Chapter 49. Complications of General Surgical Procedures

As surgical procedures take place more commonly in outpatient settings and inpatient lengths of stay decrease, the emergency physician will encounter an increasing number of postoperative patients and their complications. Common clinical situations presenting to the emergency department include: fever, respiratory complications, genitourinary complaints, wound infections, vascular problems, and complications of drug therapy. Specific problems not covered in other chapters of this book are discussed here.

Fever

The causes of postoperative fever are the 5 Ws: wind (respiratory), water (urinary tract infection [UTI]), wound, walking (deep venous thrombosis [DVT]), and wonder drugs (drug fever or pseudomembranous colitis [PMC]). Fever in the first 24 hours is usually due to atelectasis, but wound infections with necrotizing fasciitis, or clostridial infections must also be considered. In the first 72 hours, pneumonia, atelectasis, intravenous catheter-related thrombophlebitis, and infections are the major causes. UTIs are seen 3 to 5 days postoperatively. DVT does not typically occur until 5 days after the procedure, and wound infections generally manifest 7 to 10 days after surgery. Antibiotic-induced PMC is seen 6 weeks after surgery.

Respiratory Complications

Postoperative pain, splinting, and inadequate clearance of secretions contribute to the development of atelectasis. Fever, tachypnea, tachycardia, and mild hypoxia may be seen. Pneumonia may develop 24 to 96 hours later (see Chapter 30). Pulmonary embolism can occur any time postoperatively (see Chapter 25).

Genitourinary Complications

UTIs may occur after any procedure, but are more common after instrumentation of the GU tract or bladder catheterization. Elderly men, patients undergoing anorectal surgery and those receiving spinal or epidural anesthesia are at increased risk for urinary retention presenting with lower abdominal pain and the inability to urinate (see Chapter 54). Decreased urine output should raise concerns for renal failure resulting from multiple causes (see Chapter 50). Volume depletion is the most common cause.

Wound Complications

Hematomas result from inadequate hemostasis leading to pain and swelling at the surgical site. Careful evaluation, including possibly opening a small portion of the wound, to rule out infection must be undertaken. Seromas are collections of clear fluid under the wound. Wound infections may present with pain, swelling, erythema drainage and tenderness. Risk factors include extremes of age, diabetes, poor nutrition, necrotic tissue, poor perfusion, foreign bodies, and hematomas. Necrotizing fasciitis should be considered in a systemically ill patient with rapidly expanding infection (see Chapter 90). Superficial or deep fascial wound dehiscence can occur due to diabetes, poor nutrition, chronic steroid use, and inadequate or improper closure of the wound. Operative exploration may be required to determine the extent of dehiscence.

Vascular Complications

Superficial thrombophlebitis manifests with erythema, warmth, and fullness of the affected vein. It usually occurs in the upper extremities after intravenous catheter insertion or in the lower extremities due to stasis in varicose veins. DVT commonly occurs in the lower extremities postoperatively (see Chapter 25).

Drug Therapy Complications

Numerous medications may lead to fever without any associated concomitant infection. Additionally, many antibiotics prescribed perioperatively can cause antibiotic-induced diarrhea. PMC, the most serious diarrheal complication, is caused by Clostridium difficile toxin. Watery or even bloody diarrhea, fever, and crampy abdominal pain are the usual complaints.

Postoperative patients with fever should have an evaluation focusing on the elements detailed above. Patients with suspected respiratory complications should have chest x-rays. Radiographs may demonstrate atelectasis, pneumonia, or pneumothorax. Additional imaging like CT or ultrasound may be indicated based on the operative procedure performed.

Patients with oliguria or anuria should be evaluated for signs of hypovolemia or urinary retention. Diagnosis of PMC is established by demonstrating C difficile cytotoxin in the stool. Nevertheless, in 27% of cases, the assay may be negative.

Contact the surgeon who performed the procedure to discuss patients who present with postoperative complications. Patients who are toxic appearing, have underlying debilitating conditions or elderly require hospitalization.

1. Patients with mild atelectasis and no evidence of hypoxemia may be managed as outpatients with pain control and increased deep breathing.

2. Postoperative pneumonia may be polymicrobial. Admission and antibiotic therapy to cover nosocomial infections such as Pseudomonas and methicillin-resistant Staph aureus is usually recommended (see Chapter 30).

3. Nontoxic patients with UTI can be managed as outpatients with oral antibiotic therapy geared toward appropriate organisms. Consider gram-positive flora when instrumentation has occurred. Ill appearing patients require admission.

4. Wound hematomas may require removal of some sutures and evacuation. Consultation with the surgeon before treatment is appropriate. Seromas can be confirmed and treated with needle aspiration. Admission may not be necessary for either of these processes.

