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24 Post-Operative Complications After Emergency Laparotomy
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Fig. 24.6 This patient has a previous prolonged history of total colectomy with end ileostomy for
large bowel obstruction secondary to sigmoid cancer. The patient presented with small bowel
obstruction that failed to resolve with non-operative management. The initial operation found ischemic small bowel 40 cm proximal to the end ileostomy, requiring small bowel resection.
Unfortunately, there was an anastomotic leak on post-operative day 4. The patient was taken back
to theatre. The end ileostomy was fully mobilized and the anastomosis was resected. The neo end
ileostomy was fashioned on the upper abdomen. Given the contamination, a prophylactic negative
pressure wound dressing was placed on the wound. Following that, on day 3, the negative pressure
wound dressing was removed and there was evidence of bile staining on the midline wound, consistent with ECF. The patient was managed with the abovementioned strategies successfully. The
ECF resolved
405
Prior to any reintervention, adequate time of at least 6months should be allowed
with optimization of all modiable factors. Planning of the anatomy of the ECFs
can be performed with CT with oral contrast and/or sinogram.
These patients should be referred to a centre with expertise in managing complex
ECFs or entero-atmospheric stula with abdominal wall reconstruction.
Stoma-Related Complications
In the emergency setting, when a stoma is formed, it can be associated with a range
of mild to severe complications. We describe the most common complications
encountered as the followings:
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Z. Q. Ng and D. Weber
High Output Stoma
It is dened as an output of more than 1.2–1.5L/24h recorded in the ileostomy. In
the event where it is not secondary to anatomical proximity of the ileostomy, the
majority of cases will resolve in a few weeks with intestinal adaptation. A small
proportion of patients will require medication to reduce the intestinal transit time.
Multidisciplinary management is crucial [28, 29]. The accurate recording of the
oral intake and stoma output helps to determine the necessary management. Any
uids and electrolytes losses should be replaced intravenously. Any potential factors
such as infections (Clostridium difcile), use of prokinetics (metoclopramide, domperidone) or metformin should be carefully reviewed. Introduction of certain foods
can help to thicken up the consistency of the output. Different types of rehydration
solution can be given to the patients; St Mark’s solution (consisting of glucose,
sodium bicarbonate and sodium chloride) can be easily prepared by patients themselves in the outpatient setting [30].
Proton pump inhibitors such as pantoprazole 40mg once a day is used to reduce
gastric secretions. Loperamide is usually given 30min before the meals. It is important to make sure that the capsule is opened. The doses can be titrated according to
the output. Codeine can be added on top to slow the intestinal transit. It should be
used with caution in patients with chronic renal failure as it can lead to drowsiness
from its retained metabolites.
In cases with signicant high output, keeping nil orally initially helps to control
the output. Total parenteral nutrition is usually provided till oral intake is reestablished. The use of somatostatin analogue which reduces pancreatic secretions
can be trialled for a short term. The authors’ experience is that if it makes a difference to the stoma output, a long-acting somatostatin analogue can be used.
In certain cases, despite optimal medical management, the patients may still
require replacement of intravenous uids and electrolytes daily. This could be carried out in the outpatient setting with same principles of patients on home parenteral
nutrition.
A protocol/guideline adopted in the authors’ institute is illustrated in Fig.24.7.
Stoma Retraction
It is often a difcult problem to manage with mucocutaneous separation and stoma
retraction [31]. The faecal content seeps into the parastomal space leading to wound
infection that requires drainage and dressings (Fig.24.8). Regular stoma therapist
review with regular dressing change in the parastomal space is needed. Mild stomal
retraction can be managed with specic stoma appliances. In cases with severe
retraction, it is likely to require revision.
Able to self-manage:
GP review in 3 to 7
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-
407
Discharge
Daily Assessment
Initial Management - on Day 2
days
for discharge.
•
• 1L/day stable, OK
1. Observe the trend of
stoma output over the
next 48 hours.
