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Gastrointestinal Surgery

Step by Step Management


Gastrointestinal Surgery
Step by Step Management

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
Alwarpet
Chennai
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.

First Edition: 2005


ISBN 81-8061-429-8
Typeset at JPBMP typesetting unit
Printed at Replika Press Pvt Ltd., 310 EPIP, HSIDC, Kundli, Sonepat (Haryana)
To
My grandparents Mrs and Dr M Devaji Rao,
Mrs and Dr CN Venkoba Rao
My parents Mrs Uma Bai and Dr D Siva Rao
My wife Kalpana, daughters Bhavna and Kirthana
Preface
The purpose of this book is to present a concise but in-depth information of the various problems a surgeon
faces in choosing and preparing a patient for surgery and also managing the various complications that follow
after surgery of the gastrointestinal system. Suffice it to say, careful preoperative preparation, emphasis on
rigid intraoperative techniques, and thorough postoperative support will lessen the incidence of complications
following gastrointestinal surgery. To have a complete and accurate surgical technique, proper and systematic
training is necessary.
It is very much understood that the time a postgraduate gets to spend in the wards with his or her patients
is very little, the period of training is short. During this short period he hardly sees the complications in his
own patients, especially the delayed ones. Once out of the training and is independent, and encounters the
complications, he finds it difficult to manage as it is the first encounter, and also feels embarrassed to take the
help of the senior colleagues or teachers. The management is thus by intuition. This habit may increase the
morbidity and mortality of the patients. This book takes this into consideration and the complications are
listed as early and late in order of occurrence of the postoperative period and also the organ concerned, which
should act as a ready reckoner.
Even today, in spite of many advances in research and techniques, conventional tubes and drains and
suture materials form an integral part of good surgery. Separate chapters are made detailing them, which
should be certainly useful in increasing the safety of the operated patient.
Once complicated, the patients go through a very morbid and turbulent period, especially those whose
nutritional status is poor or uncorrected, more so in those who undergo emergency surgery. Cancer patients
are no less in this aspect. Separate chapters are devoted to perioperative nutrition.
Management of gastrointestinal surgery is never complete without knowing about the stomata and the
fistulae. Bowel care is another avenue, which needs to be understood for good and successful surgery. Detailed
account is given for these in separate chapters.
There are occasions when other specialists like the urologists and gynaecologists inadvertently end up
doing gastrointestinal surgery to manage a necessity or to correct iatrogenic injuries of the gastrointestinal
tract, and may have the necessity to manage them postoperatively. In such situations, this manual will be of
great use, as the surgeons themselves can manage without involving any other gastrointestinal surgeon at
least for a short time, which may help to maintain the privacy and secrecy of the situation.
The topic of complications does not have a high popularity within the surgical community and books
devoted exclusively to this topic are not many. By going back and forth between the chapters, I am sure the
user will be able to manage his or her patients before and after surgery, very efficiently. It is hoped that this
volume will serve as a carry on hand manual and also act as a stimulus to those interested in giving top-class
surgicare towards the safety of their patients, reducing the morbidity and mortality.

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

2. Sutures and Needles in Gastrointestinal Surgery 2

3. Staplers in Gastrointestinal Surgery 8

4. Tubes and Drains in Gastrointestinal Surgery 14

5. Preoperative Preparation in Gastrointestinal Surgery (General) 25

6. Postoperative Management in Gastrointestinal Surgery (General) 32

7. Pre- and Postoperative Management in Foregut


(Oesophagus, Stomach and Duodenum) Surgery 37

8. Pre- and Postoperative Management in Midgut (Small Intestine) Surgery 73

9. Pre- and Postoperative Management in Hindgut (Colon, Rectum and Anus) Surgery 96

10. Pre- and Postoperative Management in Hepatic Surgery 120

11. Pre- and Postoperative Management in Biliary Surgery 129

12. Pre- and Postoperative Management in Pancreatic Surgery 140

13. Pre- and Postoperative Management in Splenic Surgery 149

14. Pre- and Postoperative Management in Laparoscopic Surgery 153

15. Nutrition in Perioperative Period 156

16. Nutrition in Cancer Patients 170

17. Surgical Management of Anastomotic Leakage and Intra-abdominal Sepsis 171

18. Management of Postoperative Gastrointestinal Fistulae 177

19. Stoma Care 190

20. Pain Control in Gastrointestinal Surgery 196

21. Bowel Care 198

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

Table 2.1: Properties of suture materials


Type Material Source Tissue Retention of tensile Potential Potential
response strength advantages disadvantages
Absorbable Catgut Sheep Inflammation Plain—2/3 lost Cheap Unpredictable
submucosa more marked in 5-6 days loss of tensile
with plain than Chromic-2/3 lost strength and
chromic in 10-15 days potentiation of
sepsis
Absorbable Polyglycolic Synthetic Slight-muted Total loss in 30 days Predictable loss High cost
acid polymer inflammatory 50% loss in 5 days, of strength; less
Polyglactin reaction total loss in 14 days, potentiation
(Vicryl) absorbed in 35-42 days of sepsis

Polydioxanone 20% loss in 28 days,


(PDS) absorbed in 180 days

Polygle- 50% loss in 7 days,


caprone 80% loss in 14 days,
(Monocryl) absorbed in 90-120 days
Non- Linen Vegetable Moderate ½ lost in 3-6 months Cheap Variable perfor-
absorbable inflammation mance, poten-
tiation of sepsis
Non- Cotton Cotton seed Moderate ½ lost in 3-6 months Cheap Variable perfor-
absorbable plant inflammation mance, poten-
tiation of sepsis
Non- Silk Silkworm Mild to ½ lost in 2-12 months Fairly cheap Potentiation of
absorbable moderate sepsis
inflammation
Non- Nylon Synthetic Minimal 2/3 strength retained Potentiation of Knot slippage
absorbable polyamide up to 6 months sepsis less in
monofilament
Non- Poly- Synthetic Minimal 2/3 strength retained Low sepsis rate High cost,
absorbable propylene up to 6 months Knot slippage
Non- Coated Synthetic Minimal to 2/3 strength retained Low sepsis rate High cost,
absorbable polyester moderate up to 6 months Knot slippage
Non- Polytetro- Synthetic Minimal 2/3 strength retained Minimal suture High cost
absorbable fluroethylene up to 6 months line bleeding
(PTFE)
Non- Stainless steel Synthetic Virtually nil Fatigue fracture at Inert Troublesome
absorbable 1 year knots, severe
wound pain

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

there is a foreign body, which can harbor organisms. Handling


Catgut, braided nylon and silk increase sepsis rate
An ideal suture should handle in a friendly way,
significantly, whereas polypropylene and polyglycolic
running smoothly through the tissue and not catching.
acid appear indifferent. There is some evidence that
The knots made by any suture should bend down
polyglycolic acid sutures actually retain their strength
easily and be severe with a minimum number of
longer in the presence of bacterial infection. There
appears some relationship between the configuration throws. Optimal knotting technique thus depends on
of a suture (multi or monofilament) and its propensity the suture materials in use and surgeons should vary
to promote wound infection. their approach accordingly.
Two factors could be important: Knotting
1. Bacterial adherence to the surface of a suture
2. The ability of bacteria to gain access to the The ideal knot for synthetic materials is a double throw
interstices of a multifilament material. followed by a single throw followed by a third double
throw. Additional throws on the knot compound only the
Sutures and Tissue Response foreign body reaction without significant benefit. The
All sutures produce some tissue response. Three smallest size of suture material which will hold the tissues
components of this can be identified: in apposition without breaking should be used and the
1. Reaction to injury consequent upon the passage of correct knot should be tied to maintain security. The
material through tissue, which is determined by the selection of appropriate size is necessary (Table 2.2).
physical properties of the sutures, e.g., braided or It should be remembered that all suture materials
twisted material will do more harm than show a difference between the knot pull strength and
monofilaments. the straight pull strength. When a knot is placed on a
2. The inflammatory response evoked by the foreign body. suture material, the strength at the knot can be 10-40
FB reaction is greatest for natural materials (catgut, percent weaker, depending on the material. When a
collagen, silk, linen and cotton) and more marked suture fails, it always breaks at the knot, some damage been
with braided than with monofilaments. inflicted on the material and it is commonly iatrogenic, due
3. The inflammatory reaction that accompanies the to rough handling, defective surgical instruments, and
destruction of biodegradable sutures. This is severe inadvertent crushing.
with plain catgut, marked with chromic catgut and
Table 2.2: Metric gauging of suture material
much reduced though not entirely absent with the
synthetic materials such as polyglycolic acid as Gauge
they undergo hydrolysis rather than proteolytic Metric Catgut Non-absorbables/
digestion. It is this property that makes them number Synthetic absorbables
attractive as a substitute for catgut. 0.1 — —
It is interesting to note that no truly allergenic reac- 0.2 — 10/0
0.3 — 9/0
tion has been seen to suture materials in spite of the
0.3 — 8/0 Virgin silk
fact that the natural materials must contain potentially 0.4 — 8/0
antigenic substance. 0.5 8/0 7/0
0.7 7/0 6/0
Mechanical Properties 1 6/0 5/0
The suture materials can be classified into four broad 1.5 5/0 4/0
2 4/0 3/0
groups based on their mechanical properties: 3 3/0 2/0
1. Relatively ductile and strong—polyglycolic acid, 3.5 2/0 0
polyglactin and monofilament nylon 4 0 1
2. Relatively hard and strong—braided polyester and 5 1 2
silk 6 2 3 and 4
3. Relatively ductile and tough but weak— poly- 7 3 5
8 4 6
propylene
4. Relatively ductile and weak but soft—braided Metric number represents the diameter of the suture in terms
nylon. in tenths of a millimeter.
Chapter 2: Sutures and Needles in Gastrointestinal Surgery 5
Sterilization of suture materials also alters their Anatomy of Surgical Needle
characteristics. Most suture materials are sterilized by
The anatomy of a surgical needle is given in Figure 2.1.
gamma irradiation by ethylene oxide gas. Sterilization
will reduce the tensile strength by approximately
10 percent.

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.

Carbon steel Stainless steel


Range% (m/m) Range% (m/m)
Fig. 2.2: Different needle shapes
CARBON (C) 1.2-1.3% 0.6-0.7%
SILICON (Si) 0.10-0.35% 0.50% maximum Body of the needles can be round, oval, flat and
MANGANESE (Mn) 0.20-0.45% 1.00% maximum triangular and the needles can be straight or curved.
CHROMIUM(Cr) 0.10-0.40% 12.00 to 13.00%
SULPHUR (S) 0.025 maximum 0.03% maximum Needle Types
PHOSPHORUS (P) 0.035 maximum 0.025 maximum
The basic classification of needles is normally by
NICKEL (Ni) 0.50 maximum
needle type, (Fig. 2.3) such as:
6 Gastrointestinal Surgery: Step by Step Management

Fig. 2.4: Jeurgen Breuner needle (JB needle)

Selection and Use of Needle Holders


1. The size of the needleholder must be appropriate
Fig. 2.3: Different needle types for the size of needle selected.
2. It must be made from good quality steel with a
1. Round bodied secure jaw design.
2. Conventional cutting 3. When the needleholder with the needle is passed
3. Reverse cutting in the direction in which it will start to be used
4. Tapercut, and without need for readjustments.
5. VisiBlack. 4. Needles should be grasped in an area about 1/3
1. Round-bodied needles can have: to 1/2 of the distance from the swagged area to
a. taper point for soft and easily penetrated tissues the point. Avoid placement near the swagged
and area.
b. micro-point for soft tissues like vessels 5. The needle should be placed securely in the tip
2. Conventional cutting needles have two opposing of the needleholder jaws (Fig. 2.5A).
cutting edges with a third on inside curve, and 6. When placing the needle in tissue, any force
change its cross section from a triangle to a applied should be in the direction following the
flattened body, for tough tissue curve of the needle (Fig. 2.5B).
3. Reverse cutting needles have the cutting edge on 7. Do not take excessively large bites of tissue with
the outer curve, for tough, difficult to penetrate small needles.
tissues 8. Do not damage taper points or cutting edges
4. Tapercut needles have taper body for tough tissue when using the needleholder to pull the needle
5. VisiBlack needles have slim taper point needles out through the tissue. Grasp as far back as
with a black finish for improved visibility and possible (Fig. 2.5C).
penetration 9. Do not force a blunt needle through tissue—
obtain a new one.
JB Needle (Needle for Gastrointestinal Surgery) 10. Avoid using the needle to bridge or approximate
Juergen Breuner invented a special needle, which is tissues for suturing.
an oval round-bodied needle specially designed for 11. If the needle is held too tightly in a sharp or hard
gastrointestinal anastomosis. It has been developed jawed or defective needleholder, the needle may
with a unique geometry which aids precise placement be damaged or notched in such a manner that it
of the needle and easily separates the layers of tissues will have more of a tendency to bend or break on
during intestinal anastomosis. Its flattened underside successive passes through tissue.
provides optimum control for gliding between 12. In some patients, the tissues may be tougher or
individual tissue layers. The needle VISI BLACK fibrosed more than normal and require use of a
provides easy visibility in the operating field without heavier gauge needle.
any glare. The needle as well as suture glide through 13. In a deep confined area, ideal positioning of the
tissue with a feel similar to a surf board gliding needle may not be possible. The surgeon should
through the waves, a phenomenon which can aptly proceed with caution or use a heavier gauge
be called the SURF EFFECT (Fig. 2.4). needle.
Chapter 2: Sutures and Needles in Gastrointestinal Surgery 7
suture. As the healing progresses, the contribution
made by the suture gradually decreases until finally
it is redundant, since the support function is taken over
by the healed wound. It is preferred that the suture loses
its strength and absorb at the same rate as the tissue gains
strength and heals, thus avoiding complications caused by
its continued presence as a foreign body. Most skin sutures
are removed at 7-10 days, when the tensile strength
of the wound is very weak, but the skin wound does
not break down because of the protective action of
the elastin.

CONCLUSION

Surgeons should have adequate knowledge of the


physical and biological properties inherent to
individual suture materials and the relevance of these
properties to the clinical situation, where rates of
healing and tissue response vary considerably. This
will help the surgeon have a more scientific approach
Figs 2.5A to C: Selection and use of needleholders to the problem of wound closure and hopefully, to
consistent and reproducible results, regardless of the
The holding of a wound together for the initial clinical situation. Surgical technique is more important
postoperative period is entirely dependent on the than the suture material used in any given clinical situation.
3
Staplers in Gastrointestinal Surgery
History come in different lengths to accommodate the different
tissue thickness encountered.
Mechanical sutures placed with a stapling instrument
were first introduced in clinical surgery by Humer
Sizes
Hultl of Budapest in 1908. The primary aim for this
desire was to seal bowel ends rapidly and reduce or i. The curved circular stapler used in the end-to-
even eliminate peritoneal soiling and contamination end anastomosis (EEA stapler) is available in four
from open bowel lumina. Since then, many inno- sizes and with universal color coding, 21 mm
vations were made in the manufacture and use of (light green anvil), 25 mm (white anvil), 29 mm
stapling instruments. (blue anvil) and 33 mm (dark green anvil) (Fig.
Laboratory studies have shown that the fine 3.1).
atraumatic stainless steel staples placed into tissues
that are compressed and immobilized but not crushed
were the equivalent of manual sutures and hence do
not, in most instances, require a reinforcing layer of
sutures.
Table 3.1 gives a brief history of evolution of
stapling instruments.

Purpose
The staplers are now available to carry out most types
of gastrointestinal anastomosis.

Varieties Fig. 3.1: End-to-end anastomosis (circular) staplers

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. 3.4C: End-to-end anastomosis— Fig. 3.4D: End-to-end anastomosis—


closing the gap closing the gap

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

Figs 3.7A to C: End-to-side anastomosis


12 Gastrointestinal Surgery: Step by Step Management

A B C D

Figs 3.8A to D: Side-to-side anastomosis

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.

Method of Introduction (Fig. 4.2)


The procedure is explained to the patient. The head
of bed is elevated 90° or the patient sits up at side of Fig. 4.1: Ryle’s tube
bed. A side-lying position is less desirable but may be
advisable for a patient who is unable to sit up. Intu- become cyanotic. Placement of the tube is confirmed
bation should not be performed with the patient lying in the following ways:
supine unless his/her head is elevated. The nasal • Gastric contents are aspirated with a syringe
passages are examined for possible obstructions. The • Approximately 10-25 cc of air is introduced into
patient alternately closes each nostril and breathes. the tube using a syringe while listening to the
The more patent nostril should be used for insertion. patient’s stomach with a stethoscope.
The first 10 cm of the tube should be lubricated with
water-soluble lubricant before insertion. The All Tubes Passed for Nasoenteric Feedings
lubricated tip is introduced through the selected Should be Confirmed by X-ray Examination
nostril and when it reaches the oropharynx, swallo-
The tube is to be fixed with tapes to the cheek without
wing movements are encouraged so that the tube gets
any traction on the nasal ala.
directed into the esophagus and then into the stomach.
The tube generally starts draining the bile stained Maintenance These tubes need to be maintained well,
gastric juice, and the tube is pushed a little further, so free from blockage and encrustations as they may
that the tip lies in the most dependent position in the block the lumen. Washing these tubes with about 30 ml
stomach. Accidental placement of the tube in the of lukewarm water with a 10-20 ml syringe before and after
trachea usually induces coughing or choking in the every time a feed is given becomes mandatory to keep these
conscious patient, while the unconscious patient may tubes patent.
Chapter 4: Tubes and Drains in Gastrointestinal Surgery 15
For enteral feeding Discussed separately (page 16).
Removal The Ryle’s tube is removed, when it is not
required anymore. In a postoperative patient, the tube
is removed, when any three of the following signs are
present:
1. The aspirate is less than 500 ml/24 hours
2. Appearance of bowel sounds
3. Sensation of appetite
4. Passing of flatus
5. Passing of faeces
Difficulties When there is no gastric aspirate for a
considerable period of time, the possibilities are that
the tip is not in the dependent position, and is
projecting above the level of the gastric juice (Fig. 4.3).
The tube is withdrawn a little, aspirated and fixed.
Injecting saline or water or air, and hearing the
gurgling with a stethoscope in the region of the
stomach will be useful only in the unconscious but
not in a conscious patient, as it is not tolerated if it
enters the bronchial tree. Such injection sometimes
pushes the flakes or blood like a one-way valve (Fig.
4.4) and may not allow the aspirate to come through
the tube. Since there are four lateral eyes, such a
possibility is remote, but possible. When the aspirate
is nil with absent bowel sounds, it is wise to replace
the tube. Removal is easy, gentle pulling is adequate,
but when the tip reaches the nostril, it is wise to protect

Fig. 4.2: Method of introduction of Ryle’s tube

Use It is used for gastric aspiration and enteral


feeding.

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

Fig. 4.4: Valve mechanism of the flaskes

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.

Size It is available in various sizes varying from 8F to Optimum Time of Introduction


16F.
It is introduced in situations where enteral feeds are
Length 90 to 120 cm. required, such as conditions of catabolism.
Chapter 4: Tubes and Drains in Gastrointestinal Surgery 17
Optimum Time of Removal varying from 24F to 32F, and jejunostomy tubes are
usually of size 10F.
It is removed when it is not required any more for
feeding purposes. Length Gastrostomy feeding tube is about 25 cm long.
Jejunostomy feeding tube is 75 cm long.
Ostomy Tubes (for Open Surgery)
Varieties The tubes are of two varieties: Method of Introduction
1. Gastrostomy tube (tube introduced into the These tubes can be introduced by an open surgery or
stomach). by laparoscopic method.
2. Jejunostomy tube (tube introduced into the jeju-
num). Maintenance These tubes need to be maintained well,
free from blockage and encrustations as they may
Appearance These tubes are available in the form of block the lumen. Washing these tubes with about 30 ml
kits or any tube like the Malecot’s catheter (Fig. 4.6), of lukewarm water with a 10 to 20 ml syringe before and
Foley’s catheter (Fig. 4.7) or any feeding tube can be after every time a feed is given becomes mandatory to keep
used as an ostomy tube. There are commercially these tubes patent.
available tubes also specific for this purpose. The
ostomy tubes are made of biocompatible polyurethane Use They are used for feeding purposes.
or silicon, have a radiopaque stripe, an open-end feed-
ing port, and two side feeding ports. Skin anchor or Optimum Time of Introduction
inflatable balloon is designed to minimize tube The need to introduce them is to feed from an area
migration. distal to the obstruction, like gastrostomy in obstruc-
Size Since feeding is the main purpose of these tubes, ting lesions of the esophagus or jejunostomy in
large bore tubes are preferred, gastrostomy tubes obstructing lesions of the stomach and duodenum.

Optimum Time of Removal


Removal is done when it is not needed any more and
simply pulling the tube is adequate and easy.
Strapping the ostomy should be adequate and it is
bound to close.

Fig. 4.6: Malecot’s catheter


Percutaneous Endoscopic Jejunostomy (PEJ) and
Percutaneous Endoscopic Jejunostomy (PEJ)
Varieties The tubes are of two varieties. They are
introduced with the help of a gastroscope.
1. Gastrostomy tube (tube introduced into the
stomach)
2. Jejunostomy tube (tube introduced into the jeju-
num).

Appearance These tubes are available in the form of


kits (Fig. 4.8A). They are made of biodegradable
polyurethane with radiopaque stripe, with an open-
end feeding port and two side feeding ports.

Fig. 4.7: Foley’s catheter Size They vary from 9F to 15F.


18 Gastrointestinal Surgery: Step by Step Management

Length Gastrostomy tubes are 30-35 cm and


jejunostomy feeding tube is 120 cm long.

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.

Optimum Time of Introduction


The need to introduce them is to feed from an area
distal to the obstruction, like gastrostomy in
obstructing lesions of the esophagus or jejunostomy
in obstructing lesions of the stomach and duodenum.
Figs 4.9: Percutaneous jejunostomy (PEJ) tube
Optimum Time of Removal introduced with endoscopic guidance

Removal is done when it is not needed any more and


simply pulling the tube is adequate and easy.
Strapping the ostomy should be adequate and it is
bound to close.
Note The alternative to all above methods is the
laparoscopic insertion of gastrostomy for which a kit
is available.

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.

Optimum Time of Introduction


The T-tube is introduced during surgery for stones or
obstruction of the common bile duct, after extracting
the stones out.

Optimum Time of Removal


The optimum time of removal is the eighth day, after
performing a cholangiogram and clamping the tube Fig. 4.12B: Sengstaken-
for at least for 24 hour period of no pain, no fever and Blakemore tube in situ
no rigor and the tube can be easily pulled out.
The Minnesota tube (four lumen) has an extra
Sengstaken-Blakemore Tube
channel that allows aspiration above the esophageal
Varieties The Sengstaken-Blakemore tube (three balloon and is marked at 5 cm intervals (Figs 4.13A
lumen) is a wide bore nasogastric tube with inflatable and B). A three-lumen tube should have an extra
balloons. The gastric balloon compresses the cardia nasogastric tube taped alongside it, to act as the
and fundal varices, preventing blood flow to the esophageal aspiration channel to suck the swallowed
esophageal varices. The esophageal balloon comp- saliva and prevent the accumulation of saliva above
resses esophageal varices (Figs 4.12A and B). the distended esophageal balloon and spilling over
20 Gastrointestinal Surgery: Step by Step Management

A
B

Figs 4.13A and B: Minnesota tube in situ

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

Length and size Since it is available as a corrugated


sheet, the length and the number of corrugations are
decided by the surgeon according to the situation.

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.

Optimum Time of Introduction


The drain is inserted as the concluding part of the
surgery after thorough peritoneal wash, and
preferably through a separate stab wound (using a B
long forceps) to avoid contamination of the main
wound by the discharging fluid. A colostomy bag may Figs 4.15A and B: Tube drains
be applied around the drain, so that the drainage fluid
collects in the bag without soiling the bed. Malecot’s tube drains are made of rubber and have side
flanges at the bottom end of the tube for securing at
Optimum Time of Removal the edge of the drain site preventing from getting
The drain is removed as soon as drainage has ceased dislodged.
or is negligible—usually within 72 hours, excepting Foley’s catheters have inflatable bulb at the lower end
the drainage kept near the closed duodenal stump for securing at the edge of the drain site preventing
whose blow out is expected to occur around the 5th from getting dislodged.
postoperative day, or when the bowel movements are
recovered fully. The length of the drain can be reduced Sizes All tube drains are available in various lengths
by cutting the length after partial withdrawal at an and various diameters of size from 8F to 34F.
interim period, which will drain the collected fluid
Method of Introduction
near the midlength.
The drains are brought out by separate stab wound.
Tube Drains without Suction The stab wound is made as small as possible, the
Varieties There are many varieties of tube drains: fingers of the left hand within the peritoneal cavity
i. Simple tube drains (Figs 4.15A and B). being used to protect the bowel from injury, and the
ii. Malecot’s tube drains (flanges at the bottom end drain introduced with the aid of forceps. The tube is
of the tube—Fig. 4.6). connected to a closed system of graduated collection
iii. Foley’s catheters (inflatable bulb at the lower bag [e.g. urobag (Fig. 4.16)] or placed into an ostomy
end—Fig. 4.7). bag (Fig. 4.17) which does not restrict the patient’s
mobility. The drain needs to be sutured to the skin to
Appearance
prevent it from getting pulled out accidentally.
Simple tube drains These are simple tube drains of
various lengths and have a radiopaque line with many Use This drain is used to drain the fluid potentially
lateral eyes for efficient drainage of fluid. expected to collect in a particular area, and has the
Chapter 4: Tubes and Drains in Gastrointestinal Surgery 23
Optimum Time of Introduction
The tube is inserted as the concluding part of the
surgery after thorough peritoneal wash, and through
a separate stab wound (using a long forceps) to avoid
contamination of the main wound by the discharging
fluid.

Optimum Time of Removal


The tube is removed as soon as drainage has ceased
or is negligible—usually within 72 hours, excepting
the drainage kept near the closed duodenal stump
whose blow out is expected to occur around the 5th
postoperative day, or when the bowel movements are
recovered fully.

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.

Fig. 4.17: Tube drain connected to the ostomy bag

advantages of not soiling the bed when connected to


the bag and enables direct determination of the
quantity as the bag is marked with graduated quan-
tities. Being a closed drainage system, it has a very
low potential for infection. Fig. 4.18: Suction drain
24 Gastrointestinal Surgery: Step by Step Management

Use This drain is used to drain the fluid potentially


expected to collect in a particular area, and has the
advantage of not soiling the bed as the collected
drainage fluid is within the bellow, but needs to be
measured by pouring in a measuring container
separately. Being a closed drainage system, it has a
very low potential for infection. The suction drains are
not used in the peritoneal cavity for the fear of suction being
applied to the contents of the abdomen such as the small
bowel and omentum.
Fig. 4.19: Sump drain
Time of Introduction
Use Since most intraperitoneal drains are relatively
The tube is inserted as the concluding part of the inefficient, and drain only by overflow, suction drains
surgery after thorough peritoneal wash, and through are used, especially during the drainage of the pelvic
a separate stab wound (using a long forceps) to avoid cavity. Since suction cannot be applied to a single tube,
contamination of the main wound by the discharging since its action will draw surrounding bowel and
fluid. omentum and the drainage will cease immediately,
“Sump drainage” by using two tubes, one within the
Optimum Time of Removal other, has been found satisfactory. A number of holes
The tube is removed as soon as drainage has ceased are cut in the lower part of the outer tube and the inner
or is negligible—usually within 72 hours. tube has a single hole cut in it close to its end.
Continuous current of air, activated by the suction,
Sump Drainage Tubes passes down through the outer tube and up through
the inner tube. Any fluid collecting in the outer tube
Appearance It is a two-lumen tube, the outer tube is immediately sucked away. No suction occurs at the
having multiple holes and the suction applied to the openings in the outer tube, so that the surrounding
inner tube (Fig. 4.19). tissues are not drawn against it. Only gentle suction
Size They are available in various sizes ranging from is applied, no more than faint bubbling of air being
24 to 32F or can be made by the surgeon as per the heard by an ear placed against the tubing. If blocked,
requirements. the removal and replacement of the inner tube is easy
and atraumatic. This method of suction drainage can
Length They are available in various lengths from 90 be used to any part of the abdominal cavity, in
cm to 120 cm or can be made by the surgeon as per Morison’s pouch or in the pelvis. For drainage from
the requirements. the pelvis, the patient should be nursed in the propped
up position, so that the fluid collects in the most
Method of Introduction
dependent part of the abdominal cavity.
The tube is inserted as the concluding part of the
surgery after thorough wash, and through a separate Optimum Time of Removal
stab wound (using a long forceps) to avoid conta- The tube is removed as soon as drainage has ceased
mination of the main wound by the discharging fluid. or is negligible.
5
Preoperative Preparation in
Gastrointestinal Surgery (General)
In every patient undergoing major abdominal surgery, if indicated. If bronchitis is a problem, oral antibiotics
cardiac, pulmonary and renal functions must be may also be indicated.
considered, more so in jaundiced patients. It is true
that the prognosis and their incidence of complications RENAL
vary generally with the patient’s “general condition.” Renal insufficiency is common in jaundiced patients,
This rather vague term is an expression of multiple especially those with cirrhosis and cholangitis. Since
organ functions, including cardiac/respiratory, renal, fluid management can be quite complex in jaundiced
hepatic and above all, the nutritional status. This is patients, invasive hemodynamic monitoring with
especially true of the patients with obstructive jaun- central venous catheters to assist in assessing
dice and those with hepatocellular disease severe intravascular volume, may be needed.
enough to cause jaundice are prone to develop many
secondary problems. In addition, special attention HEPATIC
must be focused on the nutritional status, coagula-
bility, immune function and presence or absence of The liver has immense reserve and regenerative
biliary sepsis in the jaundiced patient. The reason for powers. It is estimated that 75 percent of hepatic function
this is the virtual absence of artificial support for must be absent for any changes in hepatic function tests to
hepatic functions. Whereas hemodialysis, ventilatory occur. Carefully directed history taking and physical
support, parenteral and enteral nutrition, and various examination are useful in assessing the hepatic status
forms of cardiac support are available, our efforts at of the patient. In operating on a patient with liver
replacing the numerous functions of the liver are disease, an albumin of greater than 3.5 gm percent
pathetic and primitive. and a prothrombin time that is essentially normal or
less than 2 seconds prolonged are desirable. Unless
CARDIOPULMONARY an elevation of enzymes is 10 times the normal, much
In assessing the cardiopulmonary state, adequate attention need not be given.
history should include information about loss of The most important step in preoperative prepa-
stamina, exercise intolerance, shortness of breath, ration of the patient with liver disease is to attempt to
smoking and importantly the recent weight loss. A improve Child’s class (Table 5.1); nutrition is a critical
simple measure of both pulmonary and cardiac function is and perhaps the most important aspect. If a patient
to ask the patient to walk up two flights of steps; if he or she can go from class B to class A, the prognosis improves
can do so without stopping, pulmonary and cardiac reserves dramatically; the operative mortality drops from 10
are most likely normal. to 15 percent to 1 to 2 percent.
Assessing the cardiopulmonary status includes,
apart from the examination, an electrocardiography, CIRRHOSIS
echocardiography and/or stress testing. Preoperative Although it is inevitable that portal hypertension
pulmonary preparation should include cessation of accompanies cirrhosis, some distortion in the normal
smoking, instruction in deep breathing and incentive portal flow is almost inevitable, and the secondary
spirometry, and the administration of bronchodilators effects of porto-venous shunt have a major role in
26 Gastrointestinal Surgery: Step by Step Management

Table 5.1: Child’s clinical and laboratory classification of cirrhotic patients


Group designation
A B C
(minimal) (moderate) (advanced)
Serum bilirubin (mg/dl) < 2.0 2.0 –3.0 > 3.0
Serum albumin (Gm/dl) > 3.5 3.0-3.5 < 3.0
Ascites None Easily controlled Poorly controlled
Neurological disorder None Minimal Advanced—coma
Nutrition Excellent Good Poor-wasting

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

The optimal basal intake of fluid in average conditions Isolyte E solution


is in the region of 2-3 liters in 24 hours, 1 litre for Dextrose—5 gm Na+ 140
Sodium chloride—0.5 gm K+ 10
insensible loss (via the expired air and evaporation
Sodium acetate—0.64 gm Cl– 103
from the skin), 1-2 liters to promote an adequate Potassium chloride—75 mg Ca++ 5
urinary flow, of which the acceptable minimum is 500 Sodium citrate—75 mg Mg++ 3
ml. Since the normal daily requirement of salt is about Calcium chloride—35 mg Acetate– 47
5 gm, this will be adequately met by 600 ml of isotonic Magnesium chloride—31 mg Citrate– 8
saline solution; thus, two or three 1/2 litre of glucose Sodium metabisulphite—20 mg
solution should be given for every 1/2 litre of saline. Isolyte M solution
Any abnormal losses by vomiting, etc., should be Dextrose—5 gm Na+ 40
compensated for by a corresponding increase in the amount Sodium chloride—91 mg K+ 35
Sodium acetate—0.28 gm Cl– 40
of saline infused, so that daily balance is achieved. Various Potassium chloride—0.15 gm Acetate– 20
source of excess fluid loss in seen some special situations in Dibasic potassium
surgical patients are given in Table 5.6. phosphate—0.13 gm Phosphate– 15
The rate of administration—in drops per minute— Sodium metabisulphite—21 mg
derived from the following calculation: Isolyte G solution
1 ml = 15 drops Dextrose—5 gm Na+ 63
2500 ml = 15 × 2500 drops Sodium chloride—0.37 gm K+ 17
Ammonium chloride—0.37 gm Cl– 150
If this 2500 ml ( 15 × 2500 drops) has to be infused Potassium chloride—0.13 gm NH4– 70
in 24 hours (i.e. 24 × 60 minutes), Sodium sulphite—15 mg
2500 × 15 Isolyte P solution
in 1 minute __________ = 26 drops Dextrose—5 gm Na+ 26
24 × 60
Dibasic potassium
or simply by multiplying the required number of phosphate—27 mg K+ 20
liters per day by 11. Sodium acetate—315 mg Cl – 21
Potassium chloride—130 mg Mg++ 3 346
Number of liters/day multiplied by 11 = number of drops/min Magnesium chloride—31 mg Acetate– 23
Liters/day (n) × 11 n drops per/min Sodium metabisulphite—21 mg PO4– 3
30 Gastrointestinal Surgery: Step by Step Management

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.

