Tag Archives: Postoperative Complications

True or False: Atelectasis as cause of postoperative fever.

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One discussion this week included atelectasis as a potential cause of postoperative fever.

Reference: Crompton JG, Crompton PD, Matzinger P. Does atelectasis cause fever after surgery? Putting a damper on dogma. JAMA Surgery. 2019 Mar 6:154(5):375-376. doi:10.1001/jamasurg.2018.5645.

Summary: Fever and atelectasis are common after surgery, and in the absence of infectious causative mechanisms, atelectasis is commonly thought to be a cause of fever. The therapeutic implication of atelectasis as a putative cause of postoperative fever has been the widespread adoption of incentive spirometry to reduce atelectasis.

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Air cholangiogram as effective measure for postoperative biliary complications

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One discussion this week involved air cholangiograms.

Reference: Zimmitti G, et al. Systematic use of an intraoperative air leak test at the time of major liver resection reduces the rate of postoperative biliary complications. Journal of the American College of Surgeons. 2013 Dec;217(6):1028-1037. doi: 10.1016/j.jamcollsurg.2013.07.392.

Summary: Advances in surgical technique and better understanding of liver anatomy and physiology have facilitated a decrease in postoperative hepatic insufficiency rates and in perioperative blood transfusion needs. However, these improvements have not been paralleled by a decrease in the rate of postoperative bile leak, which remains the Achilles’ heel of liver resection. While in many cases a postoperative bile leak can be managed successfully with drainage and antibiotics, it almost always entails longer length of stay and increased hospital costs.

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Ureteral catheters and injury during colectomy: A NSQIP study

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One discussion this week included ureteral injuries during colectomy.

Reference: Coakley KM, et al. Prophylactic ureteral catheters for colectomy: A National Surgical Quality Improvement Program-based analysis. Diseases of the Colon and Rectum. 2018 Jan;61(1):84-88. doi:10.1097/DCR.0000000000000976.

Summary: Despite improvement in technique and technology, using prophylactic ureteral catheters to avoid iatrogenic ureteral injury during colectomy remains controversial. The aim of this retrospective study was to evaluate outcomes and costs attributable to prophylactic ureteral catheters with colectomy. Conducted at a signle tertiary care center, the authors pulled clinical data, 2012-2014, from ACS NSQIP database.

A total of 51,125 patients were identified with a mean age of 60.9 ± 14.9 years and a BMI of 28.4 ± 6.7 k/m; 4.90% (n = 2486) of colectomies were performed with prophylactic catheters, and 333 ureteral injuries (0.65%) were identified.

  • Prophylactic ureteral catheters were most commonly used for diverticular disease (42.2%; n = 1048), with injury occurring most often during colectomy for diverticular disease (36.0%; n = 120).
  • Univariate analysis of outcomes demonstrated higher rates of ileus, wound infection, urinary tract infection, urinary tract infection as reason for readmission, superficial site infection, and 30-day readmission in patients with prophylactic ureteral catheter placement.
  • On multivariate analysis, prophylactic ureteral catheter placement was associated with a lower rate of ureteral injury (OR = 0.45 (95% CI, 0.25-0.81)).
  • Additional research is needed to delineate patient populations most likely to benefit from prophylactic ureteral stent placement.

Prophylactic Flomax for prevention of postoperative urinary retention

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One discussion this week involved the use of prophylactic flomax in preventing postoperatuve urinary retention (POUR).

Reference: Ghuman A, et al. Prophylactic use of alpha-1 adrenergic blocking agents for prevention of postoperative urinary retention: A review & meta-analysis of randomized clinical trials. American Journal of Surgery. 2018 May;215(5):973-979. doi: 10.1016/j.amjsurg.2018.01.015. Epub 2018 Feb 3.

Summary: With an increase in outpatient and fast-track surgical procedures, urethral catheterization is used less commonly thus increasing the likelihood of POUR. Urethral catheterization, a mainstay of initial management for patients with POUR, can
be associated with prolonged length of hospital stay and complications, such as urinary tract infections that may increase cost of care.

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Simultaneous vs staged colorectal and hepatic resections

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One discussion this week involved the comparison of simultaneous and staged resections of colorectal cancer and synchronous colorectal liver metastases (SCRLM).

Reference: Reddy SK, et al. Simultaneous resections of colorectal cancer and synchronous liver metastases: a multi-institutional analysis. Annals of Surgical Oncology. 2007 Dec;14(12):3481-3491. doi:10.1245/s10434-007-9522-5

Summary: In a retrospective study of 610 patients at three institutions between 1985 and 2006, the authors compared postoperative morbidity and mortality after simultaneous and staged resections of colorectal cancer and SCRLM.

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The Carotid Revascularization Endarterectomy vs Stenting Trial (CREST)

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One discussion this week involved the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST).

Reference: Brott TG, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. New England Journal of Medicine. 2010 Jul 1;363(1):11-23. doi:10.1056/NEJMoa0912321.

Summary:  CREST is an RCT with blinded end-point adjudication whose aim was “to compare the outcomes of carotid-artery stenting with those of carotid endarterectomy among patients with symptomatic or asymptomatic extracranial carotid stenosis” (p.12).

Between December 2000 through July 2008, 2522 patients were enrolled in 108 centers in the US and 9 in Canada. Of those, 1271 patients were randomly assigned to undergo carotid-artery stenting.

Primary findings include (p.18):

  • Carotid revascularization performed by highly qualified surgeons and interventionists is effective and safe.
  • Stroke was more likely after carotid-artery stenting.
  • Myocardial infarction was more likely after carotid endarterectomy, but the effect on the quality of life was less than the effect of stroke.
  • Younger patients had slightly fewer events after carotid-artery stenting than after carotid endarterectomy.
  • Older patients had few events after carotid endarterectomy.
  • Low absolute risk of recurrent stroke suggests that both carotid-artery stenting and carotid endarterectomy are clinically durable and reflect advances in medical therapy.