SURGERY: Surgical Complication Post-operative fever

Don Davy Guinto, MD

Days 0 to 2
General Post-Operative Complications
Mild fever
Immediate o Temperature: <38 (common)
o Tissue damage and necrosis at operation site
Primary hemorrhage o Hematoma
o Either starting intra-op or following post-operative Persistent fever
increase in blood pressure o Temperature: >38
Large vessel injury o Atelactasis: the collapsed lung may become
Failure/inadequate hemostasis secondarily infected
Bleeding diathesis o Specific infections related to the surgery
Coagulopathy Biliary infection post biliary surgery
o Replace blood loss/component, prompt return to or to UTI post-urological surgery
re-explore Blood transfusion or drug reaction
Atelactasis
o Loss in functional residual capacity Days 3-5
o Poor pain control, poor inspiratory effort – collapse of
lower lobes Bronchopneumonia
o Predispose to pneumonia Sepsis
o Sit patients up >45, adequate analgesia Wound infection
Shock Drip site infection or phlebitis
Blood loss Abscess formation
AMI o Subphrenic or pelvic
Pulmonary embolism
After 5 days
ARDS/ Septicemia
Low urine output- inadequate fluid replacement intra and post-
Specific complications related to surgery
operatively o Bowel anastomosis breakdown
o Fistula formation
Early
After the first week
Acute confusion
o Dehydration Wound infection
o Sepsis
Distant sites of infection
o Neurologic
o Urinary tract infection (UTI)
Nausea and vomiting
o Deep vein thrombosis (DVT)
o Analgesia or anesthetic-related o Pulmonary embolus (PE)
o Paralytic ileus
Fever of various origin Hemorrhage
Secondary hemorrhage resulting from infection
Pneumonia Large volume blood transfusion, may be exacerbate hemorrhage
Wound or anastomosis dehiscence by consumption coagulopathy
Deep Vein Thrombosis (DVT) Use of pre-operative anticoagulants
Acute urinary retention o Give protamine if heparin has been used
UTI Unrecognized bleeding diathesis
Post operative wound infection Perform clotting screen and platelet count
Bowel obstruction due to fibrinous adhesions Ensure good intravenous access and insert (CVP) catheter
Paralytic ileus Cross match blood
Clotting screen
Late o If abnormal, give FFP or Platelet concentrate
Consider surgical re-exploration
Bowel obstruction due to fibrous adhesions Late post-operative hemorrhage several days after surgery
Bowel resection related complications o Usually due to infection damaging vessels at the
Persistent sinus/fistula operation site
Incisional hernia Treat infection and consider exploratory surgery
Recurrence of reason for surgery (malignancy)