Position in Bed Intake-Output Chart


After returning to the postoperative ward, the patient Intake Output
Date Time Oral IV Qty Urine Vomit Others Qty
should be placed in semi-prone position, to avoid the
risk of vomitus being aspirated into the respiratory
passages. If the patient is fully conscious, he can be
turned to his back head elevated. When the condition
permits, he may be allowed to adopt to any position
Antibiotics
which he finds most comfortable.
The antibiotics started in the preoperative period are
Sedation continued for a period of 3 to 5 days postoperatively,
With modern anaesthesia, the patients pass especially in contaminated cases, till the evidence of
imperceptibly from the state of anaesthesia to sleep, infection abates. But in clean cases, the opstoperative
and may awake immediately after operation, but may uses of antibiotics is limited to one of two doses only.
remain drowsy. Till the patient is fully awake, and if
Ambulation and Bedrest
only the patient becomes uncomfortable and restless,
a further dose of sedative is given. During recent years, the principles of early ambulation
have become more and more widely accepted. After
Analgesics operations like appendicectomy, the patient may be
Administration of analgesics is a good practice, to keep encouraged to get up for a little while on the evening
the patient comfortable. of the operation, and if possible walk to the toilet. The
benefits are considerable. Cardiac, respiratory and
Diet and Fluid Intake excretory functions are stimulated and complications
Though there are many surgeons who allow sips of such as respiratory lesions and retention of urine are
water in the immediate postoperative period, it is rendered less frequent. The psychological benefits are
better to withhold fluids by mouth. Intravenous fluids incalculable—especially to male patients to whom the
are given as a routine, in order to replace the fluid necessity of having to ask a nurse for a bedpan may
lost during surgery. All necessary precautions, be a greater ordeal than the operation itself. Young
including the keeping of a fluid balance chart, must patients and the attendants appreciate their early
be taken against overdosage. Plasma or blood discharge from the hospital on the 3rd or 4th
transfusions may be given according to the needs of a postoperative day with stitches in situ.
Chapter 6: Postoperative Management in Gastrointestinal Surgery (General) 33
Bowel Action and keep the stomach empty. Nasogastric aspiration
One of the benefits of early ambulation is that normal may be initiated to keep the stomach empty in some
bowel function may be attained within 2 or 3 days of cases.
operation without the necessity of laxatives.
Suppositories are useful when the bowel action is Abdominal Distension
delayed, and when colicky pain occurs due to flatulent In its mild form this may be regarded as a sequel to
distension, a frequent source of discomfort. abdominal operations, rather as a complication, since
some temporary inhibition of peristalsis is inevitable.
COMPLICATIONS If this persists beyond 48 to 72 hours, and is associated
1. Vomiting with vomiting with the absence of bowel sounds on
2. Retention of urine auscultation, nasogastric aspiration is needed. The
3. Hiccough tube should normally be retained until there is
4. Abdominal distension evidence of peristaltic activity as shown by bowel
5. Pulmonary complications sounds on auscultation or by the passage of flatus per
6. Phlebothrombosis rectum (see Chapter 4—Nasogastric tube).
7. Postoperative peritonitis
8. Postoperative renal failure Pulmonary Complications
9. Burst abdomen These include conditions such as bronchitis, pneu-
10. Parotitis monia and pulmonary atelectasis. Deep breathing
exercises and chest physiotherapy have made these
Vomiting less and less frequent. In general, the treatment is on
After modern anaesthesia, vomiting does not normally medical lines, but bronchoscopy may be employed to
occur or is no more than transient. Antiemetics do help remove liquid secretion and plugs of mucus from the
at this juncture. Persistent vomiting may indicate the bronchi; tracheostomy may be needed in patients on
threat of serious complications such as paralytic ileus ventilator and may be a life-saving procedure.
or acute dilatation of stomach, which requires gastric
decompression. The most sensible treatment is to keep Phlebothrombosis
the stomach empty as far as possible by intermittent Phlebothrombosis is not a specific problem of gastro-
or continuous nasogastric aspiration. If the aspiration intestinal surgery, but it is a relatively common
is large, it should be taken into account in the complication. It occurs usually in the deep veins of
replacement with intravenous fluids. the calf and less commonly in the femoral and iliac
veins. Its significance lies in the danger that pulmonary
Retention of Urine embolism may result from detached fragments of clot
Difficulty in initiating the act of micturition occurs entering the circulation. Routine examination daily,
chiefly in older men, especially after operations on the or the occurrence of minor elevations of temperature
pelvic organs. Simple measures like reassurance, and or pulse rate, may suggest early diagnosis. The
allowing the patient to sit or stand at the side of the prevention is by protecting the veins of the leg from
bed are useful. Providing a hot water bag on the pressure during and after operation, by low molecular
distended bladder is useful. If all these measures fail, weight heparin and compression bandages of the
catheterization may be required. Trial removal may lower limbs.
be done after 48 hours, and if there is a need for re-
catheterization, organic cause should be ruled out. Postoperative Peritonitis
This term is usually restricted to peritonitis which
Hiccough develops unexpectedly after operation. It may be due
Hiccough is fairly common after abdominal operations to accidental contamination during the operation;
especially in a lying patient. The first measure to more frequently it results at a later stage from leakage
combat hiccough is to raise the head end of the bed of bowel contents at a suture line. The onset is
34 Gastrointestinal Surgery: Step by Step Management

insidious and the diagnosis difficult, for the classical


signs of peritonitis are absent, except for some
elevation of temperature and pulse rate. Later, the
clinical picture may become that of paralytic ileus,
when there is progressive distension of the abdomen
with profuse vomiting. The prognosis must then be
guarded for the patient’s condition may steadily
deteriorate. Treatment is that of the paralytic ileus
combined with intense antibiotic therapy. Operative
intervention is seldom indicated, unless to drain
collections of pus which may have become localized,
e.g. subphrenic or pelvic abscesses.

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

Figs 6.2B and C: Procedure of closure of burst abdomen

Parotitis
Parotitis is not a common complication today. It is
controlled by good oral hygiene and antibiotics.

Objective Evidence of Impending Complications


During the postoperative period, the restoration of the
anatomical and the physiological integrity is
monitored by the drains and tubes placed in and
around the gastrointestinal tract, especially near the
place of surgery. Usually, the decompression of the
gastrointestinal tract is done by the nasogastric tube
and as the bowel activity returns, as evidenced by the
appearance of the bowel sounds, the passage of flatus
and/or the faeces, the quantity of the aspirate reduced,
as the secretions go down the gastrointestinal tract.
Removal of the nasogastric tube becomes possible at
this juncture allowing the feeding by the oral route,
which is considered to be the best and also most
satisfying to the patient. Likewise, when the
anatomical integrity of the tract gets restored,
especially after the resection and anastomosis of the
bowel, the drains kept near the anastomosis, drain less
and less of the fluid, facilitating the removal of the
tubes.
However, difficulties are encountered during
certain situations, which require special tract to
manage. The tubes and drains along with teh clinical
examination give the adequate information about the
Fig. 6.3: Techniques of closure of burst abdomen impending complication. They are given in Table 6.1.
36 Gastrointestinal Surgery: Step by Step Management

Table 6.1: Objective evidences of impending complications


Postoperative Expected complication Probable reason Management
day
1 and 2 days Gastric aspirate-nil Ryle’s tube not in the dependent Adjust
position
Blockage of tube Replace
Bloody aspirate Small bleed from anastomotic Cold water washes through
suture line Ryle’s tube and styptics
3 and 4 days Frank bloody aspirate Large bleed from anastomotic Cold water washes and styptics
suture line
Drainage fluid bilious in nature Leak from small bowel Replace IV fluids and electrolytes
anastomosis or duodenal
stump blow out
Drainage fluid faecal in nature Leak from colonic anastomosis Conservative management
Large nasogastric aspirate, Electrolyte disturbances Correction
abdominal distension and
absence of bowel sound
Abdominal distension and Electrolyte disturbances Correction
absence of bowel sounds
5 to 10 days Decreasing nasogastric Anastomotic leak or Replace IV fluids and electrolytes
aspirate. Increasing drainage duodenal stump rupture
fluid bilious in nature
Abdominal distension and Electrolyte disturbances Correction
absence of bowel sounds Fecal impaction Rectal suppositories, enemas
10 to 15 days Increasing drainage fluid Anastomotic leak or duodenal Re-explore and close the leak
bilious in nature
Non-relieving abdominal Mechanical causes Identify the cause and correct
distension and absence of
bowel sounds
7
Pre- and Postoperative
Management in Foregut
(Esophagus, Stomach
and Duodenum) Surgery
NERVE SUPPLY OF THE The surgical division of the vagus nerves
GASTROINTESTINAL TRACT (vagotomy), the main trunk or its branches (selective
and highly selective) become necessary in the
The nerve supply of the gastrointestinal tract is grossly
treatment of acid peptic disease (Fig. 7.1). The surgical
divided as:
division is not free from complications, and the nerve
1. The extrinsic nerve supply or the autonomic
supply of the gastrointestinal tract has to be studied
nervous system and
in detail to understand the complications of vagotomy
2. The intrinsic nerve supply or the enteric nervous
(see Table 7.1).
system.
Table 7.1: Nerve supply of the gastrointestinal tract
Nerve Nervous Nerves Organ Functions Action on
supply system supplied the organ

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

EARLY COMPLICATIONS OF VAGOTOMY


(see Table 7.2)
GASTRIC ATONY
Clinical Presentation
In the early postoperative period up to the 5th post-
operative day, the nasogastric aspiration may be
present in large quantities.

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.

Table 7.2: Early complications of vagotomy


Early complications Time of appearance Reason Management
Gastric atony (all vagotomies) Lasting till the 4th Disturbance of gastric pacesetter Additional nasogastric
postoperative day potentials, and vagal reflexes and suction with parasympatho-
prevention of acetylcholine from mimetic drugs
augmenting the number of action
potentials
Necrosis Lesser gastric curve 24 to 72 hours Inadvertent instrumental Gastric resection
(proximal gastric vagotomy) injury to the lesser curve
Transient dysphagia Early postoperative Diminution of esophageal Most of them improve in due
(proximal gastric vagotomy) period sphincter resting pressure course with gastrokinetics
and H2 blockers, occasionally
esophageal dilatation
Achalasia Early postoperative No good explanation Most of them improve in due
(proximal gastric vagotomy) period course with gastrokinetics
and H2 blockers, occasionally
esophageal dilatation
Chapter 7: Pre- and Postoperative Management in Foregut Surgery 39
Note: This complication can be seen following all TRANSIENT DYSPHAGIA
vagotomies, but when associated with drainage proce-
Clinical Presentation
dures, it is short lived and responds to the above
treatment The patients may complain of difficulty in swallowing.
Usually, the disorganization of the gastric pace- Pathology of Complication
setter potentials which happen due to the manipu-
No explanation is available.
lation of stomach and small bowel lasts for only 24
hours. Investigations and Diagnosis
No specific investigation is useful.
NECROSIS OF LESSER GASTRIC CURVE
Clinical Presentation Treatment

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.

Pathology of Complications ACHALASIA


The exact cause is not known. The belief is the Clinical Presentation
inadvertent instrumental injury to the lesser curve
The patients may complain of difficulty in swallowing.
vaculature causes necrosis, as the arterial supply to
the lesser curve is from end arteries. Pathology of Complication

Investigations and Diagnosis No explanation is available.

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.

Fig. 7.2: Necrosis of the lesser gastric curve


40 Gastrointestinal Surgery: Step by Step Management

Late Complications of Vagotomy Treatment


(see Table 7.3)
They disappear with passage of time, controlled diet
with carbohydrates and milk products will help. Low
POSTVAGOTOMY DIARRHOEA fluid meals with postprandial positioning of
Clinical Presentation recumbency for 20-30 minutes may prove beneficial.
Bowel binders and antispasmoidics will be useful.
They present with severe and disturbing diarrhoea.
Surgery
Surgery is indicated only when the diarrhoea is severe
Pathology of Complication
and disabling (the number of stools is > 20/day),
resulting in malnutrition and excessive weight loss.
The surgery is interpositioning of antiperistaltic jejunal
segment (Fig. 7.3).

Investigations and Diagnosis


Diagnosis is obvious and no investigation is required,
excepting related to the infection of the gastrointestinal Fig. 7.3: Interpositioning of antiperistaltic jejunal
tract. segment for correction of postvagotomy

Table 7.3: Late complications of vagotomy


Late complications Time of appearance Reason Management
Diarrhoea (most after Months after Gastric stasis + hypoacidity Disappears with time, restrict carbohydrates,
truncal vagotomy) vagotomy after → bacterial overgrowth → milk diet. Low fluid meals with recumbent
regaining gastric enteritis position for 20-30 mts antibiotics. Codeine,
peristalsis Lomotil. Surgery (interposition of
antiperistaltic jejunal segment) when > 20
stools/day

Reflux esophagitis Days/months/ Disruption of right crural sling Gastrokinetics, antacids


years after fibers during mobilization of
vagotomy the vagi

Reflux Months-years Gastroesophageal acid Gastrokinetics, antacids, esophageal


esophageal stricture after vagotomy reflux and esophagitis dilatation

Cholelithiasis 4-5 months Denervation of the hepatic Management of cholelithiasis


(mostly after after vagotomy vagi → hypotonia of the
truncal vagotomy) gallbladder
Chapter 7: Pre- and Postoperative Management in Foregut Surgery 41
REFLUX ESOPHAGITIS AND STRICTURE
Clinical Presentation
The patient presents with upper abdominal dyspepsia
and retrosternal burning and eructations, sometimes
with pain in the chest.

Pathology of Complication
The injury caused to the right crural sling fibres during
mobilization of vagi can cause this complication. A B

Investigations and Diagnosis


Barium meal in Trendelenburg position may show the
reflux, endoscopic biopsy of the oesophago-gastric
junction may show inflammatory changes in the lower
esophagus (Fig. 7.4A). Radionuclide scan will show
gastroesophageal reflux (Fig. 7.5).

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.

Investigations and Diagnosis


Radionuclide scan can document hypotonia of the
gallbladder (Fig. 7.6) when there are no stones and Fig. 7.5: Radionuclide scan showing
gastroesophageal reflux
ultrasonography is useful in diagnosis of cholelithiasis
(Fig. 7.7).
Note: Truncal vagotomy increases the formation of
gallstones, but in selective vagotomies where hepatic
Treatment denervation does not occur, the incidence of gallstones
Cholecystectomy for calculous cholecystitis. is negligible.
42 Gastrointestinal Surgery: Step by Step Management

Fig. 7.8: Transhiatal esophagectomy


(with esophagastric anastomosis)

Fig. 7.6: Radionuclide scan showing


gallbladder solitary dyskinesia

Fig. 7.9: Esophagogastrectomy (with colon interposition)

Fig. 7.7: Ultrasonography of the gallbladder


showing solitary gallstones
Fig. 7.10: Esophageal perforation closure
ESOPHAGUS
Variety of operations are performed in the esophagus
for various indications and various situations and they
consist of:
• Transhiatal esophagectomy (with esophagogastric
anastomosis—Fig. 7.8).
• Esophagogastrectomy (with colon interposition—
Fig. 7.9)
• Esophageal perforation closures (Fig. 7.10)
• Surgery for fundoplication (Fig. 7.11)
• Esophagomyotomy (Fig. 7.12) Fig. 7.11: Surgery for fundoplication
Chapter 7: Pre- and Postoperative Management in Foregut Surgery 43
• Antifungal drugs Administration of an antifungal
agent like Mycostatin for 5 days before surgery is
needed as fungi seem to inhabit these carcinomas.
• Antibiotics Antibiotics are necessary as bacterial
growths of aerobic and anaerobic organisms are
cultured in esophageal cancer, the commonest
being Bacteroides. A combination of a cephalo-
sporin, an aminoglycoside and metronidazole will
cover these organisms in the perioperative period.

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

Chest drain is removed as soon as drainage is Treatment


minimal and the chest X-ray satisfactory, and often
Immediate resuture of the disruption is the treatment
before commencing feeding. Leak is suspected when
of choice supplemented by the intercostal drainage of
there is undue fever or if a pleural effusion develops,
the pleural space, with adequate antibiotic coverage.
and they must be confirmed by gastrografin swallow.
The management of anastomotic leaks can roughly
Intra-abdominal drains kept near the intra-
be divided into four categories (Table 7.5).
abdominal anastomosis are removed when the
motility of the bowel returns to normal with the
passage of flatus and/or faeces. If there is evidence of
infection or sepsis without an obvious etiology, the Table 7.5: Definition of anastomotic leaks after
surgeon must suspect a leaked anastomosis. esophageal surgery and management
Patients who have generally recovered sufficiently Leak Definition Treatment
are to be discharged 6 to 8 days after surgery. Radiological* No clinical signs No change in mana-
gement
EARLY COMPLICATIONS OF ESOPHAGEAL Clinical minor ** Local inflam- Drain wound
SURGERY (see Table 7.4) mation cervical Delay oral intake
ANASTOMOTIC LEAKS wound
X-ray contained
Clinical Presentation leak (thoracic
anastomosis)
The patient presents with fever above 38°C, with Fever, leuco- Antibiotics
difficulty in breathing and chest pain and tightness of cytosis,
the chest in the postoperative period. Clinical major *** Severe disruption Change management
Pathology of Complication on endoscopy
Sepsis CT- guided drainage
This is due to the anastomotic leak due to disruption (Reintervention)
of anastomosis resulting in a pyothorax and in some
Conduit Endoscopic Reintervention
cases into an external esophageal fistula or may be an necrosis **** confirmation
internal fistula communicating with the tracheo-
bronchial tree. In case of an asymptomatic leak only discovered at X-ray
contrast study, little specific treatment is required—delay in
Investigations and Diagnosis oral intake, especially solids for a few days will suffice*.
Chest roentgenogram will help in the diagnosis of a In the presence of a minor, well-contained leak, nil-by-
mouth regimen with TPN will help. Administration of
leak.
antibiotics will be necessary depending on the infectious
parameters. Usually, there is no need for nasogastric tube in
these cases **.
Table 7.4: Early complications of esophageal surgery
When the leak is major, more aggressive treatment is
Compli- Time of Reason Management necessary. The treatment depends on the location of the
cations appearance anastomosis and the perianastomotic fluid accumulation. Local
Anasto- 2nd-5th Disruption of Immediate collections if any, have to be drained. When the defect is
motic postoperative anastomosis resuture substantial, the local repair becomes difficult in the presence
leaks day* of mediastinitis. In that case, a take down of the anastomosis
Dysphagia Early post- Edema of the No specific with temporary esophagostomy and feeding jejunostomy may
operative period anastomosis treatment be the only option ***. Early postoperative esophagoscopy and
dilatation of a leaking anastomosis is accepted to influence
Hoarseness Early post- Recurrent No specific
healing because relative narrowing by local inflammation and
of voice operative period laryngeal treatment
spasm may contribute to obstruction distal to the leak and
nerve paresis
adversely affect spontaneous closure.
due to traction
In the case of necrosis of the proximal part of the conduit,
Complications of gastrectomy may occur when a resection of the necrotic part, debridement of the
esophagectomy is combined with gastrectomy (see under mediastinum, esophagostomy and feeding jejunostomy is the
complications of gastric surgery). treatment of choice ****.
Chapter 7: Pre- and Postoperative Management in Foregut Surgery 45
Note
• Unexplained postoperative fever above 38°C (101°F)
following esophageal operation should never be
attributed to pulmonary complications, urinary tract
sepsis or any other cause until anastomotic leak has been
conclusively excluded with a contrast study of the
anastomosis.
• A concomitant pyloroplasty or pyloromyotomy is
essential to prevent gastric distension after total
esophagectomy, which in turn reduces the incidence of
anastomotic leaks, but may induce duodenogastric reflux
resulting itself in anastomotic ulceration, stenosis and
eventually formation of Barrett’s metaplasia.
• Posterior mediastinal route is found to be superior to
the retrosternal route because of shorter distance, in
reducing the incidence of anastomotic leaks.
Fig. 7.13: Edema and inflammation of the esophago-jejunal
anastomosis—suture material visible
DYSPHAGIA
Investigations and Diagnosis
Clinical Presentation
Direct laryngoscopy to visualize the vocal cords which
In the early postoperative period about the 2nd to 5th
may show decreased movement—paresis.
postoperative day, the patient may present with
difficulty in swallowing. Treatment
No specific treatment is required. They recover in due
Pathology of Complication
course of time.
The edema of the anastomotic area may be the cause.
LATE COMPLICATIONS OF ESOPHAGEAL
Investigations and Diagnosis SURGERY (see Table 7.6)
No specific investigation is required in the early PERSISTENT DYSPHAGIA
postoperative period, but esophagoscopy (Fig. 7.13)
Clinical Presentation
may be useful.
The patient may present with persistent dysphagia
Treatment continuing from or not present in the early post-
The dysphagia resolves as the edema subsides, and operative period.
no specific treatment is required.
Table 7.6: Late complications of esophageal surgery
HOARSENESS OF VOICE Compli- Time of Reason Management
cations appearance
Clinical Presentation
Persistent Late post- Stricture or Dilatation or
The patient presents with change in voice amounting dysphagia operative Local recur- Appropriate
to hoarseness. period rence treatment

Pathology of Complication Secondary 4-8 weeks Cricopharyn- Dilatation by


cervical geal dysfunc- bougies
This may be due to the traction applied to recurrent dysphagia tion (46F or larger)
laryngeal nerves during the mobilization of the with feeding
jejunostomy
esophagus during surgery.
46 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.

Investigations and Diagnosis


Upper gastrointestinal endoscopy will help to
differentiate the benign (Fig. 7.4A) and malignant (Fig.
7.14) strictures.

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.

Table 7.7: Varieties of gastric surgery


Procedure excisional Variety Reconstruction Indication
Gastrectomy Total gastrectomy (100%) End-to-end esophago-jejunostomy Carcinoma of stomach
(Removal of (loop or Roux-en-Y) (Linitis plastica)
stomach)
Subtotal gastrectomy (85%) End-to-side gastrojejunostomy Carcinoma of stomach (body)
and duodenal stump closure
(Billroth II)
Lower partial End-to-end gastroduodenostomy Carcinoma of stomach
gastrectomy (50%) duodenal stump closure (Billroth II) (antrum, pylorus and
I part of duodenum)
End-to-end gastroduodenostomy Benign ulcer disease
(Billroth I) of gastroduodenum
Excision of ulcers Primary closures Benign gastric ulcers Benign ulcer disease
Bypass Gastrojejunostomy Side to side Duodenal ulcer
Chapter 7: Pre- and Postoperative Management in Foregut Surgery 47
• Gastrotomy—in some cases the stomach is opened
and closed back (e.g., removal of foreign bodies).

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

obvious etiology, the surgeon must suspect a leaked


anastomosis.
Patients who have generally recovered sufficiently
are discharged 6 to 8 days after surgery.

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

Table 7.8: Early complications of gastric surgery


Early Time of Reason Management
complications appearance
Early intragastric Persistence of Bleeding from anastomotic area Ice saline lavage, blood transfusion.
hemorrhage bloody aspirate If bleeding persists with
beyond 48 hours drop in vital signs, reoperation
Delayed Several days Bleeding from unresected ulcer Horsley’s slit on anterior duodenal wall
intragastric after surgery and obliterate the ulcer with ‘8’ sutures
hemorrhage with 2-0 silk Billroth I or catheter
duodenostomy with Billroth II
gastrectomy, or Roux-en-Y reconstruction
as per surgeon’s choice
Extragastric 24-48 hours later Injury to adjacent organs like liver, If vital signs drop, and NG aspirate is
hemorrhage spleen, vasa bevia, pancreatic bed, clear, CT scan to be done. Exploratory
left gastric artery and coronary vein laparotomy may be necessary

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

Surgical Treatment Pathology of Complication


Reoperation should not be postponed when faced with Such bleeding may result from a duodenal ulcer
continuous bleeding. The gastric pouch should be deliberately not removed or from inadequate
opened much above the gastroenterostomy or undersewing of a bleeding ulcer at the time of original
gastroduodenostomy using a transverse incision and operation.
blood clots should be evacuated. Saline irrigations are
done and enough suction should be applied to clear Investigations and Diagnosis
the stomach pouch well. Manual pressure on the It is difficult to assess the amount of blood loss by
distended gastric pouch is quite effective in evacuating nasogastric aspirate, as there may be retained blood
the clots. Saline irrigations and moist saline packs are clots in the stomach which cannot be aspirated, and
applied to the gastric mucosa to remove small clots also some blood is bound to travel down the intestine.
and debris. Care should to be taken not to damage the Gastroduodenoscopy may be done if it is more than
mucosa while suction, especially the use of metal tips, as it 15 days after surgery (Figs 7.17A and B).
may result in diffuse gastric mucosal bleeding. The
bleeding site is usually a single vessel at the lesser Treatment
curvature or at the anastomosis. A single “figure of
8” suture will usually control the bleeding. The Treatment consists of the following.
nasogastric aspiration should be done to clear the
blood remnants and the tube flushed well to be sure
that the aspirate is clear or only mildly tinged.

DELAYED INTRAGASTRIC HEMORRHAGE

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

g. Bleeding at the site of vagotomy from the subdia- Treatment


phragmatic vessels. It consists of the establishment of prompt and
adequate sump drainage of the right upper quadrant,
Investigations and Diagnosis along with internal drainage of the afferent jejunal loop
Computed tomography scan of the abdomen is useful via either a tube gastrostomy, jejunostomy or
in such circumstances. nasogastric intubation. Penrose drain should be app-
lied in addition to sump drainage in the right upper
Treatment quadrant. The aim is to create a controlled external
If vital signs are not promptly restored after two or fistula. Exploration and corrective surgery may be
more units of blood, exploratory laparotomy is indi- needed if obstruction is identified.
cated. The splenic laceration is sutured and all Note: Although the morbidity is high following a duodenal
attempts should be made to preserve the spleen unless stump fistula, with prompt diagnosis and surgical drainage,
a major splenic fracture or multiple fractures are most cases recover and the prognosis is favorable.
present. The bleeding vessel if any is identified and
ligated. SUTURE LINE LEAK AFTER BILLROTH I
GASTRECTOMY (GASTRODUODENOSTOMY)
DUODENAL STUMP LEAKAGE
Clinical Presentation
Clinical Presentation
These patients present with a bile-stained fluid leak
One of the serious complication that may follow through the drain left near the anastomosis. This
Billroth II gastrectomy. These patients present with a occurs usually from the 2nd to 5th postoperative day.
bile leak through the drain left near the closed duo- The symptoms may be relatively subtle, with only a
denal stump. This occurs usually from the 2nd to 5th moderate degree of pain, fever and leukocytosis.
postoperative day. The patient experiences severe
abdominal pain and fever, and a shock-like picture. Pathology of Complication
Sometimes, symptoms may be relatively subtle, with
This occurs when the gastroduodenal anastomosis is
only a moderate degree of pain, fever and leuko-
performed in the presence of a severely diseased and
cytosis, rarely with jaundice.
scarred duodenum.
Pathology of Complication
Investigations and Diagnosis
Several factors are responsible for the duodenal stump
Gastrografin study may be done. The leak may be
leakage. They are:
demonstrated by contrast-enhanced CT scan, which
a. Severely diseased and scarred duodenal bulb
may reveal intraluminal fluid or gas in the right upper
precluding adequate closure
abdomen.
b. Excessive suture closure leading to tissue necrosis
c. Postoperative pancreatitis with acute inflam-
Treatment
matory exudate in the area of the closed stump
which may retard stump healing Medical
d. Poor nutritional state Small leaks cease by 24 to 48 hours and need only
e. Improper surgical technique nasogastric suction and supportive therapy.
f. Localized infection and sepsis.
Surgical
Investigations and Diagnosis
Failure of medical management warrants surgical
The leak may be demonstrated by CT scan with oral intervention.
contrast, which may reveal fluid or gas in the right • If the leak is minimal or moderate with minimal
upper abdomen. signs of peritoneal irritation, and not responding
Chapter 7: Pre- and Postoperative Management in Foregut Surgery 53
to medical management, the rent may be closed
with an omental patch.
• If the leak is large and the rent is large and the
disruption is large, Billroth I reconstruction should
be converted into Billroth II or a Roux-en-Y, supple-
mented by a feeding jejunostomy.

Note: The leakage from a gastroduodenal anastomosis is


associated with less morbidity than the duodenal stump
leakage.

SUTURE LINE LEAK AFTER BILLROTH II


GASTRECTOMY (GASTROJEJUNOSTOMY) OR Figs 7.20: Miniresection of stomach, Billroth II to Roux-en-Y
SIMPLE GASTROJEJUNOSTOMY
Clinical Presentation LEAKAGE FROM PYLOROPLASTY
These patients present with a bile-stained fluid leak Clinical Presentation
through the drain left near the anastomosis. This
occurs usually from the 2nd to 5th postoperative day. These patients present with a bile-stained fluid leak
The symptoms may be relatively subtle, with only a through the drain left near the pyloroplasty. This
moderate degree of pain, fever and leukocytosis. occurs usually from the 2nd to 5th postoperative day.
The symptoms may be relatively subtle, with only a
Pathology of Complication moderate degree of pain, fever and leukocytosis.
This occurs when there is increased tension on the
anastomotic line or necrosis due to jeopardized blood Pathology of Complication
supply. This occurs due to edema and inflammatory reaction
at pyloroplasty site.
Investigations and Diagnosis
Gastrografin study may be done. The leak may be Investigation
demonstrated by contrast-enhanced CT scan, which
may reveal fluid or gas in the right upper abdomen. The leak may be demonstrated by contrast-enhanced
CT scan, which may reveal fluid or gas in the right
Treatment upper abdomen.
Medical
Treatment
Small leaks cease by 24 to 48 hours and need only
Distal gastric resection with closure of the duodenal
nasogastric suction and supportive therapy.
stump with either a Billroth II or Roux-en-Y recons-
Surgical truction, as Billroth I reconstruction would not be feasi-
ble due to edema and reaction at the pyloroplasty site.
Failure of medical management warrants surgical Suture obliteration of the pyloroplasty with
intervention. gastrojejunostomy is an option.
If the leak is minimal with minimal signs of
peritoneal irritation, the rent may be closed with an Note: Leaks from disruption of pyloroplasty is unusual
omental patch. If the leak is large and the disruption
GASTRIC REMNANT NECROSIS
is wide, Billroth II reconstruction should be converted
into a miniresection of the gastric remnant followed Clinical Presentation
by a Billroth II or a Roux-en-Y, supplemented by a
These patients present with a drainage of dark brown
feeding jejunostomy (Fig. 7.20).
fluid through the drain kept near the anastomosis. This
Note: Leak from gastrojejunostomy is very unusual. occurs usually from the 2nd to 5th postoperative day.
54 Gastrointestinal Surgery: Step by Step Management

The patient experiences severe abdominal pain and


fever, and presents a shock-like picture.

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

Fig. 7.24: Total gastrectomy with cervical esophagostomy


and feeding jejunostomy

upper abdominal discomfort, nausea and or vomiting,


with inadequate gastric emptying, requiring rein-
sertion of the nasogastric tube. Continuous decom-
pression with fluid replacement will be required for
several days. When the obstruction persists for more
than 2 weeks, investigations are done to find the cause
Fig. 7.21: Gastric remnant necrosis (endoscopic view) of obstruction.
Chapter 7: Pre- and Postoperative Management in Foregut Surgery 55
Pathology of Complication tachycardia and also shock-like picture in the early
postoperative period.
The causes for this complication are:
a. Stomal edema
Pathology of Complication
b. Improper surgical technique
c. Extensive duodenal pathology The commonest cause of leakage of a closed duodenal
d. Postoperative suture line bleeding stump is afferent loop obstruction. The reasons for
e. Anastomotic leakage mechanical obstruction of the afferent loop are:
f. Acute pancreatitis a. Twist of the afferent loop
g. Inflammatory adhesions (after Billroth II recons- b. Volvulus of the afferent loop
truction) c. Internal herniation
h. Mesocolic herniation involving the afferent and d. Jejunogastric intussusception
efferent loops e. Kink at the gastrojejunostomy site.
i. Extensive fat necrosis The pressure inside the afferent loop will increase
j. Inflamed omentum. as it becomes a closed loop, and when the pressure
goes beyond the pancreatic ductal pressure, the serum
Investigations and Diagnosis amylase levels rise.
Gastrografin examination to determine the emptying
Investigations and Diagnosis
pattern and endoscopic examination to find the cause
of obstruction are required. Gastrografin swallow will show the non-entry of the
contrast into the afferent loop, CT scan may aid the
Treatment diagnosis. A plain film may reveal the presence of an
enormously dilated afferent loop. Endoscopy is rarely
Most cases will recover by conservative management, of help in diagnosis.
continuous nasogastric suction and intravenous fluids
for several days, unless there is mechanical obstruc- Treatment
tion.
When the recovery takes more than 2 weeks, it is Exploration will be needed and the treatment will
wise to operate. The options are: depend upon the operative findings.
a. To relieve the obstruction after a Billroth I recons- • If the patient is seriously ill, simple entero-
truction, dismantle the gastroduodenostomy and enterostomy between the afferent and the efferent
redo the same, or convert to Bilroth II or Roux-en- loops should be enough to decompress the afferent
Y reconstruction. loop (Fig. 7.25)
b. To relieve the obstruction after a Billroth II recons- • If the patient is not seriously ill, and there is enough
truction: time for definitive surgery, and if a volvulus or a
• If kinking and adhesions are found, they are kink in the long afferent loop is found, the loop
released and a feeding jejunostomy is per- may be shortened and reanastomosed (Fig. 7.26),
formed. or simply the afferent loop be divided near the
• If both afferent and efferent loops are found gastroenterostomy stoma and a Roux-en-Y
herniated into the lesser sac, they are reduced reconstruction is done.
and preventive measures taken. • If there is a delay in diagnosis and if the distal part
• If either loop be found nonviable, resection with of the afferent loop is found gangrenous, it may be
Roux-en-Y reconstruction is done. resected and a Roux-en-Y reconstruction is done
• If there is complete necrosis of the afferent loop,
pancreaticoduodenectomy will be required.
ACUTE AFFERENT LOOP OBSTRUCTION
Note: This complication is infrequently encountered today,
Clinical Presentation
as many surgeons have learnt not to leave a long afferent
The patient presents with severe upper abdominal loop. The raised levels of serum amylase should not deter
pain, tenderness of the upper abdomen, leucocytosis, the surgeon from operating on these patients.
56 Gastrointestinal Surgery: Step by Step Management

• If the afferent loop is long, it should be divided at


the gastroenterostomy and Roux-en-Y recons-
truction is done (Fig. 7.27)
• If the efferent loop is gangrenous, it will require
division and anastomosis, or a Roux-en-Y recons-
truction (Fig. 7.28).
Note: This complication can be prevented by fixing both
the afferent and efferent loops to the parietal peritoneum
during the first surgery.

