Complications and management of upper GI 高雄醫學大學附設醫院胃腸及一般外科謝建勳

Transcription

1 Complications and management of upper GI surgery 高雄醫學大學附設醫院胃腸及一般外科謝建勳

2 Introduction-1 Any surgical intervention, elective or acute, laparoscopic or open, may lead to postoperative complications. Depends on the age and general health of the patient, the type of anesthesia, surgical site and the procedure. Abdominal procedures may cause a variety of postoperative complications related to the surgical site stomach, biliary tract or bowel.

3 Introduction-2 Although the incidence of complicated peptic ulceration and gastric cancer have declined significantly over the past several decades, gastric operations for treatment of morbid obesity have undergone explosive growth Complications from gastric operations are common and frequent severe

4 What Is a Surgical Complication? World J Surg (2008) 32: negative outcome Sequela any deviation from the normal postoperative course an undesirable, unintended, and direct result of an operation affecting the patient which would not have occurred had the operation gone as well as could reasonably be hoped. any deviation from the ideal postoperative course that is not inherent in the procedure and does not comprise a failure to cure.

5 Risk Factors for 30-Day Hospital Readmission among General Surgery Patients 163/1442 (11.3%) patients were readmitted within 30 days of discharge. The most common reasons for readmission were gastrointestinal problem/complication (27.6%), surgical infection(22.1%), and failure to thrive/malnutrition (10.4%). Post-surgical complication contribute significantly to hospital profit margins (J Am Coll Surg 2012;215: )

6 Classification of Surgical Complications (Dindo et al, Ann Surg 2004)

7 Diagnosis and Treatment of Major Abdominal Complications --Multidisciplinary Work Adequate treatment will involve a good coordination of the three disciplines involved in treatment: The surgeon The intervention radiologist The gastroenterologist

8 Immediate Complications Primary hemorrhage: either starting during surgery or following postoperative increase in blood pressure - replace blood loss and may require return to theatre to re-explore the wound. Basal atelectasis: minor lung collapse. Shock: blood loss, acute myocardial infarction, pulmonary embolism or septicemia. Low urine output: inadequate fluid replacement intra-operatively and postoperatively

9 Early Complications Acute confusion: exclude dehydration and sepsis. Nausea and vomiting: analgesia or anaesthetic-related; paralytic ileus. Fever Secondary hemorrhage: often as a result of infection. Pneumonia. Wound or anastomosis dehiscence. DVT. Acute urinary retention. Urinary tract infection (UTI). Postoperative wound infection. Bowel obstruction due to fibrinous adhesions. Paralytic Ileus.

10 Late Complications Bowel obstruction due to fibrous adhesions. Incisional hernia. Persistent sinus. Recurrence of reason for surgery - eg, malignancy

11 Nonsurgical and surgical complications Gastric motility disorder Pulmonary problems Pyrexia of unknown origin Thrombocytosis Gastric content aspiration Pain Chest expansion poor Oliguria Thrombophilia Urine retention Disuse atrophy of muscle Pulmonary collapse Renal failure, acute Embolism Nausea and vomiting Anastomotic leak Intra-abdominal abscess Wound infection Ileus Hemorrhage Incisional hernia

12 Major complications after digestive surgery 1. Leakage of an anastomosis 2. Bleeding in the abdominal cavity or in the tract 3. Intraperitoneal abscesses, or surgical site infections and wound dehiscence 4. Mechanical bowel obstruction

13 Anastomotic leakage or breakdown Small leaks are common, causing small localized abscesses with delayed recovery of bowel function. It is often diagnosed late in the postoperative period. It usually resolves with IV fluids and delayed oral intake but may need surgery. Major breakdown causes generalized peritonitis and progressive sepsis needing surgery for peritoneal toilet and antibiotics. A local abscess can develop into a fistula.

