Professional Documents
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S Devaji Rao
MS MNAMS FICS
Senior Consultant in
General Surgery, Surgical Gastroenterology
and
Surgical Oncology
St. Isabel’s Hospital, Mylapore
Chennai
India
Paterson Cancer Centre
Vijaya Health Centre Campus
Vadapalani
Chennai
India
Harvey Healthcare Limited
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India
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Gastrointestinal Surgery Step by Step Management
© 2005, S Devaji Rao
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or
transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise,
without the prior written permission of the author and the publisher.
This book has been published in good faith that the material provided by author is original. Every effort
is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible
for any inadvertent error(s). In case of any dispute, all legal matters to be settled under Delhi jurisdiction
only.
S Devaji Rao
Acknowledgements
The motivating factor behind this attempt is the teaching and devotion of my teachers Professor IK Dhawan,
and Professor S Nundy, retired Professors of Surgery of All India Institute of Medical Sciences, New Delhi, my
alumni institutions, whom I thank profusely. My special thanks goes to Prof Naofumi Nagasue of Shimane
Medical University, Izumo, Japan, who was a great source of inspiration during my training in Liver surgery
at Japan.
I express my sincere thanks to my colleague Dr J Vijayan, Senior surgical gastroenterologist, Chennai, who
was of great help in going through the manuscript, correcting the subject matter and proofreading. My sincere
thanks goes to my friend Dr KM Lakshmipathy, Specialist in Nuclear scans and therapy at Vijaya Nuclear
Scans and Therapy, Vijaya Health Centre, Chennai, for providing me the photographs of nuclear scans. I thank
my colleagues Dr A Chandrasekar Rao, Senior Consultant in Surgery, St. Isabel’s Hospital and Apollo Speciality
Hospital, Chennai and Dr Mani Veeraraghaven, Endoscopist, The Endoscopy Centre, Chennai for providing
me some of their clinical photographs. My special thanks to my classmate and friend Professor R Surendran,
Professor and Head, Department of Surgical Gastroenterology, Stanley Medical College, Chennai for providing
me some clinical photographs from his large collection.
My sincere thanks goes to my daughters Bhavna and Kirthana who rendered the illustrative work with
neat drawings.
Finally, my thanks and deep appreciation to my wife, Kalpana and family who have tolerated my preoccu-
pation with this work during many evenings, over many a weekend and during the holidays.
Contents
1. Introduction 1
9. Pre- and Postoperative Management in Hindgut (Colon, Rectum and Anus) Surgery 96
Index 203
1
Introduction
Most operations fall into the category of “elective”, incisional hernias. Of these, the anastomotic leaks
“intermediate elective” and “straightforward carry the extreme risk of progressing to generalized
emergency”. In the first two categories, the patients peritonitis, septicaemia and death—worst scenario
are fairly in good fluid and electrolyte and nutritional indeed. It is proved beyond doubt that the compli-
equilibrium, but in the last category, they may not be cation rate is much more in cancer patients, when
so. Major operations, especially involving the compared to those with benign disease.
gastrointestinal tract pose particular problems of fluid Iatrogenic injuries to the organ involved in the
management whether the operation is elective or an specified surgery or to the adjacent organ also play a
emergency. In any case, knowledge of the intravenous large role in creating complications in the post-
fluids and the fluids used for nutritional buildup of a operative period.
patient and their administration, both before, during Prevention is the next step in the management of
and after surgery becomes very important for a complications. Patient’s co-morbidity is a clear risk
surgeon’s successful management of an operated factor for complications. Nutritional corrective
patient. Careful preoperative and postoperative measures, modern imaging techniques, both
assessment of patients having major surgery is diagnostic and therapeutic, such as helical CT scan,
essential so that the problems can be recognized early. ultrasonography and endoscopic retrograde
In spite of the best of preoperative preparation and cholangiopancreatography (ERCP)-aided decom-
the operative techniques, complications do occur due pressive procedures are able to prepare the patients
to various causes. well before surgery, thus reducing the morbidity and
Patients admitted to a surgical ward and having mortality due to complications in the postoperative
undergone a gastrointestinal surgery, have more than period.
10 percent chance to encounter severe adverse effect Whatever said and done, management of
of the surgical treatment. For some types of complications after gastrointestinal surgery needs
gastrointestinal surgery, the risk of complication can knowledge, tact and patience and complete under-
be as high as 50 percent. The complications vary from standing on the scientific basis, for success at the end
a superficial wound infection to anastomotic leaks to of the road.
2
Sutures and Needles in
Gastrointestinal Surgery
SURGICAL SUTURES 2. disappear as soon as its work is accomplished
3. be free from the risks of infection
As far back as records go, sutures have been used to
4. be a non-irritant.
hold wound ends together and to arrest hemorrhage.
A long shelf life is essential. Absorbable sutures
The thread and the instruments for its applications
are chemically labile and biodegradable when
were made from any convenient available material,
and the very earliest eyed needles were fashioned from compared to the non-absorbables. Packaging is also
bone; threads were made from bark fibers and hair. important to maintain sterility, allow easy identifi-
Susruta, the father of Ancient Indian surgery, used cation and ease of opening. Each suture package now
large black ants to bite the edges of a wound together, consists of an outer layer which when opened releases
their powerful jaws acting as clips. The ant’s body was an inner package, the surface and the contents of which
then twisted off leaving the head in place. Egyptians are also sterile. If the inner package is exposed during
used linen strips, coated with an adhesive mixture of an operation, but not opened, the suture can be used
flour and honey for skin closure. at a later date after resterilization of the cover.
Physick (1768-1837) made large contributions to Sterilizing fluids are available for this purpose.
absorbable materials, which would perform its
function and then disappear. Joseph Lister (1827-1912) Classification of Suture Materials
realized that infective agents might lurk in the sutures
and if these could be killed the suture could safely be Suture materials are either absorbable or nonabsor-
left in the body. Up to this time, the end of the ligature bable, based on their property of being absorbed by
used to control the bleeding from the blood vessels, the body tissue (Table 2.1), ultimately losing its ten-
and was left long enough to protrude out of the sile strength over a period of time. Non-absorbables
wound. After a very long period of time, the tightly by definition, do not get absorbed, but some lose
tied end of the vessel sloughed and allowed the strength without any change in the mass of the suture
ligature to be withdrawn, but this produced hemor- material. In other non-absorbables, especially those
rhage. In 1867, he treated catgut with carbolic acid, as of synthetic or polymeric origin, there is negligible loss
a sterilizing agent and then iodine replaced it. The of tensile strength or change in mass following
absorption was delayed by chromicising the catgut. implant.
Catgut constitutes nearly one half of currently used
sutures today. New synthetic filaments like nylon, Strength
polypropylene and polyester are now available as
nonabsorbable sutures. Synthetic absorbables have The new synthetic absorbable sutures are made by
also been developed for use as surgical sutures now. extrusion and their diameter and strength can be very
Lord Moynihan considered four requirements for accurately controlled. Catgut, on the other hand, must
an ideal suture. They should: be checked individually to exclude weak segments
1. achieve its purpose that it be sufficient to hold parts and graded to determine the minimal cross-section.
together against whatever stresses to which they The process is painstaking and tedious, involving
are subject multiple quality checks and even then filaments may
Chapter 2: Sutures and Needles in Gastrointestinal Surgery 3
slip through which are weak for their nominal gauge. application of a clip. Catgut and synthetic absorbables
The suture must be strong enough to maintain tissue lose 40 percent of the strength by knotting.
apposition for a specified time and catgut is the least
predictable in this respect. Thoughtless handling can Sutures and Infection
diminish strength, like when it is tangled and a knot allowed The healthy wound is remarkably resistant to
to form during stitching or the thread is crushed by the infection, but there is a striking enhancement when
4 Gastrointestinal Surgery: Step by Step Management
Selection of Sutures
The decision is between absorbables or non-
absorbables and this is simple and rational. Having
decided between absorbable and nonabsorbable
sutures, the next step is to pick a monofilament or
multifilament suture. Monofilaments run smoothly
and atraumatically through tissue, but as has been
mentioned, the synthetics are prone to tangle, can cut Fig. 2.1: Anatomy of a surgical needle
the tissues and may need careful knotting. Multi-
filaments run less smoothly but are very easy to handle Shapes of Needles
and knot securely but they are more prone to harbor The basic shapes of the surgical needle (Fig. 2.2) are:
bacteria. The following are some of the examples: 1. Straight, and
• Hernia repairs—nonabsorbable sutures 2. Curved needles (available in all segments of a circle
• Mass abdominal closures—monofilament non- 1/4 to 5/8 and the length varies from 6 mm to 90
absorbables mm)
• Intestinal anastomosis—synthetic absorbables • 1/4 circle,
• Biliary and urinary tracts—synthetic absorbables. • 3/8 circle or curved
The purpose of the suture is to hold the wound in • 1/2 circle and
apposition until such time as the healing process is • 5/8 circle
sufficiently advanced to make its continued presence
in the tissues unnecessary. The ideal suture that is,
one which could be useful on all occasions, the surgeon
merely having to select the size of his suture and
needle does not exist.
Needles
Surgical needles must be rigid enough to prevent
excessive handling, yet flexible enough not to break
under normal flexing stress and the material should
take a fine point and tempered steel satisfies this.
The chemical composition of steel used in the
making of surgical needles is given below.
CONCLUSION
Purpose
The staplers are now available to carry out most types
of gastrointestinal anastomosis.
Disposable and angled instruments are available for ii. The linear staplers are available with reloadable
use in particular circumstances, and the metal staples cartridges made of titanium in sizes of 30 mm, 60
mm and 90 mm (Fig. 3.2).
Table 3.1: Brief history of evolution of
stapling instruments
• Two-step procedure (Hultl 1908)
• Tissue compression and immobilization + placement of
B-formation of staples
• Double-staggered staple rows (Hultl)
• Single Indian file staple rows (V. Petz, 1924)
• Obliquely placed staples in single rows (S. Sandor, 1936)
• Variable tissue and staple compression
• Interchangeable cartridges (H. Friedrich, 1934)
• Expansion from stapled visceral closures to linear and
circular anastomosis (soviet)
• Sequential and simultaneous staple placement
• Disposable, preloaded sterile cartridges
• Creation of new and totally disposable instruments Fig. 3.2: Linear staplers
Chapter 3: Staplers in Gastrointestinal Surgery 9
iii. The linear cutters are also available with safety marked blue in colour by the manufacturers. For the
lockouts and with reload units made of titanium thicker tissue, such as the gastric wall, there are 4.8-
in sizes of 55 mm (blue cartridge); 55 mm thick 5.5 mm staples which close to a height of 1.6-1.7 mm
tissue reload unit (green cartridge) and 75 mm and come with green colour code. Use of too small a
(blue cartridge) and 75 mm thick tissue reload stapler or conversely, use of too large a stapler on
unit (green cartridge) (Fig. 3.3). thinner tissue leads to the risk of leakage, as the suture
closure is adjustable, whereas the staple closure is
standardized.
Method of Application
For end-to-end anastomosis (e.g., colorectal,
esophagojejunal). For colorectal anastomosis, the
stapling gun (Figs 3.4A to D) is introduced into the
rectum, brought out through the distal cut end of the
bowel. The largest anvil should be chosen that will fit
comfortably into the proximal lumen. Proximal and
distal guts are snugged tightly around the central rod
using purse-string sutures and the anvil is then
approximated to the cartridge by closing the
instrument (Figs 3.5A and B). When the gun is fired, a
circular double row of stainless-steel staples is inser-
Fig. 3.3: Linear cutters ted, and at the same time a complete 5 mm rim of
each bowel end (the doughnut) is resected. The gun is
Selection of Size of Stapler now opened 2-3 cm to allow the stapled flange of
colorectal walls to recede outwards from its grasp.
The size of the stapler should be chosen with thought
Next it is rotated to tear any residual strands of mucosa
given to the thickness of tissue involved. Most of the
that were not completely divided by the trephine, and
large and small bowels are stapled with 3.5 mm to 4.5
then gently withdrawn, leaving a nicely inverted end-
mm staples that close to a height of 1.2 mm and are
to-end stapled anastomosis. The machine is then
Fig. 3.4A: End-to-end anastomosis—Inserting the gun Fig. 3.4B: End-to-end anastomosis—
Purse-string to proximal gut
10 Gastrointestinal Surgery: Step by Step Management
Fig. 3.5A: Circular stapler introduced through the anus Fig. 3.5B: Proximal segment being approximated
to the distal segment
withdrawn, the doughnuts are checked and the where there is failure to divide all the mucosa. The
anastomosis is complete (Fig. 3.6). best solution for this embarrassing situation is to make
The withdrawal of the instrument is generally 3-4 cm longitudinal cut on the anterior aspect of the
achieved without any significant trauma to the colon stump 2-3 cm above the anastomosis to bare the
anastomosed bowel. Extrication is difficult in cases head of the gun, which can then be simply unscrewed
Chapter 3: Staplers in Gastrointestinal Surgery 11
• By filling the rectum with colored solution such as
povidone-iodine through a catheter from below.
Escape of this solution indicates a defective
anastomosis.
Whenever the anastomosis is found to be defective,
the defect should be repaired by silk sutures. It may
be worthwhile to do a proximal diversion, if the repair
is not satisfactory.
For end-to-side anastomosis, the circular staplers
can be used with a slightly different technique
(Figs 3.7A to C). The gun is introduced through an
Fig. 3.6: End-to-end anastomosis—“doughnuts” enterotomy in the bowel to have end anastomosis and
purse string applied. Make a small incision in the side
and removed, allowing the rest of the instrument to anastomosis bowel, through which the spindle end
be withdrawn per anum. can be pushed until the cartridge comes into contact
with the wall. It is not necessary to insert a purse-string
Checking the State of Anastomosis
suture. Appose the anvil and cartridge, actuate the
When the anastomosis is done low down in the pelvic machine, separate the anvil and cartridge and
cavity, the integrity of the anastomosis can be checked withdraw it. The gun is withdrawn, and the
in many ways: enterotomy is closed with a linear stapler.
• By checking the doughnuts, whether they are For side-to-side anastomosis, a different instru-
complete and intact, but should be done after the ment, linear cutter is used (Figs 3.8A to D), resembling
removal of the purse string suture, as non-removal a pair of scissors. They insert four parallel, linear rows
may give a false impression of its being intact. An of staples and at the same time cut between the two
incomplete disc very strongly suggests that the middle rows. The instrument separates into two parts,
anastomosis is defective, while a complete disc and can be used to unite two tubes, producing a stoma
makes it highly likely, but not absolutely certain, between them. The two parts of gut are laid together
that a sound anastomosis has been achieved. which are to be anastomosed. A hole is made in each
• By filling up the pelvis with warm saline to sub- tube so that the separated jaws of the stapler can be
merge the anastomotic site and inject air through inserted and laid parallel to each other. The two halves
a fine catheter in the rectum, while the bowel is are locked together after ensuring that no extraneous
compressed with fingers above the anastomosis. tissue is inadvertently trapped. The stapler is
The air leaks as bubbles if there is a defective activated, then the two halves are separated and
anastomosis. withdrawn. From within the hole, the ends of the
A B C D
staple lines are identified and picked up with tissue Advantages and Disadvantages
forceps. The forceps is separated to create a linear
Using a mechanical stapler does not guarantee a
defect. The defect is closed either with sutures or a
perfect result. The staplers reduce the time involved
linear stapler of suitable length is applied (Figs 3.8A
in fashioning an anastomosis and facilitate certain
to D). This allows rapid bypass surgery in unwell
operations that can be difficult to complete by hand,
patients or those with cancer. The linear cutter can
such as oesophageal resection or low anterior resection
also be used to staple and divide the bowel at the same
of the rectum. On the other hand, there are many
time (Fig. 3.9).
situations where the stapler is inappropriate (e.g.,
For occluding the lumen of a bowel, yet another
choledochojejunostomy) or unnecessary (most small
set of instruments (Fig. 3.10) has been designed to
bowel anastomosis). A gastroenterology surgeon
place a double row of staples across the end of a
should be versatile and try to acquire experience in
segment. The staple line can be 30, 60 or 90 mm long.
both methods of gastrointestinal anastomosis.
The flattened gut is held between the jaws of the
instrument. When the stapler is actuated, the staples
are pushed through both the layers of the flat tube COMPLICATIONS AFTER USAGE OF
and strike the shaped anvil so they are turned over INTESTINAL STAPLERS
and closed. It is usually unnecessary to reinforce the
linear closure with sutures because the B-shaped Anastomotic Leakage
closure is secure and hemostatic. The stomach, This is the most serious postoperative complication.
duodenum and rectum can be closed using linear To prevent this, it is better to test the anastomosis
staplers and the bowel to be resected can be cut away intraoperatively by instillation of povidone-iodine or
by using a scalpel against the fired stapling device saline solution to assess the leakage. The incidence of
before its removal.
Fig. 3.9: Linear cutter in use Fig. 3.10: Linear stapler in use
Chapter 3: Staplers in Gastrointestinal Surgery 13
leakage is increased in low rectal anastomoses in
patients:
• Who have inadequate bowel preparation
• Poor blood supply to both ends of the bowel
• Tension on the anastomosis
Prevention: Prevention is by
Good Surgical Technique
Rectovaginal or Rectovesical Fistula Fig. 3.11: Mode of action of circular stapler
and completed two-layered anastomosis
Though it is rare, this is known to occur after inadver-
tent incorporation of a portion of the vagina into the should be sent for histopathology examination to
end-to-end anastomosis, especially in women who exclude recurrent malignancy.
have undergone previous hysterectomy, when the
Functional End-to-end Anastomosis
rectovaginal septum may be scarred and adherent and
difficult to separate. Rectovaginal fistula is also known To avoid a stricture, this anastomosis is useful which
to occur after anastomotic leakage and resultant employs Linear cutter and Linear staplers (Figs 3.12A
abscess which drains through the vagina, the point of to D).
least resistance. The treatment is proximal faecal Basic rules of sound surgical technique apply to stapled
diversion. as well as to sutured anastomoses. It should be realized
that a hand sewn insecure anastomosis cannot be
Hemorrhage rescued by an expensive mechanical device. Adequate
This complication is rare. This is usually from the blood supply, absence of sepsis, freedom from tension
staple line and is self-limited. When the bleeding is and adequately cleared serosal surfaces are necessary
ongoing, transanal endoscopic visualization of the for proper healing of any type of anastomosis.
anastomosis can be performed and the bleeding point Manipulation of a stapled anastomosis should be
coagulated or suture ligated. accomplished with respect for the delicacy of the
tissues involved.
Anastomotic Stricture
The incidence of stricture formation is said to be more
common with the use of EEA stapler. This may be due
to:
• Stapled anastomosis heal by secondary intention
because the mucosa of the bowel is not apposed
but is separated by the muscular and serosal layers
(Fig. 3.11).
• The scar is perfectly circular.
Generally, after stapled anastomosis, some A
evidence of stricture is recognized, as a standard rigid B
sigmoidoscope cannot be passed beyond an anasto-
mosis in the first 2 to 3 months after operation. With
repeated passage of stools through the anastomosis,
gradual dilatation occurs. Only in a small percentage of
patients, symptomatic stricture occurs, especially in those
where 25 mm stapler is used.
A symptomatic stricture that persists beyond
3 months should be treated. The treatment is by dila- D
tation with a bougie or a sigmoidoscope after excision C
of scar tissue of the anastomosis in three or four areas
with standard biopsy forceps. The excised tissue Figs 3.12A to D: Functional end-to-end anastomosis
4
Tubes and Drains in
Gastrointestinal Surgery
TUBES
Nasogastric Tube (Ryle’s Tube)
Appearance It is a long tube with radiopaque line
provided throughout the length for X-ray visuali-
zation. It has a distal conical end with corrosion-
resistant stainless steel balls sealed into the tube to
assist the passage during intubation. It has four lateral
eyes for efficient aspiration and administration
(Fig. 4.1).
Size It is available in various sizes varying from 10F
to 20F.
Length 105 cm.
Time of Introduction
For gastric decompression Used in various
situations. They are:
• In a patient who is being prepared for gastro-
intestinal surgery
• When an intestinal anastomosis is contemplated,
it is introduced preoperatively on the table soon
after tracheal intubation
• In laparoscopic surgery, where gastric decompres-
sion is needed, to prevent the distended stomach
coming in the way, introduced on the operation
table
• To decompress a distended stomach due to varied
causes. Fig. 4.3: Ryle’s tube tip above the fluid level
16 Gastrointestinal Surgery: Step by Step Management
the tip with a pad so that the secretions and the mucus
adherent to the tip does not get spilt on the patient’s
face or the doctor’s dress. Since the tube is made of Fig. 4.5: Nasojejunal tube
PVC, it gains rigidity when left for a long time, and
removal may be traumatic and difficult sometimes. Method of Introduction
Instances of knotting of Ryle’s tube have been reported
It is introduced through one of the nostrils into the
in the literature.
stomach through the nasopharynx. After establishing
that the nasopharynx is clear on the side of intro-
Enteral Feeding Tubes
duction, the lubricated tube tip is introduced and
Varieties The enteral feeding tubes are of two when it reaches the oropharynx, swallowing move-
varieties: ments are encouraged so that the tube gets directed
1. Nasoenteral tubes (introduced through the nose) into the esophagus and then into the stomach. The
a. Nasogastric tube (Ryle’s tube)—discussed in tube generally starts draining the bile-stained gastric
previous paragraphs juice, and the tube is pushed a little further, the patient
b. Nasojejunal tube turning to his right side, so that the tube enters the
c. Nasoenteric tube. duodenum and later to his left, so that the tube enters
2. Ostomy tubes (Direct placement tubes) the jejunum. Confirmation is done radiologically.
a. Gastrostomy tube However, sufficient time is allowed for the tube to pass
b. Jejunostomy tube the pylorus before the X-ray films are made. The tube
may also to be taken to the jejunum by an endoscope.
Nasojejunal and Nasoenteric Tubes The tube fixed with tapes to the cheek without any
Appearance It is a long silicon or polyurethane tube traction on the nasal ala.
with radiopaque line with interval markings provided Maintenance These tubes need to be maintained well,
throughout the length for X-ray visualization (Fig. 4.5). free from blockage and encrustations as they may
It has a distal conical end with corrosion-resistant block the lumen. Washing these tubes with about 30 ml
stainless steel balls sealed into the tube to assist the of lukewarm water with a 10 to 20 ml syringe before and
passage during intubation. It has four lateral eyes for after every time a feed is given becomes mandatory to keep
efficient aspiration and administration. They are these tubes patent.
available as kits in push, pull or introducer technique
with endoscopic aid. Use It is used for enteral feeding.
Method of Introduction
These tubes can be introduced by endoscopically
aided techniques. The gastroscope is introduced to
inflate the stomach and illuminate the puncture site
in the anterior abdominal wall. The puncture is made
with the plastic cannula and the loop of thread is
pulled into the mouth with the gastroscope. The
gastrostomy tube is tied to the thread loop and rail
roaded to the gastrostomy site and fixed (push or pull
technique—Fig. 4.8B).
Figure 4.9 shows the jejunostomy tube introduced A B
with endoscopic guidance. Figs 4.8A and B: (A) Percutaneous endoscopic gastrostomy
Maintenance These tubes need to be maintained well, (PEG) kit, (B) Percutaneous gastrostomy tube in situ
free from blockage and encrustations as they may
block the lumen. Washing these tubes with about 30 ml
of lukewarm water with a 10 to 20 ml syringe before and
after every time a feed is given becomes mandatory to keep
these tubes patent.
Use They are used for feeding purposes.
T-Tube
Varieties It is a T-shaped tube made of soft latex
rubber or polyvinyl chloride, available in sizes of 12F
to 16F.
Appearance It is a T-shaped tube, the horizontal limb
of the T is short and the vertical limb very long about
100 cm (Fig. 4.10). Fig. 4.10: T-tube
Chapter 4: Tubes and Drains in Gastrointestinal Surgery 19
Method of Introduction (Fig. 4.11)
The T-tube is inserted into the common bile duct, after
incising the duct and enlarging the incision by sharp
cutting, between stay sutures. The T-tube is inserted
after removing the ellipse from the junction of the
horizontal and vertical limbs of the T (or by cutting of
a strip of the wall of the short limb) to facilitate its
removal postoperatively. The limbs of the T should Figs 4.11: Fashioning and method of introduction of T-tube
be short (not exceeding 6 cm), so that the distal limb
does not pass through the ampulla of Vater and the
proximal limb does not obstruct either of the hepatic
ducts. The common bile duct is closed with interrup-
ted sutures, and saline solution is injected into the T-
tube to demonstrate absence of leaks. The T-tube
should be brought out through a stab wound and fixed
to the skin to prevent dislodgement when the major
incision is dressed.
Maintenance The T-tube is connected to a urobag
separately, to prevent infection and also to have a
correct calculation of the output.
Use The main purpose of introduction of this tube is
to drain the biliary tree in the presence of distal
Fig. 4.12A: Sengstaken-Blakemore tube
obstruction and reduce jaundice and the liver failure.
Subsequent interventional radiology and choledo-
choscopy become easy through the T-tube or its tract,
when the size of the tube is not less than 14F.
A
B
into the lungs causing aspiration pneumonia. Pediatric percent gastrografin is injected into the gastric balloon
tubes are also available. and double clamped. Excessive resistance to inflation
The Linton-Nachlas tube has a single large gastric suggests that the gastric balloon is in the esophagus.
balloon. Compared with the Sengstaken tube, it is The patient should not experience any pain. The
more effective for controlling hemorrhage from gastric esophageal balloon is then inflated (usually about 100-
than from esophageal varices. 120 ml) to between 30 and 40 mm of Hg on a
manometer, i.e. slightly greater than the pressure
Method of Introduction known or expected in the portal vein and is then
The tube is easier to pass if kept in an icebox, as the clamped.
rubber is temporarily stiffened. All the equipment The position of the gastric balloon is checked by
should be kept in a box ready to use in an emergency. radiography and if satisfactorily placed, the tube is
Prior to its use, the balloons must be tested, aspiration marked and taped firmly to the side of the mouth. No
channels checked and the tube lubricated. Resusci- traction is necessary.
tation equipment should be at hand. With the patient Maintenance Trained personnel must be at the bed-
positioned head down on his left side, and with two side at all times, with a pair of scissors to cut through
assistants performing continuous pharyngeal the tube if respiratory distress occurs. The tube’s posi-
aspiration, the tube is inserted through the mouth. A tion using the marking at the mouth, and esophageal
Magill’s forceps is useful to feed the tube down. If the balloon pressure are checked hourly. The esophageal
tube fails to pass, it should be inserted with the patient suction channel is attached to continuous low pressure
intubated and lightly anesthetized. The airway must suction and the gastric aspiration is done hourly or
always be protected by insertion of a cuffed more frequently if continued bleeding is suspected.
endotracheal tube in semicomatose or comatose The gastric balloon is checked if aspirations indicate
patients; intravenous sedation alone should never be fresh bleeding, or if its position is in doubt. Medication
used. With the tube in the stomach, well beyond the can be given through the gastric aspiration channel.
40 cm mark from the incisor teeth, the gastric channel
Use It is used in the acute management of bleeding
is aspirated and air blown through to check its
esophageal varices to control bleeding in preparation
position. The gastric balloon is then inflated with 100
to surgery.
ml of air initially and then pulled back gently to ensure
that it is in the stomach and impacts below the lower
Optimum Time of Introduction
esophageal sphincter at 35 to 43 cm mark from the
teeth depending on the size of the patient. The Balloon tamponade should be used to reduce excessive
guidewire is withdrawn and 250 to 400 ml of air or 25 blood loss, or if insufficient compatible blood is
Chapter 4: Tubes and Drains in Gastrointestinal Surgery 21
immediately available, or for patient transfer if there Drain Management
is active bleeding. Some centres use it routinely before
It is essential to know the following to give a proper
endoscopic sclerotherapy.
drain management:
• What operative procedure did the patient have and
Optimum Time of Removal
what surgical sites are being drained?