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Infection Surgical injury

Infectious complications – main causes of post-operative morbidity Unavoidable tissue damage to nerves during surgery
in abdominal surgery o Facial nerve: Total Parotidectomy
Surgical wound infection o Recurrent laryngeal nerve: Thyroidectomy
o most common occurring within the 1st week o Nervi erigentes: Empotence following prostate surgery
o Localized pain o Ilioinguinal nerve: inguinal herniorrhaphy
o Redness and slight discharge usually caused by
Risk of injury during transport to and handling of patients in the
Staphylococci
OR under general anesthesia
o Cellulitis and abscesses
o Injuries due to falls from OR table, stretcher
Usually occur after bowel-related surgery
o Damage to diseased bones and joints during
Present within 1st to 3rd week – Pyrexia and spreading cellulitis or
positioning
abscess
o Nerve palsies
Antibiotics, abscess – drainage
o Deeper abscess may require surgical re-exploration. o Diathermy burns
o Healing by secondary intention
Respiratory complications
Gas gangrene is uncommon and life threatening
Wound sinus – late infectious complication from a deep chronic
Occur in up to 15% of general anesthetic and major surgery
abscess that can occur after apparently normal healing
Causes:
Usually needs re-exploration to remove the underlying cause like
o Malnutrition
non-absorbable suture or mesh.
o Inadequate analgesia
Impaired wound healing o Inadequate mechanical ventilation
o Inadequate pulmonary toilet – risk for bronchial
Factors which may affect healing rate are: plugging and lobar collapse
o Poor blood supply o Aspiration
o Excess suture tension o Injury – pneumothorax, hemothorax
o Long term steroids Atelactasis (alveolar collapse)
o Immunosuppressive therapy o Caused when airways beome obstructed, usually by
o Radiotherapy
bronchial secretions
o Severe connective tissue diseases
o Most cases are mild and may go unnoticed
o Malnutrition and vitamin deficiency
o 15-40% of ventilated patients
Wound dehiscence o Symptoms:
Slow recovery from operations
Affects about 2% of mid-line laparotomy wounds Poor color
Serious complication with a mortality of up to 30% Mild tachypnea
Due to failure of wound closure technique Tachycardia
Usually occurs between 7 and 10 days post-operatively Low-grade fever
Heralded by serosanguinous discharge from wound o Prevention:
Assumed that the defect involves the whole of the wound pre and post-operative physiotherapy
Initial management: Severe cases: Positive pressure ventilation
o Opiate analgesia Pneumonia
o Sterile dressing to wound o VAP, requires antibiotics, C & S physiotherapy
o Fluid resuscitation Aspiration pneumonitis
o Early return to OR to re-suture under general anesthesia
o Sterile inflammation of the lungs from inhaling gastric
Incisional hernia contents
o History of vomiting or regurgitation with rapid onset of
Occurs in 10-15% of abdominal wounds usually appearing within the breathlessness and wheezing
first year o Non-starved patient undergoing emergency surgery is
Can be delayed by up to 15 years after surgery at risk
Risk factors: o Mortality is nearly 50%
o Obesity o Requires urgent treatment:
o Distension and poor muscle tone Bronchial suction
o Wound infection and multiple use of same incision site Positive pressure ventilation
Presents as bulge in abdominal wall close to previous wound. Prophylactic antibiotics
Usually asymptomtic but there may be pain especially if IV Steroids
strangulation occurs.
Tends to enlarge overtime and become a nuisance.
Management: Surgical repair where there is pain, strangulation or
nuisance

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Acute Respiratory distress syndrome Head and neck

Rapid, shallow breathing, severe hypoxia with scattered Thyroid and Parathyroid: Bleeding/Hematoma, Seroma
crepitations
Chest pains or hemoptysis, appearing 24-48 hours after surgery /
trauma
Occurs in many conditions associated with direct or systemic
insult to the lung
o Example: Multiple trauma with shock
Requires intensive care with mechanical ventilation with
positive-end pressure

Inclusion criteria for ARDS

Recurrent Laryngeal Nerve (RLN) Injury
o <5% of patients
Acute onset
o Of those with injury, 10% permanent
Predisposing factor
o Dissection near the inferior thyroid artery – common
PaO2:FiO2<200 (Regardless of positive end expiratory pressure
area
Bilateral infiltrates
o Diagnosis: Direct Laryngoscopy – vocal cord
Pulmonary artery occlusion pressure <18 mmHg
apposition, stridor, labored breathing
No clinical evidence of right heart failure
o Treatment: Intraop transection – primary re-
approximation of perineurium with non-asorbable
sutures
Thrombo-embolism
Temporary palsy- function returns in 1-2
Major cause of complications and death after surgery months
Deep venous thrombosis (DVT) Permanent palsy – stenting techniques
o Many cases are silent o Prevention: identify the RLN
o Swelling of leg, tenderness of calf muscle and
increased warmth
o Calf pain on passive dorsi flesion of foot
o Diagnosis: Venography or Doppler ultrasound
Pulmonary embolism
o Classic sudden dyspnea and cardiovascular collapse
with pleuritic chest pain, pleural rub and hemoptysis
o Smaller PE’s are more common and present with
confusion, breathlessness and chest pain
o Diagnosis:
Ventilation/perfusion scanning
Pulmonary angiography or Dynamic CT
Management:
o intravenous heparin or Electrolyte abnormalities
o Subcutaneous Low Molecular Weight Heparin for 5
days plus oral warfarin Hypocalcemia – inadvent removal, injury or devascularization of
parathyroids
Common urinary problems Transient in up to 50%
Permanent - <2%
Urinary retention
Diagnosis:
o Common immediate post-op complication
o Circumoral
o Management:
o Fingertrip numbness
Adequate analgesia
o Anxiety
Catheterization
o Confusion
Urinary tract infection
o Chvostek’s & Trousseau’s Sign
o Very common, especially in women, may not present
o Tetany
with typical symptoms
Treatment: Calcium – IV or Oral
o Management:
Prevention: Meticulous dissection
Antibiotics and adequate fluid intake
Acute renal failure
o Often due to episode of severe or prolonged
hypotension
o Other causes: antibiotics, surgery to aorta
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Complications of Thyroidectomy Neck dissection