14 Etiology: Anastomotic Leak 1. Poor surgical technique 2. Distal obstruction 3. Inadequate proximal decompression Manifest as localized or generalized peritonitis Treatment: Small leaks: 1. Conservative / NPO 2. Proximal decompression 3. Antibiotic Large leaks: 1. Surgical intervention

15 Enteric Fistula-1 Abnormal communication between two lining epithelium Etiology: 1. Anastomotic leak 2. Poor blood supply 3. Trauma 4. Infection 5. Inadvertent suturing of bowel wall while closing the fascia 6. carcinoma

16 Enteric Fistula-2 1. Gastric and duodenal fistula: Subtotal gastrectomy ---> gastrojejunal and duodenal stump Due to suture line failure Treatment: NPO / TPN Place NG tube past the leak and give elemental diet Antibiotic Majority close spontaneously within 6 wks Failure to close 1. distal obstruction 2. large leak 3. Infection 4. Cancer Surgery resect the fistula and the bowel segment then reconstruction

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18 Laparoscopic repair of PDU

19 Abdominal wound picture Right J-P jejunostomy Drain tube Left J-P R t pigtail

20 Risk factor in perforated duodenal Age >65 years ASA stage III or IV ulcer Surgery after onset >24 hours All 3 factors-- Mortality 61%` Complications are more frequent and more severe when large defect or penetration into other organs require resectional therapy

21 Postoperative hemorrhage in gastric surgery Inadvertent injury of spleen Local packing or suturing Splenectomy increased pancreatic fistula, Pancreatitis or subhrenic abscess Intraluminal hemorrhage Cause: suture line bleeding from submucosal vessel Gastric lavage Endoscopic hemostasis, Angiographic embolization Reoperation for uncontrollable bleeding

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23 Mechanical bowel obstruction Early mechanical obstruction: caused by a twisted or trapped loop of bowel or adhesions occurring approximately one week after surgery. It may settle with nasogastric aspiration plus IV fluids or progress and require surgery. Late mechanical obstruction: adhesions can organize and persist, commonly causing isolated episodes of small bowel obstruction months or years after surgery.

24 Mechanical bowel obstruction-1 1. Stomal obstruction (due to local edema) Causes of edema: a. Electrolyte imbalance b. Incomplete hemostasis c. Hypoprotenemia d. Leakage from anastomosis e. Inadequate proximal decompression f. Incorporation of too much tissue w/in the suture

25 Mechanical bowel obstruction-2 2. Other causes: a. Intussusception b. Volvulus Symptoms c. Post-operative adhesion d. Herniation 3 rd 4 th postop day Abdominal distention, pain, increase NG tube drainage, bilious material

26 Mechanical bowel obstruction-3 Treatment: 1. Proximal decompression (NPO / NG Tube) 2. Correct fluid and electrolyte imbalance 3. Hyperalimentation (TPN) No improvement > Re-operation

27 Postoperative fibrous adhesion The most common cause of bowel obstruction Could be partial or complete Fluid and electrolyte imbalance Usually present a colicky abdominal pain with abdominal distention w/o bowel movement. Late cases might present with silent abdomen Treatment: NGTube decompression, NPO, correct fluid and electrolyte imbalance Surgical intervention adhesiolysis or resection

28 Delayed return of bowel function (Ileus) Temporary disruption of peristalsis: nausea, anorexia or vomiting Usually appears with the re-introduction of fluids. Ileus or adynamic obstruction The more prolonged extensive form with vomiting and intolerance to oral intake needs to be distinguished from mechanical obstruction Radiological contrast study Conservative treatment

29 Wound Complications Dehiscence Seroma Hematoma Infection Incisional Hernia

30 Incisional hernia This occurs in 10-15% of abdominal wounds, usually appearing within the first year but can be delayed by up to 15 years after surgery. Risk factors include obesity, distension and poor muscle tone, wound infection and multiple use of the same incision site. It presents as a bulge in the abdominal wall close to a previous wound. It is usually asymptomatic but There may be pain, especially if strangulation occurs. It tends to enlarge over time and become a nuisance. Management: surgical repair where there is pain, strangulation or nuisance. The use of laparoscopic techniques and biosynthetic mesh is being evaluated.

31 Incisional Hernia

32 Hernia at the trocar site

33 Gastric resection for cancer High rate of postoperative complication Mortality rate decreased only in high volume Overall hospital stay decreased

34 Postgastrectomy syndromes-1 1. Result from the loss of reservoir function, denervation, disruption of the pyloric mechanism and the type of reconstruction. 2. About 25% of all patients following gastric surgery 3. Only 1-4% will develop severe, debilitating symptoms

35 Postgastrectomy syndromes-2 Dumping syndrome Roux stasis syndrome Afferent loop syndrome Efferent loop syndrome Postvagotomy diarrhea Chronic gastric atony (Gastric paresis) Alkaline reflux gastritis

36 Gastric paresis Can occur early in as many as half of patients after gastric resection. Unable to tolerate diet 7 to 14 days after surgery.. Metabolic --> electrolyte abnormalities (K+, Mg++, Ca++), endocrine (hypothyroid, hyperglycemia), medications (opiates, etc.). Functional --> gastric outlet obstruction, truncal vagotomy Mechanical --> most common. stomal edema, small leak, adhesions, kinking, hematoma, intussusception, stricture. Dx --> must include at least EGD and gastric emptying studies. UGI Tx --> smaller meals, Reglan (DA antagonist), Erythromycin (motilin agonist), Domperidone (Ach release),ppi Near-total or even total gastrectomy. Most advocate R-Y and completion vagotomy.