The tamponade should last for no more than 24 hours, • What type of drain was placed intraoperatively?
preferably no more than 12 hours, because pressure • What is the nature of the drainage fluid?
necrosis can occur. The esophageal balloon is deflated
first, then the gastric balloon 1-2 hours later. The Points to note
deflated tube can be left in situ if there is a delay before a. Increased drainage can be due to vessel leakage or
surgery or sclerotherapy, so that if rebleeding should may be caused by catheter erosion into a vessel.
occur, reintubation is not necessary. The rate of bleeding should be documented every
30-60 minutes. Increased drainage may be from
DRAINS increased lymph drainage, or anastomotic leak of
A drain forms a channel along which fluids (blood, appropriate organs involved in surgery as the case
serum, pus, bile or other intestinal content) can reach may be. Drainage of urine may represent fistulae
the surface while allowing the main wound to be anywhere along the urinary tract
closed. The drain itself may form the channel when it b. Purulent drainage indicates infection
is tubular or it may form a channel in the tissues when c. Sudden cessation of drainage may be due to
it is a strip of ribbon. Though too much cannot be occlusion of catheter by tissue debris
expected from the use of drains, a well-placed drain d. Drain exit wound infection will show erythema,
inserted before the calamity has occurred may be induration and pain at the drain exit sites
lifesaving, provided the leak is also properly dealt e. Usually drain management does not require emer-
with. gent or urgent action with exception of mediastinal
Surgical drains are of two basic types: tubes after cardiac surgery.
a. Passive—they drain by gravity and capillary
action, and the drainage is further facilitated by Corrugated Drains
transient increases in intra-abdominal pressure, as
Varieties The corrugated tubes were made of India
with coughing, e.g. Foley’s and Malecot’s catheters.
red rubber and in recent times in polyvinyl chloride
b. Active–the drainage with these drains are
(Fig. 4.14).
accomplished by suction from a simple bulb device
or a suction pump. Appearance They are available as broad sheets with
Drainage of the peritoneal cavity is now carried corrugations in various lengths and sizes.
out less frequently than in former years. It is realized
that the peritoneum is comparatively resistant to
infection, and that it is impossible to drain the cavity
as a whole for more than 48 to 72 hours, since the drain
gets walled off by plastic adhesions. In cases of severe
peritoneal sepsis or when leaks are expected in the
postoperative period, drainage during this period is
of undoubted value, since, by allowing the escape of
inflammatory exudate or frank pus, it reduces toxemia
and promotes the recovery of intestinal tone.
Whenever drains are inserted, this should be
recorded in the notes and drains labeled (in case of
tube drains) and the nurses should be instructed to
manage them. Fig. 4.14: Corrugated drains
22 Gastrointestinal Surgery: Step by Step Management
Method of Introduction
The drains are brought out by separate stab wound.
The stab wound is made to the size of the width of the
cut drain sheet, the fingers of the left hand within the
peritoneal cavity being used to protect the bowel from
A
injury, and the drain introduced with the aid of
forceps. The drain needs to be transfixed and sutured
to the skin to prevent it from getting pulled out
accidentally.
Use This drain is used to drain the fluid potentially
expected to collect in a particular area.
Suction Tubes
Varieties The suction drainage tubes are made of
polyvinyl chloride (Fig. 4.18).
Appearance The suction drainage tubes are attached
to a bellow for suction.
Sizes All tube drains are available in various lengths
Fig. 4.16: Tube drain connected to the urobag
and various diameters of size from 8F to 34F.
Method of Introduction
The drains are brought out by separate stab wound.
The stab wound is made as small as possible, the drain
needs to be transfixed and sutured to the skin to
prevent it from getting pulled out accidentally.
cardiovascular, renal, electrolyte imbalance and fluid patient has a shortened clot lysis time and hypo-
retention, and encephalopathic complications of portal fibrinogenemia, ε-aminocaproic acid may be given.
hypertension.
The principal danger of portal hypertension is from CHOLANGITIS
GI bleeding from thin-walled varices as well as from Partial or complete obstruction of the bile duct can
an increased incidence of gastric ulcers, duodenal give rise to cholangitis. Though antibiotics are useful,
ulcers and also from gastritis. The other problems are in toxic cholangitis, urgent biliary decompression like
electrolyte and fluid abnormalities, renal dysfunction, endoscopic sphincterotomy becomes important.
hepatorenal syndrome, coagulation defects, hepatic
ANTIBIOTICS
encephalopathy and malnutrition.
The organisms most commonly isolated from the
NUTRITION biliary tree are, Escherichia coli, Klebsiella pneumonia,
Enterococcus and the anaerobe Bacteroides fragilis. Four
Preoperative hyperalimentation has been shown to be factors must be considered when choosing the
of benefit in reducing morbidity and mortality in antibiotics for jaundiced patient.
malnourished individuals. Characteristics of patients 1. The antibacterial spectrum
at risk include: 2. Serum and liver concentrations
1. Serum albumin levels less than 3 gm/100 ml 3. Biliary excretion
2. Weight loss of 10-20 percent over several months 4. Toxicity.
3. Serum transferrin levels of less than 200 mg/dl. Prophylactic antibiotics should be administered in all
patients undergoing operative or non-operative
COAGULATION
manipulations of the biliary tree including cholangiography
Patients with obstructive jaundice, cholangitis or and sphincterotomy. In uncomplicated cases a broad-
cirrhosis are all prone to excessive intraoperative spectrum first generation cephalosporin such as
bleeding, common clotting defect being prolongation cefazolin usually provides adequate coverage. In
of prothrombin time (PT), which is usually reversible complicated situations, where multiple organisms are
by parenteral vitamin K (10 mgm). In cirrhotics, likely to be present, broader-spectrum antibiotics,
clotting abnormalities may be more complicated and which cover anaerobes are required.
include: In the preoperative surgical prophylaxis the
1. Thrombocytopenia secondary to hypersplenism antibiotic dose should be given 1 to 2 hours preopera-
2. Prolongation of prothrombin time (PT) and partial tively and depending on the pharmacodymics, once
thromboplastin time (PTT) again intraoperatively, if necessary (Table 5.2).
3. Fibrinolysis. Empirical use of antibiotics in gastrointestinal
If PTT continues to be prolonged in spite of the surgery has a definite role to play.
administration of vitamin K, fresh frozen plasma The advantages are:
should be given. For thrombocytopenia, intra- i. Protects healthy susceptible individuals of all ages
operative platelet infusions may be required. If the who are exposed to infections
Chapter 5: Preoperative Preparation in Gastrointestinal Surgery (General) 27
Table 5.2: Preoperative surgical prophylaxis—the ment must necessarily be curtailed, but conditions
antibiotic dosage such as shock, water or salt depletion should receive
Procedure Drug Dosage adequate correction.
Gastroduodenal Cefazolin 1 gm 1 hr preoperatively Teeth and Oral Hygiene
Cefuroxime 1.5 gm ½ to 1 hour Any oral or pharyngeal sepsis predisposes to
preoperatively
postoperative respiratory infection or to the inflam-
Biliary tract Cefazolin 1 gm 1 hr preoperatively, mation of the parotid glands, which makes a
1-2 more doses 8 hrly satisfactory state of oral hygiene obtained.
postoperatively
Diet
Cefuroxime 1.5 gm ½ to 1 hour
preoperatively Extensive diet restriction is no longer advocated in
general cases. On the contrary, the average hospital
Colon surgery Erythromycin 1 gm at 1 pm, 2 pm and
postoperative 11 pm day before surgery
patient benefits from a period on a full well-balanced
+ neomycin diet, which is restricted only on the day before
postoperative operation. A light dinner, or fluids alone, are given
1-3 doses of 1 gm intravenously 1 hr that evening, and nothing except weak tea or clear
cefoxitin or preoperatively, 1-2 more fluid drink is allowed on the day of the operation. A
cefotetan doses 8 hrly postoperatively period of 6 hours of fasting is reasonable.
ii. Prevents infectious complications after operations Gastric Aspiration and Lavage
in surgically traumatised and potentially conta- In patients with persistent vomiting and in all cases
minated areas (gallbladder surgery, surgery of the of diseases of stomach and duodenum, a nasogastric
colon) tube should be passed in order that all the stomach
iii. Prevents colonization of surgically placed foreign contents can be drawn off before the patient is taken
body to the theatre. The tube is left in situ during the
iv. Protects individuals susceptible to reactivation of operation, so that further aspiration can be carried out
infection by virtue of medication or therapy as required. This is a valuable precaution in preventing
v. Protects patients with biologic propensity to vomitus being aspirated to the bronchial tree during
develop bacterial complications anaesthesia.
vi. Protects patients prone to develop infection by Bowel Action
virtue of immunologic structure. If the bowel action has been regular, administration
The disadvantages are: of a laxative is unnecessary, but if given, a mild
i. Toxic and hypersensitivity reactions to antibiotics laxative on the day prior to surgery may be justified.
ii. Superinfection—often with more resistant It is a common practice to give suppositories on the
organisms evening before operation. For all operations on the
iii. Alteration of ecology of hospital flora colon or rectum where resection is likely to be carried
iv. May encourage poor technique—hygienic or out, special preparation is required (See Chapter 9).
surgical.
The antibiotics started in the preoperative period Urinary System
are continued for 3-5 days postoperatively, but in clean Insertion of a Foley’s catheter is advised in surgeries
cases, the postoperative use is limited to one or two of the pelvic organs or when the surgery is performed
doses only. close to the urinary bladder, to keep the urinary
bladder decompressed and also to monitor the output.
Preoperative Preparation
For all major operations in the abdominal viscera, the Blood
patient should be admitted to the hospital several days Where blood transfusions are anticipated, it is better
beforehand, to enable a full clinical examination and to start the intravenous infusion with the blood set
any special investigations to be carried out. In emer- and also keep the required units of blood readily
gency conditions, any scheme of preoperative treat- available when needed. The number of units of blood
28 Gastrointestinal Surgery: Step by Step Management
to be kept ready depends upon the assessment by the Table 5.3: Summary of normal daily fluid and
surgeon. electrolyte input and output
Input Output
Fluid and Electrolyte Therapy
Water
It is now accepted as a valuable and indeed essential
Diet 2300 ml Urine 1300-1800 ml (minimum
part of modern surgical treatment, both pre- and obligatory volume—400 ml)
postoperative. The essentials of such therapy are: Metabolism 200 ml Skin loss 500 ml
1. to make good any fluid deficit already incurred Lung loss 500 ml (obligatory)
2. to ensure an adequate balance of intake and output Faecal loss 100 ml
and also replace when needed Sodium
3. to administer fluids which contain the appropriate Diet 150 mmol/day Urine 140 mmol/day
minerals as per the patient’s needs. (range 50-300 mmol) Faecal loss 5 mmol/day
Most problems of fluid, electrolyte and acid-base Skin transpiration 5 mmol/day
and nutritional management are relatively straigh- Potassium
tforward and can be worked out with reasoning and Diet 100 mmol/day Urine 85 mmol/day
common sense. Problems are minimized if high-risk (range 50-200 mmol/day) (rarely falls < 15 mmol/day)
Faecal loss 10 mmol/day
patients are assessed properly before operation and
(obligatory)+
cardiovascular status and fluid balance are monitored Skin < 5 mmol/day
closely before and after operation. It should be
remembered that severely ill patients with abdominal
infection and fistulae are likely to suffer major should be discouraged. It can be used when an
problems of fluid balance and nutrition. intravenous infusion is required only for a day or two
An average adult normally loses between 2.5 and and there are no special fluid or electrolyte problems.
3 liters of fluid in 24 hours (Table 5.3). The loss is as For most patients, the daily water and sodium
follows: requirements are best met by using appropriate
Insensible loss through skin and lungs: 1000 ml quantities of normal saline solution (0.9% sodium
Insensible loss through faeces : 100 ml chloride) and 5 percent dextrose (glucose) solutions.
Sensible loss through urine : 1300-1800 ml
Potassium
(about 60 ml/hour)
Fluid normally enters the body by oral intake of Basic potassium requirements are met by infusing 60
fluids and food but about 200 ml of water is produced to 80 mmol of potassium chloride in divided doses
as a by-product of metabolism. About 100-150 mmol over 24 hour period. Premixed intravenous fluids are
of sodium ions and 50-100 mmol of potassium ions now available with 20 mmol of potassium chloride in
are lost each day in the urine and this is balanced by 500 ml container. If premixed solutions are not availa-
normal dietary intake. ble, potassium chloride can be added to intravenous
When a patient is deprived of all oral intake—as infusions but care must be taken to ensure thorough
occurs in the perioperative period or in coma— mixing. Concentrations of potassium chloride greater
isotonic electrolyte solutions of different types are than 40 mmol in 500 ml should be avoided for general
given intravenously as a substitute. use, and bolus injections of potassium chloride must
never be given because rapid increases in plasma
Water and Sodium potassium causes cardiac arrest.
In an uncomplicated patient, the daily water and Note: Added potassium is not usually required in the
sodium requirements can be given as 2.5-3 liters of immediate postoperative period because potassium is
standard dextrose-saline solution containing 5 percent released from damaged cells and raises the serum potassium
dextrose and 0.18 percent sodium chloride (this has concentration.
only one-fifth the salt content of ‘normal saline’). This
fluid regimen is often, however, automatically Solutions
prescribed without considering special requirements The choice of solution for intravenous infusion is a
of individual patients. For this reason, its general use matter of some difficulty, as no clear-cut rules are laid
Chapter 5: Preoperative Preparation in Gastrointestinal Surgery (General) 29
down. The two solutions in most general use are isotonic Table 5.4: Composition of commonly
(0.9%) saline and 5 to 10 percent, glucose solution, if desired used parenteral fluids
these may be combined in the form of “glucose-saline.” In Composition in 100 ml Concentration Osmolarity
general, the normal requirement of the body for salt of electrolytes (mOsm/L)
is in the region of 5 gm/day, and this will be met very in mEq/L
adequately by 600 ml of isotonic salt solution. When 5% dextrose solution
the patient’s main need is for water alone, any Dextrose—5 gm — 253
additional fluid should be given in the form of glucose Dextrose normal saline solution
solution. Proportionately, much larger quantities of Dextrose—5 gm Na+ 154 308
saline will, however, be required when there is actual Sodium chloride—0.9 gm Cl– 154
loss of gastrointestinal secretions, for in general such Dextrose half normal saline solution
losses should be replaced with saline. Dextrose—5 gm Na+ 77 407
The composition of commonly used parenteral Sodium chloride—0.45 gm Cl– 77
fluids is given in Table 5.4. Lactated Ringer’s solution
Sample daily intravenous fluid regimens as a substi- Sodium hydroxide—0.32 gm Na+ 131 273
tute to oral intake in uncomplicated cases is given in Sodium chloride—0.6 gm K+ 5
Table 5.5. Potassium chloride—0.04 gm Ca++ 2
Calcium chloride—0.027 gm Cl– 111
Quantity to be Administered and Rate of Flow HCO3– 29
Table 5.5: Samples of daily intravenous fluid regimens Daily Fluid Balance
Prescription 1 (for 24 hours—each bag to be given in 4 hours) The keeping of a daily fluid balance chart is an
— 500 ml 0.9 percent sodium chloride + 20 mmol KCl essential safeguard whenever a patient is being treated
— 500 ml 5 percent dextrose by continuous intravenous infusion—whether this be
— 500 ml 5 percent dextrose + 20 mmol KCl pre- or postoperatively. An exact record must be kept
— 500 ml 5 percent dextrose
— 500 ml 5 percent dextrose + 20 mmol KCl
throughout the 24 hours of all fluid intake—by
— 500 ml 5 percent dextrose stomach (orally or by gastric “drip”) and by infusion
(intravenous). The output—by urine, by vomiting or
Prescription 2 (for 24 hours—each bag to be given in 4 hours)
— 500 ml dextrose saline + 20 mmol KCl
by gastric aspiration, by fistulous discharge or by
— 500 ml dextrose saline diarrhea—must be similarly recorded (the fluid
— 500 ml dextrose saline + 20 mmol KCl content of solid faeces can be disregarded). To the total
— 500 ml dextrose saline amount of the recorded output must be added about
— 500 ml dextrose saline + 20 mmol KCl 1 litre for “insensible” loss. The intake output should
— 500 ml dextrose saline
be compared after each 12 hours, and any fluid debt
or negative balance should be replaced during the
Table 5.6: Sources of excess fluid loss in ensuing 12-hour period.
surgical patients
Intake-Output Chart
Sources of excess fluid loss in surgical patients
Intake Output
Date Time Oral IV Qty Urine Vomit Others Qty
Blood loss—trauma and surgical
Plasma loss—burns
Gastrointestinal fluid loss—vomiting, nasogastric
aspiration, diarrhoea, sequestration in obstructed or
adynamic bowel, loss through a fistula or ileostomy
Inflammatory exudate into the peritoneal cavity—
generalized peritonitis and acute pancreatitis.
Gastrointestinal Fluid Loss
Septicemia—massive peripheral vasodilatation causes
relative hypovolemia. Between 5 and 9 liters of electrolyte-rich fluid is
Abnormal insensible loss—fever, excess sweating or
normally secreted into the upper gastrointestinal tract
hyperventilation. each day as saliva, gastric juice, bile, pancreatic fluid
and succus entericus. Most of the fluid is reabsorbed
in the lower gastrointestinal tract. The normal daily
Intravenous therapy should be discontinued when 2½ gastrointestinal secretions and their electrolyte
liters (i.e., 100 ml/hour) can be taken orally. compositions are given in Table 5.7.
Table 5.7: Normal daily gastrointestinal secretions and their electrolyte compositions
Secretion Volume (L) Na+ (mmol/L) K+ (mmol/L) Cl– (mmol/L) HCO3– (mmol/L)
Saliva 1-1.5 20-80 10-20 20-40 20-160
Gastric juice 1-2.5 20-100 5-10 120-160 Nil
Bile Upto 1 150-250 5-10 40-60 20-60
Pancreatic fluid 1-2 120 5-10 10-60 20-80
Succus entericus 2-3 140 5 Variable Variable
Chapter 5: Preoperative Preparation in Gastrointestinal Surgery (General) 31
Large volumes of water and electrolytes may be be estimated, aided by observation of urine output
lost from the body by vomiting, nasogastric aspiration, and blood pressure.
sequestration in obstructed or adynamic bowel or
Ileostomy Losses
drainage via a fistula or an ileostomy. Abnormal fluid
Although majority of patients with a normally
losses must be measured or estimated as accurately
functioning ileostomy have no clinical evidence of any
as possible for proper intravenous replacement. As a
deficiency, occult deficiencies of water and sodium
general rule, gastrointestinal fluid losses should be
are probably common, especially in overactive
replaced by an equivalent volume of normal saline
ileostomies, as the output is 5 times the normal faecal
and, potassium chloride added as necessary. The
output and the sodium loss 4-5 times the normal faecal
intestinal losses which cannot be measured, should sodium loss.
6
Postoperative Management in
Gastrointestinal Surgery (General)
GENERAL MEASURES patient. In the modern practice, it is wiser to regulate
dietary progress by the needs and reactions of the
The adoption of a careful postoperative regime in
patient, rather than by the arbitrary rules of former
gastrointestinal cases has led to a considerable reduc-
years. An exact record must be maintained throughout
tion in mortality and morbidity and complications
the 24 hours for exact replacement.
have become much less frequent.
Postoperative Renal Failure Fig. 6.1: Purulent discharge from the wound
This may follow severe sepsis or prolonged hypo- (6th postoperative day)
tension such as may be associated with extensive
injury or operations on the liver. Diuretics given intra-
venously may rapidly increase the urinary output but
if renal failure persists, the fluid intake should be
restricted so as to maintain the daily fluid balance.
Burst Abdomen
Disruption of the abdominal wound is seen in elderly
or debilitated subjects, especially if they are suffering
from advanced malignant disease, protein or vitamin
C deficiency or uremia and also those on prolonged
steroid therapy. Persistent cough, vomiting or abdo-
minal distension may be contributing causes. The
disruption is likely to occur around the 10th post- Fig. 6.2A: Bowel seen through the gaping wound
operative day. In many cases, there is no warning of (10th postoperative day)
the catastrophe, but sometimes, the patient may have
complained of some discomfort in the wound, and a • Clean and disinfect the surrounding skin
serosanguineous/purulent discharge may have been • Towel the skin
noted (Fig. 6.1). Immediate operative repair is • Return the contents and retain them with a moist
mandatory. pack (Fig. 6.2B)
• Repair the wound using through and through thick
The First Aid Treatment nylon sutures which are made to traverse all layers
of the abdominal wall from skin to peritoneum, as
• Reassure the patient mattress sutures, tied over small swabs or rubber
• Cover the parts with sterile towels wrung out of tubing, so that they do not cut through the skin
warm saline (Fig. 6.2C).
• Instruct the patient not to cough, if at all possible. • Additional sutures may be inserted to draw the
skin edges together, but accurate coaptation of
Definitive Treatment
these layers should not be attempted lest drainage
Single layer closure with feusin suture (Figs 6.2A, B from the wound be impeded.
and C). The diagramatic representation of the technique
• Wrap the abdominal parts in fresh packs wrung of the closure of the burst abdomen is shown in
out of warm saline Figure 6.3.
Chapter 6: Postoperative Management in Gastrointestinal Surgery (General) 35
Parotitis
Parotitis is not a common complication today. It is
controlled by good oral hygiene and antibiotics.
Extrinsic
Autonomic Parasympathetic Vagus nerves Esophagus to mid Mixed motor secrete Increase GI
nervous system nervous system transverse colon acetylcholine Sensory-
(ANS) carry pain from the gut
Pelvic splanchnic Midtransverse
nerves colon to the rectum
Sympathetic Terminate on the Mixed-motor- Inhibition of
nervous ENS but a few inhibitory effect peristalsis,
system terminate directly Sensory-carry pain vasoconstriction,
on the blood vessels from the gut no significant effect
on GI section
Intrinsic
Enteric Auerbach’s Auerbach’s Terminate on Mixed-motor- Contraction
nervous (myenteric) (myenteric) smooth muscle action on muscles relaxation of smooth
system situated between plexus-situated cells of the GIT, and secretions muscles of GIT and
between the exocrine glands, sensory-take part influence GIT
muscle layers APUD cells in GI reflexes secretions
Meissner’s plexus- Interconnected
situated in the with Auerbach’s
submucosa plexus
38 Gastrointestinal Surgery: Step by Step Management
Pathology of Complications
This is due to incoordinated peristaltic activity of the
stomach, probably due to the disturbance of:
• Gastric pace-setter potentials
• Ectopic pacemaker
• Vagal reflexes by dissociation of the neural impul-
ses from the stomach, and prevention of acetyl-
choline from augmenting the action potentials.
Fig. 7.1: Varieties of vagotomy. The abdominal vagi, showing
Investigations and Diagnosis
the level of nerve section in (1) truncal vagotomy, (2) selective
vagotomy and (3) highly selective vagotomy Gastrografin study will show delayed emptying with
no evidence of narrowing or obstruction.
VAGUS NERVES Endoscopy may reveal retention of large quantities
The vagotomy is usually performed with other of gastric fluid.
supplementary procedures like gastric resections or
Treatment
bypass procedures. It is not performed as a sole
procedure excepting when it is required for comple- This is usually relieved by additional nasogastric
tion, following incomplete vagotomy in the past. The suction and administration of parasympathomimetic
complications of vagotomy can be early or long-term. drugs.
The patients present with sudden upper abdominal Generally, they recover without treatment. Rarely,
pain, severe in nature. Examination reveals marked some patients may require esophageal dilatation.
tenderness and rigidity and may present with a shock- Note: This is encountered more often after proximal
like picture. gastric vagotomy than after other vagotomies.
CT scan and gastroscopy (Fig. 7.2) may be useful in Investigations and Diagnosis
diagnosis. No specific investigation is useful.
Treatment Treatment
Depending upon the area of necrosis, gastric resection Generally, they recover without treatment. Rarely,
with gatro-enteric anastomosis may be required. some patients may require esophageal dilatation.
Note: This complication follows only proximal gastric Note: This is encountered more often proximal gastric
vagotomy. vagotomy than after other vagotomies.
Pathology of Complication
The injury caused to the right crural sling fibres during
mobilization of vagi can cause this complication. A B
Treatment
Medical: The treatment consists of administration of C D
H2 blockers or proton pump inhibitors along with Figs 7.4A to D: (A) Esophageal stricture caused by
gastrokinetics like mosapride. Rarely, once stricture inflammation; (B, C) Stricture dilatation by balloon tipped
has formed, dilatation may be required (Figs 7.4B to catheter; (D) Result after dilatation
D).
CHOLELITHIASIS
Clinical Presentation
The patient may present with upper abdominal
dyspepsia, right hypochondrial pain, as a dull ache
or severely colicky pain.
Pathology of Complication
Division of hepatic vagi as in truncal vagotomy,
reduces the gallbladder tone and increases the volume
of the gallbladder. This hypotonia of the gallbladder
is the cause of formation of gallstones.
POSTOPERATIVE MANAGEMENT
Treatment in an intensive care unit is advised for 48
Fig. 7.12: Esophagomyotomy
hours.
PREOPERATIVE PREPARATION IN ELECTIVE Ventilatory Support
SURGERY OF THE ESOPHAGUS
It is preferable to ventilate these patients for 12 hours,
Esophageal surgery may give poor results because of and an immediate chest X-ray is necessary to exclude
inadequate patient preparation before surgery. left-sided pneumothorax and ensure expansion of the
Correction of Undernutrition right lung.
Correction of nutritional status plays a major role for
Nasogastric Aspiration
the patients for esophageal surgery. These patients
usually have such a poor nutrition which reflects on A period of ileus in the postoperative period occurs,
their cellular immunity. during which the patient is maintained on intravenous
• It is correctable and needs to be corrected by fluids, and nasogastric aspiration regularly for a
administration of oral liquefied high-calorie diet period of about 48 hours. The nasogastric tube can be
supplemented by vitamins, especially vitamins B removed when bowel sounds return, the volume of
and C. If oral intake is not possible, the same can aspirate drops below 500 ml and there is passage of
be administered through a fine tube passed flatus. Oral feeding is allowed after 5 to 6 days with
through the structured area. If the stricture is small amounts of fluid, increasing only slowly, but it
impassable, feeding jejunostomy or feeding should be allowed only after establishment of intact
gastrostomy is made. Depleted patients should be anastomosis radiologically. If restoration of oral
given total parenteral nutrition (TPN) containing feeding is delayed, a period of parenteral nutrition
300 to 400 gm nitrogen/kg per day and roughly would be appropriate. After surgery for hiatus hernia
equal amounts of glucose and fat calories to (fundoplication), a barium examination is obtained on
provide a total energy intake of > 50 percent of the seventh postoperative day to demonstrate the
estimated resting energy expenditure or > 20 unobstructed passage of barium into stomach prior
percent of estimated total energy expenditure. If to starting a solid oral feed.
gastrostomy is performed, care must be taken not to Intravenous fluids are maintained until the
damage the right gastroepiploic vessels, which are needed detection of adequate bowel sounds indicating that
for the mobilization for definitive surgery. jejunostomy feeding can start or, when the patient is
• Chest physiotherapy Most patients with esophageal taking sufficient fluids orally usually by the 4th
cancers are smokers and may also have some postoperative day.
amount of aspiration pneumonitis. Chest physio- Urinary catheter is normally discontinued between
therapy helps in the postoperative recovery of the the second and fourth day of surgery.
patient. Antibiotic prophylaxis is continued for 24 hours
• Diet A liquid diet is necessary for 2 to 3 days before in clean cases and continued for a reasonable time of
surgery to keep the esophagus free of debris; no about 5 to 7 days in contaminated cases and till the
oral intake is allowed for 24 hours. evidence of sepsis disappears.
44 Gastrointestinal Surgery: Step by Step Management
Pathology of Complication
This dysphagia may be due to local recurrence of the
malignancy or stricture of the esophagus at the site of
anastomosis.
Treatment
Chronic PPI therapy combined with repeated pneu-
matic dilatation is the key factor in the treatment of
non-malignant strictures (Figs 7.4B to D). Malignancy Fig. 7.14: Malignant stricture of the anastomotic area
requires appropriate management.
Note: Incidence of anastomotic strictures is found to Treatment
be more with circular stapler anastomosis than after
Dilatation of the esophagus with bougies generally of
hand-sewn single layer anastomosis.
size more than 46F with feeding jejunostomy is the
treatment of choice.
SECONDARY CERVICAL DYSPHAGIA
Clinical Presentation STOMACH AND DUODENUM
The patient may present with dysphagia with a feeling Variety of operations (Figs 7.15A to C) are performed
of obstruction in the cervical region. on the stomach and duodenum for various indications
and various situations and they consist of (see Table
Pathology of Complication 7.7):
This is due to dysfunction of cricopharyngeus muscle. • Gastrectomy (resections or removal of part or the
whole of stomach) with anastomosis to maintain
Investigations and Diagnosis the continuity.
The documentation of cricopharyngeal dysfunction • Esophagogastrectomy—removal of upper stomach
may be studied by esophageal motility tests. may involve lower or more part of esophagus.
