal pain are common symptoms in ED patients with a history of bariatric surgery. In the first few postoperative Tintinalli_Sec09_p0473-0562.indd 559 8/2/19 6:51 PM 560 SECTION 9: Gastrointestinal Disorders weeks, consider life-threatening problems such as anastomotic leak and intra-abdominal bleeding. In patients with abdominal pain, tachycardia, or abdominal tenderness in the early postoperative period, a CT scan is often required to rule out these diagnoses. A common complication of the Roux-en-Y gastric bypass is dump ing syndrome, which can occur either right after the meal (early) or 2 to 4 hours later (late). Dumping symptoms occur when the pylorus is bypassed or removed. The hyperosmolar chyme contents of the stomach are dumped into the jejunum, causing rapid influx of extracellular fluid and an autonomic response. Patients experience nausea, epigastric dis comfort, palpitations, colicky abdominal pain, diaphoresis, and, in some cases, dizziness and syncope. Patients with early dumping symptoms experience diarrhea, whereas those with late dumping symptoms, 2 to 4 hours postprandially, usually do not. The late dumping syndrome is believed to be due to a reactive hypoglycemia. The mainstay of treat ment is dietary modification; consumption of small, dry meals; and separation of solids from liquids. In refractory cases, pyloroplasty can be tried. Most patients with dumping syndrome do not require hospital admission. Patients with gastroesophageal reflux disease present with burning epigastric pain that is aggravated by meals and unrelieved by vomiting. The syndrome is caused by reflux of bile into the stomach. Diagnosis is made clinically, but other potential diagnoses are often ruled out with endoscopic examination. Wernicke’s encephalopathy is a rare, but serious, complication that must be considered in a patient with a history of bariatric surgery who presents with any cerebellar signs, ophthalmoplegia, weakness, and/or memory disturbances. Although vitamin deficiencies are common with both Roux-en-Y gastric bypass and biliopancreatic diversion, vitamin 12 deficiency is the only one that requires emergent intervention.  NONBARIATRIC GASTRIC SURGERY Patients who have undergone partial or complete gastrectomy for non bariatric reasons can present with a few distinct syndromes: dumping syndrome, alkaline reflux gastritis, afferent loop syndrome, and postvagotomy diarrhea. Although these complications are rare, the symptoms can be disabling. Dumping syndrome as a result of nonbariatric gastric surgery is treated in the same way as dumping syndrome after bariatric procedures. Patients with afferent loop syndrome also develop severe epigastric pain 1 to 2 hours after eating, which is relieved by vomiting. The vomi tus is bilious, without food. The syndrome occurs in patients who have undergone gastroenterostomy (Billroth II) reconstruction after partial gastrectomy. Diagnosis is made by contrast radiography or endoscopy. Operative reconstruction is required. Truncal vagotomy usually results in increased bowel movements, but occasionally results in diarrhea. Diarrhea is variable in occurrence and not associated with food intake. It is often unpredictable and explosive, which can lead to weight loss, malnutrition, and severe social complications. The incidence of the diarrhea decreases with time, and treatment is mostly symptomatic. LAPAROSCOPIC SURGERY  BILIARY TRACT SURGERY More than 90% of all cholecystectomies are now performed laparo scopically.

ften unpredictable and explosive, which can lead to weight loss, malnutrition, and severe social complications. The incidence of the diarrhea decreases with time, and treatment is mostly symptomatic. LAPAROSCOPIC SURGERY  BILIARY TRACT SURGERY More than 90% of all cholecystectomies are now performed laparo scopically. Complications can occur after open and laparoscopic cho lecystectomies (Table 87-5); complications can also be related to the laparoscopic technique (Table 87-6). The evaluation of abdominal pain after cholecystectomy depends on the clinical condition of the patient. If there are signs of peritoneal irritation or fever, an injury to the biliary system is likely. Obtain an abdominal CT in addition to a CBC, electrolyte measurements, liver function tests, and serum lipase level. A collection of bile can be seen on CT, but endoscopic retrograde cholangiopancreatography is required to identify the specific site of the injury. Depending on the endoscopic TABLE 87-4 Complications of Gastric Bypass Procedures Complication Presentation Signs and Symptoms Diagnostic Test Anastomotic leak 0–28 d Tachycardia, fever, abdominal pain, nausea, vomiting, hypotension Clinical suspicion. CT scan or upper GI study is useful, but may be negative Intra-abdominal bleeding 0–28 d Tachycardia, abdominal pain, hypotension CT scan or upper GI study Intraluminal GI bleeding Hours to months Melena, hematemesis, hypotension, altered mental status Emergent endoscopy Ventral hernia Anytime Pain at incision site or palpable hernia Clinical diagnosis Bowel obstruction 1 wk to 8 mo Nausea, vomiting, abdominal pain Plain radiography or CT looking for air-fluid