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

JEJUNAL LOOP (EFFERENT LOOP) HERNIATION


Clinical Presentation
The patient presents with epigastric fullness, upper
abdominal pain, nausea and vomiting, between 3rd
and 7th postoperative days, but it is more prone to
occur during the long-term follow-up.

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.

Investigations and Diagnosis


Gastrografin study will show obstruction of the
efferent loop, when supplemented by the CT scan, the
diagnosis should be easy.

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.

Investigations and Diagnosis


Markedly elevated serum amylase level is diagnostic.
CT scan is useful in determining the pancreatic inflam-
mation and localization of abscesses.
A B C
Treatment
The management may be medical or surgical. Figs 7.29A to C: Cystoenterostomy (A) Cystogastrostomy,
(B) Cystoduodenostomy, (C) Cystojejunostomy (Roux-en-Y)
58 Gastrointestinal Surgery: Step by Step Management

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

When obstruction like the gallstones are found in the


common bile duct, they have to be removed either by
open surgery (choledochotomy) or by ERCP sphinc-
terotomy and basketing.
Fig. 7.30: Inadvertent gastroileostomy
INADVERTENT GASTROILEOSTOMY (Fig. 7.30)
Clinical Presentation
LONG-TERM COMPLICATIONS
The patient presents with foul belching, profuse OF GASTRIC SURGERY (see Table 7.9)
diarrhoea, and electrolyte disturbances. Rapid weight Excepting a small percentage, majority of the patients
loss occurs along with malnutrition and cachexia. who undergo gastric surgery especially gastrectomy,
have a satisfactory and symptom-free postoperative
Pathology of Complication
period. The undesirable side effects in this 20 to 25
This usually occurs in a poor-risk patient being opera- percent may take place for various reasons such as:
ted in extreme haste under unfavorable conditions, • Loss of gastric tissue
especially under poor anaesthesia by an inexperienced • Bypass, removal or alteration of pyloric sphincter
surgeon. mechanism
Vagotomy performed in addition to gastric surgery
Investigations and Diagnosis also contributes to the development of the compli-
cations for prolonged periods of time. It is to be noted
Gastrografin study will demonstrate the gastro-
that these symptoms form a symptom complex and
ileostomy.
are patient-specific and the same symptom does not
occur in similar patients and also one patient can
Treatment
experience combination of symptoms. This should be
Medical noted clearly as the remedial operation if need to be
Total parenteral nutrition should be used as an adjunct performed, should take care of all the symptoms.
in the preoperative preparation.
ALKALINE REFLUX GASTRITIS
Surgical
Clinical Presentation
Early surgical correction is necessary to prevent death
from electrolyte depletion and multiple organ failure. The patient presents with burning epigastric pain
If the initial operation is gastroileostomy alone, it different from the original ulcer pain before surgery.
should be treated by take down of gastroileostomy The pain is worsened by food intake and bilious
along with vagotomy and antral resection. If it is a vomiting is constantly present, which does not relieve
complication following Billroth II reconstruction, the the pain. The vomitus often contains food mixed with
gastroilestomy should be taken down and a gastro- bile. The symptoms may result in diminished caloric
jejunostomy done or Roux-en-Y reconstruction done. intake, weight loss and anemia.
Chapter 7: Pre- and Postoperative Management in Foregut Surgery 59
Pathology of Complication
The complication is due to the reflux of the duodenal
contents (bile, pancreatic juice and duodenal contents)
producing an irritation of the gastric mucosa.

Investigations and Diagnosis


The diagnosis is made by careful history taking.

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

Table 7.9: Long-term complications of gastric surgery


Long-term complications Time of appearance Reason Management
Alkaline reflux gastritis Few weeks after gastric Gastric mucosal injury due H2 blockers, gastrokinetics,
(60-100% after partial surgery to reflux of bile, pancreatic Roux-en-Y procedure in failure
gastrectomy) juice and duodenal content of medical management
Early dumping syndrome Few weeks after gastric Change in levels of hor- Frequent intake of protein and fat
(begins within 10-30 min surgery (most common mones like neurotensin, rich, low carbohydrate and low salt
of food intake) after partial gastric resection, vasoactive intestinal solid diet with reduced fluid
vagotomy and drainage, peptide, pancreatic poly- intake.
vagotomy and enterectomy peptide, insulin and Interposition of jejunum
and uncommon after glucagon (Fig. 7.33) (iso or antiperistaltic) with
selective vagotomy) vagotomy and various pouch
operations
Late dumping Months and years Reactive hypoglycemia due Frequent intake of protein and fat
(begins 2-4 hours after surgery to release of enteroglucagon rich, carbohydrate low diet with
after food intake) (Fig. 7.39) reduced fluid intake.
Malabsorption Months and years after Due to steatorrhoea caused Pancreatic enzymes
surgery by ‘pancreaticocibal asyn-
chrony’ due to pancreatic
denervation or duodenal
exclusion (Fig. 7.40)
Weight loss Months and years Inadequate food intake due Modify the diet and eating habits
after surgery to the fear of postprandial and also consume a balanced diet
symptoms of dumping, with adequate caloric content
epigastric pain, diarrhoea, preferably by a dietician
severe vomiting and
dysphagia after
vagotomy (Fig. 7.40)
Anemia Months and years Decreased intake of iron or Iron supplements [ferrous sulphate
(Microcytic anemia, after surgery iron malabsorption and/or or ferrous fumarate
iron deficiency anemia) blood loss from mucosa (100-200 mg of iron daily)]
around the anastomosis
Megaloblastic anemia Vitamin B12 deficiency Inj. Cyanocobalamin IM
caused by gastric mucosal 1 mg every 2 months for lifetime
atrophy (Fig. 7.41)
Folate deficiency Oral folate replacements,
10-15 mg daily
Chronic gastric atony Months-years after Loss of gastric vagal Prokinetic drugs, surgery in select
vagotomy innervation (Fig. 7.42) cases
Gastric stasis and Months and years after Gastric outlet obstruction or Surgery to relieve obstruction,
bezoar formation surgery pre-existing gastric motility Fiber digestant or endoscopic/
(trichobezoar, dysfunction (Fig. 7.43) surgical removal of bezoars
phytobezoar, or both)
Small gastric remnant Months and years after Loss of reservoir function Medical management
syndrome surgery (Fig. 7.46) Hunt-Lawrence pouch or
Tanner Roux-19 pouch
Roux stasis syndrome Months and years after Pathology not clear Near total gastrectomy +
surgery (Fig. 7.49) adjustment of the Roux limb
Gastric remnant carcinoma Months and years after Duodenal reflux resulting Radical surgical procedures
surgery in deconjugation of bile salts
in the presence of gastric
hypoacidity
Contd...
Chapter 7: Pre- and Postoperative Management in Foregut Surgery 61

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

EARLY DUMPING SYNDROME • **The vasoactive intestinal hormones responsible


for the vasomotor symptoms are serotonin, gastric
Clinical Presentation
inhibitory polypeptide (GIP), vasoactive inhibitory
The clinical presentation consists of gastrointestinal peptide (VIP) and neurotensin.
and vasomotor symptoms. The symptoms begin
within 10 to 30 minutes of food intake in response to
Investigations and Diagnosis
the ingestion of hyperosmolar, carbohydrate-rich
food. They are: Careful history taking is more useful than laboratory
• Gastrointestinal symptoms* Abdominal fullness, investigations.
crampy abdominal pain, nausea, vomiting and There is no specific investigation to document early
explosive diarrhoea dumping excepting for motility studies by scinti-
• Vasomotor symptoms** Diaphoresis, weakness, graphy using both solid and liquid-phase markers to
dizziness, flushing and palpitations document rapid gastric emptying, but they are not
These may be mild to moderate and may dis- very important. Levels of various hormones like
appear with time. The symptoms may be severe neurotensin, vasoactive intestinal peptide, pancreatic
and refractory to medical treatment. polypeptide, insulin and glucagon are raised, but they
are not diagnostic.
Pathology of Complication (Fig. 7.33)
• *Sudden entry of large amounts of carbohydrate- Treatment
rich liquid in the small bowel leads to fluid shifts Medical
from the intravascular space into the bowel lumen
producing the vasomotor and gastrointestinal Changes in dietary habits like the consumption of
symptoms. frequent small meals with reduction of carbohydrates,
62 Gastrointestinal Surgery: Step by Step Management

Fig. 7.34: Henley’s operation (isoperistaltic transfer)

Fig. 7.33: Pathology of early dumping syndrome

restriction of fluid intake with meals, and restriction


of extra salt are useful in the management.

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

Fig. 7.36A: Triple limb pouch constructed with jejunal


segments and connected

Fig. 7.38: Terrence Kennedy operation for severe dumping

jejunal segment between the gastric remnant and


the Roux-en-Y (Fig. 7.38).
Note: A long follow-up is essential in assessing any
operative procedure for dumping syndrome and
surgery for dumping should be restricted only to those
rare patients with severe symptoms that have lasted
for at least 1 year and are unresponsive to all other
Fig. 7.36B: Triple limb pouch constructed using forms of treatment. The interposition of an antiperis-
Roux-en-Y principle taltic jejunal segment often created gastric retention
and is not advocated by many. It is mandatory to
complete the vagotomy and antral resection in all
cases.

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.

Pathology of Complication (Fig. 7.39)


*The four surgical factors which increase gastric
emptying are:
• Loss of proximal gastric receptive relaxation due
Fig. 7.37: Interposition of reversed jejunal segment to vagotomy
64 Gastrointestinal Surgery: Step by Step Management

MALABSORPTION AND WEIGHT LOSS


Clinical Presentation
The patients present with excessive weight loss,
fatigue and anemia with or without diarrhoea and
usually in the absence of dumping symptoms.

Pathology of Complication (Fig. 7.40)


Malabsorption is more prone to occur with Billroth II
anastomosis if a long afferent loop is constructed, the
stasis in the afferent loop may impair fat absorption
and overgrowth of bacteria. Ineffective mixing of
pancreatic enzyme with food may occur due to the
delay in emptying of the afferent loop.
Fig. 7.39: Pathology of late dumping
Investigations and Diagnosis
• Loss of gastric capacity due to gastric resection
• Loss of control of emptying due to ablation of the Investigations related to malabsorption and anemia
pylorus may be needed to make the diagnosis.
• Loss of duodenal feedback inhibition of gastric
emptying due to duodenal bypass Treatment
**Release of enteroglucagon in response to Medical
carbohydrate diet, sensitizes β cell to stimuli and
causes increased secretion of insulin-producing Modification of diet and eating habits will be useful.
hypoglycemia. Consumption of a balanced diet with adequate caloric
content with addition of pancreatic enzymes will be
useful.
Investigations and Diagnosis
Careful history taking will give the diagnosis. Surgical
Surgical correction consists of conversion of Billroth
Treatment II to Billroth I or a Roux-en-Y diversion, but the sur-
Medical gery is extremely rarely required.

Frequent small quantities of food with reduced


carbohydrate content of the meal with increased
protein component. The attacks may be controlled by
the intake of small quantities of glucose-containing
foods between meals. In patients with striking
symptoms, insulin may be administered before meals
to correct the hyperglycemia and facilitate glucose
absorption by the small intestine.

Surgical
The procedures described for the treatment of early
dumping syndrome may be chosen in select cases, but
the requirement is extremely rare.

Note: As a rule, borborygmi and diarrhoea do not accompany


the late dumping syndrome. Fig. 7.40: Pathology of malabsorption and weight loss
Chapter 7: Pre- and Postoperative Management in Foregut Surgery 65
ANEMIA Pathology of Complication (Fig. 7.42)
Clinical Presentation
These patients present with decreased hematocrit
levels.

Pathology of Complication (Fig. 7.41)


The anemia could be microcytic iron deficiency
anemia or megaloblastic anemia.

Fig. 7.42: Pathology of gastric atony

Investigations and Diagnosis


The diagnosis is based on elimination of mechanical
or functional causes of obstruction. Contrast radio-
graphy demonstrates a distended, flaccid gastric rem-
nant without evidence of mechanical obstruction.
Endoscopy is performed to rule out any mechanical
obstruction. The diagnosis is confirmed by scinti-
graphy, which shows delayed gastric emptying,
especially of solids
Fig. 7.41: Pathology of anemia
Treatment

Investigations and Diagnosis Medical

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.

CHRONIC GASTRIC ATONY BEZOAR FORMATION


Clinical Presentation Clinical Presentation
The patients complain of fullness and pain in the The patients present with upper abdominal pain,
epigastrium and postprandial fullness, nausea and abdominal distension and vomiting. Infrequently,
vomiting of partially digested food eaten hours or days they may present with hematemesis, perforation and
before. malnutrition.
66 Gastrointestinal Surgery: Step by Step Management

Pathology of Complication (Fig. 7.43)


Bezoars consist of mixtures of hair (trichobezoars),
fruit and vegetable matter (phytobezoar), or mixtures
of both (trichophytobezoars).

Fig. 7.45: Removal of trichobezoar by open surgery

SMALL GASTRIC REMNANT SYNDROME


Clinical Presentation
The patient may present with dumping, fullness,
Fig. 7.43: Pathology of bezoar formation epigastric distress, weight loss and nutritional defects.

Investigations and Diagnosis Pathology of Complication (Fig. 7.46)


Ultrasonography and gastroscopy (Fig. 7.44) will help
in the diagnosis. Contrast radiography may
demonstrate a distended, flaccid gastric remnant
without evidence of mechanical obstruction.

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.

Hunt-Lawrence Pouch Operation


The afferent jejunal loop of the Billroth II recons-
truction is divided 10 to 12 cm from the intact
gastrojejunostomy. The end of the 10 to 12 cm segment
is closed and then anastomosed side-to-side to the
efferent jejunal limb, creating a double-limb pouch just
distal to the gastrojejunostomy. The proximal divided
afferent jejunal limb is anastomosed to the efferent
jejunal limb (Roux-en-Y) 60 cm distal to the gastro-
jejunostomy (Fig. 7.47A).
Figure 7.47B shows the operative photograph of
the same pouch.
If the original surgery was Billroth I reconstruction,
Fig. 7.47B: Hunt-Lawrence pouch—operative photograph
the gastroduodenostomy is taken down and the
duodenal stump closed. The jejunum is divided
approximately 15 inches distal to the ligament of Treitz
and the distal end is closed. The long efferent loop is
folded back upon itself and the two adjacent limbs
are converted into a single pouch approximately 10-
12 cm in length. The pouch is anastomosed to the small
gastric remnant. The afferent jejunal limb is
anastomosed end-to-side to the efferent loop
approximately 60 cm below the pouch.
The Tanner 19 reservoir pouch is a circular pouch
connected to the remnant of the stomach, in Roux
principle (Fig. 7.48).
Fig. 7.48: Tanner’s Roux 19 operation for
ROUX STASIS SYNDROME small gastric remnant syndrome

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.

Pathology of Complication (Fig. 7.49)


The exact pathology is not clear, but both the vagoto-
mized gastric remnant and the Roux-en-Y recons-
truction seem to have a role in the development of
this syndrome.
The length of the Roux limb is found to have defi-
nite correlation with delayed transit time through the
intestinal segment.
Transection of the jejunum in the construction of
the limb prevents the propagation of pacesetter poten-
tials resulting in slower transit. Ectopic pacemaker
Fig. 7.47A: Hunt-Lawrence pouch for treatment potentials, which act retrogradely contribute to this
of small gastric remnant syndrome delayed transit.
68 Gastrointestinal Surgery: Step by Step Management

Fig. 7.49: Pathology of roux stasis

Phase III of the interdigestive motor complex are


irregular and their propagation isoperistaltically is
improper resulting in the delayed transit.*
Truncal vagotomy results in the loss of vagal inner-
vation of the jejunum, which results in diminished
strength in jejunal contractions.
Investigations and Diagnosis Fig. 7.50: Uncut roux operation
Investigations to rule out mechanical causes like GASTRIC REMNANT CARCINOMA
barium radiography and endoscopy are essential.
Scintigraphic imaging is the best way to quantitate Clinical Presentation
the delayed emptying of solids and liquids through The patient may present with nausea, loss of appetite,
the gastric remnant and the Roux limb. loss of weight and upper abdominal pain with or
Treatment without vomiting.
Medical
Pathology of Complication
Medical therapy is seldom successful.
The pathology of this complication is not very clear,
Surgical but the reflux of duodenal contents producing
Near—total gastrectomy and adjustment of the length deconjugation of bile salts in the presence of gastric
of the Roux limb to a final length of 40 cm. hypoacidity is suggested.

Prevention Investigations and Diagnosis


“Uncut Roux” gastroenterostomy (Fig. 7.50)—a loop Gastroscopy is diagnostic. It is suggested that the
of gastrojejunostomy is made, the afferent loop is patients undergoing Billroth II anastomosis, should
occluded by staples, which prevents the flow, but have annual or biannual endoscopic examinations
allows normal propagation of intestinal pacesetter with biopsies and cytologic studies of the gastric
potentials to the Roux limb. The afferent and efferent remnant.
limbs are anastomosed in a side-to-side fashion
(entero-enterostomy). With respect to bile flow, this Treatment
functions like a conventional Roux, but the adverse
effects of jejunal transection are avoided. Radical excision of the gastric remnant with lymph
node dissection.
Note: *Phase III is a cyclically recurring pattern of orga- Note: This complication is more common after Billroth II
nized intense motor activity in the fasting state which is reconstruction.
thought to sweep the bowel clear of all residue after the
RECURRENT ULCER
digestion is complete.
It is impossible to reverse the motor abnormalities in Clinical Presentation
the Roux limb by any surgery once the limb has been The patient presents with upper abdominal pain
constructed. relieved by intake of food.
Chapter 7: Pre- and Postoperative Management in Foregut Surgery 69
Pathology of Complication GASTROJEJUNOCOLIC FISTULA
The various causes of this complication are: Clinical Presentation
a. Incomplete vagotomy
The patient presents with marked weight loss,
b. Retained antrum after Billroth II reconstruction
emaciation, diarrhoea and faecal belching.
c. G-cell hyperplasia
d. Gastrinoma Pathology of Complication
e. Multiple endocrine neoplasia
Small anastomotic leaks and abscesses may open into
f. Long afferent loop
the adjacent colon to form a fistula. This will allow
g. Ulcerogenic drugs
the entry of colonic bacterial flora into the proximal
h. Gastric stasis
small bowel, producing fulminant enteritis. Diversion
of small bowel contents into the colon is also a
Investigations and Diagnosis contributing factor.
Gastroduodenoscopy is diagnostic. Investigations and Diagnosis
Gastrografin study of the upper or lower GI tract (Fig.
Treatment 7.51) and gastroduodenoscopy are useful in diagnosis.
The surgical treatment varies according to the
Treatment
previous surgery, and they are:
a. If the original operation is vagotomy with a The treatment consists of vagotomy, a distal 50 percent
drainage procedure, and all other causes of gastrectomy, limited colon resection or closure of the
recurrent ulcer are ruled out, and if the vagotomy colonic fistula (Fig. 7.52). Reconstruction may be
is found to be incomplete, it has to be completed. Billroth I, Billroth II or Roux-en-Y reconstruction.
b. If the gastrectomy (Billroth I or II reconstruction)
was found to be inadequate, additional gastric CHRONIC AFFERENT LOOP OBSTRUCTION
tissue must be excised to approximate 50 percent Clinical Presentation
distal resection (inclusion of antrum) along with
the addition of vagotomy* The patient presents with upper abdominal pain
c. If the original operation is vagotomy and related to consumption of meals, relieved by vomiting
antrectomy, the remedial operation is total
gastrectomy and a Roux-en-Y reconstruction**
d. If the original operation is proximal gastric
vagotomy, reoperation is rarely required, and if
needed, antrectomy with Bilroth I reconstruction
should be done. The proximal gastric vagotomy
may be converted into Truncal vagotomy***
Note
• Recurrent ulcers may be a long-term complication
following any standard operation for duodenal ulcer but
unusual after the surgery for gastric ulcer
• The rate of occurrence of recurrent ulcers after Billroth
I reconstruction is more when compared to after Billroth
II reconstruction*
• It is unusual to encounter a recurrent ulcer following
vagotomy and antrectomy**
• Recurrent ulcers following proximal gastric vagotomy
are small and shallow and can usually be managed with Fig. 7.51: Gastrojejunocolic fistula (barium enema).
drug therapy alone*** Stomach filled with contrast
70 Gastrointestinal Surgery: Step by Step Management

efferent jejunal loop. An internal hernia may also


account for this pathology.

Investigations and Diagnosis


Upper gastrointestinal endoscopy and CT scan are
useful in diagnosis.

Treatment

Fig. 7.52: Operative photograph of gastrojejunocolic fistula


Simple division of the adhesive band may suffice
many times. Rarely conversion of Billroth II to Billroth
which is projectile. The vomitus is bilious and mixed I or construction of Roux-en-Y may be needed.
with food. It may be blood stained, especially in
patients with reflux gastritis. This complication may INTERNAL HERNIA
occur after many years after the primary surgery. Clinical Presentation
The patient presents with acute proximal small bowel
Pathology of Complication
obstruction, and the symptoms are less severe and
This complication occurs after a Billroth II recons- may be intermittent. The vomitus is bile stained if the
truction with a long afferent loop. Intermittent efferent loop is obstructed and it does not contain bile
obstruction is seen when this long redundant loop if the afferent loop is blocked.
undergoes a twist, volvulus or a kink at the gastro-
jejunostomy site. The obstruction is usually mild and Pathology of Complication
corrects itself as the secretions collect in the loops. Only Following an antecolic gastrojejunostomy, a large
when the intraluminal pressure of the afferent loop potential space is created through which a loop of
becomes very high, projectile vomiting occurs. small bowel may herniate, resulting in obstruction.
The loop may be a part of afferent (when the afferent
Investigations and Diagnosis loop is long and redundant) or efferent or both.
Following a retrocolic gastrojejunostomy, two
Upper gastrointestinal endoscopy and CT scan are
potential spaces are created, one located cephalad to
useful in diagnosis.
the transverse mesocolon and the other caudad to the
mesocolon, but the latter is prone to create compli-
Treatment cations.
Conversion of Billroth II to Billroth I or Roux-en-Y
reconstruction is the treatment. Investigations and Diagnosis
Upper GI endoscopy and Barium meal studies are use-
CHRONIC EFFERENT LOOP OBSTRUCTION ful in diagnosis.
Clinical Presentation Treatment
The patient complains of upper abdominal discomfort At surgery, treatment consists in reduction of the
with nausea. Bilious vomiting can also occur, inter- herniated intestine.
mittently. • If the loop is viable, simple closure of anastomotic
traps with interrupted silk sutures and suture of
Pathology of Complication
the afferent and efferent loops of the jejunum to
The blockage is usually mild, intermittent and the posterior parietal peritoneum may be sufficient.
recurrent, but it may create a surgical emergency. The • If the bowel is nonviable and gangrenous, it should
blockage is due to partial or total obstruction of the be resected and anastomosed.
Chapter 7: Pre- and Postoperative Management in Foregut Surgery 71
• If the gastroenterostomy itself is gangrenous, a new Treatment
gastroenterostomy or a Roux-en-Y reconstruction
The treatment consists of reduction of the herniated
may be made.
small bowel and anchor the bowel to the parietes.
Note: Internal herniation occurs less frequently after a • If the bowel is nonviable, resection may be
retrocolic anastomosis. required.
• If the gastroenterostomy itself is gangrenous, a new
JEJUNOGASTRIC INTUSSUSCEPTION gastroenterostomy or a Roux-en-Y reconstruction
Clinical Presentation may be made.
Note: Retrograde jejunogastric intussusception is more
The patient presents with severe upper abdominal
common than the antegrade intussusception.
pain which may be associated with nausea or vomi-
ting. A firm mass may be palpable per abdomen in COMPLICATIONS OF GASTROSTOMY
the epigastrium. (see Table 7.10)
INTRAPERITONEAL LEAK AFTER
Pathology of Complication GASTROSTOMY
Intussusception of the jejunal loop into the gastric Clinical Presentation
remnant.
The patient presents with fever and signs of peritonitis.

Investigations and Diagnosis Pathology of Complication


Barium meal or gastrografin study may reveal a coiled By not fixing or improperly fixing the stomach around
spring appearance in the gastric remnant, a sign the gastrostomy to the parietes, the gastric contents
diagnostic of intussusception. Upper GI endoscopy and the feeds administered through the gastrostomy
may be useful (Fig. 7.53). tube, may leak into the general peritoneal cavity and
result in peritonitis.

Investigation and Diagnosis


Ultrasonography will reveal the leak and collection
of purulent material in the abdominal cavity.

Treatment
It is wise to open the abdomen and do a thorough
peritoneal toileting and refashion the gastrostomy.

EXCORIATION AND INFECTION OF


GASTROSTOMY STOMA
Clinical Presentation
The patient presents with pain and seropurulent
Fig. 7.53: Jejunogastric intussusception (endoscopic view) discharge around the gastrostomy stoma.

Table 7.10: Complications of gastrostomy


Complications Time of appearance Reason Management
Intraperitoneal leak Early post op period Not fixing the stomach Peritoneal drainage and revision
to the parietes gastrostomy
Excoriation and infection Anytime Infection Local care and antibiotics
72 Gastrointestinal Surgery: Step by Step Management

Pathology of Complication Investigations and Diagnosis


The acidic secretions of the stomach along with the No special investigation is required, as the diagnosis
food administered through the gastrostomy tube, may is evident.
regurgitate through the stoma peritubally, and create Treatment
excoriation of the skin. The skin losing its integrity
gets secondarily infected and creates painful discharge Local care of the peritubal area with frequent wiping
of seropurulent material. with wet cotton and administration of appropriate
antibiotics should suffice. The patency of the tube has
to be established. If the tube has not been changed for
a longtime, it is better to replace the tube.
8
Pre- and Postoperative
Management in Midgut
(Small Bowel) Surgery
Variety of operations are performed in the small bowel
for various indications and various situations and they
consist of:
• Enterectomy (resections or removal of segments of small
bowel with or without large bowel) with anastomosis
(ileo-ileostomy/ileocolostomy) to maintain the
continuity by end to end anastomosis, end-to-side
anastomosis or side to side anastomosis (Figs 8.1A
Fig. 8.1A to C: (A) End-to-end ileo-ileostomy, (B) End-to-
to C).
side ileostomy, (C) Side-to-side ileo-ileostomy
• Bypass procedures without resections (ileo-ileostomy/
ileocolostomy—Figs 8.2A and B).
• Enterotomy In some cases the small bowel is opened
and closed back (e.g., removal of foreign bodies).
• Enterostomy or ileostomy connect the small bowel
lumen to the exterior (e.g., feeding jejunostomy,
terminal or end ileostomy, loop ileostomy, loop-
end ileostomy—Figs 8.3A to C).

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).

Correction of Fluid and Electrolyte Imbalance


Figs 8.2A and B: (A) Ileo-ileostomy, (B) Ileo-colostomy
Many times, the pathology of the small bowel is a sur-
prise and they present in an acute form with obstruc-
tion. Such a situation is a surgical emergency, and the
patients have some amount of fluid and electrolyte
disturbances and judicious administration of intra-
venous fluids with electrolytes is important.

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

Table 8.1: Early complications of small bowel surgery


Early Time of Reason Management
complications appearance
Wound infection 2nd-3rd post- Contamination of wound Removal of sutures and allow the pus to
operative day by bowel contents drain, irrigate the wound and appropriate
antibiotic therapy
Anastomotic leak 3rd-5th day Inaccurate apposition of Management of leak
bowel segments and other (see chapter 17)
causes (see chapter 17)
Intra-abdominal 5-10th day Collection of contaminated Drainage under US guidance or open drainage
abscess material in the peritoneal cavity
Chapter 8: Pre- and Postoperative Management in Midgut (Small Bowel) Surgery 75
removed and the wound be allowed to heal by secon-
dary intention.

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.

Surgical Investigations and Diagnosis


Surgical treatment becomes necessary when there is Ultrasonography and CT scan help in diagnosis and
evidence of obstruction, active disease or interruption localising the abscesses.
76 Gastrointestinal Surgery: Step by Step Management

Table 8.2: Late complications of small bowel surgery


Late complications Time of appearance Reason Management

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.

ADHESIONS INTERNAL FISTULAE

Clinical Presentation Clinical Presentation


Internal fistulae may remain asymptomatic when they
The patient presents with recurrent attacks of
involve adjacent bowel loops and when the bypassed
abdominal pain with features of subacute intestinal
obstruction like vomiting, abdominal distension and
or constipation.

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.

Investigations and Diagnosis


Careful history taking and clinical examination will
help in diagnosis. Rarely X-rays of abdomen like
barium meal series and follow-through will help in
diagnosis. Fig. 8.5: Release of adhesions by open surgery
Chapter 8: Pre- and Postoperative Management in Midgut (Small Bowel) Surgery 77
segment is short. Chronic recurrent urinary tract infec-
tions may be the only complication with enterovesical
fistulae (See Chapter 18 also).
Pathology of Complication
This is a sequel to an anastomotic leak and communi-
cation with the neighboring organ or into another
organ as a resolving phase of generalized peritonitis.

Investigations and Diagnosis


Ultrasonography, CT scan with contrast or isotope
scanning are useful diagnostic tools.

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.

EXTERNAL FISTULAE Fig. 8.6: Fistulogram showing the abscess cavity

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

NUTRITIONAL DEFICIENCIES Pathology of Complication


Clinical Presentation This results due to massive resections of small bowel
The patients may present with a variety of symptoms for:
like diarrhoea, steatorrhea, anemia, weight loss, • mesenteric occlusion
abdominal pain, multiple vitamin deficiencies. • midgut volvulus
• traumatic disruption of the superior mesenteric
Pathology of Complication vessels
This is due to stagnation of small intestinal contents Absorption defects may be divided into three
by postoperative complications like stricture, stenosis, categories, they are:
fistulae, blind pouch formation or diverticula. The 1. Vitamin B12—due to the resection of terminal ileum
bacterial flora are altered in the stagnant area, both in 2. Water and electrolytes—due to a very short transit
number and quality. time and watery diarrhoea
• They successfully compete for vitamin B12, pro- 3. Fat:
ducing a systemic deficiency of vitamin B12 and a. gastric hypersecretion in massive resections and
megaloblastic anemia. the low pH in the small bowel interferes with
• When the bacteria in the stagnant area deconjugate fat digestion
bile salts, they disrupt the micellar solubilization b. interruption of the normal enterohepatic circu-
of fats producing steatorrhoea. lation of bile salts resulting in loss of intra-
• They also cause absorptive defects of other macro- luminal absorption of fats
and micronutrients. c. soaps and fatty acids formed during fat diges-
tion, if not absorbed, irritate the colonic mucosa,
Investigations and Diagnosis
further increasing diarrhoea and steatorrhoea
Series of laboratory tests are needed for diagnosis (see
Chapter 15).
Investigations and Diagnosis
Treatment
Diagnosis is very clear with consideration of operation
Medical findings.
When there is no obvious demonstrable obstructive
pathology which is causing the nutritional defi- Treatment
ciencies, medical management with the administration The key to treatment of short bowel syndrome is to
of vitamin B 12 and antibiotics like Ciprofloxacin control diarrhoea and steatorrhea.
(quinolones) may be adequate to treat the altered
bacterial flora. Depending on the deficiency, the Medical
macro- and micronutrients need to be replaced.
Diet Restriction of dietary fat to 30 to 50 gm daily.
Surgical
Drugs Drugs to slow intestinal motility like Lomotil,
If any surgical correctable lesion is found, surgery is Loperamide, Codeine are useful.
indicated for permanent cure.
Note: No nutritional deficits are produced by the resection Bile salts Oral bile salts or their derivatives—Choles-
of the entire jejunum. Loss of the entire ileum is compatible tyramine increase fat absorption.
with essentially normal nutrition, though B12 replacement Intravenous alimentation Parenteral hyperalimentation
will always be necessary since the sole site of absorption is has a definite role in the management, but there is no
the lower ileum and adaptation does not occur. hope for extrahospital existence when resections are
above 60 percent.
SHORT BOWEL SYNDROME
Clinical Presentation Surgical
The patient is severely emaciated and under- Allotransplantation of a segment of intestine is the
nourished. only hope.
Chapter 8: Pre- and Postoperative Management in Midgut (Small Bowel) Surgery 79
ILEOSTOMY maintain sufficient blood supply, to allow the end of
a divided bowel to reach beyond the skin level.
An ileostomy is an opening constructed between the
Occasionally, a previous loop ileostomy may be
small intestine and the abdominal wall, usually by
converted to a loop-end stoma by transection and
using a distal ileum but sometimes more proximal
closure of the efferent limb of the ileum just inside the
small intestine. The surgical construction of an ileos-
peritoneal cavity. In these patients, the mesenteric
tomy must be more precise, than that for a colostomy
defect is not obliterated unless a loop-end ileostomy
because the content is liquid, high volume, and
is constructed during a primary procedure.
corrosive to the peristomal skin. Therefore, the stoma
must be accurately located preoperatively, and it must
have a spigot configuration to allow an appliance to PREOPERATIVE MANAGEMENT
seal effectively and precisely around the stoma, which This largely depends upon the underlying condition
avoids many complications. for which the ileostomy is planned. The surgeon,
There are three types of ileostomy (Figs 8.3A to C), stoma nurse or the ostomate should discuss the impli-
they are: cations of surgery with the patient and his or her
• End ileostomy family, providing reassurance and encouragement.
• Loop ileostomy Most patients will benefit from reading relevant lite-
• Loop-end ileostomy. rature available from local or national stoma
End ileostomy is constructed under various circum- associations.
stances.
• After completion of abdominal colectomy and POSTOPERATIVE MANAGEMENT
proctocolectomy It is usual to fit an appliance as soon as the ileostomy
• Temporary end ileostomy may be done as a staged has been constructed. A well-constructed ileostomy
procedure and later anastomosed to the colon or should allow the patient to display normal physical
rectum, as in inflammatory bowel disease, colonic vigor, to eat a well balanced, palatable diet, and to
trauma, complex colonic fistulae. engage in normal recreational and sexual activity.
• When constructing an ileal conduit for urinary There should be no prolapse or retraction, the skin
diversion. should remain normal, and the appliance should not
Loop ileostomy may be used to provide diversion leak. Between 500 to 800 ml of thick liquid content
(usually temporary) in the following conditions: should be passed per day.
• Above an ileal pouch-anal anastomosis for mucosal
ulcerative colitis or familial polyposis EARLY COMPLICATIONS OF ILEOSTOMY
• Above a continent ileal reservoir (see Table 8.3)
• Above enterocutaneous fistulae, before or after
surgical resection HEMORRHAGE
• As an alternative to colostomy when it is difficult. Clinical Presentation
The advantage of a loop ileostomy is that the
mesenteric vessels are not divided in its construction, The patient presents with oozing of blood from the
so that ischemia is virtually impossible. The major mucosal surface of the ileostomy.
advantage is that the amount of ileal protrusion above
Pathology of Complication
the skin level is limited and the disadvantage is that
with passage of time is more prone to recession than This is due to bleeding from mucosal vessels.
an end stoma.
Investigations and Diagnosis
Loop-end ileostomy may be used as a primary
procedure for the definitive stoma in patients with ileal The diagnosis is obvious and no investigation is
urinary conduits or in obese patients with a thick required, except when a coagulation defect is
abdominal wall, where it would be difficult to anticipated.
80 Gastrointestinal Surgery: Step by Step Management

Table 8.3: Early complications of ileostomy


Early complications Time of appearance Reason Management
Hemorrhage 1st postoperative day Bleeding from mucosal vessels Application of adrenaline-soaked
swab, occasionally ligation of a
mesenteric vessel is required
Mucosal slough 2nd to 5th Ischemia or excessive tension If minor no treatment, otherwise revision
postoperative day Application of tight appliance Release the pressure of the flange
flange

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.