Seroma Hemorrhage/ hematoma: Internal Jugular vein, Subclavian vein,

Wound infection Carotid artery
Completion thyroidectomy – rate of complications higher due to o Immediate repair
scarring and inflammation Pneumothorax – dissection near the apex
o Aspiration or chest tube
Thyroid storm Air embolism – large volume of air enters Internal Jugular Vein
Cyanosis, hypotension, Loud churning noise over precordial
Extreme hyperthyroid state
area
<10%: mortality 20-30%
o Pack or clamp vein, turn patient to left side, head
Precipitating factors: dowm, aspiration of air from the heart
o Intercurrent illness or infection
Nerve damage
o Surgery
o Marginal Mandibular Branch of Facial Nerve
o Radioiodine treatment
o Cervical sympathetic chain
o Withdrawal of anti-thyroid
o Spinal accessory nerve
o Vigorous thyroid palpation
o Hypoglossal nerve
o Iodinated contrast dye
o Vagus nerve
o Thyroid hormone ingestion
o Brachial plexus
o Stress
Chylous fistula – thoracic duct
o Trauma
Wound infection, skin flap loss
Diagnosis:
Salivary Fistula – Small & Large Leak – Local Care, TPN
o Hyperpyrexia
Facial Edema – Bilateral Internal Jugular Vein
o Dehydration
Carotid rupture – 3-7%
o Heart rate >140
o Predisposing factors:
o Dysrhythmias, Congestive heart failure
Radiation therapy
o Confusion, Agitation, Delirium
Infection
o Coma, seizures,
Salivary fistula
o Nausea, vomiting, diarrhea
Suction catheters eroding the vessel
o Elevated T3, T4, 24 hr. radioiodine uptake
Exposure/dehiscence
o Suppressed TSH
Pressure, ligate?
Treatment: start when clinically suspected, defer surgery
o Block thyroid hormone synthesis Parotidectomy
PTU
Methimazole Bleeding
o Block thyroid hormone secretion Seroma
Logul’s iodine or saturated solution of Facial nerve paralysis/paresis – immediate grafting using the
potassium iodine Greater Auricular or Sural Nerve
Lithium Frey syndrome – erythema & sweating on the cheek related to
Plasmapheresis eating Gustatory sweating
peritoneal dialysis o Anticholinergic
o Block Peripheral Action of Thyroid Hormone o Antiperspirant
Propranolol o Botulinum and surgery
Esmolol Salivary fistula
Guanethidine or Reserpine
o Supportive Head and neck surgery
Fluid and electrolytes
Pressors Carotid blow out
Paracetamol o 50% mortality rate
Cooling blankets o Over manipulation during surgery
Glucocorticoids o Ligation
Digitalis Air embolism
Preventive o Jugular vein manipulation
o Meticulous search for the precipitating factor o Dysrrthmia
o Vigilant monitoring of signs and symptoms of o Right lateral decubitus position
hyperthyroidism (Pre-op)
o Adequate control of the thyrotoxic state- euthyroid

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Tracheostomy Esophagus

Transhiatal vs Transthoracic oesophagectomy for cancer

o Hemorrhage
o Tracheobronchial injury
o Pneumothorax
o Recurrent Laryngeal Nerve Injury
o Pulmonary Complications
o Cardiovascular complications
o Anastomotic leak

