GASTROINTESTINAL COMPLICATIONS

1. GASTROINTESTINAL COMPLICATIONS

2. scope • Early Postoperative Bowel Obstruction • Acute Abdominal Compartment Syndrome • Postoperative Gastrointestinal Bleeding • Stomal Complications • Anastomotic Leak • Intestinal Fistula • Pancreatic Fistulas

3. scope • Early Postoperative Bowel Obstruction • Acute Abdominal Compartment Syndrome • Postoperative Gastrointestinal Bleeding • Stomal Complications • Anastomotic Leak • Intestinal Fistula • Pancreatic Fistulas

4. Early Postoperative Bowel Obstruction

5. Early Postoperative Bowel Obstruction • Obstruction occurring within 30 days after surgery • Functional Obstruction • adynamicor paralytic ileus • Mechanical Obstruction • luminal, mural, or extraintestinal

6. Postoperative bowel motility • Small bowel motility within several hours • Gastric motility within 24 to 48 hours • Colonic motility within 48 to 72 hours Presence of bowel sounds, flatus, and bowel movements.

7. 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)   

8. Causes of Mechanical postoperative small bowel obstruction • Adhesions (92%) • Phlegmonor abscess • Internal hernia • Intestinal ischemia • Intussusception

9. Differentiation between adynamicileus and mechanical obstruction Adynamicileus -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 valvulaeconniventesin the bowel proximal to the point of obstruction and little or no gas in the bowel distal to the obstruction

10. Management • Three-step approach • Resuscitation • Investigation • Surgical intervention

11. Treatment • Adynamicileus • expectantly waiting for resolution • Partial mechanical small bowel obstruction • initially managed expectantly 7 to 14 days, • If stable and clinical and radiologic improvement continues • Emergency relaparotomy • (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.

12. scope • Early Postoperative Bowel Obstruction • Acute Abdominal Compartment Syndrome • Postoperative Gastrointestinal Bleeding • Stomal Complications • Anastomotic Leak • Intestinal Fistula • Pancreatic Fistulas

13. Acute Abdominal Compartment Syndrome

14. Acute Abdominal Compartment Syndrome • Increased intra-abdominal pressure greater than 12 mm.Hg • Associated with • Rising peak airway pressure • Hypoxia • Difficult ventilation • Oliguriaor anuria

15. Most commonAbdominal Compartment Syndrome • Multiple trauma • ileus, coagulopathy, capillary leak, and massive fluid resuscitation and transfusion • ICU setting (nontrauma setting) • ascites, retroperitoneal hemorrhage

16. Presentation and Diagnosis • Difficulty breathing ,elevated peak airway pressure, hypoxia, worsening hypercapnia • Abdomenal distention and tense • Reduced Cardiac output • Oliguria • Neurologic deterioration

17. 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   

18. Treatment • surgical • organ dysfunction + intra-abdominal hypertension (15 to 20 mm Hg ) • Decompression • abdomen is tense + signs of extreme ventilatory dysfunction + oliguria

19. scope • Early Postoperative Bowel Obstruction • Acute Abdominal Compartment Syndrome • Postoperative Gastrointestinal Bleeding • Stomal Complications • Anastomotic Leak • Intestinal Fistula • Pancreatic Fistulas

20. Postoperative Gastrointestinal Bleeding

21. Postoperative Gastrointestinal Bleeding • Stress ulceration is a serious complication • Clinically significant bleeding • Hemodynamic instability • Transfusion of blood products • Operative intervention less than 5% • Associated with significant mortality

22. Risk Factors for Stress Erosions • Multiple trauma    • Head trauma    • Major burns    • Clotting abnormalities    • Severe sepsis    • Systemic inflammatory response syndrome    • Cardiac bypass    • Intracranial operations

23. Presentation and Diagnosis • Melena • Hematemesis • Hematochezia • Hemodynamic compromise • Decresehematocrit

24. Treatment The basic principles of management of postoperative GI bleeding include the following:    1.    Fluid resuscitation 2.    Checking and monitoring clotting parameters and correcting abnormalities 3.    Identification and treatment of aggravating factors 4.    Transfusion of blood products    5.    Identification and treatment of the source of the bleeding