2. Escalate to the next
4. Diet - low residue, thickening foods
1. Stop free water
5. Low dose Loperamide 2mg QID
2. St Marks Solution
3. Oral electrolytes replacement
• Phone call follow
• Daily self-record
level if there is no
improvement.De-escalate
when there is
improvement
1. StMarks Solution
6. Fluid Balance Chart
up in 3 days
Authority
Loperamide Script
follow up
• STN outpatient
•
Unable to self-
manage:
-Output down
3. Consider increasing
doses of Loperamide
/Codeine concurrently
with escalation to next
level.Ensure Loperamide
capsules are opened for
administration and timed
30 minutes prior to meals
4. Ongoing dietician review
for protein
supplementation/TPN.
3. Diet - low residue, thickening foods
4. Loperamide 4mg QID
5. Pantoprazole 40mg BD
2. IV hydration and IV electrolytes
6. Fluid Balance Chart
4. Loperamide 8mg QID
1. Diet - low residue, thickening foods.
2. St Marks Solution
3. IV hydration and IV electrolytes
trending, can
discharge with Silver
Chain and GP follow
up
- Early referral back to
hospital if worsening
5. For severe HSO,
optimize doses of
loperamide, codeine and
octreotide before
considering for TPN.
7. Fluid Balance Chart
5. Pantoprazole 40mg BD
6. Codeine 15mg TDS
1. Diet - low residue, thickening foods.
2. St Marks Solution
to prevent AKI/severe
electrolytes
derangement
6. Prolonged stay >7 days,
consider psychology input.
4. Loperamide 12mg QID
5. Pantoprazole 40mg BD
6. Codeine 30mg TDS
3. IV hydration and IV electrolytes
CAUSES:
RULE OUT OTHER
,
1. Intraabdominal
sepsis
2. Intermittent
obstruction
3. Gastro infection
e.g. C. Diff
4. Medications
(prokinetics
Pre-High Stoma Output
1L – 1.5L/24hours for 48 hours
nurse)
dietician, stoma
metformin)
(Clinician, nurse,
MDT INVOLVEMENT
1.5L – 2L/24hours
Mild High Stoma Output
-
weights
recording of
daily fluid
balance
severity of HSO,
escalate/de
1. Stool Spec
2. Daily body
3. Accurate
4. Always review
2L – 3 L/24hours
Moderate High Stoma Output
escalate as
appropriate
5. Patient
>3L/24hours
Severe High Stoma Output
education
Fig. 24.7 Classication of severity of high output stoma with management strategy in the author’s institution
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Z. Q. Ng and D. Weber
Fig. 24.8 This patient was morbidly obese with history of chronic renal failure on peritoneal
dialysis. The patient initially presented with abdominal sepsis thought to be secondary to infected
peritoneal dialysis catheter. A CT scan showed localized perforated sigmoid diverticulitis which
failed to respond to intravenous antibiotics. He underwent a Hartmann’s procedure. The colonic
conduit was difcult to bring through due to the thick abdominal wall and the surrounding epiploic
appendages were thickened due to long-term peritoneal dialysis despite large stomal trephine created and mobilization of the proximal colon. It became apparent there was mild degree of stomal
retraction and mucocutaneous separation on post-operative day 5. The parastomal mucocutaneous
separation at the medial aspect was lled with feculent content with wound infection. It was a challenging problem to perform frequent dressing change and the constant feculent contamination. A
CT scan performed ruled out any deeper collection. With the assistance of the stoma therapist, the
parastomal wound was carefully managed with modied stomal appliances and resolved
The Ischemic Stoma
This is often apparent on day 1 post-EL, ranging from mild ischemia to complete
gangrene/necrosis [31]. Most cases stem from colostomy. In cases of mild ischemia,
usually it is managed with close observation and the majority of cases do not need
any intervention. Supportive care from the stoma therapist with different stoma
appliances usually sufce. In the longer term, there is a possibility of stomal stenosis which requires revision.