37 Gastric paresis after gastric excision

38 Afferent Loop Syndrome-1 Acute type 1. Complete obstruction of afferent limb-- by adhesions, ulcer, tumor, internal herniation 2. Severe RUQ or epigastric pain, hyperamylasemia- confuse with pancreatitis. 3. Perforation peritonitis-- death 4. Diagnosis --> UGI, Endoscopy& Abdominal CT 5. Prompt surgical intervention to correct underlying cause.

39 Afferent Loop Syndrome-2 Chronic type From partial obstruction. Much more common. Severe postprandial pain, bile and pancreatic secretions build in afferent limb until the intraluminal pressure overcomes the obstruction, resulting in projectile bilious vomiting that provides immediate relief of pain. Blind Loop Syndrome --> bacterial overgrowth of the chronically obstructed limb, binds with B12 and deconjugates bile acids, leads to megaloblastic anemia and diarrhea

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41 Diagnosis of ALS

42 Treatment of ALS (AJR 2012;199:W761) (Digestive endoscopy 2013;25:630)

43 Surgical technique Revision of a B II Conversion of B II to B I Conversion of a B II to R-Y with a long roux limb. Requires a complete vagotomy to prevent marginal ulcer. Create enteroenterostomy below the stoma if adhesions prohibitive.

44 Multiple options

45 Efferent Loop Syndrome After Gastric Surgery Much less common Can be difficult to distinguish from afferent loop syndrome and bile reflux gastritis Crampy LUQ and epigastric pain, nausea, bilious vomiting. From adhesions or internal hernia of the limb behind the gastro-j anastomosis in a right-to-left direction. Physical exam, upper GI radiography, or a CT scan Surgery

46 Dumping Syndrome-1 1. As many as 25% experience some symptoms. 2. Usually resolves with time % will have debilitating symptoms, less than 1% will require surgical intervention 4. Loss of pyloric regulation and receptive relaxation leads to rapid emptying of stomach contents into proximal bowel.

47 Dumping Syndrome-2 10 to 30 minutes after ingestion--early GI symptoms of postprandial epigastric fullness, nausea, vomiting, crampy pain, belching, explosive diarrhea Accompanied or followed by cardiovascular symptoms of tachycardia, palpitations, diaphoresis, lightheadedness, flushing

48 Dumping Syndrome-3 Rapid entry of hyperosmolar chyme into the small bowel triggers rapid fluid shifts from the intravascular space to the gut lumen to establish isotonicity, leads to gut distention Fluid shifts can cause hypotension, triggering autonomic catecholamine surge Multiple gut hormones implicated, serotonin, VIP, CCK, neurotensin, peptide YY, enteroglucagon, etc.

49 Dumping Syndrome-4 Usually resolves with time Can be diagnosed with a provocative test using an oral challenge with 50 g glucose Tx: frequent small meals, separate Tx: frequent small meals, separate solids/liquids, avoiding high-carb meals

50 Dumping Syndrome-5 Occurs 2 to 3 hours after meals --Delay Much less common than early dumping Rapid delivery of sugars into small bowel causes hyperglycemia and marked increase in insulin release, inducing a marked hypoglycemia Insulin shock causes catecholamine release with tachycardia, tachypnea, palpitations, diaphoresis and confusion

51 Dumping Syndrome-6 Medical Management Dietary modification Pectin --> binds carbs and delays absorption Acarbose --> alpha-glucosidase inhibitor Octreotide Surgical revision for refractory cases

52 Goal of revision Decrease the rapid gastric emptying and/or restore the gastric reservoir Jejunal interposition procedures Isoperistaltic Antiperistaltic Conversion to a Roux-en-Y

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55 Laparoscopic gastric surgery Laparoscopic gastrectomy for cancer Laparoscopic gastric bypass for morbid obesity Laparoscopic stapling for gastric submucosal tumors For perforated duodenal ulcer or bleeding gastric ulcer