levels Stomal stenosis 2 mo to 1 y Postprandial abdominal pain, nausea, vomiting Endoscopy or upper GI study Stomal ulcer Months to years Abdominal pain, upper GI bleed Endoscopy Stomal obstruction Months to years Nausea and vomiting with solids and liquids Endoscopy Cholelithiasis/cholecystitis Months to years Abdominal pain with fatty foods, fever, tachycardia US Dumping syndrome Anytime Diarrhea, abdominal cramps, nausea, vomiting, tachycardia, palpitations, flushing, dizziness, syncope Clinical diagnosis or endoscopy Vitamin deficiencies Months to years Weakness, bone loss, anemia, fractures, neuropathy, hypercalcemia CBC, iron studies, parathyroid hormone studies, vitamin levels Gastric slippage Days to years Abdominal pain, dysphagia, food intolerance, reflux Upper GI study Esophageal, gastric pouch dilation After band adjustment Epigastric abdominal pain, dysphagia, reflux Upper GI study Gastric necrosis Anytime Abdominal pain Upper GI study TABLE 87-5 Complications of Cholecystectomy •  Bile  leak •  Bile  duct stricture •  Bleeding •  Bowel  injury •  Intra-abdominal  abscess •  Acute  myocardial infarction •  Pancreatitis •  Peritonitis •  Pulmonary  complications •  Retained  common duct stones or stones spilled into peritoneum •  Splenic  injury •  Umbilical  hernia •  Wound  infection Tintinalli_Sec09_p0473-0562.indd 560 8/2/19 6:51 PM

eeding •  Bowel  injury •  Intra-abdominal  abscess •  Acute  myocardial infarction •  Pancreatitis •  Peritonitis •  Pulmonary  complications •  Retained  common duct stones or stones spilled into peritoneum •  Splenic  injury •  Umbilical  hernia •  Wound  infection Tintinalli_Sec09_p0473-0562.indd 560 8/2/19 6:51 PM CHAPTER 87: Complications of General Surgical Procedures 561 retrograde cholangiopancreatography results, reoperation may be necessary. Small collections of bile may require only observation or percutaneous drainage. Patients presenting soon after cholecystectomy with pain, pancreati tis, and/or jaundice may have retained common duct stones. If US does not demonstrate a dilated common bile duct or if CT does not reveal an intra-abdominal collection of fluid, an endoscopic retrograde cholan giopancreatography should be performed. Endoscopic sphincterotomy is usually an effective means of dealing with retained stones. Patients presenting late after cholecystectomy with fever, pain, and jaundice may have bile duct stricture. Diagnosis requires endoscopic retrograde cholangiopancreatography. Insertion of stents is usually tried first, but surgical repair may be necessary. A more recent concern has been the spillage of gallstones into the peritoneal cavity at the time of surgery. Initially, such stones were thought to be innocuous. However, they have been linked to abdominal pain, pelvic pain, dysmenorrhea, intra-abdominal abscess, colocutaneous fistula, and implantation into the ovary with subsequent infertility.  OTHER LAPAROSCOPIC SURGERIES Laparoscopic techniques are used for cholecystectomy, appendectomy, colon resection, antireflux surgery, herniorrhaphy, fundoplication, and most gynecologic and urologic surgical procedures. As with any laparoscopic procedure, there are risks related to the pneumoperitoneum and insertion of the trocar (Table 87-6). In addition to the potential for bowel injury, major vessel injury, and splenic injury, gynecologic and urologic procedures carry a risk of injury to the urinary bladder and ureters. STOMAS The two most commonly placed stomas are the ileostomy and the colostomy. Problems with stomas can be quite debilitating. Most acute complications are related to technical errors of stoma placement. Other complications include the development of Crohn’s disease or carcinoma at the stomal site, stomal ischemia and necrosis, peristomal skin irrita tion, peristomal hernia, and stomal prolapse. Ischemia and stomal necrosis are manifested very early in the post operative course. The cause is inadequate blood supply to the stoma. Normally, the stoma is pink, without evidence of cyanosis. Any evidence of compromised blood flow requires surgical evaluation. Peristomal maceration and skin destruction are most likely secondary to a poor seal of the stomal appliance. Consult an enterostomal therapist for a properly fitting appliance. Stomal prolapse can occur with ileostomies and colostomies. The cause is usually inadequate fixation of the intra-abdominal portion or too large an abdominal wall opening. Patients present with stoma pro trusion, with or without pain. Examine the stoma for viability. It should be pink and painless. If the tissue is viable, attempt reduction and follow with surgical consultation. Definitive therapy requires surgical revision. Parastomal hernias can develop if the abdominal wall opening is too large. Determine if the hernia is incarcerated, attempt reduction, and consult a surgeon. Definitive therapy requires local reconstruction of the orifice. COLONOSCOPY Potential complications of colonoscopy include hemorrhage, perfora tion, retroperitoneal abscess, pneumoscrotum, pneumothorax, volvulus, postcolonoscopy distention, splenic rupture, appendicitis, bacteremia, and infection.