Indications: Stomach and Duodenum

o Relief of airway obstruction
o Pulmonary toileting Delayed gastric emptying /Gastric Statis
o Facilitation of prolonged ventilator support o Due to gastric motor dysfunction or mechanical obstruction
Advantage over endotracheal intubations: o Prokinetic agents
o improved patient comfort o Prolonged gastroparesis best treated with completion
o Decreased requirements for sedation gastrectomy and the creation of an Oesophageal-Jejunal
o More effective pulmonary toiler Anastomosis with a jejunal J pouch
o Increased airway security Roux syndrome
Intraoperative complications are rare, but include: o Nausea, vomiting and symptoms similar to delayed gastric
o Damage to the great vessels (Carotid artery/Jugular emptying
Vein) o Large gastric remnant and truncal vagotomy experience this
o Injury to the posterior wall of the trachea and syndrome more often
esophagus o Prokinetic agents and acid suppression therapy, and possibly
o Injury to the cupula of the lung, resulting in surgical therapy to diminish the size of the gastric remnant
pneumothorax Dumping syndrome
Complications: o Due to the ablation of the pylorus, and the loss of regulation of
o Overall mortality rate of tracheostomy is 2.2% the osmolarity of food entering the small bowel
o Complication rate as high as 65% in some studies o Occurs 15-30 minutes after eating
o Most common complication is wound infection o Nausea, cramping, diarrhea, light-headedness, diaphoresis and
o Complications may be intraoperative, early palpitations
postoperative and late postoperative o Octreotide is also useful in managing symptoms, especially
o Late complication are most likely related to tracheal diarrhea
stenosis or collapse, or to excessive granulation tissue o Revision, Bilroth 1 or 2
o Hemorrhage- Trachea – Innominate fistula Post-vagotomy diarrhea
o At the site of tracheal stoma, granulation tissue can o Due to the loss of autonomic control of intestinal motility
form a bulky obstruction o Dietary modifications such as limiting liquids with meals and
o Bronchoscopy can be used to resect granuloma or limiting carbohydrates and dairy products also have some degree
treated with endoscopic laser ablation of success
o Conversion to a Roux-en-Y-gastrojejunostomy if the patient has
Breast had a previous Bilroth I or II procedure or the interposition of a
reversed 10 cm segment of jejunum 100 cm distal to the ligament
Modified Radical Mastectomy of Treitz may slow intestinal transit time
Seroma beneath skin flap & Axilla – most common complication Afferent loop syndrome
in 30% of cases o Stricture or kinking of the afferent loop of a Bilroth II anastomosis,
o Closed system drainage helps, catheter drains preventing the flow of bile from reaching the food in the afferent
removed if <30 ML/D limb
Skin flap necrosis/ infections – Tension, Aerobic & Anaerobic o Treatment: Conversion to a Bilroth I anastomosis, if able or
bacteria – Debridement/ Antibiotics conversion to a Roux-en-Y-gastrojejunostomy with the afferent
Hemorrhage – moderate to severe, rare loop connected to the Roux loop approximately 60 cm distal to
Significant lymphedema - 10-20% the gastrojejunostomy to prevent bile reflux
o Factors:
Extensive axillary dissection
Radiation therpy
Presence of pathologic lymph nodes
Obesity
Treatment: Compressive sleeves

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Complications of bowel surgery Enterocutaneous fistula

