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Preventing and managing non‐urological surgical complications

Brant A. Inman, MD, MSCary N. Robertson Associate Professor

Vice Chief of Urology

Learning objectives

• Discuss ERAS principles and how they reduce complications

• Identify some common postoperative complications

• Discuss principles of complication management

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www.erassociety.org

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Postoperative delirium

• Incidence 10-30%

• Key risk factors:1. Age

2. Preop MMSE

3. Preop alcoholism

• Consequences– Increased LOS

– Mortality

Van Meenen et al. J Am Geriatr Soc 2014Schenning et al. Anesthesiol Clin 2015

Large et al. Urology 2013

Hamilton et al. Anesthesiol 2017

Postop delirium is associated with a 4X increased risk of death

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Delirium prevention

• Orientation to setting– Glasses

– Hearing aids

– Family

• Increase mobility

• Proactive geriatrics (POSH @ Duke)

• Control pain but avoid narcotics

• Reduce polypharmacy

• Sleep preservation

Van Meenen et al. J Am Geriatr Soc 2014; Schenning et al. Anesthesiol Clin 2015

Neufeld et al. J Am Geriatr Soc 2016

Antipsychotics may prevent delirium in select patients, but they do not reduce LOS or prevent mortality

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Nerve injuries

• Mechanisms:– Surgical: obturator, genitofemoral, femoral– Positioning: brachial plexus, sciatic, ulnar, peroneal

• Symptoms:– Sensory: pain and numbness– Motor: weakness and paralysis

• Workup:– Imaging (if hematoma suspected)– EMG @ 4 weeks postop (demyelination time)– Physical therapy

Sawyer et al. Anesthesia 2000

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Sawyer et al. Anesthesia 2000

Common peroneal Brachial plexusSaphenous nerve

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Diaphragmatic and pleural injuries• Pleural injury >> Diaphragm injury

– pneumothorax > hemothorax– PCNL 2-5%; Partial Nx 1-2%

• Management options:– Nephrostomy – Thoracostomy– Suture repair– Patch reconstruction

Sharma et al. Urolithiasis 2016;  Zaid et al. Urol Oncol 2017;  Aron et al. J Urol 2007

Suture repair Patch repair

• Horizontal mattress• Non-absorbable

• Pericardium• Gore-Tex

Finley et al. Thorac Surg Clin 2009

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Aspiration pneumonia• 10% of in-hospital pneumonias• Risks:

– Swallowing dysfunction (e.g., MS, stroke)– GERD (e.g., esophagectomy, rheumatologic)– Enteric tube feeds

• Chemical pneumonitis– Acid burn of lung– Usually high volume aspiration

• Infectious aspiration pneumonia– Bronchial lavage = best way to get culture– Anaerobes: 30%, later presentation, cavitation– Aerobes: Strep, Kleb, E.coli, Staph

Meta-analysis: Popping et al. Arch Surg 2008

Epidural analgesia reduces pulmonary complications

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Meta-analysis: Thomson et al. Br J Surg 2009

Smoking cessation decreases operative complication rates

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Postop bowel dysfunction

Johnson et al. Cleveland Clin J Med 2009

Nasogastric tubes delay the return of bowel function

Meta-analysis: Zhao et al. Int J Clin Exp Med 2014

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Choi et al. Urology 2011

N=60RCT

Gum chewing speeds up return of GI function

Lee et al. Eur Urol 2014

N= 277

Alvimopan (Entereg) reduces postoperative ileus

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Kauf et al. J Urol 2014

Alvimopan (Entereg) is expensive, but the cost of ileus is greater

Duke cost is about 1000$ for 5 days

Meta-analysis: Smith et al. Cochrane Database Syst Rev 2014

Preoperative carbohydrate drink given 2 hours prior to surgery improves postop GI function

Time to bowel movement

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Meta-analysis (colorectal): Cao et al. Int J Colorectal Dis 2012Meta-analysis (cystectomy): Deng et al. Urol Int 2014

Bowel preps do not prevent anastomotic leakage, surgical site infections, or postoperative complications

Small bowel injury

• Incidence unknown (0.5-2%)

• Small bowel = most common site (40%)– Veress needle and trocars are primary reason

– Cautery injuries present 2-3 days later

• Port site hernia (0.5% -1%)