MUCOSAL SLOUGH HIGH OUTPUT


Clinical Presentation
Clinical Presentation
After the patient resumes normal food and liquid
By about the 2nd to 5th postoperative day, the mucosa intake, ileostomy effluent may be in large quantities.
may darken in color and slough.
Pathology of Complication
Pathology of Complication
It may indicate pseudo-obstruction or ileus.
This is due to ischemia or excessive tension on the
ileostomy, or application of tight appliance flange. Investigations and Diagnosis
No specific investigation is required excepting a plain
Investigations and Diagnosis X-ray of the abdomen to rule out obstruction.
No specific investigation is required, and the diagnosis Treatment
is obvious.
Oral fluid restriction and binding agents like
loperamide and lomotil should help.
Treatment
Medical PARASTOMAL SKIN IRRITATION
Clinical Presentation
If the flange of the appliance is tight, it needs to be
changed. If the sloughing is minor, it requires no The patient presents with erythematous or ulcerated
treatment. skin around the stoma, sometimes bleeding.
Chapter 8: Pre- and Postoperative Management in Midgut (Small Bowel) Surgery 81
Pathology of Complication
This may be due to various reasons. They are:
1. Allergy to pouch adhesives
2. Allergy to adhesive tapes
3. Candidiasis
4. Folliculitis
5. Trauma from frequent pouch changes
6. Psoriasis
7. Eczema

Investigations and Diagnosis


Careful examination of the parastomal area and Fig. 8.7: Paraileostomy ulceration
judicious application of mind will help the diagnosis.

Treatment Pathology of Complication

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

Investigations and Diagnosis Surgical


The diagnosis is obvious and introduction of probe If the fistulous opening is far from the ileostomy and
or fistulogram may be of use. interferes with the application of the appliance, it
should be excised surgically with revision of stoma.

Treatment LATE COMPLICATIONS OF ILEOSTOMY


Medical (see Table 8.4)
OBSTRUCTION
If the fistulous opening is close to the ileostomy and
the discharge is within the appliance, no treatment is Clinical Presentation
required. A small modification of the appliance so as The patient may complain of abdominal distension
to encompass the fistula within the appliance may be and vomiting with the relative diminution of ileos-
needed. tomy effluent.

Table 8.4: Late complications of ileostomy


Late complications Time of appearance Reason Management
Obstruction Months-years after surgery Bolus obstruction Irrigation with 100 ml warm saline
Intra-abdominal adhesions Adhesion release
stenosis Local repair
Stenosis Months-years after surgery Tight opening in the abdominal Local repair
wall or is secondary to healed
ulcerations
Recession Months-years after surgery Too large abdominal opening or Local repair
inadequate fixation of the ileum
at the fascial plane
Retraction Months-years after surgery Insufficient intestine being used Surgical repair if obstruction results,
for the construction of stoma or a formal laparotomy may be needed
inadequate fixation of the ileum with mobilization of mesentery and
at the fascial plane refashioning of stoma
Prolapse Months-years after surgery Excessive length of small bowel Local repair
or inadequate fixation of the
mesentery within the abdomen
Parastomal Months-years after surgery Large opening of the abdominal Reduce the sac and local repair
hernia stoma site
Excessive Months-years after surgery Misjudgment of the length Local repair
length of stoma of bowel
Parastomal Months-years after surgery Mucocutaneous suture line Drainage of abscesses
abscesses breakdown/when a hematoma
becomes infected
Parastomal fistula Months-years after surgery Pressure of the appliance, Increase flange size
Deep mucocutaneous sutures If far away, fistulectomy and
reconstruct the stoma
Ulceration Months-years after surgery Mechanical pressure by the Local treatment
appliance
Granuloma Months-years after surgery Mechanical pressure by the Excision and cauterization
appliance
Chapter 8: Pre- and Postoperative Management in Midgut (Small Bowel) Surgery 83
Pathology of Complication Treatment
Bowel obstruction may occur at any time because of Medical
various reasons. They are:
1. Adhesions Dilatation may be due using a finger (Fig. 8.9) or metal
2. Volvulus dilators (Fig. 8.10).
3. Entrapment of ileum in the fascial closure
Surgical
4. Food bolus obstruction
5. Recurrent disease (Crohn’s disease). Local repair may have to be done, by mobilizing the
terminal ileum and refashioning (Fig. 8.11). The
Investigations and Diagnosis operative photograph is shown in Figures 8.12A and B.
Plain X-ray may show distended small bowel loops.

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.

Investigations and Diagnosis


The diagnosis is obvious.

Fig. 8.8: Stenosis of ileostomy Fig. 8.10: Dilatation of stenosis with a metal dilator
84 Gastrointestinal Surgery: Step by Step Management

Fig. 8.11: Ileostomy stenosis repair

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.

Investigations and Diagnosis


The diagnosis is obvious and needs no investigation.

Treatment
A
Local repair (Fig. 8.14).

Fig. 8.13: Recession of ileostomy

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

PROLAPSE PARASTOMAL HERNIA


Clinical Presentation Clinical Presentation
The stoma appears to be very much above the surface The patient presents with a swelling at the parastomal
and the mucosa may get ulcerated recurrently by region, which may interfere with the application of
coming in contact with the appliance (Figs 8.15A the appliance.
and B).
Pathology of Complication
Pathology of Complication This may be due to the abdominal opening being large.
This is because of a long loop of small bowel fashioned Investigations and Diagnosis
outside the skin for creation of ileostomy.
The diagnosis is obvious.
Investigations and Diagnosis Treatment
The diagnosis of prolapse is obvious. Local repair (Fig. 8.17). The stoma is detached from
the mucocutaneous junction and ileum mobilized to
Treatment
the fascial level. A transverse ‘help’ incision is made
Local repair (Fig. 8.16). The ileum is detached at the in the skin, the hernial sac identified and reduced and
mucocutaneous junction, eversion of stoma reduced, the stoma is refashioned after closing the ‘help’
amputated to the required length (effective length of incision. A “Mercedes” repair (Fig. 8.18) may be
3 cm) and resutured mucocutaneously. required in some cases.
86 Gastrointestinal Surgery: Step by Step Management

amputated to the required length (effective length of


3 cm) and resutured mucocutaneously.

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.

Investigations and Diagnosis


The diagnosis is obvious.

Treatment
Drainage of abscesses.

Fig. 8.18: Mercedes repair PARASTOMAL FISTULA


EXCESSIVE LENGTH OF STOMA Clinical Presentation
Clinical Presentation The patient may present with a discharging sinus
The stoma appears to be very much above the surface wound anywhere around the ileostomy.
and the mucosa may get ulcerated recurrently by
Pathology of Complication
coming in contact with the appliance.
This may occur as a result of suturing of the bowel
Pathology of Complication wall to the rectus fascia by a deeper full-thickness
This is because of a long loop of small bowel fashioned stitch.
outside the skin for creation of ileostomy.
Investigations and Diagnosis
Investigations and Diagnosis The diagnosis is obvious and introduction of probe
The diagnosis of prolapse is obvious. or fistulography, ileography and ileoscopy may be of
use in locating the fistulae or in diagnosing recurrent
Treatment Crohn’s disease.
Local repair (Fig. 8.19) The ileum is detached at the
mucocutaneous junction, eversion of stoma reduced, Treatment
Medical
If the fistulous opening is close to the ileostomy 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.

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.

Investigations and Diagnosis


Biopsy of the ulcer may be required if the healing is
delayed.

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

• retention of faeces due to faulty siting of tube


• retention of faeces due to slipping of tube asso-
ciated with edema of the valve
The tube may be manipulated further into the
reservoir with care. Injection of water-soluble contrast
will give an outline of the reservoir and show the posi-
tion of the valve. If the siting of the catheter is found
Fig. 8.22: Koch’s pouch: The pouch is constructed out of ‘U’ to be satisfactory, conservative treatment is continued.
loop of ileum; the valve is a reversal intussusception of ileum If the ileostomy continues to be inactive beyond five
and the stoma is placed inconspicously in the lower abdomen or six days, the need for re-operation will arise.
The tube is kept in position for at least three to four
The creation of a reservoir does not normally alter weeks. At the end of this period, it is useful to have a
the function of the portion of the ileum involved, ‘pantaloonogram’ made after a small gentle injection
although stagnant loop syndrome and ileitis have been of gastrografin into the reservoir. Intermittent
recorded. The reservoir is emptied twice daily by the clamping of the tube is done for ten minutes every
introduction of a catheter, which can damage or three hours for seven to ten days. After four weeks,
perforate the bowel and a further complication, is the indwelling tube is withdrawn and intermittent
failure of the valve to function satisfactorily. Free of intubation practised, at every three hours during the
complications, however, the procedure can prove very day and once at night. The night intubation may be
acceptable to the patient. omitted gradually and the day intubations are done
rather frequently.
POSTOPERATIVE MANAGEMENT The convenient tube for intermittent intubation is
a translucent plastic tube, of 28F. While the patient
The postoperative management after reservoir
stands or sits, the lubricated tube is introduced into
ileostomy follows basically the same care given after the stoma, directed backwards, inwards and slightly
major abdominal surgery in general. downwards, or in whatever direction the patient is
Intravenous fluids are administered for a few days experienced. When the reservoir is entered, usually
or longer depending on the occurrence of the paralytic at a depth of about 7 to 10 cm, there is a gush of
ileus. intestinal contents along the tube, the external end of
Oral feeds are limited to clear fluids until there is which is held over a mug or kidney tray to catch the
a free discharge of faeces from the ileostomy. discharge. Emptying is assisted by to-and-fro
movement of the tube combined with a little pressure
Management of Continent Ileostomy by the other hand on the lower abdomen. If the faeces
The patient comes back from the operation theatre are thick, the tube may need frequent washes or the
with a plastic catheter tied in the ileostomy and reservoir itself may require some washes through the
connected to a urinary bag for continuous drainage, tube. The overall time for complete evacuation of the
and this needs special care. reservoir varies from 10 to 15 minutes. Between
The ileal mucosa exposed at the stoma needs to be intubations, if perfect continence is achieved, the
stoma is simply covered with a piece of dry gauze
examined periodically for the first 24 to 36 hours for
and strapping. If there is leakage of faeces, ordinary
its pink color establishing its viability. The discharge
ileostomy bag may be worn for some part of 24 hours.
through the tube is generally blood stained for the first
two or three days, discharging about 50 to 100 ml
EARLY COMPLICATIONS OF CONTINENT
daily. Without complications, the fluid assumes a ILEOSTOMY (see Table 8.5)
faecal character and thenceforth it is satisfactory. When
the faecal material fails to appear associated with LEAKAGE FROM SUTURE LINE IN THE
abdominal distension, with persistent nasogastric RESERVOIR WITH PERITONITIS
aspirate, the following are to be considered:
Clinical Presentation
• paralytic ileus
• mechanical obstruction of small bowel proximal The patient may present with tachycardia, abdominal
to the reservoir distension and signs of peritonitis.
Chapter 8: Pre- and Postoperative Management in Midgut (Small Bowel) Surgery 89
Table 8.5: Early complications of continent ileostomy
Early complications Time of appearance Reason Management
Leakage from suture line in Early postoperative period Suture line breakdown Relaparotomy, repair of suture line.
the reservoir with peritonitis Removal of reservoir and conven-
tional ileostomy or a proximal loop
ileostomy
Necrosis of the exit conduit Early postoperative period Decreased vascularity Generally subside on its own to form
of the conduit a contracted track requiring dilatation

Pathology of Complication Treatment


This may be due to breakdown of suture line due to Medical
avascularity or increased tension at the suture line.
Many of them subside on their own and recover fully.
Investigations and Diagnosis Those recovered develop a granulating track without
epithelial lining leading to the reservoir and contracted
CT scan may show collection of fluid around the track which requires frequent dilatations.
reservoir suture line, but clinical diagnosis is the most
important. Surgical
If they become incontinent, reoperation should be
Treatment performed to construct a new valve.
Medical LATE COMPLICATIONS OF CONTINENT
Small leaks may resolve without any special treatment, ILEOSTOMY (see Table 8.6)
excepting the administration of antibiotics. FAECAL INCONTINENCE

Surgical Clinical Presentation

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

Table 8.6: Late complications of continent ileostomy


Early complications Time of appearance Reason Management
Faecal incontinence Late postoperative period Partial or complete extrusion of Minor incontinence, intermittent
valve or perforation or fistula intubation, major incontinence
through the valve wearing of an ileostomy bag
Leakage of Late postoperative period Discharging abscess, ileitis Use of pads with frequent changing
mucoid material
Retention Late postoperative period Extrusion of valve Dilatation with tube or finger,
reconstruction of valve in severe
cases
Stomal stenosis Late postoperative period Necrosis of exit conduit or Dilatation in mild cases, revision of
extrusion of valve due to conduit in severe cases
avascularity
Profuse diarrhoea Late postoperative period Reservoir ileitis or bacterial Antibiotics
overgrowth (Stagnant loop
syndrome)
Volvulus of Late postoperative period Twist of reservoir around its axis Laparotomy—simple untwisting
reservoir and fixing, reconstruction of
reservoir in some cases

When the incontinence is gross, intubation is never Pathology of Complication


easy as the exit conduit is angulated due to the extru-
This may occur due to:
ded valve, and wearing an ileostomy bag is the only
• discharging abscess
option.
• local ileitis.
Surgical
Investigations and Diagnosis
Various surgical procedures are available when the
This may be diagnosed using a narrow-bore sigmoi-
incontinence is gross. They are:
doscope.
• reconstruction of the original nipple-valve
• construction of a new nipple-valve Treatment
• excision of reservoir and construction of a new
reservoir with a new nipple-valve No effective treatment is available, excepting to
• use of indwelling ileostomy valve device. suggest using pads and change frequently.

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.

Various surgical procedures are available when there VOLVULUS OF RESERVOIR


is definite extrusion of valve. They are:
Clinical Presentation
• reconstruction of the original nipple-valve
• construction of a new nipple-valve The patient presents with severe abdominal pain and
• excision of reservoir and construction of a new reduction of the ileostomy output.
reservoir with a new nipple-valve
• use of indwelling ileostomy valve device. Pathology of Complication
This occurs due to twisting of the reservoir around its
STOMAL STENOSIS axis.
Clinical Presentation Investigations and Diagnosis
The patient presents with diminished output from the Plain radiographs may show reservoir with air fluid
ileostomy passing out with difficulty. levels.

Pathology of Complication Treatment


The treatment is surgical by laparotomy. If the bowel
This occurs due to sloughing of exit-conduit and
nipple valve due to avascularity. is viable, simple untwisting and fixation to the parietes
should be adequate. If the reservoir is necrosed, it
Investigations and Diagnosis needs to be excised with a reconstruction of new
The diagnosis is obvious visible externally. reservoir or a simple conventional end ileostomy.
Park’s pouch is the created pouch which is
Treatment anastomosed to the anal epithelium, transanally either
Medical manually or using a stapling device. This overcomes
the difficulties of the nipple valve and the ever-present
This can be managed generally by repeated dilatations ectopic anus (Figs 8.23A and B).
for very long periods of time.

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 complications of Park’s pouch are: EARLY COMPLICATIONS OF APPENDICECTOMY


1. Cuff abscesses between the mucosal tube that (see Table 8.7)
remain after rectal excision.
HEMORRHAGE
2. Leaking anastomotic lines leading to pelvic
abscess, septicemia. Clinical Presentation
3. Stenosis of ileoanal anastomosis. The patient may present with severe pain and tender-
4. Pouchitis. ness in the right iliac fossa, with signs of localized
5. Recurrent intestinal obstruction. peritonitis.
APPENDIX
PREOPERATIVE MANAGEMENT Pathology of Complication

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

POSTOPERATIVE MANAGEMENT Investigations and Diagnosis


Nasogastric aspiration is not needed for surgery of Ultrasonography or CT scan will be of use in diagnosis.
simple infections of the appendix, excepting when
there is severe peritonitis and additional procedures Treatment
are performed.
Exploration of the operated area along with ligation
Postoperative Complications of of mesoappendix once more and wound closed with
Appendicectomy and Management a generous tube drain.

The large difference between the usually smooth PARALYTIC ILEUS


postoperative course after appendicectomy of early
Clinical Presentation
acute appendicitis and the stormy recovery that so
often accompanies the removal of a gangrenous The patient presents with abdominal distension and
appendix emphasizes the importance of early sometimes vomiting, and examination of the abdomen
diagnosis and treatment. reveals absent bowel sounds.

Table 8.7: Early complications of appendicectomy


Early complications Time of appearance Reason Management
Hemorrhage 2-3rd postoperative day Leakage from the stump or Exploration, ligation of meso-
slipped arterial ligature appendix once more and wound
closed with a generous tube drain
Paralytic ileus Early postoperative period Accompaniment of peritonitis Gastric aspiration, intravenous
or electrolyte disturbances fluids, antibiotic therapy
Septic complications
Wound abscess 5th-7th postoperative day Local infection Removal of a suture and gentle
probing to release pus
Pelvic abscess 7th-10th postoperative day Resolving localized peritonitis Transrectal drainage and antibiotics
Subphrenic abscess 7th-10th postoperative day Resolved generalized peritonitis Ultrasound–guided drainage and
antibiotics
Rupture of stump Few days after appendicec- Sloughing of caecal wall or Immediate laparotomy and
or caecal wall tomy administration of enema in caecostomy
the postoperative period
Chapter 8: Pre- and Postoperative Management in Midgut (Small Bowel) Surgery 93
Pathology of Complication
This may be due to:
• Peritonitis
• Electrolyte imbalances—hypokalemia (in patients
with vomiting).

Investigations and Diagnosis


Examination of the abdomen shows absent bowel
sounds indicating a delayed recovery of the small
bowel motility, and estimations of serum electrolyte
levels. Plain X-ray of the abdomen shows distended
loops of small bowel (Fig. 8.24).

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.

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 (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

Investigations and Diagnosis


Ultrasonography and CT scan help in diagnosis and
legalizing the abscesses.

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.

Fig. 8.27: Caeco-cutaneous fistula (post-appendicectomy)


Pathology of Complication
Postoperative adhesions in the operated area can cause
such symptoms.
LATE COMPLICATIONS
OF APPENDICECTOMY (see Table 8.8) Investigations and Diagnosis
HERNIA Careful history taking and clinical examination will
Clinical Presentation help in diagnosis. Rarely X-rays of abdomen like
barium meal series will help in diagnosis.
The patient presents with boggy swelling in the
operated area with or without pain. Treatment
Medical
Pathology of Complication
Medical management should suffice in most cases.
The weakness of the muscular structures in the
operated area and causes which increase intra-abdo- Surgical
minal pressure like chronic cough, chronic sneezing, Release of adhesions by open surgery or by
bronchial asthma, and chronic constipation. laparoscopy may be needed in some cases.

Investigations and Diagnosis INFERTILITY (IN WOMEN)

The diagnosis is obvious. Clinical Presentation


Inability to conceive by women who have had
Table 8.8: Late complications of appendicectomy appendicectomy in younger age.
Late Time of Reason Management
Pathology of Complication
complications appearance
Hernia Years later History of Surgical repair Postoperative adhesions and resultant damage to the
prolonged fallopian tube.
sepsis
Investigations and Diagnosis
Intestinal Years later Adhesions Surgery if needed
obstruction Investigations related to infertility and a diagnostic
Infertility Years later Adhesions Laparoscopy and laparoscopy is of great help in such patients.
(in women) and tubal adhesion release
damage and treatment of Treatment
female infertility Treatment for infertility.
9
Pre- and Postoperative
Management in Hindgut
(Colon, Rectum and Anus) Surgery
Variety of operations are performed in the large bowel
and rectum for various indications and various
situations and thfey consist of (Fig. 9.1):
• Colectomy (resection or removal of segments or whole
of the large bowel) with anastomosis to maintain the
continuity.
• Bypass procedures without resections (continuity
maintained by ileocolostomy or colocolostomy).
• Colotomy—in some cases, the large bowel is opened
and closed back (e.g., removal of foreign bodies).
• Colostomy—connect the large bowel lumen to the
exterior (e.g., terminal or loop colostomy).

PREOPERATIVE PREPARATION OF LARGE


BOWEL IN ELECTIVE SURGERY
It should be remembered that the colon should always
be empty when elective operation on the colon is
undertaken. The colon needs to be cleansed:
i. mechanically
ii. bacteriologically and
iii. chemically.

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)

Table 9.1: Early complications of perineal surgery


Early complications Time of appearance Reason Management
Early hemorrhage 1st to 2nd postoperative day Inadequate replacement of blood Appropriate amount of blood
and shock after replacement, re-exploration if
abdomino- necessary
perineal resections
Rupture of pelvic 1st to 2nd postoperative day Giving way of the sutures of Suture of peritoneum with support
peritoneum the pelvic peritoneum from below
Infection of 3rd to 5th postoperative day Contamination of the anal Removal of sutures, drainage and
perineal wound contents irrigation
Necrosis and 7th-10th postoperative day Pressure on the sacral region Open the wound fully and allow to
separation on the perineal wound by sitting heal or secondary suturing
Chapter 9: Pre- & Postoperative Management in Hindgut (Colon, Rectum & Anus) Surgery 99
EARLY HEMORRHAGE AND SHOCK Treatment
Clinical Presentation Surgical
The patient presents with signs of shock like The treatment is always surgical. If the affected loop
tachycardia and hypotension. is nonviable, it will have to be resected. It may be
possible to close the gap in the peritoneum by simple
Pathology of Complication suturing or assisted by omental graft. The pelvic
This generally results from inadequately replaced peritoneum should be well supported by a gauze pack
blood loss from the pelvic cavity. Though the raw inside a plastic bag inserted into the pelvic cavity from
surfaces of this cavity appear perfectly dry imme- below for four to five days. Rarely, it may be possible
diately before the conclusion of abdominal part of the to push the bowel from below and suture the pelvic
surgery, a fair amount of oozing of serosanguinous peritoneum with support from below.
fluid is not uncommon for 2 to 3 days after surgery,
INFECTION OF PERINEAL WOUND
occasionally a brisk hemorrhage.
Clinical Presentation
Investigations and Diagnosis
The patient presents with discharging perineal wound
The loss is difficult to assess, and there is a tendency (sometimes stitch abscesses) around the 3rd-5th
to undertransfuse. postoperative day.

Treatment Pathology of Complication


Adequate amount of replacement of blood is all that Infection of the wound occurs due to handling of
is necessary. If the bleeding persists at a considerable anorectum and soilage of the peritoneum by contents
rate, re-exploration of the perineal wound is necessary. of the anorectum.
Note: This complication is common after perineal surgery
Investigations and Diagnosis
associated with colorectal surgery.
The pathogenic organism should be isolated in culture.
RUPTURE OF PELVIC PERITONEUM
Treatment
Clinical Presentation
Local care with dressings and administration of
The patient in the postoperative period presents with
systemic antibiotics. The suture or staple should be
small bowel projecting through the perineal wound,
removed and the wound be allowed to heal by
or may become visible when dressings are changed.
secondary intention.
The patient may present with severe abdominal pain
with a sensation of something ‘giving way.’ Note: This is a well-known complication of perineal wound
(as an adjunct to colonic surgery as in abdomino-perineal
Pathology of Complication resections).
Though extremely rare, it has occurred, with the onset
Clinical Presentation
due to separation of the sutured pelvic peritoneum,
following a strain such as an episode of violent cough- The patient may develop separation of the wound
ing or sneezing. edges.

Investigations and Diagnosis Pathology of Complication


The prolapsed loop of bowel may be visible through Pressure on the perineal wound by sitting may cause
the perineal wound, but it is diagnosed from the abdo- separation of wound edges. Despite the avoidance of
minal side. pressure on the perineal wound by not allowing the
100 Gastrointestinal Surgery: Step by Step Management

patient to sit on the sacral region during the early Treatment


postoperative period, necrosis of the perineal skin or
Medical
separation of wound edges (due to avascularity of skin
edges) may still take place, particularly in elderly Urgent treatment with replacement of blood and/or
debilitated individuals. plasma, with massive therapy with broad-spectrum
antibiotics particularly effective against coliform
Investigations and Diagnosis organisms is necessary.
The diagnosis is obvious.
STENOSIS
Treatment Clinical Presentation
It is best to open the wound fully and allow to heal by The patient presents with a stenosis or narrowing of
secondary intention; and if the wound is deep, it is the scar.
better to resuture the wound after trimming the edges.
Pathology of Complication
LATE COMPLICATIONS OF PERINEAL SURGERY This results when the perineal wound is managed on
(as an adjunct to colorectal surgery) (see Table 9.2) the “open” regime, resulting in a narrowing either as
LATE HEMORRHAGE AND SHOCK an hourglass constriction of the wound cavity or as a
stenosis at the skin level.
Clinical Presentation
Investigations and Diagnosis
The patient presents with signs of shock some days or
weeks after surgery. No special investigation is required.

Pathology of Complication Treatment

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.

Investigations and Diagnosis PERSISTENT SINUS


Determination of levels of hemoglobin, packed cell Clinical Presentation
volume and blood cultures are useful, but time is The patient presents with a discharging wound in or
limited. around the perineal scar.

Table 9.2: Late complications of perineal surgery


Late complications Time of appearance Reason Management
Late hemorrhage Some days or weeks Sepsis of perineal wound Massive blood transfusions and
from perineal after surgery immediate exploration of perineum
wound after
abdomino-perineal
resections
Stenosis Months after surgery Open management of the Incision of the stenosis
perineal wound
Persistent sinus Months after surgery Retention of foreign material Exploration of the sinus and
like gauze in the wound adequate treatment
Perineal or sacral Months after surgery Lax perineum Repair procedures
hernia
Local recurrence Months-years after surgery Spillage or left over tumor tissue Radiotherapy
Phantom rectum Months-years after surgery Not known Firm reassurance
Chapter 9: Pre- & Postoperative Management in Hindgut (Colon, Rectum & Anus) Surgery 101

Pathology of Complication LOCAL RECURRENCE


This is due to: Clinical Presentation
• faulty healing of the perineal wound as the skin The patient may present in various ways. They are:
edges may invaginate in the healing granulation. • Pain in the perineal wound
• may be due to retention of foreign material like • Pain in the sacral or sciatic regions
swab. • Local swelling with induration
• infection of sacrum producing osteomyelitis with • Abscess
sequestrum formation. • Discharging fistula
• recurrence of growth in the pelvic cavity. • Edema of lower limbs
• Urinary symptoms.
Investigations and Diagnosis
The sinus needs to be explored or sinogram may be Pathology of Complication
needed. Any granulation tissue to be biopsied to rule Residual or spillage of tumor cells in the area will pro-
out chronic granulomatous diseases like tuberculosis duce the local recurrence.
or malignancy.
Investigations and Diagnosis
Treatment
It may be confirmed by radiological examination
The sinus may be curetted with the administration of showing destruction of sacrum, and exploration does
appropriate antibiotics, if local recurrence is docu- not yield any better result, as the above symptoms
mented, wide excision is needed. may be due to various other causes also.

PERINEAL OR SACRAL HERNIA Treatment


Clinical Presentation If local recurrence is documented, it is better to
administer radiotherapy locally.
The patient presents with a bulge in the perineal
region, more commonly in females than males. This
PHANTOM RECTUM
may be symptomless or give rise to a dragging sensa-
tion in the perineum on standing or walking. Clinical Presentation

Pathology of Complication The patient presents with the complaints of wanting


to pass faeces or flatus by the natural route. Sometimes
This happens when the pelvic peritoneum is left the rectal sensation is felt when the colostomy acts.
unsutured as in extended excisions and pelvic clear-
ance operations. Pathology of Complication

Investigations and Diagnosis The cause is unknown.

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

Table 9.3: Early complications of colonic surgery


Early complications Time of appearance Reason Management
Wound infection 2nd-3rd postoperative day Contamination of wound Removal of sutures and allow the
by colonic contents pus to drain, irrigate the wound
and appropriate antibiotic
therapy
Intra-abdominal 5th-10th postoperative day Collection of contaminated Drainage under US guidance
abscess material in the peritoneal cavity
Anastomotic 3rd-5th postoperative day Inaccurate apposition of colonic Management of leakage
leakage segments and other cause (see Chapter 17)
(see Chapter 17)
Urinary fistula Days after surgery Injury to the ureter, Appropriate surgical treatment
bladder or urethra

EARLY COMPLICATIONS OR COLONIC are also a frequent cause of intra-abdominal abscess


SURGERY (Table 9.3) formation.
WOUND INFECTION
Investigations and Diagnosis
Clinical Presentation
Ultrasonography (Fig. 9.2) and CT (Fig. 9.3) scan help
The patient presents with discharging wound around in diagnosis and localizing the abscesses.
the 2nd-3rd postoperative day.

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

Fig. 9.3: CT scan showing right paracolic abscess

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.

Table 9.4: Late complications of colonic surgery


Late complications Time of appearance Reason Management
Adhesions Months-years after surgery Postoperative fibrinous exudates Conservative and if it fails
adhesiolysis
Internal colonic Months-years after surgery Small anastomotic leaks creeping Some may require revision surgery
fistulae into the adjoining organs
External colonic Months-after surgery Anastomotic leaks draining to Management of fistulae
fistulae (colo- the exterior (see Chapter 18)
cutaneous fistulae)
Disorders of Months-years after surgery Injury to parasympathetic inner- No specific treatment
sexual function vation or to nervi erigentes
Intestinal Late postoperative period Mechanical obstruction of Surgery
obstruction small bowel
Chapter 9: Pre- & Postoperative Management in Hindgut (Colon, Rectum & Anus) Surgery 105

INTERNAL COLONIC FISTULAE Investigations and Diagnosis


Clinical Presentation Diagnosis of colocutaneous fistula is very easy. The
main symptoms and signs of a colocutaneous fistula
Internal colonic fistulae like colovaginal fistulae
are self-evident with the passage of flatus and faeces
present with vaginal discharge of faecal matter. The through an incision on the abdominal wall following
volume varying from a small stain to profuse surgical resection.
discharge. Coloenteric fistulae present with abdominal Though not helpful, proctoscopy should be per-
pain and diarrhea and a mass is usually found on formed to exclude underlying pathology. Barium
physical examination. enema with thin water-soluble contrast may demons-
trate the fistula. A CT scan with contrast may be of
Pathology of Complication use in some cases. Fistulogram may give required
This is a sequel to an anastomotic leak, leading to information as to the origin of the fistula and asso-
abscess and fistula formation, communicating with the ciated abscesses.
neighboring organ or into another organ as a resolving Treatment
phase of generalized peritonitis.
Medical
Investigations and Diagnosis If the output from a leaking colorectal anastomosis is
low and not associated with an abscess cavity, it may
Diagnosis of internal colonic fistulae is straight- be expected to close without surgical intervention.
forward, recognized by the discharge of faecal matter Closure frequently occurs while the patient is allowed to
through the output of the organ with which it is linked. eat a normal diet. Higher output fistulae may close more
Ultrasonography, CT scan with contrast or isotope quickly and conveniently with parenteral nutrition
scanning are useful diagnostic tools. and having the patient avoid eating. Since there is a
large colonization of bacteria, administration of wide-
Treatment spectrum antibiotics to cover coliform organisms is
Surgical necessary. The skin around the fistulous opening
needs to be given special attention and appliances may
Treatment of internal colonic fistulae is surgical, be applied to collect the effluent.
because they link normally sterile organs with the gut.
In patients who are not septic or hypoalbuminaemic, Surgical Treatment
resection and primary anatomosis after good bowel Surgical treatment like proximal diversion is useful
preparation should be adequate. In patients who are in certain situations. An ileostomy is preferred over a
septic and hypoalbuminemic and anemic, resection colostomy. When a colostomy is considered, it
and exteriorization is the safest procedure. involves the transverse colon because sigmoid has
been resected. The diverting stoma is kept for a
EXTERNAL COLONIC minimum of 3 months.
(COLOCUTANEOUS) FISTULAE
DISORDERS OF SEXUAL FUNCTION
Clinical Presentation Clinical Presentation
Patients with colocutaneous fistulae present with The patient may complain of impotence or failure of
fever, abdominal mass, obstruction, rectal bleeding ejaculation.
and peritonitis. They have obvious feculent discharge
through the drain site or through the main wound. Pathology of Complication
Injury to the parasympathetic innervation and also
Pathology of Complication
direct injury to the stems of the nervi erigentes are
This is due to the leak of colonic anastomosis or considered to be the causes of impotence, and injury
necrosis of large intestine due to intra-abdominal to the nerve supply of seminal vesicles is known to
abscess, ultimately forming a fistula to the exterior. cause failure of ejaculation.
106 Gastrointestinal Surgery: Step by Step Management

Investigations and Diagnosis


Investigations relating to impotence may be done.

