General Principles of Recognition of Major Complications Following Surgery of the Digestive Tract

Abstract

Major complications following surgery of the digestive tract are associated with increased morbidity, prolonged intensive care and hospital stay, and even mortality. Infectious complications are frequent; an infectious complication rate of 21 % has recently been described following colorectal surgery. Among the most severe infectious complications are anastomotic failures. Reported leakage rates range from 0.6 to 23 %. The reconstruction following resections, and not so much dissection and resection itself, causes most surgical adverse events. The frequency and consequences vary according to the target organ and the executed operation. A postoperative mortality of 12–39 % following anastomotic leakage has been reported, compared to 2–5 % without leakage. On the opposite, incidence of clinical anastomotic leakage was 42 % among patients who died and 11 % in the uneventful group in a large population-based trial.

Even if an anastomosis can be preserved, late complications are observed frequently, such as anastomotic strictures leading to obstruction or continence problems. Furthermore, anastomotic leakages may result in permanent stomata. Conflicting results persist whether anastomotic leakage is associated with an increased local recurrence rate and a worse oncologic outcome.

Early recognition and intervention can prevent severe consequences of major complications, such as systemic inflammatory response syndrome (SIRS), sepsis, multiple organ failure, and death. Early diagnosis and repair within 5 days following initial surgery was not associated with mortality in a retrospective analysis of 655 patients, whereas repair in a later postoperative course was associated with a mortality rate of 18 %.

Sepsis can be difficult to distinguish from the systemic inflammatory response related to surgical trauma. Since clinical features of complications can be nonspecific and interpretation of diagnostic tests can be incorrect, early diagnosis remains a challenge, even in the era of the widespread availability of imaging techniques. A median time to clinical diagnosis of a complicated postoperative course was 8 days in recent studies.

These results emphasize the importance of early recognition of complications. The question remains when anastomotic dehiscence occurs after a standard operative procedure. The daily assessment of patients’ clinical condition is the most important guidance for the surgeon. A patient has to clinically improve every day during a normal postoperative course, and every decline should prompt evaluation of the possible problem.

This chapter focuses on clinical features and diagnostics contributing to early recognition of major complications following abdominal surgery.