In cases with complete gangrene and necrosis, the extent of it usually goes
beyond the fascia level. It will require a return to theatre to determine the extent
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409
(Fig.24.8). The stoma along with the colonic conduit needs to be mobilized until it
is tension free with good marginal blood supply. In obese patients with a thick
abdominal wall, it is advisable to position the stoma in the upper quadrant of the
abdomen (which has a thinner abdominal wall) and ensure adequate trephine size.
Wound Dehiscence/Burst Abdomen
It is no longer a frequent complication post-EL but can still occur. Often, it is due to
a combination of factors from patient factors (diabetes, smoking, obesity, recti diastasis, and sarcopenia) [32–35] to technical aspect and post-operative supercial or
deep surgical site infections and ileus/intestinal obstruction. To reduce the risk of
long-term incisional hernia, recent evidence recommends the suture to be of smaller
calibre and bites [36]. The pitfall with that technique is junior surgical trainees may
not completely grasp the adequate fascia for closure [37].
In acute burst abdomen, the evisceration of the intra-abdominal organs is obvious (Fig.24.9). Sterile large packs soaked in saline should be placed on top and
covered with Ioban while awaiting return to theatre. In return to theatre, the fascial
Fig. 24.9 This was a
middle-aged male patient
that underwent an
emergency Hartmann’s
procedure for obstructing
sigmoid cancer
On post-operative day 1, it
was apparent that the stoma
looked ischemic with some
degree of gangrene. The
patient was taken back to
theatre which found the
ischemic stoma extended
proximally beyond the fascia
level. The proximal colonic
conduit was fully mobilized
including the splenic exure
to ensure no tension and good
marginal blood supply prior
to refashioning a new end
colostomy
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Fig. 24.10 This patient
underwent a laparotomy
for perforated Meckel’s
diverticulitis.
Intraoperatively, there was
also signicant sigmoid
diverticulitis where the
Meckel’s was adherent to.
An en-bloc small bowel
resection with anterior
resection was performed.
Given the signicant
contamination, an Abcarian
end ileostomy was
performed. On postoperative day 1, the patient
had a large cough with a
deep wound dehiscence as
evident by the presence to
omentum on view. He was
taken back to theatre to
close the fascia. The fascia
closure was reinforced
with interrupted gure of
“8” sutures
Z. Q. Ng and D. Weber
closure is redone, and additional interrupted stitches can be placed at equal intervals
(Fig.24.10).
Any attempt to perform component separation should be considered carefully as
it may impact on future hernia repair if there is an occurrence of incisional hernia.
There is some evidence to suggest that prophylactic placement of mesh in the midline incision is safe and effective in preventing incisional hernia [38]. Nevertheless,
there is no rm recommendation from the European Hernia Society currently [39].
The authors have not needed to perform that frequently as the incidence of burst
abdomen and incisional hernia is low.
Venous Thromboembolism (VTE)
The incidence of VTE is reported up to 2% after EL. VTE represents a spectrum of
conditions ranging from deep vein thrombosis to pulmonary embolism [40].
Preventative strategies commence prior to EL.Compressive stockings and calf compression pumps are applied prior to the EL and continue post-operatively. Postoperatively, early mobilization is encouraged. Unless there is a contraindication for
24 Post-Operative Complications After Emergency Laparotomy
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chemical VTE prophylaxis, patients should receive either subcutaneous Heparin or
low molecular weight Heparin (Enoxaparin). There is Cochrane evidence in 2019
that in major abdominal surgery, extended period of VTE prophylaxis up to 28days
should be given [41]. However, this practice is variable and dependent on the institution. The authors’ practice is selective based on patient’s previous history of VTE
events and likelihood of remaining immobile.
Deep vein thrombosis usually manifests with lower limb swelling and tenderness
at the calf. A duplex ultrasound is performed to conrm its location and extent.
Advice from the haematologist should be sought for choice of anticoagulation. In
recent times, the novel oral anticoagulants of either Rivaroxaban, Apixaban or
Dabigatran can be prescribed. Alternatively, subcutaneous injection with Enoxaparin
either once a day (1.5mg/kg) or twice a day (1mg/kg) can be given.