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

Fig. 9.7: Siting of colostomy stoma

• The stability of the appliance should not be


compromised when the patient moves or changes
position
• The stoma site must be visible to the patient for
care and if below the umbilicus, it must be sited
on the summit of the infra-umbilical rectal mound.
Effectively, there are four suitable stoma sites over
the flat surface of the rectus above or below the
umbilicus (Fig. 9.7).
Sometimes, the stoma may have to be created at
nonconventional sites, but the unsuitable sites have
to be avoided for proper stoma care (Fig. 9.8).
There are four main types of colostomy (Figs 9.9A
to D):
i. Loop colostomy
ii. Double barreled colostomy
iii. Divided colostomy (Devine’s)
iv. Terminal colostomy. Fig. 9.8: Unconventional site for ileostomy

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

PREOPERATIVE MANAGEMENT OF and particularly also if flatus is being passed freely. It


COLOSTOMY is useful to insert a finger in the stoma to make sure
that the bowel is not being constricted by the
When circumstances allow, a full bowel preparation
abdominal wall. Sometimes, withdrawal of the finger
is preferable. Many of the conditions, however, in
is followed by a burst of flatus or a gush of faeces. A
which a loop stoma is constructed are ‘urgent’ or
bisacodyl suppository may be inserted into the
‘emergency’ in nature, which precludes bowel
colostomy to initiate the action, and sometimes a
preparation. Preoperative systemic antibiotics are
colostomy wash out.
given against aerobic and anaerobic organisms.
It is usual to fit an appliance as soon as the colos-
Allaying the Patient’s Fears and tomy has been constructed. As the effluent from a
Misapprehensions transverse loop colostomy may be somewhat liquid,
codeine phosphate, loperamide or other constipating
It is the surgeon’s responsibility to see that the patient
agents may be useful.
is properly instructed in the care of the colostomy. The
With a terminal colostomy, particularly in a
aim of the surgeon and the staff is to teach and prepare
younger and motivated patient, there is much to
the patient so that he is able to look after his colostomy
recommend colostomy irrigation for long-term
entirely by himself by the time he is discharged from
management, after the patient has completely reco-
the hospital.
vered from surgery.
Since an average lay person is repelled by the
If the technique of immediate suture of the end of
thought of an artificial anus and sometimes it may
the colon to the skin edges with silk stitches has been
require repeated explanations to induce him to accept
employed, the sutures should be removed on the
this. Sometimes a talk with another patient who has a
seventh to tenth day.
well-established colostomy may be required to
convince the patient. It should be emphasized further Long-term Colostomy Management
that very many patients have been able to return to It should be understood that a colostomy is a sphinc-
their previous occupations and activities and also not terless opening, and the aim of its management is to
been debarred from recreation and social life. It should enable the patient to cope with this incontinent anus
be made clear that they can play active games like with the minimum of soiling and inconvenience.
golf, cricket, tennis and even swimming, of course, in The left colon usually stores faeces and plays a
accordance with their age and general condition. small role in fluid absorption. In the absence of a
sphincter, the frequency with which the colostomy acts
POSTOPERATIVE MANAGEMENT OF depends on the motility of the patient’s colon. It takes
COLOSTOMY up to 3 months for an activity pattern to be established,
General Management and never the same as the preoperative status. The
regularity with which the colostomy functions may
The general care of the patient will be largely deter-
vary from one or two actions per day to an almost
mined by the indication for performing the colostomy.
continuous discharge.
It is wise to maintain intravenous fluids until the
Two main methods of colostomy control are:
patient has at least passed flatus.
1. Natural method—high–fibre diet and laxatives
It is important to check the viability of the intestine
2. Irrigation.
in the early postoperative period and also to make
sure that it has not retracted. Natural method A fibre diet and the judicious use of
laxatives can control the activity of the colostomy to a
Immediate Care of the Colostomy predictable pattern. When successful, the colostomy
(see Chapter 19) acts mainly in the morning, the colon being stimulated
by a hot drink and breakfast, and less commonly, after
It is usually two or three days before the colostomy
the evening meal. The natural method requires the
discharges faeces, although flatus may escape before
wearing of the appliance throughout the day.
then, exceptionally the fecal output. There is no need
for alarm for three or four days postoperatively of Irrigation method The patient with a properly cons-
there is no faecal output, so long as the patient is able tructed, well-functioning colostomy may prefer to irri-
to take fluids by mouth without nausea or vomiting gate once a day or every other day and to wear only a
Chapter 9: Pre- & Postoperative Management in Hindgut (Colon, Rectum & Anus) Surgery 109

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

Table 9.5: Early complications of colostomy


Early complications Time of appearance Reason Management
Loss of viability Early postoperative period Compromised mesenteric Reconstruction of colostomy
(Necrosis) blood supply
Infection Early postoperative period Hematoma surrounding the Antibiotics and adequate
colostomy drainage
Separation of Early postoperative period Tension at the mucocutaneous If more than half the circumference
colostomy junction is involved, reconstruct the colostomy
110 Gastrointestinal Surgery: Step by Step Management

LOSS OF VIABILITY (NECROSIS) Investigations and Diagnosis


Clinical Presentation The diagnosis is obvious.
The patient presents in the early postoperative period Treatment
with darkening of colour of colostomy. Local care with antibiotics is enough, in due course it
Pathology of Complication will heal.
This may be to: LATE COMPLICATIONS OF COLOSTOMY
• inadequacy of blood supply or (see Table 9.6)
• too tight compression of the bowel by the opening
in the anterior abdominal wall. STRICTURE AND RETRACTION OF COLOSTOMY

Investigations and Diagnosis Clinical Presentation

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

Table 9.6: Late complications of colostomy


Late complications Time of appearance Reason Management
Stricture and Months-years after surgery Conservative management of Reconstruction of colostomy
retraction of partial necrosis and muco-
colostomy cutaneous separation
Stenosis of Months-years after surgery Leaving the colostomy without Reconstruction of colostomy
colostomy mucocutaneous approximation
Fistula formation Months-years after surgery Localized infection of a suture Modification of the appliance or
Fistulotomy or refashioning of entire
colostomy
Prolapse Months-years after surgery Operating when the colon is Convert to end colostomy and
(of loop dilated and the opening becomes mucous fistula if it is to be
colostomy) excessive once the colon permanent
decompresses
Prolapse Months-years after surgery Operating when the colon is Local repair—with resection of
(of end colostomy) dilated and the opening excess colon
becomes excessive once Resitting of stoma when it is associa-
the colon decompresses ted with hernia or when it is
recurrent
Parastomal hernia Months-years after surgery When stoma is located lateral Conservative management in most
(paracolostomy to rectus muscle occasions
hernia) Surgical management—local repair
with or without a mesh, or resitting
of stoma
Colostomy Months-years after surgery Careless irrigation with a Laparotomy and reconstruction of
perforation catheter or during contrast the colostomy with adequate drain-
X-ray studies with a catheter age if significant faecal/barium
contamination

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

Investigations and Diagnosis


The diagnosis is obvious and introduction of probe
or fistulography, sigmoidoscopy may be of use in
locating the internal opening of the fistula.

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.

PROLAPSE (OF LOOP COLOSTOMY)


Fig. 9.12: Prolapse of loop colostomy
Clinical Presentation
The patient presents with a prolapse of the stoma
generally the distal of the double barrel stoma, rarely
of the proximal stoma or both openings (Fig. 9.12).

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

Fig. 9.14: Repair of prolapse of end colostomy

of the stoma needs to be done if it is recurrent or when Pathology of Complication


combined with hernia.
This may be due to the colostomy fashioned outside
PARASTOMAL HERNIA the rectus muscle.
(PARACOLOSTOMY HERNIA)
Investigations and Diagnosis
Clinical Presentation
The diagnosis is obvious.
The patient presents with a swelling in the para-
colostomy area (Figs 9.15A and B). Treatment
Medical
Most may be managed conservatively with special
care of appliances and girdles (Fig. 9.16), because they
are harmless and the results of surgery are
disappointing, with high incidence of recurrence.

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.

PREOPERATIVE MANAGEMENT Pathology of Complication


Infection of the wound occurs as there is handling of
It should be remembered that the colon should always
the infected colon and soilage of the wound.
be empty when elective operation on the colon is
undertaken. The colon needs to be cleansed: Investigations and Diagnosis
i. mechanically,
The pathogenic organism be isolated in culture.
ii. bacteriologically and
iii. chemically. Treatment
Method of Preopera- Preoperative day 1 Local care with dressings and administration of
cleansing tive day 2 systemic antibiotics. The suture or staple should be
Mechanical Oral Oral laxative at night removed and the wound be allowed to heal by secon-
laxative Enema of both the dary intention.
at night loops of transverse
colostomy BREAKDOWN OF COLOSTOMY
Bacterio- Intestinal antibiotics parenterally + CLOSURE SUTURE LINE
logical Metronidazole
Clinical Presentation
cleansing
Chemical Nonabsorbable The patient presents with external wound infection
cleaning antibodies orally and faeculent discharge.

Diet Milk-based Clear liquids Pathology of Complication


schedule liquids Supplementary IV infusion of Breakdown of the colostomy closure suture line may
crystolloid plasma expanders
be due to the ends being nonviable due to decreased
vascularity or undernutrition.
POSTOPERATIVE MANAGEMENT
Investigations and Diagnosis
It is unusual for the patient to require a nasogastric Faeculent discharge from the wound should indicate
tube after colostomy closure. Intravenous fluids are the diagnosis.
maintained until flatus is passed and a diet is
gradually introduced. Treatment
The colostomy needs to be re-established again and
EARLY COMPLICATIONS OF CLOSURE closure to be contemplated at a later date.
COLOSTOMY (see Table 9.7)
LATE COMPLICATION OF COLOSTOMY
CLOSURE (see Table 9.8)
Table 9.7: Early complications of colostomy closure
Table 9.8: Late complication of colostomy closure
Early Time of Reason Management
complications appearance Late Time of Reason Management
complication appearance
Wound 2nd-5th post- Infection Antibiotics
infection operative day Wound hernia Years after Weakness Repair with
surgery of colos- or without
Breakdown 2nd-5th post- Non-viable Re-establish
tomy site mesh
of suture line operative day suture line colostomy
116 Gastrointestinal Surgery: Step by Step Management

WOUND HERNIA suggest additional pathology. Special attention is


Clinical Presentation given to patients who have a history of soft stools or
diarrhoea to rule out the possibility of inflammatory
The patient presents with boggy swelling in the bowel disease, which is a specific contraindication for
operated area with or without pain. hemorrhoidectomy.
The patient is informed that he will be in the
Pathology of Complication
hospital for 1 to 2 days and that he should refrain from
The weakness of the muscular structures in the any heavy lifting for a period of 2 weeks after surgery.
operated area and causes which increase intra-abdo- He is advised that complete healing will not occur for
minal pressure like chronic cough, chronic sneezing, a period of approximately 3 to 4 weeks, and that his
bronchial asthma, chronic constipation. chance of returning to the operative room for a
complication related to surgery usually is 1 percent.
Investigations an Diagnosis Oral preoperative preparation is not indicated for
The diagnosis is obvious. this procedure.
Oral laxative is given in the night before surgery.
Treatment One disposable enema is given in the morning of
Local repair with or without mesh is the treatment of surgery.
choice.
POSTOPERATIVE MANAGEMENT
PRE- AND POSTOPERATIVE
After, the operation, patients are encouraged to take
MANAGEMENT IN ANORECTAL SURGERY
sips of water until such time as they void
Surgery of the anorectum can be of various types and spontaneously, which reduces the catheterization rate
the commonest is the hemorrhoidectomy. This can be remarkably. Once postoperative voiding has taken
done either as open or closed technique, and the pre- place, patients are allowed fluids and food as desired.
and the postoperative care remain the same. The rectal Early activities are encouraged.
surgery can be of higher magnitudes as in the case of Warm packs are applied to the perineum during
rectal prolapse, tumors of the rectum and may or may the immediate postoperative period. After 24 hours,
not involve removal of the rectum and may end up patients are encouraged to take as many Sitz baths as
with an anastomosis or only as a terminal colostomy, required for cleanliness and comfort. A small dressing
in patients with inoperable tumors of the rectum. is put in perianal area to collect whatever discharge
Since the advent of the rubber band ligature tech- or drainage may be present. No other local treatment
nique for bleeding internal hemorrhoids, indications is carried out. Patients are given mild laxatives and
for surgery have been limited to prolapse, pain, because they receive only a small quantity of enema
bleeding not controlled by other methods, and in asso- before surgery, they usually have their first bowel
ciation with other surgical conditions of the anal canal action on the second or third postoperative day, and
e.g., fissure and fistula. mild bleeding during the first stools is acceptable.
The most frequent indication for hemorrhoidec- Dilatation is not carried out in the hospital. Patients
tomy is rectal mucosal prolapse associated with
are discharged on the day after surgery and advised
prolapsing mixed hemorrhoids. When surgery is
to report back at the clinic after 10 to 14 days for
required for fissures or fistula associated with hemor-
examination.
rhoids, hemorrhoidectomy may be added at that time.
The patients are advised to keep their stools soft
and pass without straining by taking some laxative,
PREOPERATIVE MANAGEMENT
fruits and high-fibre diet, till complete healing of the
All patients undergoing hemorrhoidectomy should wound occurs. This will facilitate wound healing,
undergo preoperative sigmoidoscopy or colonoscopy reduce the discomfort while defecating and also avoid
if they are older than 40 years and their symptoms episodes of bleeding from the raw areas of surgery.
Chapter 9: Pre- & Postoperative Management in Hindgut (Colon, Rectum & Anus) Surgery 117

EARLY COMPLICATIONS AFTER ANORECTAL SURGERY (see Table 9.9)

Table 9.9: Early complications of anorectal surgery


Early complications Time of appearance Reason Management
Hemorrhage
Reactionary Immediate postoperative Inadequate hemostasis, opening Pressure application with adrena-
period up of a small bleeding point line-soaked gauze and if necessary
hemostasis with artery forceps in
the operation theatre
Retention of urine Immediate postoperative Parasympathetic block following Parasympathetic drug like prostig-
period low spinal anesthesia mine or carbachol, if needed
catheterization
Secondary 7th-10th postoperative day Sepsis of vascular pedicles Small bleeds—adrenaline packs
Large bleeds—examination and
appropriate hemostasis

REACTIONARY HEMORRHAGE Treatment


Clinical Presentation Male patients will need to stand and pass urine. The
Usually in the postoperative period, soon after the next step is to administer a drug such as Prostigmine
patient’s return to the ward, or later in the evening, 1 ml by subcutaneous injection. This has its maximum
may present with bleeding from the operated wound. effect within 15 to 20 minutes and often helps to
This may be minimal to severe. overcome his or her retention. Lastly, if 1 or 2 injections
of prostigmine or carbachol are ineffective, the patient
Pathology of Complication
will have to be catheterized.
This may be due to opening up of a small bleeding
point in one of the external wounds. SECONDARY HEMORRHAGE

Investigations and Diagnosis Clinical Presentation


No specific investigation is required. This is generally Since it occurs around the 7th to 10th postoperative
detected by the nursing staff as an excessive ooze. day, this may occur at home, as many of these patients
are discharged much earlier. The bleeding follows
Treatment defecation. This bleeding may escape into the colon
Packing with adrenaline-soaked gauze may help. and rectum without presenting further outside, and
Some cases may require hemostasis with an artery present with pallor with raised pulse rate and fall of
forceps in the operation theatre. blood pressure.

RETENTION OF URINE Pathology of Complication

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

Clinical Presentation Rectal examination will give the diagnosis, in which


insertion of finger or the proctoscope will be preven-
The patient presents with a painful nonhealing wound ted (Fig. 9.19). Many times, the fibrosis may be felt by
in the postoperative period. the examining finger.
Pathology of Complication Treatment
This is due to incomplete healing of the wound. It may Anal dilatation with anal dilators or anal stretching
occur in the midline posteriorly or anteriorly, in with fingers will cure the problem. Rarely, stricturo-
connection with the right posterior (7 o’ clock) or right plasty may have to be done.
anterior (11 o’clock) hemorrhoid wounds, especially
when the latter have included accessory piles in the
median plane itself. SKIN TAGS
Clinical Presentation
Investigations and Diagnosis
The patient presents with tags of skin in the perianal
The diagnosis is obvious. region.

Table 9.10: Late complications of anorectal surgery


Late complications Time of appearance Reason Management
Fissure formation Months later Incomplete healing of Sphincter stretch or internal
hemorrhoidectomy wound sphincterotomy
Anal stenosis Months later Large areas of skin excision Anal dilatation under general
anesthesia
Anal stricture Months later Large areas of skin excision Anal dilatation under general
anesthesia
Skin tags Months later Sequel to resolving edema of No treatment if small
skin-mucosa bridges Excision if they are of inconvenience
Anal incontinence Months later Division of anal sphincter Perineal exercises, sphincteroplasty,
colostomy
Recurrence of fistula Months later Inadequate removal Surgery
Chapter 9: Pre- & Postoperative Management in Hindgut (Colon, Rectum & Anus) Surgery 119

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

Fig. 9.19: Anal stenosis Clinical Presentation


The patient presents with the discharge of sero-
Pathology of Complication
purulent material from the scar of fistulectomy
The occurrence of edema in the perianal skin adjacent (Fig. 9.20).
to hemorrhoidectomy wounds with the formation of
painful skin tags end up as lax skin tags.
Investigations and Diagnosis
Diagnosis is obvious but need to be differentiated from
warts, condylomata or carcinoma.
Treatment
They need no treatment and may have to be excised if
the patient considers them a blemish and demands
surgery.

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.

Management of Patients with


Obstructive Jaundice
Many patients with hepatic pathology may present
with obstructive jaundice.
• Relief of jaundice It is to be realized that a patient
with obstructive jaundice is not a normal patient
and the biliary obstruction compromises hepato-
cyte function and carries a very high risk for post-
operative failure. It is understood that preoperative
decompression to relieve jaundice in conjunction with
either enteral or parenteral nutrition improves hepatic
Fig. 10.1: Nomenclature of hepatic resections function with a better outcome.
Chapter 10: Pre- and Postoperative Management in Hepatic Surgery 121
• Prevention of infection When decompression is Monitoring includes regular measurement of heart
attempted by endoscopic or percutaneous manipu- rate, blood pressure, oxygen saturation, urine output,
lation, the sterility of the biliary tract is compro- central venous pressure and conscious level, judged
mised; thus a cephalosporin and an aminoglycoside and using a simple sedative scoring system combined with
if anaerobes are cultured, metronidazole are added in an assessment of pain control.
the preoperative preparation of hepatobiliary Patients undergoing major hepatic resection and
surgery. those with poor preoperative liver function are at
• Correction of coagulation profile Patients with decrea- particular risk of developing postoperative hepatic
sed hepatic function presenting with obstructive decompensation. Maintenance of adequate liver
jaundice fail to produce vitamin K. Vitamin K is function can be judged by regular assessment of
given as 5 to 10 mg intravenously or intramuscu- conscious level, acid-base status, blood glucose levels,
larly every other day for three days, in the pre- blood lactate concentrations and prothrombin time.
operative period. Serum bilirubin and serum aspartate transferase
• Prevention of renal failure Postoperative renal failure and alanine transferase (probably due to hepatic artery
is increased in obstructive jaundice, probably due ligation) are raised early in the postoperative period,
to mediation of periportal sympathetic nerves. whereas alkaline phosphatase tends to rise and serum
However, it is best to assume as increased risk of albumin to fall after the first 10 to 14 days. The above
renal failure. Adequate hydration, especially with changes presumably reflect direct damage to the
sodium-containing solutions, diminishes the hepatic parenchyma, the consequences of hypo-
incidence of renal failure in the postoperative volemia, reduced hepatic blood flow in the pre-
period. operative period and possibly infection.
• Preparation of the gut Any time the gut is to be Gastric decompression for 2 days, following which
entered, a full bowel preparation should be initia- oral intake is begun.
ted with erythromycin base (500 mg , po, qid) and Drains placed to monitor for drainage of blood or
neomycin (500 mg, po, qid) on the day before bile should be removed when they have served their
surgery. Catharsis with lactulose is satisfactory. purpose, that is around 72 hours.
Glucose and albumin infusion until oral intake is
POSTOPERATIVE MANAGEMENT adequate.
Antibiotics for at least 3 days.
High dependency nursing or intensive care will be
required to provide adequate observation of vital signs EARLY COMPLICATIONS OF HEPATIC SURGERY
and conscious level and to detect ongoing blood losses. (see Table 10.1)

Table 10.1: Early complications of hepatic surgery

Early complications Time of appearance Reason Management


Hyperbiliru- 2nd-3rd postoperative day Hepatic parenchymal damage, Conservative
binemia hypovolemia, infection
and jaundice
Hypoprothrom- 2nd-3rd postoperative day Wash out of coagulation factors, Vitmain K, fresh frozen plasma,
binemia transfusion reaction, DIC platelet transfusions
Continued 2nd-3rd postoperative day Coagulopathy, Correction of coagulopathy
bleeding insufficient hemostasis Coeliac angiogram and selective
embolization
Persistent bile 3rd-5th postoperative day Injury to bile ducts Most of them close spontaneously,
leakage and If there is distal obstruction, biliary
biliary fistula enteric anastomosis
Subphrenic abscess 5th postoperative day Infected collection of hemorrhage Ultrasound or CT–guided drainage
122 Gastrointestinal Surgery: Step by Step Management

HYPERBILIRUBINEMIA AND JAUNDICE CONTINUED BLEEDING


Clinical Presentation Clinical Presentation
The patient presents with yellowish discoloration of The patient presents with continued bleeding from the
conjunctivae and skin. drain site and probably from the main wound.

Pathology of Complication Pathology of Complication

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.

Serial estimation of serum bilirubin will help in Investigations and Diagnosis


diagnosis. The determination of the coagulation profile,
especially the prothrombin time (PT), and partial
Treatment
thromboplastin time (PTT).
Most of the times, the bilirubinemia subsides. When
it does not, this may be due to infection or distal Treatment
obstruction. Adequate administration of wide-spec- The treatment is administration of fresh frozen plasma
trum antibiotics is necessary. Distal obstruction if any, and platelet transfusion. If after correction of coagulo-
needs to be bypassed by biliary enteric anastomosis. pathy, the hemorrhage persists, bleeding from an
unoccluded vessel must be assumed and coeliac
HYPOPROTHROMBINEMIA angiogram should be performed. If bleeding is from
one of the hepatic arteries, selective embolization
Clinical Presentation
should be tried.
The patient presents with continued bleeding from the
drain site and probably from the main wound. PERSISTENT BILE LEAKAGE
AND BILIARY FISTULA
Pathology of Complication Clinical Presentation
Hemorrhage from the liver in the immediate post- The patient presents with leak of bile through the
operative period may either be from coagulopathy or drains with signs of peritonitis and jaundice.
insufficient hemostasis.
Coagulopathy may result, alone or in combination, Pathology of Complication
• from wash out of coagulation factors with multiple There may be inadvertent bile duct injury and insuffi-
transfusions, cient or slipped bile duct ligature. Bile causes chemical
• transfusion reaction and peritonitis due to the presence of bile acids or to the
• disseminated intravascular coagulation triggered reflux of active pancreatic enzymes through a common
by tissue injury. channel. Peritoneal absorption of bile may lead to
elevation of bilirubin levels in blood, and jaundice.
Investigations and Diagnosis
The determination of the coagulation profile. Investigations and Diagnosis
The diagnosis is obvious and needs no special
Treatment investigation except a CT scan to rule out any collec-
The treatment is administration of fresh frozen plasma, tions of bile in the peritoneal cavity. HIDA scan is
injections of vitamin K and platelet transfusion. useful in locating the site of the fistula.
Chapter 10: Pre- and Postoperative Management in Hepatic Surgery 123
Treatment STRICTURE OF BILE DUCTS
Most of the leaks will heal if there is no distal obstruc- Clinical Presentation
tion, and drains must be left in place until closure
occurs. Administration of wide–spectrum antibiotics The patient may present with jaundice.
is essential. If a biliary fistula becomes persistent, distal Pathology of Complication
obstructions have to be ruled out. If there is any distal
obstruction identified, bypass procedures like biliary Inadvertent injury to the bile ductal system
enteric anastomosis (Roux-en-Y) have to be done. unrecognized during original surgery.

SUBPHRENIC ABSCESS Investigations and Diagnosis

Clinical Presentation Ultrasonography and CT scan may show the level of


obstruction and the effects of obstruction, the dila-
The patient presents with general malaise and the tation of the biliary system proximal to the obstruction.
recovery and convalescence is not in a normal manner. Contrast studies through ERCP or through percuta-
There may be fever (low/moderate/high grade), with neous transhepatic cholangiography (PTC) will show
leucocytosis. The acute picture may be subdued by the level and nature of obstruction.
the administration of antibiotics. Physical examination
may not be of any value in most cases. Treatment
If the stricture is passable, stents may be applied with
Pathology of Complication
dilatation. Impassable strictures need to be bypassed
This complication occurs due to the collection of blood by biliary enteric anastomosis.
due to hemorrhage from the liver surface and infection
into subphrenic space. RECURRENCE OF MALIGNANCY
Clinical Presentation
Investigations and Diagnosis
Ultrasonography and CT scan help in diagnosis and The patient may present with general malaise, loss of
localizing the abscesses. appetite, loss of weight, abdominal pain, and
abdominal distension with or without jaundice.
Treatment Pathology of Complication
The abscess should be drained early before the This is due to residual tumor tissue in the hepatic
patient’s condition deteriorates, and also prevent a parenchyma with insufficient clear tumor resections.
general peritonitis which in turn deteriorate the condi-
tion further. The drainage may be done either i) Investigations and Diagnosis
transabdominally or posteriorly depending upon their Ultrasonography and CT scan will localize the
location, or ii) by percutaneous aspiration or catheter recurrent tumor masses.
drainage under ultrasound or CT guidance, and by
administration of appropriate antibiotics. Treatment

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

Table 10.2: Late complications of hepatic surgery


Late complications Time of appearance Reason Management
Stricture of Months-years after surgery Inadvertent injury to the Biliary enteric anastomosis
bile ducts biliary ductal system
Recurrence Months-years after surgery Residual tumor tissue Resections, bypass procedures
of malignancy
124 Gastrointestinal Surgery: Step by Step Management

recurrence is multiple. If there is a solitary local recur-


rence, local resection of the liver may be done.

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

Fig. 10.3: Management of upper GI bleeding


126 Gastrointestinal Surgery: Step by Step Management

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.

Table 10.3: Early complications of shunt surgery


Early complications Time of appearance Reason Management
Transient ascites Early postoperative period Infection of ascites Sodium restriction and infusion of
and jaundice salt-poor albumin, 50 g every 12 h
during the first 48 h after surgery,
jaundice disappears in 6 months
Hypokalemic Early postoperative period Sudden diversion of portal Infusion of 80-120 mmol of
alkalosis and blood into the systemic potassium and neomycin
encephalopathy circulation postoperatively
128 Gastrointestinal Surgery: Step by Step Management

LATE COMPLICATION OF SHUNT SURGERY


(see Table 10.4)

Table 10.4: Late complication of shunt surgery


Rebleeding Late postoperative period Occlusion of the shunt Injection sclerotherapy, esophageal
transection, or perform another shunt

REBLEEDING Investigations and Diagnosis


Clinical Presentation Venography will establish the diagnosis.
The patient presents with upper gastrointestinal bleed
in the form of hemetemesis. Treatment

Pathology of Complication The treatment options available are:


• Injection sclerotherapy
This may occur due to the occlusion of the shunt • Esophageal transection
already performed. • Performance of another shunt
11
Pre- and Postoperative
Management in
Biliary Tract Surgery
Variety of operations are performed in the biliary Surgery of the Biliary Ductal System
system for various indications for various situations
• Choledochotomy (opening of the common bile
and they consist of the following.
duct and closure with or without T-tube
Surgery of the Gallbladder drainage— Figs 11.2A and B).
• Choledocho-enterostomy (anastomosis of common
• Cholecystectomy—removal of gallbladder
bile duct with bowel).
(Fig. 11.1A).
1. Choledocho-duodenostomy (anastomosis of
• Bypass procedures without removal of gallbladder
common bile duct with duodenum—Fig. 11.3
(e.g., cholecysto-duodenostomy or cholecysto-
A).
jejunostomy—loop or Roux-en-Y—Fig. 11.1B).
2. Choledocho-jejunostomy (anastomosis of
• Cholecystostomy—connect the gallbladder to the
common bile duct with jejunum—loop or Roux-
exterior (Fig. 11.1C).
en-Y reconstruction—Figs 11.3B and C).
• Hepatico-jejunostomy (anastomosis of common
A
hepatic duct with jejunul-loop or Roux-en-Y
reconstruction—Figs 11.4A and B).
• Sphincterotomy (Fig. 11.5A) or sphincteroplasty (Fig.
11.5B).

B(1) (2) (3)

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

Figs 11.3A to C: Choledocho-enterostomy: (A) Choledocho-


duodenostomy, (B) Choledochojejunostomy, (C) Choledo-
chojejunostomy (Roux-en-Y)

Figs 11.6: Percutaneous transhepatic


cholangiography (PTC)

A B

Figs 11.4A and B: (A) Hepaticojejunostomy (loop),


(B) Hepaticojejunostomy (Roux-en-Y)

Figs 11.7: Endoscopic retrograde cholangio-


pancreatography (ERCP)

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.

POSTOPERATIVE MANAGEMENT Investigations and Diagnosis

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

Table 11.1: Early biliary complications of biliary tract surgery


Early complications Time of appearance Reason Management
Biliary peritonitis 2nd-5th postoperative day Leak from the gallbladder Antibiotics and adequate drainage
bed with infection
Hematoma 2nd-5th postoperative day Slipped ligature of cystic artery Small hematomas resolve and if they
or from the gallbladder bed cause biliary obstruction, need
decompression
Bile collection 2nd-5th postoperative day Leak from the gallbladder bed Small bilomas resolve and if they
or giving way of the cystic cause biliary obstruction, need
duct stump decompression
Abscess 2nd-5th postoperative day Infection of the collected bile Antibiotics and adequate drainage
or blood or both
Fistula 7th-10th postoperative day Persistence of the tract from Closure of fistula
the point of leak to the exterior
through the drain tract
132 Gastrointestinal Surgery: Step by Step Management

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.

HEMATOMA Pathology of Complication


Clinical Presentation This is due to:
In the early postoperative period around the 2nd-5th • the infection of collected bile or blood or both
postoperative day, the patient may present with low- • collection of infected bile.
grade fever with severe pain in the right hypo-
chondrium and severe tenderness in that area. Investigations and Diagnosis

Pathology of Complication Ultrasonography or CT scan is useful in diagnosis of


the subhepatic collection.
This is due to slipped ligature of cystic artery or ooze
from the gallbladder bed. Treatment
Investigations and Diagnosis Adequate administration of antibiotics and drainage
Ultrasonography or CT scan is useful in diagnosis. of abscess under ultrasound or CT guidance or by
open drainage to relieve obstruction (Fig. 11.8).
Treatment
Small collections of blood usually resolve; and if they EXTERNAL BILIARY FISTULA
cause biliary obstruction, they need to be aspirated Clinical Presentation (See Chapter 18 also)
under ultrasound or CT guidance or by open drainage
to relieve obstruction (Fig. 11.8). Around the 7th to 10th postoperative day, the patient
may present with high-grade fever with discharging
BILE COLLECTION (BILEOMA) wound in the right hypochondrium probably at the
Clinical Presentation drain site. The external diversion of bile from the
gastrointestinal tract may lead to depletion of electro-
In the early postoperative period around the 2nd-5th lytes and fluid, sometimes, protein calorie malnutri-
postoperative day, the patient may present with low– tion and weight loss, which is directly proportional
grade fever with severe pain in the right hypo- to the length of time of the fistula and quantity of loss*.
chondrium and severe tenderness in that area. At the same time, absence of bile in the gut will
Pathology of Complication interfere with absorption of fat soluble vitamins A, D
and K.
This is due to bile leak from the gallbladder fossa or
slippage of cystic duct ligature or clip.

Investigations and Diagnosis


Ultrasonography or CT scan is useful in diagnosis.

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.