d consult a surgeon. Definitive therapy requires local reconstruction of the orifice. COLONOSCOPY Potential complications of colonoscopy include hemorrhage, perfora tion, retroperitoneal abscess, pneumoscrotum, pneumothorax, volvulus, postcolonoscopy distention, splenic rupture, appendicitis, bacteremia, and infection. 18 Hemorrhage is the most common complication and can be secondary to polypectomy procedures, biopsies, laceration of the mucosa by the instrument, or tearing of the mesentery or spleen. If the bleeding is intraluminal, the patient will develop rectal bleeding. Patients with mesenteric or splenic injury have signs of intra-abdominal bleeding. Treatment of intraluminal bleeding depends on the magnitude of hemorrhage. Intra-abdominal bleeding requires emergency laparotomy. Colon perforation with pneumoperitoneum usually is evident immediately, but can take several hours to manifest. 19 Perforation is usually secondary to intrinsic disease of the colon (e.g., diverticulitis) or to vigorous manipulation during the procedure. Most patients require immedi ate laparotomy, but in some patients presenting late (1 to 2 days later) without signs of peritonitis, hospital observation may be appropriate. RECTAL SURGERY Patients who have undergone hemorrhoidectomy frequently have problems with postoperative urinary retention, the management of which has been discussed previously in the section “Urinary Retention. ” Three other problems that can occur are constipation, rectal hemorrhage, and rectal prolapse. The management of constipation in a patient who has undergone rectal surgery is no different from management in any other patient. Perform gentle rectal examination to identify fecal impaction, and if present, remove the impaction. Otherwise, enemas can be used. Post hemorrhoidectomy rectal hemorrhage can occur immediately post operatively but may be delayed up to weeks after the surgery. Causes of delayed bleeding include sepsis of the pedicle, disruption of a clot, and sloughing of tissue. Bleeding can be scant or massive. Temporary balloon tamponade using a Foley catheter may temporize until surgical ligation of the involved vessel is performed. Mucosal prolapse occurs when the surgeon has not removed all redundant mucosa during hemorrhoidectomy and is much more common than rectal prolapse. Local treatment by a surgeon is usually corrective. Rectal prolapse can occur after any anorectal surgical procedure and likely is related to injury of the puborectalis muscle. The diagnosis is obvious on examination. The treatment is reduction (see Chapter 85, “ Anorectal Disorders”) and surgical consultation. Infection after anorectal surgery is surprisingly uncommon. The patient usually complains of increasing pain and fever. Examination of the area is necessary to detect an abscess or cellulitis. Fournier’s gangrene may follow anorectal surgery. If this is suspected, give broadspectrum parenteral antibiotics immediately. The patient must undergo immediate surgical debridement. REFERENCES The complete reference list is available online at www.TintinalliEM.com. TABLE 87-6 Complications of Laparoscopy Related to pneumoperitoneum •  Cardiac  arrhythmias during the procedure •  Subcutaneous  emphysema •  Pneumothorax •  Pneumomediastinum •  Carbon  dioxide embolization Related to insertion of needle and trocar •  Bleeding  from trocar site •  GI  tract injuries •  Laceration •  Intestinal  burns •  GU  tract injuries •  Major  vessel injuries •  Hernia  from trocar site •  Wound  infection Miscellaneous •  Retained  intra-abdominal gallstones •  Biliary  cutaneous fistula •  Chronic  pain •  Infertility •  Cholelithiasis •  Metastases  to the trocar site Tintinalli_Sec09_p0473-0562.indd 561 8/2/19 6:51 PM

urns •  GU  tract injuries •  Major  vessel injuries •  Hernia  from trocar site •  Wound  infection Miscellaneous •  Retained  intra-abdominal gallstones •  Biliary  cutaneous fistula •  Chronic  pain •  Infertility •  Cholelithiasis •  Metastases  to the trocar site Tintinalli_Sec09_p0473-0562.indd 561 8/2/19 6:51 PM Tintinalli_Sec09_p0473-0562.indd 562 8/2/19 6:51 PM This page intentionally left blank