Postoperative complications in co

lorectal surgery
• Intraoperative factors
• Perioperative
• Long-term complications
Intraoperative Factors that Contribute
to Postoperative Outcomes
Operative Approach and Postoperative Impac
t
 Luminal Organ Injuries and Postoperative
Impact

• Luminal organ injuries: accidental puncture laceration(i.e. accidental perforatio

n of a blood vessels, nerve, organ)(e.g. serosa tear, enterotomy, and injury to th
e ureter, bladder, spleen, and blood vessels.) was more correlated with complex
ity of the operation and largely had no impact on postoperative recovery.
• Vascular injury and failure of hemostatic devices
-intraoperative blood transfusion
 careful attention to hemostasis is not only consistent with good operative tec
hnique but also contributes to decreased postoperative morbidity.
-Major vascular injury Is relatively rare: 7/404 in retropeitoneal laparoscopic ne
phrectomy. 3 of then need conversion to open or repair of t he injury through t
he extraction site.
-postop complication in the group sustaining an injury was 25%.
• vascular injuries at the time of trocar insertion are rare and can be eliminated by
an open, Hasson access technique.

• Laparoscopic staplers and clips, electrothermal bipolar vessel sealers(EBVs), mon

opolar electrocautery scissors(MES), and ultrasonic coatulating shears(UCS)
- blood loss: UCS< MES
-hemostatic control: UCS and EBVS better than MES
-laparoscopic staples/clips used for pedicle ligation in colectomy were associated
with more failures in vessel ligation and cost more when compared to EBVS
-for laparoscopic colorectal resection found that bipolar sealers reduced both th
e time spent and the cost of disposable instruments for achieving vascular contro
l
-However, the amount of blood loss associated with device failure was higher in t
hose using EBVS for pedicle ligation
• electrothermal bipolar vessel sealing allows for faster op
erating times, less blood loss, and less sealing failure. Ho
wever, sealing failure with an energy device often leads t
o more blood loss than sealing failure with the use of cli
ps and vascular staplers
• For device failure or inadequate seal, we favor the use of
clips or alternatively an endo-loop, as blindly sealing ves
sels in a crimson fi eld is often fraught with complication
. In the setting of a known atherosclerotic vessel, the ap
plication of a vascular stapler should be considered.
Urologic injuries and their management
• Ureteral injury: 0.3-1.5%
-Risk factors for ureteral injury in this study included the pres
ence of rectal cancer, adhesions, metastatic cancer, weight lo
ss/malnutrition, and teaching hospitals.
-significantly higher rate of ureteral injury associated with la
paroscopic colectomy compared to open (0.66 % versus 0.15
%, P < 0.05)
-female sex, increased operative blood loss, and reoperation
conferred an increased risk of iatrogenic injury
-Ureteral injuries were associated with higher morbidity and
mortality, longer length of stay, and higher hospital charges
• Most data suggest that placement of ureteral stents ne
ither reduces the incidence of injury nor ensures intrao
perative identification of injury
• Independent predictors of stent utilization included div
erticular disease, LAR and APR, recent radiation therap
y, and more recent year of operation
• No statistically signifi cant differences in any primary or
secondary endpoints, including overall renal complicati
ons. There was, however, a statistically signifi cant incr
ease in length of stay associated with stent utilization,
• Early identifi cation of injury is paramount in minimizing morbidity a
nd preserving renal function.
• Diagnosis: on-table intravenous pyelogram ( IVP ), retrograde injecti
on of methylene blue, intravenous administration of methylene blue
or indigo carmine, or ureteral catheter contrast administration.
• Injuries can be classified as laceration, ligation, devascularization, or
energy related.
• Transection and laceration are repaired based on location of injury.
• absorbable suture (to prevent stone formation), tension-free spatula
ted anastomosis over an indwelling stent, and placement of a closed
suction drain.
• injuries in the proximal one-third (2 % of injurie
s), repair depends on length of the damaged se
gment. Simple spatulated ureteroureterostomy
(UU) is the preferred method of repair.
• Bowel interposition can be utilized for long-seg
ment damage.
• a psoas hitch or Boari flap can be used to reach
the upper ureter, more commonly used for injur
ies of the middle or distal third. Injuries
• Injuries to the middle third account for 7 %
of ureteral injuries, and the preferred method of repair is via ureteroureterostomy for short-s
egment injury.
• A psoas hitch or Boari flap should be used if a tension-free anastomosis is not possible
• transureteroureterostomy (TUU) can be performed with anastomosis to the contralateral uni
njured ureter
• Injuries to the distal onethird of the ureter are preferentially repaired with ureteroneocystost
omy. A Foley catheter should be left in place for 7–14
days with stent removal 4–6 weeks after surgery
 Bladder injury
• Risk factor: previous operations, radiation treatment, malignant infiltration, chronic infecti