Investigations and Diagnosis


Diagnosis is obvious as the leak is frankly bilious.
Precise diagnosis of the site and often of the cause of
the fistula is radiological. They are:
1. Ultrasonography (Fig. 11.9)—shows the cause of
distal obstruction if any
2. CT scan (Fig. 11.10)—shows the cause of distal
obstruction if any
Fig. 11.10: CT scan showing two
3. T-tube cholangiography (Fig. 11.11)—when tube CBD stones (arrow)
is left in situ
4. Fistulography (Fig. 11. 12)—when the tube is not 8. Fiber-optic choledochoscopy (Fig. 11.16)—it can be
left in situ manipulated through the T-tube tract and the
5. Percutaneous transhepatic cholangiography fistulous tract can be viewed directly.
(PTC—Fig. 11.13)
6. Endoscopic retrograde cholangiography (ERCP— Treatment
Fig. 11.14)
Treatment of external biliary fistula consists of:
7. Isotope studies of the biliary system (injection of
• Correction of electrolyte and fluid imbalance
HIDA)—apart from the origin of the fistulous tract,
• Correction of malnutrition
it gives the index of liver function and biliary
• Control of skin excoriation (Fig. 11.17)
secretion (Fig. 11.15)
• Control of intra-abdominal infection
134 Gastrointestinal Surgery: Step by Step Management

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

• Determination of cause, site and level of fistula and


likelihood of spontaneous closure.
If there is no distal obstruction, the fistula closes
spontaneously in a few weeks. Sometimes, TPN may
be needed as supplementation. When the fistulae do
not close spontaneously after conservative treatment,
they require surgical intervention.
Postcholecystostomy biliary fistulae
• Removal of gallstones in the gallbladder, bile duct
or both **
• Surgical excision or bypass of malignant obstruc-
tion unrecognized at the time of original operation. Fig. 11.17: Bile leak and skin excoriation
Chapter 11: Pre- and Postoperative Management in Biliary Tract Surgery 135
Postcholecystectomy biliary fistulae It is wiser to treat Prevention
infection, nourish the patient and wait.
Meticulous technique with mucosa-to-mucosa anasto-
• If fistulography or cholangiography reveals stones
mosis obviates leaks after biliary-intestinal anasto-
in the common bile duct, they need to be extracted.
mosis.
• If fistulography or cholangiography reveals any
Intraoperative choledochoscopy reduces the
continuity of the damaged duct, spontaneous
incidence of retained stones.
closure is almost always possible, but end in a stric-
ture. Definitive repair of bile duct stricture should LATE BILIARY COMPLICATIONS OF BILIARY
be delayed, as dilatation of proximal duct is easier TRACT SURGERY (see Table 11.2)
to repair at a later date.
• If fistulography or cholangiography reveals total
disruption of the damaged duct, and the fluid loss
is too heavy and prolonged, it is wiser to perform
an internal fistulo-jejunostomy and definitive
stricture repair at a later date.
Postcholedochotomy biliary fistulae If the cause is due to
retained stones, they need to be extracted**
• If the fistula is due to unrecognized malignant Fig. 11.18: ERCP basketing
obstruction, surgical excision or appropriate biliary
enteric bypass would be required.
**The choices available for removal of CBD stones are:
• Extraction either by ERCP-aided balloon extraction
or basketing (Fig. 11.18), with sphincterotomy
(nasobilary drainage using a catheter placed
through endoscope, to relieve jaundice, when the
stone is creating a total blockage of the duct or diffi-
cult to extract and also for administration of stone
dissolving agents—Fig. 11.19).
• Extraction using a choledochoscope through the
T-tube tract.
• Extraction using per-oral ‘mother-baby’ choledo-
choscopes (Fig. 11.20).
• Surgical choledocholithotomy for difficult to ex-
tract stones by endoscopic procedures.
• Biliary enteric bypass like choledochoduodeno-
Fig. 11.19: Nasobiliary drainage
stomy for impacted stones in the distal duct (Figs
11.3 and 11.4).
Postbiliary-intestinal anastomoses biliary fistulae Gene-
rally, they close spontaneously if the distal bowel is
emptied without obstruction, and need no surgical
intervention.
Note:* Short periods of total biliary diversion of up to
three weeks may not cause serious depletion of electro-
lytes and the body is able to compensate for this loss.
In a small minority of patients, especially in the
very elderly and those with generalized disease, it may
be reasonable to leave the stone in situ if the leak closes
or it is minimal. Fig. 11.20: Mother Baby choledochoscope
136 Gastrointestinal Surgery: Step by Step Management

Table 11.2: Late biliary complications of biliary tract surgery


Late complications Time of appearance Reason Management
Cystic duct stone Months or years after surgery Residual cystic duct stump No treatment if asymptomatic,
revision if symptomatic
Cystic duct neuroma Months or years after surgery Entanglement of the nerve Analgesics
Cystic duct inflammation Months or years after surgery Infection Antibiotics
CBD stones Months or years after surgery Residual stones Removal by ERCP basketing
Benign CBD stricture Months or years after surgery Injury to CBD Biliary enteric anastomosis
Tumor Months or years after surgery Not known Excision and anastomosis
Biliary enteric fistula Months or years after surgery Injury to CBD and bowel Revision anastomosis
Sump syndrome Months or years after surgery Descending infection from liver Sphincterotomy
Papillary dysfunction Months or years after surgery Not known Antispasmodics
Papillary stenosis Months or years after surgery Injury during surgery Papillotomy or papilloplasty

CYSTIC DUCT STONE CYSTIC DUCT INFLAMMATION


(CYSTIC DUCT REMNANT SYNDROME)
Clinical Presentation
Clinical Presentation
The patient may complain of fever and pain in the
The patient may present with pain in the right right hypochondrium or epigastrium.
hypochondrium or may be asymptomatic.
Pathology of Complication
Pathology of Complication
This is due to infection of the cystic duct remnant.
This may be due to a retained stone in a residual cystic
duct stump. Investigations and Diagnosis

Investigations and Diagnosis No investigation will be of use. Ultrasonography to


rule out any other pathology in that area.
Ultrasonography or CT scan or ERCP will help in
diagnosis. Treatment
Treatment Administration of wide-spectrum antibiotics will be
• If asymptomatic, no treatment is required. useful.
• If the patient is symptomatic, revision surgery may CBD STONES
have to be done.
Clinical Presentation
CYSTIC DUCT NEUROMA The patient presents with upper abdominal pain and
Clinical Presentation obstructive jaundice.
The patient may complain of pain in the right Pathology of Complication
hypochondrium.
This is due to partial or total obstruction of the CBD
Pathology of Complication by residual stones in the common bile duct.
This is due the entanglement of nerve in the cystic Investigations and Diagnosis
duct suture.
Precise diagnosis is radiological. They are:
Investigations and Diagnosis 1. Ultrasonography (Fig. 11.9) (conventional or
Small neuromas may not be seen in any investigation. endoscopic)
2. CT scan (Fig. 11.10)
Treatment 3. Percutaneous transhepatic cholangiography (Fig.
Analgesics should suffice in the management of pain. 11.13)
Chapter 11: Pre- and Postoperative Management in Biliary Tract Surgery 137
4. Endoscopic retrograde cholangiopancreatography
(Fig. 11.14)
5. Isotope studies of the biliary system (Injection of
HIDA)—apart from the identification of stones in
the CBD, it gives the index of liver function and
biliary secretion
6. Peroral mother baby choledochoscopy (Fig. 11.20)

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).

BENIGN CBD STRICTURE


Clinical Presentation
The patient presents with upper abdominal pain and
obstructive jaundice.

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

anastomosis of CBD over a T-tube can be made


(Fig. 11.24). However, biliary enteric bypass
(choledochoduodenostomy or choledochojejunos-
tomy) is superior to end-to-end anastomosis (Fig.
11.3).
• For strictures of retropancreatic portion or the
immediate supraduodenal part of the CBD—side-
to-side or end-to-side choledochoduodenostomy
is preferred.
• For strictures involving the common hepatic
duct—bypass procedures like hepaticojejunostomy
(Roux-en-Y) has to be done (Fig. 11.4).

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.

BILIARY ENTERIC FISTULA Isotope Studies


Clinical Presentation HIDA scan is useful in diagnosis of biliary enteric
fistulae
Many of these patients remain asymptomatic.
Treatment
Pathology of Complication
Most of these patients are asymptomatic and require
Instrumental damage to the distal common bile duct
no treatment. When there are symptoms, excision of
during explorations of the duct can cause choledo-
fistula will be required appropriate to the patient’s
choduodenal fistula and rarely cause choledocho-colic
condition.
fistula.
SUMP SYNDROME
Investigations and Diagnosis
Clinical Presentation
There are no specific serological tests for biliary-enteric
fistulae. Radiological tests are useful in many The patient presents with fever, with rigor, abdominal
situations. pain and jaundice.
Chapter 11: Pre- and Postoperative Management in Biliary Tract Surgery 139
Pathology of Complication
This follows side-to-side choledochoduodenostomy,
due to descending infection from the liver produces
cholangitis, if there is distal outlet obstruction.

Investigations and Diagnosis


Ultrasonography and CT scan are useful in diagnosis. Fig. 11.25A: Endoscopic sphincterotomy

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

Investigations and Diagnosis


Investigations and Diagnosis
Ultrasonography and CT scan are useful in evaluating
the dilatation of the ductal system. Ultrasonography and CT scan are useful in evaluating
the dilatation of the ductal system.
Treatment
Treatment
The treatment is medical and administration of anti-
spasmodics should suffice. The treatment modalities available are:
• Endoscopic sphincterotomy (Fig. 11.25A).
PAPILLARY STENOSIS • Transduodenal sphincterotomy or sphinctero-
plasty (Fig. 11.25B).
Clinical Presentation
• Side-to-side choledocho-duodenostomy (Fig. 11.3).
The patient presents with fever, with rigor, abdominal
pain and jaundice. EXTRABILIARY COMPLICATIONS
Although symptoms can arise from abnormalities in
Pathology of Complication
the biliary tract, they can also result from concurrent
Probing of the papilla with rigid instruments may disease in other organs which may or may not relate
injure the tissue and cause stenosis by scarring. to the cholecystectomy.
12
Pre- and Postoperative
Management in
Pancreatic Surgery
Variety of operations are performed in the pancreas
(Fig. 12.1) for various indications and various situ-
ations and they consist of:
• Resection of the pancreatic tail.
• Distal pancreatectomy (removal of distal pancreas
and spleen).
• Left pancreatectomy (removal of the body and tail
of the pancreas).
• Subtotal pancreatectomy (removal of part of the
head, the body and tail of the pancreas).
• Pancreatoduodenectomy Whipple’s pancreato-
duodenectomy (removal of proximal part of
pancreas) resection of pancreatic head will include
distal half of stomach, duodenum, proximal part
of jejunum and distal biliary tree (Fig. 12.2).
• Total pancreatectomy (removal of entire pancreas).
• Bypass procedures without removal of pancreas
(e.g., pancreatojejunostomy).
Operations on the pancreas are some of the most
challenging in gastrointestinal surgery for the Fig. 12.1: Nomenclature of pancreatic operations
following reasons:
1. The pancreas is relatively inaccessible in its retro- As in all areas of surgery, operative morbidity and
peritoneal position, obscured by the greater omen- the mortality are influenced by patient selection,
tum and transverse colon needing good deal of patient preparation, standards of preoperative care,
mobilization. and the skill and experience of the surgeon.
2. The pancreas is intimately related to major blood Refinements in operative technique, pre- and post-
vessels. operative management and methods of anesthesia have
3. The pancreas has a rich arterial supply. contributed significantly to the reduction in mortality and
4. The pancreas has shared blood supply and close morbidity associated with pancreatic resection.
anatomical relationship that adjacent organs are Though the morbidity and mortality rates of
routinely removed as part of pancreatic resection. pancreatic surgery have come down considerably, the
5. Disease of pancreas may present with obstructive risk of developing insulin-dependent diabetes mellitus
jaundice increasing the morbidity. and significant exocrine deficiency is increased by any
Chapter 12: Pre- and Postoperative Management in Pancreatic Surgery 141

Bile

Recurrence

Fig. 12.3: Percutaneous transhepatic drainage

mised; thus, a cephalosporin and an aminoglyco-


Fig. 12.2: Diagrammatic representation of the areas resected side to cover gram-positive and gram-negative
in pancreaticoduodenectomy and in total pancreatectomy organisms particularly Escherichia coli, Klebsiella and
Enterococcus and if anaerobes are cultured,
form of pancreatic resection, and in patients with
metronidazole are added in the preoperative
alcohol-associated disease, the long-term outlook
preparation of pancreatic surgery in the presence
depends greatly on whether the patient is able to
of obstructive jaundice.
abstain from alcohol.
• Correction of hematological profile A hematocrit of at
Majority of pancreatic surgeries whether curative
least 40 percent is essential prior to operation.
or palliative, end up in an anastomosis of the pancreas
Patients with decreased hepatic function presen-
with the biliary tree and/or the intestine. There are
ting with obstructive jaundice fail to produce
many variants of such anastomoses (about 70 after
vitamin K. Vitmain K is given as 5 to 10 mg intra-
pancreatoduodenectomy) and the percentage of
venously or intramuscularly every other day for
incidence of complications may vary, but they are to
three days, in the preoperative period.
be taken very seriously.
• Prevention of renal failure Postoperative renal failure
PREOPERATIVE MANAGEMENT is increased in incidence in obstructive jaundice,
probably due to mediation of periportal sympa-
In all patients being considered for major pancreatic
surgery, apart from the routine preparation, special thetic nerves. However, it is best to understand the
attention should be given to the preparation for the increased risk of renal failure. Adequate hydration,
patients for pancreatic surgery. There may be severe especially with sodium-containing solutions,
derangements in energy metabolism and protein diminishes the incidence of renal failure in the
synthesis due to hepatocyte dysfunction, anorexia, postoperative period.
decreased caloric intake and impaired digestion and • Correction of diabetes mellitus Many of the patients
assimilation of proteins, fats and carbohydrates, suffering of pancreatic diseases do present with
especially in jaundiced patients. diabetes mellitus, and this needs to be corrected
• Relief of jaundice and correction of malnutrition well before surgery with the administration of
Synchronous use of biliary decompression either insulin.
external (transhepatic drainage—Fig. 12.3) or inter-
nal (sphincterotomy—Figs 11.25A and B) and POSTOPERATIVE MANAGEMENT
hyperalimentation is known to decrease the Postoperative care of pancreatic surgery differs very
postoperative mortality and morbidity. little from any upper gut surgery but there are special
• Prevention of infection When decompression is considerations.
attempted by endoscopic or percutaneous manipu- High dependency intensive care The patient is
lation, the sterility of the biliary tract is compro- usually extubated on the operating table and nursed
142 Gastrointestinal Surgery: Step by Step Management

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

Table 12.1: Early complications of pancreatic surgery


Early complications Time of appearance Reason Management
Gastrointestinal Within 24 hr of surgery From anastomotic suture line Blood replacement, endoscopic
hemorrhage injection of adrenaline or
cauterization or reoperation
After 5th postoperative day From marginal ulcer or associa- Endoscopy and medical
ted with anastomotic leak management
Extragastric Within a few days Bleeding from retroperitoneal Early relaparotomy, evacuation
hemorrhage vessels in the pancreatic bed of clots and suture repair
Delayed gastric 3rd-5th postoperative day Several factors* Prolonged gastric decompression,
emptying prokinetic agents like bethanecol,
metoclopramide, cisapride, erythro-
mycin derivatives
Biliary leak 3rd-7th postoperative day Failure of biliary enteric Medical management as most leaks
(after biliary enteric anastomosis seal spontaneously in a few weeks
anastomosis) if no distal obstruction
Pancreatic leak 3rd-7th postoperative day Failure of healing at pancreatic- Conservative management in 80%
(after pancreatic enteric anastomosis when the loss is < 50 ml, as they
enteric anastomosis) generally heal in 2-3 weeks without
range from a harmless any special therapy
fistula to disastrous
peritonitis with genera-
lized sepsis
Collection of fluid Percutaneous drainage procedures
not communicating in about 10%,
with the drainage Completion Pancreatectomy in rare
tube and sub- intractable
phrenic abscess cases
TPN if available
Wound infection 5th-7th postoperative day Infection of the wound Suture or staple removal, drainage
contaminated by the contents and allowing healing by secondary
of the gastroduodenum intention
Intra-abdominal 10th-15th postoperative day Leaks from the pancreatic- Antibiotics in small abscesses and
abscess enteric anastomosis or any surgical drainage in larger abscesses
other anastomosis
Chylous ascites 10th-15th postoperative day Extensive retroperitoneal lymph No treatment as it will cease in a
node dissection resulting in injury couple of weeks and parenteral
to the main lymphatic channel nutrition is of help
Note: When abdomen is reopened for relaparotomies, it is not always easy to differentiate anastomotic breakdown from acute pancreatitis
of the remaining pancreas with peripancreatic necrosis.

Surgical the stomach pouch well. Care should be taken not to


damage the mucosa while suction, as it may result in diffuse
Reoperation should not be postponed when faced with gastric mucosal bleeding. The bleeding site is usually a
continuous bleeding. The gastric pouch should be single vessel at the lesser curvature or at the anasto-
opened much above the gastroenterostomy or mosis, which needs to be sutured with a stitch. The
gastroduodenostomy using a transverse incision and nasogastric aspiration should be done to clear the
blood clots should be evacuated. Saline irrigations are blood remnants and the tube flushed well to be sure
done and enough suction should be applied to clear that the aspirate is clear or only mildly tinged.
144 Gastrointestinal Surgery: Step by Step Management

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

Pathology of Complication Pathology of Complication


This complication occurs due to the spillage of duo- This is due to extensive retroperitoneal lymph node
denal, gastric or jejunal contents, into the peritoneal dissection resulting in injury to the main lymphatic
cavity. Anastomotic leaks are also a frequent cause of channels.
intra-abdominal abscess formation.
Investigations and Diagnosis Investigations and Diagnosis
Ultrasonography and CT scan help in localizing the Peritoneal tap of chylous fluid is diagnostic. CT scan
abscesses. is useful in determining the leak and also to localize
collections.
Treatment
The abscess should be drained early before the Treatment
patient’s condition deteriorates, and also prevent a
The ascites resolves in a few weeks, but the injury to
general peritonitis which in turn deteriorate the
major lymphatic channel may require ligation. TPN
condition further. The drainage may be done either:
may be required to maintain good nutritional status.
i) transabdominally or posteriorly depending upon
Early nonsurgical complications like cardio-
their location, or ii) by percutaneous aspiration or
pulmonary, hepatic insufficiency and renal failure are
catheter drainage under ultrasound or CT guidance,
associated with pancreatic resections, although none
and by administration of appropriate antibiotics.
are really specific to pancreatic resection. Their
CHYLOUS ASCITES management does not differ from those following
Clinical Presentation other major operations.
The patient presents with lymphorrhoea through the
drains which may reach alarming proportions with
loss of several liters of fluid daily which needs to be LATE COMPLICATIONS OF PANCREATIC
replaced parenterally. SURGERY (see Table 12.2)

Table 12.2: Late complications of pancreatic surgery


Late complications Time of appearance Reason Management
Marginal ulceration 2nd week Non-vagotomy partial gastrec- Proton pump inhibitors
tomy or pancreatectomy itself Rarely vagotomy and revision
surgery

Secondary extragastric After 2-3 weeks Erosion or infection If due to pancreatic anastomotic
hemorrhage dehiscence, completion pancreatec-
tomy

Obstructive jaundice After 12 weeks Stenosis of anastomosis/local Percutaneous transhepatic biliary


recurrence (Downstream drainage and stenting
choledocho-jejunostomy)

Second primary carcinoma After 12 weeks Multicentric carcinoma Total pancreatectomy/radiation

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.

Truncal vagotomy alone may be useful in refractile Treatment


cases, revision surgery is extremely rarely required. Percutaneous transhepatic drainage and stenting for
tumors at the hilum of the liver (Fig. 12.3). For relieving
SECONDARY EXTRAGASTRIC HEMORRHAGE
jaundice, for the recurrent tumors at the mesenteric
Clinical Presentation root, second Roux-en-Y reconstruction may be made
(Fig. 12.4).
This occurs after 2-3 weeks postoperatively. If after
an uneventful course, the patient presents with a SECOND PRIMARY CARCINOMA
raised temperature, little abdominal pain and also
Clinical Presentation
passes blood in his stool (the ‘sentinel bleed’), this is
the complication to think of. The patient presents with signs and symptoms of
malignancy with or without jaundice.
Pathology of Complication
This is due to secondary hemorrhage from retro-
peritoneal vessels possibly due to erosion or infection.

Investigations and Diagnosis


Immediate endoscopy to define the source of bleeding
and also the status of anastomosis.

Treatment
Medical
Measures to manage them with blood transfusions. Fig. 12.4: Second Roux-en-Y operation
148 Gastrointestinal Surgery: Step by Step Management

Pathology of Complication Treatment


This may be a missed tumor of multicentric carcinoma The treatment is medical and replacements of insulin
originally. are needed.
Note: This is commonly found when more than 50 percent
Investigations and Diagnosis of the pancreas is removed.
CT scan is useful in diagnosis.
EXOCRINE DEFICIENCY
Treatment
Clinical Presentation
Total pancreatectomy is the treatment of choice and
in inoperable cases, radiation or chemotherapy may The patient presents with disturbance in digestion and
be used as palliative treatment schedules. presents with symptoms of malabsorption.

ENDOCRINE DEFICIENCY Pathology of Complication


Clinical Presentation This is caused by:
• Removal of exocrine tissue as part of the removed
The patient may present with increased levels of sugar pancreatic tissue.
in the blood (diabetes mellitus), and severe wasting • Stenosis at the pancreatojejunostomy site.
suggestive of metastatic disease.
Investigations and Diagnosis
Pathology of Complication
Determinations of enzyme levels in the blood and
This is caused by: faeces will help in the diagnosis.
• Removal of endocrine tissue as part of the removed
pancreatic tissue. Treatment
• Fibrosis of pancreatic remnant leading to a loss of
islet cell tissue. Administrations of enzymes rich in lipase, fat-soluble
vitamins, calcium and trace elements.
Investigations and Diagnosis
Note: This is commonly found when more than 50 percent
Determinations of blood sugar level. of the pancreas is removed.
13
Pre-and Postoperative
Management in
Splenic Surgery
Splenectomy is traditionally indicated for various tions for surgery, so long as the marrow has a good
conditions like trauma, hereditary spherocytosis and productive capacity.
elliptocytosis, idiopathic thrombocytopenic purpura, • Correction of fluid imbalance The fluid volume needs
as part of total gastrectomy, and also recently for a to be corrected with crystalloids and colloids, as
variety of indications like chronic lymphoid early as possible.
leukaemia, chronic myeloid leukaemia, and lympho- • Prevention of infection Administration of prophy-
mas. Since severe infection is a dreaded complication lactic antibiotics is necessary.
of splenectomy even years later, it is suggested that • Arrangements for blood transfusion For elective
every effort should be made to conserve a part or the surgery of the spleen, 2 units of blood need to be
whole of the spleen, especially in children. kept crossmatched, and for emergency surgery,
Administration of prophylactic antibiotics is manda- especially in trauma, at least 6 units of blood should
tory in all splenectomized patients at least for a period be kept crossmatched, for surgery.
of 2 years after surgery. Alternatively, it is better to
vaccinate them against pneumococcal infection. POSTOPERATIVE MANAGEMENT
Variety of operations are performed on the spleen.
They are: A period of ileus is anticipated in the postoperative
1. Suturing of lacerations period, during which the patient is maintained on
2. Partial splenectomy intravenous fluids, and nasogastric aspiration regularly
3. Total splenectomy. 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
PREOPERATIVE MANAGEMENT
passage of flatus. Peristalsis returns to the small bowel
The preoperative management for surgery of the before the stomach and colon regain their motility. Clear
spleen should follow the general guidelines (see liquids are begun and if tolerated, the diet is advanced
chapter 5) when performed as elective surgery. When to normal intake over the next 2 days.
performed in conjunction with gastric, pancreatic, and Intravenous fluids are maintained until the patient
colonic surgeries, or as part of surgical treatment for is taking sufficient fluids orally.
portal hypertension, the preparation varies appro- Urinary catheter is normally discontinued between
priate to the organ involved (given in appropriate the second and fourth day of surgery.
chapters). Antibiotic prophylaxis is continued for 24 hours
• Correction of hematological profile Hematocrit values, in clean cases and for a reasonable time of about 5-7
total leucocyte count and platelet counts are to be days in contaminated cases and till the evidence of
corrected. Decreased values are no contraindica- sepsis disappears.
150 Gastrointestinal Surgery: Step by Step Management

Intra-abdominal drains kept at the splenic bed are SUBPHRENIC ABSCESS


removed when the drainage is minimal, which is
Clinical Presentation
usually around the 2nd postoperative day. The drains
kept near the anastomosis (when splenectomy is The patient presents with general malaise and the
associated with total gastrectomy, distal pancreatec- recovery and convalescence is not in a normal manner.
tomy or left colectomy) are removed around the 5th There may be fever (low/moderate/high grade), with
postoperative day. leucocytosis. The acute picture may be subdued by
Patients who have generally recovered sufficiently the administration of antibiotics. Physical examination
are discharged 6 to 8 days after surgery. may not be of any value in most cases.

EARLY COMPLICATIONS OF SURGERY Pathology of Complication


(Table 13.1) This complication occurs due to the collection of blood
due to hemorrhage from the operative field or from
Table 13.1: Early complications of splenic surgery
bleeding from short gastric vessels and infection into
Early Time of Reason Management left subphrenic space.
complications appearance
Postopera- Early post- Slippage of Re-exploration Investigations and Diagnosis
tive bleeding operative ligature of
period short gastric Ultrasonography and CT scan help in diagnosis and
vessels localizing the abscesses.
Subphrenic 7th-10th post- Infection of Ultrasound-
abscess operative day subphrenic guided aspi-
Treatment
hematoma ration or The abscess should be drained early before the
drainage
patient’s condition deteriorates, and also prevent a
Left lower 7-10th post- Damage or Medical mana- general peritonitis which in turn may deteriorate the
lobe operative day inadvertent gement and condition further. The drainage may be done either
atelectasis opening of physiotherapy
(1) transabdominally or posteriorly depending upon
the pleura
their location or (2) by percutaneous aspiration or
catheter drainage under ultrasound or CT guidance,
POSTOPERATIVE BLEEDING and by administration of appropriate antibiotics.
Clinical Presentation
The patient presents with bleeding from the operative LEFT LOWER LOBE ATELECTASIS
field through the drainage tube in the early post- Clinical Presentation
operative period.
The patient presents with difficulty in breathing.
Pathology of Complication
Pathology of Complication
The bleeding is generally from the slippage of ligature
of the short gastric vessels. This may occur due to inadvertent opening of the left
lower pleura.
Investigations and Diagnosis
Investigations and Diagnosis
No specific investigation is required.
Chest X-ray will show the atelectasis of the left lower
Treatment lobe with shift of the trachea to the left side.
Reexploration of the abdomen is necessary and the
bleeding vessel should be clamped followed by perfect Treatment
hemostasis. Chest physiotherapy is the treatment of choice.
Chapter 13: Pre and Postoperative Management in Splenic Surgery 151

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

Pathology of Complication Treatment


This occurs due to: After a quick examination, blood is taken for cultures
• Lack of splenic macrophages to clear opsonized and start on oral or intravenous antibiotics, e.g. third
microorganisms generation cephalosporin.
• Lack of type-specific antibodies
• Cardiovascular collapse occurs due to adrenal Note: Avoid splenectomy wherever possible or delay
hemorrhage—Waterhouse-Friderichsen syndrome till the patient is older than 5 years, immunize the
• The causative organisms are bacteria such as S. patient with polyvalent pneumococcal, meningococcal
pneumoniae, H. influenzae (types b and f), N. and conjugated Hemophilus vaccine—preferably two
meningitidis, Ps. aeruginosa, E. coli and other weeks or at least 72 hours before splenectomy.
encapsulated organisms. Protozoa such as Prophylactic antibiotics such as Penicillin V 250 mg
Plasmodium and Babesia. (or Erythromycin if Penicillin sensitive) twice daily
for 1 year postsplenectomy or till the patient is 18 years
Investigations and Diagnosis old. Educate the patient.
Leucocytosis and isolation of orgnanism in blood is Insist on patient’s taking medical alert card with
diagnostic. the patient.
14
Pre-and Postoperative
Management in
Laparoscopic Surgery
BASIC LAPAROSCOPY AND INSTRUMENTATION • It lacks the tactile sensation.
Despite these problems, surgeons have found an
Principles
ever-increasing role for this minimally invasive form
Laparoscopy is a form of endoscopy in which the of surgery. Many of the intra-abdominal procedures
surgeon uses a rigid telescope to visualize the can be performed with laparoscope with its attendant
abdominal cavity. The goal of this procedure is to diag- limitations and problems. The major advantages of
nose and/or treat various intra-abdominal disorders laparoscopic surgery are that:
without the need for larger, more disabling laparo- • Recovery from this procedure is far faster than
tomy incisions. Although laparoscopy has been from the standard open operation
performed for many years in the past, the recent • Patients can be discharged early
developments in the television camera miniaturization • They have far less pain and seem to show a reduced
and other instrumentation now make it possible to metabolic upset and return to work earlier.
perform a multitude of therapeutic procedures and is
developing at an extraordinary pace. Surgeons are
PREOPERATIVE PREPARATION
challenged with the need to keep up with the changes
and to learn the new procedures. Although the The preparation of patients undergoing laparoscopic
premiere laparoscopic procedure is cholecystectomy, surgery is almost identical to the conventional surgery,
the technology has been pushed into the management so that conversion from the laparoscopic approach to
of other abdominal pathologies: colon and rectal an open technique can be undertaken if the intra-
surgeries, surgery of various types of hernia, abdominal findings preclude the minimally invasive
management of peptic ulcer and gastro-esophageal technique. For most of the laparoscopic procedures, a
reflux, diagnostic oncology, urologic procedures, and urinary catheter and nasogastric tube are used to
common bile duct exploration. decompress the urinary bladder and the stomach
Laparoscopic surgery varies in many ways from respectively, which will decrease the likelihood of
conventional surgery. their injury during the insertion of the insufflation
• Special skills and instrumentation are required needle or trocar, and will allow better visualization of
• Peritoneal cavity must be distended with carbon the upper and lower abdomen.
dioxide to provide necessary exposure and space Preoperative patient education about this tech-
in which to operate nique is essential, if needed with the video presen-
• The use of rigid laparoscope alters the surgeon’s tation. Among many things, the potential benefits of
perspective and severely limits the field of view laparoscopic approach should be detailed and specific
• It lacks the depth perception effort should be made to explain the possible
154 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

4. Alcoholism lation inadequate through decreased activity of


5. No oral intake of diet over 10 days essential enzymes. It is estimated that a loss of 30
6. Protracted nutrient loss due to malabsorption percent of the body weight is fatal in 30 percent of
syndrome, GI fistulae, renal dialysis, open wounds patients. It would be difficult for a patient to survive
7. Increased energy demands due to multiple if there is 1/3rd loss of his body protein.
fractures, major infections like septicemia, exten-
sive burns
8. Intake of drugs which act as anti-nutrients or Routes of Alimentation
increase catabolic activities e.g., antibiotics, While plasma and red cell volume can be restored to
hepatotoxic drugs normal levels of blood transfusions, the preoperative
replenishment of tissue protein loss is not possible in
Table 15.2: Data needed for nutritional assessment some surgical patients, because positive protein
Anthropometric data Height balance cannot be achieved, until the required opera-
Weight tion is completed or because the operation cannot be
Arm muscle circumference safely postponed to a point of improved nutritional
Skin fold thickness (biceps, tri-
status. Mild isolated protein deficits are compatible
ceps, suprascapular, supra-
iliac) with recovery from the stress of major operation.
Biochemical data Plasma Urea and electrolytes Prevention of losses of body stores is important.
Creatinine Prevention of blood losses from an intestinal malig-
Fasting glucose, ketones, nancy is much more sensible than attempting to
immunoreactive glucagon and reverse negative nitrogen balance with high calorie
insulin
Serum Albumin
and high protein alimentation. But if the protein
Protein energy deficiency exists in a patient with a disease not
Transferrin requiring immediate operation, the reversal of his
Iron negative nitrogen balance by providing adequate
Vitamin B12 nutrients is to his advantage.
Folate
The routes available for providing nutritents are:
Calcium
Phosphate 1. Oral
Magnesium 2. Rectal
Urine Electrolytes 3. Tube (nasogastric, nasoduodenal, nasojejunal,
Calcium esophagostomy, gastrostomy, jejunostomy)
Phosphate 4. Subcutaneous
Magnesium
Glucose
5. Intraperitoneal
Creatinine 6. Intraarterial
Total nitrogen 7. Intramedullary
Urea nitrogen 8. Intravenous.
Dietary data Full dietary history Though glucose and protein derivatives are known
Current intake of carbo-
to be absorbed from the large intestine, the quantities
hydrates and proteins
absorbed are too small to be of practical value. Rectal
route for feeding is, therefore, not recommended now.
Clinical Effects of Undernutrition The complications, discomfort and limited usefulness
The undernourished patient requiring surgical inter- of the subcutaneous, intraperitoneal, intramedullary
vention is at a serious disadvantage. Undernutrition and intraarterial routes make them impractical and
leads to: undesirable avenues for nutrient administration.
1. Impaired wound healing Ultimately, the available safer routes are:
2. Decreased resistance to infection and wound gape 1. Oral
The undernutrition may interfere with cardio- 2. Tube
vascular and pulmonary function and make venti- 3. Intravenous
Chapter 15: Nutrition in the Perioperative Period 159
Fortunately, in the management of average surgical Generally, these mixtures are prepared as 25
patient who requires a major operation, no significant percent weight per volume solution providing about
nutritional problem exists other than providing him 1000 calories and 20-40 gm of amino acids per litre.
normal balanced diet. Even in patients with moderate Because of high osmolality (840-1100 milliosmol/litre) only
nutritional deficiencies, who may not be able to take about 100-150 ml should be given per feeding, and not more
food orally for 5 to 7 days after operation, a complex than 2000 ml is administered per day to an average patient.
nutritional regimen is not required. But cautiously adjusting the concentration and rate
of administration, the amount can be raised to 5200
Oral Feeding ml daily for prolonged periods of time.
If the alimentary tract is normal or moderately
Tube Feeding
impaired, oral route is the most preferred and effective
route for supplying nutrients. It is often said “if the Patients with severe weakness and inoperable
gut works, use it.” obstructing tumors of the intestinal system cannot be
When loss of appetite or nausea interferes with oral orally fed. They are fed via a small rubber catheter or
intake, measures such as persuasion by relatives and polyethylene tube, which can be introduced through
nurses and feeding small high protein meals in an the nose (nasogastric tube, nasoduodenal tube,
attractive manner at intervals may help. Dietitian nasojejunal tube) or through an artificial opening
plays a major role in formulating attractive and appeti- (esophagostomy, gastrostomy and jejunostomy)
zing meals. Drugs like antiemetics may exert a bene- created by a surgeon distal to the obstruction in the
ficial effect in selected patients. intestine (Fig. 15.1).
The use of chemically defined diets has been
studied extensively for many years; the dietary
mixtures consist of:
1. Purified amino acids
2. Glucose
3. Sucrose
4. Essential fatty acids
5. Mixtures of glucose and hydrolyzed starch
6. Water
7. Fat-soluble vitamins
8. Trace elements such as zinc, copper, etc.
In spite of adding various flavoring materials to
mask the taste and smell in these mixtures, the
currently available dietary mixtures are rather
unpalatable and must often be fed by tube. These
mixtures are bulk free and require minimal digestion
as they are already in absorbable form. The adminis-
tration of these mixtures requires at least a sufficient
segment of small intestine for absorption. These diets
may cause nausea, vomiting and diarrhoea, depen-
ding on the nutrient concentration and the rate of
administration.
Hyperglycemia and glucosuria tend to occur,
especially in diabetics and in the presence of infection.
Deranged blood clotting due to hypoproteinemia will occur
unless vitamin K is added, because there is no vitamin K
present in these diets. Fig. 15.1: Routes of tube feeding
160 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

Table 15.3: Intermittent feeding schedule


Day Time Strength Rate (5-10 ml/mt) Volume Calories
1 9 AM, Full 100 ml 200 200
11 AM, 1 PM, 3 PM, Full 150 ml 450 450
5, 7, 9, 11 PM Full 200 ml 800 800
____
1450

2 7, 9, 11 AM Full 250 ml (8 feeds) 2000 2000


1,3,5,7,9 PM
3 7, 10 AM Full 400 ml (5 feeds) 2000 2000
1,4, 7 PM

Table 15.4: Continuous feeding schedule


Day Time Strength Rate (5-10 ml/mt) Volume Calories
1 1st 8 hours ½ 50 400 200
2nd 8 hours ½ 75 600 300
3rd 8 hours ½ 100 800 400
____
900
2 1st 8 hours ¾ 100 800 600
2nd 8 hours ¾ 100 800 600
3rd 8 hours ¾ 100 800 600
____
1800
3 1st 8 hours Full 100 800 800-800
2nd 8 hours Full 100-125 800-1000 800-1000
3rd 8 hours Full 125 800-1000 800-1000
_________
2400-2800

Nutren Fibre (Nestle) is one such popularly used


fibre-enriched tube feeding formula, as shown in
Table 15.5.
There are many complications (Table 15.6) that can
develop during intestinal feeding but most can be
easily remedied at an early stage by careful moni-
toring.
The feeding formula is chosen, taking into account:
1. Digestive capability and absorptive capacity
2. Type of feeding route
3. Energy and protein requirement

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

Administration of Intravenous Nutrition but is found to be independent of changes in the amino


acid/dextrose pump rate.
The parenteral nutrition is delivered through two
Monitoring the patient is necessary during paren-
common routes:
teral administration of nutrition. This is done by:
1. Infraclavicular subclavian vein
1. Daily determination of blood urea, electrolytes and
2. Supraclavicular internal jugular vein.
body weight.
Both routes are popular and permit the delivery
2. Determination three times a week of hemogram,
of hypertonic nutrient solutions in a dependable
serum magnesium, zinc, alkaline phosphatase,
manner.
SGOT and SGPT.
3. Determination four times a day of urine glucose.
Right Atrial Catheters
These are centrally placed Silastic Broviac and the Complications of Intravenous Nutrition
longer Hickman catheters, which can be single, double The complications fall broadly into three categories:
or even triple lumen. These are placed via either the mechanical, septic and metabolic. They are summa-
superior or inferior vena cava. These are useful for rized in Table 15.12.
long-term venous access for prolonged periods of
nutrient administration. The need for insertion of Specific Indications for the Use of
catheter through a lower limb vein to the inferior vena Intravenous Hyperalimentation
cava becomes necessary in the following situations: Since intravenous hyperalimentation provides one
• Thrombosis of subclavian vein and a half to two times the basal requirements, a state
• Burns or trauma of the upper body of anabolism can be achieved during conditions
• Radiotherapy for the upper body usually associated with catabolic response. Weight
• Fresh tracheostomy. gain, wound healing, increased strength and activity
The delivery of amino acid/dextrose infusate is and an improved sense of well-being are observed in
controlled by the use of volumetric pump. Fat emul- adults and usual growth and development have been
sion requires manual rate setting and maintenance, attained in infants who are severely undernourished.

