Tag Archives: Postoperative Complications

Post-Cholecystectomy Biliary Complications

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Pesce A, et al. Iatrogenic bile duct injury: impact and management challenges. Clin Exp Gastroenterol. 2019 Mar 6;12:121-128. Free full-text.

“Iatrogenic BDIs represent a serious complication which can be brought on by cholecystectomy. The errors leading to laparoscopic bile duct lesions stem principally from misperception of the biliary anatomy. Any effort toward the reduction of the risk profile of everyday cholecystectomy is appreciated. The key points to successful treatment are characterized by early recognition, control of any intra-abdominal fluid collection and infection, nutritional balance, multidisciplinary approach, and surgical repair by an experienced surgeon in biliary reconstruction.”

Pekolj J, et al. Intraoperative management and repair of bile duct injuries sustained during 10,123 laparoscopic cholecystectomies in a high-volume referral center. J Am Coll Surg. 2013 May;216(5):894-901. Full-text for Emory users.

Results: Among 10,123 LC performed during the study period, 19 patients had a BDI sustained during the procedure. Intraoperative cholangiography was routinely used. Bile duct injury was diagnosed intraoperatively in 17 patients (89.4%). Mean age was 56.4 years (range 18 to 81 years) and 15 patients were women (88%). According to the Strasberg classification of BDI, there were 3 type C lesions, 12 type D lesions, and 2 type E2 lesions. There were no associated vascular injuries. Twelve cases (71%) were converted to open surgery. The repairs included 10 primary biliary closures, 4 Roux-en-Y hepaticojejunostomies, 2 end to end anastomosis, and 1 laparoscopic transpapillary drainage. Postoperative complications occurred in 5 patients (29.4%). During the follow-up period, early biliary strictures developed in 2 patients (11.7%) and were treated by percutaneous dilation and a Roux-en-Y hepaticojejunostomy with satisfactory long-term results.

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Article of interest: Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction

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Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ. Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg. 2012 Nov;204(5):709-16.

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Background: Several modifications of the classic retromuscular Stoppa technique to facilitate dissection beyond the lateral border of the rectus sheath recently were reported. We describe a novel technique of transversus abdominis muscle release (TAR) for posterior component separation during major abdominal wall reconstructions.

Methods: Retrospective review of consecutive patients undergoing TAR. Briefly, the retromuscular space is developed laterally to the edge of the rectus sheath. The posterior rectus sheath is incised 0.5-1 cm underlying medial to the linea semilunaris to expose the medial edge of the transversus abdominis muscle. The muscle then is divided, allowing entrance to the space anterior to the transversalis fascia. The posterior rectus fascia then is advanced medially. The mesh is placed as a sublay and the linea alba is restored ventral to the mesh.

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Abdominal surgery in neutropenic patients

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Jolissaint JS, et al. Timing and Outcomes of Abdominal Surgery in Neutropenic Patients. J Gastrointest Surg. 2019 Apr;23(4):643-650.

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Results: Amongst 237 patients, mortality was 11.8% (28/237) and morbidity 54.5% (130/237). Absolute neutrophil count < 500 cells/μL (50% vs. 20.6%, P < 0.01) and perforated viscus (35.7% vs. 14.8%, P = 0.01) were associated with mortality. Perforated viscus (25.4% vs. 7.5%) was also associated with morbidity. Urgent operations were associated with higher morbidity (63.6% vs 34.7%, P < 0.001) and mortality (16.4% vs 1.4%, P = 0.002) when compared to elective operations. Transfer from an outside hospital (22.3% vs. 11.2%, P = 0.02) and longer median time from admission to operation (2 days (IQR 0-6) vs. 1 day (IQR 0-3), P < 0.01) were associated with morbidity. An ANC threshold of 350 provided the best discrimination for mortality.

Conclusions: Elective surgery in the appropriately chosen neutropenic patient is relatively safe. For patients with obvious surgical pathology, we advocate for earlier operation and a lower threshold for surgical consultation in an effort expedite the diagnosis and necessary treatment.

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Postoperative outcomes in surgical COVID-19 patients

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COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet. 2020 Jul 4;396(10243):27-38. Erratum in: Lancet. 2020 Jun 9.

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Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28-2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65-3·22], p<0·0001), American Society of Anesthesiologists grades 3-5 versus grades 1-2 (2·35 [1·57-3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01-2·39], p=0·046), emergency versus elective surgery (1·67 [1·06-2·63], p=0·026), and major versus minor surgery (1·52 [1·01-2·31], p=0·047).

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Adhesiolysis-related morbidity in abdominal surgery

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ten Broek RP, et al. Adhesiolysis-related morbidity in abdominal surgery. Ann Surg. 2013 Jul;258(1):98-106. 

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Results: A total of 755 (out of 844) surgeries in 715 patients were included. Adhesiolysis was required in 475 (62.9%) of operations. Median adhesiolysis time was 20 minutes (range: 1-177). Fifty patients (10.5%) undergoing adhesiolysis inadvertently incurred bowel defect, compared with 0 (0%) without adhesiolysis (P < 0.001). In univariate and multivariate analyses, adhesiolysis was associated with an increase of sepsis incidence [odds ratio (OR): 5.12; 95% confidence interval (CI): 1.06-24.71], intra-abdominal complications (OR: 3.46; 95% CI: 1.49-8.05) and wound infection (OR: 2.45; 95% CI: 1.01-5.94), longer hospital stay (2.06 ± 1.06 days), and higher hospital costs [$18,579 (15,204-21,954) vs $14,063 (12,471-15,655)]. Mortality after adhesiolysis complicated by a bowel defect was 4 out of 50 (8%), compared with 7 out of 425 (1.6%) after uncomplicated adhesiolysis (OR: 5.19; 95% CI: 1.47-18.41).

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Laparoscopic Cholecystectomy Versus Percutaneous Catheter Drainage for Acute Cholecystitis in High Risk Patients (CHOCOLATE): Multicentre Randomised Clinical Trial

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Loozen CS, et al. Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial. BMJ. 2018 Oct 8; 363:k3965.

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what this study adds

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Preoperative communication with older patients and their families about high-risk surgical outcomes

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Berian JR, et al. Association of Loss of Independence With Readmission and Death After Discharge in Older Patients After Surgical Procedures. JAMA Surg. 2016 Sep 21;151(9): e161689.

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Results: Of the 5077 patients included in this study, 2736 (53.9%) were female and 3876 (76.3%) were white, with a mean (SD) age of 75 (7) years. For this cohort, LOI increased with age; LOI occurred in 1386 of 2780 patients (49.9%) aged 65 to 74 years, 1162 of 1726 (67.3%) aged 75 to 84 years, and 479 of 571 (83.9%) 85 years and older (P < .001). Readmission occurred in 517 patients (10.2%). In a risk-adjusted model, LOI was strongly associated with readmission (odds ratio, 1.7; 95% CI, 1.4-2.2) and postoperative complication (odds ratio, 6.7; 95% CI, 4.9-9.0). Death after discharge occurred in 69 patients (1.4%). After risk adjustment, LOI was the strongest factor associated with death after discharge (odds ratio, 6.7; 95% CI, 2.4-19.3). Postoperative complication was not significantly associated with death after discharge.

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