on, and inflammatory conditions.
• Diagnosis: CT cystogram or fluoroscopic cystogram.
• complications of missed bladder injury: colovesical or
enterovesical fistula (Diagnosis: abdominopelvic CT with oral or rectal contrast)
• Primary repair (cystorrhaphy) +closed suction drains
• Small extraperitoneal injuries  7–14 d of Foley decompression.
• Larger or intraperitoneal bladder injuries operative repair.
• injuries to the ventral bladder, dome, or posterior bladder away from ureteral orifices 2
layers mucosal and seromusclar closure.
• Avoid permanent sutures
• posterior bladder or trigone, near the ureteral orifices injury anterior cystotomy
• IV Indigo carmine to identify ureteral orifice
• Delayed diagnosis of urine leak from the bladder percutaneous drainage of a urinoma a
nd continued Foley catheter decompression.
 Urethral injury
• Traumatic Foley insertion
• 3.2/1000 catheter insertions 0.7/1000
• Extirpative surgery, history of radiation therapy and ar
e prone to fistula formation.
• Diagnosis:
- Intraoperatively, retrograde injection of methylene bl
ue-tinted saline
- Cystoscopy, retrograde urethrogram, exam under ane
sthesia, and CT scan with both oral and rectal contrast
• Primary repair
• omental flap or local tissue flap
• suprapubic catheter
• Spontaneous closure of rectourethral fistula is extremely rare
Stage 1—low (<4 cm from anal verge, nonirradiated)
Stage 2—high (>4 cm from anal verge, nonirradiated)
Stage 3—small (<2 cm diameter, irradiated)
Stage 4—large (>2 cm diameter, irradiated)
Stage 5—large (ischial decubitus fistula)
• Fecal diversion is recommended for stages 3 through 5, usually i
n advance.
Postoperative Management Decisions
that Contribute to Postoperative
Complications
 IV fluid management
•
@ standard fluid <-> restricted fluid protocol
-restricted protocol: earlier return of bowel function, shor
ter length of stay(LOS) and lower rates of complications
@ ERAS(enhanced recovery after surgery)
- LOS ↓ 2.5 days, postop morbidity was 50 % lower comp
ared to standard patient group
 Wound management
•
- no evidence that one type of wound dressing d
ecreased incidence of SSI over any other type
- contamination at the time of surgery
- a wound hematoma or seroma (wound probing
v.s. standard= 3% v.s. 19% Surgical site infection;
shorter LOS by 2 days)[ not a reproducible study]
 Bladder management
• High risk of urinary tract infection (UTI) and catheter-as
sociated UTI(CAUTI)
• 4.1 (colorectal op): 1.8%(other general op)
• Risk factor: female sex; ASA class >2; procedure of a tot
al colectomy, proctocolectomy, or APR; functional statu
s of partially or totally dependent; and age greater than
75; presence of indwelling catheter, number of catheter
days, and incidence of postoperative urinary retention
• Asymptomatic bacteriuiraUnnecessary antibiotic use
• Early removal of urinary catheter?
 Pain management
• Low patient satisfaction scores of pain control higher rate of
postop mortality
• Correlation between high postoperative pain scores and the de
velopment of postoperative delirium
• High pain high dose opioidresp. depression and overseda
tion
• Epidural pain control> IV
• Lapa < open
• ERAS: increase non-opioid-based pain regimens, e.g. local bock
s: transversus abdomininis plane(TAP) block
• pain control improves the overall patient experience.
Long term complications
 Genitourinary complications
• Bladder dysfunction(autonomic pelvic plexus), inciden
ce: APR (~50%), LAR(15-25%)
• Parasympathetic detrusor denervation impaired con
tractility of the bladderrecover within 6 months mos
tly
• hydronephrosis, urinary reflux, pyelonephritis, and dec
lining renal function may ensue
• urodynamics
 Fertility complications
• Infertility rate in UC female: preop: postop (res
torative proctocolectomy)=15%:48%.
• FAP: no association between fertility problems
and type of surgery but did report an increase
d risk of fertility difficulty in women undergoin
g surgical procedures earlier in life.
 Bowel dysfunction
• low anterior resection syndrome
• Sphincter-sparing LAR: 50-90% have bowel dysfunction
• ARP: better cognitive and social function, less pain, sleep disturbance,
diarrhea and constipation
• LAR: better sexual function, 72% with some degree fecal incontinence
• the quality of life after rectal cancer surgery is closely associated with
the severity of the low anterior resection syndrome which are seemed
to be correlated with tumor height more than 5 cm, total mesorectal
excision, and patient treatment with radiotherapy
• Restorative and sphincter-sparing techniques are superior to permane
nt stoma??? quality of life (QoL) is better in APR than in LAR group
• Short-course RT increase sexual dysfunction, and level of fecal incon
tinence
 Impact of Postoperative Complications
on Oncologic Outcomes
• Postoperative complications  worse long-ter
m survival
• either delay in receiving or complete omission
of chemotherapy in patients with clear indicati
ons for systemic treatment.
• Postoperative complications decreased over
all survival
 Conclusion
• Focus on preventing postoperative complicatio
ns is beneficial to the patient’s short-term heal
th, quality of life, long-term physiologic and on
cologic outcomes, and decreasing costs associ
ated with postoperative complications.