Table 15.12: Complications of intravenous nutrition and methods to prevent them


Complications Methods of prevention
Mechanical complications
Catheter misplacement By using correct position of patient
Damage to adjacent structures By following technique of insertion carefully
Catheter embolism By adequately protecting and strapping
Thrombophlebitis By following aseptic technique
Air embolism Use of locking devices
Catheter blockage Use of proper drip rate
Septic complications
Sepsis By following strict aseptic technique and changing of catheter
within 12 hours if there is sepsis
Metabolic complications
Acute
Hyperglycemia/hypoglycemia Addition of fat source to glucose-based TPN
Blood electrolyte abnormalities Exact replacement of electrolytes
Fluid overload Exact replenishment of fluids
Hyperlipidemia Proper use of fat source
Chronic
Metabolic bone disease
Alterations in bile composition
Deterioration of liver function
Chapter 15: Nutrition in the Perioperative Period 167
But the basic indications for application of Starting Nutritional Support
intravenous nutrition clinically have been made clear.
Nutritional support is started based on the patient’s
It is used for support and management of patients,
baseline nutritional status, either enterally or
who:
parenterally.
1. Cannot eat
In a 57-year-old male patient who is 166 cm tall
2. Will not eat
and weighing 67 kg, with a postoperative gastrointes-
3. Should not eat
tinal fistula, the caloric requirement is calculated as
4. Cannot eat enough.
follows:
The special demanding conditions of gastro-
intestinal system are enterocutaneous fistulae, inflam- Basal energy requirement (BEE)
matory bowel disease, and short bowel syndrome. = 66.5 + 13.8 (67 kg) + 5 (166) – 6.8 (57)
= 66.5 + 924.6 + 830 – 387.6
Nutritional Management of Patients with = 1433.5
Gastrointestinal Fistulae
Caloric requirement
Nutritional support plays a key and integral role in = 1434 × 1.1 (activity level) × 1.2 (stress level)
the management of patients with gastrointestinal = 1893 kcal (1900 kcal)
fistulae. It needs to be instituted early to minimize The formulation should contain the following
erosion of body cell mass, to prevent further physio- standard caloric distribution, as given in Table 15. 13.
logic deteriorization of the patient, and to initiate The standard solution can be modified based on
repletion in an otherwise malnourished patient. It also the patient’s coexisting condition(s).
allows the gastrointestinal tract to rest and facilitates
the healing of a fistula. The role of nutritional support Pre-and Postoperative Nutrition
in the management of a patient with a GI fistula is in Hepatobiliary Surgery
shown in Figure 15.4.
The role of nutritional support as either total paren- Amino acid, Fat and Protein Metabolism
teral nutrition (TPN) or enteral nutrition in fistula During starvation, the body’s store of glycogen is
management is primarily that of supportive care to depleted within 24 hours. The body’s glucose needs
prevent further deterioration of malnutrition. It is are met by gluconeogenesis from glycogenic amino
understood clearly that nutritional support decreases acids, lactase, pyruvate and glycerol. Muscle and fat
or modifies the composition of GI and pancreatic stores are mobilized to make the precursor substances
secretions. Thus, it is considered to play a primary available. During starvation, sepsis and injury, and
therapeutic role. fatty acid mobilization leads to ketone body
As shown in Figure 15.4, nutritional support is production.
initiated early to prevent further nutritional losses and Bile salt production and exocrine pancreatic secre-
to replenish nutritional deficiencies. Part of the initial tion control the normal digestion and absorption of
phase of fistula management is to stop oral intake fat. Glycolysis, lipogenesis and fat deposition are
while determining the optimal route for nutritional promoted by the action of insulin, using energy from
support. Depending upon the fistula site, the route the tricarboxylic acid cycle. When insulin levels fall
can be either parenteral or enteral. during ketosis, the beta-oxidation of fatty acids leads
to ketogenesis, gluconeogenesis and lipolysis. Half of
Stopping Oral Intake
In a patient with suspected gastric, duodenal, Table 15.13 Standard caloric distribution of a formulation
pancreatic or small bowel fistula, it is recommended
Nutrient source gm kcal % Total calories
to stop all forms of oral intake because feeding
stimulates further losses of fluids, electrolytes, and Glucose 270 950 50
protein via the fistula, which further deteriorates the Fat 70 630 30
patient’s health. In addition, continued losses through
Protein 95 380 20
upper GI fistula hinder the healing of the fistula.
168 Gastrointestinal Surgery: Step by Step Management

Fig. 15.4: Nutritional management of gastrointestinal fistulae

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.

Whenever TPN is started, the end point needs to be


Home Nutritional Support
thought of, and should be reviewed on a regular basis
to ensure maximum benefit and cost effectiveness with Many times, situations may warrant continuing
least harm to the patient and should be revised by the nutritional support either enteral or parenteral, and
progress or deterioration of the patient’s condition. his or her management followed in the home setting.
Generally, three clinical conditions dictate stopping Home nutritional support is preferred when:
nutritional support. They are: • It is expected to improve the quality of patient’s
1. Development of a life-threatening complication, life and decrease costs.
such as sepsis, hyperglycemia, nonketotic coma • Support system for maintaining at home is
and hyperammonemia. available.
16
Nutrition in Cancer Patients
It is extremely common to find serious malnutrition should be based on individual merits taking into
in patients and gross weight loss in patients with account the symptoms of the patient, as in Table 16.1.
malignancy of the gastrointestinal tract, especially the
upper third. The average daily intake of food goes Table 16.1: Symptoms and nutritional support
down to less than half of the normal intake. Emotional Symptom Nutrition plan
stress or physical limitations may be responsible for Loss of appetite Offer small, frequent feeds
decrease in food intake. Loss of appetite, altered taste, Adjust meal size to appetite
nausea, difficulty in swallowing, early fullness and Minimize food odors
Create a pleasing atmosphere
vomiting are found in a high proportion of nutri-
tionally depleted patients with cancer. Alterations in taste Avoid smelly foods
Although decreased oral intake and increased Serve foods at room temperature
extrarenal losses clearly play a major part in the Mouth dryness Modify food to liquid consistency
undernourished cancer patients, there is good Add sauces, gravies or juices
evidence that the presence of tumor also affects the Serve liquids with meals
nutritional status of a patient in a more direct manner. Nausea/vomiting Give dry bland foods
The demands of tumor growth affect the host protein Avoid offensive odors
metabolism by disturbing the nutritional balance Advise to eat and drink slowly
between anabolism and catabolism. Progression of Moth sores Avoid acidic, salty or spicy food
disease is associated with increased breakdown of Diarrhoea Increase fluid consumption
tissue protein. All these produce a synergistic effect Increase potassium intake
and produce a state of rapid depletion of nutrition Use low-residue diet
which is recognized clinically as ‘cachexia’. Avoid gas-producing foods such as
The goals of nutritional management of patients tubers and beverages
with cancer are two-fold: Constipation Increase fluid consumption
1. Achievement and maintenance of reasonable Increase fiber foods as tolerated
weight
2. Prevention or correction of nutritional imbalances The trauma of operation and its associated events
and deficiencies. produce physical and metabolic demands on the
For this, a program of aggressive nutritional patient which require an optimal nutritional manage-
management is required. Even though most patients ment and this is especially the case with cancer
respond to aggressive nutritional support along with patients, when the surgical removal may be extensive.
clinical therapy, the outcome for an individual patient Since the introduction of preoperative parenteral
may vary. nutrition in patients who have lost more than 8 percent
of body weight in preceding 6 months before opera-
tion, the resectability rate has increased from 4 to 34
NUTRITIONAL SUPPORT FOR
percent. Thus, preoperative nutritional therapy
THE CANCER PATIENT
reduces the overall postoperative complications rate
Whenever possible, the gastrointestinal tract should from 39 to 18 percent and mortality from 30 to 10
be used for feeding the patient. The nutritional support percent.
17
Management of Anastomotic
Leakage and Intra-abdominal
Sepsis
PRINCIPLES AND JUSTIFICATION ASYMPTOMATIC LEAKS
Leakage from anastomosed bowel is almost always Clinical Presentation and Management
the result of bad judgement and/or poor technique at
Small leaks are seen after bowel anastomosis like those
the time of construction. Leakage rates vary widely
from low rectal anastomoses in which integrity of the
between surgeons and although anastomotic leakage
anastomosis is checked postoperatively by radio-
occurs even in the best of hands, rates can be possibly
paque enema. Small leaks do occur in the upper bowel
made very low and this must be the goal of all
also, but they are rarely checked. When the leaks are
gastrointestinal surgeons.
not associated with infection, as evidenced by absence
Anastomotic failure occurs when the bowel is
of persistent swinging pyrexia and signs of
ischemic, when it is inadequately mobilized (resulting
inflammation, and as normal bowel function returns,
in tension on the anastomosis) and when seromuscular
no intervention is required. The leak will heal
apposition of the divided intestinal ends is inaccurate.
spontaneously without complications.
Furthermore, the presence of severe malnutrition and
intra-abdominal sepsis also compromise anastomotic LEAKS ASSOCIATED WITH
healing and, therefore, when conditions for anasto- GENERALIZED PERITONITIS
motic healing are not ideal, the surgeon should not
Clinical Presentation
hesitate to exteriorize the intestinal ends and recons-
truct the intestine at a later date. It may be appropriate The disruption of an anastomosis with leakage of
to protect a primary anastomosis by fashioning a enteric contents into the peritoneal cavity can occur
proximal diverting stoma, which can be closed when at any time after surgery but is most usually 2 to 5
the anastomosis has healed. Should anastomotic days after surgery. As the bowel contents are dis-
leakage occur, prompt institution of the correct charged into the peritoneal cavity, they become tachy-
management will limit the risk of further major cardiac, and show signs of generalized peritonitis. In
complications and death. The approach to this prob- a short time, they deteriorate with the development
lem will depend upon the type of leakage and the of peripheral circulatory failure and reduced urine
general condition of the patient. output. The abdominal distension depends on the
Anastomotic leaks can be categorized into four amount of gas leakage and intestinal stasis. The
principal types: abdomen becomes tense and tympanitic with
1. Asymptomatic leaks radiological evidence of pneumoperitoneum.
2. Leaks associated with generalized peritonitis
3. Leaks associated with localized infection or abscess Diagnosis
formation The diagnosis may be difficult, especially in immuno-
4. Leaks associated with an enterocutaneous fistula. suppressed and elderly patients; but in most cases, an
172 Gastrointestinal Surgery: Step by Step Management

experienced surgeon will be able to make a clinical


diagnosis. These patients need immediate resusci-
tation and early surgery.

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.

LEAKS ASSOCIATED WITH LOCALIZED


INFECTION OR ABSCESS FORMATION
The first event is dehiscence of an anastomosis of an
otherwise surgically closed segment of the stomach
or small or large intestine.
• Dehiscence of anastomosis → localized infection
→ abscess formation
The above situations are difficult to diagnose clinically
A B so that the next event can be averted, but suspicion of the
Fig. 17.4A and B: (A) Saline packings, (B) Closure over event and immediate care may contain the entire process
saline packs and irrigation and reduce the morbidity and mortality of the patient.
All wound healing depends on formation and
deposition of collagen, which contains amino acids,
hydroxyproline and hydroxylysine. When a wound
is formed, whether traumatic or operative, the collagen
around the wound undergoes degradation in the first
2 days. From the 3rd to the 5th day, collagen synthesis
occurs with little degradation. If this process pro-
gresses well, by the 7th day, the wound is stronger
than the surrounding tissue. If by any reason, this
process of healing is interrupted, the fibrin clot dissol-
ves around the 5th-7th day, and the luminal contents
escape following a dehiscence and its sequelae,
Fig. 17.5: Closure with releasing incisions resulting in abscess and or a fistula (Table 17.1).
As GI secretions leak out, they are walled off by
omentum or loops of small bowel or other viscera. The
adhesions from the operation also tend to localize the
collection in the area from which it originated. Because
patients often remain in supine position, the fluid of
these collections tend to accumulate in predictable,
Table 17.1: Wound healing process
Postoperative days Wound healing process
Normal Compromised
1 and 2 Degradation Degradation of collagen
of collagen
Fig. 17.6A: Laparostomy 3 to 5 Continues Continues collagen
collagen synthesis
synthesis
6 and 7 Collagen syn- Collagen synthesis
thesis with little interrupted by various
degradation factors
7th day after Strong wound Wound dehiscence—
Fig. 17.6B: Zipper mesh abscess-fistula
174 Gastrointestinal Surgery: Step by Step Management

well-defined areas that are largely dependent in


position. However, the formation of abscesses in the
subphrenic spaces is not only a result of their anato-
mical dependency, but also because fluid is drawn into
these spaces by negative intra-abdominal pressures
produced by the respiratory movements of the
diaphragm.
The formation of abscesses have a certain predic-
table pattern due to the anatomical configuration of
the peritoneal cavity. This cavity is divided into three
compartments: the supracolic, infracolic and pelvic.
The transverse colon forms the division between the
compartment into superior (anterior) and inferior
(posterior) spaces. Figure 17.7 shows the compart-
ments and the common sites of intra-abdominal
abscesses. Fig. 17.7: Common sites of intra-abdominal abscesses

Supracolic (Subphrenic) Compartment


This compartment is further divided into four
potential spaces where abscess occur. Figures 17.8A
and B show the transverse section and the sagittal
section of the compartment and the abscesses in the
compartment.
1. The left superior (anterior) space—(left subphrenic
space) lies in front of the left lobe of the liver, the
lesser omentum and the anterior surface of the
stomach. The medial boundary is the falciparum
ligament and laterally is the spleen, gastrosplenic
omentum and diaphragm.
2. The left inferior (posterior) space (left subhepatic Fig. 17.8A: Transverse section (top view)
space) is essentially the lesser sac.
3. The right superior (anterior) space (right subphrenic
space) lies between the right lobe of the liver and
the diaphragm and is medially bound by the
falciparum ligament.
4. The right inferior (posterior) space (Hepatorenal pouch
or Morison’s pouch) (right subhepatic space) lies
behind the right lobe of the liver and in front of
the right kidney.

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

The patients with GI fistulae can present with four


features. They are: and stabilization in the treatment of patients with
a. profound dehydration fistulae.
b. electrolyte imbalance The general principles of GI fistula management
c. malnutrition are divided into three phases of care:
d. sepsis. a. Diagnosis and recognition
Recognizing and treating these complications of b. Stabilization and investigation
GI fistulae are the underlying principles or recognition c. Treatment and definitive care.
178 Gastrointestinal Surgery: Step by Step Management

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

Stabilization Postoperative enterocutaneous fistulae form about 75


to 85 percent of all gastrointestinal fistulae, occurring
The goal in stabilization of GI fistulae is to control the commonly after operations for cancer, inflammatory
major complications of fistulae such as fluid and bowel disease, lysis of adhesions and pancreatitis,
electrolyte imbalances, malnutrition and sepsis. especially after emergency surgery, where the
Stabilization consists of: patient’s nutritional status is poor or the preoperative
• intravenous resuscitation preparation of the patient is poor.
• administration of broad-spectrum antibiotics The factors which can reduce the occurrence of
• correction of anemia postoperative fistulae are:
• electrolyte repletion • Anastomosis of healthy bowel away from disease
• drainage of obvious abscesses or inflammation.
• nutritional support • Administration of preoperative antibiotics (intra-
• control of the fistula drainage luminal or systemic).
• protection of skin. • Tension free anastomosis.
Investigations • Meticulous anastomosis.
• Secure abdominal closure.
Fistulograms and CT scans are obtained and endos-
• Maximization of preoperative nutritional status.
copy is done if indicated.
• Maintenance of adequate oxygen-carrying capacity
The questions to be answered by the fistulogram
postoperatively.
include the following.
1. What is the cause of the fistula? PATHOPHYSIOLOGY, CLINICAL
2. Is the bowel completely disrupted or is it a lateral PRESENTATION AND MANAGEMENT OF
fistula with the bowel in continuity? ENTEROCUTANEOUS FISTULAE
3. What is the length of the fistula tract?
ESOPHAGEAL FISTULAE
4. Is there an abscess cavity?
5. What is the size of the bowel wall defect? Majority of esophageal fistulae are postoperative and
6. Is there a distal obstruction? follow esophageal instrumentation, head and neck
Chapter 18: Management of Postoperative Gastrointestinal Fistulae 179

Table 18.1: Classification of gastrointestinal fistulae and their significance


Significance
__________________________________
Scheme Classification Favorable Unfavorable
Anatomic Internal Esophageal, Duodenal stump, Gastric, Lateral duodenal, Ileal,
External Pancreatobiliary, Jejunal Complete disruption, Epithelialization,
Organ involved (small leak, tract < 2 cm, Distal obstruction
defect < 1 sq. cm)
Physiologic Output Output does not prognosticate Output does not prognosticate closure
Low < 200 ml/day closure
Moderate
(200-500 ml/day)
High > 500 ml/day
Etiologic Disease process Appendicitis, Diverticulitis, Malnourished, Sepsis,Transferrin < 200 mg/dl,
Postoperative Cancer, Inflammatory bowel disease,
Foreign body, Radiation

surgery and esophageal transectional surgery (as an Surgical


adjunct to esophagogastrostomy). They may occur in:
When the patient is not allowed to take food orally, a
• Cervical region—cervical esophago-cutaneous
feeding gastrostomy or a feeding jejunostomy is
fistulae
performed for enteral feeding.
• Thoracic region—thoracic esophageal fistulae
When there is evidence of cellulitis or abscess,
(rarely it presents on the skin surface).
cervical drainage should be done with or without
CERVICAL ESOPHAGO-CUTANEOUS FISTULAE repair of perforation (Repair depends on the size of
the defect and the ability to find the area of the leak).
Etiology
Correction of nutritional imbalance A large percentage
They are seen after surgery for oropharyngeal cancer, of these patients have a history of tobacco or alcohol
cervical spine surgery, leak after cervical anastomosis abuse, which contribute to their overall poor health
as part of esophagectomy with esophageal replace- and malnutrition. Due to the preoperative pathology
ment with stomach or colon. itself they may be undernourished and anemic,
Clinical Presentation which need to be attended to.
They present with pain, dysphagia, fever and leuko- Note: * Barium is preferred to aqueous contrasts, as
cytosis. Acute perforations are recognized by crepita- small amount of aspirated barium into the bronchial
tion and tenderness in the neck. tree clears quickly, whereas aqueous iodinated
Investigations and Diagnosis contrast produce acute pulmonary edema when it
enters the bronchial tree, and also provides inferior
Radiography mucosal coating and lower radiographic density.
Plain film They show an increased distance between
the trachea and the spine, mediastinal emphysema, THORACIC ESOPHAGEAL FISTULAE
widening of the mediastinum, pleural effusion or
Etiology
pneumothorax.
Contrast study Water-soluble contrast (barium) may The causes are prolonged intubation, blunt or pene-
reveal evidence of perforation or fistula. trating trauma, endoscopy, dilation, foreign body
ingestion, surgery and malignancy.
Treatment
Medical Clinical Presentation
Broad-spectrum antibiotics, nothing by mouth for They present with cough, chest pain, hemoptysis,
several days and careful observation. pneumonia or empyema.
180 Gastrointestinal Surgery: Step by Step Management

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.

Broad-spectrum antibiotics, nothing by mouth for Investigations and Diagnosis


several days and careful observation.
Radiography
Correction of nutritional imbalance A large percentage
of these patients have a history of tobacco or alcohol Plain X-ray may show pleural effusion or lung infil-
abuse, which contribute to their overall poor health trates.
and malnutrition. Due to the preoperative pathology
itself they may be undernourished and anemic, which Contrast Study
need to be attended to. Water-soluble contrast by mouth may reveal evidence
of fistula.
Surgical
When the patient is not allowed to take food orally, a Treatment
feeding gastrostomy or a feeding jejunostomy is General principles of assessment and management of
performed for enteral feeding. fistula are to be applied:
When there is evidence of pleural collection as 1. Resuscitation and skin protection
empyema, intercostal drainage should be done. Repair 2. Institution of nutritional treatment
of perforation (Repair depends on the size of the defect 3. Assessment and treatment
and the ability to find the area of the leak) should be 4. Treatment plan.
Chapter 18: Management of Postoperative Gastrointestinal Fistulae 181
Medical Most of the external fistulae close spontaneously, when
correctly managed, but the internal fistulae virtually require
Nothing by mouth* and nasogastric aspiration for
surgical operation to close them, if it is considered necessary
several days and careful observation.
to do so.
Correction of nutritional imbalances The three approaches to the surgical management
• Correction of fluid and electrolyte imbalances be done of these fistulae are:
by calculating the output and its nature, the volume 1. Exclusion
and composition of the effluent** be measured and 2. Resection
the electrolyte content analyzed. 3. Closure of the leak
• Correction of malnutrition is done by total parenteral
nutrition (TPN). Higher output fistulae may close Exclusion
more quickly and conveniently with parenteral
1. The exclusion of a fistula is usually reserved for the
nutrition and having the patient avoid eating.
very sick patient. It is often not the treatment of
Control of infection and inflammation by adminis-
choice, as it requires a second surgical procedure
tration of wide spectrum antibiotics is extremely
to restore intestinal continuity after the fistula
important, to reduce the mortality.
heals. This procedure involves resection of the
Somatostatin analogues like Octreotide are useful in
diseased segment followed by exteriorization of the
the treatment of such fistulae.
ends. If the duodenum cannot be exteriorized, a
Note: *The total output of the stomach, duodenum, duodenostomy tube is placed (Fig. 18.4). This
pancreas and biliary tract is about 4 L per day, and operation converts an uncontrolled anastomotic
also oral intake dramatically increases the volume of leak into a controlled external fistula.
secretions from the salivary glands, stomach, Advantages: It avoids the difficulty and likely
duodenum and pancreas. failure of reanastomosis in a contaminated field.
**Since the effluent may be a combination of 2. Pyloric exclusion with gastrojejunostomy It involves
secretions from proximal and distal areas to the stapling of the pylorus followed by gastro-
fistulous tract, the volume and electrolytes should be jejunostomy. Gastrojejunostomy to exclude a
measured separately. diseased duodenum without a resection is not
advocated by many because, gastric contents pre-
Surgical ferentially flow through the pylorus and not
When the patient is not allowed to take food orally, a through the newly constructed gastrojejunostomy,
feeding jejunostomy is performed for enteral feeding. as the pyloric lumen is quickly restored within
Localized collections of pus should be drained. weeks and the fistula may persist.
Since these fistulae can cause excoriation of skin, skin
Resection
care is extremely important. Appliances may have to
be used to collect the effluents. Resection of the anastomotic leak is usually the
The surgical management of gastroduodenal operation of choice. The diseased segment is resected
fistulae is not straightforward. No rules indicate which and a new anastomosis is performed, provided the
postoperative external fistulae will fail to medical field is not contaminated. If the leak occurred after a
management and require surgical correction. gastrectomy and a Billroth I procedure, it should be
Certainly, certain underlying diseases prevent converted into a Billroth II procedure. If the duodenal
fistulae from closing spontaneously. They are: end is fibrotic and successful and safe closure is
a. Sepsis and malnutrition. doubtful, an end duodenostomy tube may be placed
b. Malignancy, previously irradiated bowel, inflam- (Fig. 18.4).
matory bowel disease.
c. Foreign body or an abscess as part of fistulous Closure of the Leak
complex. When resection becomes impossible due to the
d. Complete disruption of bowel or distal obstruction. compromise of the lumen, as in lateral duodenal
e. Epithelialization of the fistulous tract. fistulae, they can be managed by a serosal patch and
182 Gastrointestinal Surgery: Step by Step Management

SMALL BOWEL FISTULAE


Etiology
Seventy-five to eighty-five percent of small bowel
fistulae are postoperative and the rest 15 to 25 percent
is due to diseases like cancer, Crohn’s disease, trauma
and ischemic bowel disease.

Classification of Small Bowel Fistulae


Intestinal fistulae are classified as:
1. Internal (fistulous communication between two
segments of bowel or between a segment of
intestine and another hollow viscus).
2. External [direct fistulous communication single
(Fig. 18.6A) or multiple (Fig. 18.6B) between the
intestine and the skin of the abdominal wall or the
Fig. 18.4: Tube duodenostomy vagina].

Roux-en-Y anastomosis (Fig. 18.5). The bowel to be


patched must be cleansed of fat and have an adequate
blood supply. The edges of the defect are approxi-
mated, if possible. The defect can be patched with
jejunum or a defunctioning Roux limb. The benefit of
using a limb of bowel is that if the sealed defect leaks
again, the leak would be contained within the intes-
tinal limb. The disadvantage is that it requires an extra
anastomosis.

Fig. 18.6A: Single fistulous opening

Fig. 18.5: Serosal patch Fig. 18.6B: Multiple fistulous openings


Chapter 18: Management of Postoperative Gastrointestinal Fistulae 183
3. Mixed (complex fistulae involving both internal
and external communication, often through an
abscess cavity).
External fistulae are further classified on the basis
of their output:
Low output: Daily output does not exceed 200 ml
Moderate output: Daily output ranges between 200
and 500 ml
High output: Daily output exceeds 500 ml.

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.

Investigations and Diagnosis Control of Infection


Control of infection and inflammation are extremely
External fistulae are easily recognized as drainage of important, to reduce the mortality.
enteric contents to the skin or to the vagina is obvious. When sepsis is encountered, currently available methods
The typical clinical presentation includes febrile of nutritional support do not reverse malnutrition and
postoperative course with erythematous wound that hypercatabolism unless sepsis is controlled first.
begins to leak purulent material and finally enteric In all, when managed judiciously, external fistulae close
contents. If the diagnosis is in doubt, confirmation can in about 70 percent of cases.
be obtained by oral administration of a nonabsorbable Most lateral small bowel fistulae will close
marker (Charcoal or Congo red) or by injection of spontaneously on parenteral nutrition, provided there
water-soluble radiopaque contrast into the fistula is no distal obstruction, no associated abscess cavity
opening (fistulogram) (Fig. 18.7). Ultrasonography, CT and also the bowel itself not heavily involved with
scan with contrast or isotope scanning are useful disease such as tumor or Crohn’s disease.
diagnostic tools. The seriousness of external fistula generally
depends upon its anatomic location and the volume
Treatment of output it produces. Generally, the more proximal a
small bowel fistula, the larger the amount of output
Medical
and the resultant electrolyte imbalance and the
Nothing by mouth, nasogastric aspiration, and malnutrition. The amount of output alone does not deter-
intravenous antibiotics are important. mine the likelihood of spontaneous closure.
184 Gastrointestinal Surgery: Step by Step Management

The other factors which hinder the spontaneous


closure are:
a. Sepsis and malnutrition
b. Malignancy, previously irradiated bowel, inflam-
matory bowel disease
c. Foreign body or an abscess as part of fistulous
complex (Fig. 18.8)
d. Complete disruption of bowel (Fig. 18.9)
e. Distal obstruction (Fig. 18.10)
f. Epithelialization of the fistulous tract (Fig. 18.11).

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

Fig. 18.13: One-piece ileostomy pouch

Fig. 18.11: Epithelialization of fistula

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

management and there is evidence of obstruction,


active disease or interruption of bowel continuity and
spontaneous closure becomes unlikely, and when the
closure has not occurred by 4 to 6 weeks. Surgery is
the excision of the fistulous tract with a part of the
involved or diseased bowel.

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.

External Colonic Fistulae


The external colonic fistulae are caused by a compli-
cation or are the result of a surgical procedure, such
as a leaking anastomosis or incision and drainage of
an abscess resulting from underlying pathology,
Fig. 18.15: Skin barrier—karaya based powder
commonest being the diverticulitis. Occasionally, this
can be due to the erosion of the anterior abdominal
wall of a colonic malignancy.

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.

Investigations and Diagnosis


Diagnosis of colocutaneous fistula is very easy. The
main symptoms and signs of a colocutaneous fistula
are self-evident with the passage of flatus and faeces
through an incision on the abdominal wall following
surgical resection.
Though not helpful, proctoscopy should be
performed to exclude underlying pathology. Barium
enema with thin water-soluble contrast may demons-
trate the fistula. A CT scan with contrast may be of
use in some cases. Fistulogram and Vaginogram may
give required information as to the origin of the fistula
Fig. 18.16: Skin barrier—paste and associated abscesses.
Chapter 18: Management of Postoperative Gastrointestinal Fistulae 187
Treatment Surgical
Medical Surgical treatment like proximal diversion is useful
in certain situations. An ileostomy is preferred over a
Because the contents of the colon are colonized with
colostomy. When a colostomy is considered, it
bacteria, control of sepsis is an important component
involves the transverse colon because sigmoid has
in the management of these patients.
been resected. The diverting stoma is kept for a mini-
The skin around the fistula needs special attention.
mum of 3 months. Before closing the stoma, a clinical
Skin care management (see Chapter 19—Stoma examination is done to check the anastomosis.
Care) The effects of continuous moisture on the skin Invariably, there is a degree of narrowing. An opening
and the degree of chemical irritation of effluent of 12 mm diameter allows acceptable closure of the
(depending on where the fistula originated in the large stoma. If the stricture is long and/or less than 12 mm
bowel) can severely compromise skin integrity. The in size and unable to be dilated because of scarring
draining fistulae cause odor, wetness, burning pain and fibrosis, re-resection of the anastomosis with
and discomfort secondary to skin erosion. The goals construction of a new anastomosis is indicated. The
of skin care management are to maintain skin integrity stoma is closed after establishing that the new
and to contain the effluent. anastomosis is sound and well healed.
The following are to be assessed in the skin care:
Internal Colonic Fistulae
1. Origin of the fistula
2. Nature of the effluent Internal colonic fistulae like colovaginal fistulae
3. Condition of the skin present with vaginal discharge of faecal matter. The
4. Location of the fistula opening. volume varying from a small stain to profuse dis-
charge. Coloenteric fistulae present with abdominal
Pouches Many different pouches are available which pain and diarrhoea and a mass is usually found on
offer a variety of features for pouching GI fistulae. physical examination. They may occur spontaneously
They vary in size to accommodate small and large or after surgery following anastomotic leaks, abscess
perifistular surface areas. Ostomy pouches are availa- and fistula formation.
ble in one (Fig. 18.13) or two piece (Figs 18.14A and B)
designs with either a drainable clip closure of Diagnosis
urostomy type closure. One-piece pouch systems are Diagnosis of internal colonic fistulae is straight-
more flexible than the two-piece systems because the forward, recognized by the discharge of faecal matter
attachment being eliminated (details in Chapter 19— through the output of the organ with which it is linked.
Stoma Care).
Treatment
Skin barriers They come in a variety of forms—solid
wafers (pectin based), powder (Fig. 18.15) (pectin or Treatment of internal colonic fistulae is surgical,
karaya based), paste (Fig. 18.16) (pectin based), spray because they link normally sterile organs with the gut.
and wipes (alcohol based), ointments and creams (zinc In patients who are not septic or hypoalbuminemic,
or petroleum based). They give second skin protection resection and primary anatomosis after good bowel
from faecal drainage and can withstand the effects of preparation should be adequate. In patients who are
effluent for a variable period of time (details in Chapter septic and hypoalbuminemic and anemic, resection
19—Stoma Care). and exteriorization is the safest procedure.
If the output from a leaking colorectal anastomosis Note: Colonic fistulae associated with the ascending
is low and not associated with an abscess cavity, it colon may result in large volume losses, whereas fluid
may be expected to close without surgical inter- loss from the descending colon is usually less as the
vention. Closure frequently occurs while the patient is consistency of the colonic contents is more liquid in
allowed to eat a normal diet. the ascending colon.
188 Gastrointestinal Surgery: Step by Step Management

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).