56 Possible laparoscopic complications Injury to : Major blood vessels Anterior abdominal wall vessels Large bowel Small bowel Bladder Ureter Liver Stomach Spleen Subcutaneous emphysema Pneumothorax Pneumomediastinum Gas embolism Hypercarbia Post-operative shoulder pain Persistence of pneumoperitoneum Cardiac arrhythmia Cardiac arrest Nerve injury (e.g. brachial plexus injury)

57 What factors increase the risk of laparoscopic complications? 1. Complex surgery 2. Older patient 3. Extremes of weight 4. Previous abdominal surgery/adhesions 5. Poor surgical technique/inexperience 6. Faulty/incorrect equipment

58 How to reduce laparoscopic complications 1. Complications related to laparoscopic entry 2. Complications related to the operative procedure 3. Complications related to pneumoperitoneum 4. Complications related to patient position 5. Complications related to anaesthesia

59 Causes of laparoscopic operative injuries Cutting (eg. scissors, laser, monopolar electrosurgery) Burning (eg. electrosurgery, laser) Tearing (eg. blunt dissection) Ligating (eg. sutures, clips, staples)

60 Management of laparoscopic vascular Minor oozing Moderate intraperitoneal bleeding Major intraperitoneal bleeding injury Inspect under low pressure Control with electrosurgery, suturing or clips Immediate laparotomy, pressure and call surgeons Retroperitoneal bleeding Observe haematoma and laparotomy if enlarging

61 Complications

62 Management of laparoscopic bowel injury Sharp, partial thickness Full thickness, small volume contamination Full thickness, large volume contamination Small bipolar injury Large bipolar injury Monopolar injury Laparoscopic suture Laparoscopic suture, check for leakage LAPAROTOMY Laparoscopic suture LAPAROTOMY LAPAROTOMY

63 Management of laparoscopic urinary tract injury Bladder perforation < 2 cm Bladder perforation > 2 cm Ureteric transection Ureteric ligation Prolonged bladder drainage Surgical repair (by laparoscopy or laparotomy) Surgical repair (by laparoscopy or laparotomy) Remove suture

64 Laparoscopy Complications Structural injuries Vascular (epigastric vessels > greater omentum) Visceral (Small bowel > Large bowel > Liver) Gas embolism ( < 0.6%) Pneumothorax/mediastinum/pericardium More common in upper-gi surgery

65 Trocar injury to the spleen

66 Deformity of EC junction after GIST stapling

67 Underreporting of Robotic Surgery Complications (J Healthc Qual ) 1. A total of 245 events were reported to the FDA during the study period(january 1, 2000 to August 1, 2012), including 71 deaths and 174 nonfatal injuries. 2. Device failures associated with patient injuries during robot-assisted laparoscopic surgeries: a comprehensive review of FDA MAUDE database (Can J Urol )

68 Post-surgical Complications after Bariatric Surgery Anastomosis leaks or staple line leaks Pulmonary embolism or DVT Cholelithiasis Stomal ulceration Dumping syndrome Constipation

69 Nutritional Consequences after Bariatric surgery Iron deficiency anemia B12 deficiency Folate deficiency Calcium and Vitamin D deficiency

70 Subphrenic abscess after gastric bypass

71 Balloon dilatation for stoma stenosis after LRYB

72 Is There Less Morbidity After Laparoscopy Surgery At the national level, the first 10-year experience of laparoscopic fundoplication reduced the rate of serious complications (Arch Surg. 2008;143(4): ) LRYGB provided greater safety than ORYGB even after adjusting for patient-level socioeconomic and comorbidity differences (Arch Surg. 2012;147(6): )

73 Basic principles to reduce postoperative complications Weight control. Optimal nutritional support Bowel preparation in selected cases Correction of anemia. Correction of intra-operative blood loss. Technical aspects - choice of pertinent approach, meticulous technique, proper drainage. Adequate postoperative analgesia. Prophylactic use of antibiotics - the effectiveness of antibiotics in preventing surgical siteinfections (SSIs) Anastomotic leakage - stapled anastamosis or handsewn. Ileus - shorter operative times and reduction of intraoperative blood loss

74 To err is human, to forgive divine Preoperative evaluation-- open and honest discussions of the surgical goals Fine surgical technique --prompt intervention when complications are suspected Careful follow-up care --careful listening to the patient s concerns