PREOPERATIVE MANAGEMENT
The preoperative management of patients for surgery
of the stomach is for any gastrointestinal surgery in
general (see Chapter 5). The points to remember are:
• Nasogastric aspiration is required in patients with
outlet obstructive lesions of the stomach, to keep
the stomach decompressed so that the restoration
of the gastric motility is not delayed in the
postoperative period.
• Since nasogastric aspiration is done on continuous
basis for prolonged periods of time, replacement
of water and electrolytes is important so that the
imbalance is avoided, which may hamper the
restoration of gastric motility.
POSTOPERATIVE MANAGEMENT
A period of ileus is anticipated in the postoperative
period, during which the patient is maintained on
intravenous fluids, and nasogastric aspiration regu-
larly for a period of about 48 hours. The nasogastric
tube can be removed when bowel sounds return, the
volume of aspirate drops below 500 ml and there is
passage of flatus. Peristalsis returns to the small bowel
before the stomach and colon regain their motility. Clear
liquids are begun and if tolerated, the diet is advanced
to normal intake over the next 2 days. If restoration of
oral feeding is delayed, consider whether a period of
parenteral nutrition would be appropriate. Remove
the drain when fluid loss diminishes, generally at 2 to
3 days.
Figs 7.15A to C: Varieties of gastric operations (A) Partial
Intravenous fluids are maintained until the patient
gastrectomy with gastroduodenal (Billroth I) or gastrojejunal
(Billroth II) anastomosis. (B) Truncal vagotomy and antrectomy is taking sufficient fluids orally.
using a gastroduodenal anastomosis. (C) Truncal vagotomy Urinary catheter is normally discontinued between
and gastrojejunostomy or pyloroplasty the second and fourth day of surgery.
Antibiotic prophylaxis is continued for 24 hours
• Partial gastrectomy—removal of lower stomach in clean cases and continued for a reasonable time of
with gastroduodenal (Billroth I) or gastrojejunal about 5 to 7 days in contaminated cases and till the
anastomosis (Billroth II). evidence of sepsis disappears.
• Bypass procedures without resections (e.g., Intra-abdominal drains kept near the anastomosis
gastrojejunostomy or pyloroplasty). are removed when the motility of the bowel returns
• Gastrostomy—connect the stomach lumen to the to normal with the passage of flatus and/or faeces. If
exterior (e.g., feeding gastrostomy). there is evidence of infection or sepsis without an
48 Gastrointestinal Surgery: Step by Step Management
COMPLICATIONS OF GASTRIC
SURGERY AND MANAGEMENT
All gastric surgeries derange gastric function, and
during the first weeks or months after surgery, almost
all patients experience some adverse effects, which
may be mild or severe, depending on the type of
operation. In most patients symptoms decrease with
time due to physiological and psychological adap-
Figs 7.16: Motor functions of the stomach
tation. For this reason, the outcome and sequelae of
gastric surgery should be assessed at least 6 months
after surgery, or even later. EARLY COMPLICATIONS OF GASTRIC
Postgastrectomy syndromes appear as combi- SURGERY (See Table 7.8)
nations of signs and symptoms brought about
EARLY INTRAGASTRIC HEMORRHAGE
primarily by the changes in the motor function of the
stomach and upper small bowel secondary to the Clinical Presentation
operations. Immediately after gastric resection, it is not unusual
The motor functions of the stomach (Fig. 7.16) to aspirate bloody or blood-stained fluid from the
include: nasogastric tube. The colour should clear in a matter
• Accept and store bolus of ingested food—contri- of 48 hours and the aspirate should become bilious in
buted by vagal function* nature. The persistence of bloody aspirate beyond 48
• Reduce large particles to smaller size by peristalsis hours is a major concern and needs to be attended to.
of stomach and pylorus **
• Transport the food into small bowel for further
digestion and absorption by intact pylous and Pathology of Complication
activation of neural and hormonal mechanisms The site of bleeding is from:
provided by the upper small bowel*** 1. the anastomotic area (more common)
*Proximal gastric vagotomy impairs the comp- 2. small bleeding ulcer in the proximal gastric pouch
liance of proximal stomach and decreases its reservoir
function. Investigation
**Removal of gastric segments impair this function.
It is difficult to assess the amount of blood loss by
***Distal gastric vagotomy and distal gastric
nasogastric aspirate, as there may be retained blood
resection including pyloric resection decrease the
clots in the stomach which cannot be aspirated, and
mechanical-digestive function, removal of pylorus
also some blood is bound to travel down the intestine.
may allow reflux of intestinal contents into the
stomach and varieties of gastroenterostomy may
mechanically or functionally affect transporting Treatment
function of the stomach.
Treatment consists of the following.
There are unfortunately a few specific tests, and
those that are specific are of little help in clinical
Medical
practice. Thus, a careful history is still the most reliable
way of making a diagnosis on which the treatment a. Ice cold saline lavage
gets based. b. Blood transfusions.
Chapter 7: Pre- and Postoperative Management in Foregut Surgery 49
Duodenal 2nd-5th Obstruction of afferent loop, severe Sump drainage of RUQ, Nasogastric
stump leakage postoperative day duodenal bulb disease, excessive suture decompression, Feeding jejunostomy
closure of stump, bleeding from pan- if needed, Exploration and corrective
creatic bed, postoperative pancreatitis, surgery if obstruction is documented
localized infection and sepsis, improper
surgical technique
Gastro- 2nd-5th Severely diseased and scarred Usually ceases by 24 to 48 hours, mild
duodenostomy postoperative day duodenum leaks need only NG suction,
leak (Billroth I) Moderate leaks need with no peritonitis,
stump closure with Feeding jejunostomy,
Large leaks need conversion of B I to B II
with feeding jejunostomy or Roux-en-Y
reconstruction
Gastro- 2nd-5th Increased tension on the anastomotic Mild leak—resuture with omental patch
jejunostomy postoperative day line or necrosis due to jeopardized with drainage of RUQ
leak (Billroth II) blood supply Major leak—miniresection and redo
Billroth II, or Roux-en-Y with feeding
jejunostomy or simple gastrojejunostomy
Leakage from 2nd-5th Edema and reaction at pyloroplasty Closure of duodenal stump with Bill-
pyloroplasty site postoperative day site roth II, if pyloroplasty is remade, add GJ
Gastric remnant 2nd-5th Ligation of left gastric artery at its If small viable remnant—total gastrec-
necrosis postoperative day base and a concomitant splenectomy tomy with Roux-en-Y anastomosis. If
entire gastric remnant is not viable or
questionably viable–cervical esophago-
stomy with feeding jejunostomy with
colonic interposition later
Stomal 2nd-5th Stomal edema If obstruction persists beyond 2 weeks,
obstruction postoperative day Inflammatory adhesions in B II gastrografin study- medical management,
if obstruction goes beyond 15 days,
surgery (B I to B II and BII to Roux-en-Y)
Acute afferent 2nd to 5th Mechanical obstruction due to a twist, Surgery is needed depending on the
loop obstruction postoperative day volvulus, internal herniation, jejuno- operative findings—simple entero-
gastric intussusception or kink at GJ site enterostomy, Roux-en-Y reconstruction or
pancreaticoduodenectomy
Contd...
50 Gastrointestinal Surgery: Step by Step Management
Contd...
Early Time of Reason Management
complications appearance
Jejunal loop 3rd-7th Long afferent loop produces its Surgery—Reduce hernia, and close all
herniation postoperative day herniation behind the efferent loop, mesenteric traps, resect appropriate long
or longer Short afferent loop allows the efferent loops, convert to Roux-en-Y
loop to herniate
Intra-abdominal 3rd-7th Spillage of duodenal, stomach or jejunal Surgical drainage/drainage by
abscess postoperative day contents, anastomotic leaks ultrasonography guidance if possible
Postoperative 2nd-5th Injury to pancreatic ductile system Gastric suction, fluid replacements,
pancreatitis postoperative day antibiotics, Drainage of collections,
excision of fistulae, Pseudocysts need
internal drainage
Postoperative 3rd-7th Edema of the papilla in severely Subsides in a few days, rarely surgery as
jaundice postoperative day diseased duodenum per pathology
Inadvertent Recognized weeks Inadequate exposure, poor Early surgical correction
gastroileostomy later anaesthesia, inexperienced surgeon
Clinical Presentation
Intraluminal bleeding may occur in the recovery room
or several days postoperatively, after removal of the
nasogastric tube, presenting in the form of A B
hematemesis and melena. Figs 7.17A and B: Intragastric hemorrhage
Chapter 7: Pre- and Postoperative Management in Foregut Surgery 51
Medical
a. Ice cold saline lavage
b. Blood transfusions.
Surgical Treatment
Reoperation should not be postponed when faced with
continuous bleeding, in spite of medical management.
The patient’s general condition should be assessed
very closely and if hemorrhage does not abate even
after three units of blood transfusion reoperation
should be done. The decision demands sound surgical
judgement and has various alternatives. They are:
a. For the bleeding ulcers distal to the point of resec-
tion in the retrobulbar duodenum, a Horsley’s slit
on the anterior duodenal wall is done to gain access
to the ulcer crater and obliterate the ulcer with
several “figure of 8” sutures with 2-0 silk (Fig. 7.18)
b. Billroth I reconstruction after ligating and oblite- Figs 7.18: Horsley’s slit of duodenum
rating an ulcer crater locally distal to the duode-
num
c. Billroth II reconstruction or Roux-en-Y diversion
if the gastric chyme is to be prevented to traverse
the duodenal outflow
d. If the original operation is Billroth I reconstruction,
the revision surgery should be Billroth II
reconstruction or Roux-en-Y diversion
e. If the original operation is Billroth II reconstruction
or primary Roux-en-Y reconstruction, the duo-
denal stump is reopened, the bleeding ulcer trans-
fixed, and either catheter duodenostomy (Fig. 7.19)
or reclosure of the duodenal stump is performed
depending upon the duodenal tissue’s appearance
and integrity.
f. If the original operation is pyloroplasty, antral
resection with removal or suture control of the
ulcer, followed by either a Billroth I, Billroth II or
Roux-en-Y reconstruction is done.
Figs 7.19: Catheter duodenostomy
EXTRAGASTRIC HEMORRHAGE
Pathology of Complication
Clinical Presentation The reason may be intraperitoneal hemorrhage from:
In the immediate postoperative period, the patient a. Laceration of spleen
may present with suddenly elevated pulse, a falling b. Injury to the liver by the use of retractors
blood pressure and diminished urinary output. The c. Injury to the vasa brevia
skin may be moist and clammy and at first a myocar- d. Hemorrhage from the pancreatic bed
dial infarction may be suspected. If drains are kept in e. Improperly secured vessel in the greater or lesser
the peritoneal cavity, they may show drainage of omentum
bloody or blood-stained fluid, and clear nasogastric f. Hemorrhage from the right gastric artery and right
aspirate. gastroepiploic vessels
52 Gastrointestinal Surgery: Step by Step Management
Pathology of Complication
This occurs due to the ischemic necrosis of the gastric
remnant due to ligation of the left gastric artery at its
base and a concomitant splenectomy. With only phre-
nic arterial branches intact, the remnant is severely
devascularized. When the left inferior phrenic artery
itself arises from the left gastric artery, necrosis
becomes inevitable.
Fig. 7.22: Side-to-side gastrojejunostomy
Investigations and Diagnosis
with Roux-en-Y reconstruction
Endoscopy (Fig. 7.21) and gastrografin examination
would be useful. CT may be useful.
Treatment
Treatment is always surgical and the available options
are:
a. When there is a small viable proximal gastric rem-
nant, Roux–en-Y (side-to-side gastrojejunostomy)
reconstruction is made (Fig. 7.22).
b. When the entiregastric remnant has questionable
viability, total gastrectomy with esophagojejuno-
stomy (Roux-en-Y) should be performed (Fig. 7.23)
c. If the necrosis extends to the esophagus, cervical
Fig. 7.23: Total gastrectomy with
esophagostomy + feeding jejunostomy is perfor- esophagojejunostomy (Roux-en-Y)
med followed by colonic interposition through the
substernal route, at a later date (Fig. 7.24).
STOMAL OBSTRUCTION
Clinical Presentation
This complication presents with excessive nasogastric
aspirate for prolonged periods of time. When the
nasogastric tube has been removed, they present with
INTRA-ABDOMINAL ABSCESS
Figs 7.25: Entero-enterostomy
Clinical Presentation
The patient presents with general malaise and the
recovery and convalescence is not in a normal manner.
There may be fever (low/moderate/high grade), with
leucocytosis. The acute picture may be subdued by
the administration of antibiotics. Physical examination
may not be of any value in most cases.
Pathology of Complication
This complication occurs due to the spillage of duo-
denal, stomach or jejunal contents, into the peritoneal
Figs 7.26: Shortening of afferent loop
Pathology of Complication
Either the afferent or efferent jejunal loop may herniate
behind the gastrojejunal anastomosis. When the affe- Figs 7.27: Division of gastroenterostomy
rent loop is fashioned short, the efferent loop may stoma and Roux-en-Y reconstruction
herniate to cause obstruction. If the afferent loop is
long, it itself may herniate posterior to the efferent
loop.
Treatment
Re-exploration is needed and during the surgery, the Figs 7.28: Division of efferent loop
options available are as follows. and Roux-en-Y reconstruction
Chapter 7: Pre- and Postoperative Management in Foregut Surgery 57
cavity. Anastomotic leaks are also a frequent cause of Medical
intra-abdominal abscess formation. Continuous nasogastric suction, fluid and electrolyte
management, antibiotics, somatostatin or its analogue
Investigations and Diagnosis (Octreotide).
Ultrasonography and CT scan help in diagnosis and
Surgical
localizing the abscesses.
The abscesses should be drained without hesitation.
Treatment Extensive intraperitoneal drainage, debridement may
also be needed. Though unusual, external pancreatic
The abscess should be drained early before the fistulae can occur and need to be managed (see
patient’s condition deteriorates, and also prevent a Chapter 18). If pseudocyst results, it may have to be
general peritonitis which in turn deteriorates the drained internally, into the stomach (Cytogastros-
condition. The drainage may be done either (1) tomy), duodenum (Cystoduodenostomy) or a Roux-
transabdominally or posteriorly depending upon its en-Y limb depending on its anatomic location (Figs
location or (2) by percutaneous aspiration or catheter 7.29A to C).
drainage under ultrasound or CT guidance, and by
administration of appropriate antibiotics. POSTOPERATIVE JAUNDICE
Clinical Presentation
Note: Small spillages of the stomach, duodenal or jejunal
contents into the peritoneum during the surgical procedures The patient presents with mild icterus in the early
rarely lead to intraperitoneal sepsis and resolve in due course postoperative period, which usually resolves in a few
of time. days, if there is no mechanical obstruction.
Pathology of Complication
POSTOPERATIVE PANCREATITIS
This is due to various causes:
Clinical Presentation a. Postoperative edema in the duodenal area, which
The patient presents with restlessness, diffuse may produce a transient and partial obstruction
of the intrapancreatic part of the common bile duct.
abdominal pain, fever, abdominal tenderness and
b. Anastomotic leaks and the absorption of bile from
leucocytosis, within the first few postoperative days.
the peritoneal cavity
The patient may be seriously ill and may even die.
c. Overlooked common bile duct stones
Pathology of Complication d. Accidental occlusion or division of the common
bile duct
This may result due to various causes: e. Intravascular lysis
a. Operative trauma to the head and proximal part f. Ascending cholangitis
of the pancreas. g. Sepsis.
b. Extensive dissections of the supracolic compart-
ment. Investigations and Diagnosis
Both create trauma to the pancreatic ductile system, Elevated levels of conjugated bilirubin will establish
which results in the escape of pancreatic juice into the jaundice. The nature and level of obstruction may be
peritoneal cavity, which causes local peritonitis. Only determined by the Ultrasonography or CT scan.
rarely, it is of the hemorrhagic variety.
Treatment
Medical
It is medical and conservative when no obstruction is
demonstrated. Adequate antibiotic cover has to be
established to prevent ascending cholangitis and
hepatic failure.
Surgical
Gastroscopy
The gastroscopist sees bile refluxing into the stomach,
which is lined by an acutely inflamed, even ulcerated
mucosa. Gastroscopic biopsy of the gastric mucosa
will show intestinalization of the gastric glands,
inflammation, ulceration and hemorrhage (Figs 7.31A A
and B).
Scintigraphy
This is used to assess the magnitude of reflux by tagg-
ing bile with a radioactive marker and determining
the percentage of the secreted isotope reflux into the
stomach.
Treatment
Medical B
Antispasmodics, H2 blockers/Proton pump inhibitors, Figs 7.31A and B: Alkaline reflux gastritis
gastrokinetics like Metoclopramide, Cizapride,
Mozapride are useful.
Surgical
Roux-en-Y diversion is the operation of choice for the
small percentage of patients who require operation,
with completion of vagotomy if it is incomplete, and
also excision of antrum to reduce the cephalic and
humoral phase of gastric secretion, as Roux-en-Y
procedure itself is ulcerogenic. To prevent this, the
alkaline stream should be diverted from the
gastroenterostomy at least 45 to 60 cm.
When the pylorus is intact, “duodenal switch”
procedure (it leaves the suprapapillary duodenum
intact in continuity with the intact stomach preserving
the normal gastric reservoir function, antropyloric
function, the duodenal inhibition of gastric secretion
and stimulation of the duodenal mucosa by gastric
chyme) can be done (Fig. 7.32).
Note: This occurs more commonly after Billroth II type of
construction, but may also occur after Billroth I
reconstruction, gastrojejunostomy or pyloroplasty. Fig. 7.32: Duodenal switch operation
60 Gastrointestinal Surgery: Step by Step Management
Contd...
Long-term complications Time of appearance Reason Management
Recurrent ulcer Months and years after Incomplete vagotomy Complete vagotomy and resection
surgery procedures
Gastrojejunocolic fistula Months and years after Small anastomotic leaks Vagotomy + distal gastrectomy +
surgery and small abscesses may limited colon resection, BI, BII or
open into the adjacent Roux-en-Y reconstruction
transverse colon
Chronic afferent Months and years after Chronic partial obstruction Suspension of the redundant
loop obstruction surgery of unusually long afferent afferent loop, surgical shortening of
loop afferent loop, entero-enterostomy,
Convert to BI or Roux-en-Y
Chronic efferent Months and years after Chronic partial or complete Division of adhesive band, conver-
loop obstruction surgery obstruction of efferent loop sion to BI or Roux-en-Y if necessary
at or near the GJ site due to Resection of any gangrenous
adhesive band, volvulus or bowel and a new gastrojejunostomy
kink at the GJ site
Internal hernia Months and years after Herniation of afferent or Reduction of herniated bowel and
surgery efferent or both, behind or appropriate surgery depending
in front of the gastric on the viability of the herniated
remnant bowel
Jejunogastric Months and years after Prolapse of jejunum into Reduction of prolapsed jejunum
intussusception surgery the gastric remnant and appropriate surgery depending
on the viability of the bowel
Surgical
There are various operations suggested by various
authors who have shown good results. They are:
a. Henley’s operation Interposition of isoperistaltic
segment of jejunum (20-25 cm) between the gastric
remnant and the duodenum (Fig. 7.34).
b. Poth’s operation Interposition of two separate
isolated jejunal segments (one isoperistaltic and the
other antiperistaltic direction to the duodenum),
each approximately 10 to 12 cm between the gastric
remnant and the duodenum (Fig. 7.35).
c. Triple limb pouch operations Three plicated segments
of jejunum converted into a single receptacle and
placed either between the gastric remnant and the Fig. 7.35: Poth’s operation (double-limb pouch)
duodeum (Fig. 7.36A) or fashioned in a Roux-en-
Y limb (Fig. 7.36B).
d. Reversed interposition of jejunum Interposition of e. Roux-en-Y reconstruction Conventional Roux-en-Y
single reversed jejunal segment interposed reconstruction.
between the gastric remnant and the duodenum f. Terrence Kennedy’s operation Roux-en-Y recons-
(Fig. 7.37). truction with interposition of 8 to 10 cm of reversed
Chapter 7: Pre- and Postoperative Management in Foregut Surgery 63
LATE DUMPING
Clinical Presentation
The clinical presentation consists of vasomotor symp-
toms namely, sweating, weakness, palpitations,
dizziness, flushing during the late postprandial period
(2-4 hours following meals). The gastrointestinal symp-
toms are absent. The patients my decrease their food
intake with resultant weight loss and malnourishment.
These may be mild to moderate and may disappear
with time.
Surgical
The procedures described for the treatment of early
dumping syndrome may be chosen in select cases, but
the requirement is extremely rare.
Determination of hemoglobin, packed cell volume, Prokinetic drugs like metoclopramide and
serum iron, folate and B12 levels will help in the erythromycin.
diagnosis.
Surgical
Treatment When medical treatment fails, surgery is
Iron supplements in the form of ferrous sulphate or contemplated.
ferrous fumarate 100 to 200 mg daily is required in When the original surgery is vagotomy +
the treatment of microcytic anemia. pyloroplasty – antrectomy may be performed.
If anemia is due to deficiency of vitamin B12 and When the gastric remnant is distended massively,
folate, injections of Cyanocobalamin 1 mg in the form near total gastrectomy and Roux-en-Y reconstruction
of intramuscular injections and Folate as tablets 10 to (to prevent bile reflux) may be needed.
15 mg daily are required for treatment of Note: Less selective vagotomies have a high incidence of
megaloblastic anemia. delayed gastric emptying.
Treatment
Medical
Oral administration of gastroenterase or papase, to
digest the fiber mixtures. Long-term treatment consists
in the use of low-fiber diets and gastric wall muscular Fig. 7.46: Pathology of small gastric remnant syndrome
stimulants, as bezoar formation may be recurrent.
Investigations and Diagnosis
Surgical Careful history taking is useful in diagnosis. Gastro-
If the bezoars are small, they may be removed by grafin studies exhibit early emptying of stomach with
endoscopy. Very rarely, these may have to be removed no reservoir function.
by open surgery (Fig. 7.45).
Treatment
Medical
Medical management is usually successful. Small
feeds with enzyme supplements, iron, vitamins and
antispasmodics are useful.
Surgical
Patients with severe symptoms not controlled by
medical treatment may receive some benefit with a
remedial surgery. This surgery is designed to restore
Fig. 7.44: Endoscopic view of the bezoar the reservoir function of the gastric remnant and also
Chapter 7: Pre- and Postoperative Management in Foregut Surgery 67
to promote intestinal absorption. Various pouch
operations are practised. They are as follows.
Clinical Presentation
minal pain, nausea and vomiting of food, and in severe
The patients present with epigastric fullness, abdo-
cases with malnutrition and weight loss.
Treatment
Treatment
It is wise to open the abdomen and do a thorough
peritoneal toileting and refashion the gastrostomy.
PREOPERATIVE MANAGEMENT
The preoperative preparation for elective surgery of
the small bowel is in lines with the preparation for
gastrointestinal surgery in general (Chapter 5).
Nasogastric Decompression
Nasogastric decompression is required to keep the Figs 8.3A to C: (A) End ileostomy, (B) Loop ileostomy,
small bowel decompressed and in such a situation, (C) Loop-end ileostomy
74 Gastrointestinal Surgery: Step by Step Management
fluid and electrolyte correction should be more meti- there is evidence of infection or sepsis without an
culously done. obvious etiology, the surgeon must suspect a leaked
anastomosis.
Antibiotics Patients who have generally recovered sufficiently
When the small bowel pathology is associated with are to be discharged 6 to 8 days after surgery.
perforation and peritonitis, administration of anti-
biotics to cover the aerobic and anaerobic organisms Complications of Enterectomy (Resections with
are needed. Third generation cephalosporins, an amino- Ileo-ileostomy or Ileocolostomy), Bypass
glycoside and also metronidazole are administered in the Procedures (Ileo-ileostomy or Ileocolostomy) and
preoperative period. Enterotomy
Urinary catheterization is necessary to monitor the Since all these procedures involve an anastomosis of
fluid loss which will help in the replacement of fluids. one part of small bowel to another part of small bowel
(ileo-ileostomy) or large bowel (ileocolostomy), the
POSTOPERATIVE MANAGEMENT complications are similar, and are attributable to the
small bowel (Table 8.1).
Anticipate a period of postoperative ileus, during
which the patient is maintained on intravenous fluids,
EARLY COMPLICATIONS OF SMALL BOWEL
and nasogastric aspiration regularly for a period of
SURGERY (see Table 8.1)
about 48 hours. The nasogastric tube can be removed
when bowel sounds return, the volume of aspirate WOUND INFECTION
drops below 500 ml and there is passage of flatus. Clinical Presentation
Peristalsis returns to the small bowel before the stomach
and colon regain their motility. Clear liquids are begun The patient presents with erythematous wound
and if tolerated, the diet is advanced to normal intake around the 2nd to 3rd postoperative day which may
over the next 2 days. If restoration of oral feeding is start discharging pus around the 5th to 7th post-
delayed, consider whether a period of parenteral nutri- operative day.
tion would be appropriate. Remove the drain when
Pathology of Complication
fluid loss diminishes, generally at 2 to 3 days.
Intravenous fluids are maintained until the patient Infection of the wound occurs due to handling of the
is taking sufficient fluids orally. hollow organs and soilage of the peritoneum by
Urinary catheter is normally discontinued between contents of the small bowel or the large bowel as in
the second and the fourth day of surgery. ileocolostomy.
Antibiotic prophylaxis is continued for 24 hours
Investigations and Diagnosis
in clean cases and continued for a reasonable time of
about 5 to 7 days in contaminated cases and till the The pathogenic organism be isolated in culture.
evidence of sepsis disappears.
Intra-abdominal drains kept near the anastomosis Treatment
are removed when the motility of the bowel returns Local care with dressings and administration of
to normal, with the passage of flatus and or faeces. If systemic antibiotics. The suture or staple should be
ANASTOMOTIC LEAK
Clinical Presentation
The patient presents with febrile postoperative course
with erythematous wound or the drainage opening
which begins to leak purulent material and finally the
enteric contents or through the drainage tube if in situ
(Fig. 8.4).
Pathology of Complication
This is due to disruption of the anastomosis because
of excessive tension on the suture line or devasculari-
zation of anastomosis. Fig. 8.4: Discharge of bile-stained enteric contents through
the drainage tube
Investigations and Diagnosis
The diagnosis is usually obvious. If the diagnosis is in of bowel continuity and spontaneous closure becomes
doubt, confirmation can be obtained by oral adminis- unlikely, and when the closure has not occurred by 4
tration of a nonabsorbable marker (charcoal or Congo red) to 6 weeks. Surgery is the excision of the fistulous tract
or by injection of water-soluble radiopaque contrast with a part of the involved or diseased bowel.
into the fistula opening (fistulogram). Ultrasonography,
CT scan with contrast or isotope scanning are useful Note: The small bowel anastomosis does heal satisfactorily,
diagnostic tools, when there are associated abscesses. in spite of the fact that the discharge of intestinal contents
is contaminated. The key to a successful anastomosis is the
Treatment accurate union of two viable bowel ends, with complete
avoidance of tension.
Medical
Though enteral nutrition, when feasible, can be used INTRA-ABDOMINAL ABSCESS
for nutritional support, total parenteral nutrition (see Chapter 17 also)
(TPN) remains a major advance that has been proven Clinical Presentation
to increase the rate of spontaneous closure and has
The patient presents with general malaise and the
been used universally in the management of fistulae.
recovery and convalescence is not in a normal manner.
Most lateral small fistulae will close spontaneously
There may be fever (low/moderate/high grade), with
on parenteral nutrition, provided there is no distal
leucocytosis. The acute picture may be subdued by
obstruction, no associated abscess cavity and also the
the administration of antibiotics. Physical examination
bowel itself not heavily involved with disease such as
may not be of any value in most cases.
tumor or Crohn’s disease.
When sepsis is encountered, currently available
Pathology of Complication
methods of nutritional support do not reverse mal-
nutrition and hypercatabolism unless sepsis is This complication occurs due to the spillage of duo-
controlled first. In all, when managed judiciously, denal, gastric or jejunal contents, into the peritoneal
external fistulae close in about 70 percent of cases (see cavity. Anastomotic leaks are also a frequent cause of
Chapter 18). intra-abdominal abscess formation.
Adhesions Months-years after surgery Local inflammatory processes Conservative and if it fails
adhesiolysis
Internal fistulae Months-years after surgery Persistence of leak into internal Some may require revision surgery
organs
External fistulae Months-years after surgery Persistence of leak to the exterior Management of fistulae
Nutritional Years after surgery Reduction of absorptive surface Parenteral hyperalimentation,
deficiencies due to massive resections, over- vitamin B12, rarely surgery
growth deficiencies of bacterial
flora or discharge from fistula
Short bowel Months-years after surgery Reduction of absorptive surface Total parenteral nutrition
syndrome
Treatment Treatment
The abscess should be drained early before the Medical
patient’s condition deteriorates, and also prevent a
Medical management such as nil by mouth and
general peritonitis which in turn deteriorates the
intravenous supplementation of fluids and electrolytes
condition further. The drainage may be done either
should suffice in most cases.