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Colon injury

• Nephrectomy – Risk factors: T3 mass, large tumor

• PCNL (<0.5%)– Risk factors: prior surgery, anterior access,

skinny patients, kyphosis, horseshoe kidney– Tx:

Hakan. J EndoUrol 2014

Rectal injury• Prostatectomy/Cystectomy (1%) • Risk factors:

– Prior pelvic radiation– Prior rectal surgery– Prior TURP

• Management:– Primary repair (1 vs 2 layer) & bubble test– Interposition of healthy tissue– +/- Colostomy (probably best if irradiated)– Prolonged Foley & antibiotics

Sugihara et al. Int J Urol 2014;  Wedmid et al. J Urol 2013;  Slieker et al. JAMA Surg 2013

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Liver injury

• Right nephrectomy – Risk factors: T3 mass, large tumor

• Right PCNL (v. rare)

Hakan. J EndoUrol 2014

Splenic injury

• Left nephrectomy (0.8%)– Risk factors: T3 mass, large tumor– Splenectomy more likely

• Left PCNL (<0.5%)– Risk factors: upper pole access (>11th rib)– Conservative management more likely

Mayo: Wang et al. Int J Urol 2013Hakan. J EndoUrol 2014

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Splenic injury

Merchant et al. Oper Tech Gen Surg 2008

Step 1: stop the bleeding

I place a vascular clamp as close to the splenic hilum as I can to avoid clamping the pancreas

Splenic injury

Merchant et al. Oper Tech Gen Surg 2008

Step 2: if possible, fix the spleen

My preferences:• Turn Bovie to flame thrower level• Argon beam• Floseal + Surgicel + wait 20 min• Pledgeted closure (partial nephrectomy)

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Splenic injury

Merchant et al. Oper Tech Gen Surg 2008

Step 3: if not fixable, remove spleen

Advice: might be best (legally) to have general surgeon help in case of postop issues (pancreatic leak)

Steps for fast splenectomy:1. Open lesser sac 2. Divide short gastric vessels about 1‐2 cm 

from the stomach3. Staple across splenic hilum (60 cm tan)4. Some people ligate the artery proximally5. Divide the attachments to diaphragm

Splenic injury

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Splenic injury

Vaccination & post-splenectomy sepsis• Overwhelming sepsis from encapsulated bugs

(1-2% risk, 50% mortality)• Wait until 2-6 weeks postop• Due 1-2 weeks preop if spleen at risk

Bug Vaccine Revaccination

Streptococcus pneumonia Polyvalent (Pneumovax 23) Q5Y

Hemophilus influenza B HibTITER Q5Y

Neisseria meningitis Polysaccharide +/‐ diphtheria Not required

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Pancreatic injury

Varkarakis et al. Urology 2004;  Bassi et al. Surgery 2017

• Left nephrectomy/adrenalectomy– Presents as postop fluid collection

• Grades:A. Drainage alone

B. TPN + Octreotide + Abx

C. ERCP +/- surgery

Chylous ascites

Leibovitch et al. J Urol 2002; Thaler et al. Clin Biochem 2017

• RPLND and nephrectomy• Diagnosis:

– Triglycerides (>187 mg/dL)– Lipoprotein A electrophoresis– Micro: > 500 lymphocytes

• Management:– Low fat, low salt, high protein diet – TPN +/- octreotide +/- orlistat– Lymphangiography lipiodol– Ligation +/- shunt

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Splenic injury

Kim et al. Tech Vasc Intervent Radiol 2016

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Surgical site infections

• Add LOS

• Add cost

Badia et al. J Hosp Infect 2017

SSI prevention – what works?

1. IV antibiotics – best pre-incision2. Skin prep with chlorhexidine (alcohol)3. Smoking cessation4. Glucose control5. Hair clippers6. Normothermia

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Meta‐analysis: Privitera et al. Am J Infect Control 2017

De Jonge et al. Medicine 2017

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SSI prevention – what does not work?

1. Preop chlorhexidine shower2. Ioban3. Special dressings4. Masks and hats5. Wound closure method6. Postop showering7. Drains

Li et al. J Surg Res 2017

SSI prevention – what might work?

1. Topical antibiotics2. Wound protectors (contaminated sites)3. Antibiotic sutures4. Glove changing5. Perioperative oxygen6. Bowel preps (controversial)

Li et al. J Surg Res 2017

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Meta‐analysis: Heal et al. Br J Surg 2017

Topical antibiotics probably prevent SSIs

Thank you for your attention