Another common scenario where VTE is presented. There is unexplained ongoing sinus tachycardia. Pulmonary embolism needs to be excluded with a CT pulmonary angiogram. If pulmonary embolism is diagnosed, similar advice from a
Haematologist should be sought in view of therapeutic anticoagulation. Very rarely,
therapeutic anticoagulation is contraindicated due to risk of bleeding. The use of
inferior vena cava lters should be considered to prevent further propagation of clots.
A rare VTE complication of portomesenteric vein thrombosis can occur post-EL
especially if there is intestinal resection or signicant manipulation of the mesentery [42]. It is usually difcult to diagnose based on clinical assessment. A CT scan
with intravenous contrast will demonstrate the extent of the thrombosis and any
associated complications that will require surgical intervention. In the absence of
haemodynamic instability and pneumatosis coli, therapeutic anticoagulation usually sufces.
411
ERAS inEmergency Laparotomy
The practice of enhanced recovery after surgery (ERAS) is well established in the
elective setting with focus on 24-items in the pre-, intra- and post-operative period
to minimize the morbidity associated with the procedure. There is increasing interest for the application of ERAS in the emergency surgery setting [43, 44]. A few
trials showed that a modied ERAS protocol can be safely applied in the setting of
small bowel resection, colonic surgery, and perforated peptic ulcer disease [45–47].
It is likely that the current practice in most centres is based on a modied ERAS
concept with certain aspects achieving high agreement such as: selective use of nasogastric tube or early removal of nasogastric tube, goal-directed uid resuscitation, use
of opioid-sparing analgesia methods, avoidance of drain placement or early removal
of drain, early removal of indwelling urinary catheter, early mobilization, use of prophylactic DVT measures and early introduction of enteral feeding as tolerated.
Continuous education and audits are important for the medical and allied health
staff members to ensure the ongoing improvement on the practice of ERAS.
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Z. Q. Ng and D. Weber
Miscellaneous Complications andPerioperative Physician
Some of these complications may seem mild but often interconnected and can lead
to a vicious cycle and cascade of other complications.
• Urinary tract infection—early removal of indwelling urinary catheter is impor-
tant. In patients with suspected sepsis, a urine sample is collected for microscopy
and culture to direct targeted antimicrobial treatment.
• Acute kidney injury—it is manifested by the rise in creatinine level from base-
line. Most of the cases are pre-renal in origin from intravascular volume deple-
tion. In patients with underlying cardiac failure, input from cardiology colleagues
is useful to prevent the cardiorenal syndrome.
• Delirium—it is not infrequent in the geriatric patients following EL [48].
Sometimes, it is unavoidable following a general anaesthetic despite avoiding
certain medications with the potential for delirium. To tackle this, identify any
underlying cause (i.e. sepsis), avoid any use of sedatives or anti-psychotics for
behavioural management, place the patients in a less-stimulating environment.
The patient population continues to age and is medically more complex. The
perioperative management will benet from the collaboration of a physician with
special interest in this eld. This has been evident in the reduction of mortality in
orthogeriatric patients from the lessons learnt from fracture neck of femur [49]. This
service has been trialled in various subspecialties with good success [50].
The authors’ institution has a perioperative physician (geriatrician by training)
involved in the care of patients above the age of 65in the various medical conditions
and coordinate the need of rehabilitation [51]. It has helped to proactively prevent
and manage any medical complications instead of the traditional model of care [52].
Recommendations/Future Research
The occurrence of complications following emergency laparotomy often has an
impact on the patients. Nevertheless, the long-term effect especially on quality of
life is unknown. Future research should focus on the quality of life following all the
common complications following emergency laparotomy.
Acknowledgements The authors would like to thank Dr. Jih Huei Tan for his contribution in
providing some clinical photos.
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Z. Q. Ng and D. Weber
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