(1) transabdominally or posteriorly depending upon
their location or (2) by percutaneous aspiration or Surgical
catheter drainage under ultrasound or CT guidance,
and by administration of appropriate antibiotics. Cases which do not show improvement to medical
management and those with recurrent attacks will
LATE COMPLICATIONS OF SMALL BOWEL require surgery. Surgery is release of adhesions by
SURGERY (see Table 8.2) open surgery (Fig. 8.5) or by laparoscopy.
Pathology of Complication
Postoperative fibrinous adhesions resulting from the
healing of local inflammatory processes in the
operated area or resolved infections of the peritoneal
cavity can cause this complication.
Treatment
The surgical excision of fistulae are rarely required if
they are between two loops of small bowel, but it may
be needed in enterovesical fistulae to manage recur-
rent urinary infections.
Clinical Presentation
The patient generally has had gone through a febrile (TPN) remains a major advance that has been proven
and turbulent postoperative period and has had a to increase the rate of spontaneous closure and has
discharging wound from the early postoperative been used universally in the management of fistulae.
period. They present in an undernourished state, Most lateral small fistulae will close spontaneously
especially when there is associated loss of ileum on parenteral nutrition, provided there is no distal
during original surgery (see Chapter 18 also). obstruction, no associated abscess cavity and also the
bowel itself not heavily involved with disease such as
Pathology of Complication tumor or Crohn’s disease.
This is due to the disruption of the ileal anastomosis When sepsis is encountered, currently available
and persistence of the tract to the skin resulting in an methods of nutritional support do not reverse mal-
external fistula. nutrition and hypercatabolism unless sepsis is con-
trolled first. In all, when managed judiciously, external
Investigations and Diagnosis fistulae close in about 70 percent of cases.
The diagnosis is obvious and if the original surgery is
done by another surgeon, careful perusal of operative Surgical
records will help in the diagnosis. If the diagnosis is Surgical treatment becomes necessary when there is
in doubt, confirmation can be obtained by oral adminis- evidence of obstruction, active disease or interruption
tration of a nonabsorbable marker (charcoal or Congo red) of bowel continuity and spontaneous closure becomes
or by injection of water-soluble radiopaque contrast unlikely, and when the closure has not occurred by 4
into the fistula opening (fistulogram) (Fig. 8.6). to 6 weeks. It is the excision of the fistulous tract with
Ultrasonography, CT scan with contrast or isotope scanning a part of the involved or diseased bowel.
are useful diagnostic tools, when there are associated The seriousness of external fistula generally
abscesses. depends upon its anatomic location and the volume
of output it produces. Generally, the more proximal a
Treatment
small bowel fistula, the larger the amount of output
Medical and the resultant electrolyte imbalance and the mal-
Though enteral nutrition, when feasible, can be used nutrition. The amount of output alone does not determine
for nutritional support, total parenteral nutrition the likelihood of spontaneous closure (see Chapter 18).
78 Gastrointestinal Surgery: Step by Step Management
High output Early postoperative period May indicate pseudo-obstruction Withhold fluids orally, use binding
agents
Parastomal skin 3rd to 7th postoperative day Poor seal, candidiasis, allergy Rectify the offending agent
irritation to pouch material, adhesive tape
Paraileostomy Early postoperative period Infection and avascular necrosis Infection and avascular necrosis
ulceration debridement
Ileostomy Early postoperative period Adhesions, volvulus or entra- Conservative management
obstruction pment of bowel in fascial May require surgical correction
closure bolus obstruction
Ileostomy fistula Early postoperative period Suturing of bowel wall to Incorporate the fistula in the pouch, if it
Late postoperative period rectus sheath faceplate is far, revise the stoma with fistulectomy
trauma
Treatment Surgical
Application of adrenaline soaked gauze to the ileos- Revision surgery is required only when the necrosis
tomy should suffice. If the bleeding persists and is circumferential and wide and develops severe
copious, the mesenteric vessel may have to be ligated. ischemia at the mucocutaneous junction.
Appropriate treatment with the help of the dermato- Bowel obstruction may occur at any time because of
logist and stoma therapist for modifications of the various reasons. They are:
appliance may be required. 1. Adhesions
2. Volvulus
PARAILEOSTOMY ULCERATION 3. Entrapment of ileum in the fascial closure
4. Food bolus obstruction.
Clinical Presentation
The patient presents with painful extensive ulceration Investigations and Diagnosis
of the paraileostomy area (Fig. 8.7). Plain X-ray may show distended small bowel loops.
Pathology of Complication
Treatment
The parastomal irritation when neglected or appro-
priate treatment leads to severe ulcerations, especially Medical
in uncontrolled diabetics or immunocompromised The treatment is conservative. Ileostomy irrigation by
patients. gentle lavage with 50 to 100 ml of saline introduced
through a small catheter will help. This is done
Investigations and Diagnosis
repeatedly till the returns are clear.
No specific investigation excepting the evaluation of
diabetes mellitus is required. Surgical
Treatment Surgical treatment is required for relief of mechanical
obstruction due to volvulus and adhesions.
Local care is the treatment. When ulceration is
extensive, debridement may be required. A non-seal
ILEOSTOMY FISTULA
and nonadhesive appliance may have to be used
temporarily till the healing is complete. A conven- Clinical Presentation
tional pouch may be used once the healing is complete.
The patient may present with a discharging sinus
wound anywhere around the ileostomy.
ILEOSTOMY OBSTRUCTION
Clinical Presentation Pathology of Complication
The patient may complain of abdominal distension This may occur as a result of suturing of the bowel
and vomiting with the relative diminution of wall to the rectus fascia by a deeper full-thickness
ileostomy effluent. stitch.
82 Gastrointestinal Surgery: Step by Step Management
Treatment
The treatment is conservative. Ileostomy irrigation by
gentle lavage with 50 to 100 ml of saline introduced
through a small catheter will help. This is done repea-
tedly till the returns are clear.
STENOSIS
Clinical Presentation
The patient presents with the complaint of passing
hard and small quantity of stools (Fig. 8.8).
Pathology of Complication
This occurs as the following:
• Ulceration of the mucocutaneous junction may heal
with a stenosis
• Tight opening in the abdominal wall while creating Fig. 8.9: Finger dilatation of the stenosis
the stoma.
Fig. 8.8: Stenosis of ileostomy Fig. 8.10: Dilatation of stenosis with a metal dilator
84 Gastrointestinal Surgery: Step by Step Management
RECESSION
Clinical Presentation
The patient presents with soiling of the peristomal skin
and the appliance, and on examination the stoma
appears to be below the surface of the skin (Fig. 8.13).
Pathology of Complication
This results from either:
• Too large abdominal opening or
• Inadequate fixation of ileum at the fascial plane.
Treatment
A
Local repair (Fig. 8.14).
B
Figs 8.12A and B: Operative repair of ileostomy stenosis Fig. 8.14: Repair of ileostomy recession
Chapter 8: Pre- and Postoperative Management in Midgut (Small Bowel) Surgery 85
RETRACTION
Clinical Presentation
The patient presents with soiling of the peristomal skin
and the appliance; and on examination, the stoma
appears to be below the surface of the skin.
Pathology of Complication
This results from either:
• too large abdominal opening or
• inadequate fixation of ileum at the fascial plane
• insufficient intestine used for construction of
stoma.
A B
Figs 8.15A and B: (A) Prolapse of end ileostomy,
Investigations and Diagnosis (B) Prolapse of loop ileostomy
The diagnosis is obvious and needs no investigation.
Treatment
Local repair (Fig. 8.14). Surgical repair may have to
be done if there is obstruction, a formal laparotomy
may be needed to mobilize the bowel and mesentery
and the stoma may have to be refashioned.
Note: Fixed recession is called retraction. Fig. 8.16: Repair of ileostomy prolapse
PARASTOMAL ABSCESSES
Clinical Presentation
The patient presents with a painful swelling in the
parastomal region.
Fig. 8.17: Repair of parastomal hernia
Pathology of Complication
This may be due to:
• mucocutaneous suture line breaks
• infection of a hematoma.
Treatment
Drainage of abscesses.
Surgical
If the fistulous opening is far from the ileostomy and
Fig. 8.19: Repair of excessive length of ileostomy interferes with the application of the appliance, it
Chapter 8: Pre- and Postoperative Management in Midgut (Small Bowel) Surgery 87
should be excised surgically with revision of stoma
(Fig. 8.20).
ULCERATION
Clinical Presentation
The patient presents with peristomal ulcerations (Fig.
8.21).
Pathology of Complication
The ulcerations may be due to:
• ill-fitting appliance or Fig. 8.20: Repair of ileostomy fistula
• recurrence of Crohn’s disease.
Treatment
They usually heal when curetted and if they are due
to Crohn’s disease, they have to be managed
systemically.
GRANULOMA
Clinical Presentation
The patient presents with a granulomatous lesion in
Fig. 8.21: Parastomal ulceration
the peristomal region.
intussuscepting the last few centimeters of ileum, and
Pathology of Complication placing the stoma discretely out of sight in the
This may be due to mechanical pressure by the suprapubic area (Fig. 8.22). This procedure can be done
appliance. at the time of total colectomy, in ulcerative colitis and
familial polyposis or later if the patient fails to adapt
to an ileostomy.
Investigations and Diagnosis
The advantages of Koch’s continent ileostomy are:
The diagnosis is obvious and histopathology may be
1. The patient need not wear an appliance
needed if the healing is delayed.
2. The patient is continent between intubations
3. No stoma complications
Treatment
4. Better quality of life.
If it is an indication of fistula, it should be treated
The disadvantages of Koch’s continent ileostomy are:
accordingly.
1. Not all patients are continent
2. Require multiple intubations during the day
CONTINENT ILEOSTOMY
3. Can be difficult to intubate
The continent ileostomy involves the construction of 4. Surgery is prolonged
an internal reservoir (Koch pouch) from the terminal 5. If the procedure fails, the patient will lose a
ileum; a reverse nipple outflow valve is made by significant amount of small intestine.
88 Gastrointestinal Surgery: Step by Step Management
Relaparotomy may be required in some cases. During The patient presents with incontinence varying from
laparotomy, the suture line leaks should be closed with slight leakage of flatus and faeces to a considerable
reinforcing sutures with proximal defunctioning loop faecal discharge through the ileostomy after six or
ileostomy. If the peritonitis is severe, it is better to twelve months after operation.
remove the reservoir and perform a conventional end
Pathology of Complication
ileostomy.
This complication occurs due to:
• deterioration in the efficacy of the valve because
NECROSIS OF THE EXIT CONDUIT of partial or complete extrusion.
Clinical Presentation • development of a perforation or a fistula through
the valve near the base near fixing sutures.
The patient may present with bloody discharge
through the tube and also the mucosa of the stoma Investigations and Diagnosis
may turn blue or black in color.
Pantaloonograms (radiological films made after
injection of barium into the reservoir) demonstrate the
Pathology of Complication
valve extrusions well.
This is due to avascularity of the conduit.
Treatment
Investigations and Diagnosis Medical
The frequent examination of the mucosa of the stoma When the incontinence is of lesser degree, intermittent
is necessary. intubation should be enough.
90 Gastrointestinal Surgery: Step by Step Management
Note: If the valve remains in position for three months from RETENTION
the time of operation, it is then most unlikely to become Clinical Presentation
displaced. The patient complains of not passing flatus or faeces
Corrective surgery should be postponed for at least three through the ileostomy presenting as an acute crisis,
months from the time of previous operation to allow not able to intubate the ileostomy stoma.
adhesions to absorb and facilitate the dissection.
Pathology of Complication
LEAKAGE OF MUCOID MATERIAL This may be due to extrusion of the valve.
Clinical Presentation Investigations and Diagnosis
The patient may present with leakage of mucoid The diagnosis is obvious and a plain radiograph may
material unassociated with faeces or flatus. show a distended gas file reservoir.
Chapter 8: Pre- and Postoperative Management in Midgut (Small Bowel) Surgery 91
Treatment Investigations and Diagnosis
Medical Endoscopy shows inflammation of mucous membrane
with contact bleeding, sometimes with discrete ulcers.
Careful and meticulous intubation should be
attempted, rarely finger introduction may have to be Treatment
tried. Administration of antibiotics like ciprofloxacin and
Surgical also metronidazole should suffice.
Surgical
The exit conduit may need revision to release the
stenosis.
PROFUSE DIARRHEA
Clinical Presentation
The patient presents with liquid faeces, sometimes
containing blood.
Pathology of Complication
This may occur due to: Fig. 8.23: Park’s pouch: The Parks’ mucosal protectomy and
• reservoir ileitis—inflammation of the mucosa of the ileal pelvic pouch operation. (A) Construction of ileal pouch
from terminal 50 cm of small intestine (b, c, e) and the mid-
reservoir
point between (d and e) are points of folding; (abc) is the first
• stagnant loop syndrome—overgrowth of bacteria fold. The final two folds will be complete when (d and e) are
in a stagnant reservoir. approximated. (b) Appearance of completed operation
92 Gastrointestinal Surgery: Step by Step Management
The preoperative preparation for the surgery of the This may be due to:
appendix is in line with the preparation for any • leakage of blood from the appendicular stump
gastrointestinal surgery in general (Chapter 5). • slipped ligature of the appendicular artery
Treatment
Correction of electrolyte disturbances if any, naso-
gastric aspiration to relieve vomiting.
SEPTIC COMPLICATIONS
WOUND ABSCESS
Clinical Presentation
The patient presents with discharging wound around
the 5th to 7th postoperative day.
Pathology of Complication
Fig. 8.24: Paralytic ileus—distended loops of the small bowel
Infection of the wound due to handling of the infected
appendix and soilage of the wound.
Treatment
Local care with dressings and administration of
systemic antibiotics. The suture or staple should be
removed and the wound be allowed to heal by
secondary intention (Fig. 8.25).
PELVIC ABSCESS
Clinical Presentation Fig. 8.25: Wound infection after appendicectomy
The patient presents with general malaise and the
recovery and convalescence is not in a normal manner.
Pathology of Complication
There may be fever (low/moderate/high grade), with
leucocytosis. The acute picture may be subdued by This complication occurs due to incomplete resolution
the administration of antibiotics. Rectal examination of generalized peritonitis or infection of the pelvic
will show the tender pouch of Douglas. collection of blood or colonic content.
94 Gastrointestinal Surgery: Step by Step Management
Treatment
The abscess should be drained early before the
patient’s condition deteriorates, and also prevent a
general peritonitis which in turn deteriorate the
condition further. The drainage may be done trans-
rectally supported by the administration of
appropriate antibiotics.
A
SUBPHRENIC ABSCESS
Clinical Presentation
The patient presents with general malaise and the
recovery and convalescence is not in a normal manner.
There may be fever (low/moderate/high grade), with
leucocytosis. The acute picture may be subdued by
the administration of antibiotics. Physical examination
may not be of any value in most cases.
Pathology of Complication
This complication occurs due to incomplete resolution B
of generalized peritonitis.
Figs 8.26A and B: CT scan showing subphrenic abscess
(A) Before aspiration, (B) After aspiration
Investigations and Diagnosis
Pathology of Complication
Ultrasonography and CT scan help in diagnosis and
This is due to:
localizing the abscesses (Figs 8.26A and B).
• sloughing of the appendicular stump or caecal wall
• administration of an enema in the postoperative
Treatment period.
The abscess should be drained early before the
Investigations and Diagnosis
patient’s condition deteriorates, and also prevent a
general peritonitis which in turn deteriorate the Ultrasonography may be of use in localizing the collec-
condition further. The drainage may be done either i) tion of fluid in the paracaecal region.
transabdominally or posteriorly depending upon their Treatment
location or ii) by percutaneous aspiration or catheter
drainage under ultrasound or CT guidance, and by Medical
administration of appropriate antibiotics. If the leak is minimal without peritonitis, conservative
management of the faecal fistula (caeco-cutaneous) is
RUPTURE OF STUMP OR CAECAL WALL followed (Fig. 8.27).
Clinical Presentation Surgical
The patient presents with severe tenderness in the Immediate laparotomy is the treatment of choice and
right iliac fossa with signs of localized peritonitis due caecostomy is the procedure to relieve any further leak
to faecal leak. of the colonic contents, with appropriate antibiotics.
Chapter 8: Pre- and Postoperative Management in Midgut (Small Bowel) Surgery 95
Treatment
Local repair with or without mesh is the treatment of
choice.
INTESTINAL OBSTRUCTION
Clinical Presentation
The patient presents with recurrent attacks of abdo-
minal pain with features of subacute intestinal
obstruction like vomiting, abdominal distension and
or constipation.
Mechanical Cleansing
Mechanical cleansing (done a day prior to surgery). Fig. 9.1: Definition of terms (varieties of colonic surgeries)
A→C : Ileocaecectomy
• Administration of laxatives like sodium pico-
+A→B→D : Ileocaecectomy
sulphate +A→B→F : Ascending colectomy
• Administration of polyethylene glycol (afternoon +A→B→G : Extended right hemicolectomy
before surgery) +E→F→G+H : Transverse colectomy
• Diet schedule: G→I : Left hemicolectomy
F→I : Extended left hemicolectomy
— Semisolid diet till the 3rd day prior to surgery
J→K : Sigmoid colectomy
— Liquid diet till the 2nd day prior to surgery +A→B→J : Subtotal colectomy
— Clear liquid diet without milk till the day prior +A→B→K : Total colectomy
to surgery. +A→B→L : Total proctocolectomy
Chapter 9: Pre- & Postoperative Management in Hindgut (Colon, Rectum & Anus) Surgery 97
Bacteriological Cleansing Correction of Fluid and Electrolyte Imbalance
Administration of antibiotics. Many times, the pathology of the large bowel is a sur-
prise and they present in an acute form with obstruc-
Chemical Cleansing tion or perforation and peritonitis. Such a situation is
a surgical emergency, and the patients have some
Administration of antibiotics which are not absorbed amount of fluid and electrolyte disturbances and judi-
by the gut but sterilize the gut, e.g. Neomycin and cious administration of intravenous fluids is important.
Streptomycin orally.
Nasogastric Decompression
Method of Preopera- Preopera- Preoperative
cleansing tive day 3 tive day 2 day 1 Nasogastric decompression is required to keep the
bowel decompressed and in such a situation, fluid and
Mechanical Oral laxative Polyethylene-
electrolyte correction should be more meticulously
at night glycol
done.
Bacterio- Intestinal Intestinal
logical antibiotics antibiotics Antibiotics
cleansing parenterally, parenterally,
+ Metronidazole + Metronidazole When the large bowel pathology is associated with
perforation and peritonitis, administration of anti-
Chemical Nonabsorbable Nonabsorbable
biotics to cover the aerobic and anaerobic organisms
cleansing antibiotics orally antibiotics orally
are needed. Third generation cephalosporins, an
Diet Semisolid Milk-based Clear aminoglycoside and also metronidazole are administered
schedule diet liquids liquids
in the preoperative period.
Supplementary
IV infusion of Urinary catheterization is necessary to monitor the
crystolloid fluid loss which will help in the replacement of fluids
plasma expanders and also helps in the surgery of the colon in the pelvic
region.
Early preparation methods for cleaning the colon
(48-72 hours of clear liquid, laxatives, and enemas) POSTOPERATIVE MANAGEMENT
have provided a relatively faeces-free colon but are Anticipate a period of postoperative ileus, during
often time consuming, uncomfortable, and which the patient is maintained on intravenous fluids,
inconvenient for the patient. Peroral gut lavage with and nasogastric aspiration regularly for a period of
saline solution or balanced electrolyte solutions have about 48 hours. The nasogastric tube can be removed
been found to provide rapid, effective cleansing for when bowel sounds return, the volume of aspirate
colonoscopy, barium enema, and colon surgery. drops below 500 ml and there is passage of flatus.
However, the volume of 7 to 12 liters often requires Peristalsis returns to the small bowel before the stomach
nasogastric administration but results in fluid and and colon regain their motility. Clear liquids are begun
electrolyte disturbances. This has resulted in the and if tolerated, the diet is advanced to normal intake
development of osmotically balanced solutions over the next 2 days. If restoration of oral feeding is
formulated to provide minimal water absorption or delayed, consider whether a period of parenteral
secretion into the bowel lumen. Polyethylene glycol nutrition would be appropriate.
electrolyte lavage solution (PEGLEC) and oral sodium Intravenous fluids are maintained until the patient
phosphate solution (EXELYTE) are widely used laxatives is taking sufficient fluids orally.
for colonic cleansing for colonoscopy and colonic Antibiotic prophylaxis is continued for 24 hours
surgery (see Chapter 21 on Bowel care). in clean cases and continued for a reasonable time of
about 5 to 7 days in contaminated cases and till the
PREOPERATIVE MANAGEMENT
evidence of sepsis disappears.
The preoperative preparation for elective surgery of Intra-abdominal drains kept near the anastomosis,
the large bowel is in lines with the preparation for generally produce 150 to 300 ml of blood-stained fluid
gastrointestinal surgery in general (see Chapter 5). during the first 24 hours and diminishing amounts
98 Gastrointestinal Surgery: Step by Step Management
daily thereafter, so that by the fourth or fifth post- cation of damage to the posterior vaginal wall in the
operative day, there is negligible drainage. The drains form of perforation, which may at a later date, result
are removed when the motility of the bowel returns in a fistula. If the perforation is identified, it is better
to normal with the passage of flatus and/or faeces and to divide the posterior vaginal wall downwards from
the drainage is negligible. The drains may have to be the perforation, thus producing a common cavity
kept for longer periods like 10 days, when the drainage composed of the lower part of the vagina and the
continues for longer periods of time, and the drains perineal wound. After this procedure, the end result
should be left in situ for as long as necessary. If there is satisfactory, excepting a wide vaginal introitus in
is evidence of infection or sepsis without an obvious some cases.
etiology, the surgeon must suspect a leaked anastomosis. In female cases, where the posterior vaginal wall has
been excised along with the rectum, the healing is straight-
Care of the Perineal Wound forward and satisfactory. By the end of three weeks,
When primary suturing is practised and suction drainage the granulation is complete and acquires good epithe-
established, 250 to 300 ml of blood–stained fluid may lial caving in the front, as the posterior vaginal wall
be drained during the first 24 hours. This usually regenerates. When the anterior end of the perineal
dimishes to 100 ml or less daily and by about the 3rd wound breaks down, it forms a fistula from the vagina.
day, the tube may be removed totally. Occasionally, It is necessary to slit open the perineal wound as far
the drainage warrants keeping the suction going as back as the fistulous opening in its central part, which
long as 10 days. When there is a suspicion of hema- will result only in a wide vaginal introitus. Rarely,
toma or infection, it is better to remove a couple of they develop cystocele and sexual function may be
stitches and drain adequately with a sinus forceps. unsatisfactory.
When the drainage is felt to be inadequate by the
above procedure, it is better to drain by finger and Care of the Urinary Bladder
allow the wound to heal by open method, with irriga-
tions and dressings. The self-retaining urethral catheter introduced
When open drainage is adopted, there will be a immediately before the operation should be left in situ
requirement for frequent change in dressings in the for four to five days, as early removal is followed by
first two days. In the following days, the wound will retention needing further catheterization.
require irrigations with hydrogen peroxide or Eusol Patients without any complication generally
solution followed by Povidone Iodine soaked gauze recover sufficiently to be discharged by 10 days after
packs kept in place with a firm bandage. In all, the surgery.
healing is satisfactory and the patient should be able
to manage having the dressings at home.
In female cases, where posterior vaginal wall has been EARLY COMPLICATIONS OF PERINEAL SURGERY
preserved, attention should be given to the identifi- (as an adjunct to colorectal surgery) (see Table 9.1)
The prime cause of such a complication is sepsis giving It is better to correct this deformity, by incising the
rise to secondary hemorrhage. The shock is due, not scar and releasing it; and if there is any collection of
to blood loss, but to cardiorespiratory causes or to pus or fluid above the skin level, it is better to release
severe sepsis. Sepsis can cause severe bacteremia. and stretch the skin.
The bulge is obvious and presents with a cough Investigations and Diagnosis
impulse. Local examination to rule out other pathologies.
Treatment Treatment
Medical No treatment is indicated beyond “firm reassurance”.
This may be supported by a firm bandage or T
bandage, or by a special broad perineal band attached Complications of Colectomy (resection with
to the back of the colostomy belt. colocolostomy), Bypass procedures (continuity
established by Colocolostomy), and Colotomy
Surgical Since all these procedures involve an anastomosis of
Perineal repair with a Prolene mesh is the surgical one part of the colon to the other part of the colon, the
treatment of choice. complications are similar.
102 Gastrointestinal Surgery: Step by Step Management
Pathology of Complication
There is handling of the colon and soilage of the peri-
toneum by contents of the large bowel, the wound is
contaminated by the colonic contents.
Investigations and Diagnosis
The pathogenic organism be isolated in culture.
Treatment
Local care with dressings and administration of
systemic antibiotics. The suture or staple should be
removed and the wound be allowed to heal by
secondary intention.
INTRA-ABDOMINAL ABSCESS
Clinical Presentation
The patient presents with general malaise and the
recovery and convalescence is not in a normal manner.
There may be fever (low/moderate/high grade), with
leucocytosis. The acute picture may be subdued by
the administration of antibiotics. Physical examination
may not be of any value in most cases.
Pathology of Complication
This complication occurs due to the spillage of colonic Fig. 9.2: Ultrasonography showing the
contents into the peritoneal cavity. Anastomotic leaks intra-abdominal abscess
Chapter 9: Pre- & Postoperative Management in Hindgut (Colon, Rectum & Anus) Surgery 103
Treatment
The abscess should be drained early before the
patient’s condition deteriorates, and also prevent a
general peritonitis which in turn deteriorate the condi-
Fig. 9.4: Fistulogram showing the
tion further. The drainage may be done either: i)
intra-abdominal collection
transabdominally or posteriorly depending upon their
location, or ii) by percutaneous aspiration or catheter Treatment
drainage under ultrasound or CT guidance, and by
administration of appropriate antibiotics. Medical
Though enteral nutrition, when feasible, can be used
ANASTOMOTIC LEAKAGE for nutritional support, total parenteral nutrition
Clinical Presentation (TPN) remains a major advance that has been proven
The patient presents with febrile postoperative course to increase the rate of spontaneous closure and has
with erythematous wound or the drainage opening been used universally in the management of fistulae.
which begins to leak purulent material and finally the Most lateral fistulae will close spontaneously on
enteric contents (Fig. 8.4). parenteral nutrition, provided there is no distal
obstruction, no associated abscess cavity and also the
Pathology of Complication bowel itself not heavily involved with disease such as
This is due to disruption of the anastomosis because tumor or Crohn’s disease.
of excessive tension on the suture line or devascula- When sepsis is encountered, currently available
rization of anastomosis. methods of nutritional support do not reverse mal-
nutrition and hypercatabolism, unless sepsis is con-
Investigations and Diagnosis trolled first. In all, when managed judiciously, external
The diagnosis is usually obvious. If the diagnosis is in fistulae close in about 70 percent of cases.
doubt, confirmation can be obtained by oral adminis-
Surgical
tration of a nonabsorbable marker (charcoal or congo red)
or by injection of water-soluble radiopaque contrast Surgical treatment becomes necessary when there is
into the fistula opening (fistulogram) (Fig. 9.4). Ultra- evidence of obstruction, active disease or interruption
sonography, CT scan with contrast or isotope scanning of bowel continuity and spontaneous closure becomes
are useful diagnostic tools. unlikely, and when the closure has not occurred by 4
104 Gastrointestinal Surgery: Step by Step Management
to 6 weeks. It is the excision of the fistulous tract with Urinary fistula (urethral fistula) due to:
a part of the involved or diseased bowel. • Partial urethral injury—perform urethral cathe-
terization and allow spontaneous healing
URINARY FISTULA • Complete injury or failed spontaneous closure—
Clinical Presentation urethroplasty.
The patient presents with a discharge of straw-colored
clear fluid through the abdominal wound or drain LATE COMPLICATIONS OF
(where abdominal surgery is performed) or through COLONIC SURGERY (see Table 9.4)
the perineal wound or drain (where perineal surgery
ADHESIONS
is done as adjunct to abdominal surgery).