Delayed return of function: ILEUS F.R.I.E.N.D.S

o Temporary disruption of peristalsis: Nausea, Anorexia, o FB
and vomiting and usually appears with the re- o Radiation
introduction of fluids. o Infection
o More prolonged extensive form with vomiting and o Epithelialization
intolerance to oral intake – distinguish from o Neoplasm
mechanical obstruction o Distal obstruction
o If involves large bowel usually described as pseudo- o Short track
obstruction High/ Low output
o Diagnosis: PE, Plain abdominal X-ray, Barium enema Somatostatin
Early mechanical obstruction: twisted or trapped loop of bowel
or adhesions occurring approximately 1 week after surgery Enteric connection
NGT plus IV fluids or progress and require surgery
Enteric-related complications –rare
Late mechanical obstruction: adhesions can organize and persist
o Result from improper anatomic connection of bowel loops and
Causing isolated episodes of small bowel obstruction month or
are distinct from anastomosis related complications
years after surgery
Blind pouch syndrome
Treat as for early form
o Side-to-side anastomosis performed in Roux-en-Y gastric bypass
Anastomotic leakage or breakdown: small leaks are common
surgery and after intestinal resection can result in an enlarged
causing small localized abscesses with delayed recovery of bowel
peristaltic loop of the small bowel. This enlarged loop is termed
function
“blind pouch”
Usually resolves with IV fluids, delayed oral intake, antibiotics
o The blind pouches do not form until approximately 4 months
but may need surgery
after surgery. These structures do not usually increase
Major breakdown causes generalized peritonitis and progressive
significantly in size after 12 months
sepsis
o Although often an incidental finding, blind pouch can lead to
Surgery for peritoneal toilet, and antibiotics
malabsorption, gastrointestinal bleeding, and bowel perforation
Local abscess can develop into a fistula
o If symptoms are ascribed to the pouch, the pouch can be
laparoscopically removed
Anastomotic Complications
Short gut syndrome
Result of ischemia or suboptimal surgical technique, including o Malabsorption – caused by inadequate length of functioning
staple gun failure small bowel after widespread small bowel resection
Stenosis – Symptomatic anastomotic stenosis o The minimal length of small bowel (excluding the duodenum)
Upper gastrointestinal contrast series show delayed passage of required to cope without parenteral nutrition or small-bowel
contrast material. On CT, a spherical pouch or air – contrast level transplantation is estimated to be 100 cm
is suggestive of this diagnosis o Patients with a longer small bowel may also have digestive
Ulcers – anastomotic ulcers after gastric bypass procedures are problems if with n altered residual mucosa or a resected distal
common in 12-16% ileum
o Short gut syndrome – by inadvertent surgery when the ileum is
An upper gastrointestinal double-contrast barium series may
mistaken for the jejunum and a gastroileostomy rather than a
show these ulcers
gastrojejunostomy is created
Leak and perforation – most serious complication
o UGIS, CT examination may show multiple loops of non-distended
Evident in the first postoperative week
jejunum that are not pacified with oral contrast, while there is
Some anastomotic leaks are complicated by an enteroenteric,
oral contrast in the stomach, ileum and right colon
enterovesical or enterocutaneous fistula
Altered bowel position
Afferent loop obstruction
o Small bowel may become trapped in undesirable positions
Possible causes of obstruction:
postoperatively
o Adhesions
o Transmesenteric internal hernia
o Internal hernia
Can occur in any procedure, including liver transplantation
o Anastomotic stenosis
and gastric bariatric surgery, in which a Roux loop is
o Stromal ulcer
fashioned
o Recurrent tumor
Transmesenteric hernias are more common after
o Obstruction from bezoar
laparoscopic bariatric surgery than after open surgery
Chronic partial afferent-loop obstruction is termed
Transmesenteric hernias occur through the tear in the
“Afferent Loop Syndrome”
mesocolon through which the Roux loop is brought during a
retrocolic anastomosis
The reported incidence of internal hernia is about 2.5% and
it generally involves the Roux loop

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 UGIS could show the degree and location of small bowel
obstruction but is less useful in determining the cause of
obstruction
The finding of dilated proximal jejunum that remains fixed
in a high position on erect views suggests internal hernia
CT scan – more helpful in differentiating Transmesenteric
hernias from mesocolic tunnel stenosis, stenosis at the
jejunojejunostomy or adhesion-related simple bowel
obstruction
External hernia
o Ventral hernia is a major source of morbidity after any
major abdominal procedure
o A richter hernia can occur at the site of the trocar after
laparoscopic procedures
o Parastomal and lumbar are other external hernias
commonly associated with abdominal surgery
Intussusception
o Accounts for 5% of small-bowel obstruction in adults and is
more common in postoperative patients
o Possible causes include the presence of foreigh material,
such as sutures and feeding tubes and hyperperistalsis of
bowel that has been extensively handles
Adhesions
o Most common cause of bowel obstruction after surgery
o Can be symptomatic and non-obstructive
o Adhesive small bowel obstruction is classified as simple,
closed loop, or strangulating
o Symptomatic, without overt obstruction
o More than 90% of patients who have abdominal surgery
have enteric adhesions
Adhesive small-bowel obstruction
o The diagnosis of adhesion-related small bowel obstruction
is presumed on CT if there is a narrow zone of transition
without an identifiable obstructive lesion
o Although these patients rarely require surgery, those with
complete, closed-lopp or strangulating obstruction require
emergent surgery

Abdominal compartment syndrome

Increased intra-abdominal pressure related to the prolonged

exposure of the bowel and massive intravenous fluid
replacement
Oliguria, ventilation empediment and compression on the
Inferior Vena Cava

Biliary surgery

Bile leak/Bile duct injury – recognition, repair; T-tube; ERCP

stenting
Abscess
Bleeding
Wound infection
Retained stone – Choledochoscopy, ERCP, MRCP, Re-open

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