Diagnosis External Pancreatic Fistulae


External pancreatic fistulae mostly occur as compli-
Diagnosis of a biliary fistula is straightforward. They
cations of elective upper abdominal surgery, which
rarely give rise to marked skin excoriation, although
occur between 2nd and 7th postoperative day. This
for the patient’s comfort, a stoma bag should be app-
becomes evident by increased surgical drain output
lied. Fistulogram, ultrasonography and CT scanning
of serous to cloudy fluid with a high amylase content.
may reveal a distal obstructing lesion, which should
The operations which carry the risk of producing
be treated.
pancreatic fistula are:
Treatment 1. Operations on the pancreas itself (e.g., biopsy)
2. Distal pancreatectomy
Medical 3. Elective pancreaticoduodenectomy
Most external biliary fistulae close spontaneously if 4. Gastric surgery
there is no distal obstruction. In jaundiced patients, 5. Biliary tract surgery
percutaneous transhepatic cholangiography (PTC) 6. Splenectomy
and endoscopic retrograde pancreatocholangiography Postoperative fistulae are externalized because of:
(ERCP) are useful tools in diagnosing the level and 1. The placement of drains intraoperatively
nature of obstruction and in palliative decompressive 2. Spontaneous drainage via the wound
procedures. 3. Percutaneous drainage of postoperative fluid
collections.
Surgical
Surgical intervention is required to relieve the distal Table 18.2: Classification of pancreatic fistulae
obstruction, and an appropriate biliary reparative Internal External
surgery, mostly in the form of biliary enteric anasto- Pseudocyst Pancreatico-cutaneous
mosis in the form of Roux-en-Y reconstruction.
Pancreatico-enteric
Internal Biliary Fistulae Pancreatic ascites
Pancreatico-pleural
Internal biliary fistulae occur following an inflam-
matory biliary disease and are rarely postoperative Pancreatico-bronchial
and these do not cause any disability or disturbance, Pancreaticovascular
Chapter 18: Management of Postoperative Gastrointestinal Fistulae 189
Internal Pancreatic Fistulae conservative management are meticulously followed.
Internal pancreatic fistulae are uncommon. They occur The disadvantages of conservative management are
as a result of pancreatitis and pancreatic trauma. prolonged hospitalization and high cost of care.
Pancreatic pseudocyst constitutes a special type of Somatostatin and its analogues have played a
internal pancreatic fistula associated with pancreatitis. significant role in the healing of these fistulae***. They
Therapeutic percutaneous drainage of the pseudo- are administered at an initial dose of 50 mcg subcuta-
cyst creates an iatrogenic external pancreatic fistula if neously three times per day, and the dose titrated
the cyst is in continuity with the pancreatic ductal based upon fistula output. The maximal dose is 200
system, and should be avoided. mcg three times daily.
In patients with ERCP-documented strictures of
Diagnosis the pancreatic duct, transpapillary stenting is found
The diagnosis of pancreatic fistula is usually straight- to be useful. The stents are removed after 6 weeks.
forward. CT scanning of the abdomen is the most The stents have no role when the ductal continuity is
accurate means of detecting postoperative pancreatic incomplete.
collections and leak. The presence of amylase-rich
fluid confirms the diagnosis of a pancreatic leak. Surgical management In general, internal pancreatic
Fistulography can demonstrate ductal anomalies as fistulae require operative intervention more often than
well as proximity of drains to the duct and to adjacent external fistulae. The choice of operation for pancreatic
viscera. ERCP and MRCP (Magnetic Resonance fistula depends upon the site of origin of the fistula
Cholangiopancreatography) have emerged as most and the presence and location of any stricture of the
valuable means of assessing the leak, particularly pancreatic duct.
when operation is contemplated. Fistulae from body and tail—distal pancreatec-
tomy.
Treatment Fistulae from the head—internal drainage proce-
dure by Roux-en-Y pancreatico-jejunostomy or cysto-
Internal fistulae require repeated drainage under cover jejunostomy.
of broad-spectrum antibiotics. Unimpeded free drain- Pseuodycsts of pancreas—cystogastrostomy,
age of the fistula is essential. cystoduodenostomy or cystojejunostomy.
External fistulae require volume-to-volume fluid
and electrolyte replacement*. Note: *Pancreatic secretions are very hypertonic and
Skin care management Skin care is very important. rich in bicarbomate and protein, and the average
The skin around the fistula needs special attention (see output is about 800 ml/day, although more output is
Chapter 19—Stoma Care). The effects of continuous also possible. The sodium content is close to that of
moisture on the skin and the degree of chemical serum and thus normal saline is used for replacement
irritation of effluent can severely compromise skin along with added bicarbonate.
integrity. The draining fistulae cause wetness, burning **Pancreatico-cutaneous fistulae cause significant
pain and discomfort secondary to skin erosion**. skin breakdown and needs special skin care.
Approximately 80 percent of external pancreatic ***The use of somatostatin analogue may decrease
fistulae close spontaneously when the principles of the volume of the fistula to allow healing.
19
Stoma Care
DEFINITION accept this; he will gain more respect from his patient
by referring to someone more expert in this field than
A stoma is an opening of the gastrointestinal tract or
by providing poor or erroneous advice which will
urinary tract onto the abdominal wall, constructed
quickly be recognized as such. Thus, mutual respect
surgically or appearing inadvertently.
and a satisfactory partnership will be maintained.
The stoma may be a colostomy performed after
partial colonic resections, or an ileostomy performed
STOMA
after total colonic resections. A urinary conduit
involves a stoma on the anterior abdominal wall that The most important factor is the marking for the
serves to convey urine to an appliance placed on the construction of stoma (see Chapter 9), which should
skin. The conduit may consist of an intestinal segment be done only in the sitting or standing position, to
or, in some cases, a direct implantation of the ureter make the aftercare easier. A stoma is easily damaged,
(ureterostomy) or even the bladder (cystostomy) on as it is insensitive to pain, touch and heat.
the abdominal wall.
The gastrointestinal stoma may be divided as given COLOSTOMY
in the Table 19.1. A permanent colostomy is commonly sited in the left
iliac fossa, and in this situation management is usually
Table 19.1: Divisions of stoma
straightforward. Occasionally, but often temporarily,
Input stomas Gastrostomy it may have to be sited elsewhere, and the effluent
Jejunostomy may then be more liquid, the position more inconve-
Output stomas Temporary Pharyngostomy nient, the risk of trauma greater and the adhesion of
(Diversion) Esophagostomy the appliance less satisfactory. The stoma should be made
Ileostomy (loop) almost flush with the skin and should allow ample space
Colostomy (loop,
transverse, sigmoid,
around it for adherence of a plaster, which will be clear
temporary end) of the waistline, groin, umbilicus, skin folds, scars and
Permanent Ileostomy (terminal) bony prominences. Siting should be carried out
Colostomy (terminal, iliac) preoperatively with the patient sitting or standing, and
it is advisable for an appliance to be worn over the
In the care of each case, the aim is to provide an intended site for at least 24 hours to ensure that the
unobstrusive and acceptable appliance which causes siting is satisfactory.
the least inconvenience to the patient, which does not
damage the skin or stoma and collects the effluent ILEOSTOMY
satisfactorily. Each type of stoma, despite similarities, An ileostomy is usually sited in the right iliac fossa,
present different problems; it must be remembered with the conditions mentioned as in the marking of a
that a patient managing a stoma every day of the year colostomy. Though the effluent is initially fluid and
develops great experience and is more knowledgeable although it thickens, it never becomes solid. The stoma
than many doctors and nurses. If a patient’s know- should be in the form of spout, so that the effluent is
ledge is inadequate or faulty, it can be corrected by directed into the bag and lessen the risk of contact
sound medical advice. If the doctor’s knowledge is with the peristomal skin, as it contains digestive
inadequate for the particular problem, he should enzymes and chemical irritants.
Chapter 19: Stoma Care 191
THE APPLIANCE
There are a variety of appliances available (Fig. 19.1)
in the market, and the patient should be made aware
of them. There are almost always difficulties in the
first few weeks, but with practice, variation of
equipment and the passage of time, all patients should
develop complete confidence in the form of appliance
finally used.
Appliances are either:
1. Adhesive or non-adhesive
2. Disposable or non-disposable
3. Drainable or non-drainable. Fig. 19.1: Appliances
Adhesive Non-adhesive Appliances
Adhesive appliances are preferred to non-adhesives
as they provide security from leakage and odor. The
components of the adhesive appliances are either
separately available or combined with a plastic or
rubber flange over which a bag fits. It is important
that flanges and bags are of matching size and suited
to the size of the stoma (Figs 19.2A and B).
Fig. 19.2A and B: Patient with a non-disposable appliance
Disposable Non-disposable Bags
Disposable bags are made of thin plastic material
(Fig. 19.3), which can be clear or opaque and may be
decorated. They do not last many days and require to
be changed daily. Non-disposable bags are usually
of white or carbonated black rubber and require to be
washed daily with soap and water, dried thoroughly
and dusted with talcum powder. They last 2 to 3
months or longer.

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

Fitting the Non-disposable Appliance


2. The flange is stuck to the skin after applying an
(Figs 19.4A to F)
adhesive like Tr. Benzoin Co.
1. Stoma opening in the flange is cut to size of the 3. The space between the stoma and the flange is
stoma protected by zinc cream
192 Gastrointestinal Surgery: Step by Step Management

4. Stick the bag to the skin


5. Apply hypoallergenic plaster to the edges for extra
protection.

Emptying, Changing and Disposing of


Colostomy Appliances
The time at which the patient chooses to empty and/
or change the colostomy bag will vary depending on
the type of appliance used, frequency of the colostomy
actions and on his personal preference. There is no
A B
immediate urgency to empty the bag as soon as a
motion occurs, but most patients will prefer not to
have the bag in a heavily loaded condition longer than
necessary, and so, they will choose to empty it as soon
as a major colostomy action, whenever that may be.

Removal of the Appliance


With the availability of hypoallergenic plaster, the
removal of the appliance is fairly easy with little diffi-
C D culty or skin trauma, as the appliance is peeled gently
from the skin. If there is difficulty, it is better to ease
the plaster with methylated ether. Thereafter, all traces
of adhesive should be removed from the skin with
the same preparation.

E F

Figs 19.4A to F: Fitting the non-disposable appliance (A) Stoma


opening in the flange is cut to size, (B) Tr. benzoin co. applied
to skin, (C) The flange is stuck to the skin, (D) Strips of adhesive
applied for additional security, (E) Zinc cream applied for skin A B
protection, (F) Ostomy bag applied to the flange

4. The bag is clipped to the flange


5. Clip is applied to the outlet
6. Belt may be tied for extra protection.

Fitting the Disposable Appliance C


(Figs 19.5A to D) D

1. Clean and dry the skin


Figs19.5A to D: Fitting the disposable appliance (A) Stoma
2. Apply the adhesive like Tr. Benzoin co around the opening in the flange is cut to size, (B) Tr. Benzoin co. applied
stoma to skin, (C) The bag is stuck to the skin, (D) Strips of adhesive
3. Cut the stoma opening in the bag to size applied for additional security
Chapter 19: Stoma Care 193
Cleaning the Appliance Management is by
• Elimination of items which they have found to
This refers to the non-disposable bags. Regular wash-
contribute to the intestinal flatulence
ing with soap and water, and drying and powdering
• Perforating the bag with a needle at several places
of rubber bags should keep them in satisfactory
very close together on its anterior aspect near the
condition. This cleaning procedure may prove
top, and fitting an adherent ‘flatus patch’ on the
distasteful to some patients and can be avoided by
perforated part (Figs 19.6A to C).
using disposable bags. Nonopaque disposable bags,
however, allow the effluent to remain visible, and this
Detachment of Bag
is aesthetically unacceptable to other patients.
Detachment of the bag occurs due to
PROBLEMS • The bag becoming full with the effluent
• Sudden twisting or jumping
Problems of the Appliance
• Catching of bag between thigh and bed on turning
Odor over in bed
Odor should not be a problem for ileostomates, but it • Consuming large meals in late evenings.
is more difficult to prevent or eradicate for some colos- Management is by
tomates. Most bags are odor proof or odor resistant • Emptying the bag before it becomes full
and odor often indicates: • Emptying the bag before severe exercises and
• Leakage retiring to bed
• An appliance left too long • Avoiding large meals late in the evening.
• An old bag
• Incorrect fitting of the appliance. Problems of the Adhesive
Management of odor is by The principal problems with adhesive are due to:
• Consuming odor-free diet • Inefficient or incorrect application
• Deodorizing sprays in the room • Moist or unclean skin
• Keeping deodorant tablets in the bag • Wrinkles in the plaster and
• Consuming deodorizing tablets like Charcoal, • Folds in the skin.
Bismuth subgallate in a dose of 1-2 gm and 400
mg respectively, before each meal or four times
daily. B
C
Leakage A

Leakage occurs due to:


• Manufacturing faults in the bag
• Improperly applied clips or screw clips.
Management is by:
• Taking care in preparing and fitting the appliance
• Inspecting it daily and
• Emptying it before it becomes full.

Excessive Flatulence Figs 19.6A to C: Method of using flatus patch on colostomy


The bag may undergo frequent embarrassing (or ileostomy appliance (A) On the front surface of the bag near
its top numberous perforation are made with a needle, (B) The
distension. This occurs due to flatus patch has the paper covering removed from its back
• Consumption of food which contributes to surface, (C) The patch is applied to the perforated area on the
intestinal flatulence. front of the bag and covers it over completely
194 Gastrointestinal Surgery: Step by Step Management

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

Trauma Ulceration of stoma is almost always due to:


• Pressure from part of the appliance—tight belt
Trauma is a common problem and is usually caused
• Inflammatory disease of the bowel
by:
• Appliance kept too long.
• Frequent shaving and abrading the skin
• Frequent changes of adhesive plaster. Management is by
• Correctly applying the appliance
Management is by:
• Treatment of the inflammatory bowel disease, if
• Care during the removal of hair and shaving
any.
• Thorough drying before the application of the
adhesive Allergy
• Less frequent changes of adhesive plasters. Allergy may occur on direct contact of rubber with
the stoma.
Allergy
Allergic dermatitis is not rare and is usually associated Management is by
with zinc oxide adhesive plaster. Washing, drying and powdering of bags.

Management is by: Congestion


• Using hypoallergenic adhesive plasters Congestion of stoma may occur if the belt is applied
• Topical corticosteroid application too tightly. This results in edema, oozing of blood and
• Oral prednisolone. even ulceration, and is corrected by slackening the belt.

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

exert their influence by releasing carbon dioxide, Choice of Fluid


causing rectal distention when they contact water or
Several solutions can be used to clear the bowel:
mucous membrane.
1. Hypertonic solutions
2. Isotonic solutions
Manual Evacuation
3. Tap water.
Manual evacuation of the rectum should be avoided
if possible; it should only be performed if all other Hypertonic Solutions
methods of relieving constipation have failed. It is a Hypertonic solutions, e.g. sodium phosphate and
distressing often painful and potentially dangerous sodium acid phosphate in solution, act by drawing
procedure for the patient. When the rectum is full, from the intestinal cells by osmosis. This increases the
dilating the anus either by a finger or an anal dilator fluid in the faecal mass, causing first distension, then
will stimulate the defaecation reflex. contraction and defaecation. For patients who have a
large amount of faecal matter to evacuate, small
Rectal Lavage volumes of these solutions are very effective.
Definition Rectal lavage is the washing out of the Isotonic Solutions
rectum using large volumes of non-sterile fluid.
An isotonic solution can be substituted for patients
Indications Rectal lavage is performed for the with compromised electrolyte status. This is prepared
following purposes: by adding 2 level teaspoons of salt to a litre of plain
• To clear the lower bowel before investigation by water. Its effect on the bowel is similar to that of water
barium enema and thus enable good images to be in that it stimulates peristaltic action by distending
obtained the intestinal walls.
• To assist in clearing the lower bowel before major
abdominal surgery and thus reduce the risk of Tap Water
infection and aiding satisfactory healing Rectal lavage is a procedure that is normally used in
• To clear the lower bowel of residual faecal matter combination with other methods of clearing the bowel,
following previous surgery, e.g. formation of e.g. oral aperients and dietary restrictions. In this
colostomy. situation, it can be anticipated that there will be very
little residue remaining in the lower bowel. What is
Contraindications Rectal lavage is contraindicated needed, therefore, is a simple, nonsterile solution that
in patients with a history of any one of the following: can be used with relative safety in large volumes to
• Severe or prolapsed hemorrhoids wash out the residual faecal matter. The solution that
• Anal fissure (acute) fulfils these criteria ideally is tap water.
• Inflammatory bowel disease (Toxic megacolon) The disadvantages of tap water are:
• Hirschprung’s disease • It is hypotonic and
• Large tumor in the rectum or sigmoid colon • Upset the electrolyte balance.
• Postradiation proctitis The advantages of tap water are:
• Pelvic radiotherapy • It is cheap and easily available
• Recent bowel surgery • It can be easily warmed to the correct
• Congestive cardiac failure temperature (37 oC)
• Impaired renal function. • It is non-irritant to the bowel mucosa
In the last two contraindications, there is a potential • It does not cause excessive peristalsis with
risk of absorption of large quantities of water and resulting cramps and colic.
electrolytes through the bowel, creating an overload.
In other contraindications, there is a potential risk of Choice of Rectal Catheter
irritation or perforation of the bowel, due to the inser- The criteria of selection of catheter should be as
tion of the catheter and running large volumes of fluid follows:
in and out of the rectum, as the bowel is already • The catheter should be of an adequate length about
traumatized, either by disease, radiation or surgery. 30 cm
Chapter 21: Bowel Care 201
• The lumen should be large enough to allow the and electrolyte disturbances. This has resulted in the
free drainage of particulate matter, minimum of development of osmotically balanced solutions
24 F formulated to provide minimal water absorption or
• The tip of the catheter should be open ended or secretion into the bowel lumen. Polyethelene glycol
have large opposed eyelets to minimize the electrolyte lavage solution (PEGLEC) and oral
possibility of blockage sodium phosphate solutions (EXELYTE) are widely
• The catheter should be made from a soft flexible used laxatives for colonic cleansing for colonoscopy
material: rubber or plastic. and colon surgery.

Cleansing the Bowel Before Iso-osmotic Preparations


Surgery by Oral Preparations Iso-osmotic preparations containing polyethylene
Early preparation methods for cleaning the colon (48- glycol (PEG) are osmotically balanced, nonabsorbable
72 hours of clear liquid, laxatives, and enemas) have electrolyte solutions available in powder form
provided a relatively faeces-free colon but are often weighing 137 gm to be reconstituted in 2 litres of water.
time consuming, uncomfortable, and inconvenient for One litre of the solution is to be consumed in 1 hour’s
the patient. Per oral gut lavage with saline solution or time (200 ml every 10-15 minutes), followed by the
balanced electrolyte solutions have been found to rest of the solution in the next hour as before, cleanses
provide rapid, effective cleansing for colonoscopy, the bowel by washout of ingested fluid without
barium enema, and colon surgery (Table 21.2). significant fluid and electrolyte shifts. The patient may
However, the required volume of 7 to 12 litres often stop drinking the solution when the stool changes into
required nasogastric administration but result in fluid water-like (colorless or yellowish) and without any

Table 21.2: Per oral gut lavage solutions


Property Polyethylene glycol Sodium phosphate
Osmolarity Isosmotic Hyperosmotic
Absorbability Nonabsorbable Absorbable
Availability Powder form to be reconstituted Ready-to-use solution/tablets
Weight of the preparation 137 gm constituted to 2 litres solution 24.4 gm of monobasic component and 8.1 gm of the
dibasic component in a buffered aqueous solution
totalling 45 ml
Method of consumption 200 ml every 15 minutes To be consumed in full
Advantages — Small volume of the solution
consumption easy and comfortable
Disadvantages Large volume of the solution and,
difficulty of reconstitution and —
consumption
Side effects Nausea, abdominal pain, aspiration Potential to alter serum electrolytes and extracellular
of solution, toxic colitis, PEG-induced status, asymptomatic hyperphosphatemia
pancreatitis, syndrome of inappropriate
secretion of antidiuretic hormone, and
cardiac arrhythmias
Macroscopic and Nil Present
histologic changes
to the mucosa
Safety profile and Relatively safe for patients with Contraindicated in patients with renal failure, acute
contraindications electrolyte imbalance, advanced myocardial infarction, unstable angina, congestive
liver disease, compensated congestive heart failure, ileus, intestinal malabsorption, significant
heart failure or renal failure ascites
202 Gastrointestinal Surgery: Step by Step Management

solid matter which is an indication of lavage being SUMMARY


completed.
The choice of bowel preparation for colon surgery or
Hyperosmotic Preparations colonoscopy is influenced by cleansing effectiveness,
Hyperosmotic preparations containing monobasic safety, ease of completion, side effects, patient
and dibasic sodium phosphate (NaP) draw plasma tolerance, and cost. Although PEG and NaP are
water into the bowel lumen to promote evacuation. It equally effective in colonic cleansing, NaP is better
is available in the composition of 24.4 gm of monobasic tolerated. However, NaP may be contraindicated in
component and 8.1 gm of the dibasic component in a certain patient populations. The selection of prepa-
buffered aqueous solution totalling 45 ml, to be consu- ration requires clinical judgement and informed
med in full. patient preference.
Index
A Asymptomatic leaks 171 Cervical esophago-cutaneous fistulae 179
Abscess Choice of fluid
B hypertonic solutions 200
clinical presentation 132
Bacteriological cleansing 97 isotonic solutions 200
in the fistula 184
Benign CBD stricture tap water 200
investigations and diagnosis 132
clinical presentation 137 Cholangitis 26
pathology of complication 132
stricture investigations Cholecystectomy 129
treatment 132
and diagnosis 137 Choledocho-enterostomy 130
Achalasia
pathology of complication 137 Choledochotomy 58
clinical presentation 39
treatment 137 Cholelithiasis 40, 41
investigations and diagnosis 39
Bezoar formation clinical presentation 41
pathology of complication 39
clinical presentation 65 investigations and diagnosis 41
treatment 39
investigations 66 pathology of complication 41
Acute afferent loop obstruction 55
treatment 66 treatment 41
Acute pain 196
Bile collection 132 Chronic
Adhesions
Biliary enteric fistula afferent loop obstruction 69
clinical presentation 104
treatment 138 efferent loop obstruction 70
investigations and diagnosis 104
clinical presentation 138
pathology of complications 104 gastric atony 65
isotope studies 138
treatment 104 Chronic gastric atony
pathology of complication 138
Anal incontinence clinical presentation 65
Biliary fistulae 188
clinical presentation 119 pathology of 65
Biliary leak 144, 145
investigations and diagnosis 119 Chronic pain 196
investigations and diagnosis 144
pathology of complications 119 Chylous ascites
clinical presentation 144
treatment 119 clinical presentation 146
pathology of complication 144
stenosis and stricture 118, 119 investigations and diagnosis 146
treatment 145
Anastomosis pathology of complication 146
Biliary peritonitis
end-to-end 8, 9 treatment 146
clinical presentation 131
functional end-to-end 13 Circular stapler 10
investigations and diagnosis 131
Anastomotic leakage 12, 103, 171 Cirrhosis 25
pathology of complication 131
clinical presentation 103 treatment 131 Coagulation 26
investigations and diagnosis 103 Biliary tract surgery 129, 130 Colectomy 96
pathology of complications 103 early biliary complications 131 Colon rectum 96
treatment 103 late biliary complications of 136 Colon surgery 27
Anastomotic leaks 57 preoperative management 130 Colonic fistulae 186
Anatomy of surgical needle 5 Bowel care 198 Colorectal 9
Anemia Breakthrough analgesia 197 Colostomy 96, 106, 190
clinical presentation 65 Bypass procedures 96 breakdown of 115
investigations and diagnosis 65 closure of 114
pathology of complication 65 C divided 107
treatment 65 Cardiopulmonary 25 double barreled 107
Anorectal Care of the early complications of 109, 115
surgery early complications of 117 perineal wound 98 late complication of 110, 115
late complications of 118 urinary bladder 98 loop 107
pre and postoperative CBD stones postoperative management of 108, 115
management 116 clinical presentation 136 preoperative management of 108, 115
Antibiotic 26, 97, 127 investigations and diagnosis 136 separation of 110
dosage 27 pathology of complication 136 stenosis of 110
prophylaxis 43 treatment 137 terminal 107
Anus 96 Cefazolin 27 Complete disruption of bowel 184
Assessment of nutritional status 157 Cefuroxime 27 Complications of gastrostomy 71
204 Gastrointestinal Surgery: Step by Step Management
Continued bleeding 122 Early gastrointestinal hemorrhage 142 Gastric surgery
clinical presentation 122 Early hemorrhage and shock 99 complications of 48
investigations and diagnosis 122 Early intragastric hemorrhage 48 early complications of 49
pathology of complication 122 Endocrine deficiency varieties of 46
treatment 122 clinical presentation 148 Gastrocutaneous 180
Correction of undernutrition 43 investigations and diagnosis 148 Gastroduodenal 27
Crohn’s disease 103 pathology of complication 148 Gastroduodenostomy 52
Cystic duct inflammation treatment 148 Gastrografin 53
clinical presentation 136 Enemas Gastrointestinal fistulae 177
investigations and diagnosis 136 definition 199 classification of 179
pathology of complication 136 types of Gastrointestinal fluid loss 30
treatment 136 evacuant enemas 199, 200 Gastrojejunocolic fistula
Cystic duct neuroma manual evacuation 200 clinical presentation 69
clinical presentation 136 rectal lavage 200 investigations and diagnosis 69
investigations and diagnosis 136 retention enemas 199 pathology of complications 69
suppositories 199
pathology of complication 136 Gastrojejunostomy 53
Epithelialization of fistula 185
treatment 136 Gastrokinetics 40
ERCP basketing 135
Cystic duct stone Gastroscopy 59
Erythromycin 27
clinical presentation 136 Glucose and albumin infusion 121
Esophageal surgery
investigations and diagnosis 136
early complications 44 H
pathology of complication 136
late complications of 45
treatment 136 Hematoma
Esophagojejunal 9
Cystoduodenostomy 57 Esophagomyotomy 43 clinical presentation 132
Cystogastrostomy 57 Esophagus 37, 42 investigations and diagnosis 132
Cystojejunostomy (Roux-en-Y) 57 Exocrine deficiency pathology of complication 132
clinical presentation 148 treatment 132
D Hepatic surgery 120
pathology of complication 148
Daily fluid balance 30 treatment 148 early complications of 121
Delayed gastric emptying 144 External biliary fistula 132 late complications of 123
clinical presentation 144 External colonic 105 postoperative management 121
pathology of complication 144 Extrabiliary complications 139 preoperative management 120
treatment 144 Extragastric hemorrhage 51 Hepaticojejunostomy 129, 130
Delayed intragastric hemorrhage 50 Extrinsic nerve supply 37 Hindgut 96
Dextrose Hoarseness of voice
half normal saline solution 29 F clinical presentation 45
normal saline solution 29 Fibrinolysis 26 pathology of complication 45
Dibasic sodium phosphate 202 Fistula formation 111, 112 treatment 45
Disorders of sexual function 105 clinical presentation 111 Hyperbilirubinemia and jaundice 122
Distal gastric vagotomy 48 pathology of complication 111 Hyperglycemia 159
Distal obstruction 184 treatment 112 Hyperosmotic preparations 202
Diuretic therapy 126 Foregut 37 Hypokalemic alkalosis 127
Division of efferent loop 56 Fulminant sepsis 151, 152 Hypoprothrombinemia 122
Division of gastroenterostomy 56 clinical presentation 151
Drains 121 investigations and diagnosis 152 I
Duodenal stump leakage 52 pathology of complication 152 Ileocaecectomy 96
Duodenal switch 59 treatment 152
Ileostomy 190
Duodenocutaneous fistulae 180 Ileostomy losses 31
Duodenum 37 G Inadvertent gastroileostomy 58
Dysphagia 45 Gastric atony Indications for tube feeding 160
clinical presentation 45 clinical presentation 38 Infection
investigations and diagnosis 45 investigations and diagnosis 38 clinical presentation 110
pathology of complication 45 pathology of complications 38 investigations and diagnosis 110
treatment 45 treatment 38 of perineal wound 99
Gastric decompression 121 pathology of complication 110
E Gastric remnant treatment 110
Early dumping syndrome 61 carcinoma 68 Infracolic compartment 174
pathology of 62 necrosis 53 Intake-output chart 30
Index 205
Internal colonic fistulae M Papillary dysfunction 139
clinical presentation 105 Malabsorption and weight loss 64 clinical presentation 139
colonic fistulae investigations Marginal ulceration investigations and diagnosis 139
and diagnosis 105 clinical presentation 147 pathology of complication 139
pathology of complications 105 investigations and diagnosis 147 treatment 139
treatment 105 pathology of complication 147 Papillary stenosis
Internal hernia treatment 147 clinical presentation 139
clinical presentation 70 Monobasic 202 investigations and diagnosis 139
investigations and diagnosis 70 Mother baby choledochoscope 135 pathology of complication 139
pathology of complication 70 treatment 139
treatment 70 N Paracolostomy hernia 113
Intestinal obstruction Parastomal hernia 113
Nasobiliary drainage 135
clinical presentation 106 Nasogastric Partial splenectomy 149
investigations and diagnosis 106 aspiration 43 Pelvic compartment 174
pathology of complication 106 decompression 97 Peptic disease 37
treatment 106 tube 127 Perforation colostomy 114
Intestinal staplers Necrosis of lesser gastric curve 39 Perineal or sacral hernia 101
complications after usage of 12 Needle Persistent dysphagia 45
Intra-abdominal abscess for gastrointestinal surgery 6 clinical presentation 45
clinical presentation 102 types 5, 6 Persistent sinus 100
clinical presentation 145 conventional cutting 6 Phantom rectum 101
investigations and diagnosis 102 reverse cutting 6 Plurisegmentectomy 120
pathology of complication 102 round bodied 6 Postcholecystostomy biliary fistulae 133
treatment 146 tapercut, 6 Postoperative
Intra-abdominal sepsis 171 VisiBlack 6 bleeding 150
Intragastric hemorrhage 50 Nerve supply of the gastrointestinal jaundice 57
Intravenous fluids 43 tract 37 management ventilatory support 43
Intrinsic nerve supply 37 Nomenclature of pancreatic pancreatitis 57
Isolyte operations 140
Postvagotomy diarrhoea 40
E solution 29 Non-opioid analgesics 197
clinical presentation 40
M solution 29 Nutrition 26
investigations and diagnosis 40
P solution 29 Nutrition in cancer patients
pathology of 40
Iso-osmotic preparations 201
O surgery 40
J treatment 40
Obstructive jaundice 147
Potassium 28
Jejunal loop herniation 56 investigations and diagnosis 147
Preoperative
Jejunogastric intussusception 71 pathology of complication 147
management 47, 97
treatment 147
L preparation 25, 27
clinical presentation 147
blood 27
Lactated Ringer’s solution 29 Octreotide 57
Operation bowel action 27
Laparoscopic surgery 153, 154 diet 27
complications of 155 Henley’s 62
Hunt-Lawrence Pouch 67 gastric aspiration 27
physiological effects of 154 teeth and oral hygiene 27
preoperative preparation 153 Poth’s 62
triple limb pouch 62 urinary system 27
relative contraindications 154 Prevention of
Opioid analgesics 196
Laparostomy 173 infection 121
Late hemorrhage and shock 100 P renal failure 121
Laxatives 198
Pancreatic fistulae 188 Prothrombin time
definition 198
classification of 188 prolongation of 26
Leakage from pyloroplasty 53
Pancreatic leak Proximal gastric vagotomy 48
Linear cutters 9
Loop colostomy 112 clinical presentation 145
R
Loss of viability investigations and diagnosis 145
treatment 145 Reactionary hemorrhage 117
clinical presentation 110
pathology of complication 145 Rebleeding 128
investigations and diagnosis 110
Pancreatic surgery 140, 141, 142 Rectovaginal or rectovesical fistula 13
pathology of complication 110
complications of 142 Recurrence of
treatment 110
early complications of 143 fistula 119
Losses before surgery 157
preoperative management 141 malignancy 123
206 Gastrointestinal Surgery: Step by Step Management
Recurrent ulcer 68 congestion 194 pathology of complication 39
Reflux esophagitis and stricture 41 disadvantages of 194 treatment 39
Removal of gastric segments 48 divisions of 190 Trauma 194
Retention of urine 117 problems of 194 Tube
Retrograde cholangiopancreatography 1 ulceration of 194 duodenostomy 182
Reversed interposition of jejunum 62 Stomach 37 feeding contraindications for 160
Routes of alimentation 158 Stomach and duodenum 46 feeding indications for 160
Routes of tube feeding 159 Stomal obstruction 54, 55 Tumor
Roux stasis syndrome 67 clinical presentation 54 clinical presentation 138
Roux-en-Y reconstruction 62 investigations and diagnosis 55 investigations and diagnosis 138
Rupture of pelvic peritoneum 99 pathology of complication 55 pathology of complication 138
treatment 55 treatment 138
S Stricture of bile ducts
Saline packings 173 clinical presentation 123 U
Scintigraphy 59 pathology of complication 123 Unconventional site for ileostomy 107
Second primary carcinoma 147 Subphrenic abscess Unisegmentectomy 120
Secondary clinical presentation 123 Unsuitable sites for siting a stoma 106
cervical dysphagia 46 investigations and diagnosis 123 Urinary catheter 43, 127
extragastric hemorrhage 147 pathology of complication 123 Urinary fistula
hemorrhage 117 treatment 123 clinical presentation 104
Serosal Sump syndrome 138, 139 investigations and diagnosis 104
layers 13 clinical presentation 138 pathology of complication 104
patch 182 investigations and diagnosis 139 treatment 104
Serum albumin 127 pathology of complication 139
Severe skin excoriation 185 treatment 139 V
Shunt surgery 124 Supracolic compartment 174 Vagotomy
early complications of 127 Surgery of the biliary ductal system 129 complications of 37
late complication of 128 Surgery of the gallbladder 129 early complications of 38
Side-to-side anastomosis 12 Surgical sutures 2 late complications of 40
Skin barrier Suture varieties of 38
karaya based powder 186 classification of 2 Vagus nerves 38
paste 186 handling 4
Skin tags 118 infection 3 W
Small bowel fistulae knotting 4
Water and sodium 28
classification of 182 mechanical properties 4
Wedge resection 120
etiology 182 needles 2
Wound
Small gastric remnant syndrome 66 properties of materials 3
healing process 173
Sources of excess fluid loss selection of 5
Wound hernia
in surgical patients 30 tissue response 4
clinical presentation 116
Sphincterotomy 129 of lacerations 149
investigations an diagnosis 116
Splenic surgery pathology of complication 116
early complications of 150 T
treatment 116
late complications of 151 Terrence Kennedy’s operation 62 Wound infection
postoperative management 149 Thoracic esophageal fistulae 179 investigations and diagnosis 115, 145
Stapler end-to-end anastomosis 8 Thrombocytosis pathology of complication 145
Stapler linear 8 clinical presentation 151 clinical presentation 102, 115, 145
Staplers in gastrointestinal surgery 8 investigations and diagnosis 151 pathology of complication 102, 115
Stapling instruments 8 pathology of complication 151 treatment 102, 115
Stenosis 100 treatment 151
Stoma Transient dysphagia
Z
allergy 194 clinical presentation 39
care 190 investigations and diagnosis 39 Zipper mesh 173

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