Clinical Presentation
Pathology of Complication
The patient presents with recurrent attacks of
This results due to inadvertent clamping, cutting or abdominal pain with features of subacute intestinal
ligating of the ureter. obstruction like vomiting, abdominal distension and
or constipation.
Investigations and Diagnosis
The fluid is easily recognized as urine, but when doubt Pathology of Complication
exists, estimation of urea content will clinch the Fibrinous deposits in the operated area can cause
diagnosis. Intravenous pyelography and uretero- adhesions which may be firm sometimes.
graphy may give the exact location of ureteric fistula
and may reveal the presence of hydronephrosis. Investigations and Diagnosis
Fistulae of the urinary bladder and urethra may be Careful history taking and clinical examination will
determined by cystourethrography or cystoscopy and help in diagnosis. Rarely X-rays of abdomen like
or urethroscopy. barium meal series will help in diagnosis.
Treatment Treatment
Urinary fistula (ureteric fistula) due to: Medical
• Partial injury of the ureter—perform ureteric Medical management should suffice in most cases.
catheterization and allow spontaneous healing
• Complete injury of the ureter or failed catheteri- Surgical
zation and failed spontaneous closure—resection
and anastomosis (neoureterocystostomy, uretero- Release of adhesions by open surgery (Fig. 8.5) or by
ureterostomy). laparoscopy may be needed in some cases.
Treatment
Penile implants may be useful for the management of
impotence.
INTESTINAL OBSTRUCTION
Clinical Presentation
The patient presents with abdominal pain and
distension, vomiting and obstipation.
Pathology of Complication
Fig. 9.5: Intestinal obstruction (internal herniation)
The mechanical obstruction may be at various levels;
they are: permanent. A temporary stoma is used in a staged
• adherence of small bowel loop to the pelvic peri- operation in the management of malignant large
toneum at the site of suture intestinal obstruction or with certain anal operations.
• herniation of knuckle of bowel through the peri- A permanent colostomy is performed in association
toneal floor with operations to excise the rectum.
• adherence of gut to the parietes near the colostomy
• adherence of gut to the edge of mesocolon Siting of a Stoma
• strangulation of small bowel in the paracolic gutter
or lateral space on the outer side of colostomy Unsuitable sites of stoma (Figs 9.6A to D)
• drag on the terminal ileum by an ileal band during • Stomas should be placed away from flexure creases
suture of pelvic peritoneal floor. or bony prominences
• They should be away from wounds
Investigations and Diagnosis
Careful history taking, clinical examination, and
radiological examinations may be useful. Plain X-rays
of the abdomen in erect posture will show air-fluid
levels as evidence of obstruction.
Treatment
Medical
Gastric suction and intravenous fluids should be
attempted, till a definite decision is reached to the
presence of a mechanical obstruction.
Surgical
Exploratory laparotomy (Fig. 9.5) and appropriate
treatment like release of adhesions, reduction of
hernias, correction of kinks. If bowel is strangulated,
resection and anastomosis is done with or without
proximal diversions.
COLOSTOMY
A colostomy diverts faecal flow onto the anterior
abdominal wall and may be either temporary or Figs 9.6A to D: Unsuitable sites for siting a stoma
Chapter 9: Pre- & Postoperative Management in Hindgut (Colon, Rectum & Anus) Surgery 107
A B C D
Figs 9.9A to D: Types of colostomy (A) Loop colostomy, (B) Double barreled colostomy (Bloch-Paul-Mickuliez operation,
(C) Divided colostomy (Devine’s) (functional end colostomy + mucous fistula), (D) Terminal colostomy
108 Gastrointestinal Surgery: Step by Step Management
minimal appliance in the intervening period, though necessary to dilate the stoma and a finger is inserted only
he should be instructed to carry an appliance should periodically to determine the direction for placement of the
episodes of diarrhoea occur. Colostomy plugs are cone tip. Between irrigations the patient usually wears
available to allow passage of gas but not stool during a security pouch, which permits passage of gas
the period between irrigations if the patient elects to through a charcoal filter and provides a small pad to
irrigate. absorb any mucus normally secreted by the colonic
The principle of irrigation is based on the fact that mucosa (Figs 9.10A to D).
the distal colon displays a few mass peristaltic motions
each day and that these can be stimulated by disten- EARLY COMPLICATIONS OF COLOSTOMY
sion of the intestine. (see Table 9.5)
The advantages of irrigation are:
1. Absence of need for wearing an appliance at all
times
2. Provision of a more regulated life-style
3. Reduced passage of uncontrolled gas
4. Less leakage of stool between irrigations
5. General feeling of comfort.
The disadvantages are:
1. It is a time-consuming ritual
2. Uncomfortable when the bowel is distended
during irrigation B
A
3. Minimal risk of perforation.
Irrigation gives poor results in patients with:
1. Irritable bowel syndrome
2. Peristomal hernia
3. Irradiated bowel
4. Inflammatory bowel disease
5. Poor eyesight
6. Reduced manual dexterity
7. Simply fear of dealing with the intestine at the C D
abdominal wall. Figs 9.10A to D: Technique for a colostomy irrigation, using
the Hollister kit. (A) The plastic irrigating bag, tubing flow
Technique of Irrigation regulator and cone tip to fit over the end of the catheter. (B)
A cone tip that fits into the stoma enough to provide a The drainage bag has been fastened in place over the
seal, is inserted into the stoma and allow the instilla- colostomy with the belt, the lower end hanging into the toilet
bowl and the upper end opened up in preparation for application
tion of 500 to 1000 ml of water. Once the water is
of the cone tip to the stoma. (C) The cone is in place against
instilled, a drainage bag is applied, and the individual the stoma and the fluid is being allowed to flow by releasing
can proceed with morning chores. Once contractions the clip on the tubing. (D) After ten minutes or so the cone tip
are induced, the contents are evacuated through a has been withdrawn and the top of the bag sealed with the
spout or a large bore tube in the lavatory. It is not metal sealing strip
Blackening or darkening of colour of the colostomy. The patient presents with a retracted colostomy
months or years after surgery.
Treatment
Pathology of Complication
Release of tight compression if possible. If the necrosis Conservative management of partial necrosis and
is limited to the external part of colostomy, expectant mucocutaneous separation leads to stricture and
treatment is enough. If there is suspicion of deeper retraction by fibrosis.
extension, sigmoidoscopy has to be performed. If
necrosis has extended down, the wound should be Investigations and Diagnosis
reopened and colostomy has to be re-established. The diagnosis is obvious.
INFECTION Treatment
Surgical repair may have to be done if there is
Clinical Presentation
obstruction, a formal laparotomy may be needed to
The patient presents with reddish discoloration of the mobilize the bowel and mesentery and the stoma may
peristomal skin and sometimes purulent discharge. have to be refashioned (Fig. 9.11).
Pathology of Complication
STENOSIS OF COLOSTOMY
Infection of mucocutaneous junction of the colostomy
due to faecal contamination. Clinical Presentation
Investigations and Diagnosis The patient presents with stenosis of colostomy and
constipation (Fig. 9.11A).
The infection is obvious and pathogenic organism may
be isolated in culture.
Treatment
Administration of antibiotics and local dressings,
drainage of pus if necessary. The raw area thus created
heals by granulation in due course.
SEPARATION OF COLOSTOMY
Clinical Presentation
The patient presents with separation of muco-
cutaneous border of the colostomy.
Pathology of Complication
This is a sequel of infection of the mucocutaneous
junction and non-healing of the edge. Fig. 9.11A: Stenosis of colostomy
Chapter 9: Pre- & Postoperative Management in Hindgut (Colon, Rectum & Anus) Surgery 111
Pathology of Complication distal end excised leaving a soft pliable edge of bowel
and the mucocutaneous approximation done with
This is largely a complication when a colostomy is
sutures (Fig. 9.11B).
made by simply leaving the colon stump projecting
beyond the skin of the anterior abdominal wall with FISTULA FORMATION
inadequate mucocutaneous approximation. Clinical Presentation
Investigations and Diagnosis The patient presents with a discharging wound near
The diagnosis is obvious, and confirmation can be the colostomy.
done by introduction of finger which may or may not Pathology of Complication
be possible. When introduced, it may present the
This may occur as a result of suturing of the bowel
tightness.
wall to the rectus fascia by a deeper full-thickness
Treatment stitch.
Medical
Dilatation may be done using a finger (Fig. 8.9) or
metal dilators (Fig. 8.10).
Surgical
Local repair needs to be done. The colostomy is deta-
ched at the mucocutaneous junction and dissected to
the peritoneal cavity. The rim of skin and fat at the Fig. 9.11B: Local repair of stenosis of colostomy
112 Gastrointestinal Surgery: Step by Step Management
Treatment
If the fistulous opening is close to the colostomy and
the discharge is within the appliance, no treatment is
required. A small modification of the appliance so as
to encompass the fistula within the appliance may be
needed. If the fistulous opening is far from the colos-
tomy and interferes with the application of the
appliance, it may be laid open (fistulotomy) and if the
fistula is far from the colostomy, should be excised
surgically with revision of entire stoma as it is done
for paraileostomy fistula.
Pathology of Complication
Fig. 9.13: Repair of prolapse of loop colostomy
This happens when the:
• Colostomy is constructed when the colon is dilated
PROLAPSE (OF END COLOSTOMY)
during the procedure and the colon gets decom-
pressed after the procedure. Clinical Presentation
• Assessment of the length of the loop of colon The colostomy protrudes excessively from the skin
outside the skin becomes faulty. surface and rubs against the appliance.
Investigations and Diagnosis Pathology of Complication
The diagnosis is obvious. This happens when the:
• Colostomy is constructed when the colon is dilated
Treatment during the procedure and the colon gets decom-
Medical pressed after the procedure.
• Assessment of the length of the loop of colon
Conservative treatment like reduction, which is
outside the skin becomes faulty.
generally possible after a period of recumbency, can
be used. Investigations and Diagnosis
Surgical The diagnosis is obvious.
If the stoma is to be permanent, the transverse colos- Treatment
tomy may be divided and transformed into a terminal Local repair needs to be done. The colostomy is deta-
end colostomy and a distal mucous fistula (Fig. 9.13). ched at the mucocutaneous junction and dissected to
Note: Though rare, it is a well-recognized complication, the peritoneal cavity. The redundant colon is pulled
especially when the colostomy is retained for over two out, the excess colon is resected 1 to 2 cm above the
months before closure. skin level and sutured to the skin (Fig. 9.14). Resiting
Chapter 9: Pre- & Postoperative Management in Hindgut (Colon, Rectum & Anus) Surgery 113
Surgical
If the hernia is very discomforting (e.g., if it interferes
with the wearing of appliance), surgery may be done.
Surgical repair with or without repair with Prolene
A mesh (Figs 9.17A and B).
B
Figs 9.15A and B: Paracolostomy hernia Fig. 9.16: Girdle for management of paracolostomy hernia
114 Gastrointestinal Surgery: Step by Step Management
A B
Fig. 9.17A and B: (A) Surgical repair of paracolostomy hernia, (B) Repair of paracolostomy hernia
COLOSTOMY PERFORATION
Clinical Presentation
The patient may present with severe pain near the
colostomy and signs of localized peritonitis.
Pathology of Complication
This can happen due to careless intubation techniques
during irrigation or by introduction of catheters dur-
ing contrast studies, producing local trauma and
perforation and peritonitis due to faecal contamination
of the peritoneal cavity.
A
Investigations and Diagnosis
Ultrasonography or CT scan can document localized
collections near the perforation, sigmoidoscopy may
reveal perforations.
Treatment
Laparotomy and reconstruction of colostomy is the
treatment of choice. During laparotomy adequate
toiletting and drainage of peritoneal cavity is essential
to clear the faecal or the contrast material from the
peritoneal cavity.
CLOSURE OF COLOSTOMY
A loop colostomy may be closed using one of two B
techniques (Figs 9.18A and B):
Figs 9.18A and B: Closure of colostomy
• simple closure—after mobilization, the opening is
sutured (half anastomosis)
• excision of colostomy and anastomosis—the site Before closing the stoma, a clinical examination is
of the colostomy is excised and the continuity of done to check the anastomosis. Invariably, there is a
the colon is restored by end-to-end anastomosis. degree of narrowing. An opening of 12 mm diameter
The most important consideration in dealing with allows acceptable closure of the stoma. If the stricture
the closure of a temporary colostomy is deciding when is long and/or less than 12 mm in size and unable to
it is safe to restore intestinal continuity. Distal integrity be dilated because of scarring and fibrosis, re-resection
and adequacy of sphincter muscle function must be of the anastomosis with construction of a new anasto-
carefully evaluated before closure of the stoma. mosis is indicated. The stoma is closed after establi-
Chapter 9: Pre- & Postoperative Management in Hindgut (Colon, Rectum & Anus) Surgery 115
shing that the new anastomosis is sound and well WOUND INFECTION
healed.
Clinical Presentation
It is also necessary to establish the healing and
integrity of the surgical procedure done in the distal The patient presents with discharging wound around
loop, by a barium enema before the closure is done. the 2nd to 5th postoperative day.
Clinical Presentation This is due to sepsis in the pile pedicle with resulting
in softening of the wall of the main artery and eventual
In the immediate postoperative period, the patient disintegration.
presents with retention of urine.
Pathology of Complication Investigations and Diagnosis
This may be due to parasympathetic blockade by low A rectal examination is very important and the
spinal anesthesia. passage of finger in the rectum will release large soft
clots in the bowel and on withdrawal some more blood
Investigations and Diagnosis may come away. The diagnosis is confirmed by
No specific investigation is required excepting a proctoscopy, which may be very uncomfortable for
clinical examination to establish a distended urinary the patient and rather difficult for the surgeon. Good
bladder. sedation may be necessary.
118 Gastrointestinal Surgery: Step by Step Management
Treatment Treatment
Small bleeds Conservative management (packing with If it does not heal with proper Sitz baths, a sphincter
adrenaline-soaked gauze) with bedrest and sedation. stretch or internal sphincterotomy may be needed.
Large bleeds Examination under anesthesia with a
proctoscope or a bivalve speculum, to identify the ANAL STENOSIS AND ANAL STRICTURE
bleeding point, which may be cauterized or under- Clinical Presentation
run with a catgut stitch.
When bleeding points are unidentifiable, it is better The patient presents with severe constipation.
to pack the anus with packs and vaseline gauze around
a large rubber tube, to exert pressure on the hemorr- Pathology of Complication
hage site. Large areas of mucosal damage and large areas of skin
excision at the time of surgery while healing results
LATE COMPLICATIONS OF in a long column of fibrosis-stenosis.
ANORECTAL SURGERY (Table 9.10)
FISSURE FORMATION Investigations and Diagnosis
Surgical
There are many surgical procedures to correct the anal
incontinence:
1. Direct suturing of the anal sphincters.
2. Posterior sphincteroplasty and suture of pubo-
rectalis muscles.
3. Stimulation of anal sphincter tone by electronic
implant or anal plug
4. Thiersch’s operation
5. Colostomy with or without rectal excision.
RECURRENCE OF FISTULA
ANAL INCONTINENCE
Clinical Presentation
Fig. 9.20: Recurrent fistula
The patient who has undergone anal surgery may
present with loss of control of stools or a contiuous Pathology of Complication
leak per anus. Some left out fistulous tract or foreign body like a mesh
may cause recurrence of fistula, or pathologies like
Pathology of Complication Crohn’s disease, tuberculosis, and malignancy may
This results due to complete division of the internal present as recurrence.
anal sphincter apparatus. Investigations and Diagnosis
Investigations and Diagnosis Probing the fistula and/or fistulogram will help in
diagnosis, any granulomatous tissue should be
The diagnosis is by the feeling of the anal sphincter biopsied before surgery.
by finger which exhibits the loss of sphincter tone.
Treatment
Treatment Treatment depends on the diagnosis, simple recurrent
fistulae need to be removed again, probably deline-
Medical
ating them with colour dyes like methylene blue will
Majority of the patients will become better by perineal be useful. If the fistula is due to systemic or local
exercises. diseases, the treatment varies accordingly.
10
Pre- and Postoperative
Management in Hepatic Surgery
Varieties of hepatic resections are performed on the Unisegmentectomy Removal of a single segment.
liver depending on the diagnosis and the part of the
Plurisegmentectomy Removal of two or more segments.
liver involved in disease. Nomenclature is detailed in
the Figure 10.1. Wedge resection Removal of a small portion of the liver,
either within a single segment or traversing segmental
Right hepatectomy Resection of liver lateral to the main
planes as a wedge.
portal fissure (segments V, VI, VII, VIII).
Left hepatectomy Resection of liver medial to the main PREOPERATIVE MANAGEMENT
portal fissure (segments II, III, IV). The essential features of the preoperative protocol are:
Right lobectomy Resection of entire right lobe and • Angiography of both the celiac and superior
lateral segment of left lobe (hepatic parenchyma to mesenteric arteries to define the extent of hepatic
the right of the falciparum ligament and ligamentum involvement and resectability and also to
teres (segments IV, V, VI, VII, VIII). demonstrate the vascular anatomy and segmental
supply and venous phase to determine the
Left lobectomy (left lateral segmentectomy) Resection of
involvement of portal vein
left lobe medial to the falciparum ligament (seg-
• Computed tomography with contrast for definition
ments II, III).
of intrahepatic pathology
• Determination of serum albumin, prothrombin
time, activated partial prothrombin time and
platelet count, and if abnormal to be corrected.
This is transient in the early postoperative period, and Hemorrhage from the liver in the immediate post-
operative period may either be from coagulopathy or
is presumably due to:
insufficient hemostasis.
• Direct damage to liver parenchyma
Coagulopathy may result, alone or in combination:
• Consequences of hypovolemia
• From wash out of coagulation factors with multiple
• Reduced hepatic blood flow in the preoperative
transfusions
period and • Transfusion reaction
• Possibly infection. • Disseminated intravascular coagulation triggered
Investigations and Diagnosis by tissue injury.
LATE COMPLICATIONS OF HEPATIC SURGERY The treatment is palliative many times by intra-arterial
(See Table 10.2) embolization, intra-arterial antimitotic drugs as the
SHUNT SURGERY
Operations to prevent recurrent variceal bleeding are
directed either by obliterating the varices or reducing
portal pressure. With neither strategy, the underlying
disease is treated and depending on its cause, the liver
disease may progress leading to further complications,
and indeed death of the patient.
Portal systemic shunts (Fig. 10.2) are conven-
tionally divided into:
1. Total The entire splanchnic circulation is decom-
pressed. The various types are:
• Portal-caval shunt (end to side/side to side)
• Spleno-renal shunt
• Interposition H graft-mesenterico-caval
• Mesenterico-caval
2. Selective shunts in which only part of the portal
system is diverted and the remainder is
undisturbed. The various types are:
• Distal spleno-renal
• Spleno-caval
• Coronary caval
PREOPERATIVE MANAGEMENT
Preoperative management of a patient for shunt
surgery is complex and multifaceted. They are as Fig. 10.2: Kinds of portal systemic shunts: (N) Normal; (A1)
follows. end-to-side portal caval shunt (A2); side to side portal caval
shunt; (B1) spleno-renal shunt; (B2) mesenterico-caval shunt-
Management of Upper GI Bleeding (Fig. 10.3) interposition H graft; (B3); mesenterico canal shunt (end to side);
(C1) distal spleno-renal shunt; (C2) spleno-caval shunt; and (C3)
The principal danger of portal hypertension is from coronary-caval shunt
GI bleeding from thin-walled varices as well as from
an increased incidence of gastric ulcers, duodenal
ulcers and also from gastritis. The danger of bleeding 0.4 units/min) is started, iced gastric lavage using
varices is intensified in the presence of tense ascites, a large diameter tube and emergency endoscopy
and therefore, these patients should be diuresed as is carried out.
much as possible to the point at which blood urea • If bleeding esophageal varices are identified during
nitrogen and creatinine rise. endoscopy, sclerotherapy and Sengstaken-
• A combination of spironolactone and fursemide in Blakemore tamponade are performed (see Chapter
divided doses of 200 mg/day of spironolactone 4). The patient is intubated prophylactically to
and up to 80 mg of fursemide.* protect the airway, especially if encephalopathy is
• At the same time, the bleeding from varices and present.
ulcers or gastritis can be minimized with • If bleeding cannot be controlled by Pitressin,
administration of H2 blockers. sclerotherapy and Sengstaken-Blakemore tube
• If variceal bleeding occurs in the preoperative tamponade, emergency portosystemic shunt is
period, intravenous vasopressin injection (Pitressin considered if the patient is viable.
Chapter 10: Pre- and Postoperative Management in Hepatic Surgery 125
Monitoring See Child’s criteria (see Chapter 5). They need 1.1 gm
of amino acids or protein/kg/24 hr and 35 cal/kg of
Patients with established cirrhosis and liver disease
non-protein calories, at least 20 percent of which
tend to have hyperdynamic circulations, and decrea-
should be fat.
sed vascular resistance and secondarily, increased
If adequate amounts of oral intake cannot be
cardiac output. Volume status is difficult to assess
achieved via oral route, parenteral route is undertaken.
accurately using CVP (central venous pressure)
Intravenous fat may be given in those who do not
measurements as there is usually a disparity between
tolerate fat orally in excess of 20 percent of caloric
right-sided CVP and left atrial filling pressure. Thus,
requirements, and as these patients are glucose
in any major operative procedure of the cirrhotic
intolerant, serum glucose monitoring is important and
patients, Swan-Ganz monitoring is essential.
appropriate insulin administration. If because of
Diuretic Therapy encephalopathy, the patient may be incapable of
achieving 1.1 gm of amino acids/kg, a branched chain-
Patients with cirrhosis secrete increased amounts of enriched, aromatic amino acid-deficient mixture is
aldosterone and antidiuretic hormone (ADH) thereby administered with amino acids up to 100-120 g/24 hr
retaining water and sodium. The decreased pulse and at least 2,200 calories.
pressure perfusion to the kidney, resulting from
decreased peripheral resistance, may trigger renin- Prevention of Infection
angiotensin mechanism.
As with any patient with malnutrition, there is high
Correction of Impaired Clotting Mechanisms incidence of infection due to decreased host resistance.
Administration of antibiotics is important as part of
All clotting factors except factor VIII are made in the preoperative preparation for surgery.
liver. Prolonged PT and APTT, both of which are direct
indicators of impairment of hepatic reserve. Asso- Management of Ascites
ciated hypersplenism or recent alcohol ingestion may Ascites, serving as a huge third space, tends to
contribute to thrombocytopenia, which may be complicate preoperative management. If a patient can
relieved by administration of folic acid and portocaval be rendered ascites-free before operation, and if there
decompression. In patients with defective clotting is judicious administration of crystalloid and other
mechanisms, vitamin K is given. Since this does not salt-containing fluids intraoperatively, ascites
restore hemostatic mechanisms in cirrhotics, liberal accumulation can be minimized. Gentle diuresis of
use of fresh whole blood, fresh frozen plasma and ascites, without increasing the urea and creatinine, is
various components such as concentrated the most efficacious way of treating ascites before
cryoprecipitate are used. surgery.
Cleansing the Gut POSTOPERATIVE MANAGEMENT
Preparation of patients with hepatic encephalopathy Intensive care unit management for 24-48 hr is
for operation, includes cleansing the gut with non- necessary with Swan-Ganz monitoring. It is important
absorbable antibiotics (e.g., neomycin and erythro- to ‘run the patient dry’ to lessen the risk of ascites.
mycin base) as well as catharsis by lactulose to prevent Maintaining a CVP of 3-4 mm Hg is adequate, infusion
accumulation of gut bacteria and their products. of salt-containing solutions is minimized, and a urine
output of 20-30 ml/hr is sufficient. The ideal is to
Correction of Malnutrition
maintain the pulse rate below 100 beats/min and
The patient with liver disease is often both anorectic systolic BP of 100-110 mm Hg.
and cachectic, which is complex in nature. Whatever Nasogastric tube is retained in place for 24 hr.
technique(s) used, nutritional assessment and improve- Antibiotics are given in the preoperative period
ment is probably the most important aspect of but not continued in the postoperative period. If there
preoperative preparation, because malnutrition is significant biliary contamination, a 4-5 day period
correlates well with mortality in these patients. of antibiotics is appropriate.
Chapter 10: Pre- and Postoperative Management in Hepatic Surgery 127
Urinary catheter is usually removed at 48 hr. Investigations and Diagnosis
Investigations such as prothrombin time (PT),
Clinical examination reveals ascites and there is
activated partial thromboplastin time (APTT), plasma
hyperbilirubinemia.
fibrinogen and platelet count are monitored at least
once every 12 hours on the first and second post-
Treatment
operative day. A platelet count of 50,000 is acceptable.
Administration of platelets in the absence of bleeding results There is no specific treatment apart from excluding
in platelet antibodies often, if type specific platelets are used. other causes of possible impairment of liver function,
PT is maintained at no greater than 2 seconds e.g. infected ascites, continuing alcohol abuse.
prolonged, using fresh frozen plasma and vitamin K. However, jaundice usually disappears after six
Serum albumin is maintained at least 3 gm/dl by the months.
use of salt-poor albumin.
H2 antagonist is administered for at least the first HYPOKALEMIC ALKALOSIS
3 days postoperatively. AND ENCEPHALOPATHY
Diet is slowly advanced from clear liquids to a
regular diet over the next 2-3 days. Clinical Presentation
Restrictions: Sodium 2 gm, fat 30 gm for 6-8 weeks. The patient presents with deranged neurological
The fat restriction lessens the risk of chylous ascites status varying from unconsciousness to coma.
from approximately 30 percent to < 10 percent.
Patients are started on Spironolactone 50-100 mg/day Pathology of Complication
on the second postoperative day.
Venography is performed on the 7th postoperative This is due to sudden diversion of portal blood into
day, through a catheter placed through the groin and the systemic circulation.
up the vena cava, to enter the left renal vein and the
anastomosis. Investigations and Diagnosis
Patients are discharged home 7-10 days after the Determination of levels of serum electrolytes, blood
operation.
gas analysis and serum ammonia will help in diag-
EARLY COMPLICATIONS OF SHUNT SURGERY nosis.
(see Table 10.3)
Treatment
TRANSIENT ASCITES AND JAUNDICE
Clinical Presentation It is easily controlled by limitation of protein intake
and modification of the gastrointestinal flora with
The patient presents with distended abdomen and
neomycin or the use of lactulose. Management of
jaundice.
severe chronic encephalopathy is very difficult and
Pathology of Complication disappointing, and reversal of shunt cures the prob-
This occurs due to mild infection of ascites. lem, but there is an increased risk of variceal bleeding.
C
Figs 11.1A to C: Operations on the gall-
bladder (A) Cholecystectomy, (B) By-
A B
pass procedures (1) Cholcystoduodeno-
stomy, (2) Cholecystojejunostomy
(loop), (3) Cholecystojejunostomy Figs 11.2A and B: Choledochotomy (A) Closure
(Roux-en-Y) (C) Cholecystostomy without T–tube (B) Closure with T–tube
130 Gastrointestinal Surgery: Step by Step Management
B
A C
A B
A B
the general preparation (see Chapter 5) excepting
Figs 11.5A and B: (A) Sphincterotomy, (B) Sphincteroplasty
when they have obstructive jaundice. The preopera-
tive management of a patient with obstructive
jaundice is detailed in Chapter 10.
Procedures for Decompression
of the Biliary System POSTOPERATIVE MANAGEMENT
• Percutaneous transhepatic cholangiography (PTC)- Anticipate a period of postoperative ileus, during
associated decompression procedures (Fig. 11.6). which the patient is maintained on intravenous fluids.
• Endoscopic retrograde cholangiopancreatography Clear liquids are begun about 24 hours after surgery
(ERCP)-assisted decompression procedures and if tolerated, the diet is advanced to normal intake
(Fig. 11.7). over the next 2 days. Nasogastric decompression is
not routinely employed in biliary surgery excepting
PREOPERATIVE MANAGEMENT
in laparoscopy-assisted surgery (see Chapter 14).
The preparation of a patient for surgery of the biliary Intravenous fluids are maintained until the patient
tract does not involve any special procedure other than is taking sufficient fluids orally.