25. scope • Early Postoperative Bowel Obstruction • Acute Abdominal Compartment Syndrome • Postoperative Gastrointestinal Bleeding • Stomal Complications • Anastomotic Leak • Intestinal Fistula • Pancreatic Fistulas

26. Stomal Complications

27. Etiology • Stomas are widely used in the treatment of colorectal, intestinal, and urologic diseases • ileostomy, colostomy, or urostomy • occur within 30 days after surgery

28. Stomal Complications

29. 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, barriers Candida dermatitis Nystatin Traumatic dermatitis patient education ,application of a skin barrier Allergic dermatitis symptomatic relief with oral antihistamine, topical or oral steroid therapy

30. 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 Maneuvers Tunneling 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

31. scope • Early Postoperative Bowel Obstruction • Acute Abdominal Compartment Syndrome • Postoperative Gastrointestinal Bleeding • Stomal Complications • Anastomotic Leak • Intestinal Fistula • Pancreatic Fistulas

32. Anastomotic Leak

33. Etiology • level of the anastomosis • esophageal, pancreatico-enteric, and colorectal • Microcirculation at resection margins • Intraluminal distention • Emergency bowel surgery

34. Presentation and Diagnosis • The clinical manifestations result of intestinal contents • purulent discharge • Malaise, fever, abdominal pain, ileus, localized erythema around the surgical incision, and leukocytosis, • Bowel obstruction,pneumaturia, fecaluria, and pyuria

35. Treatment • Resuscitation is started immediately • crystalloid fluids , blood transfusion • NPO • NG tube • Incised and drained • Reoperation (peritonitis, intra-abdominal hemorrhage, suspected intestinal ischemia)

36. scope • Early Postoperative Bowel Obstruction • Acute Abdominal Compartment Syndrome • Postoperative Gastrointestinal Bleeding • Stomal Complications • Anastomotic Leak • Intestinal Fistula • Pancreatic Fistulas

37. Intestinal Fistula

38. Intestinal Fistula • Abnormal communication between • two epithelializedsurfaces or • two digestive organs or • hollow organ and the skin • most commonly iatrogenic

39. Presentation and Diagnosis Severity 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

40. 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

41. scope • Early Postoperative Bowel Obstruction • Acute Abdominal Compartment Syndrome • Postoperative Gastrointestinal Bleeding • Stomal Complications • Anastomotic Leak • Intestinal Fistula • Pancreatic Fistulas

42. Pancreatic Fistulas

43. Pancreatic Fistulas • Diagnosis • Cloudy fluid with a high amylase content • management • Octreotide therapy • ERCP • Fistuloenterostomy

44. HEPATOBILIARY COMPLICATIONS

45. Bile Duct Injuries • The most dreaded complication of gallbladder surgery is injury to the extrahepatic bile duct • Iaparoscopiccholecystectomy 0.4% to 0.7% • Open cholecystectomy 0.2%

46. 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 • Percutaneoustranshepaticcholangiography • Magnetic resonance cholangiopancreatography

47. Bile Duct Injuries • Prevention • proper surgical technique + adequate identification of the anatomy • Treatment • adequate resuscitation, antibiotics, and drainage, • Sphincterotomyor stent • Surgical intervention

48. EAR, NOSE, THROAT COMPLICATIONS

49. scope • Epistaxis • Acute Hearing Loss • Nosocomial Sinusitis • Parotitis

50. Epistaxis • Associated with leukemia and hemophilia, excessive anticoagulation, and hypertension. • Two general categories: • anterior • Posterior • Management • Firm pressure to the nasal ala and held for 3 to 5 minutes • packing with strip gauze for 10 to 15 minutes • Foley catheter with a 30-mL balloon • ligation of the sphenopalatine a. or anterior ethmoidal a.