5. Wound infections can often be treated with oral antibiotics unless the patient shows signs of systemic toxicity or carries significant comorbidities. Perineal infections are often polymicrobial requiring parenteral antibiotics and admission. Immediate surgical debridement and broad-spectrum parenteral antibiotics are indicated for necrotizing fasciitis (see Chapter 90).

6. Superficial thrombophlebitis is treated as an outpatient with NSAIDs, local heat application and elevation. Antibiotics may be indicated if surrounding cellulitis or lymphangitis are noted. Suppurative thrombophlebitis requires hospitalization and surgical excision.

7. Patients with suspected antibiotic-induced PMC will require fluid resuscitation and likely empiric therapy. Oral or intravenous metronidazole and oral vancomycin are treatments for this condition.

Complications of Breast Surgery

Although overall rates of complications are low following breast surgery, wound infections, hematomas, seromas, pneumothorax, and necrosis of the skin flaps may be seen. Lymphedema of the ipsilateral arm may occur after mastectomy.

Complications of Gastrointestinal Surgery

Stimulation of the splanchnic nerves during intraabdominal surgery may lead to dysmotility and a paralytic ileus. After gastrointestinal surgery, small bowel tone returns to normal within 24 hours and colonic function within 3 to 5 days.

Patients develop nausea, vomiting, constipation, abdominal distention and pain. An adynamic ileus typically resolves after bowel rest, nasogastric suction and intravenous hydration. Prolonged ileus should prompt an investigation for nonneuronal causes like peritonitis, intra-abdominal abscesses, hemoperitoneum, pneumonia, sepsis, electrolyte imbalance, or medications. Abdominal imaging, complete blood cell count, electrolytes, blood urea nitrogen, creatinine, and urinalysis should be obtained. Occasionally, surgical intervention may be necessary for obstruction due to adhesions.

Intraabdominal abscesses are caused by preoperative contamination, intraoperative spillage of bowel contents or postoperative anastomotic leaks. Diagnosis can be confirmed by computed tomography or ultrasonography. Antibiotic therapy as well as either percutaneous or surgical drainage will be required.

Pancreatitis occurs especially after direct manipulation of the pancreatic duct. The clinical spectrum extends from mild nausea and vomiting to severe abdominal pain and hemodynamic instability. Complications like pleural effusion and severe hemorrhage may occur. Serum amylase measurements are not specific and measurement of a lipase is more reliable.

Cholecystitis and biliary colic have been reported as postoperative complications. Elderly patients are more prone to develop acalculous cholecystitis. Characteristic lab findings of a calculous or obstructive process may be absent.

Fistulas, internal or external, may result from either technical complications or direct bowel injury. Fistulas can lead to electrolyte abnormalities and require surgical consultation and possible hospitalization. Anastomotic leaks occur primarily after esophageal, gastric and colonic procedures and can cause devastating consequences as a result of infection. Esophageal leaks occur within 10 days of the operation and carry very high morbidity and mortality.

Complications of bariatric surgery remain common although mortality after the procedures is low. In the weeks after surgery, patients are at risk for leaks and bleeding. Dumping syndrome is seen in gastric bypass procedures due to the rapid influx of hyperosmolar chyme into the small intestine resulting in fluid sequestration and hypovolemia. Patients experience nausea, vomiting, epigastric discomfort, palpitations, dizziness, and sometimes syncope. Other complications include gastroesophageal reflux, vitamin and electrolyte deficiencies, ulcers, obstruction, gastric slippage, and band erosion.

Complications of laparoscopic procedures include problems related to pneumoperitoneum, traumatic injury from insertion of the needle and trocar, and retained stones after cholecystectomy.

Complications of transabdominal feeding tubes and percutaneous endoscopic gastrostomy tubes include infections, hemorrhage, peritonitis, aspiration, wound dehiscence, sepsis, and obstruction of the tube. Dislodged tubes should be replaced with the appropriately sized tube (same type if possible, or a temporary foley catheter).

Acute complications arising from stomas (ileostomy or colostomy) are usually due to technical errors of stoma placement. Later complications can be from the underlying disease such as Crohn's disease or cancer. Ischemia, necrosis, skin maceration, bleeding, parastomal hernia, and prolapse may be seen.

The most common complications of colonoscopy are hemorrhage and perforation. Hemorrhage occurs typically due to polypectomy, biopsies, or mucosal lacerations or tearing. Perforation may be immediately apparent or symptoms may be delayed for several hours to days. Upright chest or abdominal radiographs may reveal free air but CT should be obtained if the films are unrevealing and suspicion is high.

Rectal surgery complications include urinary retention (frequently after hemorrhoidectomy), constipation, prolapse, bleeding, and infections.

Tetanus has been known to occur in surgical wounds although, by far, this rare disease is more common after minor trauma.