Chapter 11: Pre- and Postoperative Management in Biliary Tract Surgery 131
Urinary catheter drainage is not absolutely essen- It is arguable whether any of the symptoms that
tial but if used (as in perforations of gallbladder or in may occur after gallbladder surgery have ever been
major procedures of the biliary tract surgery) is shown to be due to the absence of the gallbladder.
normally discontinued around the second day of Though there are changes in the biliary anatomy,
surgery. physiology and metabolism, the symptoms do not
Antibiotics are given in the preoperative period correlate well with these alterations.
but not continued in the postoperative period. If there
is significant biliary contamination, a 4 to 5 day period EARLY BILIARY COMPLICATIONS OF
of antibiotics is appropriate. BILIARY TRACT SURGERY (see Table 11.1)
Investigations are important in patients with BILIARY PERITONITIS
obstructive jaundice, such as prothrombin time (PT),
activated partial thromboplastin time (APTT), plasma Clinical Presentation
fibrinogen and platelet count are monitored at least In the early postoperative period around the 2nd-5th
once every 12 hours on the first and second post- postoperative day, the patient may present with high–
operative day. A platelet count of 50,000 is acceptable. grade fever with severe pain in the right hypochon-
Administration of platelets in the absence of bleeding results drium and severe tenderness in that area.
in platelet antibodies often, if type specific platelets are used.
PT is maintained at no greater than 2 seconds Pathology of Complication
prolonged, using fresh frozen plasma and vitamin K.
Serial monitoring of bilirubin levels and alkaline This is due to the leak of infected bile from the gall-
phosphatase levels are important. bladder bed or superadded infection to the leaked bile.
The symptom complexes appearing after chole- No investigation may be of any use in diagnosis excep-
cystectomy are common and can appear at any time ting a thorough clinical examination and elimination
after operation, but irrespective of whether they have of other causes of fever in the postoperative period.
a causal relationship to cholecystectomy or not, CT scan may be of use when the leak is considerable
present an important and often challenging clinical to demonstrate a subhepatic collection.
problem. It is not surprising that problems are more
Treatment
frequent if a normal non-calculous gallbladder is
removed but this is not so if it was non-functioning or If no antibiotics are given, high-grade antibiotics such
had a pathology in it. as third or fourth generation cephalosporins are
administered. Addition of antibiotics to cover gram grade fever with severe pain in the right hypo-
negative and anaerobic organisms may be required. chondrium and severe tenderness in that area.
Treatment
Small collections of bile (bileoma) usually resolve; and
if they cause biliary obstruction, they need to be
aspirated under ultrasound or CT guidance or by open
drainage to relieve obstruction (Fig. 11.8).
ABSCESS
Clinical Presentation
In the early postoperative period around the 2nd-5th
postoperative day, the patient may present with high- Fig. 11.8: Open drainage of bileoma/bile abscess
Chapter 11: Pre- and Postoperative Management in Biliary Tract Surgery 133
Pathology of Complication
External biliary fistula may occur after various
operations of the biliary system. They are as follows.
Postcholecystostomy biliary fistulae occur due to:
• an unrecognized retained gallstone lodged within
Hartmann’s pouch
• an unrecognized distal bile duct obstruction either
as a result of retained bile duct stones or of
malignant obstruction of the biliary tree.
Postcholecystectomy biliary fistulae occur due to:
• surgical error
• anomalies of the ductal system
• surgery on gangrenous gallbladder
• slipped or sloughed ligatures on the cystic duct.
Postcholedochotomy biliary fistulae occur due to:
• residual bile duct stones
• overlooked malignant obstruction of distal bile
ducts.
Postbiliary-intestinal anastomoses biliary fistulae occur
due to: Fig. 11.9: Ultrasonography showing dilated biliary
• disruption of part of the suture line due to: ducts and dilated CBD (arrow in the lower figure)
1. technical error
2. postoperative pancreatitis
3. ischemic necrosis
• failure of the surgeon to appreciate ductal anatomy.
Fig. 11.11: T-tube cholangio- Fig. 11.12: Fistulography showing postoperative Fig. 11.13: PTC showing a external
graphy showing a stone in the biliary fistula with subphrenic (top arrow) and biliary fistula (top arrow) and an
CBD (arrow) subhepatic (bottom arrow) collections impacted stone (lower arrow)
Fig. 11.14: ERCP showing Fig. 11.15: Radionuclide scan Fig. 11.16: Fiber-optic choledochoscope
multiple stones in the CBD showing the biliary leakage into
the abdominal drain
Treatment
The choices available for removal of CBD stones are:
• Extraction either by ERCP-aided balloon extraction
or basketing, with sphincterotomy (Fig. 11.18). Fig. 11.21: Choledochoscope basketing
Nasobiliary drainage using a catheter placed
through endoscope, to relieve jaundice, when the
stone is creating a total blockage of the duct (Fig.
11.19).
• Dissolution of stones using various dissolution
agents may also be attempted.
• Extraction using a choledochoscope and basketing
(Fig. 11.21) or balloon extraction (Fig. 11.22).
• Extraction using per-oral mother-baby choledo-
choscopes
• Surgical choledocholithotomy (Fig. 11.2) for diffi-
cult to extract stones by endoscopic procedures.
• Biliary enteric bypass like choledochoduo- Fig. 11.22: Choledochoscope balloon extraction
denostomy for impacted stones in the distal duct
(Figs 11.3 and 11.4).
Pathology of Complication
This is due to injury to the common bile duct during
original surgery. Fig. 11.23: PTC showing
stricture of CBD
Investigations and Diagnosis
Precise diagnosis is radiological. They are: in the CBD, it gives the index of liver function and
1. Ultrasonography—reveals dilated intrahepatic biliary secretion
radicals 6. Peroral mother baby choledochoscopy to visualize
2. CT scan—reveals dilated intrahepatic radicals the stricture.
3. Percutaneous transhepatic cholangiography
(Fig. 11.23) to delineate the stricture. Treatment
4. Endoscopic retrograde cholangiography The treatment is always surgical. They are:
5. Isotope studies of the biliary system (injection of • When the stricture is easily accessible and small
HIDA)—apart from the identification of strictures with good distal ductal anatomy, end-to-end
138 Gastrointestinal Surgery: Step by Step Management
TUMOR
Clinical Presentation
The patient presents with upper abdominal pain and
obstructive jaundice. Fig. 11.24: CBD repair, end-to-end anastomosis
over a T-tube
Pathology of Complication
The exact pathology is not known. Plain and Barium Contrast Radiographs
Investigations and Diagnosis Penumobilia (presence of air in the biliary tree) may
be noted in the plain film. Barium meal or barium
Ultrasonography, ERCP and serial bilirubin estima- enema may demonstrate reflux of contrast into the
tions will help in diagnosis. fistula by using both the modalities concurrently, the
diagnosis rate is high.
Treatment Direct injection of contrast material through PTC
Excision of tumor and biliary enteric anastomosis like or ERCP describes the pathology.
hepaticojejunostomy (Roux-en-Y) has to be done Ultrasonography is a very useful diagnostic aid in
(Fig. 11.4). the preoperative evaluation of fistula.
Treatment
Endoscopic sphincterotomy is useful in relieving the
obstruction and symptoms.
PAPILLARY DYSFUNCTION
Clinical Presentation
The patient presents with fever, with rigor, abdominal
pain and mild jaundice.
Pathology of Complication
The pathology is not known. Fig. 11.25B: Transduodenal sphincterotomy
Bile
Recurrence
in a high dependency unit because of particular risk 2. They may need urgent and risky relaparotomies
factors. 3. They may prove fatal.
Nasogastric tube is removed on the second to third Pancreatoduodenectomy remains one of the most
postoperative day unless there is copious gastric formidable operations and was given the title “cadillac
aspirate. of abdominal operations”, but it is also told that, “it is
Chest physiotherapy The patient is encouraged to not the cadillac the surgeon is trying to drive, it is a
keep the chest clear by deep breathing and coughing. formula car,” such is the risk of complication rate and
Epidural anaesthesia is usually maintained for 48 the responsibility of the surgeon.
hours to minimize pain and assist the physiotherapist The complications after pancreatic surgery are
in avoiding respiratory complications. divided into:
Urinary catheter can normally be removed within 1. Early
24-48 hours. a. surgical
Blood glucose levels should be checked frequently b. nonsurgical
as many patients develop insulin-dependent diabetes 2. Late
mellitus after pancreatic resection or need adjustment a. surgical
of their normal insulin requirements. Postoperative b. nonsurgical
rebound hyperglycemia of up to 200 to 300 mg/dl is
EARLY COMPLICATIONS OF PANCREATIC
not uncommon in insulinoma patients within 12 to 18
SURGERY (see Table 12.1)
hours after surgery. For this reason, glucose-
containing solution should not be given during the EARLY GASTROINTESTINAL HEMORRHAGE
first 24 hours after surgery.
Clinical Presentation
Antibiotic prophylaxis is continued for 24 hours.
Low-dose subcutaneous heparin is maintained for Immediately after gastric resection, as part of pancre-
7 to 10 days. atic surgery as in pancreatoduodenectomy, it is not
H 2 receptor antagonists are prescribed for 3 unusual to aspirate bloody or blood-stained fluid from
months as a safeguard against stress ulceration. the nasogastric tube. The colour should clear in a
Somatostatin analogue, Octreotide, is used in a matter of 48 hours and the aspirate should become
dose of 100 to 150 mcg subcutaneously 1 hour before bilious in nature. The persistance of bloody aspirate beyond
surgery and may be continued for 3 to 5 days every 6 48 hours is a major concern and needs to be attended to.
to 8 hr, to reduce the risk of leakage from the
pancreatojejunal anastomosis. Pathology of Complication
Subhepatic drain is usually shortened on the 5th The site of bleeding is from:
day and then removed on the 7th postoperative day. 1. The anastomotic area (more common)
If drainage is copious, the fluid is examined for 2. Small bleeding ulcer in the proximal gastric pouch
amylase (to rule out a pancreatic leak) or bile. On 3. Erosion of a ligated artery following a pancreatic
occasion, many litres of lymph fluid are drained daily, leak.
particularly after extensive retroperitoneal lymph
node dissection. But this fluid loss invariably subsides Investigation
spontaneously, even though it may take 2 to 3 weeks. It is difficult to assess the amount of blood loss by
Splinting jejunal tube (kept for pancreatojejuno- nasogastric aspirate, as there may be retained blood
stomy) is retained for at least 14 days, and a contrast clots in the stomach which cannot be aspirated, and
may be used to check the integrity of the anastomosis also some blood is bound to travel down the intestine.
before removing the tube if there is any cause for
concern. Treatment
The treatment consists of the following.
COMPLICATIONS FOLLOWING
PANCREATIC SURGERY Medical
Complications of pancreatic surgery, especially a. Ice cold saline lavage
Whipple’s operation (Pancreatoduodenectomy), are b. Endoscopic injection of adrenaline 1:10000 at the
important for three reasons. They are as follows: site of bleeding
1. They lead to significant postoperative stay c. Blood transfusions.
Chapter 12: Pre- and Postoperative Management in Pancreatic Surgery 143
EXTRAGASTRIC HEMORRHAGE and superior mesenteric axis and recognition and treatment
of coagulation defects, particularly in jaundiced patients.
Clinical Presentation
In the immediate postoperative period, the patient DELAYED GASTRIC EMPTYING
may present with suddenly elevated pulse, a falling Clinical Presentation
blood pressure and diminished urinary output. The
The patient presents with increasing nasogastric
skin may be moist and clammy and at first a myocar-
aspirate lasting for more than two weeks.
dial infarction may be suspected. Drains kept in the
peritoneal cavity may show drainage of bloody or Pathology of Complication
blood-stained fluid, and clear nasogastric aspirate. The delayed gastric emptying may be due to several
factors. They are:
Pathology of Complication
a. gastric atony after resection of the duodenal pace-
The reason may be intraperitoneal hemorrhage from: maker and disruption of the gastroduodenal neural
a. Laceration of spleen connections
b. Injury to the liver by the use of retractors b. ischemic injury to the antropyloric muscle mecha-
c. Injury to the vasa brevia nism
d. Hemorrhage from the pancreatic bed and c. gastric dysrhythmias secondary to intra-abdominal
retroperitoneal operative field vessels from erosion complications such as anastomotic leak or abscess
of a ligated artery following a pancreatic leak d. gastric atony in response to a reduction in circu-
e. Improperly secured vessel in the greater or lesser lating levels of motilin.
omentum
f. Hemorrhage from the right gastric artery and right Investigations and Diagnosis
gastroepiploic vessels. No investigations are required for a period of two
weeks, and if the aspirate does not show any sign of
Investigations and Diagnosis reduction after this period, upper GI endoscopy
should be done to rule out any mechanical obstruction.
CT scan of the abdomen is useful in such circum-
stances. Treatment
Medical
Treatment
The treatment is conservative and consists of:
If vital signs are not promptly restored after two or a. prolonged gastric decompression,
more units of blood, exploratory laparotomy is indi- b. intravenous water and electrolyte substitution,
cated. The splenic laceration is sutured and all c. prokinetic drugs like bethanecol, metroclopramide,
attempts should be made to preserve the spleen unless erythromycin derivatives.
a major splenic fracture or multiple fractures are
BILIARY LEAK
present. The bleeding vessel if any is identified and
ligated. Clinical Presentation
If a consumption coagulopathy is recognized, the The patient presents with discharge of bile or bile-
clots should be gently removed and the abdomen stained fluid through the drain kept near the biliary
reclosed with drainage after thorough irrigation. A enteric anastomosis, between the 3rd and 7th
discrete bleeding point is rarely found. postoperative days.
Note: Simple extragastric hemorrhage may or may not Pathology of Complication
present with blood loss via the drain, and with or without The complication is due to the disruption of the biliary
increasing abdominal pain, tachycardia and drop in enteric anastomosis.
hemoglobin levels.
The prime cause for this complication is some Investigations and Diagnosis
intraoperative technical fault, and it is vital to ensure that The diagnosis is obvious. Isotope scan (Fig. 11.15) can
the entire operative field is dry before closing the abdomen, demonstrate the level of the leak and CT scan may be
particular care being taken in the region of the portal vein useful in locating localised collections of bile if any.
Chapter 12: Pre- and Postoperative Management in Pancreatic Surgery 145
Treatment Larger leaks with peritonitis should be treated with
antibiotics.
Medical
Total parenteral nutrition (TPN) and adminis-
Most leaks heal spontaneously in a few weeks if there tration of Octreotide are important in the management
is no distal obstruction. of such situations.
Surgical Surgical
Localised collections of bile or bilious fluids should Percutaneous procedures may be required in about
be aspirated under ultrasound guidance if found to 10 percent of the cases when there is localised
be the cause for prolonged leaks and also when they collections.
occur as a residue after the active leak. Larger leaks with peritonitis not responding to
medical management, need to be treated surgically—
PANCREATIC LEAK
laparotomy and drainage of the peritoneal cavity.
Clinical Presentation Completion pancreatectomy may be required in
The patient presents with discharge of clear fluid retractable cases. TPN may be used in such cases.
through the drain kept near the pancreatico-enteric Note: A concentration of 100,000 units/l amylase persisting
anastomosis, between the 3rd and 7th postoperative in the drainage fluid for 1 week after injury indicates the
days. The following signs and symptoms supported presence of a pancreatic fistula.
by the laboratory investigations in the early Ultrasonography is not helpful in the early postoperative
postoperative period after pancreatic surgery need to period to diagnose leaks.
be given due importance. They are:
• pulse rate—tachycardia WOUND INFECTION
• temperature—raised Clinical Presentation
• respiration—tachypnea
• examination of abdomen —tenderness not present The patient presents with discharging wound around
before the 5th to 7th postoperative day.
• leucocytosis Pathology of Complication
• elevated serum creatinine levels
Infection of the wound occurs as there is handling of
• elevated serum lactate levels
the hollow organs and soilage of the peritoneum by
• elevated serum amylase levels.
contents of the gastroduodenum.
This leak ranges from a harmless fistula to disas-
trous peritonitis with generalized sepsis. Investigations and Diagnosis
The pathogenic organism be isolated in culture.
Pathology of Complication
The complication is due to the disruption of the Treatment
pancreatico-enteric anastomosis. Local care with dressings and administration of syste-
mic antibiotics. The suture or staple should be
Investigations and Diagnosis
removed and the wound be allowed to heal by
The fluid is characteristically clear and excoriating to secondary intention.
the surrounding skin, and the presence of amylase
should give suspicion of a pancreatic leak. CT scan
INTRA-ABDOMINAL ABSCESS
may be useful in locating localized collections of bile.
Clinical Presentation
Treatment
The patient presents with general malaise and the
Medical
recovery and convalescence is not in a normal manner.
The treatment is conservative in 80 percent of the cases There may be fever (low/moderate/high grade), with
and when the loss is less than 50 ml/day, they heal in leucocytosis. The acute picture may be subdued by
2 to 3 weeks time without any specific therapy. Skin the administration of antibiotics. Physical examination
care is important (see Chapter 19—Stoma care). may not be of any value in most cases.
146 Gastrointestinal Surgery: Step by Step Management
Secondary extragastric After 2-3 weeks Erosion or infection If due to pancreatic anastomotic
hemorrhage dehiscence, completion pancreatec-
tomy
Endocrine deficiency About 18 months Removal of endocrine tissue Replacement with insulin
(Common when > 50% later
of the pancreas is removed)
Exocrine deficiency About 18 months Removal of exocrine tissue Administration of enzymes rich in
(Common when > 50% later lipase, fat-soluble vitamins, calcium
of the pancreas is removed) and trace elements
Chapter 12: Pre- and Postoperative Management in Pancreatic Surgery 147
MARGINAL ULCERATION Surgical
Clinical Presentation If due to pancreatic anastomotic dehiscence, comple-
tion pancreatectomy is the best treatment.
The patient presents with upper abdominal dyspepsia,
pain, hematemesis and malena.
OBSTRUCTIVE JAUNDICE
Pathology of Complication Clinical Presentation
It was thought that this complication is due to non- The patient presents with icterus sometimes of severe
inclusion of vagotomy in pancreatic resections and degree.
also due to the ulcerogenic potential of pancreatec-
tomy itself. Many feel that vagotomy is not necessary Pathology of Complication
if the patient does not already suffer from duodenal This can result due to various causes. They may be
ulcer. benign or malignant:
a. benign:
Investigations and Diagnosis • stricture of biliary enteric anastomosis
Endoscopy is useful in diagnosis. • common duct stones.
b. malignant:
Treatment • local recurrence at the mesenteric root
• recurrence at the hilum of the liver.
Medical
Investigations and Diagnosis
Administration of proton pump inhibitors will help.
Determinations of serum bilirubin levels, the level and
Surgical nature of obstruction, using CT scan.
Treatment
Medical
Measures to manage them with blood transfusions. Fig. 12.4: Second Roux-en-Y operation
148 Gastrointestinal Surgery: Step by Step Management
LATE COMPLICATIONS OF SPLENIC SURGERY Note: It is not unusual to see changes in blood after
(see Table 13.2) splenectomy. They are:
• Red cell changes—Target cells, acanthocytes,
Table 13.2: Late complications of splenic surgery
erythroblasts, Howell-Jolly bodies, Heinz bodies,
Late complications Time of Reason Management Pappenheimer bodies, slight reticulocytosis.
appearance
• Platelet changes—Thrombocytosis which may be
Thrombocytosis Late post- Reactive Hydration persistent but which usually does not exceed 1
> 2 million/cmm operative thrombo- only or acetyl- million/cmm.
period cytosis salicylic acid • White cell changes—Initial neutrophilia which
or dipyridamole then regresses. Lymphocytosis and monocytosis
Thrombosis of Late post- Hypercoa- Anticoagulants may persist.
splenic and operative gulability and antibiotics
portal veins period and stasis THROMBOSIS OF SPLENIC AND PORTAL VEINS
of blood in
the splenic Clinical Presentation
vein, throm-
The patient may present with episodes of bleeding
bus progres-
sing into without encephalopathy and ascites. The liver function
portal vein tests are normal.
Fulminant sepsis Late post- Various Antibiotics Pathology of Complication
operative organisms
period This is generally believed to be due to:
• Combined effect of a hypercoagulable state and
THROMBOCYTOSIS stasis of blood in the stump of splenic vein
• Aberrant coagulation originating in the stump of
More than 2 million/cmm.
splenic vein progressing proximally to portal vein.
Clinical Presentation Investigations and Diagnosis
The patient may present with episodes of upper GI Ultrasonography and contrast-enhanced CT of portal
bleeding without encephalopathy and ascites. The vein, splenic vein and venous phase of visceral
liver function tests are normal. angiography will localize the nature and level of
obstruction.
Pathology of Complication
This thrombocytosis is due to: Treatment
• Elimination of splenic sequestration Early detection of portal and splenic vein thrombosis
• Removal of a regulatory humoral factor produced is important, because it has high morbidity and
by the spleen mortality, if left untreated. Urgent treatment with
• Persistent anemia thrombolytic agents like heparin and intravenous
• Altered platelet function. antibiotics, followed by anticoagulation, is indicated.
Patients with evidence of bowel infarction should
Investigations and Diagnosis
undergo laparotomy and bowel resection.
Platelet count of 4,00,000/cmm is defined as thrombo-
cytosis. The diagnosis should readily be apparent from
FULMINANT SEPSIS
initial history, and should have routine screening for
malignancy to rule out myeloproliferative disorders. Clinical Presentation
The patient presents with signs of infection like fever,
Treatment
leucocytosis, etc., more frequent in younger patients
Platelet count up to 1 million/cmm should not create but can also happen in adults, years after splenectomy,
concern, but larger count needs to be treated. It but most common in the first few months. Usually, it
responds to good hydration and antiplatelet drugs like has an abrupt onset, rapid course and cardiovascular
acetyl-salicylic acid or dipyridamole should be useful. collapse.
152 Gastrointestinal Surgery: Step by Step Management
complications of the surgery. An ‘informed consent’ Table 14.1: Physiological effects of laparoscopic surgery
is necessary, which includes the fact that the patient Complication Reason
has been given in-depth information, regarding the
Cardiovascular effects
surgery, including possible risks, complications or
failure to meet expectations. Bradycardia Positioning and visceral traction
Sudden cardiovascular Severe atypical reactions
collapse
Anesthetic Considerations in
Laparoscopic Surgery Circulatory impairment Decrease in venous return—due to
increase in pressure on intra-
The sudden emergence of laparoscopic abdominal abdominal vessels due to carbon
surgery for upper abdominal procedures has challen- dioxide insufflation
ged the anesthetist to adapt many of the standard Circulatory impairment Use of reverse Trendelenberg’s
anesthetic choices. position required to move the
Regardless of the anesthetic technique used, strict abdominal contents down in upper
abdominal surgery may cause
vigilance is very important. Despite the fact that
decrease in venous return by a
laparoscopic surgery has smaller incisions and is less gravitational pooling of blood in
invasive to the patient, there are significant physio- the lower extremities
logic effects (Table 14.1) that need to be considered. Decrease in cardiac Increase in the mean pulmonary
The effects can be divided into three categories: output artery wedge pressure due to the
1. Cardiovascular increase in tidal volume required
2. Pulmonary to compensate carbon dioxide
absorption
3. Gastrointestinal.
Noncardiogenic Carbon dioxide embolism
pulmonary edema
Absolute Contraindications
Neurologic Anoxia or cerebral embolism
1. Hypovolemic shock and hemodynamic instability Due complications
to unstable blood pressure or poor preload. They Venous gas embolism Pressure in the vein or the central
cannot tolerate the hemodynamic stresses of venous pressure is less than the
surrounding abdominal insuffla-
positioning and insufflation.
tion pressure
2. Massive bleeding The origin of bleeding may be
Massive bleeding Injury to vessels from inadvertent
difficult to identify and remedy laparoscopically.
entry by the trocar into the vessels
3. Severe cardiac decompensation Insufflation and
positioning may throw the decompensated heart Pulmonary effects
into irreversible arrhythmia and failure. Pulmonary atelectasis, Hypercarbia due to carbon-dioxide
4. Intestinal obstruction with extensive bowel distension decrease in the func- insufflation
tional residual capacity
Risk of perforation as well as minimal potential
of the lungs
for visualization.
Subcutaneous Improper placement of the insuff-
5. Large pelvic or abdominal mass Gives poor
emphysema lating needle and high insufflating
visualization and possible eruption of the mass pressures
prior to pathologic identification.
6. Multiple previous surgeries—adhesions present
the most difficult roadblock to trocar insertion and
Relative Contraindications
also risks of perforation of an adherent loop of
1. Peritonitis of uncertain origin—fear of spreading bowel
the infection systemically 7. Late pregnancy
2. Diaphragmatic hernia 8. Gross obesity—the abdominal cavity becomes
3. Chronic pulmonary disease more remote, necessitating a longer Verres needle
4. Uncorrectable coagulopathies and also difficult positioning because of hemo-
5. Portal hypertension dynamic and respiratory considerations.
Chapter 14: Pre- and Postoperative Management in Laparoscopic Surgery 155
POSTOPERATIVE MANAGEMENT Postoperative Complications
1. Appropriate monitoring during early postopera- 1. Postoperative shoulder pain from CO2 irritation of the
tive period to ensure a smooth transition from diaphragm is universal and should be discussed
anesthesia. preoperatively with the patient. Incorrect posi-
2. Invasive monitoring if necessary, especially in tioning and deep Trendelenburg’s positioning also
pulmonary or cardiac patients. cause shoulder pain. Surgeons should remember that
3. Pain management. extensive operative procedures although performed
4. Early mobilization and oral intake. through small incisions, may carry the same inherent
amount of pain as the same major procedure. Post-
COMPLICATIONS OF LAPAROSCOPIC SURGERY operative analgesia and often hospital observation
Complications may be early or delayed. Early compli- are necessary for any procedure lasting longer than
cations during the procedure can be corrected if 2 to 2½ hours. If the pain does not subside within
recognized via laparoscopy or laparotomy. Delayed 48 hours, it should alert the surgeon to look
complications can be divided into those that occur exhaustively for urinary or gastrointestinal tract
shortly after the procedure such as bleeding or late injury.
complications such as bowel injury or infection. 2. Neurologic sequelae are rare because a few nerve
roots are affected by intra-abdominal surgery.
During Procedure 3. Groin herniation after laparoscopy has been
1. Related to abdominal puncture and pneumo- reported. Intestinal incarceration in such a hernia
peritoneum during the procedure could potentially cause
2. Related to the procedure and the organs involved severe pain and evidence of bowel obstruction
in surgery of specific nature: within 24 hr. Consequently, it should always be
a. Bile duct injuries—CBD, CHD, RHD, cystic part of differential diagnosis for pain, nausea and
duct (during hepatobiliary surgery) vomiting after laparoscopy.
b. Vascular injuries—portal vessels, iliac vessels, 4. Complications related to the procedure itself: As
aorta, IVC (during hepatobiliary surgery) discussed in various chapters.
c. Gastrointestinal injuries—small intestine, colon, Though complications in laparoscopy are found
duodenum, stomach (during any intra-abdo- to be rare, it is important that the laparoscopist knows
minal laparoscopic surgery) his or her equipment, have had adequate initial
d. Delayed bile leak (after biliary surgery). training and active preceptorship programs. Good
Complications are frequently related to operator laparoscopists understand the limitations and realize
training or experience. Adequate training encom- that not every case can be accomplished via laparaos-
passes basic information with respect to equipment copy and also should prepare the patient and himself
and techniques, observation of a teaching surgeon, for major open surgery, should technical difficulties
preceptorship with an experienced surgeon. or complications arise. If a laparotomy is needed, it should
Failure to complete a procedure laparoscopically should not be viewed as a failure but instead as sound surgical
not be considered a complication. judgement.
15
Nutrition in the
Perioperative Period
It is clearly evident that by all data available that 4 kcal/gm when burnt in the body, whereas its storage
undernourished patients undergoing surgery and form, glycogen yields only 1-2 kcal/gm. Stored glyco-
those not receiving their proper nutrition during the gen could supply basal caloric requirements only for
pre- and the postoperative period are disadvantaged less than a day. Protein stored in the body mainly in
as far as the outcome of the surgery is concerned. An skeletal muscle yields only 1 kcal/gm when oxidized,
acute loss of 30 percent of body weight is found to be as it is not completely burnt.
uniformly fatal in seriously ill surgical patients. The The average adult man consumes 1800 calories/
fact that parenteral nutrition has decreased this day, even when he does not do any work as organs
mortality has made surgeons appreciate the impor- like heart, brain, kidneys, etc. are continuously work-
tance of maintaining the nutritional status in their ing. This is called basal requirement. If he does not
patients. take food, i.e. he fasts, this energy comes from the
breakdown of tissue protein (75 gm), adipose tissue
Body Composition and Energy Stores fat (160 gm) and tissue glycogen (180 gm of glucose).
An adequate understanding of the nutritional aspects At the same time, he will excrete 12-15 gm of nitrogen
of surgery requires knowledge of the normal require- in his urine mostly in the form of urea and will lose
ments of carbohydrates, fat, protein, electrolytes and approximately 500 gm of body weight due to break-
micronutrients such as vitamins and trace elements. down of adipose tissue fat. During non-fasting, the
The capability of the patients to meet the energy calorie requirement for basal metabolism is meted out
requirements in the events of severe injury, major by the intake of food.
operation, infection or starvation alone or in combi- The body composition of a normal man weighing
nation depends on: 70 kg is given below stressing the sources of energy
• The available body stores of potential energy and in emergency. It is detailed in Table 15.1.
nutrients Table 15.1: Body composition and the calorie source
• The capability to mobilize and utilize them and Component Weight (kg) Calories available
• To the extent, the external essential nutrients can if burnt (kc)
be assimilated and used to prevent depletion of Water and minerals 48.7 —
body stores. Fat 15.0 141,000
Biologically available fuels are stored in a rather Protein (muscle) 6.0 24,000
Glycogen (muscle) 0.15 600
dormant form as neutral fat or glycogen and in a
Glycogen (liver) 0.075 300
dynamic form as protein. Glucose (extracellular fluid) 0.020 80
Fat in human adipose tissue is stored in essentially 69.945 165,980
water free form and yields approximately 9 kcal/gm
of fat burnt. A limited amount of carbohydrate is Total tissue protein is relatively fixed in amount
stored as glycogen. Approximately 2 kg of glycogen and calorie storage or release takes place mainly due
is present in body reserves, 2/3rd in the muscle and to an increase or decrease in the body fat mass. Fat
1/3rd in the liver. Most carbohydrates like sugar yield depots serve as main source of energy. The small stores
Chapter 15: Nutrition in the Perioperative Period 157
of carbohydrates are used only during emergency. markedly increased excretion of potassium and
Proteins can also be used during emergency but will nitrogen in the urine. This negative nitrogen balance
result in loss of some of the important functions. may last for 2 to 5 days, but varies in intensity and
duration with the type and extent of surgery and may
Losses Before Surgery last several weeks after major complicated surgical
A period of starvation before surgery accompanies all procedures. The reduction in the absorptive surface
surgical procedures. In well-nourished individuals, as in major bowel resections cause a major upset in
this appears to leave the patient with no serious ill nutritional status.
effect. But in the case of patients who are suffering
Nitrogen losses in certain conditions after operation
from nutritional deficiencies there may be a loss of
muscle mass at the rate of 50-75 gm/day and this Condition Average nitrogen Time period
loss per day (gm)* for loss
would decrease the body proteins to levels which
would not be physiologically tolerated. Smooth Subtotal gastrectomy 54 5 days
Vagotomy pyloroplasty 75 5 days
muscle and skeletal muscle as well as cardiac muscle Gastrectomy 175 10 days
would suffer a decrease in contractile protein elements Cholecystectomy 114 10 days
to the point of decrease in cardiovascular dynamics
*assuming 3 gm of nitrogen loss per 100 ml of blood loss
and ventilation. These patients may also have low
levels of blood hemoglobin, serum albumin, vitamins
Assessment of Nutritional Status
A and C. Hence, it becomes mandatory to bring the
nutritional status with respect to calories, protein and It is clear that the nutritional status of any patient
vitamins to a certain level before the surgical admitted to the hospital for surgery is poor. It is,
procedures are started on them. therefore, necessary to assess the nutritional status of
the patient prior to surgery and during hospitalization.
Nitrogen losses in certain conditions before operation
A truly reliable baseline can be only obtained if the
Condition Average nitrogen loss per day (gm) initial assessment is made promptly following
Small bowel obstruction 11 admission of the patient. Delay may result in distor-
Bleeding peptic ulcer 20 tion of several of the measurements due to the
Total starvation 14
influence of factors such as IV fluids and transfusions
Losses During Surgery given. The data required to determine the nutritional
assessment are given in Table 15.2.
The significant measurable protein loss that occurs
during surgery is secondary to hemorrhage and tissue Dietary History
trauma. Water and electrolyte derangements occur
The diet history as a tool for obtaining accurate
during lengthy operative procedures, but their effects
information about food intake is valuable despite its
on the nutritional status of the patients are generally
limitations, especially when used in conjunction with
transitory and easily corrected.
a 24 hour recall of food intake. Diet history will reveal
Nitrogen losses in certain conditions during operation
specific deficiencies of nutrients, which can be
corrected by suitably altering the diet.
Condition Average nitrogen loss per day (gm)*
Abdomino-perineal 12 Identification of High Risk Patients
resection Patients having any of the following can be considered
Complicated gastric 18 as high risk patients:
surgery
1. Gross underweight Weight/height less than 80
*assuming 3 gm of nitrogen loss per 100 ml of blood loss percent of standard
2. Gross overweight Weight/height greater than 120
Losses After Surgery percent of standard
It is clearly shown that protein catabolism consistently 3. Recent loss of 10 percent or more of usual body
occurs immediately after a surgery, accompanied by weight
158 Gastrointestinal Surgery: Step by Step Management
Transnasal passage of feeding tube into the Chemically formulated diets should be diluted to
stomach or the intestine is generally the feeding route isotonicity at about 5 to 10 percent weight per volume
employed when possible. A surgical procedure is thus concentration and delivered at a rate of 40-50 ml per
avoided, and this route is generally well tolerated hour. If necessary, liquid vitamins and oral medica-
when small bore, pliant feeding tubes are used. The tions can be added to any of the tube feedings. Since
disadvantage is that, these tubes can be readily these mixtures are expensive, a simple and economic way
removed by the disoriented or uncooperative patient. of preparing a liquid diet, is to homogenize a normal home
When larger bore tubes are used, they are irritating made diet, prepared by avoiding heavy fibres to a consistency
and the competency of the gastro-esophageal sphinc- in which it can be fed through the tube. Dietitians should
ter is compromised. try to work out liquid mixtures from normal diets,
Feeding ostomies require surgical insertion (see which can be tube fed.
Chapter 4—Tubes and drains). They are generally The tube feeding can be done on a continuous basis
indicated when obstruction makes insertion through instead of bolus feed throughout the day as bolus feeds
the nares impossible or when long-term feeding is may cause problems of sudden influx of a large
anticipated. volume of food in the stomach or small intestine. This
The feedings delivered beyond the duodenum take can be done by gravity drip method (Fig. 15.2A) or
advantage of both gastroesophageal and pyloric using intestine volumetric pumps. Feeding can be
sphincters in preventing regurgitation. either intermittent or continuous. Sample schedules
for such feedings are given in Tables 15.3 and 15.4.
Indications for Tube Feeding
The infusion volumetric pumps (Fig. 15.2B) are
1. Anorexia most useful in situations where the patient is being
2. Coma fed straight into the small intestine or when the desired
3. Head and neck surgery rate of feeding is less than 200 ml per hour. Some are
4. Physical impairment (fractured jaw, obstructing battery operated and have alarm systems to advise
lesions of pharynx and esophagus) the cessation of flow or low charge of the battery.
5. Hypermetabolic states (burns, severe infection, There are a large number of intestinal feeding
multiple injuries). solutions available which are classified as:
Contraindications for Tube Feeding 1. Supplements
2. Meal replacements
1. Adynamic ileus—loss of intestinal peristalsis due
to defective neuromuscular mechanism occurring 3. Defined formula diets
in the immediate postoperative period, spinal 4. Feeding modules.
injuries).
Commercially Available Preparations
2. Intestinal obstruction (mechanical).
3. Intractable vomiting due to electrolyte imbalances The commercially available preparations should
4. Proximal high output enterocutaneous fistulae— provide at least 15 percent calories from proteins to
communication between small intestine and skin support healing and anabolism. The protein can be
(when the secretions exceed 2500 ml/day). obtained from whey/milk/soya blend for a high
The constituents of nutrient mixtures as well as quality, well tolerated protein source. The carbo-
individual constituents of mixtures (when one wants hydrate level should be moderate to reduce the risk
to prepare by himself) are commercially available for of hypoglycemia, preferably obtained from
tube feedings, especially for the paediatric patients. maltodextrin. The fat source is from 25 percent of lipid
The dietary mixtures, if well tolerated without as medium chain triglycerides. Addition of fibre, as a
nausea and vomiting, the concentration can be increa- well-balanced mixture of insoluble, soluble and
sed to 25 percent weight per volume in 24 hours. Daily prebiotic soluble fibres reduces constipation and
total volume can be progressively increased by 500 diarrhoea, reduces cholesterol level, maintains colonic
ml per day until the desired calorie and protein levels health, ecology and controls growth of pathogenic
are achieved. If nausea or vomiting occurs, administration bacteria and maintains gut integrity. Current research
should be slowed or stopped entirely for 12 to 24 hours and suggests that fibre-enriched diets may be preferable
then restarted slowly. to traditional low-residue diets for enteral feeding.
Chapter 15: Nutrition in the Perioperative Period 161
Parenteral Nutrition
When gastrointestinal feeding is inadequate, ill
advised, impractical or impossible, it is necessary to
provide nutrients through an alternate route, and the
only avenue currently feasible is the intravenous route.
Fig. 15.2A: Gravity drip Fig. 15.2B: Volumetric pump for Total parenteral nutrition aims to provide patient’s
method for feeding tube tube feeding nutritional requirements without recourse to oral
162 Gastrointestinal Surgery: Step by Step Management
Table 15.5: Details of formulation Nutren Fibre of extra water and electrolytes arising from fistula
Energy kcal/100 gm 430 losses, with allowances for extra nitrogen and extra
Protein G 17.2
energy requirements caused by hypercatabolism
Fat G 16.3 associated with sepsis.
Carbohydrate G 54.3 The basic requirements for parenteral nutrition
Dietary fibre G 6.5 regimen are:
Vitamin A IU 1700 1. Water
Vitamin D IU 120
2. Electrolytes
Vitamin E IU 12
Vitamin K Mcg 21 3. Nitrogen as synthetic amino acids
Vitamin C Mg 60 4. Energy source—usually glucose and fat
Vitamin B1 Mg 0.86 5. Trace elements and vitamins.
Vitamin B2 Mg 1 Dextrose, fructose, ethyl alcohol, protein hydro-
Niacin Mg 12 lysates, amino acid mixture, human serum albumin,
Vitamin B6 Mg 1.7
Folic acid Mcg 230
plasma protein fraction and whole blood can be
Pantothenic acid Mg 6 administered by the intravenous route. In some
Vitamin B12 Mcg 3.4 countries, glycerol, gelatin, sorbitol, xylitol and fat
Biotin Mcg 170 emulsions are also used. The mixture should be
Choline Mg 190 prepared in such a way as to be easily administered
Taurine Mg 34
through peripheral and central venous systems.
Carnitine Mg 34
Sodium Mg 375
Potassium Mg 540 Carbohydrates for Intravenous Administration
Chloride Mg 515
Dextrose is probably the most commonly employed
Phosphorus Mg 290
Magnesium Mg 115 parenteral nutrient with the exception of water. This
Manganese Mcg 1155 should not be surprising in view of its essential role
Iron Mg 5.2 in metabolism, its normal presence in the blood, its
Iodine Mcg 43 easy availability and its low cost.
Copper Mg 0.6 A 5 percent dextrose is really a 5 percent dextrose
Zinc Mg 6
Selenium Mcg 17
monohydrate solution, and only 91 percent of it is
Chromium Mcg 17 calorigenic. The calorie equivalent of dextrose is 3.75
Molybdenum Mcg 52 cal/gm than 4.1 cal/gm derived from carbohydrates
in general. Therefore, the calorie potential of a litre of
5 percent solution is 50 × 0.91 × 3.75 = 170 calories,
Table 15.6: Complications of intestinal feeding
instead of the often-stated 200 calories.
1. Mechanical Blockage of feeding tube The rate of administration of dextrose without
Pharyngeal irritation exceeding its proper metabolic utilization and without
Regurgitation into respiratory tract
producing glucosuria is 0.5 gm/hr/kg body weight
Complications relating to openings
for adults and about 1.2 gm/hr/kg body weight for
2. Gastrointestinal Diarrhoea mature newborns of normal weight.
Abdominal pain
While dextrose utilization requires insulin, fructose
Nausea and vomiting
utilization can take place in the absence of insulin.
3. Metabolic Increased blood glucose Hence, fructose is suggested in diabetic patients. A
Hyperosmolar dehydration and coma
litre of 5 percent fructose will yield 188 calories. In
Fluid retention
Low potassium and low sodium spite of claims, there seems to be no practical
advantage of fructose over dextrose.
feeding. The administered formulation should, Invert sugar is a mixture of equal parts of dextrose
therefore, need to be a combination of the patient’s and fructose and 5 percent invert sugar solution
normal requirements plus the extra requirements provides 188 calories. Here again, there is no practical
posed by the disease. This will usually take the form advantage of invert sugar over dextrose alone.
Chapter 15: Nutrition in the Perioperative Period 163
Protein Derivatives for Glycerol addition renders the aqueous phase isotonic
Intravenous Administration with blood. Intralipid is available in 10 percent and
20 percent concentrations. The size of the fat particles
An estimate of nitrogen requirements can be obtained
will be between 0.13 μm and 0.16 μm. It is isotonic
by calculating the urinary nitrogen loss and adding
and supplies essential fatty acids and gives 9 kcal/
on 3-4 gm. Thus, a patient expelling only 6 gm of
gm of solution enabling provision of a relatively high
nitrogen in the urine would have 9 gm returned by
caloric input for a small volume of infusate.
intravenous infusion. On the other hand, a very septic
In general, the quantity of intravenously
patient, eliminating 20 gm of nitrogen a day would
administered fat should not exceed 3 gm/kg/body
probably not benefit by the provision of 23 gm of
weight/day when administered at a rate of about 1
intravenous nitrogen. In such a patient, the best plan
ml/minute.
is to provide 15 to 18 gm by intravenous infusion and
Adverse reactions like fat embolism, local
make strenuous efforts to eliminate the sepsis, thereby
inflammation and difficulty in maintaining uniform
reducing the nitrogen output.
particle size of the emulsion have made the use
Protein hydrolysates are derived by the acid or
restricted. Soya bean oil is used for preparing fat
enzymatic hydrolysis of protein like casein or fibrin
emulsions.
and contain easily absorbable amino acids. These
hydrolysates contain approximately 50-60 percent
Combined Administration of
amino acids and 40-45 percent dipeptides and
Various Calorie Sources
tripeptides. Such solutions supply amino acids for
cellular growth, repair and healing. Since protein The relative merits of a mixture of carbohydrates and
hydrolysates are equal to 80 percent of whole protein, fats as calorie source in intravenous nutrition have
a 5 percent solution can yield approximately 170 long been debated. Recent studies suggest that fat in
calories per litre. conjunction with glucose may be more effective as an
energy source than equi-calorie amounts of glucose
alone. Fat emulsion can be infused simultaneously
Fat Emulsions for Intravenous Administration
with amino acids or dextrose solution by the use of a
Since fat has a high calorie density of 9 calories/gm, a 3-way connection (Figs 15.3A and B).
10 percent solution of fat emulsion will provide In summary, an intravenous solution must fulfil
approximately 900 calories per litre. several criteria. They are:
Intralipid is a fat emulsion made from fractionated 1. It must not contain fever-producing organisms
soya bean oil, using egg phospholipid as an emulsifier. 2. It must exert sufficient osmotic pressure
A B
Figs 15.3A and B: Simultaneous amino acid and fat infusion using 3-way connection
164 Gastrointestinal Surgery: Step by Step Management
3. The nutrient should be able to flow normally in Table 15.7: Indications and contraindications of TPN
the blood
Indications Contraindications
4. It must not alter the ionic equilibrium of blood
5. It must be stable for several weeks when stored in Malabsorption or “shortgut syndrome” Functional
Mechanical bowel obstruction accessible GI tract
cold. Severe acute pancreatitis Extremely poor
Humans can tolerate only 2.5 to 3.5 litres of solution Intestinal pseudo-obstruction prognosis
in 24 hours as larger amounts may overload the Shock and/or sepsis with intestinal
circulation and cause congestive cardiac failure. The ischemia
concentrations of nutrients have to be limited to 5 to Inability to use the GIT for at least 7 days
10 percent for peripheral venous infusions, as higher hydrolysate or pure ammonia. It provides about 5.25
concentrations will inflame the peripheral veins. to 6 gm of nitrogen equivalent to 32.5 to 37.5 gm of
Hence, one can supply only about 500-700 calories per protein and approximately 900 to 1000 calories per
day through the peripheral vein, which is only 1/3rd litre. The model formula is given in Table 15.8.
of calories required in a resting patient. Modifications of the standard adult formula are
Aims of Parenteral Hyperalimentation needed for treatment of patients with heart, liver and
kidney diseases, since they do not tolerate volume
The primary aim of total parenteral nutrition (TPN) overload, sodium, calcium, and potassium depending
is to provide carbohydrates, protein moieties, and on the nature of the disease.
other essential nutrients exclusively by vein for
prolonged periods of time, in quantities substantially Types of Parenteral Formulations
greater than the basal requirements, so that a positive
nitrogen balance and an anabolic state are achieved, The selection of nutrient solutions for different
during conditions usually associated with catabolic catabolic states largely centers on admixture of the
responses like high fever, multiple fractures and major substrates: carbohydrate, fat and protein.
severe infections. Sources of energy for patients undergoing surgical
In situations where the need for bypassing the stress should include both carbohydrates and lipids.
gastrointestinal tract occur, TPN becomes the only Glucose tolerance with TPN is optimal when 30-50
means of providing nutrition. All nutrients for infu- percent of the caloric source is derived from fat
sion are concentrated in a fluid volume equal to because maximum rate of glucose utilization is
normal daily water requirements and infused in a high approximately 15 gm/hr in a variety of pathophysio-
flow, large diameter central vein such as superior vena logical conditions. The lipids are used to meet essential
cava, which drains directly into the heart. The infusion fatty acid needs and to avoid the ill effects of glucose
should be given at a constant rate for 24 hours a day overload.
to permit maximal utilization and minimal excretion
Determination of Patient’s Caloric Needs
of the substrates. This has proved successful in an ever-
increasing number of clinical problems. In clinical practice and in the absence of sophisticated
techniques for measuring energy requirements, caloric
Indications for Total Parenteral Nutrition are
1. As a support in a starving patient as in patients Table 15.8: Model formula of adult
with obstructing lesions of GIT hyperalimentation solution
2. For the injured—septic patient as in septicemia 165 gm of anhydrous dextrose + 860 ml 5% dextrose in 5%
3. As an adjunct treatment in cancer. fibrin hydrolysate
Indications and contraindications for use of TPN Volume 1000 ml
are shown in Table 15.7. Dextrose 280 gm
Fibrin hydrolysate 43 gm
Composition of Nutrient Solutions
Nitrogen 6 gm
The nutrient mixture is a hypertonic solution about 6
Sodium 0.184 gm
times more concentrated than blood. It consists of 20
to 25 percent dextrose and 4-5 percent protein Potassium 0.585 gm
Chapter 15: Nutrition in the Perioperative Period 165
needs to meet basal metabolic expenditure (BME) are Table 15.10: Daily electrolyte requirements
calculated using the Harris-Benedict equations. These in nutrition schedules
predictive equations are based on height (H), weight Daily requirement Forms used in TPN
(W), age (A), and gender of normal adult men and solution
women. Sodium 70-100 mEq/day Chloride, acetate,
For men: BME (kcal/day) = 66.470 + 13.7516 (W) phosphate
+ 5.0033 (H) – 6.7550 (A) Potassium 70-100 mEq/day Chloride, acetate,
For women: BME (kcal/day) = 665.095 + 9.563 (W) phosphate
+ 1.8596 (H) – 4.6756 (A) Magnesium 15-20 mEq/day Sulphate
Since only glucose significantly suppresses
Calcium 10-20 mEq/day Gluconate
gluconeogenesis, parenteral glucose should constitute
Phosphate 20-30 mmol/day Sodium, potassium
the major caloric source in TPN and rest of the calories
should come from fat, whose use also meets the need
for essential fatty acid requirements. Thus, the Vitamins and Trace Elements
addition of fat to glucose TPN can achieve effective The recommended daily maintenance doses for
protein-sparing and anabolism. vitamins and trace elements are given in Table 15.11.
Protein calories are usually not included in calcu- It should be kept in mind that calculations of
lations of daily caloric intake. Protein requirements, nutrient needs are only general approximations.
such as amino acids for intravenous feeding, are the
same as those for normal oral feeding. It is recom- Energy and Nitrogen Needs
mended that 1.0 to 1.2 g/kg/day should be given for Energy derived from enteral or parenteral nutrients
maintenance, 1.5 to 2.0 g/kg/day for repletion and must include the caloric cost of several factors, like:
2.0 to 2.5 g/kg/day to patients with excessive losses, 1. Resting energy requirement
as shown in Table 15.9. 2. Increased energy requirement due to illnesses
(stress factor)
Water and Electrolyte Requirements 3. Energy for physical activity (energy factor).
The ideal amount of water required is 1 ml for each
calorie spent, i.e. 1 ml/kcal/24 hr. Special attention Table 15.11: Daily maintenance dose for
should be given for the factors which increase water vitamins and trace elements
and energy needs. They are: Element Oral Intravenous
1. Fever Thiamine 1.4 mg 3 mg/day
2. Sepsis Riboflavine 1.6 mg 3.6 mg/day
3. External losses like those from fistula. Nicotinic acid 18 mg 40 mg/day
Pyridoxine 2.2 mg 4 mg/day
The usual daily requirements of electrolytes during Pantothenic acid 7 mg 15 mg/day
enteral or parenteral nutrition are shown in Folate 400 mcg 400 mcg/day
Table 15.10. Cyanocobalamin 3 mcg 5 mcg/day
Ascorbic acid 60 mg 100 mg/day
Table 15.9: Usual recommendations for TPN Vitamin A 1000 mcg 2500 IU/day
Vitamin D 5 mcg 5 mcg/day
Maintenance Moderate stress Severe stress
Vitamin E 10 mg 50 mg/day
Calorie Vitamin K – 10 mg/week
requirements Iron 2 mg 2 mg
25-30 kcal/kg/day 30-40 kcal/kg/day 40-45 kcal/kg/day Zinc 15 mg 4-10 mg
Copper 2-3 mg 0.5 mg
Protein Chromium 0.05-0.2 mg 10-15 mcg
requirements Iodine 150 mcg 150 mcg
1.0-1.2 g/kg/day 1.5-2.0 g/kg/day 2.0-2.5 g/kg/day Fluorine 1.5-4 mg 0.4 mg
Nonprotein calorie Manganese 2.3 mg 0.15-0.8 mg
to nitrogen ratio Molybdenum 100 mcg 100-200 mcg
200-300 : 1 150 : 1 < 100 : 1 Selenium 20–50 mcg 40-120 mcg
166 Gastrointestinal Surgery: Step by Step Management
the body’s deposit of fat is stored in the subcutaneous are metabolized preferentially by muscle tissue. The
tissues and the rest is found mainly around the kidney, muscle itself provides alanine and glutamate which
in the omentum and the gut mesentery. The presence undergo gluconeogenesis in the liver and kidneys.
of cirrhosis may alter the normal metabolism of fat. The synthesis of plasma proteins is an important
After protein digestion, amino acids are absorbed function of the liver. Albumin is essential to maintain
into the splanchnic circulation. Glutamate, aspartate oncotic pressure and to carry unconjugated bilirubin
and glutamine are utilized by the intestine after and other poorly soluble substances. Transferrin and
absorption and the other amino acids pass to the liver. caeruloplasmin control the carriage of iron and copper,
In the liver they may be absorbed by hepatocytes, or and prealbumin and retinol-binding protein are the
pass into the general circulation. Leucine, isoleucine carriers of thyroxine and vitamin A. The immuno-
and valine, known as the branched-chain amino acids, globulins are also produced by the liver and have an
Chapter 15: Nutrition in the Perioperative Period 169
Specific Nutritional Problems in Hepatobiliary Disease
Problem Nutritional defects Solutions
Obstructive jaundice Anorexia Oral/enteral bile salts
Malabsorption of fats and fat-soluble vitamins Intravenous fats/vitamins
Intramuscular Vit K
Relief of obstruction
Cirrhosis/hepatocellular Glucose intolerance/insulin resistance Oral/enteral vegetable protein
failure Branched, chain amino acid deficiency Branched-chain supplements
Vitamin A, C, E, Folate deficiency Intravenous supplements
Infection/inflammation Increased metabolic rate Intravenous fat and dextrose
Glucose intolerance/insulin resistance Antibiotics/abscess drainage
Cancer Anorexia Oral/enteral supplements
Increased protein catabolism Intravenous feeding + albumin
important role to play in the maintenance of the 2. When maximum benefit is achieved, such as
immune response. healing of fistula, and when the patient is able to
eat 60 percent of his caloric requirements.
Indications for Stopping Nutritional Support 3. When the disease progresses to be terminal.
Treatment
Medical
The patient with generalized peritonitis needs
aggressive treatment, namely intravenous fluid
resuscitation and sometimes pulmonary support in
an intensive care unit, which is essential as part of
preparation for surgery. Administration of broad-
spectrum antibiotics is an important part of therapy.
Pharmacological support (e.g. dopamine) may be Fig. 17.1: Primary closure of minor leaks
required to improve the cardiac response and to
maintain systemic vascular resistance.
Surgical
The surgery consists of reopening of the abdomen,
careful and meticulous separation of the fibrinous
adhesions and release of pockets of fluid between the
loops of the bowel, best done by finger dissection and
every effort be made not to perforate the bowel. The
leak usually arises from the hole in one part of the
anastomosis, only rarely the entire anastomosis comes
apart.
The leak may be closed surgically in three ways:
1. primarily (in minor leaks with minimal peritonitis)
(Fig. 17.1)
A B
2. proximal stoma construction or exteriorization of
Figs 17.2A and B: Exteriorization of bowel ends
the ends (in patients with major or total disruptions
with gross peritonitis) (Figs 17.2A and B)
3. closure of distal stump and creation of a stoma
(when the distal bowel is short and cannot be
brought to the surface) (Fig. 17.3).
In all such cases, the skin closure needs special
attention. The deep layers may be closed with No. 1
polydiaxanone and the superficial layers are irrigated
with saline and packed with gauze (Figs 17.4A and B)
and the gauze changed 12 hourly until healthy
granulation is seen and may be closed under local
anesthesia at a later date.
In long-standing peritonitis, when approximation
becomes difficult, releasing incisions may be made
laterally on the anterior rectus sheath (Fig. 17.5).
In a very small number of cases, where conta-
mination of the abdominal cavity is extremely severe
or long-standing, formal laparostomy (Fig. 17.6 A)
with a zipper mesh (Fig. 17.6 B) may be necessary. Fig. 17.3: Closure of distal stump
Chapter 17: Management of Anastomotic Leakage and Intra-abdominal Sepsis 173
Following intra-abdominal toilet and the placement
of suction drains, the abdomen is packed with saline-
soaked gauze. The packs are changed 12 to 18 hourly
and formal closure done at a later date.
Infracolic Compartment
This is divided into right and left areas by the small
bowel mesentery. Further subdivision of each side into
paracolic gutters and lower quadrant areas broadly Fig. 17.8B: Sagittal section
divides the infracolic compartment into four
Intercommunication of
dependent areas.
Various Intraperitoneal Spaces
Pelvic Compartment Collections in each paracolic gutter communicate
This compartment lies in the pelvic cavity. freely with the pelvic cavity, but while the right
Chapter 17: Management of Anastomotic Leakage and Intra-abdominal Sepsis 175
paracolic collections may track upwards into the ment of psoas muscle outlines, small bowel
hepatorenal pouch, collections on the left side are obstruction pattern.
hindered by the phrenico-colic ligament, which is a Ultrasound is the preferred primary method of
transverse fold of peritoneum between the diaphragm imaging suspected intra-abdominal abscesses. It is a
and the splenic flexure of the colon. useful modality for therapeutic drainage procedures
CT imaging is more sensitive than ultrasound and
Symptoms and Signs is valuable in patients with multiple abscesses. Dis-
The patients who are septic, frequently manifest tended bowel, stomas, skin incisions and dressings can
intermittent high, spiking fevers with chills, diapho- interfere with ultrasound imaging and not with CT.
resis and tachycardia. Often these patients present Magnetic resonance imaging (MRI) and radio-
with ileus with nausea and vomiting, obstipation and nuclide imaging have limited roles. Although radio-
malaise. However, the symptoms and signs in patients nuclide imaging is sensitive, the specificity is low and
with intra-abdominal abscesses (Table 17.2) are often their usefulness is now largely limited to patients in
nonspecific, hence the surgical aphorism: ‘pus whom the abscesses are strongly suspected but other
somewhere, pus nowhere, pus under the diaphragm’. imaging modalities have failed to provide adequate
A high index of suspicion is advocated. diagnostic information.
Treatment
Investigations and Diagnosis
Medical
Plain radiographs, ultrasound and computed tomo-
graphy all have complimentary role to play in the If no obvious collections are identified, conservative
diagnosis and management of intra-abdominal treatment is adequate.
abscesses.
Plain radiographs may show: Surgical
• Chest radiograph Pleural effusion, basal atelectasis, If collections are detected, the infected fluid is aspi-
raised hemidiaphragm rated under ultrasound or CT guidance, microbiologic
• Abdominal radiograph Air-fluid levels, soft tissue studies done and appropriate broad-spectrum
mass, displacement of internal organs, enhance- antibiotics administered and a catheter left in place
Table 17.2: Intra-abdominal abscesses: common sites, causes and clinical presentation
Abscesses Postoperative causes Clinical presentation
Right and left subphrenic abscess Anastomotic leak following gastric, Lower chest pain, dyspnoea, shoulder pain
hepatobiliary or splenic surgery and persistent hiccoughs. Signs of atelec-
tasis or basal effusion on chest examination
Right and left subhepatic abscess Leaks from lower biliary tract and Abdominal pain
pancreatic surgery
Right paracolic abscess Leaks from 2nd part of duodenum, Diarrhoea, passage of mucus in stools
right colon and ileum
Left paracolic abscess Leaks from left colon and jejunum Diarrhoea, passage of mucus in stools
Right lower quadrant abscesses Leaks after appendicular surgery, Hip pain, flexion of the right hip and pain on
gastroduodenal surgery extension
Left lower quadrant abscess Leaks from left colon Diarrhoea, passage of mucus in stools, hip
pain, flexion of the left hip and pain on
extension
Pelvic abscess Leaks from appendicular and Diarrhoea, passage of mucus in stools
colorectal surgery
176 Gastrointestinal Surgery: Step by Step Management
for decompression. Cultures from these collections are Leaks Associated with an Enterocutaneous Fistula
primarily polymicrobial, involving both aerobic (e.g.
Postoperative gastrointestinal fistulae are a conse-
Escherichia coli) and anerobic bacteria (e.g. Bacteroides
quence of loss of integrity of one or more parts of the
fragilis).
intestines. Enterocutaneous fistulae occur in the
Single collections amenable for aspiration by
following sequence:
radiological guidance may be aspirated. If the
• Dehiscence of anastomosis:
drainage is not satisfactory, they may be drained by
→ Localized infection
open surgery by extraperitoneal approach wherever
→ Small abscess formation
possible. Multiple collections, however, need to be
→ Burrowing of septic focus into a contiguous
drained by peritoneal re-exploration.
structure or surface
During re-exploration, it is essential to:
→ Fistula formation.
• Establish that there are no points of obstructions
• In some cases of anastomotic leak, the surrounding
distal to the fistulous opening.
inflammatory reaction is so marked that the leak-
• Adequate drainage of the abscesses and irrigation
age is confined and a generalized peritonitis does
• Sampling of collection fluids for cultures
not occur. The patient develops pain and swelling
• Leaving drains in place for dependent drainage
in the area of leakage, associated with a raised
from supine position
temperature and constitutional disturbance. The
• Avoidance of fresh GI anastomoses
remaining part of the abdomen remains soft
• Proximal diversions where needed.
although there may be a degree of intestinal
Laparoscopic drainage of certain abscesses may be
obstruction, but normal bowel function may
an alternative to open surgical drainage and are useful
continue. Eventually, a fistula presents through the
in liver, appendiceal, tubo-ovarian and pelvic abs-
wound or drain site with the discharge of pus, gas
cesses.
and enteric content, usually followed by relief of
Appropriate broad-spectrum antibiotic therapy is
constitutional and obstructive symptoms.
an important adjunct in the overall management stra-
tegy of these patients. The Principles of Surgical Management of
Note Enterocutaneous Fistulae Consist of
• In the early postoperative period of a patient who
• Management of sepsis
has undergone gastrointestinal surgery, when the
• Management of nutrition
patients are febrile, in the absence of thrombo-
• Management of fistula.
phlebitis, infection of the urine and lungs, intra-
abdominal abscess needs to be excluded. Management of Sepsis
• If the patient does not improve after drainage of
Appropriate broad-spectrum antibiotic therapy is an
abscess, and significant clinical improvement is not
important adjunct in the overall management strategy
seen in 24 to 48 hours, another focus of infection or
of these patients.
organ dysfunction should be considered.
These patients present with low-grade swinging Management of Nutrition
pyrexia and when the abscess is superficial and close
to the surface, can cause erythema, edema and loca- Total parenteral nutrition (TPN) is essential in patients
lized tenderness. Supplementary investigations (e.g. in the management of gastrointestinal fistulae,
ultrasonography, computed tomography and isotope especially the high output fistulae.
scanning) are useful in defining the anatomy and
localizing occult collections of pus. The abscess may
Management of Fistula
be drained with the help of ultrasonography or
computed tomography. When the drainage is incomp- The management of fistula is exactly the same as that
lete, a formal laparotomy with placement of drains is of management of created GI stomas (see Chapter 19–
justifiable. Stoma Care).
18
Management of Postoperative
Gastrointestinal Fistulae
DEFINITION
A fistula is an abnormal communication or tract
between two epithelial surfaces.
A gastrointestinal fistula may communicate with
two organs of the gastrointestinal system, or with
organs of other system or the skin surface. They can
be classified in many ways.
CLASSIFICATION
Gastrointestinal fistulae can be classified as:
1. Internal (connecting two organs of the GI system
or different systems)—Fig. 18.1A.
Figs 18.1A and B: (A) Internal fistula, (B) External fistula
2. External (connecting the gut, directly or indirectly,
with the body surface)—Fig. 18.1B.
Gastrointestinal fistulae can be further classified
as:
1. Simple (communication with the other viscus or the
body surface directly as a single tract)—Fig. 18.2A.
2. Complicated (many tracks communicating with
more than one viscus, or drainage into an asso-
ciated abscess cavity)—Fig. 18.2B.
Gastrointestinal fistulae can be classified further
as:
1. End fistulae (those arising from a hollow viscus
where there is no further gastrointestinal conti-
nuity)—Fig. 18.3A.
2. Lateral fistulae (those originating in partial defects
of the GI tract)—Fig. 18.3B Figs 18.2A and B: (A) Simple fistula, (B) Complex fistula
Treatment
These basic principles and stages of therapy can be
applied to nearly all GI fistulae to avert and treat the
metabolic complications associated with fistulae
which play a major role in the patient’s mortality.
Tarzani et al outlines seven general tasks in the
treatment of fistulae. They are as follows:
1. Nothing by mouth, total bowel rest
2. Place a nasogastric tube
3. Begin treatment with a H2 antagonist
4. Protect the skin
Figs 18.3A and B: (A) End fistula, (B) Lateral fistula 5. If sepsis, such as diffuse peritonitis or an abscess
exist, the patient should be taken to the operating
Factors associated with non-healing fistulae room for drainage
include (FRIEND): 6. Correction of fluid, electrolyte, and nutritional
a. Foreign body imbalances
b. Radiation 7. Administration of broad-spectrum antibiotics.
c. Inflammation/infection/inflammatory bowel The classification of gastrointestinal fistulae has its
disease own significance, as shown in Table 18.1.
d. Epithelialization
e. Neoplasm POSTOPERATIVE
f. Distal obstruction. ENTEROCUTANEOUS FISTULAE
Investigations and Diagnosis done at a later date. If this results in a stricture, the
esophagus may have to be resected with stomach or
Recognizing these fistulae requires a high index of
colon transplantation.
clinical suspicion.
GASTROCUTANEOUS AND
Radiography
DUODENOCUTANEOUS FISTULAE
Plain film They show an increased distance between
Etiology
the trachea and the spine, mediastinal emphysema,
widening of the mediastinum, pleural effusion or Gastric and duodenal fistulae are iatrogenic in 70 to
pneumothorax. 85 percent of cases, mostly after gastric, duodenal and
biliary surgery. After surgery for benign disease, the
Contrast study Thin barium may reveal evidence of
incidence is 1 to 3 percent and after surgery for cancer,
perforation or fistula (when esophago-tracheo-
it is about 15 percent. Other less common causes of
bronchial fistula is suspected contrast studies are
gastrocutaneous and duodenocutaneous fistulae are
withheld, but if it is really warranted, thin barium is
trauma, inflammatory diseases, foreign bodies,
preferred*).
neoplasms and Crohn’s disease.
Note: *Barium is preferred to aqueous contrasts, as Duodenal fistulae carry a mortality rate of about 3
small amount of aspirated barium into the bronchial percent. End duodenal stump fistulae close in about
tree clears quickly, whereas since aqueous iodinated 85 percent and lateral duodenal fistulae close in about
contrast has an osmolarity nearly six times that of 30 to 40 percent.
serum, can produce acute pulmonary edema when it
enters the bronchial tree, and also provides inferior Clinical Presentation
mucosal coating and lower radiographic density.
They have a sluggish postoperative course, not
Thoracic esophago-cutaneous fistulae are rare and progressing as expected and present with severe
they are more serious and life threatening leading to abdominal pain, tenderness, fever and/or
septicemia and multiple organ failure, as they leak into leucocytosis. The drain exit wound or the main wound
the pleural cavity and produce empyema. may show signs of inflammation and look cellulitic.
Within a day of this presentation, there will be a
Treatment copious discharge of frank enteric contents in the
Medical wound or on the dressing.
Clinical Presentation
They have a sluggish postoperative course, not pro-
gressing as expected and present with severe abdo-
minal pain, tenderness, fever and/or leucocytosis. The
drain exit wound or the main wound may show signs
of inflammation and look cellulitic. Within a day of Fig. 18.7: Fistulogram showing the abscess cavity
this presentation, there will be a copious discharge of
frank enteric contents in the wound or on the dressing. Correction of nutritional imbalances
• Correction of electrolyte abnormalities is important,
Complications
as the volume of small intestinal secretions is large,
Internal fistulae may remain asymptomatic when they although the fistula output is usually only a fraction
involve adjacent bowel loops and the bypassed of this amount. The electrolyte content of the
segment is short. Chronic recurrent urinary tract infec- effluent is replaced volume for volume with
tions may be the only complication with enterovesical normal saline to approximate the sodium and chlo-
fistulae. External fistulae present with the following ride content of small intestinal fluid.
complications: • Correction of malnutrition is done by total parenteral
a. Fluid and electrolyte abnormalities nutrition (TPN). Higher output fistulae may close
b. Malnutrition more quickly and conveniently with parenteral
c. Sepsis. nutrition and having the patient avoid eating.
Surgical
Localized collections of pus should be drained. Fig. 18.8: Abscess in the fistula
Appliances may have to be used to collect the effluents.
The skin around the fistula needs special attention.
Skin care management (see Chapter 19—Stoma
Care). The effects of continuous moisture on the skin
and the degree of chemical irritation of effluent
(depending on where the fistula originated in the GI
tract) can severely compromise skin integrity. The
draining fistulae cause odor, wetness, burning pain
and discomfort secondary to skin erosion (Figs 18.12A
and B). The goals of skin care management are to
maintain skin integrity and to contain the effluent.
The following are to be assessed in the skin care:
1. Origin of the fistula
2. Nature of the effluent
Fig. 18.9: Complete disruption of bowel
3. Condition of the skin
4. Location of the fistula opening.
Pouches Many different pouches are available which
offer a variety of features for pouching GI fistulae.
They vary in size to accommodate small and large
perifistular surface areas. Ostomy pouches are availa-
ble in one (Fig. 18.13) or two (Figs 18.14A and B) piece
designs with either a drainable clip closure of
urostomy type closure. One-piece pouch systems are
more flexible than the two-piece systems because the
attachment ring is eliminated (details in Chapter 19—
Stoma Care).
Skin barriers They come in a variety of forms—solid
wafers (pectin based), powder (Figs 18.15) (pectin or Fig. 18.10: Distal obstruction
karaya based), paste (pectin based, Fig. 18.16), spray
and wipes (alcohol based), ointments and creams (zinc Immediate operation is reserved only for the
or petroleum based). They give second skin protection patients with hemorrhage or intra-abdominal abscess
from faecal drainage and can withstand the effects of with uncontrolled septicemia.
effluent for a variable period of time (details in Chapter Elective surgery is indicated only to a small
19—Stoma Care). percentage of patients who do not improve on medical
Chapter 18: Management of Postoperative Gastrointestinal Fistulae 185
A A
B B
Figs 18.12A and B: Severe skin excoriation Figs 18.14A and B: Two-piece ileostomy pouch
186 Gastrointestinal Surgery: Step by Step Management
COLONIC FISTULAE
Majority of colonic fistulae are iatrogenic and the rest
15 percent is due to diseases like cancer. Radiation
therapy before surgery increases the risk of post-
operative fistulae. During surgery, if the colonic resec-
tion is inadequate and the anastomotic site harbors
tumor cells, they predispose to fistula formation.
Colonic fistulae are uncommon. They may be exter-
nal or internal.
Clinical Presentation
Patients with colocutaneous fistulae present with
fever, abdominal mass, obstruction, rectal bleeding
and peritonitis. They have obvious faeculent discharge
through the drain site or through the main wound.
Normal saline is used volume for volume to replace the and need no treatment. However, fistulous connec-
fluid losses. tions between the bile duct and other organs like small
bowel or duodenum when they cause recurrent
BILIARY FISTULAE attacks of ascending cholangitis, do require surgical
External Biliary Fistulae corrections.
External biliary fistulae are primarily postoperative
PANCREATIC FISTULAE
excepting a few which follow trauma such as stab
injuries, gunshot wounds, and road traffic accidents. Pancreatic fistulae occur when the pancreatic duct or
Their presence nearly always indicates damage to a one of its branches is disrupted by surgery, direct
duct associated with distal obstruction to normal trauma and as a result of inflammatory disease. They
biliary flow. may communicate externally with the skin or less
frequently, internally with a variety of hollow organs
Clinical Presentation or a body cavity. The treatment for pancreatic fistulae
The patients exhibit leakage of bile-stained drainage has largely been conservative, with operation being
fluid through the drain site after upper gut surgery or reserved for those with prolonged outputs or life-
hepatopancreaticobiliary surgery with fever, abdo- threatening complications.
minal pain and leucocytosis in their early post- Pancreatic fistulae are classified as either internal
operative period. or external (see Table 18.2).
Non-drainable/Drainable Bags
Non-drainable bags are used only by colostomates
and require changing with each bowel evacuation;
they are not suitable for ileostomates. Drainable bags
can be emptied, without being detached, by means of
a plastic clip or screw-type insert which closes on
opening at the lower end of the bag.
Fitting and Changing an Appliance Fig. 19.3: Patient with a disposable appliance
E F
Management is by Management is by
• Cleaning and drying the skin • Application of stomahesive
• Applying additional hypoallergenic plaster to the • Platform dressings—a layer of lint is placed over
edges. the treated skin and completely covered by adhe-
sive strapping attached to healthy skin. This
Problems of the Skin platform is then used as a base for attachment of
Skin problems are much more common in the appliance in the usual manner. This will proba-
ileostomates than in colostomates, as an adhesive bly stay secure for about 48 hours, and healing
appliance is almost always used, the effluent is more usually occurs within a few days.
fluid and it contains chemical irritants and digestive
Problems of Stoma
enzymes, which rapidly damage the skin (Fig. 19.7).
In all cases, skin lesions are largely preventable. Ulceration of Stoma
Contamination
Contamination of the skin usually results from contact
of effluent with the peristomal area. This may irritate,
digest or infect the skin and can loosen adhesion and
allow spread.
Management is by:
• Cleaning and drying the skin
• Applying preparations like stomahesive
• Occasionally, use corticosteroids and antibiotic
ointments.
Sweat Rash
Sweat rash can occur under the plaster or on the skin
in contact with the bag, rubber or plastic. Fig. 19.7: Parastomal ulceration
Chapter 19: Stoma Care 195
Disadvantages of a Stoma each day with liberal amounts of sodium. In hot
climates, potassium supplements should be added.
Diet The colostomates may have to avoid foods which
Trauma The stomates are exposed to the risk of direct
may obstruct or cause fluid stools. Likewise, odor-
trauma to the stoma, but many of them are involved
producing substances like, fish, onions, and garlic may
with many active sports without any difficulty. The
have to be avoided. Flatus can be troublesome and is
trauma occurs when repeated irrigations are made and
usually ascribed to legumes, and they may have to be
also when finger insertion is made regularly. Both
avoided. Only trial and error can provide accurate
should be avoided.
information of diet for each individual.
Psychosocial problems All but a few ileostomates
Fluid and electrolytes Colostomates do not usually find life with a stoma full and satisfactory. Probably,
experience excessive loss of fluid and electrolytes. In only about 5 percent find it difficult to accept a stoma,
the first week after ileostomy, however, there is a loss and this may affect their social relationships, sexual
of about 1 litre of fluid and 100 to 160 mmol/litre relationships and marriage.
(mEq) of sodium; but after 2 to 3 weeks, these amounts Drugs Drugs are rarely required for control of a stoma
are usually halved. This fall is due to a decrease in if sensible diet is taken. The drug assistance may be
ileal motility, which facilitates increased absorption. needed to relieve constipation, which is usually a mild
In patients who have bowel resections, the loss is much laxative. Purgatives should be avoided. It is better to
more and continuous monitoring is necessary. The keep the colostomates slightly constipated to manage
ileostomates should consume at least 2 litres of fluid their bags.
20
Pain Control in
Gastrointestinal Surgery
Pain is not a simple sensation but a complex pheno- vein thrombosis, chest infection and pressure ulcer.
menon having both a cognitive (physical) and an effec- With severe pain, activity of the sympathetic nervous
tive (emotional) component. The aim of pain assess- system and the neuroendocrine “stress response”
ment is to identify all the factors that affect the patient’s cause platelet activation, changes in regional blood
perception of pain. In spite of the availability of several flow and stress on the heart. These can lead to
classifications of pain, it is classified as acute and impaired wound healing and myocardial ischemia.
chronic.
MANAGEMENT OF PAIN
ACUTE PAIN
Oral administration of analgesics may not always be
Acute pain usually has a brief duration and has a appropriate and consideration should be given to
protective function. It is normally associated with other routes of administrations e.g., rectal, parenteral
injury or disease and is expected to subside when the and sublingual, and transdermal.
injury or disease process has resolved.
PHARMACOLOGICAL TECHNIQUES
CHRONIC PAIN
Opioid Analgesics
Chronic pain is usually prolonged and defined as a
Opioids are the first line treatment for pain that follows
pain that exists for more than 3 months. It is often
major surgery. This should be titrated to achieve pain
associated with major changes in personality, lifestyle
relief while minimizing any unwanted side effects. The
and functional ability.
commonly used opioids are morphine, diamorphine
and fentanyl, administered through intravenous,
PAIN ASSESSMENT FOR SURGICAL PATIENTS
epidural, subcutaneous, intramuscular or oral routes.
For surgical pain to be controlled effectively, pain must Low concentrations of local anesthetics and opioids
be assessed regularly and systematically. The process can be infused directly into the epidural space using
of pain assessment begins before surgery and a catheter. Though intramuscular route is used for
continues through discharge. The assessment includes administering analgesics in India, this is less preferred
consideration of factors such as anxiety, pre-existing to PCA and epidural analgesia in other countries. Oral
pain, location and intensity of pain. opioids are used less frequently in the immediate
postoperative period because most patients are nil by
Need for Effective Pain Control mouth for a period of time, especially after
There are several reasons why pain needs to be well gastrointestinal surgery.
controlled following surgery. Uncontrolled pain can
Patient-controlled Analgesia
lead to increased anxiety and muscle tension which
further exacerbate pain, which can delay the recovery Since the use of opioids as continuous intravenous
process by hindering mobilization and deep breathing, infusions need monitoring the potential risk of
which increases the risk of patient developing deep respiratory depression, patient-controlled analgesia
Chapter 20: Pain Control in Gastrointestinal Surgery 197
(PCA) is a safer alternative in the ward environment.
With PCA, patients self-administer intermittent doses
of opioids, by using an infusion pump and timing
device. When in pain, the patient presses a button
connected to the pump and set dose of opioid is deli-
vered to the patient. Because the PCA pump is desi-
gned to deliver small frequent doses of analgesia at
timed intervals, the risk of respiratory depression is
less than with continuous infusion. Tramadol tends
to be well tolerated as an alternative to morphine. PCA
pumps are typically syringe pumps (Fig. 20.1), in
which the syringe pump forces down on the syringe
piston, collapsing the syringe at a preset rate, but the
distinguishing feature is the ability of the pump to Fig. 20.1: Pump device
deliver doses on demand, which occurs when the
to patient care, they do not replace the need for good
patient pushes a button.
nursing assessment and intervention.
Advantages of Syringe Drivers Non-opioid Analgesics
1. It avoids the necessity of intermittent injections The use of non-opioid analgesics, such as paracetamol
2. Mixtures of drugs can be administered or combinations, is recommended for minor surgical
3. Infusion timing is accurate procedures or when the pain following major surgery
4. Rate can be adjusted as per the patient’s needs begins to subside. Nonsteroidal anti-inflammatory
Infusion options of a PCA pump are usually cate- drugs (NSAIDs) have been shown to provide better
gorized into three types: pain relief than paracetamol combinations for acute
1. Basal A ‘baseline’ rate can be accompanied by inter- pain, keeping in mind the side effects like coagulation
mittent doses requested by patients. This aims to problems, renal impairment and gastrointestinal
achieve pain relief with minimal medication, but disturbances.
not to achieve a totally pain-free state.
2. Continuous Designed for the patient who needs Breakthrough Analgesia
maximum pain relief without the option of demand The analgesics are given at regular intervals to keep
dosing, e.g. epidural. the patient pain-free: ‘stat’, ‘rescue’ or ‘breakthrough’
3. Demand Drug delivered by intermittent infusion doses of analgesia are given if the background dose
when button is pushed and can be used alone or of the drug is not sufficient to adequately control pain
supplemented by the basal rate. Doses can be levels and an additional dose is required. There should
limited by a designated maximum amount. not be a time limit on this type of prescription because
Careful calculation and control of flow rates are it would need to be given when and if the patient
essential as delivery of fluids and medications may demonstrated any sign of discomfort or pain.
be critical due to any of the factors mentioned above. Breakthrough doses are calculated on a 4-hour
There are many infusion control devices available to equivalence; for example, if a patient was prescribed
assist the nurse in this task, ranging from the simple 40 mg of an analgesic, the equivalent breakthrough
to the complex. A knowledge of these systems and dose would be 10 mg. If several breakthrough doses
their application is necessary to ensure appropriate are required within a 24-hour period, then the
choice. Although these devices provide a valuable aid background analgesia would have to be increased.
21
Bowel Care
PHYSIOLOGY OF FAECAL EVACUATION If these natural reflexes are inhibited on a regular basis,
they are eventually suppressed and reflex defaecation
The main events of digestion and absorption occur in
is inhibited. This results in severe constipation.
the small intestine. Movement through the small
The rectum is very sensitive to rises in pressure,
bowel is divided into segmentation and peristalsis,
even of 2 to 3 mm Hg, and distention will cause a peri-
the former mixes the intestinal contents and brings neal sensation with a consequent desire to defaecate.
particles of food into contact with the mucosa for A coordinated reflex empties the bowel from mid-
absorption. Intestinal contents usually remain in the transverse colon to the anus. During this phase, the
small bowel for 3-5 hours and it is moved by peristaltic diaphragm, abdominal and levator ani muscles
action, controlled by the autonomic nervous system. contract and glottis closes. Waves of peristalsis occur
Absorption of nutrients, electrolytes and water occur in the distal colon and the anal sphincter relaxes,
by diffusion, facilitated diffusion, osmosis and active allowing the evacuation of faeces.
transport. The constipated individual has his colon loaded
From the ileocaecal sphincter to the anus, the colon with faecal matter and is a cause of concern when sur-
is approximately 1.5 meters in length. Its main function gery of his gastrointestinal system is contemplated,
is to eliminate the waste products of digestion by the especially of the colon itself.
propulsion of faeces towards the anus. In addition, it The colon needs to be kept reasonably empty just before
produces mucus to lubricate the faecal mass, thus surgery and absolutely empty when it is colonic surgery.
aiding its expulsion. Faeces consist of the unabsorbed
end products of digestion, bile pigments, cellulose, LAXATIVES
bacteria, epithelial cells, mucus and some inorganic
material. They are semisolid in consistency and Definition
contain about 70 percent water. Laxatives are defined as drugs which loosen bowel
The movement of faeces through the colon towards contents and encourage evacuation. The types of
the anus is by peristaltic action. Three to four times a laxatives available are given in Table 21.1.
day there is a strong peristaltic wave. The wave begins Stimulant laxatives are administered as a routine
at the middle of the transverse colon and quickly for all gastrointestinal surgeries in the previous night
drives the colonic contents into the rectum, gastrocolic
reflex initiated by the food in the stomach. The colon
Table 21.1: Laxatives
absorbs 2 litres of water in 24 hours. If faeces are not
Type of Example Brand names and
expelled, they will therefore, gradually become hard laxative sources
due to dehydration and will be difficult to expel. If Stool Liquid paraffin Agarol, Cremaffin
there is insufficient roughage (fibre) in the faeces, softeners
colonic stasis occurs. This leads to continued water Osmotic Sodium, Potassium Milk of magnesia
absorption and the faeces will harden still further. agents and Magnesium salts
Lactulose Looz, Duphalac
Faeces normally remain in the sigmoid colon until
Stimulant Bisacodyl Dulcolax
the stimulus to defaecate occurs. This stimulus varies laxatives Sodium picosulphate Colvac
in individuals according to habit, which can be cont- Glycerin Glycerol
rolled by conscious effort. This stimulus disappears Bulk Dietary fibre Bran, Fybogel (isaphgula)
in a few minutes and does not return for several hours. producers Methyl cellulose
Chapter 21: Bowel Care 199
to keep the rectum empty, which will be of use in the Three types of retention enemas are in common use:
postoperative period. • Arachis oil (may be obtained in a single-disposable
pack)
ENEMAS • Olive oil
• Prednisolone
Definition Enemas containing arachis oil and olive oil will
An enema is the introduction into the rectum or lower soften and lubricate impacted faeces. These work by
colon a stream of fluid for the purpose of producing a penetrating faeces, increasing the bulk and soften the
bowel action or instilling medication. stools. They work most effectively when warmed, to
Enemas may be prescribed to clean the lower bowel body temperature, and retained for as long as possible.
before surgery, but it is contraindicated under the
following circumstances: Suppositories
1. In paralytic ileus
Definition A suppository is a solid or semisolid pellet
2. In colonic obstruction
introduced into the anal canal for evacuation or
3. Where the administration of tap water or soap and
medicinal purposes.
water enemas may cause circulatory overload,
Lubricant suppositories should be inserted directly
mucosal damage and necrosis, hyperkalemia and
into the faeces and allowed to dissolve to enable
cardiac arrhythmias
softening of the faecal mass. However, stimulant
4. Where the administration of large amounts of fluid
types, such as bisacodyl (Dulcolax), and medicinal
high into the colon may cause perforation and
suppositories must come into contact with the mucous
hemorrhage
membrane of the rectum if they are to be effective
5. Following gastrointestinal surgery, where suture
(Figs 21.1A and B). Other types, such as sodium
lines may get ruptured
bicarbonate and anhydrous sodium acid phosphate,
6. Hypertonic saline enemas in patients with inflam-
matory or ulcerative conditions of the large colon
7. Perforation of the large bowel.
Types of Enemas
Evacuant Enemas
Definition An evacuant enema is a solution intro-
duced into the rectum or lower colon with the
intention of its being expelled, along with faecal matter
and flatus, within a few minutes.
The following solutions are used:
a. Phosphate enemas with standard or long rectal A
tubes in single dose disposable packs
b. Dioctyl sodium sulphosuccinate 0.1 percent,
sorbitol 25 percent in single dose disposable packs
c. Sodium citrate 450 mg, sodium alkylsulphoacetate
45 mg, sorbic acid 5 mg in single dose disposable
packs
Enemas containing Dioctyl sodium sulpho-
succinate lubricate and soften impacted faeces.
Retention Enemas
Definition A retention enema is a solution introduced B
into the rectum or lower colon with the intention of Figs 21.1A and B: Insertion of suppositories (A) Laxative
being retained for a specified period of time. suppository (B) Medicinal suppository
200 Gastrointestinal Surgery: Step by Step Management